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Hawk H, Valdivia H. Bedside Methods for Transpyloric Feeding Tube Insertion in Hospitalized Children: A Systematic Review of Randomized and non-Randomized Trials. J Pediatr Nurs 2021; 60:238-246. [PMID: 34304053 DOI: 10.1016/j.pedn.2021.06.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 11/18/2022]
Abstract
PROBLEM Enteral nutrition is a critical component of therapy for many hospitalized children. Some children, especially those with critical illness, require post-pyloric enteral nutrition, but placement of post-pyloric feeding tubes poses challenges, necessitating costly fluoroscopy procedures and delaying initiation of enteral nutrition. There is no established standard method for pediatric transpyloric tube placement at the bedside. ELIGIBILITY CRITERIA We searched for trials that assessed the efficacy of methods for transpyloric tube placement at the bedside. Studies that evaluated gastric insufflation, prokinetic agents, pH guided devices, and electromagnetic devices with an objective of bedside transpyloric tube placement in children ages one month to 18 years were included. RESULTS After each author independently reviewed the search results, we agreed on fourteen articles for inclusion, consisting of six randomized controlled trials, five quasi-experimental studies, and three cohort studies. Intervention protocols varied, both within and between studies, with most trials incorporating more than one variable in the intervention. CONCLUSIONS The heterogeneity of the research does not provide clear direction about best practices. All interventions demonstrated some efficacy, with the exception of erythromycin. Gastric insufflation, the most prevalent intervention studied, is safe and at least moderately effective. The research demonstrates the positive impact of a small, trained team of personnel for the insertion of a transpyloric tube. IMPLICATIONS High quality studies with clear protocols evaluating a single variable are needed in order to establish a bedside transpyloric tube placement protocol. We recommend studies on the efficacy of a dedicated team for this procedure.
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Affiliation(s)
- Heather Hawk
- Oregon Health and Science University, School of Nursing, OR, United States of America.
| | - Hector Valdivia
- Seattle Children's Hospital, Pediatric Intensive Care Unit & Clinical Effectiveness, WA, United States of America.
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Williams L. Postpyloric Tube Insertion in Children: What Method Is Best? AACN Adv Crit Care 2020; 31:419-424. [PMID: 33313708 DOI: 10.4037/aacnacc2020263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Lori Williams
- Lori Williams is Clinical Nurse Specialist, Pediatric Universal Care Unit and Float Team, American Family Children's Hospital, University of Wisconsin Hospitals and Clinics, 1675 Highland Avenue, Room 7404, Madison, WI 53792
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Turner AD, Hamilton SM, Callif C, Ariagno KA, Arena AE, Mehta NM, Martinez EE. Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit. Nutr Clin Pract 2020; 35:299-305. [PMID: 31990093 DOI: 10.1002/ncp.10452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program. METHODS In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined. RESULTS The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction. CONCLUSION Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.
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Affiliation(s)
| | - Susan M Hamilton
- Department of Cardiovascular/Critical Care Nursing, Boston, Massachusetts, USA
| | - Charles Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA
| | - Katelyn A Ariagno
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anastasia E Arena
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Abstract
BACKGROUND Patients in the neonatal intensive care unit are a vulnerable population with specific nutritional requirements, which include increased protein and caloric needs for adequate growth. Some infants cannot tolerate gastric feeds and need to have postpyloric feeds to grow. Placement of a postpyloric tube can be done by gastric insufflation. Gastric insufflation is a technique where air is inserted into the stomach as a nasogastric tube is advanced through the pylorus to the duodenum. There is research to support this technique in pediatrics, but scant evidence exists for placement of postpyloric tubes in the infant population. PURPOSE The aim of this quality improvement practice project was to determine whether the current practice for postpyloric tube placement by the bedside nurses in the neonatal intensive care unit is safe and effective. METHODS Data were prospectively collected on 38 infants requiring placement of 60 postpyloric tubes over an 8-week period. RESULTS The results indicate a success rate of 95.6% for tube placement when a subset of infants diagnosed with congenital diaphragmatic hernia (CDH) (n = 15) was excluded. Six (40%) of the 15 infants with CDH had postpyloric tubes placed successfully. Nursing years of experience did not affect successful postpyloric tube placement. IMPLICATIONS FOR PRACTICE The postpyloric tube placement policy was modified as a result of findings from this project. Placement of a postpyloric tube with one attempt by the bedside nurse was safe and effective in most preterm infants in our care excluding patients with CDH. The new policy reduced infants' exposure to radiation due to a decrease in the number of x-rays in comparison to interventional radiology placement. IMPLICATIONS FOR RESEARCH Further research should be done by units that primarily care for low birth-weight premature infants.
