Point-of-Care Ultrasound for Confirmation of Nasogastric and Orogastric Tube Placement in Pediatric Patients

Point-of-care ultrasound for non-vascular invasive procedures in critically ill neonates and children: current status and future perspectives

Point-of-care ultrasound (POCUS) has been established as an essential bedside tool for real-time image guidance of invasive procedures in critically ill neonates and children. While procedural guidance using POCUS has become the standard of care across many adult medicine subspecialties, its use has more recently gained popularity in neonatal and pediatric medicine due in part to improvement in technology and integration of POCUS into physician training programs. With increasing use, emerging data have supported its adoption and shown improvement in pediatric outcomes. Procedures that have traditionally relied on physical landmarks, such as thoracentesis and lumbar puncture, can now be performed under direct visualization using POCUS, increasing success, and reducing complications in our most vulnerable patients. In this review, we describe a global and comprehensive use of POCUS to assist all steps of different non-vascular invasive procedures and the evidence base to support such approach.

CONCLUSION

There has been a recent growth of supportive evidence for using point-of-care ultrasound to guide neonatal and pediatric percutaneous procedural interventions. A global and comprehensive approach for the use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures.

WHAT IS KNOWN

• Point-of-care ultrasound has been established as a powerful tool providing for real-time image guidance of invasive procedures in critically ill neonates and children and allowing to increase both safety and success.

WHAT IS NEW

• A global and comprehensive use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures: from diagnosis to semi-quantitative assessment, and from real-time puncture to follow-up.

Postoperative Handheld Gastric Point-of-Care Ultrasound and Delayed Bowel Function

BACKGROUND

Delayed bowel function (DBF) following intra-abdominal surgery is a common problem that contributes to postoperative complications and prolonged length of stay. Use of a handheld gastric point-of-care ultrasound (GPOCUS) can identify a full vs empty stomach in the postoperative period. We hypothesized that the findings of a full stomach identified on a postoperative day 1 (POD1) GPOCUS exam would predict an increased risk of delayed bowel function.

STUDY DESIGN

A blinded, prospective cohort study was performed. Postoperative colorectal surgery patients were identified as having either a full or empty stomach based on previously published definitions. GPOCUS examinations were performed on POD1 using a handheld ultrasound device, and the clinicians were blinded to the results. Demographic and perioperative data were collected. The primary outcome variable was gastrointestinal-3 (GI-3) recovery, defined as time to tolerance of diet and either flatus or bowel movement.

RESULTS

Fifty-six patients agreed to participate in the study; fifty were eligible and included. Eighteen patients' stomachs were identified as full on POD1 GPOCUS examination, and thirty-two were identified as empty. No significant demographic or perioperative differences existed between groups. Patients with full stomachs had significantly delayed GI-3 recovery (4 vs 1 days, p < 0.0001) and longer length of stay (5 vs 3 days, p < 0.0001). Full-stomach patients also had significantly more emesis and nasogastric tube (NGT) placement (both p < 0.05).

CONCLUSIONS

GPOCUS performed on POD1 can predict DBF, length of stay, likelihood of emesis, and NGT placement. Use of handheld devices for GPOCUS showed promise for the identification of patients at high risk for DBF and could provide an opportunity for pre-emptive intervention.

Ultrasound to Verify Gastric Tube Position in Infants and Children: A Systematic Review

BACKGROUND

Placement of gastric tubes is commonly performed in infants and children but malpositioning is common and is associated with significant complications.

OBJECTIVE

The aim of this systematic review is to identify the evidence on the use of ultrasound to verify correct gastric tube placement in infants and children and gaps in the research.

METHODS

This review was performed using CINAHL, PUBMED, EMBASE and Web of Science databases. Studies were included if they used an empirical study design, were published in English, included infants or children, and evaluated the use of ultrasound to verify correct gastric tube placement compared to radiograph. Sensitivity, specificity, positive and negative predictive values were evaluated.

RESULTS

Four articles were included in the review. Sensitivity estimates were 0.88 to 1.00 and a positive predictive value of 0.99 was reported in one study. Specificity was not reported in any of the included studies. Ultrasound may be an important method to correctly identify gastric tube placement in infants and children with less radiation exposure and cost.

IMPLICATIONS FOR PRACTICE

Ultrasound could be a used to verify gastric tube positioning in infants and children for both initial placement and continued verification leading to reduced radiation exposure and cost.

