4-Point ultrasonography to confirm the correct position of the nasogastric tube in 114 critically ill patients

Artificial intelligence in the detection of non-biological materials

Artificial Intelligence (AI) has emerged as a transformative force within medical imaging, making significant strides within emergency radiology. Presently, there is a strong reliance on radiologists to accurately diagnose and characterize foreign bodies in a timely fashion, a task that can be readily augmented with AI tools. This article will first explore the most common clinical scenarios involving foreign bodies, such as retained surgical instruments, open and penetrating injuries, catheter and tube malposition, and foreign body ingestion and aspiration. By initially exploring the existing imaging techniques employed for diagnosing these conditions, the potential role of AI in detecting non-biological materials can be better elucidated. Yet, the heterogeneous nature of foreign bodies and limited data availability complicates the development of computer-aided detection models. Despite these challenges, integrating AI can potentially decrease radiologist workload, enhance diagnostic accuracy, and improve patient outcomes.

Usefulness of ultrasound in confirming the correct placement of Ryle's tube compared to the traditional method of auscultation in normal versus overweight and obese patients

Background and Aims

Auscultation to verify Ryle's tube position is difficult in obese patients. We compared the usefulness of ultrasonography (USG) versus auscultation in confirming the correct Ryle's tube placement in normal versus overweight or obese patients, time taken for confirmation, and incidence of reinsertion.

Material and Methods

A prospective, observational study was carried out on 80 patients. Patients with a body mass index (BMI)>25 kg/m2 formed group O and those with BMI <25 kg/m2 constituted group N. After Ryle's tube insertion correct placement was first confirmed by auscultation. The presence of a gurgling sound over the epigastrium was graded (definite/doubtful/absent). During USG evaluation, if Ryle's tube was not visualized at the subxiphoid region, 20mL of air was injected, looking for dynamic fogging in the stomach. If auscultation yielded doubtful or absent results and USG also failed to confirm, Ryle's tube was repositioned and confirmed.

Results

Group O had a significantly higher BMI. Auscultation time and the time taken for USG confirmation were significantly longer in group O. The percentage of patients with definite auscultatory signs was significantly higher in group N. Significantly higher number of patients in group O had doubtful/absent auscultatory signs. Ryle's tube and fogging visualization with USG and the requirement of reinsertion were comparable in both groups. The percentage of patients with definite auscultatory confirmation and definite USG confirmation were comparable in group N. However, in group O, significantly lesser patients had definite auscultatory confirmation compared to definite USG signs.

Conclusion

Confirmation of the correct placement of Ryle's tube using ultrasound is easier than auscultation in overweight and obese patients. In normal patients, both techniques are equally useful.

Bedside ultrasonic localization of the nasogastric tube in a patient with severe COVID-19: A case report

BACKGROUND

The indwelling nasogastric tube is commonly used for supplying enteral nutrition to patients who are unable to feed themselves, and accurate positioning is essential in the indwelling nasogastric tube in the body of the aforementioned patients. In clinical practice, abdominal radiography, auscultation, and clinical determination of the pH of the gastric juice are routinely used by medical personnel to determine the position of the tube; however, those treatments have proved limitations in specific cases. There are few case reports on the precise positioning of the nasogastric tube in patients with coronavirus disease 2019 (COVID-19), for whom a supply of necessary nutrition support is significant throughout the process of treatment.

