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Wollmer E, Ungell AL, Nicolas JM, Klein S. Review of paediatric gastrointestinal physiology relevant to the absorption of orally administered medicines. Adv Drug Deliv Rev 2022; 181:114084. [PMID: 34929252 DOI: 10.1016/j.addr.2021.114084] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/13/2021] [Accepted: 12/13/2021] [Indexed: 12/11/2022]
Abstract
Despite much progress in regulations to improve paediatric drug development, there remains a significant need to develop better medications for children. For the design of oral dosage forms, a detailed understanding of the specific gastrointestinal (GI) conditions in children of different age categories and how they differ from GI conditions in adults is essential. Several review articles have been published addressing the ontogeny of GI characteristics, including luminal conditions in the GI tract of children. However, the data reported in most of these reviews are of limited quality because (1) information was cited from very old publications and sometimes low quality sources, (2) data gaps in the original data were filled with textbook knowledge, (3) data obtained on healthy and sick children were mixed, (4) average data obtained on groups of patients were mixed with data obtained on individual patients, and (5) results obtained using investigative techniques that may have altered the outcome of the respective studies were considered. Consequently, many of these reviews draw conclusions that may be incorrect. The aim of the present review was to provide a comprehensive and updated overview of the available original data on the ontogeny of GI luminal conditions relevant to oral drug absorption in the paediatric population. To this end, the PubMed and Web of Science metadatabases were searched for appropriate studies that examined age-related conditions in the oral cavity, esophagus, stomach, small intestine, and colon. Maturation was observed for several GI parameters, and corresponding data sets were identified for each paediatric age group. However, it also became clear that the ontogeny of several GI traits in the paediatric population is not yet known. The review article provides a robust and valuable data set for the development of paediatric in vitro and in silico biopharmaceutical tools to support the development of age-appropriate dosage forms. In addition, it provides important information on existing data gaps and should provide impetus for further systematic and well-designed in vivo studies on GI physiology in children of specific age groups in order to close existing knowledge gaps and to sustainably improve oral drug therapy in children.
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Lavoie J, Smith A, Stelter A, Uhing M, Blom K, Goday PS. Reining in Nasogastric Tubes: Implementation of a Pediatric Bridle Program. J Pediatr Nurs 2021; 61:1-6. [PMID: 33689975 DOI: 10.1016/j.pedn.2021.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 11/29/2022]
Abstract
Nasogastric tubes (NG) used for enteral nutrition support of medically complex children (MCC) are often inadvertently removed, risking frequent replacements. Bridles have been shown to provide a safe securement method for NGs in adult patients, but are not widely used in pediatrics. Furthermore, nutritional management of MCC is often fragmented. We established a pediatric NG bridle program to bridge the gap amongst disciplines and improve patient outcomes. In January 2018, a multidisciplinary work group involving nurses, physicians, clinical dietitians, advanced practice providers, and speech-language pathologists was established to develop criteria for patient referral and policies, procedures, and order sets for nutritional management of MCC children with bridled NG tubes. Formal teaching sessions engaged clinicians and administrators to participate in building a successful program. Relevant outcomes of interest are tracked continuously for process performance improvement measures and are reviewed quarterly by the core work group. Patient enrollment began in May 2018 and to date, 244 patients have been enrolled. Adhering to strict enrollment criteria, competency modules and review of patient status provided a solid core for the program and process review. Successful implementation of an NG Bridle program was achieved. Outcomes of interest continue to be monitored for process improvement. Balancing measures are also being tracked for potential downstream effects.
