Bedside sonographic-guided versus blind nasoenteric feeding tube placement in critically ill patients

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.

Predictive value of transabdominal intestinal sonography in critically ill patients: a prospective observational study

BACKGROUND

This study examined the feasibility of transabdominal intestinal ultrasonography in evaluating acute gastrointestinal injury (AGI).

METHODS

A total of 116 patients were included. Intestinal ultrasonography was conducted daily within 1 week after admission to the intensive care unit. Ultrasonography indicators including intestinal diameter, changes in the intestinal folds, thickness of the intestinal wall, stratification of the intestinal wall, and intestinal peristalsis (movement of the intestinal contents) were observed to determine the acute gastrointestinal injury ultrasonography (AGIUS) score. The gastrointestinal and urinary tract sonography ultrasound (GUTS) protocol score was also calculated. During the first week of the study, the gastrointestinal failure (GIF) score was determined daily. The correlations between transabdominal intestinal scores (AGIUS and GUTS) and the GIF score were analyzed to clarify the feasibility of evaluating AGI through observation of the intestine. The utility of intestinal ultrasonography indicators in predicting feeding intolerance was investigated to improve the ability of clinicians to manage AGI.

RESULTS

A total of 751 ultrasonic examinations were performed with 511 images (68%) considered to be of "good quality." AGIUS and GUTS scores differed significantly between AGI patients (GIF score 0-2) and non-AGI patients (GIF score 3-4) (p < 0.001). Both scores correlated positively with GIF score (r = 0.54, p < 0.001; r = 0.66, p < 0.001). These ultrasonography indicators could predict feeding intolerance, with an area under the receiver operating characteristic curve of 0.60 (0.48-0.71; intestinal diameter), 0.76 (0.67-0.85; intestinal folds), 0.71 (0.62-0.80; wall thickness), 0.77 (0.69-0.86; wall stratification), and 0.78 (0.68-0.88; intestinal peristalsis). Compared to patients with a normal rate of peristalsis (5-10/min), patients with abnormal peristalsis rates (< 5/min or > 10/min) have increased risk for feeding intolerance (16/83 vs. 25/33, p < 0.001).

CONCLUSIONS

The transabdominal intestinal ultrasonography represents an effective means for assessing gastrointestinal injury in critically ill patients. Intestinal ultrasonography indicators, especially the degree of intestinal peristalsis, may be used to predict feeding intolerance.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT03589248. Registered 04 July 2018-retrospectively registered.

Electromagnetically guided bedside placement of post-pyloric feeding tubes in critical care

Post-pyloric feeding is recommended in critically ill patients with gastro-intestinal intolerance. However, traditional placement methods are logistically difficult and carry potential risks. The authors retrospectively compared the position of post-pyloric feeding tubes (PPFTs) using an electromagnetic device that demonstrated by X-ray and analysed the complication rates, proportion of lung placements avoided and the time taken to establish enteral feeding. Forty placements in 37 mechanically ventilated patients were analysed; there was a success rate of 87.5%. Sensitivity and specificity were 77% (95% CI 59.9-89.6%) and 100% (95% CI 48.0-100%). Five lung placements were identified in real time and therefore avoided. The mean (SD) time from PPFT placement to X-ray was 134 minutes (± 139 minutes) and, to feeding, 276 minutes (± 213 minutes). In conclusion, placement of PPFT using an electromagnetic device carries a high success rate, is safe and feasible to undertake at the bedside in mechanically ventilated patients.

Placement of a Jejunal Feeding Tube via an Ultrasound-Guided Antral Progressive Water Injection Method

Background

Jejunal feeding tube allows the nutrition of critical care patients more easy and safe. However, its placement remains a challenge. This study aimed to introduce a jejunal feeding tube through an ultrasound-guided antral progressive water injection method and subsequently to examine its efficacy.

Methods

Between April 2016 and April 2017, 54 patients hospitalized in the Department of Critical Care Medicine, Peking Union Medical College Hospital, China who needed nutritional support through a jejunal feeding tube were recruited for this study. Patients who applied ultrasound-guided antral progressive water injection method were classified into the experimental group. Patients who applied conventional method were registered as control group.

Results

No significant differences were found in age, body mass index, and Acute Physiology and Chronic Health Evaluation score, but a significant difference in operation time was found between the experimental group and the control group. Of the 24 individuals in the control group, 17 displayed clear catheter sound shadows once the tube entered the esophagus. In comparison, of the 30 individuals in the experimental group, all harbored catheter sound shadows through the esophageal gas injection method. Subsequent observation revealed that in the control group (via ultrasonographic observation), 15 individuals underwent successful antral tube entry, for a success rate of 63%. In the experimental group (via antral progressive water injection), 27 individuals underwent successful antral tube entry, for a success rate of 90%. There was a significant difference between the success rates of the two groups (χ² = 5.834, P = 0.022).

Conclusion

The antral progressive water injection method for the placement of a jejunal feeding tube is more effective than the traditional ultrasonic placement method.

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.

Blind bedside postpyloric placement of spiral tube as rescue therapy in critically ill patients: a prospective, tricentric, observational study

Background

Various special techniques for blind bedside transpyloric tube placement have been introduced into clinical practice. However, transpyloric spiral tube placement facilitated by a blind bedside method has not yet been reported. The objective of this prospective study was to evaluate the safety and efficiency of blind bedside postpyloric placement of a spiral tube as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients.

