Use of small-bore feeding tubes: successes and failures

Enteral Nutrition Therapy: Historical Perspective, Utilization, and Complications

PURPOSE OF REVIEW

Enteral nutrition (EN) therapy can provide vital nutrition support for patients with various medical conditions as long as it is indicated and supported by ethical reasoning. This review seeks to offer a detailed account of the history of EN development, highlighting key milestones and recent advances in the field. Additionally, it covers common complications associated with EN and their management.

RECENT FINDINGS

After years of research and development, we have reached newer generations of enteral feeding formulations, more options for enteral tubes and connectors, and a better understanding of EN therapy challenges. Given the availability of many different formulas, selecting a feeding formula with the best evidence for specific indications for enteral feeding is recommended. Initiation of enteral feeding with standard polymeric formula remains the standard of care. Transition to small-bore connectors remains suboptimal. Evidence-based practices should be followed to recognize and reduce possible enteral feeding complications early.

[Safe position check of gastric tubes: an often underestimated topic to prevent possible severe complications]

The insertion of a gastric tube in the operating room (OR) or in an intensive care unit (ICU) is a routine procedure. Although the tube is often inserted by nursing staff, the indications and selection of the procedure for position control remain the physician's responsibility. For immediate position control, the injection of air through the inserted tube with simultaneous auscultation of the epigastrium is probably the most simple and common clinical method. A typical "bubbling" is often regarded as a sufficiently reliable sign of correct gastric tube position. This procedure can be described as a routine standard both in the OR and the ICU; however, numerous examples from clinical practice and quality reviews show gastric tube mispositioning in esophageal, bronchial, pulmonary or even pleural positions in individual cases. Since auscultation findings are misinterpreted as tracheal, bronchial, or pleural secretions, mispositioning may remain undetected. In addition, adequate documentation of the procedure is lacking. In the worst case, hyperosmolar tube feeding occurs via the malpositioned tube into the lungs or pleural space causing subsequent severe pneumonia or pleuritis, which is often fatal for the patient outcome. In contrast to many other similar procedures in intensive care medicine, such as the installation of central venous catheters or endotracheal intubation, to our knowledge there is no uniform standard for forensic verification of the correct position after gastric tube positioning. The present work provides an overview of existing practices and the scientific background for confirmation of gastric tube positioning without ionizing radiation.

Ultrasound-Assisted versus Endoscopic Nasojejunal Tube Placement for Acute Pancreatitis: A Retrospective Feasibility Study

Objective

The optimal technique for nasojejunal tube (NJT) placement in terms of facilitating early enteral nutrition (EN) in patients with acute pancreatitis (AP) is unclear. In this study, we aimed to evaluate the impact of two common techniques on EN implementation and clinical outcomes in a group of AP patients.

Methods

This is a retrospective study. All the data were extracted from an electronic database from August 2015 to October 2017. Patients with a diagnosis of AP requiring NJT placement were retrospectively analyzed. The primary outcome was the successful procedural rate.

Results

A total of 53 eligible patients were enrolled, of whom 30 received an ultrasound-assisted technique and the rest received the endoscopy method (n = 23). There was no difference in success rates of initial placement procedures between the two groups (93.3% and 95.7% in the ultrasound-assisted group and endoscopy group, respectively). The mean amount of EN delivery within the first three days after NJT placement was significantly higher in the ultrasound-assisted group (841.4 kcal (95% CI: 738.8, 944 kcal) vs. 652.5 kcal (95% CI: 562.5, 742.6 kcal), P = 0.018). Moreover, a slight increased postprocedural intra-abdominal pressure (IAP) was observed in patients undergoing endoscopic procedures, but not in the ultrasound-assisted group, especially at 6 hours after NJT placement (0.35 vs. -2.01 from baseline, P < 0.05). For clinical outcomes, we observed no difference between groups.

Conclusion

Compared with endoscopic procedures, ultrasound-assisted NJT placement possesses the acceptable success rates of initial placement procedures.

Nasogastric/nasoenteric tube-related adverse events: an integrative review

Objective:

to analyze in the scientific literature the evidence on nasogastric/nasoenteric tube related adverse events in adult patients.