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Affiliation(s)
- Julie Lavoie
- Pediatric Gastroenterology and Nutrition, Children's Hospital of Wisconsin, WI, United States.
| | - Amber Smith
- Clinical Nutrition, University of California San Francisco, United States
| | - Ashley Stelter
- Advanced Practice Nursing & Herma Heart Institute, Children's Hospital of Wisconsin, United States
| | - Michael Uhing
- Neonatology, Medical College of Wisconsin, United States
| | - Krista Blom
- Masters Family Speech and Hearing Center, Children's Hospital of Wisconsin, United States
| | - Praveen S Goday
- Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, United States
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Pawar G, Papadatou-Soulou E, Mason J, Muhammed R, Watson A, Cotter C, Abdallah M, Harrad S, Mackie C, Arien T, Inghelbrecht S, Batchelor H. Characterisation of fasted state gastric and intestinal fluids collected from children. Eur J Pharm Biopharm 2020; 158:156-165. [PMID: 33259897 DOI: 10.1016/j.ejpb.2020.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
Fundamental knowledge about the composition of intestinal fluids in paediatric populations is currently unavailable. This study aimed to characterise gastric and intestinal fluid from paediatric populations. Gastric and intestinal fluid samples were obtained during routine clinical endoscopy from paediatric patients at a large teaching hospital. These fluids were characterised to measure the pH; buffer capacity; osmolality; bile acid concentration and composition. A total of 55 children were recruited to the study aged from 11 months to 15 years of age where 53 gastric fluid samples and 40 intestinal fluid samples were obtained. pH values recorded ranged from pH 0.57 to 11.05 (median: 2.50) in gastric fluids and from 0.89 to 8.97 (median: 3.27) in intestinal fluids. The buffer capacity did not change significantly between gastric and intestinal fluids with median values of 12 mM/L/ΔpH for both fluids. Gastric fluid osmolality values ranged from 1 to 615 mOsm/kg, while intestinal fluid values ranged from 35 to 631 mOsm/kg. Gastric fluid bile acid concentrations ranged from 0.002 to 2.3 mM with a median value of 0.017 mM whilst intestinal fluid bile acid concentrations ranged from 0.0008 to 3.3 mM with a median value of 0.178 mM. Glycocholate; taurocholic acid; glycochenodeoxycholate and taurochenodeoxycholate were the most commonly identified bile acids within paediatric intestinal fluids. All compositional components were associated with large inter-individual variability. Further work is required to develop simulated paediatric media and to explore the impact of these media on drug solubility and dissolution.
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Affiliation(s)
- Gopal Pawar
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston B15 2TT, United Kingdom
| | - Eleni Papadatou-Soulou
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston B15 2TT, United Kingdom
| | - Julie Mason
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston B15 2TT, United Kingdom
| | - Rafeeq Muhammed
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - Alison Watson
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - Catherine Cotter
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - Mohamed Abdallah
- School of Geography, Earth, and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Department of Analytical Chemistry, Faculty of Pharmacy, Assiut University, 71526 Assiut, Egypt
| | - Stuart Harrad
- School of Geography, Earth, and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Claire Mackie
- Janssen Research and Development, Turnhoutseweg 34, 2340 Beerse, Belgium
| | - Tina Arien
- Janssen Research and Development, Turnhoutseweg 34, 2340 Beerse, Belgium
| | | | - Hannah Batchelor
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston B15 2TT, United Kingdom; Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, United Kingdom.
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Methods of Gastric Tube Placement Verification in Neonates, Infants, and Children: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2020; 115:653-661. [PMID: 31464742 DOI: 10.14309/ajg.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Abstract
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.
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Dias FDSB, Almeida BPD, Alvares BR, Jales RM, Caldas JPDS, Carmona EV. Use of pH reagent strips to verify gastric tube placement in newborns. Rev Lat Am Enfermagem 2019; 27:e3227. [PMID: 31826168 PMCID: PMC6896807 DOI: 10.1590/1518-8345.3150.3227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 09/11/2019] [Indexed: 11/26/2022] Open
Abstract
Objective: to confirm the accuracy of the pH test in identifying the placement of the gastric tube in newborns. Method: double-blind, diagnostic test study conducted with 162 newborns admitted to a neonatal intensive care unit and an intermediate care unit. The subjects were submitted to enteral intubation, followed by pH test with reagent strip, which was analyzed by a nurse, and radiological examination, analyzed by radiologist. Blinding was kept among professionals regarding test results. Diagnostic accuracy analysis of the pH test in relation to the radiological exam was performed. Results: the sample consisted of 56.17% boys, with average birth weight of 1,886.79g (SD 743,41), 32.92 (SD 2.99) weeks of gestational age and the mean pH was 3.36 (SD 1.27). Considering the cutoff point of pH≤5.5, the sensitivity was 96.25%, specificity 50%, positive predictive value 99.35% and negative predictive value 14.29%. Conclusion: The pH test performed with reagent strips is sensitive to identify the correct placement of the gastric tube, so it can be used as an adjuvant technique in the evaluation of the gastric tube placement. In interpreting the results, pH ≤5.5 points to correct placement and values > 5.5 require radiological confirmation.
