In a 66‑year‑old woman with a mental disability who repeatedly removes her nasogastric feeding tube and has persistently high gastric residual volumes (>120 mL) triggering a hold‑feeding protocol, what is the best management to ensure safe nutrition?

Management of Recurrent Nasogastric Tube Removal and High Gastric Residuals in a Mentally Disabled Patient

This patient should be transitioned to comfort feeding with careful hand-feeding assistance rather than continued tube feeding, as the evidence strongly indicates that tube feeding in cognitively impaired patients who repeatedly remove their tubes does not improve outcomes and increases the risk of physical restraints, aspiration, and distress. 1

Primary Recommendation: Transition to Comfort Feeding

• Discontinue nasogastric tube feeding and implement an individualized "comfort feeding" care plan that focuses on hand-feeding assistance, as this approach prioritizes quality of life without the complications of repeated tube insertions and physical restraints. 1

• The repeated tube removal is a clear indication that this intervention is causing distress and is not in the patient's best interest, particularly given her cognitive disability. 1

• Evidence demonstrates that tube feeding in cognitively impaired patients does not improve long-term outcomes, does not reduce aspiration risk, and frequently requires physical restraints that further compromise quality of life. 1

If Tube Feeding Must Continue: Alternative Approaches

Address the High Gastric Residuals First

The facility's 120 mL residual threshold is overly conservative and likely contributing to inadequate nutrition delivery.

• Liberalize the gastric residual volume threshold to 200-250 mL before holding feeds, as volumes below this are often composed primarily of gastric secretions rather than retained formula. 2, 3

• Consider using refractometry and Brix value measurements to distinguish retained formula from endogenous gastric secretions, as traditional residual volumes alone cannot make this distinction. 2, 3

• Check gastric residuals every 4 hours during continuous feeding, but only hold feeds if aspirates exceed 200 mL. 4

Pharmacologic Management of Delayed Gastric Emptying

• Administer intravenous erythromycin 200 mg combined with metoclopramide as first-line prokinetic therapy to improve gastric emptying and reduce residual volumes. 5, 6

• A single dose of IV erythromycin has been shown to allow successful continuation of nasogastric feeding in 90% of patients with large gastric residuals. 6

Consider Post-Pyloric Feeding

• Transition to nasojejunal feeding if gastric feeding continues to fail, as post-pyloric feeding significantly reduces gastric residual volumes and improves feeding tolerance. 7

• Nasojejunal feeding reduces total gastric residual volume by approximately 50% in the first 48 hours (517 mL vs. 975 mL) and decreases the incidence of single residuals >150 mL from 74% to 32%. 7

• Endoscopic placement of nasojejunal tubes has a 98% success rate with no significant complications. 7

• Post-pyloric feeding requires continuous administration rather than bolus feeding due to loss of the gastric reservoir. 4

Secure the Tube to Prevent Removal

• Use nasal bridles for high-risk patients who repeatedly remove their tubes, as this significantly reduces dislodgement rates compared to standard tape securement. 8

• Proper tube securement is critical, as dislodgement occurs in 40-80% of cases without adequate securement methods. 8

Consider Percutaneous Gastrostomy

• If feeding is expected to continue beyond 4-6 weeks, place a PEG tube rather than repeatedly replacing nasogastric tubes in the emergency department. 1, 8

• However, this recommendation must be weighed against the ethical considerations for cognitively impaired patients, as PEG placement in advanced dementia is associated with increased use of physical restraints and does not improve survival or quality of life. 1

Critical Ethical Considerations

The most important question is whether continued tube feeding serves this patient's best interests given her cognitive disability and repeated tube removal.

• Each decision for or against artificial nutrition in patients with cognitive impairment must be made individually with respect to general prognosis and the patient's presumed preferences. 1

• Tube feeding in cognitively impaired patients who resist the intervention often requires physical restraints, which themselves carry significant risks and compromise dignity. 1

• The patient's repeated removal of the tube may represent her only means of expressing unwillingness to accept this intervention. 1

Common Pitfalls to Avoid

• Do not continue the cycle of repeated NG tube placements in the emergency department without addressing the underlying issues of feeding intolerance and the patient's resistance to the intervention. 1

• Do not use overly conservative gastric residual volume thresholds (such as 120 mL) that result in frequent feed interruptions and inadequate nutrition delivery. 2, 3

• Do not assume that tube feeding is always superior to careful hand-feeding in cognitively impaired patients, as the evidence does not support this assumption. 1

• Do not place a PEG tube without thorough discussion of the ethical implications and evidence showing lack of benefit in advanced cognitive impairment. 1