What is the best enteric feeding option for a confused patient who repeatedly pulls out their Nasal Gastric (NG) tube?

Best Enteric Feeding for Confused Patients with Recurrent NG Tube Self-Removal

For a confused patient who repeatedly pulls out their nasogastric tube, placement of a percutaneous endoscopic gastrostomy (PEG) tube is the definitive solution and should be pursued without delay if enteral nutrition is expected to continue beyond 4 weeks. 1

Primary Recommendation: Transition to PEG

PEG tube placement is strongly recommended for this clinical scenario because it directly addresses the core problem of tube dislodgement while providing superior outcomes across multiple domains 1:

• Tube dislodgement rates are dramatically lower with PEG (83% reduction in self-extubation risk compared to NG tubes) 2
• Intervention failure rates drop significantly with PEG tubes, including feeding interruption, tube blocking, and poor adherence (relative risk 0.18) 2
• Patient restraint requirements decrease substantially (7% with PEG vs 22% with NG tubes requiring physical fixation) 3
• Feeding can continue uninterrupted with PEG, whereas NG feeding must be stopped in approximately 17% of cases due to complications 3

Duration-Based Decision Algorithm

The timing threshold for PEG placement is critical 1:

• If enteral nutrition is needed for >4 weeks: PEG is the preferred route (Grade B recommendation, 93% consensus) 1
• If enteral nutrition is needed for 2-3 weeks or longer: Consider early PEG placement, particularly in confused patients at high risk for tube removal 2
• If enteral nutrition is needed for <4 weeks: NG tube remains appropriate only if the patient tolerates it 1

Critical caveat: In confused patients who repeatedly remove NG tubes, the standard 4-week threshold should be shortened because the patient is not successfully receiving nutrition through the NG route 3.

Interim Management While Arranging PEG

If PEG placement cannot be performed immediately, consider these temporary measures 4:

• Nasal bridles reduce accidental NG tube removal from 36% to 10% compared to tape alone 4
• Use fine-bore NG tubes (8-12 French) to minimize discomfort that triggers removal 4
• Ensure proper tube securement using low-adherent film as a contact layer with full-adherent tape 4
• Avoid physical restraints as the sole solution, as this worsens quality of life without addressing the underlying problem 3

Evidence Supporting PEG Over NG in This Population

The superiority of PEG is particularly pronounced in confused or cognitively impaired patients 2, 3:

• Quality of life improvements: Reduced inconvenience (relative risk 0.03), reduced discomfort (relative risk 0.03), improved body image (relative risk 0.01), and better social activities (relative risk 0.01) 2
• Nutritional efficacy is superior: Better weight gain, mid-arm circumference improvement (mean difference 1.16 cm), and serum albumin levels (mean difference 6.03 g/L) 2
• Nursing care is significantly easier: Mean convenience score of 2.0 for PEG vs 2.6 for NG tubes (scale 1-5, lower is better) 3
• Patient satisfaction is higher: Mean patient score of 1.8 for PEG vs 2.3 for NG tubes 3

PEG Placement Considerations

Preprocedural requirements 1:

• Obtain informed consent from legally authorized representative if patient lacks capacity 1
• Administer single dose of first-generation cephalosporin immediately before procedure to reduce peristomal infection risk 1
• Confirm adequate gastrointestinal function and realistic prognosis 2
• Assess coagulation status (INR) and manage anticoagulation appropriately 5, 6

PEG technique preference 1:

• PEG is preferred over surgical gastrostomy due to lower complication rates, reduced costs, and shorter procedure time 1
• Percutaneous laparoscopic assisted gastrostomy (PLAG) is a safe alternative if standard PEG is not feasible 1

Special Situations Requiring Jejunal Access

Consider PEG with jejunal extension (PEG-J) or direct percutaneous endoscopic jejunostomy (PEJ) if 1:

• Gastroduodenal motility disorders are present 1
• Gastric outlet stenosis exists 1
• High aspiration risk persists despite gastric feeding attempts 1
• Severe delayed gastric emptying despite prokinetic therapy 1

Important note: Small bowel feeding requires reduced and cycled feeding rates to prevent dumping symptoms 1.

Common Pitfalls and How to Avoid Them

• Do not delay PEG placement in confused patients who repeatedly remove NG tubes, as this prolongs malnutrition and increases nursing burden 2, 3
• Do not rely on physical restraints as a long-term solution for NG tube retention in confused patients 3
• Do not use PEG as a substitute for good nursing care or for administrative convenience alone; ensure appropriate medical indication exists 2
• Do not place PEG in patients with distal enteral obstruction, severe uncorrectable coagulopathy, or hemodynamic instability 6
• Ensure proper patient selection by confirming adequate gastrointestinal function before PEG placement 2, 6

Safety Profile

Mortality and major complications 2:

• No significant difference in overall mortality rates between PEG and NG tubes 2
• No significant difference in aspiration pneumonia rates in systematic reviews 2
• High mortality after PEG is typically due to underlying disease severity, not the procedure itself 2
• Most PEG complications are minor and preventable with appropriate care 5, 6, 7