Increasing the safety of blind gastric tube placement in pediatric patients: the design and testing of a procedure using a carbon dioxide detection device

A Randomized Clinical Trial to Compare Three Different Methods for Estimating Orogastric Tube Insertion Length in Newborns: A Single-Center Experience in China

Background: Orogastric (OG) and nasogastric (NG) tubes are frequently used in the NICU. Obtaining a relatively accurate estimated length before insertion could significantly reduce complications. While previous studies have mainly focused on the NG tube, OG tubes are more commonly used in China. Purpose: The objective was to determine whether there were differences in the rate of accurate placement among the adapted nose-ear-xiphoid (NEX) method, nose-ear-midway to the umbilicus (NEMU) method, and weight-based (WB) equation in estimating the OG tube insertion distance. Methods: A randomized, controlled, open-label clinical trial to compare the three methods was conducted in a single center. After enrollment, newborns were randomly assigned into three groups. By radiological assessment, the anatomical region for OG tube placement was analyzed. The primary metric was the tip within the gastric body, and the second metric was strictly accurate placement defined as the tube was not looped back within the stomach and the end was located more than 2 cm but less than 5 cm into the stomach, referred to as T10. Results: This study recruited 156 newborns with the majority being preterm infants (n = 96; 61.5 percent), with an average birth weight of 2,200.8 ± 757.8 g. For the WB equation, 96.2 percent (50 cases) of the OG tubes were placed within the stomach, and the rates were 78.8 percent (41 cases) in the adapted NEX and NEMU methods. The strictly accurate placement rates were highest for the WB equation at 80.8 percent (42/52), followed by the adapted NEX method at 65.4 percent (34/52), and the NEMU method at 57.7 percent (30/52). Conclusion: The WB equation for estimating the insertion depth of the OG tube in newborn infants resulted in more precise placement compared to the adapted NEX and NEMU methods.

Diagnostic accuracy of end-tidal carbon dioxide detection in determining correct placement of nasogastric tube: An updated systematic review with meta-analysis

BACKGROUND

Misplacement of the nasogastric tube in the respiratory tract could cause serious complications and even death. Thus, nasogastric tube verification is necessary for optimal patient safety and comfort. Although end-tidal carbon dioxide detection is considered an effective approach to determine nasogastric tube location, there is a paucity of up-to-date evidence.

OBJECTIVES

To review the diagnostic accuracy of end-tidal carbon dioxide detection in determining inadvertent airway intubation and verifying correct placement of nasogastric tubes.

DESIGN

A systematic review and meta-analysis.

METHODS

We searched clinical trials that evaluated the diagnostic accuracy of colorimetric capnometry or capnography in detecting nasogastric tubes located in the airway and differentiating between inadvertent airway intubation and correct nasogastric tube placement in any adult care setting. Four English language databases - Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL - and four Chinese language databases - China Biomedical Literature Database, WanFang Data, China National Knowledge Infrastructure, and Airiti Library - were searched from July 2009 to March 2021. Clinical trial registration databases and reference lists of included studies and relevant reviews were also searched. Two reviewers extracted the data of all included studies using a data extraction form. Two reviewers assessed the methodological quality independently with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We conducted meta-analysis using the hierarchical bivariate model and estimated the pool sensitivity and specificity of capnography and colorimetric capnometry. Forest plots were generated to display the results. Heterogeneity was investigated by meta-regression. The certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluations framework.

RESULTS

Of 1,155 records identified, seven new studies were added to this update and a total of 16 studies were analysed in the systematic review. The total absolute number of true positive, false negative, true negative, and false positive observations were 142, 6, 1,500, and 65 respectively. Low to very low certainty of evidence indicated that the use of colorimetric capnometry or capnography is potentially an effective method in differentiating between respiratory and nasogastric tube placement for critically ill adult patients. Pooled results (13 studies, 1,541 intubations) for sensitivity and specificity were 0.96 (95% confidence interval [0.88, 0.99]) and 0.99 (95% confidence interval [0.96, 1.00]), respectively.

CONCLUSIONS

Colorimetric capnometry and capnography may have the potential to be of high sensitivity and specificity for the detection of inadvertent airway nasogastric tube placements in critically ill adults. More evidence is required to generalize the updated findings to different types of patients and settings.

Verifying the placement and length of feeding tubes in canine and feline neonates

Background

Tube feeding is a common procedure in neonatology. In humans, tube misplacement reportedly occurs in up to 59% of all cases and may lead to perforation in 1.1% of preterm intubated neonates. While numerous studies on optimal tube placement have been performed in human neonates, current recommendations on tube feeding in canine and feline neonatology are based, at best, on studies performed in adult animals. Herein, we aimed to test ultrasonography as a tool to verify tube placement in puppies and kittens and to compare different anatomical predictive markers used in human, canine and feline neonates.