Method:

integrative literature review through the search of publications in journals indexed in PubMed/MEDLINE, CINAHL, LILACS, EMBASE and Scopus, and hand searching, was undertaken up to April 2017.

Results:

the sample consisted of 69 primary studies, mainly in English and published in the USA and UK. They were divided in two main categories and subcategories: the first category refers to Mechanical Adverse Events (respiratory complications; esophageal or pharyngeal complications; tube obstruction; intestinal perforation; intracranial perforation and unplanned tube removal) and the second alludes to Others (pressure injury related to fixation and misconnections). Death was reported in 16 articles.

Conclusion:

nasogastric/nasoenteric tube related adverse events are relatively common and the majority involved respiratory harm that resulted in increased hospitalization and/or death. The results may contribute to healthcare professionals, especially nurses, to develop an evidence-based guideline for insertion and correct positioning of bedside enteral tubes in adult patients.

Feasibility and safety of a novel electromagnetic device for small-bore feeding tube placement

Background

Misplacement of enteral feeding tubes (EFT) in the lungs is a serious and potentially fatal event. A recent Food and Drug Administration Patient Safety Alert emphasized the need for improved technology for the safe and effective delivery of EFTs.

Objective

We investigated the feasibility and safety of ENvue, a novel electromagnetic tracking system (EMTS) to aid qualified operators in the placement of EFT.

Methods

This is a prospective, single-arm study of patients in intensive care units at two US hospitals who required EFTs. The primary outcome was appropriate placement of EFTs without occurrence of guidance-related adverse events (AEs), as confirmed by both EMTS and radiography. Secondary outcomes were reconfirmation of the EFT tip location at a follow-up visit using the EMTS compared with radiography, tube retrograde migration from initial location and AEs.

Results

Sixty-five patients were included in the intent-to-treat analysis. EFTs were successfully placed in 57 patients. In eight patients, placement was unsuccessful due to anatomic abnormalities. According to both the EMTS and radiography, no lung placements occurred. No pneumothoraces were reported, nor any guidance-related AEs. Precise agreement of tube tip location was achieved between the EMTS evaluations and radiographs for 56 of the 58 (96.5%) successful placements (one patient had two placements). Tube tip location was re-confirmed 12–49 hours after EFT insertion by the EMTS and radiographs in 48 patients (84%). For 43/48 patients (89.5%), full agreement between the EMTS and radiography evaluations was observed. For the five remaining patients, the misalignment between the evaluations was within the gastrointestinal tract. Retrograde migration from the initial location was observed in 4/49 patients (8%).

Conclusion

A novel electromagnetic system demonstrated feasibility and safety of real-time and follow-up tracking of EFT placement into the stomach and small intestine, as confirmed by radiographs. No inadvertent placements into the lungs were documented.

Level of evidence

Level V (large case series).

Clinical usefulness of capnographic monitoring when inserting a feeding tube in critically ill patients: retrospective cohort study

BACKGROUND

It is not rare for a small-bore feeding tube to be inserted incorrectly into the respiratory system in critically ill patients. Thus, monitoring is necessary to prevent respiratory malplacement of the tube. We investigated the utility of capnographic monitoring to prevent respiratory complications due to feeding tube mispositioning in critically ill patients.

METHODS

This study was a pre and post-interventional study, including 445 feeding tube placements events studied retrospectively in the medical and surgical intensive care units of the Samsung Medical Center. We compared outcomes between time periods before and after capnographic monitoring and documented any respiratory complications.

RESULTS

Feeding tubes were inserted in 275 cases without capnographic monitoring. Capnographic monitoring was performed in 170 cases. Sixteen patients (4%) had respiratory complications of all tube placements. Feeding tube was inserted into the trachea in 11 (2%) patients and for a pneumothorax in five (1%) patients. Fourteen cases of respiratory complications were detected in the control group (14/275, 5%, 10 tracheal insertions and four pneumothoraxes). Two respiratory complications were detected in the capnographic monitoring group (2/170, 1%, one tracheal insertion and one pneumothorax). Respiratory complications were detected less frequently in the capnographic monitoring group than that in the control group (P = 0.035).

