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Tsujimoto Y, Kataoka Y, Banno M, Anan K, Shiroshita A, Jujo S. Ultrasonography for confirmation of gastric tube placement. Cochrane Database Syst Rev 2024; 7:CD012083. [PMID: 39051488 PMCID: PMC11270641 DOI: 10.1002/14651858.cd012083.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
BACKGROUND Gastric tubes are commonly used for the administration of drugs and tube feeding for people who are unable to swallow. Feeding via a tube misplaced in the trachea can result in severe pneumonia. Therefore, the confirmation of tube placement in the stomach after tube insertion is important. Recent studies have reported that ultrasonography provides good diagnostic accuracy estimates in the confirmation of appropriate tube placement. Hence, ultrasound could provide a promising alternative to X-rays in the confirmation of tube placement, especially in settings where X-ray facilities are unavailable or difficult to access. OBJECTIVES To assess the diagnostic accuracy of ultrasound alone or in combination with other methods for gastric tube placement confirmation in children and adults. SEARCH METHODS This systematic review is an update of a previously published Cochrane review. For this update, we searched the Cochrane Library (2021, Issue 6), MEDLINE (to April 2023), Embase (to April 2023), five other databases (to July 2021), and reference lists of articles, and contacted study authors. SELECTION CRITERIA We included studies that evaluated the diagnostic accuracy of naso- and orogastric tube placement confirmed by ultrasound visualization using X-ray visualization as the reference standard. We included cross-sectional studies and case-control studies. We excluded case series or case reports. We excluded studies if X-ray visualization was not the reference standard or if the tube being placed was a gastrostomy or enteric tube. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the methodological quality and extracted data from each of the included studies. We contacted the authors of the included studies to obtain missing data. There were sparse data for specificity. Therefore, we performed a meta-analysis of only sensitivity using a univariate random-effects logistic regression model to combine data from studies that used the same method and echo window. MAIN RESULTS We identified 12 new studies in addition to 10 studies included in the earlier version of this review, totalling 1939 participants and 1944 tube insertions. Overall, we judged the risk of bias in the included studies as low or unclear. No study was at low risk of bias or low concern for applicability in every QUADAS-2 domain. There were limited data (152 participants) for misplacement detection (specificity) due to the low incidence of misplacement. The summary sensitivity of ultrasound on neck and abdomen echo windows were 0.96 (95% confidence interval (CI) 0.92 to 0.98; moderate-certainty evidence) for air injection and 0.98 (95% CI 0.83 to 1.00; moderate-certainty evidence) for saline injection. The summary sensitivity of ultrasound on abdomen echo window was 0.96 (95% CI 0.65 to 1.00; very low-certainty evidence) for air injection and 0.97 (95% CI 0.95 to 0.99; moderate-certainty evidence) for procedures without injection. The certainty of evidence for specificity across all methods was very low due to the very small sample size. For settings where X-ray was not readily available and participants underwent gastric tube insertion for drainage (8 studies, 552 participants), sensitivity estimates of ultrasound in combination with other confirmatory tests ranged from 0.86 to 0.98 and specificity estimates of 1.00 with wide CIs. For studies of ultrasound alone (9 studies, 782 participants), sensitivity estimates ranged from 0.77 to 0.98 and specificity estimates were 1.00 with wide CIs or not estimable due to no occurrence of misplacement. AUTHORS' CONCLUSIONS Of 22 studies that assessed the diagnostic accuracy of gastric tube placement, few studies had a low risk of bias. Based on limited evidence, ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement. However, in settings where X-ray is not readily available, ultrasound may be useful to detect misplaced gastric tubes. Larger studies are needed to determine the possibility of adverse events when ultrasound is used to confirm tube placement.
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Affiliation(s)
- Yasushi Tsujimoto
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
- Oku Medical Clinic, Osaka, Japan
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Yuki Kataoka
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
| | - Masahiro Banno
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Psychiatry, Seichiryo Hospital, Nagoya, Japan
| | - Keisuke Anan
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Akihiro Shiroshita
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Satoshi Jujo
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
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Claiborne MK, Gross T, McGreevy J, Riemann M, Temkit M, Augenstein J. Point-of-Care Ultrasound for Confirmation of Nasogastric and Orogastric Tube Placement in Pediatric Patients. Pediatr Emerg Care 2021; 37:e1611-e1615. [PMID: 32555015 DOI: 10.1097/pec.0000000000002134] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The aim of the study was to investigate the role of point-of-care ultrasound (POCUS) as an alternative imaging modality to confirm proper placement for nasogastric tubes (NGTs) and orogastric tubes (OGTs) in pediatric patients. METHODS This was a prospective descriptive study performed at a tertiary care free-standing children's hospital. Patients 21 years and younger requiring radiographic confirmation of NGT or OGT placement were eligible for enrollment. Bedside ultrasonography examination of the epigastric area was performed by a blinded pediatric emergency medicine physician. An abdominal radiograph was obtained to confirm NGT or OGT placement in all patients. RESULTS A total of 26 patients with a mean age of 2.6 years (standard deviation, 3.9 years) were enrolled. All 26 patients had x-ray confirmation of NGT and OGTs correctly placed in the stomach. Confirmation of NGT or OGT placement by ultrasound was obtained in 23 patients. For these 23 patients, POCUS agreed with radiographic findings. For 3 patients, the NGT and OGT was unable to be identified by ultrasound. The sensitivity of ultrasound for detecting a properly placed tube was 88% (95% confidence interval, 70.0%-97.6%). CONCLUSIONS This pilot study described ultrasound confirmation of NGT or OGT placement. If confirmed in larger studies, POCUS can be used as an objective tool for the confirmation of NGT or OGT placement in pediatric patients and limit the need for routine x-ray confirmation.