Methods

This prospective, tricentric, observational study was conducted in the intensive care units (ICUs) of three tertiary hospitals. A total of 127 consecutive patients with failed spontaneous transpyloric spiral tube migration despite using prokinetic agents and still required enteral nutrition for more than 3 days were included. The spiral tube was inserted postpylorically using the blind bedside technique. All patients received metoclopramide intravenously prior to tube insertion. The exact tube tip position was determined by radiography. The primary efficacy endpoint was the success rate of postpyloric spiral tube placement. Secondary efficacy endpoints were success rate of a spiral tube placed in the third portion of the duodenum (D3) or beyond, success rate of placement in the proximal jejunum, time to insertion, length of insertion, and number of attempts. Safety endpoints were metoclopramide-related and major adverse tube-associated events.

Results

In 81.9% of patients, the spiral feeding tubes were placed postpylorically; of these, 55.1% were placed in D3 or beyond and 33.9% were placed in the proximal jejunum, with a median time to insertion of 14 min and an average number of attempts of 1.4. The mean length of insertion was 95.6 cm. The adverse event incidence was 26.0%, and no serious adverse event was observed.

Conclusions

Blind bedside postpyloric placement of a spiral tube, as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients, is safe and effective. This technique may facilitate the early initiation of postpyloric feeding in the ICU.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-OPN-16008206. Registered on 1 April 2016.

Ultrasonography for confirmation of gastric tube placement

BACKGROUND

Gastric tubes are commonly used for the administration of drugs and tube feeding for people who are unable to swallow. Feeding via a tube misplaced in the trachea can result in severe pneumonia. Therefore, the confirmation of tube placement in the stomach after tube insertion is important. Recent studies have reported that ultrasonography provides good diagnostic accuracy estimates in the confirmation of appropriate tube placement. Hence, ultrasound could provide a promising alternative to X-rays in the confirmation of tube placement, especially in settings where X-ray facilities are unavailable or difficult to access.

OBJECTIVES

To assess the diagnostic accuracy of ultrasound for gastric tube placement confirmation.

SEARCH METHODS

We searched the Cochrane Library (2016, Issue 3), MEDLINE (to March 2016), Embase (to March 2016), National Institute for Health Research (NIHR) PROSPERO Register (to May 2016), Aggressive Research Intelligence Facility Databases (to May 2016), ClinicalTrials.gov (to May 2016), ISRCTN registry (May 2016), World Health Organization International Clinical Trials Registry Platform (to May 2016) and reference lists of articles, and contacted study authors.

SELECTION CRITERIA

We included studies that evaluated the diagnostic accuracy of naso- and orogastric tube placement confirmed by ultrasound visualization using X-ray visualization as the reference standard. We included cross-sectional studies, and case-control studies. We excluded case series or case reports. Studies were excluded if X-ray visualization was not the reference standard or if the tube being placed was a gastrostomy or enteric tube.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from each of the included studies. We contacted authors of the included studies to obtain missing data.

MAIN RESULTS

We identified 10 studies (545 participants and 560 tube insertions) which met our inclusion criteria.No study was assigned low risk of bias or low concern in every QUADAS-2 domain. We judged only three (30%) studies to have low risk of bias in the participant selection domain because they performed ultrasound after they confirmed correct position by other methods.Few data (43 participants) were available for misplacement detection (specificity) due to the low incidence of misplacement. We did not perform a meta-analysis because of considerable heterogeneity of the index test such as the difference of echo window, the combination of ultrasound with other confirmation methods (e.g. saline flush visualization by ultrasound) and ultrasound during the insertion of the tube. For all settings, sensitivity estimates for individual studies ranged from 0.50 to 1.00 and specificity estimates from 0.17 to 1.00. For settings where X-ray was not readily available and participants underwent gastric tube insertion for drainage (four studies, 305 participants), sensitivity estimates of ultrasound in combination with other confirmatory tests ranged from 0.86 to 0.98 and specificity estimates of 1.00 with wide confidence intervals.For the studies using ultrasound alone (four studies, 314 participants), sensitivity estimates ranged from 0.91 to 0.98 and specificity estimates from 0.67 to 1.00.

AUTHORS' CONCLUSIONS

Of 10 studies that assessed the diagnostic accuracy of gastric tube placement, few studies had a low risk of bias. Based on limited evidence, ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement. However, in settings where X-ray is not readily available, ultrasound may be useful to detect misplaced gastric tubes. Larger studies are needed to determine the possibility of adverse events when ultrasound is used to confirm tube placement.

Role of Ultrasonography in Detecting the Localisation of the Nasoenteric Tube

OBJECTIVE

In this study, we aimed to determine the success rate of nasoenteric tube (NET) insertion into the postpyloric area using ultrasonography (USG) and compare with the commonly used method direct abdominal graphy.

METHODS

A single anaesthesiologist placed all the NETs. The NET was visualised by two radiologists simultaneously using USG. The localisation of the tube was confirmed using an abdominal graph in all patients.