CONCLUSIONS

Capnographic monitoring is simple, easy to learn, and may be useful to prevent respiratory complications when placing a feeding tube in a critically ill patient.

The Placement of Post-pyloric Feeding Tubes Using DRX-Revolution Mobile X-Ray System in an ICU. A Case Series

Enteral nutrition is crucial for ensuring that critically ill patients have a proper intake of food, water, and medicine. Methods to ensure this requirement should be initiated as early as possible. The use of PPF has several advantages compared to the use of a nasogastric feeding tube. In the present paper, the cases of three critically ill patients with a nonfunctional gastrointestinal system on admission to ICU, are detailed. Enteral feeding through a nasogastric tube by prokinetic agent therapy had been unsuccessful. The bedside placement of a post-pyloric feeding tube by the DRX-Revolution X-ray system is described.

Thoracic trauma in horses

Traumatic injuries involving the thorax can be superficial, necessitating only routine wound care, or they may extend to deeper tissue planes and disrupt structures immediately vital to respiratory and cardiac function. Diagnostic imaging, especially ultrasound, should be considered part of a comprehensive examination, both at admission and during follow-up. Horses generally respond well to diligent monitoring, intervention for complications, and appropriate medical or surgical care after sustaining traumatic wounds of the thorax. This article reviews the various types of thoracic injury and their management.

Metoclopramide or domperidone improves post-pyloric placement of spiral nasojejunal tubes in critically ill patients: a prospective, multicenter, open-label, randomized, controlled clinical trial

INTRODUCTION

The use of prokinetic agents on post-pyloric placement of spiral nasojejunal tubes is controversial. The aim of the present study was to examine if metoclopramide or domperidone can increase the success rate of post-pyloric placement of spiral nasojejunal tubes.

METHODS

A multicenter, open-label, randomized, controlled trial was conducted in seven hospitals in China between April 2012 and February 2014. Patients admitted to the intensive care unit and requiring enteral nutrition for more than three days were randomly assigned to the metoclopramide, domperidone or control groups (1:1:1 ratio). The primary outcome was defined as the success rate of post-pyloric placement of spiral nasojejunal tubes, assessed 24 hours after initial placement. Secondary outcomes included success rate of post-D1, post-D2, post-D3 and proximal jejunum placement and tube migration distance. Safety of the study drugs and the tubes during the entire study period were recorded.

RESULTS

In total, 307 patients were allocated to the metoclopramide (n = 103), domperidone (n = 100) or control group (n = 104). The success rate of post-pyloric placement after 24 hours in the metoclopramide, domperidone and control groups was 55.0%, 51.5% and 27.3%, respectively (P = 0.0001). Logistic regression analysis identified the use of prokinetic agents, Acute Physiology and Chronic Health Evaluation (APACHE) II score <20, Sequential Organ Failure Assessment (SOFA) score <12 and without vasopressor as independent factors influencing the success rate of post-pyloric placement. No serious drug-related adverse reaction was observed.

CONCLUSIONS

Prokinetic agents, such as metoclopramide or domperidone, are effective at improving the success rate of post-pyloric placement of spiral nasojejunal tubes in critically ill patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-TRC-12001956 . Registered 21 February 2012.

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

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

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

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

Analysis of an electromagnetic tube placement device versus a self-advancing nasal jejunal device for postpyloric feeding tube placement

BACKGROUND

Initiation of enteral feeding is an important part of the best practice model for critically ill patients. Although nasogastric feeding is appropriate for the majority of patients requiring short-term nutrition support, certain patients benefit greatly from postpyloric feeding.

OBJECTIVE

To determine which of 2 specialized enteral tube systems achieved postpyloric placement on initial insertion attempt most efficiently.

DESIGN

Retrospective study comparing the Tiger 2 tube (T2T) and Cortrak Enteral Access System (C-EAS).

SETTING

Academic medical center, mixed intensive care unit (ICU).

PATIENTS

All patients admitted to the ICU between 2009 and 2013 who had either a C-EAS or T2T placed.

