Enteral access

Feeding characteristics and growth among children with prenatal exposure to Zika virus with and without microcephaly in the microcephaly epidemic research group pediatric cohort

OBJECTIVE

To describe the feeding characteristics and growth of children with prenatal exposure to Zika virus (ZIKV) from birth to 48 months.

DESIGN

Using data from the prospective Microcephaly Epidemic Research Group Pediatric Cohort (MERG-PC), children without microcephaly born to mothers with evidence of ZIKV infection during pregnancy (ZIKV-exposed children without microcephaly) and children with Zika-related microcephaly were compared using repeated cross-sectional analyses within the following age strata: birth; 1 to 12; 13 to 24; 25 to 36; and 37 to 48 months. The groups were compared in relation to prematurity, birth weight, breastfeeding, alternative feeding routes, dysphagia and anthropometric profiles based on the World Health Organization Anthro z-scores (weight-length/height, weight-age, length/height-age and BMI-age).

RESULTS

The first assessment included 248 children, 77 (31.05%) with microcephaly and 171 (68.95%) without microcephaly. The final assessment was performed on 86 children. Prematurity was 2.35 times higher and low birth weight was 3.49 times higher in children with microcephaly. The frequency of breastfeeding was high (> 80%) in both groups. On discharge from the maternity hospital, the frequency of children requiring alternative feeding route in both groups was less than 5%. After 12 months of age, children with microcephaly required alternative feeding route more often than children without microcephaly. In children with microcephaly, the z-score of all growth indicators was lower than in children without microcephaly.

CONCLUSIONS

Children with Zika-related microcephaly were more frequently premature and low birth weight and remained with nutritional parameters, i.e., weight-for-age, weight-for-length/height and length/height-for-age below those of the children without microcephaly.

Enteral tolerance in critically ill patients

Enteral nutrition (EN) can maintain the structure and function of the gastrointestinal mucosa better than parenteral nutrition. In critically ill patients, EN must be discontinued or interrupted, if gastrointestinal complications, particularly vomiting and bowel movement disorders, do not resolve with appropriate management. To avoid such gastrointestinal complications, EN should be started as soon as possible with a small amount of EN first and gradually increased. EN itself may also promote intestinal peristalsis. The measures to decrease the risk of reflux and aspiration include elevation the head of the bed (30° to 45°), switch to continuous administration, administration of prokinetic drugs or narcotic antagonists to promote gastrointestinal motility, and switch to jejunal access (postpyloric route). Moreover, the control of bowel movement is also important for intensive care and management. In particular, prolonged diarrhea can cause deficiency in nutrient absorption, malnutrition, and increase in mortality. In addition, diarrhea may cause a decrease the circulating blood volume, metabolic acidosis, electrolyte abnormalities, and contamination of surgical wounds and pressure ulcers. If diarrhea occurs in critically ill patients on EN management, it is important to determine whether diarrhea is EN-related or not. After ruling out the other causes of diarrhea, the measures to prevent EN-related diarrhea include switch to continuous infusion, switch to gastric feeding, adjustment of agents that improve gastrointestinal peristalsis or laxative, administration of antidiarrheal drugs, changing the type of EN formula, and semisolidification of EN formula. One of the best ways to success for EN management is to continue as long as possible without interruption and discontinuation of EN easily by appropriate measures, even if gastrointestinal complications occur.

Enteral Access in Mechanically Ventilated Patients

The early institution of enteral nutrition is now accepted as the preferred route of feeding in critically ill patients with a functioning gastrointestinal tract. It is particularly important to establish early enteral nutrition in mechanically ventilated patients because of the metabolic demands associated with mechanical ventilation. The options for enteral access in mechanically ventilated patients are reviewed, with an emphasis on those techniques that may be performed at the bedside. The advantages, disadvantages, and complications of the different techniques will be considered.

Enteral Nutrition for Adults in the Hospital Setting

In patients unable to tolerate oral intake, multiple options of nutrient delivery are available to the clinician. Administration of enteral nutrition (EN) has long been considered the standard of care for nutrition support among patients unable to meet energy and protein requirements orally. Healthcare practitioners must make careful decisions related to ordering, administering, and monitoring EN therapy. In the hospital setting, the registered dietitian is a key resource in enteral formula selection and method of administration, monitoring for and troubleshooting EN-related complications, and transitioning to oral feeding. The hospital setting also presents many unique challenges in providing optimal nutrition to the enterally fed patient.