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Affiliation(s)
| | | | | | | | - M'hamed Temkit
- Clinical Research, Phoenix Children's Hospital, Phoenix, AZ
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Mori T, Takei H, Ihara T, Hagiwara Y, Nomura O. Ultrasound-guided nasogastric tube placement in a pediatric emergency department. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:106-109. [PMID: 33289079 DOI: 10.1002/jcu.22958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 06/12/2023]
Abstract
Nasogastric tube (NGT) insertion is commonly performed in pediatric emergency care. Point-of-care ultrasound is used for confirming NGT insertion, but reports of its use in the pediatric emergency department (ED) are scarce. We describe our experience of ultrasound-guided NGT placement in a pediatric ED. The study pool consisted of twelve patients and the NGT tip was successfully visualized in the esophagus and gastric cardia in all cases, demonstrating that ultrasound has the potential to be a useful alternative to conventional methods of NGT insertion in the pediatric ED.
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Affiliation(s)
- Takaaki Mori
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hirokazu Takei
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Takateru Ihara
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yusuke Hagiwara
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Nomura
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
- Department of Emergency and Disaster Medicine, Hirosaki University, Hirosaki-shi Aomori, Japan
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Mori T, Takei H, Nomura O, Ihara T, Hagiwara Y. Pediatric Case of Successful Point-of-Care Ultrasound-Guided Nasogastric Tube Placement. J Emerg Med 2020; 59:e57-e60. [PMID: 32456958 DOI: 10.1016/j.jemermed.2020.04.029] [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: 02/10/2020] [Revised: 04/05/2020] [Accepted: 04/09/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Nasogastric tube (NGT) placement is commonly performed in pediatric emergency care and is classically confirmed by any one of several methods, among which auscultation or aspiration and radiography comprise the currently recognized as the reference standard. Point-of-care ultrasound (POCUS) is used to confirm NGT insertion, especially in adults or prehospital patients, but reports of its use in the pediatric emergency department (ED) are still scarce. We report a case of successful POCUS-guided NGT placement in a pediatric ED. CASE REPORT A 3-year-old male undergoing remission therapy for acute lymphocytic leukemia presented to our ED with fever and decreased appetite. Tumor lysis syndrome was diagnosed, and endotracheal intubation was required because of the need for emergency hemodialysis for hypercalcemia. Because of difficulty in guiding the tube through the nose, ultrasound-guided placement was attempted. In the transverse view over the neck below the level of the cricoid cartilage, the 10-Fr NGT was visualized under ultrasound guidance as it passed through the esophagus. Subsequently, the entry of the NGT tip into the gastric cardia was confirmed on the subxiphoid longitudinal view. A chest radiograph confirmed the presence of the NGT in the stomach. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the utility of POCUS for NGT placement was reported in adult patients, reports of its use in pediatric cases are still few. POCUS is a real-time, noninvasive, time-saving procedure that can be a useful alternative to radiography for confirming correct NGT placement.