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Goggans M, Pickard S, West AN, Shah S, Kimura D. Transpyloric Feeding Tube Placement Using Electromagnetic Placement Device in Children. Nutr Clin Pract 2016; 32:233-237. [DOI: 10.1177/0884533616682683] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Margaret Goggans
- Department of Nutrition Therapy, Le Bonheur Children’s Hospital, Memphis, Tennessee, USA
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sharon Pickard
- Education Services, Le Bonheur Children’s Hospital, Memphis, Tennessee, USA
| | - Alina Nico West
- Division of Critical Care Medicine, Le Bonheur Children’s Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Samir Shah
- Division of Critical Care Medicine, Le Bonheur Children’s Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Dai Kimura
- Division of Critical Care Medicine, Le Bonheur Children’s Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Von der Brelie C, Seifert M, Rot S, Tittel A, Sanft C, Meier U, Lemcke J. Sedation of Patients with Acute Aneurysmal Subarachnoid Hemorrhage with Ketamine Is Safe and Might Influence the Occurrence of Cerebral Infarctions Associated with Delayed Cerebral Ischemia. World Neurosurg 2016; 97:374-382. [PMID: 27742511 DOI: 10.1016/j.wneu.2016.09.121] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 09/25/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Ketamine has neuroprotective characteristics as well as beneficial cardiocirculatory properties and may thus reduce vasopressor consumption. In contrast, sedation with ketamine (like any other sedative drug) has side effects. This study assesses the influence of ketamine on intracranial pressure (ICP), on the consumption of vasopressors in induced hypertension therapy, and on the occurrence of delayed cerebral ischemia (DCI)-associated cerebral infarctions, with particular focus on the complications of sedation in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS This is a retrospective, observational study. Sixty-five patients with SAH who underwent a period of sedation were included. The clinical course variables (Richmond Agitation and Sedation scale score, ICP values, consumption of vasopressors, complications of sedation, outcome, and other clinical parameters) were analyzed. Cranial computed tomography results were analyzed. RESULTS Forty-one patients underwent sedation including ketamine (63.1%). Ketamine decreased the ICP in 92.7% of the cases. Vasopressors was reduced in 53.6%. DCI-associated cerebral infarctions occurred significantly less often in the patient cohort being treated with sedation including ketamine (7.3% vs. 25% in the nonketamine group; P = 0.04). The rate of major complications was not higher in the ketamine group. Outcome was not different regarding the groups if they were sedated with or without ketamine. CONCLUSIONS Ketamine decreases the ICP and is not associated with a higher rate of complications. The rate of DCI-associated cerebral infarctions was lower in the ketamine group. Ketamine administration led to a reduction of vasopressors used for induced hypertension.
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Affiliation(s)
- Christian Von der Brelie
- Department of Neurosurgery, University of Göttingen, Göttingen, Germany; Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany.