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Parker LA, Withers JH, Talaga E. Comparison of Neonatal Nursing Practices for Determining Feeding Tube Insertion Length and Verifying Gastric Placement With Current Best Evidence. Adv Neonatal Care 2018; 18:307-317. [PMID: 29889728 DOI: 10.1097/anc.0000000000000526] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Oral-nasogastric feeding tubes (FTs) are often malpositioned, placing infants at risk for complications. Confusion exists regarding the accuracy of methods to determine FT insertion length and verify gastric FT placement, and it is unknown whether evidence-based methods are used by neonatal nurses. PURPOSE To compare individual and unit-based neonatal nursing practices regarding methods used to determine FT insertion length and verify gastric FT placement. METHODS Neonatal nurses were surveyed about individual and unit-based practices regarding methods used to determine FT insertion length and verify gastric FT placement in infants in the neonatal intensive care unit. RESULTS Sixty neonatal nurses completed the survey, with 63% utilizing the nose-ear-midway to the umbilicus method, which was included in 50% of protocols and is associated with up to a 90% accuracy rate. Although it has an unacceptably high inaccuracy rate, the nose-to-ear-to-xiphoid method was used by 32% of nurses and recommended in 30% of protocols. To verify gastric FT placement, 98% of nurses used auscultation of a whoosh sound and 83% used aspiration of gastric contents. Neither verification method is supported by evidence or recommended for use. IMPLICATIONS FOR PRACTICE A lack of consistency exists between nursing practice and evidence-based methods. IMPLICATIONS FOR RESEARCH Research is needed to determine more accurate and reliable ways to determine FT insertion depth and verify gastric FT placement in neonates.
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Guimarães M, Statelova M, Holm R, Reppas C, Symilllides M, Vertzoni M, Fotaki N. Biopharmaceutical considerations in paediatrics with a view to the evaluation of orally administered drug products - a PEARRL review. ACTA ACUST UNITED AC 2018; 71:603-642. [PMID: 29971768 DOI: 10.1111/jphp.12955] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 05/28/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVES In this review, the current biopharmaceutical approaches for evaluation of oral formulation performance in paediatrics are discussed. KEY FINDINGS The paediatric gastrointestinal (GI) tract undergoes numerous morphological and physiological changes throughout its development and growth. Some physiological parameters are yet to be investigated, limiting the use of the existing in vitro biopharmaceutical tools to predict the in vivo performance of paediatric formulations. Meals and frequencies of their administration evolve during childhood and affect oral drug absorption. Furthermore, the establishment of a paediatric Biopharmaceutics Classification System (pBCS), based on the adult Biopharmaceutics Classification System (BCS), requires criteria adjustments. The usefulness of computational simulation and modeling for extrapolation of adult data to paediatrics has been confirmed as a tool for predicting drug formulation performance. Despite the great number of successful physiologically based pharmacokinetic models to simulate drug disposition, the simulation of drug absorption from the GI tract is a complicating issue in paediatric populations. SUMMARY The biopharmaceutics tools for investigation of oral drug absorption in paediatrics need further development, refinement and validation. A combination of in vitro and in silico methods could compensate for the uncertainties accompanying each method on its own.
