If a stomach peg, NG tube and central line are all not options, how can we get Mom the nutrition she needs?

1 answer | Last updated: Sep 14, 2017
A fellow caregiver asked...

My mother-in-law was recently diagnosed with pancreatic cancer which cannot be operated on. The day before she was due for her first chemotherapy appointment she was struck down with a right hemisphere stroke affecting her left side.

This was two weeks ago and, if anything, we have seen a decline in her health since having the stroke.

Her current situation is she is on anti-nausea drugs which were prescribed before the stroke, and now is on morphine which is controlling pain caused by the cancer. However during the first five days after the stroke she was fairly alert and able to talk if only a few words, but now she is constantly sleeping.

Although we understand this could be due to her brain needing to heal, the speech and physical therapists are unable to do anything at the moment. We seem to be getting conflicting stories from the hospital. The doctors don't seem sure what to do next as she is unable to swallow and a stomach peg, central line and NG tube have all been ruled out.

The doctors seem confident she will come out of this but we are just unsure how long she can go just on a saline drip. Is there any other way of getting nourishment in her?

Any help much appreciated

Expert Answers

James Castle, M.D. is a neurologist at NorthShore University HealthSystem (affiliated with The University of Chicago) and an expert on strokes.

Sorry to hear about this predicament. I have a few thoughts:

First, it may be helpful to pin down exactly why she is nonresponsive. A few possibilities come to mind. First, often with patients who have suffered a right hemisphere stroke, they are more awake then you realize. They suffer from something called an "eye opening apraxia" - which is to say that they inappropriately have their eyes closed even though they are actually awake. It may be helpful to see if responds to verbal cues and answers questions. Second, it is always a good idea to make sure she is not harboring an infection. People with new strokes are at very high risk of aspiration pneumonia and/or urinary tract infections. Either one could cause her to sleep all day. Third, make sure that her medicines are minimized to only what she absolutely needs - anymore and she may be overly sedated by them. Finally, re-checking a head CT to make sure that she has not had any additional strokes, bleeding, or swelling is helpful.

If all of this fails to help her, then unfortunately you are left with the 3 feeding options you have listed. It is typically ok to wait a week before feeding someone, but more than that is usually harmful. An NG tube would be the most straightforward method, followed by the PEG. A central line is usually my last option. I would ask your doctor specifically why they are avoiding these, and see if the reasons cannot be reversed. For example, if it is because she has a low platelet count, and they fear bleeding, then ask if platelets could be transfused in preparation for the placement.

I can't think of too many reasons why a central line could not be placed for nutrition other than a bleeding disorder (which can often be corrected for the placement) or a blood stream infection (which can often be treated with antibiotics).

IV fluid is simply not enough nutrition. It does not carry nearly enough calories, and no protein.