Analysis of an electromagnetic tube placement device versus a self-advancing nasal jejunal device for postpyloric feeding tube placement

Intrapulmonary Feeding Tube Placements While Using an Electromagnetic Placement Device: A Review (2019-2021)

BACKGROUND

Intrapulmonary placements of feeding tubes inserted with use of an electromagnetic placement device (EMPD) continue to occur.

OBJECTIVE

To describe circumstances and outcomes associated with intrapulmonary feeding tube placements during use of an EMPD.

METHODS

A retrospective review of reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database of intrapulmonary feeding tube placements during use of an EMPD from 2019 through 2021. Complications, outcomes, operator training, interference from anatomical variations and medical devices, and the use and accuracy of radiographs in identifying pulmonary placements were recorded.

RESULTS

Sixty-two cases of intrapulmonary tube placement were identified; 10 were associated with a fatal outcome. Pneumothorax occurred in 35 cases and feedings were delivered into the lung in 11 cases. User error was cited in 6 cases and was implicit in most others. Little information was provided about operator training. Four intrapulmonary placements were associated with anatomical variations and 1 with a left ventricular assist device. Radiographic follow-up was described in 28 cases and correctly identified 23 of the intrapulmonary placements.

CONCLUSIONS

User error was a significant factor, which highlights the need for empirical data to clarify the amount of training needed to safely credential EMPD operators. Clearer information is needed about anatomical variations that may contraindicate use of an EMPD, as well as medical devices that may interfere with an EMPD. Use of follow-up radiographs, interpreted by qualified personnel, is supported to increase the probability of identifying intrapulmonary tube placements.

National Survey of Feeding Tube Verification Practices: An Urgent Call for Auscultation Deimplementation

BACKGROUND

Harm events such as pneumothoraces and pneumonia continue to be associated with feeding tube insertion. Most bedside verification methods are not accurate to discriminate pulmonary from gastrointestinal system. Evidence-based clinical practice guidelines do not support auscultation of feeding tubes in adults, yet auscultation is the most common method used.

OBJECTIVES

Our survey assessed national feeding tube verification practices used by critical care nurses, including progress in auscultation method deimplementation, and stylet reinsertion and cleansing practices.

METHODS

A national survey of 408 critical care nurses was performed.

RESULTS

The majority performed auscultation (311 of 408 [76%]) to verify feeding tube placement. In the final multivariable model, nursing education, facility type, observation of colleagues performing auscultation, and awareness of an institutional policy were associated with auscultation of feeding tubes. Thirty-five percent used enteral access devices to verify initial feeding tube placement. Stylet cleansing methods were variable; 38% of reinserted stylets were not cleansed.

DISCUSSION

Minimal progress has been made in deimplementation of auscultation in the past 7 years despite passive knowledge dissemination in research articles, clinical practice guidelines, and procedure manuals. Although pH measure is used as a first-line feeding tube verification method in the United Kingdom, it is rarely used in the United States. Clinical practice guidelines should be updated to incorporate new research on enteral access systems.

CONCLUSIONS

Tradition-based practices such as auscultation and certain stylet cleansing methods should be deimplemented. A focused interdisciplinary, multifaceted program is needed to deimplement auscultation practice for adult feeding tubes.

Pneumothoraces Prevented With Use of Electromagnetic Device to Place Feeding Tubes

BACKGROUND

A US Food and Drug Administration safety letter warned about the risk for pneumothoraces during feeding tube insertion despite the use of electromagnetic placement devices that provide real-time visualization of feeding tube position.

OBJECTIVES

To systematically assess pulmonary placement and pneumothoraces in CORTRAK-assisted feeding tube insertions.

METHODS

CINAHL, MEDLINE, and Cochrane databases were searched for studies of CORTRAK-assisted feeding tube insertion. Thirty-two studies documenting pulmonary placement and/or complications of feeding tube insertion were found.

