How to initiate nutrition supplementation via Nasogastric (NG) tube?

Initiating Nutrition Supplementation via Nasogastric (NG) Tube

Early tube feeding (within 24 hours) should be initiated in patients who cannot start oral nutrition or in whom oral intake will be inadequate (<50% of caloric requirement) for more than 7 days. 1

Preparation and Verification

1. Verify tube placement before starting feeding

   • Confirm correct NG tube position using pH testing prior to every use 1
   • For nasojejunal tubes, confirm position by x-ray 8-12 hours after placement 1

2. Patient positioning

   • Maintain patient in semi-upright position (elevation of 30° or more) during feeding and for 30 minutes after feeding to reduce aspiration risk 2

Initiation Protocol

For Nasogastric Feeding:

• Start feeding immediately after confirming tube placement 1
• No need for dilution of feeds unless additional fluid is specifically required 1
• No need for starter regimens with reduced volumes in patients who had reasonable nutritional intake in the last week 1

For Gastrostomy Feeding:

• Begin enteral nutrition within 2-4 hours after uncomplicated gastrostomy tube placement 1
• No need for water trials prior to commencing enteral nutrition 1

For Jejunal Feeding:

• Follow a graduated program:
  • Start with 10 mL/h for the first 24 hours
  • Increase by 20 mL/h until nutritional target is reached (usually by day 6) 1

Feed Administration

Rate and Volume:

• If no specialized advice is available, 30 mL/kg/day of standard 1 kcal/mL feed is often appropriate 1
• Caution: This may be excessive in undernourished or metabolically unstable patients 1

Monitoring for Aspiration Risk:

• Check gastric residual volume regularly
• If gastric aspirate at 4 hours is >200 mL, review feeding regimen 2
• Critical volume for aspiration risk: 25 mL (>0.4 mL/kg) 2

Complication Prevention

Common Complications to Monitor:

• Tube dislodgement (48.5%)
• Electrolyte alterations (45.5%)
• Hyperglycemia (34.5%)
• Diarrhea (32.8%)
• Constipation (29.7%)
• Vomiting (20.4%)
• Tube clogging (12.5%)
• Lung aspiration (3.1%) 3

Prevention Strategies:

• Check gastric residue periodically
• Consider post-pyloric placement in unconscious patients
• Use protective mittens in agitated patients 3
• For long-term NG tubes, change every 4-6 weeks, swapping to alternate nostril 1

Documentation Requirements

• Document tube placement verification
• Record feed type, rate, and volume
• Monitor and document tolerance and complications
• Consider using a standardized NG tube documentation bundle to improve adherence to guidelines 4

Special Considerations

• Exercise caution if refeeding syndrome is suspected 1
• Consider gastrostomy or jejunostomy if enteral feeding is likely to be required for more than 4-6 weeks 1
• For post-surgical patients not tolerating oral intake, consider enteral feeding within 1-2 days for severely malnourished patients, 3-5 days for moderately malnourished patients, and within 7 days for normally or over-nourished patients 1

By following this structured approach to initiating NG tube feeding, you can optimize nutritional support while minimizing complications and improving patient outcomes.