Results

The predictive tube length when held bent between the last rib and the mouth may induce trauma compared to when held straight. A strong positive linear correlation was observed between birthweight and gastric cardia localization. Ultrasonography findings were similar to coeliotomy findings. Stomach volume was less than 2 mL per 100 g in the less-than-one-day-old studied puppies (n = 25) and kittens (n = 28).

Conclusions

A weight-based equation was calculated to help predict appropriate tube placement. Ultrasonography can be used to control gastric tube placement, and neonates less than one-day-old have a smaller stomach capacity. Further studies are required to evaluate whether more-than-one-day-old puppies follow the same linear correlation with their weight. Further in vivo studies are warranted to determine the gold standard procedure for tube feeding in neonatal puppies and kittens.

Electromagnetic Versus Blind Guidance of a Postpyloric Feeding Tube in Critically Ill Children

BACKGROUND AND OBJECTIVES

Postpyloric feeding tube placement is a time-consuming procedure associated with multiple attempts and radiation exposure. Our objective with this study is to compare the time, attempts, and radiation exposure using the electromagnetic versus blind method to place a postpyloric feeding tube in critically ill children. Our hypothesis is that using electromagnetic guidance decreases the procedure time, number of x-rays, and number of attempts, compared to the blind method.

METHODS

Eleven pediatric nurses participated in a randomized controlled intention-to-treat study at an academic pediatric medical, surgical, and congenital cardiac ICU. University of Texas Health Epidemiology and Biostatistics generated a randomization sequence with sealed envelopes. A standard (2-sided) F-test of association between the electromagnetic and blind method yielded 40 subjects with 86% power. Data were analyzed with Fisher's exact test for categorical variables and the Wilcoxon rank test for continuous variables, with data documented as median (interquartile range [IQR]).

RESULTS

We randomly assigned 52 patients to either the electromagnetic (n = 28) or blind method (n = 24). The number of attempts and radiographs was at a median of 2 (IQR: 1-2.25) using the blind method, compared to the electromagnetic method at a median of 1 (IQR: 1.0-1.0; P = .001). Successful guidance was 96.4% with the electromagnetic method, compared to only 66.7% with the blind technique (P = .008). The total time required was 2.5 minutes (IQR: 2.0-7.25) with the electromagnetic method, compared to 19 minutes (IQR: 9.25-27.0) for the blind method (P = .001).

CONCLUSIONS

Electromagnetic guidance is a superior, faster, and overall safer method to place a postpyloric feeding tube in critically ill children.

Methods of Gastric Tube Placement Verification in Neonates, Infants, and Children: A Systematic Review and Meta-Analysis

INTRODUCTION

The objective was to evaluate diagnostic performance of multiple methods used to assess gastric tube placement verification in neonates, infants, and children.

METHODS

A systematic review using the methods outlined in the Cochrane Handbook for Reviews of Diagnostic Test Accuracy was conducted. Eight databases were searched. Studies on neonates, infants, and children in which researchers compared different methods for gastric tube placement verification with x-ray reference standard were eligible in the review.

RESULTS

Eight studies involving 911 participants that evaluated 9 index tests for gastric tube placement verification were included. Most studies were of moderate methodological quality, and most index tests were assessed in small individual studies. pH testing with cutoff values ≤ 6 for gastric tube position confirmation was the only index test subjected to meta-analysis, with the summary sensitivity and specificity being 0.77 (95% confidence interval [CI] 0.56-0.90) and 0.42 (95% CI 0.16-0.73). Other tests for gastric tube placement verification showed great variations in sensitivities and specificities.

DISCUSSION

pH ≤ 6 is not sufficiently accurate to be recommended for gastric tube placement verification in neonates, infants, and children. Diagnostic performance of pH ≤ 4 or 5 and other methods cannot be determined because of the paucity of data and methodological variations in studies. Clinical practice related to the diagnostic tests used will continue to be dictated by local preferences and cost factors, until stronger evidence becomes available.

Nasogastric/Nasoenteric tube-related incidents in hospitalised patients: a study protocol of a multicentre prospective cohort study

INTRODUCTION

Hospitalised patients with nasogastric/nasoenteric tube (NGT/NET) are at constant risk of incidents; therefore, healthcare professionals need to routinely monitor risks and adopt strategies for patient safety and quality of care.

AIM

This study aimed to evaluate the NGT/NET-related incidents in hospitalised patients and associated factors.