CASE SUMMARY

A 79-year-old patient, diagnosed with COVID-19 at the stage of combined syndromes with severe bacterial lung infection, respiratory failure, multiple co-morbidities, and a poor nutritional status, was presented to us and required an indwelling nasogastric tube for enteral nutrition support. After pre-treatment assessments including observation of the patient’s nasal feeding status and examination of the nasal septal deviation, inflammation, obstruction, nasal leakage of cerebrospinal fluid, and other disorders that might render intubation inappropriate, we measured and marked the length of the nasogastric tube to be placed and delivered the tube to the intended length in the standard manner. Then further scrutiny was conducted to ensure that the tube was not coiled in the mouth, and gentle movements were made to avoid damage to the esophageal mucosa. However, back draw of the gastric juice using an empty needle failed, and the stethoscope could not be used for auscultation due to the specific condition presented by the internal organs of the patient, and the end of the tube was placed in saline with no bubbles spilling out. Therefore, it was not possible to determine whether the nasogastric tube was placed exactly in the stomach and no nutrient infusion was performed for the time being. Subsequently, the ultrasound probe was utilized to view the condition of the patient’s stomach, where the nasogastric tube was found to be translucent and running parallel to the esophagus shaped as “=”. The pre-conditions were achieved and 100 mL nutritional fluid was fed to the patient, who did not experience any discomfort throughout the procedure. His vital signs were stable with no adverse effects.

CONCLUSION

We achieved successfully used ultrasound to position the nasogastric tube in a 79-year-old patient with COVID-19. The repeatable ultrasound application does not involve radiation and causes less disturbance in the neck, making it advantageous for rapid positioning of the nasogastric tube and worthy of clinical promotion and application.

Ultrasonographic Confirmation of Nasogastric Tube Placement in the COVID-19 Era

Background: Nasogastric tube (NGT) placement is a daily routine in the Intensive Care Unit (ICU), and misplacement of the NGT can cause serious complications. In COVID-19 ARDS patients, proning has emerged the need for frequent NGT re-evaluations. The gold standard technique, chest X-ray, is not always feasible. In the present study we report our experience with the use of ultrasonographic confirmation of NGT position. Methods: A prospective study in 276 COVID-19 ARDS patients admitted after intubation in the ICU. Ultrasonographic evaluation was performed using longitudinal or sagittal epigastric views. Examinations were performed during the initial NGT placement and every time the patients returned to the supine position after they had been proned or whenever critical care physicians or nurses considered that reconfirmation was necessary. Results: Ultrasonographic confirmation of correct NGT placement was feasible in 246/276 (89.13%) patients upon ICU admission. In 189/246 (76.8%) the tube could be visualized in the stomach (two parallel lines), in 172/246 (69.9%) the ultrasonographic whoosh test (“flash” due to air instillation through the tube, seen with ultrasonography) was evident, while in 164/246 (66.7%) both tests confirmed correct NGT placement. During ICU stay 590 ultrasonographic NGT evaluations were performed, and in 462 (78.14%) cases correct NGT placement were confirmed. In 392 cases, a chest X-ray was also ordered. The sensitivity of ultrasonographic NGT confirmation in these cases was 98.9%, specificity 57.9%, PPV 96.2%, and NPV 3.8%. The time for the full evaluation was 3.8 ± 3.4 min. Conclusion: Ultrasonographic confirmation of correct NGT placement is feasible in the initial placement, but also whenever needed thereafter, especially in the COVID-19 era, when changes in posture have become a daily practice in ARDS patients.

Nasoenteric tube doppler guided insertion. A case report and review of literature

Nasoenteric tube placement is needed in patients with gastric enteral feeding intolerance or high risk of aspiration. Several techniques are described. Ultrasound is used more commonly for gastric tube placement, but also is described in enteral tube feeding placement. Doppler technique with cold water injection is not described in the literature. We describe a new and easy to realize technique. A case of a 65 years old male patient in the intensive care unit (ICU) with gastroparesis is described. Before beginning a prokinetic drug was administered. In this technique gastric tube placement was bedside assessed with ultrasound, and then the tube was progressed with cold water injection. Duodenal position was confirmed with doppler ultrasound. Ultrasound and doppler technique for nasoenteric tube placement could be a feasible technique to use in the ICU. More studies are needed to assess the effectiveness of the technique.