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Affiliation(s)
- Mariana Guimarães
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Marina Statelova
- Department of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - René Holm
- Drug Product Development, Janssen Research and Development, Johnson & Johnson, Beerse, Belgium
| | - Christos Reppas
- Department of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Moira Symilllides
- Department of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Vertzoni
- Department of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikoletta Fotaki
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
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Metheny NA, Pawluszka A, Lulic M, Hinyard LJ, Meert KL. Testing Placement of Gastric Feeding Tubes in Infants. Am J Crit Care 2017; 26:466-473. [PMID: 29092869 DOI: 10.4037/ajcc2017378] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Inadvertent positioning of a nasogastric tube in the lung can cause serious complications, so identifying methods to detect improperly inserted tubes is imperative. OBJECTIVES To compare the sensitivity, specificity, and negative and positive predictive values of 4 pH cut points (< 4.0, < 4.5, < 5.0, and < 5.5) in differentiating gastric and tracheal aspirates under various treatment conditions and to explore the utility of a pepsin assay for distinguishing between gastric and tracheal aspirates. METHODS Gastric and tracheal aspirates were collected from critically ill infants undergoing mechanical ventilation who had nasogastric or orogastric feeding tubes. Aspirates were tested with colorimetric pH indicators and a rapid pepsin assay. Information about treatment conditions was obtained from medical records. RESULTS Two hundred twelve gastric aspirates and 60 tracheal aspirates were collected from 212 patients. Sensitivity was highest and specificity was lowest at the gastric aspirate pH cut point of less than 5.5. Positive predictive values were 100% at all pH cut points less than 5.0. Negative predictive values were higher at the pH cut point of less than 5.0 than at cut points less than 4.5. A higher percentage of pepsin-positive readings was found in gastric aspirates (88.3%) than in tracheal aspirates (5.4%). CONCLUSION For a desired positive predictive value of 100%, a pH cut point of less than 5.0 provides the best negative predictive values, regardless of gastric acid inhibitor administration and feeding status. The pepsin assay is promising as an additional marker to distinguish gastric from tracheal aspirates.
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Affiliation(s)
- Norma A. Metheny
- Norma A. Metheny is a professor of nursing at Saint Louis University, St Louis, Missouri. Ann Pawluszka is a research coordinator, Melanie Lulic is a research assistant, and Kathleen L. Meert is a professor of pediatrics and chief of critical care medicine at the Children’s Hospital of Michigan, Wayne State University, Detroit, Michigan. Leslie J. Hinyard is an associate professor and associate director for academic affairs at the Center for Health Outcomes Research, Saint Louis University
| | - Ann Pawluszka
- Norma A. Metheny is a professor of nursing at Saint Louis University, St Louis, Missouri. Ann Pawluszka is a research coordinator, Melanie Lulic is a research assistant, and Kathleen L. Meert is a professor of pediatrics and chief of critical care medicine at the Children’s Hospital of Michigan, Wayne State University, Detroit, Michigan. Leslie J. Hinyard is an associate professor and associate director for academic affairs at the Center for Health Outcomes Research, Saint Louis University
| | - Melanie Lulic
- Norma A. Metheny is a professor of nursing at Saint Louis University, St Louis, Missouri. Ann Pawluszka is a research coordinator, Melanie Lulic is a research assistant, and Kathleen L. Meert is a professor of pediatrics and chief of critical care medicine at the Children’s Hospital of Michigan, Wayne State University, Detroit, Michigan. Leslie J. Hinyard is an associate professor and associate director for academic affairs at the Center for Health Outcomes Research, Saint Louis University
| | - Leslie J. Hinyard
- Norma A. Metheny is a professor of nursing at Saint Louis University, St Louis, Missouri. Ann Pawluszka is a research coordinator, Melanie Lulic is a research assistant, and Kathleen L. Meert is a professor of pediatrics and chief of critical care medicine at the Children’s Hospital of Michigan, Wayne State University, Detroit, Michigan. Leslie J. Hinyard is an associate professor and associate director for academic affairs at the Center for Health Outcomes Research, Saint Louis University