RESULTS

Operators recognized pulmonary placement on insertion tracings during 202 CORTRAK-assisted feeding tube insertion procedures, resulting in the immediate withdrawal of 199 feeding tubes. One pneumothorax was identified later by radiography. Seven pulmonary placements were not recognized by CORTRAK operators at the time of feeding tube insertion, resulting in 2 pneumothoraces. The incidence of pneumothorax for CORTRAK-assisted feeding tube insertions was 0.02% (3 of 17039). Of the feeding tubes inserted into the pulmonary system - either found during or after the procedure -1.4% (3 of 209) resulted in pneumothoraces (as opposed to the 19% to 28% incidence of pneumothorax for blind feeding tube insertions. Operators recognizing pulmonary placement on CORTRAK insertion tracings may have prevented 97% (202 of 209) of feeding tubes from being inserted farther into the respiratory tract.

CONCLUSIONS

Feeding tube insertion with an electromagnetic placement device is advantageous over blind feeding tube insertion because the operator can recognize pulmonary placement early and withdraw the feeding tube, thus decreasing the risk of pulmonary complications.

CORTRAK Superuser Competency Assessment and Training Recommendations

BACKGROUND

Blind insertion of feeding tubes remains unsafe. Electromagnetic placement devices such as the CORTRAK Enteral Access System allow operators to interpret placement of feeding tubes in real time. However, pneumothoraces have been reported and inadequate user expertise is a concern.

OBJECTIVE

To explore factors influencing competency of CORTRAK-assisted feeding tube insertion.

METHODS

A prospective, observational pilot study was conducted. Data collection included demographics, self-confidence, clinical judgment regarding CORTRAK-assisted feeding tube insertion, and general self-efficacy. CORTRAK-assisted feeding tube insertions were performed with the Anatomical Box and CORMAN task trainers.

RESULTS

Twenty nurses who had inserted a mean of 53 CORTRAK feeding tubes participated. Participants inserted a mean of 2 CORTRAK feeding tubes weekly; each had inserted a feeding tube in the past 7 days. All superusers were competent; 1 required remediation for improper receiver unit placement. Mean (SD) scores were 35 (3.68) on a 40-point scale for self-efficacy, 4.6 (0.68) on a 5-point scale for self-reported feeding tube insertion confidence, and 4.85 (0.49) on a 5-point scale for demonstrated confidence. Participants estimated that 8 CORTRAK-assisted insertions were needed before they felt competent as super users. Confidence with the CORTRAK tracing was estimated to require 10 feeding tube insertions. Six participants continued to assess placement by auscultation, suggesting low confidence in their interpretation of the tracing.

CONCLUSIONS

At least 3 observations should be performed to assess initial competency; the number should be individualized to the operator. Interpretation of the insertion tracing is complex and requires multiple performance opportunities to gain competency and confidence for this high-risk skill.

A novel quick transendoscopic enteral tubing in mid-gut: technique and training with video

Background

This study aimed to evaluate the feasibility, safety, and value of a quick technique for transendoscopic enteral tubing (TET) through mid-gut.

Methods

A prospective interventional study was performed in a single center. A TET tube was inserted into mid-gut through the nasal orifice and fixed on the pylorus wall by one tiny titanium endoscopic clip under anesthesia. The feasibility, safety, success rate, and satisfaction with TET placement were evaluated for enteral nutrition or fecal microbiota transplantation.

Results

A total of 86 patients underwent mid-gut TET. The success rate of the TET procedure was 98.8% (85/86). Mean tubing time of the TET procedure was 4.2 ± 1.9 min. 10 cases of procedure was enough for training of general endoscopist to shorten the procedure time (7.0 min vs 4.0 min, p < 0.05). 97.7% (84/86) of patients were satisfied with the TET placement. Procedure-related and tube-related adverse events were observed in 8.1% (7/86) and 7.0% (6/86) of patients respectively. There were no moderate to severe adverse events during tube extubation.

Conclusions

TET through mid-gut is a novel, convenient, reliable and safe procedure for mid-gut administration with a high degree of patient satisfaction.

Trial registration

This research was retrospectively registered with clinicaltrials.gov. Trial registration date: 29th November 2017. Trial registration number: NCT03335982.

Electronic supplementary material

The online version of this article (10.1186/s12876-018-0766-2) contains supplementary material, which is available to authorized users.