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Affiliation(s)
- Takaaki Mori
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hirokazu Takei
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Nomura
- Department of Emergency and Disaster Medicine, Hirosaki University, Hirosaki City, Japan
| | - Takateru Ihara
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yusuke Hagiwara
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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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, 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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Tsujimoto H, Tsujimoto Y, Nakata Y, Akazawa M, Kataoka Y. Ultrasonography for confirmation of gastric tube placement. Cochrane Database Syst Rev 2017; 4:CD012083. [PMID: 28414415 PMCID: PMC6478184 DOI: 10.1002/14651858.cd012083.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastric tubes are commonly used for the administration of drugs and tube feeding for people who are unable to swallow. Feeding via a tube misplaced in the trachea can result in severe pneumonia. Therefore, the confirmation of tube placement in the stomach after tube insertion is important. Recent studies have reported that ultrasonography provides good diagnostic accuracy estimates in the confirmation of appropriate tube placement. Hence, ultrasound could provide a promising alternative to X-rays in the confirmation of tube placement, especially in settings where X-ray facilities are unavailable or difficult to access. OBJECTIVES To assess the diagnostic accuracy of ultrasound for gastric tube placement confirmation. SEARCH METHODS We searched the Cochrane Library (2016, Issue 3), MEDLINE (to March 2016), Embase (to March 2016), National Institute for Health Research (NIHR) PROSPERO Register (to May 2016), Aggressive Research Intelligence Facility Databases (to May 2016), ClinicalTrials.gov (to May 2016), ISRCTN registry (May 2016), World Health Organization International Clinical Trials Registry Platform (to May 2016) and reference lists of articles, and contacted study authors. SELECTION CRITERIA We included studies that evaluated the diagnostic accuracy of naso- and orogastric tube placement confirmed by ultrasound visualization using X-ray visualization as the reference standard. We included cross-sectional studies, and case-control studies. We excluded case series or case reports. Studies were excluded if X-ray visualization was not the reference standard or if the tube being placed was a gastrostomy or enteric tube. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the risk of bias and extracted data from each of the included studies. We contacted authors of the included studies to obtain missing data. MAIN RESULTS We identified 10 studies (545 participants and 560 tube insertions) which met our inclusion criteria.No study was assigned low risk of bias or low concern in every QUADAS-2 domain. We judged only three (30%) studies to have low risk of bias in the participant selection domain because they performed ultrasound after they confirmed correct position by other methods.Few data (43 participants) were available for misplacement detection (specificity) due to the low incidence of misplacement. We did not perform a meta-analysis because of considerable heterogeneity of the index test such as the difference of echo window, the combination of ultrasound with other confirmation methods (e.g. saline flush visualization by ultrasound) and ultrasound during the insertion of the tube. For all settings, sensitivity estimates for individual studies ranged from 0.50 to 1.00 and specificity estimates from 0.17 to 1.00. For settings where X-ray was not readily available and participants underwent gastric tube insertion for drainage (four studies, 305 participants), sensitivity estimates of ultrasound in combination with other confirmatory tests ranged from 0.86 to 0.98 and specificity estimates of 1.00 with wide confidence intervals.For the studies using ultrasound alone (four studies, 314 participants), sensitivity estimates ranged from 0.91 to 0.98 and specificity estimates from 0.67 to 1.00. AUTHORS' CONCLUSIONS Of 10 studies that assessed the diagnostic accuracy of gastric tube placement, few studies had a low risk of bias. Based on limited evidence, ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement. However, in settings where X-ray is not readily available, ultrasound may be useful to detect misplaced gastric tubes. Larger studies are needed to determine the possibility of adverse events when ultrasound is used to confirm tube placement.
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Affiliation(s)
- Hiraku Tsujimoto
- Hyogo Prefectural Amagasaki General Medical CenterHospital Care Research UnitHigashi‐Naniwa‐Cho 2‐17‐77AmagasakiHyogoJapan606‐8550
| | - Yasushi Tsujimoto
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Yukihiko Nakata
- Shimane UniversityDepartment of Mathematics1060 Nishikawatsu choMatsue690‐8504Japan
| | - Mai Akazawa
- Shiga University of Medical Science HospitalDepartment of AnesthesiaSeta‐Tsukinowa‐choOtsuShigaJapan520‐2192
| | - Yuki Kataoka
- School of Public Health in the Graduate School of Medicine, Kyoto UniversityDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
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Moriichi A, Kawaguchi A, Kobayashi Y, Yoneoka D, Ota E. The effectiveness and safety of various methods of post-pyloric feeding tube placement and verification in infants and children. Hippokratia 2016. [DOI: 10.1002/14651858.cd012231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Akinori Moriichi
- National Center for Child Health and Development; Department of Health Policy; 2-10-1, Okura, Setagaya Tokyo Japan 157-8535
| | - Atsushi Kawaguchi
- University of Alberta; Pediatrics, Pediatric Critical Care Medicine; Stollery Children's Hospital 3A3.06 Walter C MacKenzie Health Centre 8440 112 St Edmonton AB Canada T6G 2B7
| | - Yasutoshi Kobayashi
- Kobayashi Internal Medicine Clinic; Department of Internal Medicine; 3-1-26 Minato-cho Hyogo-ku Kobe City Japan 652-0812
| | - Daisuke Yoneoka
- The Graduate University for Advanced Studies; Department of Statistical Science; 10-3, Midori-Cho, Tachikawa-Shi Tokyo Japan 190-8502
| | - Erika Ota
- St. Luke's International University, Graduate School of Nursing Sciences; Global Health Nursing; 10-1 Akashi-cho Chuo-Ku Tokyo Japan 104-0044
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Nguyen L, Lewiss RE, Drew J, Saul T. A novel approach to confirming nasogastric tube placement in the ED. Am J Emerg Med 2012; 30:1662.e5-7. [DOI: 10.1016/j.ajem.2011.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 09/08/2011] [Indexed: 11/28/2022] Open
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Contrôle échographique de la position de la sonde nasogastrique en préhospitalier. ACTA ACUST UNITED AC 2012; 31:416-20. [DOI: 10.1016/j.annfar.2012.01.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 01/05/2012] [Indexed: 11/15/2022]
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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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