| | - Kathleen L. Meert
- Norma A. Metheny is a professor of nursing at Saint Louis University, St Louis, Missouri. Ann Pawluszka is a research coordinator, Melanie Lulic is a research assistant, and Kathleen L. Meert is a professor of pediatrics and chief of critical care medicine at the Children’s Hospital of Michigan, Wayne State University, Detroit, Michigan. Leslie J. Hinyard is an associate professor and associate director for academic affairs at the Center for Health Outcomes Research, Saint Louis University
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Dias FDSB, Emidio SCD, Lopes MHBDM, Shimo AKK, Beck ARM, Carmona EV. Procedures for measuring and verifying gastric tube placement in newborns: an integrative review. Rev Lat Am Enfermagem 2017; 25:e2908. [PMID: 28699995 PMCID: PMC5511002 DOI: 10.1590/1518-8345.1841.2908] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 04/06/2017] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
| | - Suellen Cristina Dias Emidio
- Doctoral student, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil. Scholarship holder at Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil
| | | | | | - Ana Raquel Medeiros Beck
- PhD, Professor, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Elenice Valentim Carmona
- PhD, Professor, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Van Den Abeele J, Rubbens J, Brouwers J, Augustijns P. The dynamic gastric environment and its impact on drug and formulation behaviour. Eur J Pharm Sci 2017; 96:207-231. [DOI: 10.1016/j.ejps.2016.08.060] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/30/2016] [Accepted: 08/30/2016] [Indexed: 02/08/2023]
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Milsom SA, Sweeting JA, Sheahan H, Haemmerle E, Windsor JA. Naso-enteric Tube Placement: A Review of Methods to Confirm Tip Location, Global Applicability and Requirements. World J Surg 2016; 39:2243-52. [PMID: 25900711 DOI: 10.1007/s00268-015-3077-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- S A Milsom
- Department of Biomedical Engineering, University of Auckland, Auckland, New Zealand
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Makic MBF, Rauen C, Watson R, Poteet AW. Examining the evidence to guide practice: challenging practice habits. Crit Care Nurse 2015; 34:28-45; quiz 46. [PMID: 24692464 DOI: 10.4037/ccn2014262] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Lyman B, Kemper C, Northington L, Yaworski JA, Wilder K, Moore C, Duesing LA, Irving S. Use of Temporary Enteral Access Devices in Hospitalized Neonatal and Pediatric Patients in the United States. JPEN J Parenter Enteral Nutr 2015; 40:574-80. [PMID: 25567784 DOI: 10.1177/0148607114567712] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 12/07/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Temporary enteral access devices (EADs), such as nasogastric (NG), orogastric (OG), and postpyloric (PP), are used in pediatric and neonatal patients to administer nutrition, fluids, and medications. While the use of these temporary EADs is common in pediatric care, it is not known how often these devices are used, what inpatient locations have the highest usage, what size tube is used for a given weight or age of patient, and how placement is verified per hospital policy. MATERIALS AND METHODS This was a multicenter 1-day prevalence study. Participating hospitals counted the number of NG, OG, and PP tubes present in their pediatric and neonatal inpatient population. Additional data collected included age, weight and location of the patient, type of hospital, census for that day, and the method(s) used to verify initial tube placement. RESULTS Of the 63 participating hospitals, there was an overall prevalence of 1991 temporary EADs in a total pediatric and neonatal inpatient census of 8333 children (24% prevalence). There were 1316 NG (66%), 414 were OG (21%), and 261 PP (17%) EADs. The neonatal intensive care unit (NICU) had the highest prevalence (61%), followed by a medical/surgical unit (21%) and pediatric intensive care unit (18%). Verification of EAD placement was reported to be aspiration from the tube (n = 21), auscultation (n = 18), measurement (n = 8), pH (n = 10), and X-ray (n = 6). CONCLUSION The use of temporary EADs is common in pediatric care. There is wide variation in how placement of these tubes is verified.