RESULTS

The blind bedside method was used for NET insertion into 34 patients. Eleven of the tubes were detected passing through the postpyloric area using USG. In one case, the NET could not be visualised in the postpyloric area using USG; however, it was detected in the postpyloric area through control abdominal radiography. In 22 patients, NETs were detected in the stomach using control abdominal radiography. The rate of imaging post pyloric using USG was 91.6%. When all cases were considered, catheter localisation was detected accurately using USG by 97% (33 in 34 patients).

CONCLUSION

USG is a reliable and practical alternative to radiography, which can be used to detect localisation of the nasogastric tube and NET.

Benefits of Postpyloric Enteral Access Placement by a Nutrition Support Dietitian

BACKGROUND

Although enteral nutrition is considered the preferred strategy for nutrition support, it is often precluded by nasogastric feeding intolerance or the inability to place feeding access into the postpyloric position. In an effort to improve enteral nutrition (EN) outcomes at our institution, the nutrition support dietitian (NSD) began placing postpyloric feeding tubes (PPFT) in intensive care unit patients.

METHODS

Intensive care unit patients who received blind, bedside PPFT placements by the NSD (n = 18) were compared with a concurrent age- and diagnosis-matched control group that received standard nutritional care without NSD intervention (n = 18). Interruption of EN infusion, appropriateness of parenteral nutrition (PN) prescription (based on American Society of Parenteral and Enteral Nutrition guidelines), and incidence of ventilator-associated pneumonia (VAP), as defined by the American College of Chest Physicians practice guidelines, were determined in each group.

RESULTS

The NSD was successful in positioning the PPFT at or distal to the third portion of the duodenum in 83% of attempts. The PPFT group demonstrated no interruption of enteral feeding compared with 56% in the control group (p < .01) and required 1 (6%) PN initiation in contrast to 8 (44%) in the control group (p < .01). There was a trend toward reduced VAP in the PPFT group (6% vs 28%, p = .07). Of the PN initiations in the control group, 88% were deemed to be potentially avoidable; 6 of 8 PNs were initiated because of gastric residuals.

CONCLUSIONS

Enteral nutrition facilitated by NSD placement of postpyloric feeding access is associated with improved tube feeding tolerance and reduced PN use. Further studies are needed to evaluate a possible effect of postpyloric feeding on the incidence of VAP.

The History of Nonsurgical Enteral Tube Feeding Access

Specialized nutrition support, particularly enteral feeding, has been used for centuries. Technologic advancements have affected the provision of enteral feeding. Feeding solutions and devices, as well as the techniques to place the feeding devices, have evolved. This article reviews the history of bedside placement methods for short-term enteral access devices.

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

PURPOSE

Nasogastric feeding tube is routinely positioned in intensive care units. The complications of misplacement are rare but very dangerous for the patients. The aim of this study is to estimate the diagnostic accuracy of this new technique, 4-point ultrasonography to confirm nasogastric tube placement in intensive care.

METHODS

One hundred fourteen critical ill patients monitored in ICU were included. The intensivist provided in real time to perform the exam in four steps: sonography from either the right or left side of the patient's neck to visualize the esophagus, sonography of epigastrium to confirm the passage through the esophagogastric junction and the positioning in antrum, sonography of the fundus. Finally, gastric placement of the nasogastric feeding tube was confirmed with thorax radiograph.

RESULTS

One hundred fourteen of the gastric tubes were visualized by sonography in the digestive tract and all were confirmed by radiography (sensitivity 100%). The entire sonographic procedure, including the longitudinal and transversal scan of the esophagus, the esophagogastric junction, the antrum and the fundus, took 10 min.

CONCLUSIONS

Our pilot study demonstrated that not weighted-tip gastric tube routinely used in Intensive Care is visible with the sonography. The pilot study confirmed the high sensitivity of the sonography in the verify correct positioning of gastric tube in the adult ICU patients. The ultrasound examination seems to be easy and rapid even when performed by a intensivist whit a sonographic training of only 40 h. The sonographic exam at the bedside was performed in a shorter time than the acquisition and reporting of the X-ray.

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.

Experience in Bedside Placement, Clinical Validity, and Cost-Efficacy of a Self-Propelled Nasojejunal Feeding Tube

BACKGROUND

The procedures needed to insert nasojejunal tubes (NJTs) are often invasive or uncomfortable for the patient and require hospital resources. The objectives of this study were to describe our experience in inserting a self-propelling NJT with distal pigtail end and evaluate clinical validity and cost efficacy of this enteral nutrition (EN) approach compared with parenteral nutrition (PN).

MATERIALS AND METHODS

Prospective study from July 2009 to December 2010, including hospitalized noncritical patients who required short-term jejunal EN. The tubes were inserted at bedside, using intravenous erythromycin as a prokinetic drug. Positioning was considered correct when the distal end was beyond the ligament of Treitz. Migration failure was considered when the tube was not positioned into the jejunum within 48 hours postinsertion.

RESULTS

Fifty-six insertions were recorded in 47 patients, most frequently in severe acute pancreatitis (69.6%). The migration rates at 18 and 48 hours postinsertion were 73.2% and 82.1%, respectively. There was migration failure in 8.9% of cases, and 8.9% were classified null (the tube was no longer in the gastrointestinal tract at 18 hours). There were no reported or observed complications. The mean duration of the EN was 12 ± 10.8 days. Five different types of EN formula were used. The total study cost was 53.9% lower compared with using PN in all patients.

