Gastric tubes in patients with severe brain injury

Introduction

Following severe brain injury most patients require intubation and ventilation. Gastric tubes, whether nasogastric or orogastric, allow the stomach to be decompressed, which can aid mechanical ventilation, reduce the risk of aspiration and provide a route for drug administration and subsequently nutrition.

Methods

A 4-month prospective audit was carried out on patients admitted to the ICU of a regional neurosurgical centre following severe brain injury. Patients were included following primary intracerebral haemorrhage or traumatic brain injury.

Results

All patients (n = 25) were admitted to the ICU from an Emergency Department. All had a Glasgow Coma Score of 3 on admission to the ICU and were intubated and ventilated prior to arrival. The mean time from accident to arrival in the ICU was 15 hours. Only 32% of patients had a gastric tube in situ on arrival in the ICU; 16% had a nasogastric tube and 16% had an orogastric tube in situ. Only 16% of patients had the gastric tube inserted at the time of rapid sequence intubation. Thirty-five percent of patients who required gastric tube insertion after admission to the ICU had documented changes in management or complications as a consequence of the procedure. These included the need for bolus sedation and muscle relaxant use, with ensuing hypotension requiring inotrope support; delay in commencement of enteral feeding and the need for extra chest radiographs to confirm the tube position.

Conclusion

Instrumentation to pass a gastric tube may cause a rise in intracranial pressure or induce hypertension, which may precipitate rebleeding in patients with intracerebral haemorrhage. Transfer times to regional neurosurgical units can be long. Optimal management of the brain-injured patient should include insertion of gastric tubes at the time of initial rapid sequence intubation. This is not current practice in the emergency department and improved awareness of the need to place gastric tubes early in brain-injured patients may avoid unnecessary complications.