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Affiliation(s)
- Beth Lyman
- Children's Mercy Hospital, Kansas City, Missouri
| | - Carol Kemper
- Children's Mercy Hospital, Kansas City, Missouri
| | - LaDonna Northington
- University of Mississippi Medical Center School of Nursing, Jackson, Mississippi
| | | | - Kerry Wilder
- Children's Medical Center of Dallas Neonatal Intensive Care Unit, Dallas, Texas
| | | | | | - Sharon Irving
- University of Pennsylvania School of Nursing and Children's Hospital of Pennsylvania, Philadelphia, Pennsylvania
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Irving SY, Lyman B, Northington L, Bartlett JA, Kemper C. Nasogastric tube placement and verification in children: review of the current literature. Nutr Clin Pract 2014; 29:267-76. [PMID: 24737681 DOI: 10.1177/0884533614531456] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Sharon Y Irving
- Children's Hospital of Philadelphia, University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania
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Irving SY, Lyman B, Northington L, Bartlett JA, Kemper C. Nasogastric tube placement and verification in children: review of the current literature. Crit Care Nurse 2014; 34:67-78. [PMID: 24735587 DOI: 10.4037/ccn2014606] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Sharon Y Irving
- Sharon Y. Irving is a pediatric critical care nurse practitioner at The Children's Hospital of Philadelphia and an assistant professor at the University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania. She is the AACN liaison for the New Opportunities for Verification of Enteral Tube Location (NOVEL) project sponsored by the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.).Beth Lyman is a senior program coordinator for the nutrition support team at Children's Mercy Hospital in Kansas City, Missouri, and is the chair of the NOVEL project sponsored by A.S.P.E.N.LaDonna Northington is director of the traditional undergraduate program at the University of Mississippi, School of Nursing, in Jackson, and a member of the Society of Pediatric Nursing.Jacqueline A. Bartlett is director of evidence-based practice at Children's Mercy Hospital in Kansas City, Missouri.Carol Kemper is vice president of quality and safety at Children's Mercy Hospital in Kansas City, Missouri and a steering committee member for the Children Health Patient Safety Organization/Children's Hospital Association.
| | - Beth Lyman
- Sharon Y. Irving is a pediatric critical care nurse practitioner at The Children's Hospital of Philadelphia and an assistant professor at the University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania. She is the AACN liaison for the New Opportunities for Verification of Enteral Tube Location (NOVEL) project sponsored by the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.).Beth Lyman is a senior program coordinator for the nutrition support team at Children's Mercy Hospital in Kansas City, Missouri, and is the chair of the NOVEL project sponsored by A.S.P.E.N.LaDonna Northington is director of the traditional undergraduate program at the University of Mississippi, School of Nursing, in Jackson, and a member of the Society of Pediatric Nursing.Jacqueline A. Bartlett is director of evidence-based practice at Children's Mercy Hospital in Kansas City, Missouri.Carol Kemper is vice president of quality and safety at Children's Mercy Hospital in Kansas City, Missouri and a steering committee member for the Children Health Patient Safety Organization/Children's Hospital Association
| | - LaDonna Northington
- Sharon Y. Irving is a pediatric critical care nurse practitioner at The Children's Hospital of Philadelphia and an assistant professor at the University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania. She is the AACN liaison for the New Opportunities for Verification of Enteral Tube Location (NOVEL) project sponsored by the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.).Beth Lyman is a senior program coordinator for the nutrition support team at Children's Mercy Hospital in Kansas City, Missouri, and is the chair of the NOVEL project sponsored by A.S.P.E.N.LaDonna Northington is director of the traditional undergraduate program at the University of Mississippi, School of Nursing, in Jackson, and a member of the Society of Pediatric Nursing.Jacqueline A. Bartlett is director of evidence-based practice at Children's Mercy Hospital in Kansas City, Missouri.Carol Kemper is vice president of quality and safety at Children's Mercy Hospital in Kansas City, Missouri and a steering committee member for the Children Health Patient Safety Organization/Children's Hospital Association
| | - Jacqueline A Bartlett