CONCLUSIONS

Our study demonstrated that bedside insertion of a self-propelling NJT is a safe, cost-effective, and successful technique for postpyloric enteral feeding in at least 73% of the patients, and only 18% of patients could eventually need other placement techniques. It can avoid the need for more aggressive or expensive placement techniques or even PN if we cannot achieve enteral access.

Malnutrition in the ICU patient population

Malnutrition has been identified as a cause for disease as well as a condition resulting from inflammation associated with acute or chronic disease. Malnutrition is common in acute-care settings, occurring in 30% to 50% of hospitalized patients. Inflammation has been associated with malnutrition and malnutrition has been associated with compromised immune status, infection, and increased intensive care unit (ICU) and hospital length of stay. The ICU nurse is in the best position to advocate for appropriate nutritional therapies and facilitate the safe delivery of nutrition.

Iatrogenic pneumothorax associated with inadvertent intrapleural NGT misplacement in two dogs

This case report presents two cases of inadvertent intrapleural nasogastric tube (NGT) misplacement with consequent creation of a bronchopleural fistula and the development of an iatrogenic pneumothorax in dogs. Due to the simplicity and relative ease of NGT placement and the lack of reported life-threatening complications in the veterinary literature, the serious risks associated with this procedure are often overlooked. Although pulmonary complications with NGT misplacement have been previously reported in the human literature, serious and potentially fatal complications have not been currently described in veterinary patients. Both of the cases described herein were medically managed with successful outcomes; however, one case was associated with significant morbidity.

A novel method of post-pyloric feeding tube placement at bedside

PURPOSE

Post-pyloric feeding tube placement is often difficult, and special equipment or peristalsis agents are used to aid insertion. Although several reports have described blind techniques for post-pyloric feeding-tube placement, no general consensus about method preference has been achieved.

MATERIALS AND METHODS

The technique is performed as follows: via the nostril, a stylet-tipped feeding tube is advanced about 70 cm; to confirm tip location to the right of the epigastric area, towards the right hypochondriac region, 5 mL shots of air are injected to enable touch detection of bubbling; finally, the tube is advanced to a length of 100 cm, during which the strength of bubbling seems to diminish under palpation.

RESULTS

We prospectively enrolled consecutive patients whose oral intake was expected to be difficult for 48 hours in the intensive care unit. Forty-one patients were enrolled and the rate of successful placement at first attempt was 95.1%. Mean duration for successful placement was 15 minutes.

CONCLUSIONS

With a novel technique, from the bedside, without special tools or drugs, we successfully placed post-pyloric feeding tubes. Essential points when inserting the tube are confirmation of the location of the tube tip by palpation of injected air, and to avoid deflection and looping.

Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement

INTRODUCTION

Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement.

METHODS

This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigator using first the low-frequency (5-1 MHz) followed by the high-frequency (10-5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation of TT placement.

RESULTS

Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10-5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode.

CONCLUSION

Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10-5 MHz) linear transducer.

Enteral feeding tubes: are insertion techniques and positioning based on anatomical evidence?

Patients in whom oral energy intake is insufficient for daily needs may develop malnutrition and its complications, such as increased infection rates, increased length of hospitalization, and death. Enteral feeding is beneficial for these patients. However, this therapy is not without complications related to the insertion and placement of enteral feeding tubes. This review aims to identify from the literature different techniques for insertion and the methods used to evaluate the placement of enteral feeding tubes.

Case series: Tension pneumothorax complicating narrow-bore enteral feeding tube placement

Frequently, narrow-bore feeding tubes are placed in critically ill hospitalized patients without difficulty. However, due to the simplicity and relative ease of bedside placement of feeding tubes, complications, including life threatening, are often minimized. We report 3 cases of severe pleuropulmonary complications after routine bedside placement of a narrow-bore enteral feeding tubes and a review of the literature. These episodes have not only prompted our adoption of a new policy specifying the routine use of ultrasound to guide feeding tube placement in obtunded or mechanically ventilated patients but also offer recommendations post-removal of misplaced feeding tubes.

A new technique for post-pyloric feeding tube placement by palpation in lean critically ill patients

Various techniques have been described for blind bedside placement of a post-pyloric feeding tube. However, there is no universal method and the technique depends on the local institutional resources and expertise. The purpose of this study was to evaluate a simple new technique for the bedside placement of a post-pyloric feeding tube in an intensive care unit using palpation to confirm tube position. We studied 47 consecutive ventilated patients (mean body mass index 22.4 ± 4.2 kg/m(2)) requiring enteral tube feeding for nutritional support. We monitored the maximum intensity point of injected air 'bubbling' by palpation and estimated tube position. We monitored the movement of the maximum intensity point from the left upper quadrant to the right upper quadrant. If the maximum intensity point on the right upper quadrant diminished or weakened, we considered the tube had proceeded beyond the pylorus. By palpation, we could feel the bubbling of the injected air in all patients, but four patients were excluded because of failure to complete the protocol. The overall success rate including the four excluded cases was 85.1% (40/47) on the first attempt and 91.5% (43/47) when we included the second attempt. The median time for 40 successful tube placements on the first attempt was 10 (7 to 23) minutes. Our new palpation technique can successfully detect the position of a feeding tube in the stomach and help guide the tube to the correct location in the post-pyloric portion of the stomach in lean critically ill patients.

