Important Facts About Intestinal Feeding Tube Placement

Choosing wisely: Enteral feeding tube selection, placement, and considerations before and beyond the procedure room

When an enteral feeding tube (EFT) is placed, it is not always known how long this nutrition support intervention will be needed. As a result, the type of device the patient originally has placed may not match the function it is required to serve or the lifestyle needs of the patient throughout their enteral nutrition journey. Medicare considers an EFT a prosthetic device, as it is replacing a permanently inoperable or nonfunctioning organ. If we think about an EFT the same way we think about a prosthetic limb, one that needs to be customized to meet all of the patient's functional and lifestyle needs, we can also begin to think beyond the procedure room and carefully consider a variety of factors that impact the patient at home receiving enteral nutrition. Proper fit, function, and style is essential in order for the patient to have a positive relationship with their EFT, contributing to their successful home enteral nutrition experience. Clinicians who care for these patients in any setting and in any capacity would benefit from enhancing their understanding of available EFT options, their design components, and available methods of placement. Many home care and outpatient clinicians adopt the role of patient advocate as it relates to a patient's enteral nutrition journey, and this expanded knowledge could be used to benefit the patient by improving their overall enteral nutrition experience and ultimately their relationship with their "prosthetic."

Nasogastric tube in mechanical ventilated patients: ETCO2 and pH measuring to confirm correct placement. A pilot study

INTRODUCTION

Nasogastric tube (NGT) placement is a procedure commonly performed in mechanically ventilated (MV) patients. Chest X-Ray is the diagnostic gold-standard to confirm its correct placement, with the downsides of requiring MV patients' mobilization and of intrinsic actinic risk. Other potential methods to confirm NGT placement have shown lower accuracy compared to chest X-ray; end-tidal CO2 (ETCO2) and pH analysis have already been singularly investigated as an alternative to the gold standard. Aim of this study was to determine threshold values in ETCO2 and pH measurement at which correct NGT positioning can be confirmed with the highest accuracy.

MATERIALS & METHODS

This was a prospective, multicenter, observational trial; a continuous cohort of eligible patients was allocated with site into two arms. Patients underwent general anesthesia, orotracheal intubation and MV; in the first and second group we respectively assessed the difference between tracheal and esophageal ETCO2 and between esophageal and gastric pH values.

RESULTS

From November 2020 to March 2021, 85 consecutive patients were enrolled: 40 in the ETCO2 group and 45 in the pH group. The ETCO2 ROC analysis for predicting NGT tracheal misplacement demonstrated an optimal ETCO2 cutoff value of 25.5 mmHg, with both sensitivity and specificity reaching 1.0 (AUC 1.0, p < 0.001). The pH ROC analysis for predicting NGT correct gastric placement resulted in an optimal pH cutoff value of 4.25, with mild diagnostic accuracy (AUC 0.79, p < 0.001).

DISCUSSION

In patients receiving MV, ETCO2 and pH measurements respectively identified incorrect and correct NGT placement, allowing the identification of threshold values potentially able to improve correct NGT positioning.

TRIAL REGISTRATION

NCT03934515 (www.clinicaltrials.gov).

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.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Rhubarb to Facilitate Placement of Nasojejunal Feeding Tubes in Patients in the Intensive Care Unit

BACKGROUND

Prokinetic agents are sometimes needed to aid in the placement of nasojejunal feeding tubes in patients at risk of malnutrition. The objective of the present study was to evaluate the feasibility of rhubarb as a new prokinetic agent to replace metoclopramide and erythromycin in the placement of nasojejunal feeding tubes.

MATERIALS AND METHODS

Ninety-four patients who required jejunal feeding tube insertion were included. They were divided into rhubarb (n = 34), metoclopramide (n = 31), and erythromycin groups (n = 29), depending on the use of rhubarb, metoclopramide, and erythromycin as the prokinetic agent. The jejunal feeding tube insertions were performed at the bedside. An abdominal x-ray was taken as the gold standard to determine the position of the tube. Cases in which insertion failed in either group were subjected to a second insertion attempt using rhubarb as the prokinetic agent.

RESULTS

The success rates in the rhubarb, metoclopramide, and erythromycin groups were 91.2%, 87.1%, and 89.7%, respectively. The difference in the success rates was not statistically significant (P = .916). The insertion times in the rhubarb, metoclopramide, and erythromycin groups were 16.0 ± 1.9 minutes, 18.0 ± 1.9 minutes, and 18.8 ± 2.2 minutes, respectively. The insertion time in the rhubarb group was significantly shorter than those in metoclopramide and erythromycin groups (P < .001). No side effects were noted in the rhubarb group.