- Sharon Y. Irving is a pediatric critical care nurse practitioner at The Children's Hospital of Philadelphia and an assistant professor at the University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania. She is the AACN liaison for the New Opportunities for Verification of Enteral Tube Location (NOVEL) project sponsored by the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.).Beth Lyman is a senior program coordinator for the nutrition support team at Children's Mercy Hospital in Kansas City, Missouri, and is the chair of the NOVEL project sponsored by A.S.P.E.N.LaDonna Northington is director of the traditional undergraduate program at the University of Mississippi, School of Nursing, in Jackson, and a member of the Society of Pediatric Nursing.Jacqueline A. Bartlett is director of evidence-based practice at Children's Mercy Hospital in Kansas City, Missouri.Carol Kemper is vice president of quality and safety at Children's Mercy Hospital in Kansas City, Missouri and a steering committee member for the Children Health Patient Safety Organization/Children's Hospital Association
| | - Carol Kemper
- Sharon Y. Irving is a pediatric critical care nurse practitioner at The Children's Hospital of Philadelphia and an assistant professor at the University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania. She is the AACN liaison for the New Opportunities for Verification of Enteral Tube Location (NOVEL) project sponsored by the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.).Beth Lyman is a senior program coordinator for the nutrition support team at Children's Mercy Hospital in Kansas City, Missouri, and is the chair of the NOVEL project sponsored by A.S.P.E.N.LaDonna Northington is director of the traditional undergraduate program at the University of Mississippi, School of Nursing, in Jackson, and a member of the Society of Pediatric Nursing.Jacqueline A. Bartlett is director of evidence-based practice at Children's Mercy Hospital in Kansas City, Missouri.Carol Kemper is vice president of quality and safety at Children's Mercy Hospital in Kansas City, Missouri and a steering committee member for the Children Health Patient Safety Organization/Children's Hospital Association
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Ellett MLC, Cohen MD, Croffie JMB, Lane KA, Austin JK, Perkins SM. Comparing bedside methods of determining placement of gastric tubes in children. J SPEC PEDIATR NURS 2014; 19:68-79. [PMID: 24393228 PMCID: PMC4096163 DOI: 10.1111/jspn.12054] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 09/19/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to compare the accuracy and predictive validity of pH, bilirubin, and CO2 in identifying gastric tube placement errors in children. DESIGN AND METHODS After the tube was inserted into 276 children, the CO2 monitor reading was obtained. Fluid was then aspirated to test pH and bilirubin. RESULTS Lack of ability to obtain tube aspirate was the best predictor of NG/OG placement errors with a sensitivity of 34.9% and a positive predictive value of 66.7%. Measuring pH, bilirubin, and CO2 of tube aspirate was less helpful. PRACTICE IMPLICATIONS Healthcare providers should suspect NG/OG tube misplacement when no fluid is aspirated.
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A review of published case reports of inadvertent pulmonary placement of nasogastric tubes in children. J Pediatr Nurs 2014; 29:e7-12. [PMID: 24071621 DOI: 10.1016/j.pedn.2013.08.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 08/24/2013] [Indexed: 01/12/2023]
Abstract
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.
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Soylu H, Wiseman NE, El-Sayed Y, Yi M, Baier RJ. Radiographic confirmation of feeding tube placement: a diagnostic tool identifying gastrointestinal anomalies. Neonatal Netw 2013; 32:89-94. [PMID: 23477975 DOI: 10.1891/0730-0832.32.2.89] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Feeding tubes are commonly used in neonatal intensive care units, and their abnormal position seen on radiographs may indicate underlying serious problems. We recently cared for two infants who presented with clinical deterioration. An abnormally placed feeding tube seen on the chest radiograph revealed underlying serious conditions. The first case was an infant 29 weeks of age who presented with right-sided pneumothorax after birth. By history and a right-side-displaced orogastric (OG) tube, iatrogenic esophageal perforation was diagnosed. The second case was a 16-day-old infant who presented with recurrent vomiting. An OG tube extending into a cystic mass at the right cardiophrenic angle resulted in diagnosis of a herniated stomach with organoaxial-type volvulus, which required surgical repair. Both cases recovered uneventfully. As illustrated in these two rare cases, feeding tube position is not only important for feeding practice, but it also has diagnostic implications in newborn infants.
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Affiliation(s)
- Hanifi Soylu
- Division of Neonatology, WS-012 Women’s Hospital, Winnipeg, MB, Canada.
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Abstract
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.