[Enteral feeding tubes for critically ill patients]

The use of enteral feeding tubes is an important part of early enteral feeding in intensive care medicine. In other faculties with non-critically ill patients, such as (oncologic) surgery, neurology, paediatrics or even in palliative care medicine feeding tubes are used under various circumstances as a temporary or definite solution. The advantage of enteral feeding tubes is the almost physiologic administration of nutrition, liquids and medication. Enteral nutrition is thought to be associated with a reduced infection rate, increased mucosal function, improved immunologic function, reduced length of hospital stay and reduced costs. However, the insertion and use of feeding tubes is potentially dangerous and may be associated with life-threatening complications (bleeding, perforation, peritonitis, etc.). Therefore, the following article will give a summary of the different types of enteral feeding tubes and their range of application. Additionally, a critical look on indication and contraindication is given as well as how to insert an enteral feeding tube.

Enteral nutrition access devices

The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, performing a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such situations, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the ASGE Governing Board. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to endoscopy in patients requiring enteral feeding access by using the keywords "endoscopy," "percutaneous," "gastrostomy," "jejunostomy," "nasogastric," "nasoenteric," "nasojejunal," "transnasal," "feeding tube," "enteric," and "button." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients

Introduction

To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU).

Methods

Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically.

Results

A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the post-pyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 - 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 - 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 - 13.0 hours) compared to 12.3 hours (8.9 - 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 - 288 Kcal) and 3.5 g (0 - 15 g) compared to 167 Kcal (70 - 411 Kcal) and 6.5 g (2.8 - 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar.

Conclusions

Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complications

Trial Registration

Clinical Trial: anzctr.org.au:ACTRN12606000367549

Whole-body ultrasound in the intensive care unit: a new role for an aged technique

Management of critically ill patients requires rapid and safe diagnostic techniques. Ultrasonography has become an indispensable tool that supplements physical examination in the intensive care unit. It enables early recognition of neurological emergencies, assists the diagnosis of abdominal and lung pathologies, and provides real-time information on the cardiac performance of critically ill patients. Furthermore, it detects possible infectious sites and renders therapeutic invasive procedures more convenient and less complicated. Whole-body ultrasound in the hands of adequately trained intensivists has the ability to reinvigorate the physical examination, without subjecting the patient to excessive irradiation and the risks of transport.

Bedside postpyloric feeding tube placement: a pilot series to validate this novel technique

OBJECTIVE

Postpyloric feeding may facilitate tolerance to enteral nutrition (EN) and offers an alternative route of feed administration when prepyloric EN fails. However, this is constrained by the difficulty of establishing nasojejunal (NJ) tube placement, which may necessitate endoscopy or radiology with the inevitable delay in the instigation of treatment. A bedside technique of NJ tube insertion has, therefore, been developed to permit blind postpyloric intubation. The primary aim of this audit was to validate the success of bedside NJ tube placement using the described technique. Secondary end points included the time taken to establish EN and the value of aspirate pH as an indicator of tube tip placement.

DESIGN

Observational.

SETTING

District general hospital.

PATIENTS

Consecutive patients requiring EN.

MEASUREMENTS AND MAIN RESULTS

The time taken to insert the tubes, the success rates in achieving the required position, and the time between the decision to feed and commencement of EN were recorded. The pH of any aspirate obtained was related to tube tip placement. Tube position was confirmed radiologically before starting EN. A total of 43 NJ tubes were inserted in 32 patients. Successful postpyloric intubation was achieved in 35 of 43 patients (81%). The median time for tube insertion was 18 (14-30) minutes. Time from the decision to feed to commencement of EN was 6 (5-18) hours. Aspirates were obtained from 26 of 43 (60%) intubations. Gastric aspirate pH readings were obtained for 19 of 43 (44%) of these intubations. Radiology reliably demonstrated the position of the tube tip in all cases.

CONCLUSIONS

By-the-bedside NJ tube placement is possible in more than 80% of patients. This may overcome delays in the commencement of feeds resulting from other methods of postpyloric tube placement. The use of aspirate pH on its own is not a reliable indicator of tube tip position.

[Usefulness of ultrathin transnasal endoscopy for the placement of nasoenteric feeding tubes]

BACKGROUND

Placement of nasoenteral feeding tubes can require endoscopic support.

AIM

To analyze the usefulness of transnasal ultrathin endoscopy in the placement of nasoenteral feeding tubes.

PATIENTS AND METHODS

We performed an ambispective study of all patients who underwent nasoenteral feeding (4.9 mm) in 2007.

RESULTS

Twenty-six procedures were performed. The mean age of the patients was 69.3+/-13 years. Nasal anesthesia was used in 23 patients (88.4%), and midazolam in 8 (30.8%). No anesthesia was used in 4 patients (15.3%).