Bedside ultrasonography for the confirmation of nasogastric tube placement: agreement between nurse and physician

ABSTRACT Objective To evaluate the agreement between nurse and physician in verifying the positioning of the nasogastric tube by ultrasonography and describe the difficulties faced by nurse in performing the technique. Method Cross-sectional study conducted in 2021, including critical patients after nasogastric tube insertion who were independently evaluated by a nurse and physician, using bedside ultrasonography. The tube was considered adequately positioned when viewed in infradiaphragmatic location in the topography of the stomach. Results In the 30 peer evaluations there was almost perfect agreement (k = 0.93; 95%CI: 0.65 - 0.99). In only one case the nurse was uncertain about the positioning. Some difficulties were reported: abdominal distention (n=2), gas interposition (n=3) and patient movement during the exam (n=2). Conclusion A trained nurse obtained very similar results to those found by a physician in identifying the nasogastric tube placement by means of ultrasonography, suggesting a reproducible and safe technique.

Ultrassonografia à beira do leito para localização da sonda nasoenteral: concordância entre enfermeiro e médico

RESUMO Objetivo Avaliar a concordância entre enfermeiroe médico na determinação da localizaçãoda sonda enteral por ultrassonografia e descrever as dificuldades encontradas pelo enfermeiro na execução da técnica. Método Estudo transversal, realizado em 2021, incluindo pacientes críticos após a inserção dasondaenteral, avaliados de modo independente por enfermeiro e médico, utilizando ultrassonografia à beira do leito. A sonda foi considerada adequadamente posicionada quando visualizada em posição infradiafragmática na topografia do estômago. Resultados Nos 30 pares de avaliações houve concordância quase perfeita (k = 0,93; IC95%: 0,65 - 0,99). Em apenas um caso houve dúvida do enfermeiro sobre o posicionamento. As dificuldades relatadas foram:distensão abdominal (n=2), interposição de gás (n=3) e movimentação do paciente durante o exame (n=2). Conclusão Um enfermeiro capacitadoobteve resultados semelhantes aos encontrados por um médico na identificação do posicionamento da sondaenteral por meio de ultrassonografia, sugerindo tratar-se de uma técnica reprodutível e segura.

Point-of-Care Ultrasound for Confirmation of Nasogastric and Orogastric Tube Placement in Pediatric Patients

OBJECTIVES

The aim of the study was to investigate the role of point-of-care ultrasound (POCUS) as an alternative imaging modality to confirm proper placement for nasogastric tubes (NGTs) and orogastric tubes (OGTs) in pediatric patients.

METHODS

This was a prospective descriptive study performed at a tertiary care free-standing children's hospital. Patients 21 years and younger requiring radiographic confirmation of NGT or OGT placement were eligible for enrollment. Bedside ultrasonography examination of the epigastric area was performed by a blinded pediatric emergency medicine physician. An abdominal radiograph was obtained to confirm NGT or OGT placement in all patients.

RESULTS

A total of 26 patients with a mean age of 2.6 years (standard deviation, 3.9 years) were enrolled. All 26 patients had x-ray confirmation of NGT and OGTs correctly placed in the stomach. Confirmation of NGT or OGT placement by ultrasound was obtained in 23 patients. For these 23 patients, POCUS agreed with radiographic findings. For 3 patients, the NGT and OGT was unable to be identified by ultrasound. The sensitivity of ultrasound for detecting a properly placed tube was 88% (95% confidence interval, 70.0%-97.6%).

CONCLUSIONS

This pilot study described ultrasound confirmation of NGT or OGT placement. If confirmed in larger studies, POCUS can be used as an objective tool for the confirmation of NGT or OGT placement in pediatric patients and limit the need for routine x-ray confirmation.

Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Ultrasonography-guided post-pyloric feeding tube insertion in medical intensive care unit patients

In this study, we investigated placement rate, complication rate and time spent of successful post-pyloric enteral feeding (PPEF) tube insertion procedure guided by ultrasonography (USG). The patients who required enteral nutrition and who admitted to medical intensive care unit (MICU) of Gazi University Hospital were included to this single-center, prospective, cohort study. It was aimed to insert the enteral feeding tube into the proximal duodenum as the post-pyloric area by ultrasonography guidance. During the PPEF tube insertion procedure, the linear probe was used to display the proximal esophagus and the convex probe was used to display the post-pyloric area, antrum and pyloric channel. 33 patients were included in this study. The median age was 68 [IQR 52-79] years. There were 17 (51.5%) woman and 22 (66.7%) intubated patients. The enteral feeding tube was successfully passed into the post-pyloric area in 29 (87.9%) patients with this technique. The median time of successful feeding tube insertion was 14 [IQR 10-25] min. The median level of the enteral feeding tube was 74 [IQR 70-76] cm. in successful placement. There was no significant difference in insertion time according to gender (female vs male; 10 [IQR 8-20] min. vs 17 [IQR 12-25] min., p = 0.052) and endotracheal intubation status (intubated vs non-intubated; 14 [IQR 10-25] min. vs 12 [IQR 10-25] min., p = 0.985). Only one complication was seen during study (self-limiting epistaxis in one patient). PPEF tube insertion under USG guidance could ensure the initiation of enteral feeding safely and rapidly without exposure to radiation in ICU patients.

Validation of sonographic assistance for placement of a nasogastric tube in pediatric patients

PURPOSE

Enteral access via nasogastric tube (NGT) placement can be essential in the provision of care in pediatric patients. Methods exist to confirm correct placement with success rates between 80% and 85%. Radiographic confirmation remains the "gold-standard," however; it exposes patients to ionizing radiation and fails to provide "real-time" information. In this study, we determined the feasibility of using sonography to assist in the placement of NGT insertions in pediatric patients that have difficulty cooperating.

METHODS

Thirty patients requiring NGT placement were stratified into three age groups. Upon NGT insertion, transverse and longitudinal ultrasound images were acquired to visualize tube progression through the esophagus. Subsequently, a focused ultrasonographic exam of the gastric antrum and body were performed. If amenable, an air bolus (1 mL/kg) was injected in the stomach if the NGT was not directly visualized. Following intubation, standard guidelines for NGT position confirmation were performed.

RESULTS

The NGT was visualized in all esophageal views and 52% of gastric views. Subgroup analysis showed that successful visualization of tube placement in the stomach ranged from 40% (7-18 years) to 70% (3-6 years). Eighty percentage of air boluses injected were visualized.

CONCLUSION

The use of ultrasonography may assist NGT placement in pediatric patients and reduce the incidence of suboptimal placement during insertion. We demonstrated successful NGT visualization through the esophagus regardless of age. NGT visualization in the stomach was challenging; however, injection of an air bolus may improve visualization. Further studies are required to improve the success rate of obtaining gastric views of the NGT.

The use of point-of-care ultrasound to guide clinical management in intra-abdominal hypertension

INTRODUCTION

The Abdominal Compartment Society (WSACS) developed a medical management algorithm with a stepwise approach to keep intra-abdominal pressure (IAP) ≤ 15 mm Hg. The role of point-of-care ultrasound (POCUS) as a bedside modality in the critical care patients is not well studied in relation to the intra-abdominal hypertension (IAH) management algorithm.

AIM

To test the role of point-of-care ultrasound (POCUS) in the medical management of patients with intra-abdominal hypertension (IAH).

METHOD

We conducted a prospective observational study. Those who met the inclusion criteria were assigned to undergo POCUS and small bowel ultrasound as adjuvant tools in their IAH management.

RESULTS

A total of 22 patients met the inclusion criteria and were included in the study. The mean age of the study participants was 65 ± 22.6 years, 61% were men, and the most frequent admission diagnoses were hepatic encephalopathy and massive ascites (five cases). Ultrasound and abdominal X-rays were comparable in confirming correct NGT position, but the ultrasound was superior in determining the gastric content (fluid vs. solid) and diagnoses of gastric paresis in two cases. Small bowel obstruction was present in four patients and confirmed with abdominal CT; two of the patients underwent surgical intervention for mesenteric vessel occlusion and transmesenteric internal hernia. Enema treatment was found to empty the bowel incompletely 72%, 56%, and 42% of the time on days 1, 2, and 3, respectively. Four patients with cirrhosis admitted with upper gastrointestinal bleeding and hepatic encephalopathy (out of a total of 8) were found to have large amounts of ascites, and US-guided paracentesis was performed.