IMPLICATIONS FOR RESEARCH

Research should focus on evaluating ultrasound specificity and the clinical feasibility of using ultrasound as a standard practice, including cost and time required to complete the exam, as well as the ability of ultrasound to verify gastric tube placement in infants weighing less than 1500 grams.

Gastric Point-of-Care Ultrasound in Acutely and Critically Ill Children (POCUS-ped): A Scoping Review

Introduction

Point-of-care ultrasound (POCUS) use is increasing in pediatric clinical settings. However, gastric POCUS is rarely used, despite its potential value in optimizing the diagnosis and management in several clinical scenarios (i.e., assessing gastric emptying and gastric volume/content, gastric foreign bodies, confirming nasogastric tube placement, and hypertrophic pyloric stenosis). This review aimed to assess how gastric POCUS may be used in acute and critically ill children.

Materials and Methods

An international expert group was established, composed of pediatricians, pediatric intensivists, anesthesiologists, radiologists, nurses, and a methodologist. A scoping review was conducted with an aim to describe the use of gastric POCUS in pediatrics in acute and critical care settings. A literature search was conducted in three databases, to identify studies published between 1998 and 2022. Abstracts and relevant full texts were screened for eligibility, and data were extracted, according to the JBI methodology (Johanna Briggs Institute).

Results

A total of 70 studies were included. Most studies (n = 47; 67%) were conducted to assess gastric emptying and gastric volume/contents. The studies assessed gastric volume, the impact of different feed types (breast milk, fortifiers, and thickeners) and feed administration modes on gastric emptying, and gastric volume/content prior to sedation or anesthesia or during surgery. Other studies described the use of gastric POCUS in foreign body ingestion (n = 6), nasogastric tube placement (n = 5), hypertrophic pyloric stenosis (n = 8), and gastric insufflation during mechanical ventilatory support (n = 4). POCUS was performed by neonatologists, anesthesiologists, emergency department physicians, and surgeons. Their learning curve was rapid, and the accuracy was high when compared to that of the ultrasound performed by radiologists (RADUS) or other gold standards (e.g., endoscopy, radiography, and MRI). No study conducted in critically ill children was found apart from that in neonatal intensive care in preterms.

Discussion

Gastric POCUS appears useful and reliable in a variety of pediatric clinical settings. It may help optimize induction in emergency sedation/anesthesia, diagnose foreign bodies and hypertrophic pyloric stenosis, and assist in confirming nasogastric tube placement, avoiding delays in obtaining confirmatory examinations (RADUS, x-rays, etc.) and reducing radiation exposure. It may be useful in pediatric intensive care but requires further investigation.

Point-of-Care Gastric Ultrasound Confirms the Inaccuracy of Gastric Residual Volume Measurement by Aspiration in Critically Ill Children: GastriPed Study

Introduction

No consensus exists on how to define enteral nutrition tolerance in critically ill children, and the relevance of gastric residual volume (GRV) is currently debated. The use of point-of-care ultrasound (POCUS) is increasing among pediatric intensivists, and gastric POCUS may offer a new bedside tool to assess feeding tolerance and pre-procedural status of the stomach content.

Materials and Methods

A prospective observational study was conducted in a tertiary pediatric intensive care unit. Children on mechanical ventilation and enteral nutrition were included. Gastric POCUS was performed to assess gastric contents (empty, full of liquids or solids), and gastric volume was calculated as per the Spencer formula. Then, GRV was aspirated and measured. The second set of gastric POCUS measurements was performed, similarly to the first one performed prior to GRV measurement. The ability of GRV measurement to empty the stomach was compared to POCUS findings. Both GRV and POCUS gastric volumes were compared with any clinical signs of enteral feeding intolerance (vomiting).

Results

Data from 64 children were analyzed. Gastric volumes were decreased between the POCUS measurements performed pre- and post-GRV aspiration [full stomach, n = 59 (92.2%) decreased to n = 46 (71.9%), p =0.001; gastric volume: 3.18 (2.40-4.60) ml/kg decreased to 2.65 (1.57-3.57), p < 0.001]. However, the stomach was not empty after GRV aspiration in 46/64 (71.9%) of the children. There was no association between signs of enteral feeding intolerance and the GRV obtained, nor with gastric volume measured with POCUS.

Discussion

Gastric residual volume aspiration failed to empty the stomach and appeared unreliable as a measure of gastric emptiness. Gastric POCUS needs further evaluation to confirm its role.