CONCLUSIONS

Rhubarb could serve as an effective prokinetic agent to promote the insertion of nasojejunal feeding tubes.

Nasogastric tube placement and verification in children: review of the current literature

Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is a common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Society for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all healthcare professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.

Nasogastric tube placement and verification in children: review of the current literature

Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Society for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all health care professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.

Nursing administration of medication via enteral tubes in adults: a systematic review

Background  Enteral tubes are frequently inserted as part of medical treatment in a wide range of patient situations. Patients with an enteral tube are cared for by nurses in a variety of settings, including general and specialised acute care areas, aged care facilities and at home. Regardless of the setting, nurses have the primary responsibility for administering medication through enteral tubes. Medication administration via an enteral tube is a reasonably common nursing intervention that entails a number of skills, including preparing the medication, verifying the tube position, flushing the tube and assessing for potential complications. If medications are not given effectively through an enteral tube, harmful consequences may result leading to increased morbidity, for example, tube occlusion, diarrhoea and aspiration pneumonia. There are resultant costs for the health-care system related to possible increased length of stay and increased use of equipment. Presently what is considered to be best practice to give medications through enteral tubes is unknown. Objectives  The objective of this systematic review was to determine the best available evidence on which nursing interventions are effective in minimising the complications associated with the administration of medications via enteral tubes in adults. Nursing interventions and considerations related to medication administration included form of medication, verifying tube placement before administration, methods used to give medication, methods used to flush tubes, maintenance of tube patency and specific practices to prevent possible complications related to the administration of enteral medications. Search strategy  The following databases were searched for literature reported in English only: CINAHL, MEDLINE, The Cochrane Library, Current Contents/All Editions, EMBASE, Australasian Medical Index and PsychINFO. There was no date restriction applied. In addition, the reference lists of all included studies were scrutinised for other potentially relevant studies. Selection criteria  Systematic reviews of randomised controlled trials (RCTs) and RCTs that compared the effectiveness of nursing interventions and considerations used in the administration of medications via enteral tubes. Other research methods, such as non-randomised controlled trials, longitudinal studies, cohort and case control studies, were also included. Exclusion criteria included studies investigating drug-nutrient interactions or the bioavailability of specific medications. Data collection and analysis  Initial consideration of potential relevance to the review was carried out by the primary author (NP). Two reviewers independently assessed study eligibility for inclusion. A meta-analysis could not be undertaken, as there were no comparable RCTs identified. All data were presented in a narrative summary. Results  There is very limited evidence regarding the effectiveness of nursing interventions in minimising the complications associated with enteral tube medication administration in adults. The review highlights a lack of high quality research on many important nursing issues relating to enteral medication administration. There is huge scope for further research. Some of the evidence that was identified included that nurses should consider the use of liquid form medications as there may be fewer tube occlusions than with solid forms in nasoenteral tubes and silicone percutaneous endoscopic gastronomy tubes. Nurses may need to consider the sorbitol content of some liquid medications, for example, elixirs, as diarrhoea has been attributed to the sorbitol content of the elixir, not the drug itself. In addition, the use of 30 mL of water for irrigation when administering medications or flushing small-diameter nasoenteral tubes may reduce the number of tube occlusions.

Accurate localization of the position of the tip of a naso/orogastric tube in children; where is the location of the gastro-esophageal junction?

BACKGROUND

Abdominal radiographs are used to determine the location of the tip of a newly placed nasogastric tube. The precise location of the gastroesophageal junction has not been well described in the radiology literature.

OBJECTIVE

To improve interpretation of radiographs taken to evaluate the location of the tip of a nasogastric tube. Using UGI barium studies, we determined the anatomical location and variability of the position of the gastroesophageal (GE) junction and the pylorus

MATERIALS AND METHODS

We reviewed 200 upper gastrointestinal barium studies (50 in each of 4 age groups). We measured the vertebral levels and distance of the gastroesophageal junction and the pylorus from the spine, the vertical distance of the gastroesophageal junction from the dome of the diaphragm and the distance from the gastroesophageal junction to the pylorus.

RESULTS

There is a constant location of the GE junction with no significant variation between age groups. There is a moderately constant location of the pylorus. The other measurements were very variable.

CONCLUSION

The location of the GE junction is very constant, irrespective of age. Tube tips below the level of the vertebral disc between the 11th and 12th thoracic vertebra and/or more than 16 mm from the left side of the spine lie in the stomach and not the lower esophagus. Our results should help in accurate radiographic description of the location of the tip of an NG tube.