CONCLUSION

POCUS can be used in the nonoperative management of IAH. It is an important tool in the diagnosis and treatment of patients with IAH.

GASTROINTESTINAL TUBE INSERTION TECHNIQUES IN CRITICAL PATIENTS: SCOPING REVIEW

ABSTRACT Objective to map the production of knowledge about the different techniques of gastrointestinal tube insertion in critically ill and/or coma patients. Method scope review carried out in December 2020 in ten data sources, following the assumptions established by the Joanna Briggs Institute (2020) and the PRISMA-ScR protocol. Results 25 studies were selected and analyzed, identifying as the main techniques for insertion of gastrointestinal tube in critically ill and/or coma patients: techniques without the aid of instrumentals, such as head flexion, lateral neck pressure, tube freezing, measurement with corrected formula of the tip of the ear-lobe tip-xiphoid process, Sellick´s maneuver, cricoid cartilage compression, SORT maneuver and gastric insufflation. In addition to techniques with the aid of instruments, such as the use of laryngoscopes and video laryngoscopes. It is noteworthy that, in order to facilitate insertion, the use of ultrasound examination, radiological, endoscopic and fluoroscopy were also identified. Conclusions the evidence analyzed reveals that there is no specific gastrointestinal tube insertion technique for universally accepted critically ill patients.

Tracheopulmonary Complications of a Malpositioned Nasogastric Tube

Tracheopulmonary complications following placement of a nasogastric (NG) feeding tube are uncommon but can cause significant morbidity and mortality. In this case report, an 83-year-old woman of American Society of Anesthesiologists class IV with underlying pulmonary disease required placement of an NG feeding tube after surgical treatment of primary squamous cell carcinoma of the tongue. Malpositioning of the NG feeding tube into the right pleural space was confirmed by computed tomography. Removal of the NG feeding tube resulted in a tension pneumothorax that necessitated chest tube placement. Because of the difficulty of blind NG feeding tube placement in this patient, the subsequently placed NG feeding tube was successfully positioned with the aid of a video laryngoscope. This case report illustrates the risk of NG feeding tube malpositioning in a nasally intubated patient undergoing head and neck surgery and discusses improvements in techniques for proper NG feeding tube placement.

Emergency department approach to gastric tube complications and review of the literature

Nasogastric and orogastric tubes (NGT/OGT) are commonly used in emergency and critical care settings, with indications including medicinal administration, gastric decompression, and enteral feeding. Previous studies have highlighted a variety of complications associated with tube placement. These range from minor occurrences such as nose bleeds and sinusitis, to more severe cases highlighting tracheobronchial perforation, tube knotting, asphyxia, pulmonary aspiration, pneumothorax, and even intracranial insertion. Patients who suffer from these complications face additional obstacles including increased time spent in intensive care settings, healthcare associated costs, and nosocomial infections. Various bedside tests have been developed to reduce the risk of these complications, and current clinical protocol has characterized radiographic imaging as the gold standard. However, air insufflation, CO2 detection (capnography), aspirate pH testing, and point of care ultrasound (POCUS) have all been implemented with varying degrees of utility. Here we present a case involving a 60-year-old male who was brought to the ED and suffered a right sided pneumothorax (PTX) following improper OGT placement. In this case, air insufflation was utilized, but was ineffective in detecting the properly placed tube; leakage of an endotracheal tube cuff served as a lead for misplacement while imaging was conducted. The purpose of this study is not only to highlight the numerous complications that are possible with NGT and OGT placement, but also to propose the use of multiple bedside tests (pH testing, CO2 detection, POCUS) as an alternative to radiographic imaging to increase sensitivity and specificity for detection of improperly placed tubes.

