A new technique for bedside placement of enteral feeding tubes: a prospective cohort study

Postpyloric Feeding Access in Infants and Children: A State of the Art Review

Achieving postpyloric feeding access is a clinical challenge faced by the pediatric gastroenterologist in everyday practice. Currently, there is limited literature published on the topic. This article provides a practical summary of the literature on the different methods utilized to achieve postpyloric feeding access including bedside, fluoroscopic, endoscopic and surgical options. Indications and complications of these methods are discussed as well as a general approach to infants and children that require intestinal feeding.

Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

GASTROINTESTINAL TUBE INSERTION TECHNIQUES IN CRITICAL PATIENTS: SCOPING REVIEW

ABSTRACT Objective to map the production of knowledge about the different techniques of gastrointestinal tube insertion in critically ill and/or coma patients. Method scope review carried out in December 2020 in ten data sources, following the assumptions established by the Joanna Briggs Institute (2020) and the PRISMA-ScR protocol. Results 25 studies were selected and analyzed, identifying as the main techniques for insertion of gastrointestinal tube in critically ill and/or coma patients: techniques without the aid of instrumentals, such as head flexion, lateral neck pressure, tube freezing, measurement with corrected formula of the tip of the ear-lobe tip-xiphoid process, Sellick´s maneuver, cricoid cartilage compression, SORT maneuver and gastric insufflation. In addition to techniques with the aid of instruments, such as the use of laryngoscopes and video laryngoscopes. It is noteworthy that, in order to facilitate insertion, the use of ultrasound examination, radiological, endoscopic and fluoroscopy were also identified. Conclusions the evidence analyzed reveals that there is no specific gastrointestinal tube insertion technique for universally accepted critically ill patients.

Systematic review on bedside electromagnetic-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes

BACKGROUND

Nasoenteral tube feeding is frequently required in hospitalized patients to either prevent or treat malnutrition, but data on the optimal strategy of tube placement are lacking.

OBJECTIVE

To compare the efficacy and safety of bedside electromagnetic (EM)-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes in adults.

DESIGN

Systematic review of the literature.

PATIENTS

Adult hospitalized patients requiring nasoenteral feeding.

INTERVENTIONS

EM-guided, endoscopic, and/or fluoroscopic nasoenteral feeding tube placement.

MAIN OUTCOME MEASUREMENTS

Success rate of tube placement and procedure- or tube-related adverse events.

RESULTS

Of 354 screened articles, 28 studies were included. Data on 4056 patients undergoing EM-guided (n = 2921), endoscopic (n = 730), and/or fluoroscopic (n = 405) nasoenteral feeding tube placement were extracted. Tube placement was successful in 3202 of 3789 (85%) EM-guided procedures compared with 706 of 793 (89%) endoscopic and 413 of 446 (93%) fluoroscopic procedures. Reinsertion rates were similar for EM-guidance (270 of 1279 [21%] patients) and endoscopy (64 of 394 [16%] patients) or fluoroscopy (10 of 38 [26%] patients). The mean (standard deviation) procedure time was shortest with EM-guided placement (13.4 [12.9] minutes), followed by endoscopy and fluoroscopy (14.9 [8.7] and 16.2 [23.6] minutes, respectively). Procedure-related adverse events were infrequent (0.4%, 4%, and 3%, respectively) and included mainly epistaxis. The tube-related adverse event rate was lowest in the EM-guided group (36 of 242 [15%] patients), followed by fluoroscopy (40 of 191 [21%] patients) and endoscopy (115 of 384 [30%] patients) and included mainly dislodgment and blockage of the tube.

LIMITATIONS

Heterogeneity and limited methodological quality of the included studies.

CONCLUSION

Bedside EM-guided placement of nasoenteral feeding tubes appears to be as safe and effective as fluoroscopic or endoscopic placement. EM-guided tube placement by nurses may be preferred over more costly procedures performed by endoscopists or radiologists, but randomized studies are lacking.

Are prospective cohort studies an appropriate tool to answer clinical nutrition questions?

