When to avoid nasogastric (NG) tube insertion in a 60-year-old lady?

When to Avoid Nasogastric (NG) Tube Insertion in a 60-Year-Old Lady

Nasogastric tube insertion should be avoided in patients with recent variceal bleeding (within 3 days), pharyngeal or esophageal pouches, reduced consciousness, impaired gag/swallowing reflexes, and known esophageal strictures or varices. 1

Absolute Contraindications

• Recent variceal bleeding: NG tube insertion should be avoided for at least three days after acute variceal bleeding 1
• Pharyngeal or esophageal pouches: Risk of perforation during insertion 1
• Severe maxillofacial trauma: Increases risk of intracranial insertion 2
• Basilar skull fractures: Risk of intracranial insertion through cribriform plate 2
• Known esophageal strictures or obstruction: Increases risk of perforation 1
• Esophageal varices: Larger tubes are unsafe in the presence of varices even if they have not bled recently 1

Relative Contraindications/High-Risk Situations

• Reduced level of consciousness: Increases risk of bronchial insertion and aspiration 1
• Impaired gag/swallowing reflexes: Higher risk of bronchial insertion even with endotracheal tubes in place 1, 3
• Severe coagulopathy: Increases risk of bleeding during insertion 2
• Nasal trauma or obstruction: May make insertion difficult or traumatic 2
• Dementia with poor prognosis: Risk-benefit ratio of enteral nutrition is unfavorable in severe dementia 1

Special Considerations for Elderly Patients

In a 60-year-old female patient, additional factors to consider include:

• Expected duration of feeding: If enteral feeding is expected to be required for more than 4 weeks, consider percutaneous gastrostomy instead of NG tube 1
• Terminal illness: Offer comfort feeding instead of enteral nutrition in terminal phase of illness 1
• Cognitive status: In patients with severe dementia, the risk-benefit ratio of enteral nutrition via NG tube is generally unfavorable 1
• Swallowing assessment: A specialist should assess the prognosis of any swallowing difficulty before long-term NG feeding is initiated 1

Complications to Consider in Decision-Making

• Immediate complications: Discomfort, trauma to nasal passages, intracranial insertion, bronchial placement, perforation of pharyngeal/esophageal pouches 1, 4
• Short-term complications: Nasopharyngeal discomfort, sore mouth, thirst, swallowing difficulties, hoarseness 1
• Long-term complications: Nasal erosions, abscess formation, sinusitis, otitis media, esophagitis, ulceration, stricturing 1, 5
• Tube displacement: Approximately 25% of NG tubes "fall out" or are pulled out by patients soon after insertion 1

Decision Algorithm for NG Tube Placement in a 60-Year-Old Woman

1. Assess indication and expected duration:

   • If feeding expected <4 weeks: Consider NG tube if appropriate 1
   • If feeding expected >4 weeks: Consider percutaneous gastrostomy 1

2. Evaluate for absolute contraindications:

   • Recent variceal bleeding, pharyngeal/esophageal pouches, severe facial trauma 1, 2
   • If present: Avoid NG tube insertion

3. Assess risk factors:

   • Reduced consciousness, impaired gag reflex, severe dementia 1
   • If multiple risk factors present: Consider alternative feeding routes

4. If proceeding with NG tube insertion:

   • Use fine bore (5-8 French gauge) tubes unless gastric aspiration is needed 1, 5
   • Verify tube position with pH testing prior to every use 5
   • Monitor for complications and reassess need daily 1

Remember that NG tube use should be considered on an individual basis, taking into account the risk of gastric stasis and aspiration related to gut dysfunction. Daily reevaluation of the need for NG tube should occur, and it should be removed as early as possible. 1