I admire & strive for efficiency, empathy, and efficacy. Thus, if a certain painful procedure extends lengths of stay without significant benefit to the patient, I’m hesitant to order it. However, sometimes it is frowned upon to not play nice in the sandbox with our Pavlov consultants who request NG tubes for small bowel obstructions.
Thus, if you must place an NG tube for an obstruction, keep today’s study in mind.
Up at The U (of Vermont), patients that were ordered an NG tube and were between 18 and 60 years of age were given 1 ml of intranasal atomized co-phenylcaine (lidocaine 5% with 0.5% phenylephrine to each nostril, followed by either placebo or 2 mg of IV midazolam with NG tube placement within 5 minutes of placebo or midazolam. Using a 100 mm VAS for pain and discomfort, as the primary endpoint, the patients were interviewed 15 or 45 minutes after the procedure.
After 51 total cases (23 of which qualified for the study), the trial was stopped early as several ED clinicians felt that midazolam prior to insertion was superior to topical anesthetics alone and did not want their patients randomized in the study.
Hence, the numbers are a good bit low. Only 13 patients in the control arm, and 10 in the treatment arm. The mean difference in pain scores was 31mm and 36mm for discomfort. None of the midazolam placements were rated difficult by nursing who placed the NG tube, whereas 3/13 in the control group were rated as difficult or very difficult to place.
So yes. The numbers are small, and the authors shed some light on questions we would have. They spoke about anecdotally about 1mg of midazolam for those over 60 years old or with known pulmonary disease – which they felt did not alleviate pain or discomfort. Here, I think a 1mg bolus followed by 0.5mg boluses as needed is reasonable.
They cite a paper stating that 91% of providers would change their practice if new literature showed a convenient way to reduce patient discomfort. Well, here it is. So, if Pavlov’s dog barks and you HAVE to place an NG tube, hopefully your institutional policy allows IV midazolam without considering it procedural sedation (or, potentially using intranasal midazolam for anxiolysis).