METHODS

This is a multicentre study, with a prospective cohort design. Data will be collected at the general medical ward of seven Brazilian hospitals in the north, northeast, southeast and south. The sample will consist of 391 patients that require an NGT/NET during hospitalisation. Three different methods will be used to identify the incidents: (1) healthcare professionals and patients/caregivers will be required to report any NGT/NET-related incidents; (2) researchers will visit the wards to get information about the incidents with healthcare professionals and patients/caregivers; (3) the researchers will review the medical records looking for information on the occurrence of any NGT/NET-related incidents. Demographic, clinical and therapeutic details will be obtained from the medical records and will be registered in an electronic data collection tool developed for the purposes of this study. The complexity of patients will be assessed by the Patient Classification System, and the severity of comorbid diseases will be assessed through the Charlson Comorbidity Index.

IMPLICATION FOR PRACTICE

The results may encourage the use of evidence effectively to influence the scientific foundation for clinical practice and the development of evidence-based policies that will prevent, manage and eliminate complications caused by NGT/NET-related incidents, and improve the quality and safety of care provided to hospitalised patients.

ETHICS AND DISSEMINATION

The study has been approved by the Research Ethics Committee. Detailed information about the study can be provided by the principal investigator. The findings will be reported through academic journals, seminar and conference presentations, social media, print media, the internet and community/stakeholder engagement activities.

The Use of Ultrasonography for Verifying Gastric Tube Placement in Newborns

BACKGROUND

The use of gastric tubes in newborns admitted to a neonatal intensive care unit is fairly high, and there is a risk of serious complications related to this procedure.

PURPOSE

Considering the need to find a method that does not involve the patient's exposure to radiation, this study aimed to evaluate the diagnostic accuracy of ultrasonography for verifying gastric tube placement in newborns.

METHODS

This was a prospective, double-blind, observational study performed in a neonatal intensive care unit, in which 159 infants had gastric intubation using ultrasound examination and radiological imaging, to verify positioning. Results were analyzed in terms of diagnostic accuracy.

RESULTS

The tubes were correctly positioned in 157 cases (98.7%), according to radiological images, and in 156 cases (98.1%), according to ultrasound. The sensitivity analysis was 0.98 and the positive predictive value was 0.99. It was not possible to perform a specificity analysis, as there were not enough negative cases in the sample.

IMPLICATIONS FOR PRACTICE

The use of ultrasonography to identify correct positioning of gastric tubes in infants and newborns shows good sensitivity.

IMPLICATIONS FOR RESEARCH

It was not possible to evaluate the ultrasonography specificity; further studies with greater samples are probably necessary, so that this objective can be achieved.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=29&autoPlay=true.

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.

Bilateral Pneumothoraces in a Trauma Patient After Dobhoff Tube Insertion

Patient: Male, 74

Final Diagnosis: Pneumothorax

Symptoms: Hypoxemia • shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Surgery

Procedures for measuring and verifying gastric tube placement in newborns: an integrative review

Objective:

to investigate evidence in the literature on procedures for measuring gastric tube insertion in newborns and verifying its placement, using alternative procedures to radiological examination.

Method:

an integrative review of the literature carried out in the Cochrane, LILACS, CINAHL, EMBASE, MEDLINE and Scopus databases using the descriptors “Intubation, gastrointestinal” and “newborns” in original articles.

Results:

seventeen publications were included and categorized as “measuring method” or “technique for verifying placement”. Regarding measuring methods, the measurements of two morphological distances and the application of two formulas, one based on weight and another based on height, were found. Regarding the techniques for assessing placement, the following were found: electromagnetic tracing, diaphragm electrical activity, CO₂ detection, indigo carmine solution, epigastrium auscultation, gastric secretion aspiration, color inspection, and evaluation of pH, enzymes and bilirubin.

Conclusion:

the measuring method using nose to earlobe to a point midway between the xiphoid process and the umbilicus measurement presents the best evidence. Equations based on weight and height need to be experimentally tested. The return of secretion into the tube aspiration, color assessment and secretion pH are reliable indicators to identify gastric tube placement, and are the currently indicated techniques.

Patient safety in the care of hospitalised children: evidence for paediatric nursing

Objectives

To describe evidence of international literature on the safe care of the hospitalised child after the World Alliance for Patient Safety and list contributions of the general theoretical framework of patient safety for paediatric nursing.

Method

An integrative literature review between 2004 and 2015 using the databases PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science and Wiley Online Library, and the descriptors Safety or Patient safety, Hospitalised child, Paediatric nursing, and Nursing care.

Results

Thirty-two articles were analysed, most of which were from North American, with a descriptive approach. The quality of the recorded information in the medical records, the use of checklists, and the training of health workers contribute to safe care in paediatric nursing and improve the medication process and partnerships with parents.

Conclusion

General information available on patient safety should be incorporated in paediatric nursing care.