INDICATIONS

stenotic esophageal lesions (42.3%), distal placement to the pathological alteration (46.1%), and failure of placement through the normal route (11.5%). We placed 13 (50%) nasoduodenal, 7 (29.6%) nasogastric and 6 (23.1%) nasojejunal tubes. The success rate was 100%. The most frequently used calibre was 12 F. There were no complications.

CONCLUSIONS

The use of transnasal ultrathin endoscopy in the placement of nasoenteral feeding tubes in our patients was safe, effective and relatively easy.

Videothoracoscopic treatment of a rare complication of nasojejunal tube insertion

OBJECTIVE

Intubation of the tracheobronchial tree is the most common type of malposition during the placement of narrow-bore enternal tubes.

CASE REPORT

In addition to other treatment components in a 65-year-old female, nasojejunal feeding was started to treat her for severe acute pancreatitis. After the placement of the narrow-bore feeding tube, she developed dyspnea and huskiness. On auscultation and X-ray investigation, the right pneumothorax was detected and the tube was found in the chest cavity. The diagnosis was confirmed by bronchoscopy. Videothoracoscopic resection and closure of the lacerated lung, using a tube thoracostomy, were performed. The patient recovered after postoperative conservative treatment for her pancreatitis.

CONCLUSION

Pneumothorax and laceration of the lung-caused by the malposition of narrow-bore enternal tube-can be successfully treated by applying videothoracoscopy.

Transnasal endoscopy for the placement of nasoenteral feeding tubes: does the working length of the endoscope matter?

BACKGROUND

Transnasal endoscopy with a small-caliber endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in patients who are critically ill. Success rates were limited by the short working length of the small-caliber endoscopes.

OBJECTIVE

To compare the success rate of a 133-cm-long, small-caliber, prototype videoendoscope with a standard 92-cm-long, small-caliber, fiberoptic endoscope for the transnasal placement of feeding tubes.

DESIGN

Randomized controlled study.

SETTING

University Hospital of Zurich, Switzerland.

PATIENTS

Patients who were critically ill were randomly assigned to transnasal feeding tube placement with the standard 92-cm-long, small-caliber, fiberoptic endoscope, or with a new 133-cm-long, small-caliber, prototype videoendoscope. Patient characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed.

MAIN OUTCOME MEASUREMENTS

Success rates of endoscopic placement of enteral feeding tubes.

RESULTS

A total of 157 patients were analyzed in 2 groups. The 2 groups were similar with regard to patient characteristics, body length, technical difficulty, and patient tolerance. The 133-cm-long instrument was superior with respect to successful placement of the nasoenteral feeding tube (93.6% vs 74.4%, P = .0008). Patient tolerance, procedure times, and overall technical difficulty were the same in both treatment groups, whereas passage through the duodenum was more difficult with the 133-cm-long instrument (P < .0001).

LIMITATIONS

In rare cases, the randomization list could not be followed correctly.

CONCLUSIONS

This study demonstrated that placement of a nasoenteral feeding tube with a 133-cm-long, small-caliber videoendoscope is feasible, safe, and distinctly more successful than with a 92-cm-long, small-caliber standard instrument.

Nasojejunal tube positioning with fluoroscopic guidance

Az enteralis táplálás indikációs köre egyre tágul, és az ily módon növekvő beteganyag ellátása egyre inkább a mindennapos gyakorlat részévé válik. Az enteralis táplálás előnyösebb az intravénásnál, ezen belül is a jejunális táplálás a legelfogadottabb, de ehhez nasojejunalis szondalevezetés szükséges. Ez lehetséges vakon, képerősítő, endoszkóp vagy ultrahang segítségével. A szerzők saját gyakorlatuk alapján a röntgenkép-erősítős technikát ismertetik, ez nem igényel speciális jártasságot, és bármely fekvőbeteg-intézményben elvégezhető. Gyors, olcsó, és kis megterhelést jelent a betegnek, nincs szükség képzett endoszkópos szakemberre, premedikációra. Hátránya, hogy kizárólag éber, kielégítő spontán légzésű, kooperáló betegnél alkalmazható, valamint röntgensugár-terheléssel jár. A szerzők az elmúlt 3 év alatt 34 esetben alkalmazták a módszert akut pancreatitises betegeiknél, súlyos szövődmények nélkül. A költséghatékonysági elveket is figyelembe véve, a fekvőbeteg-ellátás minden szintjén biztonságos módszerként ajánlják ezt az eljárást.

Nasointestinal intubation with tiger tubes: a case series indicates risk of mucosal damage

Abstract In five intubations using the tiger tube (Cook) two were successfully placed into the small intestine. Two of the three intubation failures were due to early death due to the underlying condition. Nasointestinal placement permitted successful enteral feeding. Unfortunately, both nasointestinal placements were associated with mucosal damage that appears to be related to the tube "flaps". The tiger tube facilitates nasointestinal tube placement but until concerns regarding safety are addressed its clinical use cannot be recommended.