Transnasal endoscopic placement of nasoenteric feeding tubes: outcomes and limitations in non-critically ill patients

Transnasal endoscopic placement of nasoenteric tubes (NETs) has been demonstrated to be useful in the critical care setting, with limited data on its role in non-critically ill patients. The authors collected data on consecutive patients from a non-critical care setting undergoing transnasal endoscopic NET placement. All NETs were endoscopically placed using a standard over-the-guidewire technique, and positions were confirmed with fluoroscopy. Patients were monitored until the removal of NETs or death. Twenty-two patients (median age = 62.5 years, 36.4% female) were referred for postpyloric feeding, with main indications of persistent gastrocutaneous fistula (n = 6), gastroparesis or gastric outlet obstruction (n = 5), duodenal stenosis (n = 6), acute pancreatitis (n = 4), and gastroesophageal reflux after surgery (n = 1). Postpyloric placement of NET was achieved in 19 of 22 (86.3%) patients, with 36.8% tube positions in the jejunum, 47.4% in the distal duodenum, and 15.8% in the second part of the duodenum. NET placement was least successful in cases with duodenal stenosis. NETs remained in situ for a median of 24 days (range, 2-94), with tube dislodgement (n = 3) and clogging (n = 5) as the main complications. NET feeding resulted in complete healing of gastrocutaneous fistulae in 5 of 6 patients and provision of total enteral nutrition in 3 of 4 cases of acute pancreatitis and 9 of 11 cases of gastroparesis or proximal duodenal obstruction. Transnasal endoscopy has a role in the placement of NET in non-critically ill patients requiring postpyloric feeding. However, there are some limitations, particularly in cases with altered duodenal anatomy.

Clinical experience of percutaneous endoscopic gastrostomy in Taiwanese patients--310 cases in 8 years

Although percutaneous endoscopic gastrostomy (PEG) has become a popular method for long-term tube feeding worldwide, there are only a few reports about its application in Taiwan. From May 1997 to May 2005, we performed 302 PEG insertions successfully in 310 attempts (97.4% success rate) using modified Ponsky's pull method with 24-Fr feeding tubes. All the patients received PEG for tube feeding except for two patients with cancerous peritonitis for decompression. The underlying diseases in these 308 patients who received PEG for tube feeding were 161 cerebrovascular accidents (52.3%), 62 head and neck cancers (20.1%), 21 cases of Parkinsonism (6.8%), and others. There were 11 major complications (3.6%) and 57 minor complications (18.9%). Ten patients (3.3%) died within 30 days after PEG insertion. However, no procedure-related mortality occurred. In conclusion, PEG is an effective method for tube feeding and drainage with a high success rate. PEG insertion was often indicated for patients with dysphagia caused by cerebrovascular accident, head and neck cancer, and Parkinsonism in Taiwan. It is a relatively safe procedure, with a 3.6% rate of major complications and 18.9% rate of minor complications.

[Surgical access routes in enteral nutrition]

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last < or = 6 weeks, nasoenteral tubes are the best option. In NE > or = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 +/- 21.9 days, and 72 double lumen nasojejunal tubes.

Endoscopic placement of direct percutaneous jejunostomy tubes in patients with complications after esophagectomy

BACKGROUND

Complications after esophagectomy may prevent oral intake, lead to dependence on total parenteral nutrition, and lengthen hospital stay. Direct percutaneous endoscopic placement of a jejunostomy tube allows enteral feeding in the presence of postoperative complications and eliminates the need for total parenteral nutrition.

METHODS

A total parenteral nutrition database was used to identify patients who received total parenteral nutrition because of complications after esophagectomy. Records of all patients subsequently referred for percutaneous endoscopic jejunostomy placement were reviewed.

RESULTS

Twenty-five patients with postesophagectomy complications were referred for percutaneous endoscopic jejunostomy placement. A percutaneous endoscopic jejunostomy was successfully placed in 21 patients (84%), all of whom were weaned off total parenteral nutrition. Six patients (29%) in whom percutaneous endoscopic jejunostomy placement was successful died during hospitalization at a mean of 20 days (range 5-40 days) after the procedure for reasons unrelated to percutaneous endoscopic jejunostomy tube insertion. The remaining 15 patients were discharged while receiving nutrition by means of the percutaneous endoscopic jejunostomy. Ten of them had subsequent removal of the percutaneous endoscopic jejunostomy at a mean of 131 days (range 20-281 days). There were no major percutaneous endoscopic jejunostomy-related complications. Minor complications occurred in 4 patients (19%).

CONCLUSION

Percutaneous endoscopic jejunostomy placement may be considered in patients with complications after esophagectomy. In these patients, percutaneous endoscopic jejunostomy placement avoids the need for total parenteral nutrition.