PURPOSE OF REVIEW

Randomized controlled trials can be difficult to conduct in critically ill patients and may not always be the most appropriate type of study. Cohort studies can provide valuable information in large complete populations of patients without strict exclusion criteria and without the need for informed consent, thus potentially being more representative of and applicable to daily practice.

RECENT FINDINGS

Recent cohort studies have evaluated the various aspects of the epidemiology and practice of nutrition in critically ill patients, including the proportions of patients receiving different types of nutritional support, the potential benefits of supplementary parenteral nutrition, the importance of meeting nutrition targets especially for protein, and the beneficial effects of feeding protocols on outcomes.

SUMMARY

Results from some of these cohort studies have provided an indication of how nutrition guidelines have been applied in clinical practice and which areas need to be improved. Others have generated hypotheses that will be (or are already being) tested in randomized studies.

A secure "double-check" technique of bedside post pyloric feeding tube placement using transnasal endoscopy

Enteral feeding has become an important means of providing nutritional support to seriously ill patients. Placement of the feeding tube through the pyloric ring and past the ligament of Treitz into the proximal jejunum is critical to reduce the risk of gastroesophageal regurgitation and microaspiration. We started utilizing transnasal endoscopy for intestinal feeding tube placement, placing enteral tubes for 40 patients between March 2008 and February 2009. Although we achieved a high success rate comparable to previous reports, we experienced several cases of failure, which was corrected with repeated endoscopy. Based on these experiences, we modified our method by adding a "double-check" transnasal endoscopy through the other nasal passage. After April 2010, we have placed the feeding tube by "double-check" method for all patients (more than 40 patients) who required transnasal endoscopic feeding tube placement. We have not experienced any misplacement in all these patients after 24 h later with 100% successful rate since the introduction of "double-check" procedure. We describe our experience with "double-check" transnasal endoscopic feeding tube placement, which we found to be a helpful adjunct, for patients in intensive care unit.

Endoscopic solutions to challenging enteral feeding problems

PURPOSE OF REVIEW

Enteral nutrition support is often required in patients who are unable to meet their own nutritional requirements. Endoscopists play a key role in the placement of enteral feeding catheters. This review focuses on the recently published solutions to common problems encountered during endoscopic placement of enteral feeding devices.

RECENT FINDINGS

Case reports and case series describe solutions for overcoming common problems encountered during the placement of enteral feeding devices. Transnasal techniques can simplify nasojejunal tube placement, whereas deep enteroscopy techniques provide more reliable jejunostomy placement. Endoscopic ultrasound can help when transillumination is not possible or in the setting of postsurgical anatomy like Roux-en-Y. Laparoscopic-assisted procedures are useful when endoscopic techniques have failed in adults or in select high-risk pediatric patients. The American Society for Gastrointestinal Endoscopy and the American Gastroenterology Association both published comprehensive guidelines that outline the indications, contraindications, technical aspects of feeding catheter placement, and complications.

SUMMARY

Advances in endoscopic techniques, including deep enteroscopy, endoscopic ultrasound, ultra-slim transnasal endoscopes and laparoscopic-assisted procedures, have enabled endoscopists to successfully place enteral feeding tubes in patients who previously required open procedures.

A secure "double-check" technique of bedside post pyloric feeding tube placement using transnasal endoscopy

Enteral feeding has become an important means of providing nutritional support to seriously ill patients. Placement of the feeding tube through the pyloric ring and past the ligament of Treitz into the proximal jejunum is critical to reduce the risk of gastroesophageal regurgitation and microaspiration. We started utilizing transnasal endoscopy for intestinal feeding tube placement, placing enteral tubes for 40 patients between March 2008 and February 2009. Although we achieved a high success rate comparable to previous reports, we experienced several cases of failure, which was corrected with repeated endoscopy. Based on these experiences, we modified our method by adding a ”double-check” transnasal endoscopy through the other nasal passage. After April 2010, we have placed the feeding tube by ”double-check” method for all patients (more than 40 patients) who required transnasal endoscopic feeding tube placement. We have not experienced any misplacement in all these patients after 24 h later with 100% successful rate since the introduction of ”double-check” procedure. We describe our experience with ”double-check” transnasal endoscopic feeding tube placement, which we found to be a helpful adjunct, for patients in intensive care unit.