What is the next step for a patient experiencing nausea with a Nasogastric (NG) tube?

Management of Nausea with Nasogastric Tube

For a patient experiencing nausea with a nasogastric (NG) tube, the next step should be administration of a dopamine receptor antagonist such as metoclopramide (10-20 mg IV) or haloperidol. 1

Assessment and Initial Management

1. Verify NG tube placement and function:

   • Check that the tube is properly positioned and patent
   • Ensure the tube has proper distal perforations 2
   • Confirm adequate drainage is occurring

2. Administer antiemetic medication:

   • First-line: Dopamine receptor antagonists
     • Metoclopramide 10-20 mg IV/PO every 6 hours 1, 3
     • Haloperidol 0.5-2 mg IV/PO every 4-6 hours 1
     • Olanzapine 2.5-5 mg PO/SL daily 1

3. If first-line treatment fails, add or switch to:

   • 5-HT3 receptor antagonists (ondansetron 4-8 mg IV/PO every 8 hours)
   • Anticholinergic agents (scopolamine patch)
   • Antihistamines (diphenhydramine 25-50 mg IV/PO every 6 hours)
   • Corticosteroids (dexamethasone 4-8 mg IV/PO daily) 1

Addressing Underlying Causes

Investigate and treat potential causes of nausea with NG tube:

• Gastritis or gastroesophageal reflux: Add proton pump inhibitors or H2 receptor antagonists 1
• Gastric outlet obstruction: Consider corticosteroids or endoscopic stenting 1
• Medication-induced: Review current medications, check blood levels of potential culprits (digoxin, phenytoin, carbamazepine, tricyclic antidepressants) 1
• Constipation: Implement bowel regimen if needed
• Opioid-induced: Consider opioid rotation 1

NG Tube Management Options

If nausea persists despite medication management:

1. Consider tube repositioning or replacement:

   • Nasojejunal (NJ) tube placement may reduce nausea compared to NG tube 4
   • Pre-emptive metoclopramide (10 mg IV) before tube manipulation can reduce associated nausea and discomfort 5

2. Evaluate need for continued NG decompression:

   • Early removal of NG tube when clinically appropriate, as routine prolonged use does not reduce nausea and vomiting 1, 6
   • If decompression still needed but NG tube poorly tolerated, consider alternatives:
     • Percutaneous endoscopic gastrostomy (PEG) for longer-term decompression 1
     • Percutaneous endoscopic gastrojejunostomy (PEG-J) if small bowel feeding required 4

Important Considerations and Pitfalls

• Avoid metoclopramide in cases of complete bowel obstruction as it may worsen symptoms 1
• Be cautious with dopamine antagonists in patients with Parkinson's disease or movement disorders
• Monitor for extrapyramidal side effects with metoclopramide and haloperidol
• Consider the impact of medication administration through NG tube on drug bioavailability 7
• Routine use of NG tubes does not prevent postoperative nausea and vomiting 6

By following this approach, you can effectively manage nausea in patients with NG tubes while addressing underlying causes and minimizing complications.