Evaluation of patients with jejunostomy tubes: imaging findings

PURPOSE

To determine the frequency and nature of abnormalities observed on radiographs after placement of jejunostomy (J) tubes for enteral nutrition.

MATERIALS AND METHODS

Radiology database review revealed that 280 studies of the J tube or of the small bowel with water-soluble contrast material and/or barium sulfate were performed in patients during 10 years. Review of the radiologic reports revealed abnormalities related to the placement of tubes in 105 (38%) cases. Images were reviewed to determine abnormalities in these 105 cases. Radiologic, medical, and surgical records were also reviewed to determine the clinical course and any subsequent interventions.

RESULTS

One or more complications were detected in 40 (14%) of 280 cases: small-bowel obstruction in 17 (6%) cases, nonobstructive small-bowel narrowing in six (2%), extraluminal tracks or collections in seven (2%), extravasation of contrast material to the skin in 11 (4%), jejunal hematomas in five (2%), and intussusceptions in four (1%). Mechanical problems related to the tube were detected in 52 (19%) cases, including coiling, kinking, or knotting of the tube in 38 (14%), malpositioning in five (2%), retrograde flow in four (1%), occlusion in four (1%), and a hole in one (<1%). Focal thickening of small-bowel folds was detected in 24 (9%) cases.

CONCLUSION

Radiographs in 280 patients with J tubes revealed one or more complications that resulted from tube placement (40 [14%] cases), mechanical problems related to location or function of the tube (52 [19%] cases), and development of focally thickened small-bowel folds (24 [9%] cases).

Liver transplantation for type Ib glycogenosis with reversal of cyclic neutropenia

We describe a case of glycogen storage disease type Ib in 32-year old male patient with poor metabolic control in spite of medical and nutritional management and the use of recombinant granulocyte stimulating factor. Because of this, liver transplantation was considered as a definitive treatment. We comment on the metabolic results of liver transplantation performed, with reversal of hypoglycemia, hyperuricemia, hypertriglyceridemia and cyclic neutropenia, all of which persist 4 years post-transplant. In view of this case, we believe that liver transplantation is a feasible option to consider in patients with type Ib glycogenosis as a definitive therapeutic procedure.

Electrocardiogram-guided placement of enteral feeding tubes

OBJECTIVE

To evaluate a new electrocardiogram guided method for placing nasoenteral feeding tubes in critically ill patients.

DESIGN

Prospective case series.

SETTING

Surgical intensive care unit in a tertiary center.

PATIENTS

A total of 24 patients requiring enteral feeding tube placement entered the study.

INTERVENTION

Standard 10-Fr flexible nasoenteral feeding tubes were inserted under direct vision by the nasal route. Before placement, two electrocardiographic reference recordings were made with the use of epigastric area skin electrodes, each 10 cm lateral to the midline 5 cm above the umbilical line. A continuous electrocardiographic tracing from the feeding tube was then monitored throughout the tube insertion process. A change in QRS axis simultaneous with electrocardiographic waveform change from reference point one to two was presumed to indicate tip passage beyond the midline and into the duodenum. Portable abdominal radiography was performed immediately after the procedure to confirm the anatomical location of the tube tip.

MEASUREMENTS AND MAIN RESULTS

In four patients (17%), electrocardiographic tracings in both reference leads were identical and prevented further use of this method. In the remainder, electrocardiogram guided technique compared with portable abdominal radiography confirmed the correct position of the tube tip placed by electrocardiographic guidance. Sensitivity and specificity were 100% and 75%, respectively.

CONCLUSION

This report describes a new technique of feeding tube placement. This simple and convenient bedside method allows prompt and safe initiation of enteral nutrition.

Extended indications for enteral nutritional support

With the availability of an organized nutrition support team (NST), the use of enteral nutrition (EN) can be extended to patients who would have otherwise received parenteral nutrition (PN). Although the formulation and accuracy of nutrient intake seems easier with PN, it is accepted that EN is cost effective and advantageous and should be used whenever possible. We discuss three cases in which the NST was initially consulted to provide PN. After evaluation by the dietitian, gastrointestinal access was obtained by the NST physician and EN could be initiated. The case studies show that an organized NST consisting of knowledgeable members can extend the use of EN to patients who would have otherwise received PN. The cost saving of such an approach and its efficacy in clinical practice are obvious.

Intestinal obstruction secondary to enteral feedings in burn trauma patients

BACKGROUND

Enteral feeding is preferred for maintaining gut integrity and providing nutrition in trauma patients. Recent reports suggest that use of early enteral feeds is successful and that complications are rare. A recent burn patient, who suffered apparent bowel obstruction and perforation secondary to enteral feedings, led us to review our experience with mechanical complications of tube feedings.