MEASUREMENTS

Success rate for postpyloric placement, congruency of real-time tube placement with x-ray confirmation for C-EAS, and complication rates.

RESULTS

Seventy-one T2T and 74 C-EAS patients were included. The T2T was postpyloric 62% (44/71) of attempted placements. C-EAS was postpyloric 43% (32/74) of attempted placements (P = 0.03). C-EAS tracings accurately reflected chest x-ray findings 83% and 82% for postpyloric and non-postpyloric insertion, respectively. During the entire study period, no adverse events were recorded.

CONCLUSION

Our institution evaluated 2 different systems designed to ensure postpyloric placement of a small bore feeding tube. No literature exists directly comparing the 2 systems. Our retrospective review, although limited, showed that the T2T was more effective at postpyloric placement on first attempt. Although 1 benefit of the C-EAS system may be real-time visualization, our practice showed this system to be user dependent, which likely led to less success with postpyloric placement.

Nurse initiated reinsertion of nasogastric tubes in the emergency department: a randomised controlled trial

BACKGROUND

Patients sometimes present to the Emergency Department (ED) for reinsertion of nasogastric tubes (NGT) because of tube dislodgement. They usually need to wait for a long time to see a doctor before the NGT can be reinserted. This study aimed at investigating the feasibility of nurse initiated NGT insertion for these patients in order to improve patient outcome.

METHODS

This is a prospective randomised controlled trial. Patients requiring NGT reinsertion were randomised to receive treatment by either nurse initiated reinsertion of NGT (NIRNGT) or the standard NGT insertion protocol. Questionnaires were given to both groups of patients, relatives and ED nurses afterwards. Outcome measures included door-to-treatment time, total length of stay (LoS) in the ED and the satisfaction of patients, relatives and nurses.

RESULTS

Twenty-two patients were recruited to the study and randomised: 12 in the standard NGT insertion protocol and 10 in the NIRNGT protocol. The door-to-treatment time of the NIRNGT group (mean=45.6 min) was significantly shorter than the standard NGT insertion group (mean=123.08 min; p=0.003). No statistically significant difference was detected between the total ED LoS (p=0.575). Patients, relatives and nurses were generally satisfied with the new treatment protocol.

CONCLUSION

Patients can undergo NGT reinsertion significantly faster by adopting a nurse initiated reinsertion of NGT (NIRNGT) protocol.

Post-pyloric feeding

Postpyloric feeding is an important and promising alternative to parenteral nutrition. The indications for this kind of feeding are increasing and include a variety of clinical conditions, such as gastroparesis, acute pancreatitis, gastric outlet stenosis, hyperemesis (including gravida), recurrent aspiration, tracheoesophageal fistula and stenosis in gastroenterostomy. This review discusses the differences between pre- and postpyloric feeding, indications and contraindications, advantages and disadvantages, and provides an overview of the techniques of placement of various postpyloric devices.

Early nutritional therapy: the role of enteral and parenteral routes

PURPOSE OF REVIEW

Early nutrition is defined as the initiation of nutritional therapy within 48 h of either hospital admission or surgery. However, optimal timing for initiation of nutritional therapy through either enteral or parenteral routes remains poorly defined with the existing data. We reviewed the recent literature investigating the role of early enteral and parenteral nutrition in critical illness and perioperative care.

RECENT FINDINGS

Recent studies in both trauma/surgical and nonsurgical patients support the superiority of early enteral over early parenteral nutrition. However, late commencement of enteral feeding should be avoided if the gastrointestinal tract is functional. Both prolonged hypocaloric enteral feeding and hypercaloric parenteral nutrition should be avoided, although the precise caloric target remains controversial.

SUMMARY

Early enteral nutrition remains the first option for the critically ill patient. However, there seems to be increased favor for combined enteral-parenteral therapy in cases of sustained hypocaloric enteral nutrition. The key issue is when the dual regimen should be initiated. Although more study is required to determine the optimal timing to initiate a combined enteral-parenteral approach, enteral nutrition should be initiated early and parenteral nutrition added if caloric-protein targets cannot be achieved after a few days.