Successful Placement of Nasointestinal Feeding Tubes Using an Electromagnetic Sensor-Guided Enteral Access System in Patients With Left Ventricular Assist Devices

Technology advances have made it possible to prolong life for patients with heart failure who are not transplant candidates or while awaiting transplant. Many different cardiac devices are available that can be used as a bridge to transplant (temporary support) or as a destination therapy (permanent support). Placement of these devices can cause complications that, if not addressed, could negatively impact the nutrition status of patients. Placement of nasointestinal feeding tubes using an electromagnetic sensor-guided enteral access system (EMS-EAS) has been difficult in patients with implantable devices because of the potential for interference with the EMS-EAS and the left ventricular assist device (LVAD). The purpose of this paper was to report the results using a modified method to place nasointestinal tubes in patients with LVADs by elevating the receiver off the xiphoid process. There were 42 feeding tube placements in 25 patients. Results showed a 69% success rate of placement into the small bowel, 13 unsuccessful placements, and no adverse or sentinel events associated with tube placement using this method. Results indicated the modified method is a safe approach to help expedite feeding tube placement in a nutritionally compromised patient. The success rate is comparable with non-LVAD patient populations requiring nasointestinal tube placement via EMS-EAS. To our knowledge, this is the first published case series addressing a modified method for nasointestinal tube placement in patients with LVAD. More research is needed to determine ideal separation distances or other techniques to improve the success rate in this patient population.

Enteral Nutrition: Options for Short-Term Access

The preferred method of nutrition support in the presence of a functional gastrointestinal tract is enteral nutrition (EN). Many factors contribute to the selection process for the type of enteral access device to be used. Short-term enteral access tubes are placed into the nares or, sometimes, orally, usually at bedside. The short-term access provides a means to meet patient nutrient needs and can provide a chance to assess tolerance of the tube feedings if more permanent long-term placement is determined to be required. Access for nutrition support does not come without a risk; it can be challenging, requiring an individualized approach for each patient. The selection type and access location can greatly impact the success of EN. The most advantageous tube choice must be determined carefully, taking into account the multiple considerations reviewed in this paper.

Electromagnetic-guided placement of nasoduodenal feeding tubes versus endoscopic placement: a randomized, multicenter trial

BACKGROUND AND AIMS

Electromagnetic-guided placement (EMP) of a nasoduodenal feeding tube by trained nurses is an attractive alternative to EGD-guided placement (EGDP). We aimed to compare EMP and EGDP in outpatients, ward patients, and critically ill patients with normal upper GI anatomy.

METHODS

In 3 centers with no prior experience in EMP, patients were randomized to placement of a single-lumen nasoduodenal feeding tube either with EGDP or EMP. The primary endpoint was post-pyloric position of the tube on abdominal radiography. Patients were followed for 10 days to assess patency and adverse events. The analyses were performed according to the intention-to-treat principle.

RESULTS

In total, 160 patients were randomized to EGDP (N = 76) or EMP (N = 84). Three patients withdrew informed consent, and no abdominal radiography was performed in 2 patients. Thus, 155 patients (59 intensive care unit, 38%) were included in the analyses. Rates of post-pyloric tube position between EGDP and EMP were comparable (79% vs 82%, odds ratio 1.16; 90% confidence interval, 0.58-2.38; P = .72). Adverse events were observed in 4 patients after EMP (hypoxia, GI blood loss, atrial fibrillation, abdominal pain) and in 4 after EGDP (epistaxis N = 2, GI blood loss, hypoxia). Costs of tube placements were lower for EMP compared with EGDP: $519.09 versus $622.49, respectively (P = .04).

CONCLUSIONS

Success rates and safety of EMP and EGDP in patients with normal upper GI anatomy were comparable. Lower costs and potential logistic advantages may drive centers to adopt EMP as their new standard of care. (Clinical trial registration number: NTR4286.).

Establishing Decision Trees for Predicting Successful Postpyloric Nasoenteric Tube Placement in Critically Ill Patients

BACKGROUND

Despite the use of prokinetic agents, the overall success rate for postpyloric placement via a self-propelled spiral nasoenteric tube is quite low.

METHODS

This retrospective study was conducted in the intensive care units of 11 university hospitals from 2006 to 2016 among adult patients who underwent self-propelled spiral nasoenteric tube insertion. Success was defined as postpyloric nasoenteric tube placement confirmed by abdominal x-ray scan 24 hours after tube insertion. Chi-square automatic interaction detection (CHAID), simple classification and regression trees (SimpleCart), and J48 methodologies were used to develop decision tree models, and multiple logistic regression (LR) methodology was used to develop an LR model for predicting successful postpyloric nasoenteric tube placement. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of these models.

