What are the management options for a patient on nasogastric tube (NGT) feeding experiencing significant gastric reflux when opened to drain, aside from using prokinetics?

From the Guidelines

For a patient on NGT feeding with significant backflow when open to drain, the most effective intervention beyond prokinetics is to elevate the head of the bed to at least 30-45 degrees during and for 30-60 minutes after feeding to reduce reflux risk, as well as considering a change to a post-pyloric feeding tube (nasoduodenal or nasojejunal) to bypass gastric emptying issues, as recommended by recent guidelines 1.

Key Interventions

• Elevate the head of the bed to reduce reflux risk
• Check tube placement by measuring residual volume before each feeding
• Adjust the feeding regimen by decreasing the rate and volume while increasing frequency, or switch to continuous feeding rather than bolus feeding
• Consider changing to a post-pyloric feeding tube (nasoduodenal or nasojejunal) to bypass gastric emptying issues
• Ensure proper tube positioning by confirming placement with X-ray if needed
• Evaluate for potential mechanical obstruction or tube displacement
• Address underlying causes such as electrolyte imbalances, particularly potassium and magnesium, which affect gut motility
• Consider alternative feeding formulas with lower osmolality or fat content that may be better tolerated

Rationale

These interventions aim to reduce gastric distension and improve gastric emptying, thereby minimizing backflow complications including aspiration pneumonia. The use of fine bore NG tubes is recommended unless there is a need for stomach aspiration or administration of high fibre feeds or drugs via the tube 1. Additionally, the position of a nasojejunal (NJ) tube should be confirmed by x ray 8–12 hours after placement 1.

Additional Considerations

• The ESPEN guideline recommends that if a nasogastric tube is repeatedly removed accidentally by the patient and if enteral nutrition will probably be necessary for more than 14 days, a nasal loop/bridle may be applied to secure the nasogastric tube 1.
• Gastrostomy or jejunostomy feeding should be considered whenever patients are likely to require enteral feeding for more than 4–6 weeks 1.

From the FDA Drug Label

INDICATIONS AND USAGE Diabetic Gastroparesis (Diabetic Gastric Stasis) Metoclopramide is indicated for the relief of symptoms associated with acute and recurrent diabetic gastric stasis. The patient's issue with significant back flow when open to drain while on NGT feeding is not directly addressed by the metoclopramide label.

• No direct solution is provided in the label for this specific issue.
• The label does mention the use of metoclopramide for gastric stasis, but it does not provide guidance on managing back flow during NGT feeding. 2

From the Research

Patient on NGT Feeding with Significant Back Flow

When a patient on nasogastric tube (NGT) feeding experiences significant back flow when opened to drain, it is crucial to address the issue to prevent complications and ensure adequate nutrition.

• Assessing the Situation: The first step is to assess the patient's condition and the NGT placement to identify any potential causes of the back flow.
• Alternative Prokinetics: Since the question asks for alternatives to prokinetics, we can consider other medications or methods that may help in reducing gastric reflux and improving gastric emptying.

Alternative Medications and Methods

Based on the provided studies, the following alternatives can be considered:

• Erythromycin: Studies 3, 4 suggest that erythromycin can be effective in facilitating gastric emptying and reducing residual volumes, making it a potential alternative to prokinetics.
• Metoclopramide: Although metoclopramide is a prokinetic, study 3 compares its effectiveness with erythromycin, and it may still be considered as an option, especially if erythromycin is not suitable.
• Ranitidine: Study 5 discusses the use of ranitidine in treating gastroesophageal reflux disease (GERD), which might be relevant in managing back flow, but its direct application in NGT feeding back flow is not explicitly mentioned.
• Cortrak Nasointestinal Tube: Study 6 introduces the use of a Cortrak nasointestinal tube, which has shown success in reaching the small intestine and increasing enteral nutrition delivery, potentially reducing the need for prokinetics.

Considerations

It is essential to consult with a healthcare professional before making any changes to the patient's treatment plan. The choice of alternative medication or method should be based on the patient's specific condition, medical history, and the potential benefits and risks associated with each option.