Should we continue to keep the patient NPO (nothing by mouth) and can medications be administered via the PEG (percutaneous endoscopic gastrostomy) tube?

Management of NPO Status and Medication Administration in Stroke Patient with PEG Tube

A formal swallowing assessment should be completed before resuming oral intake, and medications can be safely administered via the PEG tube while the patient remains NPO.

Swallowing Assessment Requirements

The patient was admitted as a code stroke and placed on NPO status with tube feeds. Given the negative CT brain findings for hemorrhage and no evidence of core infarction, the management of feeding and medication administration should follow evidence-based stroke guidelines:

• A formal swallowing assessment is mandatory before any oral intake can be resumed 1
• Patients should remain NPO until a validated swallowing screening tool has been used by a trained practitioner 1
• Ideally, swallowing screening should be completed within 24 hours of hospital arrival 1

Medication Administration

While the patient remains NPO:

• Oral medications should not be administered until swallowing has been formally assessed and found to be normal 1
• Medications can and should be administered via alternative routes, including the PEG tube 1
• The PEG tube provides a safe and effective route for medication administration while maintaining NPO status 1

Tube Feeding Management

For the current tube feeding status:

• Continue to keep the patient NPO until formal swallowing assessment is completed
• Tube feeds can be safely continued via the PEG tube to maintain nutritional status 1
• Nutritional compromise can occur within 2-3 weeks after stroke if adequate nutrition is not provided 1

Decision Algorithm for NPO Status and Medication Administration

1. Maintain NPO status until formal swallowing assessment is completed
2. Continue tube feeds via PEG to prevent nutritional compromise
3. Administer medications via PEG tube rather than orally
4. Arrange formal swallowing assessment within 24 hours by a trained professional
5. Resume oral intake only after swallowing assessment confirms it is safe

Common Pitfalls to Avoid

• Do not administer oral medications without swallowing assessment, even if the patient appears to swallow normally
• Do not discontinue tube feeds without ensuring alternative nutrition is safely established
• Do not assume that a negative CT brain scan means swallowing function is intact
• Do not delay swallowing assessment, as early assessment is associated with better outcomes

Special Considerations for Basilar Tip Aneurysm

The finding of a 4mm basilar tip aneurysm requires special attention but does not change the immediate management of NPO status and medication administration. The patient should continue to receive medications and nutrition via the PEG tube while awaiting MRI results and further neurological assessment.

The evidence strongly supports maintaining NPO status until formal swallowing assessment is completed, while continuing to provide medications and nutrition through the existing PEG tube to ensure patient safety and adequate care.