Investigation of the efficacy of colorimetric capnometry method used to verify the correct placement of the nasogastric tube

OBJECTIVES

This present study was designed to determine the efficacy of the colorimetric capnometry method used to verify the correct placement of the nasogastric tube.

METHODS

The present study comprised forty patients who had a nasogastric tube inserted and were being monitored in the adult intensive care unit. After the insertion of the nasogastric tube, 40 colorimetric capnometry and 40 auscultation measurements were performed. Auscultation and colorimetric capnometry results were compared with tube placement results confirmed radiologically.

RESULTS

In the confirmation of the placement of the nasogastric tube, the consistency was 97.5% (p<0.05) between the colorimetric capnometry method and the radiological method, and 82.5% (p>0.05) between the auscultatory method and the radiological method. The oesophageal placement of the nasogastric tube was detected with the colorimetric capnometry method, but the gastric and duodenal insertions were not determined. While the sensitivity and specificity of the colorimetric capnometry method in determining the correct placement of the nasogastric tube were 1.00 and 0.667 respectively, those of the auscultatory method were 0.89 and 0.0 respectively.

CONCLUSION

As a result, for the confirmation of the NGT placement, the colorimetric capnometry method is considered more reliable than the auscultatory method and is compatible with the radiological method. However, the colorimetric capnometry method is inadequate to distinguish between the gastric or duodenal insertion.

Naso-enteric Tube Placement: A Review of Methods to Confirm Tip Location, Global Applicability and Requirements

BACKGROUND

The insertion of a tube through the nose and into the stomach or beyond is a common clinical procedure for feeding and decompression. The safety, accuracy and reliability of tube insertion and methods used to confirm the location of the naso-enteric tube (NET) tip have not been systematically reviewed. The aim of this study is to review and compare these methods and determine their global applicability by end-user engagement.

METHODS

A systematic literature review of four major databases was performed to identify all relevant studies. The methods for NET tip localization were then compared for their accuracy with reference to a gold standard method (radiography or endoscopy). The global applicability of the different methods was analysed using a house of quality matrix.

RESULTS

After applying the inclusion and exclusion criteria, 76 articles were selected. Limitations were found to be associated with the 20 different methods described for NET tip localization. The method with the best combined sensitivity and specificity (where n > 1) was ultrasound/sonography, followed by external magnetic guidance, electromagnetic methods and then capnography/capnometry. The top three performance criteria that were considered most important for global applicability were cost per tube/disposable, success rate and cost for non-disposable components.

CONCLUSION

There is no ideal method for confirming NET tip localisation. While radiography (the gold standard used for comparison) and ultrasound were the most accurate methods, they are costly and not universally available. There remains the need to develop a low-cost, easy-use, accurate and reliable method for NET tip localization.

Examining the evidence to guide practice: challenging practice habits

Nurses are the largest segment of the nation's health care workforce, which makes nurses vital to the translation of evidence-based practice as a practice norm. Critical care nurses are in a position to critically appraise and apply best evidence in daily practice to improve patients' outcomes. It is important for critical care nurses to continually evaluate their current practice to ensure that they are applying the current best evidence rather than practicing on the basis of tradition. This article is based on a presentation at the 2013 National Teaching Institute of the American Association of Critical-Care Nurses. Four practice interventions that are within the realm of nursing are critiqued on the basis of current best evidence: (1) turning critically ill patients, (2) sleep promotion in the intensive care unit, (3) feeding tube management in infants and children, and (4) prevention of venothromboembolism…again. The related beliefs, current evidence, and implications for practice associated with each topic are described.

Following the evidence: enteral tube placement and verification in neonates and young children

Enteral tube placement in hospitalized neonates and young children is a common occurrence. Accurate placement and verification are imperative for patient safety. However, despite many years of research that provides evidence for a select few methods and clearly discredits the safety of others, significant variation in clinical practice is still common. Universal adoption and implementation of evidence-based practices for enteral tube placement and verification are necessary to ensure consistency and safety of all patients. This integrative review synthesizes current and seminal literature regarding the most accurate enteral tube placement and verification methods and proposes clinical practice recommendations.

A review of published case reports of inadvertent pulmonary placement of nasogastric tubes in children

PROBLEM

Little is known about the incidence of inadvertent pulmonary placement of nasogastric tubes during blind insertions in children.

PURPOSE

The purpose of this paper was to conduct a review of published case reports over the past two decades.

METHODS

An OVID Medline search was conducted of articles published from 1993 through 2012.

RESULTS

Fifteen published case reports were located; four patients died as a result of their malpositioned tubes. The auscultatory bedside method failed to detect the malpositioned tubes in all seven cases in which it was used.

CONCLUSIONS

The incidence of inadvertent pulmonary placement of nasogastric tubes is relatively low but can lead to serious and even lethal results in children. The auscultatory method to predict tube location is unreliable.