RESULTS

Successful postpyloric nasoenteric tube placement was confirmed in 427 of 939 patients enrolled. For predicting successful postpyloric nasoenteric tube placement, the performance of the 3 decision trees was similar in terms of the AUCs: 0.715 for the CHAID model, 0.682 for the SimpleCart model, and 0.671 for the J48 model. The AUC of the LR model was 0.729, which outperformed the J48 model.

CONCLUSION

Both the CHAID and LR models achieved an acceptable discrimination for predicting successful postpyloric nasoenteric tube placement and were useful for intensivists in the setting of self-propelled spiral nasoenteric tube insertion.

Update on Effectiveness of an Electromagnetic Feeding Tube-Placement Device in Detecting Respiratory Placements

BACKGROUND

Radiography is the accepted gold standard for testing feeding tube placement; however, an electromagnetic tube-placement device (ETPD) is sometimes used in lieu of radiography for this purpose. High success rates have been reported when the device was used by well-trained individuals. However, authors previously described 20 cases that occurred between 2007 and 2012 in which clinicians voluntarily reported inability to detect inadvertent tube insertions in the respiratory tract while using an ETPD.

OBJECTIVE

To describe case reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database between 2013 and 2015 regarding inadvertent respiratory placement of feeding tubes by operators using an ETPD.

METHODS

The MAUDE database was searched for cases dated from January 1, 2013, through December 31, 2015, along with selected brand names. A total of 34 cases (25 after removal of duplicates) were located in which a feeding tube was inserted into the respiratory tract during insertions assisted by an ETPD.

RESULTS

Sites of the malpositioned tubes included the right lung (n = 13), left lung (n = 6), unspecified lung (n = 4), and bronchus (n = 2). A pneumothorax occurred in 17 of the 25 misplacements; feedings were administered in 6 cases.

CONCLUSIONS

Many case reports involved clinicians failing to recognize tube misplacements in the respiratory tract while using an ETPD. These reports provide evidence that not all clinicians can use the device effectively to detect malpositioned tubes. Thus, one must continue to question the wisdom of eliminating radiographic confirmation of tube position before starting feedings.

Nutrition in acute pancreatitis: a critical review

Severe acute pancreatitis poses unique nutritional challenges. The optimal nutritional support in patients with severe acute pancreatitis has been a subject of debate for decades. This review provides a critical review of the available literature. According to current literature, enteral nutrition is superior to parenteral nutrition, although several limitations should be taken into account. The optimal route of enteral nutrition remains unclear, but normal or nasogastric tube feeding seems safe when tolerated. In patients with predicted severe acute pancreatitis an on-demand feeding strategy is advised and when patients do not tolerate an oral diet after 72 hours, enteral nutrition can be started. The use of supplements, both parenteral as enteral, are not recommended. Optimal nutritional support in severe cases often requires a tailor-made approach with day-to-day evaluation of its effectiveness.

ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient

The value of nutrition therapy for the adult hospitalized patient is derived from the outcome benefits achieved by the delivery of early enteral feeding. Nutritional assessment should identify those patients at high nutritional risk, determined by both disease severity and nutritional status. For such patients if they are unable to maintain volitional intake, enteral access should be attained and enteral nutrition (EN) initiated within 24-48 h of admission. Orogastric or nasogastric feeding is most appropriate when starting EN, switching to post-pyloric or deep jejunal feeding only in those patients who are intolerant of gastric feeds or at high risk for aspiration. Percutaneous access should be used for those patients anticipated to require EN for >4 weeks. Patients receiving EN should be monitored for risk of aspiration, tolerance, and adequacy of feeding (determined by percent of goal calories and protein delivered). Intentional permissive underfeeding (and even trophic feeding) is appropriate temporarily for certain subsets of hospitalized patients. Although a standard polymeric formula should be used routinely in most patients, an immune-modulating formula (with arginine and fish oil) should be reserved for patients who have had major surgery in a surgical ICU setting. Adequacy of nutrition therapy is enhanced by establishing nurse-driven enteral feeding protocols, increasing delivery by volume-based or top-down feeding strategies, minimizing interruptions, and eliminating the practice of gastric residual volumes. Parenteral nutrition should be used in patients at high nutritional risk when EN is not feasible or after the first week of hospitalization if EN is not sufficient. Because of their knowledge base and skill set, the gastroenterologist endoscopist is an asset to the Nutrition Support Team and should participate in providing optimal nutrition therapy to the hospitalized adult patient.