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Affiliation(s)
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- Cincinnati Children's Hospital Medical Center, USA
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Vitta L, Raghavan A, Morrell R, Sprigg A. Fluoroscopy-guided insertion of nasojejunal tubes in children - setting local diagnostic reference levels. Pediatr Radiol 2009; 39:1203-8. [PMID: 19789863 DOI: 10.1007/s00247-009-1362-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 05/21/2009] [Accepted: 06/19/2009] [Indexed: 01/15/2023]
Abstract
BACKGROUND Little is known about the radiation burden from fluoroscopy-guided insertions of nasojejunal tubes (NJTs) in children. There are no recommended or published standards of diagnostic reference levels (DRLs) available. OBJECTIVE To establish reference dose area product (DAP) levels for the fluoroscopy-guided insertion of nasojejunal tubes as a basis for setting DRLs for children. In addition, we wanted to assess our local practice and determine the success and complication rates associated with this procedure. MATERIALS AND METHODS Children who had NJT insertion procedures were identified retrospectively from the fluoroscopy database. The age of the child at the time of the procedure, DAP, screening time, outcome of the procedure, and any complications were recorded for each procedure. As the radiation dose depends on the size of the child, the children were assigned to three different age groups. The sample size, mean, median and third-quartile DAPs were calculated for each group. The third-quartile values were used to establish the DRLs. RESULTS Of 186 procedures performed, 172 were successful on the first attempt. These were performed in a total of 43 children with 60% having multiple insertions over time. The third-quartile DAPs were as follows for each age group: 0-12 months, 2.6 cGy cm(2); 1-7 years, 2.45 cGy cm(2); >8 years, 14.6 cGy cm(2). High DAP readings were obtained in the 0-12 months (n = 4) and >8 years (n = 2) age groups. No immediate complications were recorded. CONCLUSION Fluoroscopy-guided insertion of NJTs is a highly successful procedure in a selected population of children and is associated with a low complication rate. The radiation dose per procedure is relatively low.
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Affiliation(s)
- Lavanya Vitta
- Department of Radiology, Sheffield Children's Hospital, Western Bank, Sheffield, S10 2TH, UK.
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Shields L, Allgar V, Arabiat DH, El-Habbal M, Elliott B, Greenman J, Hall J, Imrie C, Kalia S, Wadhawan J. pH testing for detecting the position of nasogastric tubes in adults and children. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
OBJECTIVE The aim of this study was to determine whether pH testing is an accurate method of confirming nasogastric tube (NGT) position in children with and without gastroenteritis in the emergency department. METHODOLOGY A prospective observational study of NGT insertions was conducted at a tertiary pediatric emergency department, during a 9-month period in 2006. We evaluated methods of NGT position confirmation, pH of nasogastric aspirates from patients with and without gastroenteritis, and adverse events. RESULTS A total of 404 patients were enrolled. For 393 patients (97.3%), NGT aspirates could be obtained to assess pH. Of these patients, 294 (74.8%) had a diagnosis of gastroenteritis and 99 (25.2%) did not. There was no difference in median pH between the patients with gastroenteritis (pH, 2; interquartile range, 2-4) and those without gastroenteritis (pH, 2; interquartile range, 2-4; P = 0.09). Overall, 341 patients (86.8%) had a pH of 4 or lower. The patients with gastroenteritis were more likely to have a pH of 4 or lower than the patients without gastroenteritis (P = 0.018). Tube position was confirmed by pH alone in 332 patients (84.5%). Nine (2.6%) of the 341 patients with a pH of 4 or lower also had radiography (7 for causes other than confirmation of NGT position) indicating correct placement of all NGTs. Fifty-two patients (13.2%) had a pH higher than 4, and 18 (34%) of these had the tube position confirmed by radiography, of which 3 had tubes misplaced in the distal esophagus. Irrespective of pH level, there were no respiratory placements clinically or by radiography. Overall, 22 patients (5.6% 95% CI 3.5%-8.3%) required more than 1 attempt for NGT insertion. There were 13 minor adverse events (3.3% 95% CI 1.8%-5.6%) and no major adverse events. CONCLUSIONS Testing of gastric pH is a reliable way of confirming NGT position when the pH is 4 or lower. When the pH is higher than 4, a radiograph may be necessary.
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Freer Y, Lyon A. Nasogastric tube aspirate pH values associated with typical enteral feeding patterns in infants admitted to an NICU. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.jnn.2005.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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