Endoclips for fixation of nasoenteral feeding tubes: a review

BACKGROUND

Maintaining the position of an endoscopically placed nasoenteral feeding tube beyond the pylorus is often problematic because of retrograde migration. Fixation of a feeding tube to the small intestinal wall with an endoclip may prevent this. This article reviews available literature on the feasibility, efficacy and safety of endoclips for fixation of nasoenteral feeding tubes.

METHODS

A systematic search of the English literature was performed using MEDLINE, EMBASE and Cochrane databases to identify articles assessing the use of endoclips for fixation of feeding tubes, as well as articles assessing duration of attachment of endoclips.

RESULTS

Five cohort series were identified that evaluated the applicability of endoclips for fixation of feeding tubes to the small intestinal wall. In all patients, except one, a nasoenteral feeding tube could be successfully fixated to the small intestinal wall. During follow-up, no spontaneous migrations of feeding tubes were observed. No complications related to placement or removal of endoclips were observed. Three comparative studies evaluated duration of attachment of different types of endoclips to the gastrointestinal wall. Duration of attachment ranged from less than 1 week to more than 18 weeks, depending on the type of endoclip.

CONCLUSIONS

Based on available literature the use of endoclips for fixation of nasoenteral feeding tubes is feasible, effective and safe. Data from randomized controlled trials are needed.

Best evidence: nasogastric tube placement verification

Further research on cost-effective techniques to verify enteral tube placement is warranted using a variety of pediatric populations with differing conditions that may impact gastric pH. It is imperative that clinical facilities review current policies and procedures to ensure that evidence-based findings are guiding nursing practice. Many nurses continue to rely on auscultation to verify NGT placement. Education and competency validation can assist with current practices for NGT placement being consistently incorporated by all personnel in the health care setting. Continuing to search for evidence related to nursing care will guide the direct care RN in providing best practice.

Medication administration via enteral tubes: a survey of nurses' practices

AIM

This article is a report of a study examining the practices of acute care nurses when administering medication via enteral tubes.

BACKGROUND

Administering medication via enteral tubes is predominantly a nursing responsibility across countries. It is important to establish what nurses actually do when giving enteral medication to inform policy and continuing education development.

METHOD

In 2007, a survey was conducted using a random sample of acute care nurses at two large metropolitan hospitals in Melbourne, Australia. There were 181 Registered Nurses who participated in the study; 92 (50.8%) practised in intensive care units, 52 (28.7%) in surgical areas, 30 (16.6%) in medical areas and 7 (3.9%) were from combined medical-surgical areas. The questionnaire was developed by the researchers and a pilot study was conducted in August 2006 to test reliability, face validity and user-friendliness of the tool.

RESULTS

Nurses reported using a range of methods to verify enteral tube position prior to administering enteral medication; some were unreliable methods. A majority reported administering enteric-coated and slow or extended release forms of medication, and giving solid forms of medication when liquid form was available. Nearly all (96%) reported flushing a tube after giving medication, 28% before, and 12% always flushed between each medication.

CONCLUSION

Enteral medication administration practices are inconsistent. Some nurses are using unsafe practices and may therefore compromise patient care.

Development of a clinical practice guideline for testing nasogastric tube placement

PURPOSE

A Perth metropolitan hospital group standardized changes to nasogastric tube placement, including removal of the "whoosh test" and litmus paper, and introduction of pH testing.

DESIGN AND METHODS

Two audits were conducted: bedside data collection at a pediatric hospital and a point-prevalence audit across seven hospitals.

RESULTS

Aspirate was obtained for 97% of all tests and pH was < or = 5.5 for 84%, validating the practice changes. However, patients on continuous feeds and/or receiving acid-inhibiting medications had multiple pH testing fails.

PRACTICE IMPLICATIONS

Nasogastric tube placement continues to present a challenge for those high-risk patients on continuous feeds and/or receiving acid-inhibiting medications.

Use of small-bore feeding tubes: successes and failures

PURPOSE OF REVIEW

Early enteral nutrition is the preferred option for feeding patients who cannot meet their nutrient requirements orally. This article reviews complications associated with small-bore feeding tube insertion and potential methods to promote safe gastric or postpyloric placement. We review the available bedside methods to check the position of the feeding tube and identify inadvertent misplacements.