Pre-pyloric versus post-pyloric feeding

Optimal management of the critically ill patient involves the initiation and rapid advancement of early enteral nutrition (EN). Compared to parenteral nutrition or no nutritional support, early enteral feeding favorably impacts patient outcome by reducing infectious morbidity and shortening hospital length of stay. Controversy exists over the true risks and benefits of pre-pyloric versus post-pyloric feeding. Placement of nasogastric tubes is easier than nasojejunal tubes, initiation of EN is more expedient, and intragastric feeds may provide greater physiologic benefits. Post-pyloric feeding, on the other hand, is associated with fewer interruptions once EN has been started, may reach goal calorie provision sooner, and may reduce risk for gastroesophageal reflux and aspiration. Overall differences in outcome between the two methods of feeding, however, are minimal. Thus, the final choice for the practicing clinician on the level of infusion of enteral feeding is based on institutional factors (related to protocols and available expertise) and the degree of risk and potential tolerance of the individual patient.

Important Facts About Intestinal Feeding Tube Placement

Enteral feeding is desirable when the gastrointestinal tract is functional because it allows better use of nutrients, is safer, and is more cost-effective than parenteral nutrition. Feeding through a gastric tube, however, is often not feasible in severely ill adults and children because of gastric paresis leading to recurrent episodes of gastroesophageal reflux with the risk of subsequent aspiration. Feeding into the small intestine (duodenum or jejunum) through a nasointestinal tube, therefore, is preferred. Unfortunately, no method of enteral feeding is risk free. This literature review addresses the following 10 topics: (a) the reasons why nasointestinal tube feeding is better tolerated by some patients, (b) candidates for nasointestinal tube feeding, (c) options for selecting nasointestinal tubes, (d) recommended methods for predicting the distance to insert nasointestinal tubes, (e) recommended methods for placing nasointestinal tubes, (f) how promotility medications work and whether they facilitate nasointestinal tube placement, (g) nasointestinal tube placement error rate, (h) methods of determining the internal location of nasointestinal tubes, (i) complications associated with nasointestinal tube use, and (j) other pertinent issues surrounding feeding through nasointestinal tubes. The available research evidence is summarized and recommendations for future work are suggested.

Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients

BACKGROUND

Placement of a nasoenteric feeding tube (NET) beyond the pylorus in critically ill patients is desirable. Bedside methods are unreliable, and fluoroscopic methods require transport and/or radiation exposure. Traditional endoscopic methods require sedation and oronasal transfer techniques. Transnasal techniques of NET placement by using recently developed ultrathin endoscopes have been described. The object of this prospective study was to compare the efficacy of NET placement by using ultrathin transnasal endoscopy vs. fluoroscopic placement.

METHODS

This is a prospective randomized study of endoscopic vs. fluoroscopic NET placement. The settings of the study were intensive care units at academic medical center. The study included 100 consecutive patients who required NET placement. They received endoscopic NET placement at the bedside with a 5.1-mm, ultrathin endoscope by using a transnasal over-the-wire technique vs. fluoroscopic NET placement by using standard techniques. The procedure success was defined as postpyloric (beyond the duodenal bulb) NET placement, jejunal placement success, and procedure time.

RESULTS

Tube placement success was not significantly different between endoscopic and fluoroscopic methods (90% with both methods; p = 1.00). The endoscopic procedure duration (12.8 +/- 6.4 minutes) was significantly shorter than fluoroscopic procedure duration (19.3 +/- 12.0 minutes) (p < 0.001). Procedure duration decreased significantly (from 17.3 +/- 6.2 minutes to 8.0 minutes +/- 4.2 minutes, p = 0.04), and jejunal placement increased significantly (from 60% to 100%, p = 0.04) from the first to the last 10 endoscopic procedures.

CONCLUSIONS

NET placement success with an ultrathin transnasal endoscope is equivalent to fluoroscopic placement with faster procedure times. More distal placement and procedure times improve with increasing experience with the endoscopic technique. Endoscopic NET placement can be performed at the bedside without the need for oronasal transfer, additional sedation, or fluoroscopy.

Sonography as an alternative to radiography for nasogastric feeding tube location

OBJECTIVE

To evaluate bedside sonographic confirmation of weighted-tip nasogastric feeding tube position, by comparison to radiography.

DESIGN AND SETTING

Single-center, double-blind prospective study in a 14-bed medical intensive care unit (ICU) in a 780-bed teaching hospital.

PATIENTS

Thirty-three ICU patients undergoing nasogastric tube insertion for enteral feeding.

INTERVENTIONS

The tip of the nasogastric tube was located both by sonography and standard radiography.

MEASUREMENTS AND RESULTS

The accuracy and procedure times of sonography and radiography for nasogastric tube tip location were compared during 35 procedures in 33 patients. The nasogastric tube tip was visualized by sonography in 34 of 35 procedures (sensitivity 97%) and by radiography in all procedures. The median length of the entire procedure was 24 min and 180 min with sonography and radiography, respectively.

CONCLUSIONS

Bedside sonography performed by nonradiologists is a sensitive method for confirming the position of weighted-tip feeding nasogastric feeding tubes. It is more rapid than conventional radiography and can easily be taught to ICU physicians. Conventional radiography could be reserved for cases in which sonography is inconclusive.