Conservative treatment of iatrogenic perforations caused by gastric tubes in extremely low birth weight infants

BACKGROUND

Iatrogenic gastrointestinal perforations are rare, but life-threatening events in preterm infants.

AIM

Aim of the study was to report on incidence, management, morbidity, and mortality.

STUDY DESIGN

This was a retrospective analysis performed at a tertiary neonatal intensive care unit in Vienna, Austria.

SUBJECTS

Extremely low birth weight infants (ELBW, birth weight < 1000 g) with perforations of the upper gastrointestinal tract (GIT) caused by gastric tubes were included.

OUTCOME MEASURES

All ELBW infants born within the 6-year study period were identified and their discharge summaries or notes were screened for esophageal and gastric perforations. Data on incidence, management of GIT perforations, morbidity, and mortality were obtained.

RESULTS

During a 6-year study period 646 ELBW infants were analyzed. Incidence of perforations was 1.1% (n = 7/646). Median gestational age was 23 + 3 (range: 23 + 0-24 + 5). Perforations occurred on the third day of life (=median, range: day 2-14) and were primarily managed conservatively. Enteral feeding was stopped for 6 days (range: 4-13 days), antibiotic therapy administered for 16 days (range: 8-22 days). In one infant, gastrorrhaphy was performed.

CONCLUSIONS

Conservative treatment of upper GIT perforations led to spontaneous recovery without major complications in 85.7%.

The incidence of intraoperative gastric tube malposition verified by Point-of-Care Ultrasound

BACKGROUND

Over a million gastric tubes are placed yearly for varying medical reasons including gastric decompression. In the operating room (OR), this is performed blindly, and position is confirmed by auscultation, aspiration, or palpation by a surgeon. Despite the known risks of malpositioned gastric tubes, there is limited data in anesthesia literature about the incidence of intraoperative malpositioned gastric tubes. In this study, we use Point-of-Care ultrasonography (POCUS) to confirm gastric tube placement in the OR.

METHODS

Prospective observational study with a total of 149 subjects, all over 18 years of age, undergoing surgery with general endotracheal anesthesia and intraoperative blind placement of a gastric tube by an anesthesia provider. The primary objective of this study is to determine the incidence of malposition of blindly placed gastric tubes.

RESULTS

In our analysis, we found that out of 149 patients 110 patients were successfully visualized; the incidence of malposition was 0.14 [95% CI: 0.08-0.21]. We did not find age, Body Mass Index, or sex to be associated with predisposing patients to intraoperative malposition of gastric tube. However, increasing years of experience of anesthesia provider correlated with higher malposition rates.

CONCLUSIONS

In summary, we demonstrated that the incidence of malposition of blindly gastric tubes was 14%. Given the attendant risks of malpositioned gastric tubes, this data should inform decision algorithms for the blind placement of gastric tubes.

Verifying the Placement of Nasogastric Tubes at an Emergency Center: Comparison of Ultrasound with Chest Radiograph

The objective of this study was to verify the nasogastric tube position with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture and auscultation and to compare the effectiveness of these methods with chest radiography. This is a single-center, prospective, single-blind study. Patients who were admitted to our emergency department and had an indication of nasogastric tube placement were included. Nasogastric tube localization was verified with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture, auscultation, and direct radiography that was accepted as the ‘gold standard technique'. A total of 49 patients (27 Male, 22 Female) with a mean age of 58.3±22.7 years were included. Sensitivity of neck ultrasound was 91.5%, and positive predictive value was 100%. As for the subxiphoid ultrasound sensitivity was 78.72%. When neck ultrasound + subxiphoid ultrasound and giving water-air mixture were combined sensitivity reached 95.74%. Sensitivity of neck ultrasound + subxiphoid ultrasound + air-water mixture + auscultation was 97.87% and positive predictive value was 100%. In the light of our results, neck and subxiphoid ultrasound seem to be an alternative method for verifying nasogastric tube localization. Combination of the air-water mixture and auscultation with ultrasound improves the sensitivity.