| | - Michael Seifert
- Department of Anesthesiology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Sergej Rot
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Anja Tittel
- Department of Radiology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Carsten Sanft
- Department of Anesthesiology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Ullrich Meier
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
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Kozin ED, Remenschneider AK, Cunnane ME, Deschler DG. Otolaryngologist-assisted fluoroscopic-guided nasogastric tube placement in the postoperative laryngectomy patient. Laryngoscope 2014; 124:916-20. [PMID: 24347385 PMCID: PMC4465531 DOI: 10.1002/lary.24560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 11/21/2013] [Accepted: 12/09/2013] [Indexed: 11/09/2022]
Abstract
Laryngoscope, 124:916–920, 2014
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Affiliation(s)
- Elliott D Kozin
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
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A Canadian survey of perceived barriers to initiation and continuation of enteral feeding in PICUs. Pediatr Crit Care Med 2014; 15:e49-55. [PMID: 24196008 DOI: 10.1097/pcc.0000000000000016] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Clinicians believe nutrition support is important; however, delivery of enteral nutrition may be delayed or interrupted due to a lack of guidelines or perceived contraindications to administration. The aim of this national survey was to examine the knowledge and perceived barriers among clinicians which prevent enteral nutrition administration to PICU patients. DESIGN The survey consisted of 23 questions (19 primary and four branching). The survey was validated using a semistructured pilot test by three pediatric critical care intensivists and two pediatric critical care registered dietitians external to the study team. SETTING The survey was electronically distributed to clinicians in all PICUs across Canada. POPULATION One hundred sixty-two PICU clinicians, including 96 staff intensivists, eight clinical assistants, 36 fellows, and 22 registered dietitians from PICUs across Canada. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The survey was administered from January to March 2013. The response rate was 50% (55 staff intensivists, two clinical assistants, nine fellows, and 15 registered dietitians). There was high variability among clinicians regarding reasons to delay the onset of enteral nutrition or interrupt enteral nutrition administration. High variability (> 70% agreement and < 10% disagreement or vice versa) was found for some reasons to delay or interrupt enteral nutrition, including lactates (rising or > 2 or > 4 mmol/L), high gastric residual volumes, CT/MRI scans, and hypoplastic left heart syndrome. Sixty-eight percent of PICU clinicians reported no written feeding protocol to be in place. CONCLUSIONS Overall, there is high variability among clinicians regarding acceptable procedural and clinical barriers to enteral nutrition administration; this may be improved by a standardized feeding protocol. Therefore, further research must be conducted to provide clinicians with evidence to support their practices for enteral nutrition administration.
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Keehn A, O'Brien C, Mazurak V, Brunet-Wood K, Joffe A, de Caen A, Larsen B. Epidemiology of interruptions to nutrition support in critically ill children in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2013; 39:211-7. [PMID: 24285250 DOI: 10.1177/0148607113513800] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nutrition support is often delayed or interrupted. The aim of this study is to identify reasons for and quantify time spent without nutrition in a mixed medical-surgical-cardiac pediatric intensive care unit (PICU). METHODS Data were prospectively collected to describe the patient cohort (anthropometrics and diagnostic category) and nutrition practices (time to nutrition initiation; frequency, duration, and causes of interruptions; and overall caloric intake). Descriptive statistics were used; comparisons of groups were performed using an independent t test and P < .05 as significance. RESULTS The mean (standard deviation) time to nutrition initiation was 22.8 (16.6) hours following admission; 35% of patients were initiated after >24 hours. Nutrition was interrupted 1.2 (2.0) times per patient. Time spent without nutrition due to interruptions was 11.6 (23.0) hours, up to 102 hours. Patients spent 42.4% (28.2%) of their median (range) PICU admission of 2.9 days (0.25-39 days) without any form of nutrition. Patients aged 0-6 months had a significantly higher mean number and duration of interruptions (P = .001 and P < .001, respectively) compared with children >6 months. Interruptions due to surgery and planned extubation lasted significantly longer than all other interruptions (P < .001 and P = .001, respectively). Pediatric Risk of Mortality (PRISM) III scores were not correlated with percentage of length of stay spent without nutrition (r = 0.137). CONCLUSIONS Prolonged time to nutrition initiation and interruptions in delivery caused pediatric patients to spend a high proportion of admission without nutrition support, preventing most from meeting energy requirements. Further research addressing specific patient outcomes is required to define optimal initiation times and appropriate procedural-specific fasting times.