METHODS

We searched our registry of patients treated for acute burn trauma injury and identified patients treated for acute bowel obstruction in the past 3 years.

RESULTS

Four patients were identified, ages 22 to 44, with burns of 6 to 92% total body surface area. Each required intubation and ventilatory support during initial treatment, complicated by adult respiratory distress syndrome and sepsis. We began enteral feeds 1 to 3 days after admission. At approximately 14 days after admission, each patient deteriorated clinically, which led to emergent abdominal exploration; the tube feedings caused bowel obstruction and associated complications. Each patient improved with laparotomy.

CONCLUSION

Bowel obstruction, ischemic necrosis, or both, secondary to early and aggressive nutrition with a fiber supplemented enteral feeding is an uncommon, life-threatening complication. Understanding and early recognition of this potential complication are essential to prevention or successful treatment.

Efficacy of Jejunogram after Jejunostomy Insertion

The era of managed care has spawned a national debate over the allocation of health care resources. We hypothesized that routine postjejunostomy jejunogram rarely provides additional clinical information or changes patient management and, therefore, is unwarranted. We retrospectively reviewed the charts of 128 consecutive patients undergoing feeding jejunostomy tube insertion between January 1995 and December 1996. All patients had postinsertion jejunograms. Eighty-five (66%) of the jejunograms were performed after operative insertion of the jejunostomy, and 43 (33%) were performed after percutaneous reinsertion of a previously placed jejunostomy. Data extracted from the charts include age, sex, indication for jejunogram, length of time prior jejunostomy was in place at time of reinsertion, and results of jejunogram. There were no patients (0%) with misplaced jejunostomy or extravasation of dye, as noted on jejunogram. There were no management changes implemented as a result of jejunogram readings (P < <0.05). The use of routine jejunogram after operative insertion or reinsertion of a prior jejunostomy that has become dislodged or occluded does not alter patient management, incurs unnecessary costs, and, therefore, is unwarranted.

Nutritional support of the hospitalized patient

Comprehensive care of patients in hospitals includes assessment of nutritional status and provision of appropriate support. This approach is facilitated by knowledge of the essential differences in metabolism between starved and stressed states. Nutritional assessment and care of patients in a hospital are based on answers to the following questions: Who gets it? When do they get it? How much do they get? What route is used to administer it? What kind do they get? What are common complications of enteral and parenteral support? What nutritional aspects are pertinent to common diseases?

Bedside sonographic-guided versus blind nasoenteric feeding tube placement in critically ill patients

OBJECTIVE

To compare a blind manual bedside method for placing feeding tubes into the small bowel vs. a sonographic bedside technique in critically ill patients.

DESIGN

Prospective study with a random sample.

SETTING

Multidisciplinary intensive care unit in a tertiary care university hospital.

PATIENTS

Thirty-five adult patients. All patients were hemodynamically stable, mechanically ventilated, and required a nasoenteric tube placement for short-term enteral feeding due to impaired gastric emptying.

INTERVENTIONS

A well-known, blind, manual, bedside method for postpyloric tube placement was always attempted first in all cases. The technique was considered successful when a postpyloric location of the tip of the tube was achieved as shown by abdominal roentgenogram. However, if after 30 mins we failed to enter the small bowel, a radiologist attempted a sonographic bedside technique for postpyloric tube insertion. Finally, when the feeding tube was in place, before starting enteral nutrition, a nasogastric tube was inserted into the stomach.

MEASUREMENTS AND MAIN RESULTS

The blind manual method was successful in nine (25.7%) of the 35 patients and the final location of these feeding tubes was the proximal jejunum. The average time for placement of the feeding tubes with this manual technique was 13.9 +/- 7.4 mins (range 5 to 30). The sonographic technique was successful in 22 (84.6%) of the remaining patients and the final location of the feeding tubes was three (11%) tubes in the second portion of the duodenum, eight (31%) tubes in the third portion of the duodenum, and 11 (42%) tubes in the proximal jejunum. The average time for placement with the sonographic technique was 18.3 +/- 8.2 mins (range 5 to 35). The pyloric outlet was sonographically akinetic or severely hypokinetic in 13 patients, and in four of them, we were unable to achieve postpyloric tube placement. In these four patients, the tubes were subsequently placed by endoscopy.

CONCLUSIONS

The sonographic bedside technique for placing feeding tubes into the small bowel in critically III patients has a success rate of 84.6% (confidence interval 71% to 98%) after the failure of the blind bedside manual method, proving that the former is significantly more successful. This sonographic technique facilitates the insertion of the tubes in patients who cannot be moved and in those patients with severe impairment of the peristaltic activity of the stomach.