Electromagnetic Sensor-Guided Enteral Access Systems: A Literature Review

Enteral feeding is the nutritional support of choice for acutely ill patients with functional gastrointestinal tracts who are unable to swallow. Several benefits including reduced mortality and length of hospital stay have been associated with early initiation of enteral feeding. However, misplacement of conventional nasoenteric tubes is relatively common and can result in complications including pneumothorax. In addition, the need to confirm the position by X-ray can delay the start of using the tube. Eliminating these delays can help patients start feeding, and minimise the adverse impact on initiating hydration and medication. The purpose of this review was to critically examine whether electromagnetic sensor-guided enteral access systems (EMS-EAS) can help overcome the challenges of conventional nasoenteric feeding tube placement and confirmation. The Royal Society of Medicine's library performed two searches on Medline (1946-March 2014) and Embase (1947-March 2014) covering all papers on Cortrak or electromagnetic or magnetic guidance systems for feeding tubes in adults. Results from the literature search found an agreement between the radiographic and EMS-EAS confirmation of placement. EMS-EAS virtually eliminated the risk of misplacement and pneumothorax was not reported. In addition, studies showed a small decrease in the number of X-rays with EMS-EAS and a reduced average time to start feeding compared with blind placement. This review suggests that EMS-EAS reduces several complications associated with the misplacement of nasoenteric feeding tubes, and that there could be considerable improvements in mortality, morbidity, patient experience and cost if EMS-EAS is used instead of conventional methods.

Systematic review on bedside electromagnetic-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes

BACKGROUND

Nasoenteral tube feeding is frequently required in hospitalized patients to either prevent or treat malnutrition, but data on the optimal strategy of tube placement are lacking.

OBJECTIVE

To compare the efficacy and safety of bedside electromagnetic (EM)-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes in adults.

DESIGN

Systematic review of the literature.

PATIENTS

Adult hospitalized patients requiring nasoenteral feeding.

INTERVENTIONS

EM-guided, endoscopic, and/or fluoroscopic nasoenteral feeding tube placement.

MAIN OUTCOME MEASUREMENTS

Success rate of tube placement and procedure- or tube-related adverse events.

RESULTS

Of 354 screened articles, 28 studies were included. Data on 4056 patients undergoing EM-guided (n = 2921), endoscopic (n = 730), and/or fluoroscopic (n = 405) nasoenteral feeding tube placement were extracted. Tube placement was successful in 3202 of 3789 (85%) EM-guided procedures compared with 706 of 793 (89%) endoscopic and 413 of 446 (93%) fluoroscopic procedures. Reinsertion rates were similar for EM-guidance (270 of 1279 [21%] patients) and endoscopy (64 of 394 [16%] patients) or fluoroscopy (10 of 38 [26%] patients). The mean (standard deviation) procedure time was shortest with EM-guided placement (13.4 [12.9] minutes), followed by endoscopy and fluoroscopy (14.9 [8.7] and 16.2 [23.6] minutes, respectively). Procedure-related adverse events were infrequent (0.4%, 4%, and 3%, respectively) and included mainly epistaxis. The tube-related adverse event rate was lowest in the EM-guided group (36 of 242 [15%] patients), followed by fluoroscopy (40 of 191 [21%] patients) and endoscopy (115 of 384 [30%] patients) and included mainly dislodgment and blockage of the tube.

LIMITATIONS

Heterogeneity and limited methodological quality of the included studies.

CONCLUSION

Bedside EM-guided placement of nasoenteral feeding tubes appears to be as safe and effective as fluoroscopic or endoscopic placement. EM-guided tube placement by nurses may be preferred over more costly procedures performed by endoscopists or radiologists, but randomized studies are lacking.