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Affiliation(s)
- Alysha Keehn
- University of Alberta, Edmonton, Alberta, Canada
| | | | - Vera Mazurak
- University of Alberta, Edmonton, Alberta, Canada
| | | | - Ari Joffe
- University of Alberta, Edmonton, Alberta, Canada Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Allan de Caen
- University of Alberta, Edmonton, Alberta, Canada Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Bodil Larsen
- Stollery Children's Hospital, Edmonton, Alberta, Canada Alberta Health Services, Edmonton, Alberta, Canada
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Fluoroscopically Guided Nasojejunal Enteral Tube Placement in Infants and Young Children. AJR Am J Roentgenol 2009; 193:545-8. [DOI: 10.2214/ajr.08.1341] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Successful placement of postpyloric enteral tubes using electromagnetic guidance in critically ill children. Pediatr Crit Care Med 2009; 10:196-200. [PMID: 19188874 DOI: 10.1097/pcc.0b013e31819a3668] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Initiation of postpyloric feeding is often delayed by difficulties in placement of enteral tubes. We evaluated the effectiveness of bedside postpyloric enteral tube (PET) placement using an electromagnetic (EM)-guided device. We hypothesized that: 1) EM-guided placement of PETs would be successful more often than standard blind placement with a shorter total time to successful placement and 2) the EM-guided technique would have similar overall costs to the standard technique. DESIGN Prospective cohort trial with serial control groups in a pediatric intensive care unit at a tertiary care children's hospital. INTERVENTIONS We collected data on a cohort of consecutive pediatric intensive care unit patients who underwent PET placement by standard blind technique followed by a cohort who underwent EM-guided placement. The primary outcome measure was successful placement determined by abdominal radiography. MEASUREMENTS AND MAIN RESULTS One hundred seven patients were evaluated in the trial: 57 in the standard group and 50 in the EM-guided group. Demographic data, percent intubated, and admission diagnosis were similar in both groups. Forty-one of 50 patients (82%) in the EM-guided group had successful placement compared with 22 of 57 in the standard group (38%) (p < 0.0001). The average time to successful placement was 1.7 vs. 21 hours in the EM-guided group and standard group, respectively (p < 0.0001). Children in the EM-guided group received fewer radiographs (p = 0.007) and were given more prokinetic drugs (p = 0.045). There were no episodes of pneumothorax in either group. After controlling for prokinetic drug use, EM-guided placement was more likely to result in successful placement than the standard blind technique (odds ratio 6.4, 95% confidence interval 2.5-16.3). An annual placement rate of 250 PETs by EM guidance, based on our institution's current utilization rates, is associated with a cost savings of $55.46 per PET placed. CONCLUSION EM guidance is an efficient and cost-effective method of bedside PET placement.
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Meyer R, Harrison S, Cooper M, Habibi P. Successful blind placement of nasojejunal tubes in paediatric intensive care: impact of training and audit. J Adv Nurs 2007; 60:402-8. [DOI: 10.1111/j.1365-2648.2007.04401.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Creel AM, Winkler MK. Oral and nasal enteral tube placement errors and complications in a pediatric intensive care unit. Pediatr Crit Care Med 2007; 8:161-4. [PMID: 17273117 DOI: 10.1097/01.pcc.0000257035.54831.26] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To report five cases of errors in the placement of oral/nasal enteral tubes in a pediatric intensive care unit, and to review literature on placement techniques and complication rates. DESIGN Case series and review of the literature. SETTING A 19-bed pediatric intensive care unit in a tertiary care pediatric hospital. PATIENTS A 14-yr-old male with respiratory distress following a near drowning, a 10-yr-old male with recurrent acute lymphocytic leukemia and Pneumocystis carinii pneumonia, a 16-yr-old female with complex congenital heart disease and respiratory failure, a 16-yr-old male with status asthmaticus, and a 2-yr-old male with congenital heart disease. INTERVENTIONS None. MAIN RESULTS Five cases of enteral tube placement errors occurred in our combined medical-surgical pediatric critical care unit within the past year. All five resulted in placement of the feeding tube in the respiratory tract, four occurred despite the presence of cuffed endotracheal tubes. Three of the five patients had subsequent worsening of their respiratory status. One developed a pneumothorax, one developed pulmonary hemorrhage, and one developed an increased oxygen requirement. CONCLUSIONS Patients in the pediatric intensive care unit may have characteristics that place them at an increased risk for misplacement of oral or nasal enteral tubes into the respiratory tract. Placement of enteral tubes into the respiratory tract may cause serious morbidity and possibly mortality. Checking the placement of enteral tubes with traditional methods does not prevent misplacement in the respiratory tree, and new techniques should be considered.
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Affiliation(s)
- Amy M Creel
- Department of Pediatric Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
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.
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