A new technique for post-pyloric feeding tube placement by palpation in lean critically ill patients

Cortrak® duodenal tube placements: A solution for more patients? A preliminary survey to the introduction of electromagnetic-guided placement of naso-duodenal feeding tubes

RATIONALE

The Cortrak^® feeding tube, an electromagnetic (EM) guided feeding tube which is placed by a trained nurse at the patient's bedside, is reported to be a safe, patient friendly and cost effective answer to the disadvantages of endoscopic placement of naso-duodenal feeding tubes. However, this procedure requires a learning curve and regular practice. This study aims to evaluate whether introducing Cortrak® feeding tube placement would be profitable in a tertiary referral academic hospital.

METHODS

We re-evaluated all endoscopically placed post-pyloric feeding tubes in the years 2012-2013. Taking into consideration training for nurses to learn how to place Cortrak® feeding tubes, strict inclusion criteria were formulated for the initial retrospective analysis: age 18 years or older, normal GI anatomy and non-ICU admitted patients. As a secondary analysis we also evaluated ICU patients (age >18 and normal upper GI tract).

RESULTS

Patient records of 487 duodenal feeding tube placements in 331 patients were evaluated; 125 non-ICU placements (in 90 patients) and 84 ICU placements (in 75 ICU patients) fulfilled the inclusion criteria. Main reasons for exclusion were: abnormalities of the upper GI tract (n = 176) and endoscopy for diagnostic reasons (n = 74). Main indications for placements were gastroparesis (37%) or insufficient food intake (20%). For secondary analysis, 84 placements in 75 ICU patients were re-evaluated, with main indication gastroparesis (62%).

CONCLUSION

In our hospital, at least one quarter of the duodenal tube placements would qualify for Cortrak® placement in the initial phase. Once routine has been built up and also ICU patients could be considered, half or more patients requiring a naso-duodenal feeding tube would qualify for Cortrak® placement, adding up to 3 placements per week. The findings of this study may help to decide on the profitability of introducing this method in our own hospital. The next step will be to perform a cost-benefit analysis to study whether implementing Cortrak® in practice is cost-effective and feasible.

Naso-enteric Tube Placement: A Review of Methods to Confirm Tip Location, Global Applicability and Requirements

BACKGROUND

The insertion of a tube through the nose and into the stomach or beyond is a common clinical procedure for feeding and decompression. The safety, accuracy and reliability of tube insertion and methods used to confirm the location of the naso-enteric tube (NET) tip have not been systematically reviewed. The aim of this study is to review and compare these methods and determine their global applicability by end-user engagement.

METHODS

A systematic literature review of four major databases was performed to identify all relevant studies. The methods for NET tip localization were then compared for their accuracy with reference to a gold standard method (radiography or endoscopy). The global applicability of the different methods was analysed using a house of quality matrix.

RESULTS

After applying the inclusion and exclusion criteria, 76 articles were selected. Limitations were found to be associated with the 20 different methods described for NET tip localization. The method with the best combined sensitivity and specificity (where n > 1) was ultrasound/sonography, followed by external magnetic guidance, electromagnetic methods and then capnography/capnometry. The top three performance criteria that were considered most important for global applicability were cost per tube/disposable, success rate and cost for non-disposable components.

CONCLUSION

There is no ideal method for confirming NET tip localisation. While radiography (the gold standard used for comparison) and ultrasound were the most accurate methods, they are costly and not universally available. There remains the need to develop a low-cost, easy-use, accurate and reliable method for NET tip localization.

A novel method of post-pyloric feeding tube placement at bedside

PURPOSE

Post-pyloric feeding tube placement is often difficult, and special equipment or peristalsis agents are used to aid insertion. Although several reports have described blind techniques for post-pyloric feeding-tube placement, no general consensus about method preference has been achieved.

MATERIALS AND METHODS

The technique is performed as follows: via the nostril, a stylet-tipped feeding tube is advanced about 70 cm; to confirm tip location to the right of the epigastric area, towards the right hypochondriac region, 5 mL shots of air are injected to enable touch detection of bubbling; finally, the tube is advanced to a length of 100 cm, during which the strength of bubbling seems to diminish under palpation.

RESULTS

We prospectively enrolled consecutive patients whose oral intake was expected to be difficult for 48 hours in the intensive care unit. Forty-one patients were enrolled and the rate of successful placement at first attempt was 95.1%. Mean duration for successful placement was 15 minutes.

CONCLUSIONS

With a novel technique, from the bedside, without special tools or drugs, we successfully placed post-pyloric feeding tubes. Essential points when inserting the tube are confirmation of the location of the tube tip by palpation of injected air, and to avoid deflection and looping.