RECENT FINDINGS

Airway misplacement rates of small feeding tubes are considerable. Bedside methods (auscultation, pH, aspirate appearance, air bubbling, external length of the tube, etc.) to confirm the position of a newly inserted small-bore feeding tube have limited scientific basis. Radiographic confirmation therefore continues to be the most accurate method to ascertain tube position. Fluoroscopic and endoscopic methods are reliable but costly and are not available in many hospitals. Rigid protocols to place feeding tubes along with new emerging technology such as CO2 colorimetric paper and tubes coupled with signaling devices are promising candidates to substitute for the blind placement method.

SUMMARY

The risk of misplacement with blind bedside methods for small-bore feeding tube insertion requires a change in hospital protocols.

Complications related to feeding tube placement

PURPOSE OF REVIEW

Blind placement of a feeding tube can result in serious complications. Given the widespread use of tube feedings, even a small percentage of such problems can affect a significant number of people. The purpose of this review is to describe recent reports of feeding tube placement problems and to examine possible solutions.

RECENT FINDINGS

Multiple case reports of complications of malpositioned feeding tubes continue to surface; most are due to inadvertent placement in the respiratory tract. A tube with feeding ports in the esophagus significantly increases risk for aspiration, as does the displacement of a small bowel tube into the stomach of a patient with significantly slowed gastric motility. Isolated reports of a nasally placed tube entering the brain following head injury continue to occur, as do reports of esophageal and gastric perforation in neonates. A recent study showed that malpositioned tubes are not routinely recorded in risk management databases; it further demonstrated that a comprehensive intervention to reduce complications from small-bore nasogastric feeding tubes was effective.

SUMMARY

Complications related to malpositioned feeding tubes are usually preventable. Poor reporting of feeding tube placement errors hinders the adoption of effective protocols to prevent such errors.

Nursing administration of medication via enteral tubes in adults: a systematic review

BACKGROUND

Enteral tubes are frequently inserted as part of medical treatment in a wide range of patient situations. Patients with an enteral tube are cared for by nurses in a variety of settings, including general and specialised acute care areas, aged care facilities and at home. Regardless of the setting, nurses have the primary responsibility for administering medication through enteral tubes. Medication administration via an enteral tube is a reasonably common nursing intervention that entails a number of skills, including preparing the medication, verifying the tube position, flushing the tube and assessing for potential complications. If medications are not given effectively through an enteral tube, harmful consequences may result leading to increased morbidity, for example, tube occlusion, diarrhoea and aspiration pneumonia. There are resultant costs for the health-care system related to possible increased length of stay and increased use of equipment. Presently what is considered to be best practice to give medications through enteral tubes is unknown.

OBJECTIVES

The objective of this systematic review was to determine the best available evidence on which nursing interventions are effective in minimising the complications associated with the administration of medications via enteral tubes in adults. Nursing interventions and considerations related to medication administration included form of medication, verifying tube placement before administration, methods used to give medication, methods used to flush tubes, maintenance of tube patency and specific practices to prevent possible complications related to the administration of enteral medications.

SEARCH STRATEGY

The following databases were searched for literature reported in English only: CINAHL, MEDLINE, The Cochrane Library, Current Contents/All Editions, EMBASE, Australasian Medical Index and PsychINFO. There was no date restriction applied. In addition, the reference lists of all included studies were scrutinised for other potentially relevant studies.

SELECTION CRITERIA

Systematic reviews of randomised controlled trials (RCTs) and RCTs that compared the effectiveness of nursing interventions and considerations used in the administration of medications via enteral tubes. Other research methods, such as non-randomised controlled trials, longitudinal studies, cohort and case control studies, were also included. Exclusion criteria included studies investigating drug-nutrient interactions or the bioavailability of specific medications.

DATA COLLECTION AND ANALYSIS

Initial consideration of potential relevance to the review was carried out by the primary author (NP). Two reviewers independently assessed study eligibility for inclusion. A meta-analysis could not be undertaken, as there were no comparable RCTs identified. All data were presented in a narrative summary.

RESULTS

There is very limited evidence regarding the effectiveness of nursing interventions in minimising the complications associated with enteral tube medication administration in adults. The review highlights a lack of high quality research on many important nursing issues relating to enteral medication administration. There is huge scope for further research. Some of the evidence that was identified included that nurses should consider the use of liquid form medications as there may be fewer tube occlusions than with solid forms in nasoenteral tubes and silicone percutaneous endoscopic gastronomy tubes. Nurses may need to consider the sorbitol content of some liquid medications, for example, elixirs, as diarrhoea has been attributed to the sorbitol content of the elixir, not the drug itself. In addition, the use of 30 mL of water for irrigation when administering medications or flushing small-diameter nasoenteral tubes may reduce the number of tube occlusions.