A novel technique for post-pyloric feeding tube placement in critically ill patients: a pilot study

Delivery of enteral nutrition in critically ill patients is often hampered by gastric stasis necessitating direct feeding into the small intestine. Current techniques for placement of post-pyloric feeding catheters are complex, time consuming or both, and improvements in feeding tube placement techniques are required. The Cathlocator is a novel device that permits real time localisation of the end of feeding tubes via detection of a magnetic field generated by a small electric current in a coil incorporated in the tip of the tube. We performed a pilot study evaluating the feasibility of the Cathlocator system to guide and evaluate the placement of (1) nasoduodenal feeding tubes, and (2) nasogastric drainage tubes in critically ill patients with feed intolerance due to slow gastric emptying. A prospective study of eight critically ill patients was undertaken in the intensive care unit of a tertiary hospital. The Cathlocator was used to (1) guide the positioning of the tubes post-pylorically and (2) determine whether nasogastric and nasoduodenal tubes were placed correctly. Tube tip position was compared with data obtained by radiology. Data are expressed as median (range). Duodenal tube placement was successful in 7 of 8 patients (insertion time 12.6 min (5.3-34.4)). All nasogastric tube placements were successful (insertion time 3.4 min (0.6-10.0)). The Cathlocator accurately determined the position of both tubes without complication in all cases. The Cathlocator allows placement and location of an enteral feeding tube in real time in critically ill patients with slow gastric emptying. These findings warrant further studies into the application of this technique for placement of post-pyloric feeding tubes.

Surgeon-performed ultrasound in the ICU setting

Evaluation of critically ill patients is often challenging due to altered sensorium, underlying disease, and the presence of multiple drains or monitoring devices. In such circumstances, the ability of physicians to perform ultrasound examinations in the intensive care unit provides a useful diagnostic and therapeutic adjunct. In this article,we review the application of surgeon-performed ultrasonography in the evaluation and management of critically ill patients.

Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol

OBJECTIVE

To determine whether the implementation of a nutritional management protocol in the ICU leads to the increased use of enteral nutrition, earlier feeding, and improved clinical outcomes in patients.

DESIGN

Prospective evaluation of critically ill patients before and after the introduction of an evidence-based guideline for providing nutritional support in the ICU.

SETTING

The medical-surgical ICUs of two teaching hospitals.

PATIENTS

Two hundred critically ill adult patients who remained npo > 48 h after their admission to the ICU. One hundred patients were enrolled into the preimplementation group, and 100 patients were enrolled in the postimplementation group.

INTERVENTION

Implementation of an evidence-based ICU nutritional management protocol.

MEASUREMENT AND RESULTS

Nutritional outcome measures included the number of patients who received enteral nutrition, the time to initiate nutritional support, and the percent caloric target administered on day 4 of nutritional support. Clinical outcomes included the duration of mechanical ventilation, ICU and in-hospital length of stay (LOS), and in-hospital mortality rates. Patients in the postimplementation group were fed more frequently via the enteral route (78% vs 68%, respectively; p = 0.08), and this difference was statistically significant after adjusting for severity of illness, baseline nutritional status, and other factors (odds ratio, 2.4; 95% confidence interval [CI], 1.2 to 5.0; p = 0.009). The time to feeding and the caloric intake on day 4 of nutritional support were not different between the groups. The mean (+/- SD) duration of mechanical ventilation was shorter in the postimplementation group (17.9 +/- 31.3 vs 11.2 +/- 19.5 days, respectively; p = 0.11), and this difference was statistically significant after adjusting for age, gender, severity of illness, type of admission, baseline nutritional status, and type of nutritional support (p = 0.03). There was no difference in ICU or hospital LOS between the two groups. The risk of death was 56% lower in patients who received enteral nutrition (hazard ratio, 0.44; 95% CI, 0.24 to 0.80; p = 0.007).

CONCLUSION

An evidence-based nutritional management protocol increased the likelihood that ICU patients would receive enteral nutrition, and shortened their duration of mechanical ventilation. Enteral nutrition was associated with a reduced risk of death in those patients studied.

A novel method for insertion of post-pyloric feeding tubes at the bedside without endoscopic or fluoroscopic assistance: a prospective study

OBJECTIVE

To assess a novel method, adapted from already published literature, for bedside placement of nasojejunal feeding tubes using erythromycin, air insufflation of the stomach and continuous ECG guidance.

DESIGN AND SETTING

Prospective study in a tertiary teaching hospital.

PATIENTS AND PARTICIPANTS

40 consecutive patients who required enteral nutrition and mechanical ventilation for at least 48 h.

INTERVENTIONS

Erythromycin (200 mg) was administered intravenously 30 min prior to the insertion of the feeding tube. The post-pyloric feeding tube was then inserted into the stomach and 500 ml air insufflated. Stomach ECG was performed, and during further insertion of the tube the QRS complex was continuously monitored for a change in polarity, suggesting passage across the midline through the pylorus. At the end of the procedure aspirate was obtained from the feeding tube and checked for alkaline pH. Exact tube position was determined by abdominal radiography.

MEASUREMENTS AND RESULTS

In 88% of cases the feeding tubes were post-pyloric, with a median time to insertion of 15 min (range 7-75). No major complications were seen in 52 attempts. Change in QRS polarity had 94% sensitivity in predicting post-pyloric tip placement. Of the 32 alkaline pH aspirates 31 were post-pyloric.

CONCLUSIONS

This procedure is safe, effective and could be performed in a short time period within the confines of the intensive care unit without endoscopic assistance.