Metoclopramide or domperidone improves post-pyloric placement of spiral nasojejunal tubes in critically ill patients: a prospective, multicenter, open-label, randomized, controlled clinical trial

Bedside naso-jejunal placement is more difficult, but successful in patients with COVID-19 in critical care: A retrospective service evaluation of a dietitian-led service

The COVID-19 pandemic presented clinical and logistical challenges in the delivery of adequate nutrition in the critical care setting. The use of neuromuscular-blocking drugs, presence of maxilla-facial oedema, strict infection control procedures, and patients placed in a prone position complicated feeding tube placement. We audited the outcomes of dietitian-led naso-jejunal tube (NJT) insertions using the IRIS® (Kangaroo, USA) device, before and during the COVID-19 pandemic. NJT placement was successful in 78% of all cases (n = 50), and 87% of COVID-19 cases. Anaesthetic support was only required in COVID-19 patients (53%). NJT placement using IRIS was more difficult but achievable in patients with COVID-19.

Application and effectiveness of an improved endoscopically guided nasojejunal tube placement technique in critically ill patients: a retrospective cohort study

Background

The endoscopic nasojejunal (NJ) placement plays a pivotal role in the nutritional support of critically ill patients. However, the conventional endoscopy-guided tube insertion method presents issues of excessive procedural duration. We have enhanced the traditional endoscopy-guided catheter placement method, enabling a faster and more convenient catheter insertion.

Methods

We improved the traditional endoscopically guided technique by incorporating an extra silk thread knot at the 25 cm mark on the jejunal segment of the NJ tube to assist endoscopists in accurate tube placement. We conducted the improved NJ tube placement on critically ill patients in need of enteral nutrition (EN). Laboratory data were retrospectively collected before and after the 7-day period of NJ tube placement and EN treatment to evaluate the effectiveness and safety of the improved method.

Results

A total of 88 critically ill patients, with an average age of 59.6±15.5 years, and a male ratio of 86.4%, who underwent the improved NJ tube placement method were enrolled into analysis finally, achieving a 100% success rate of NJ tube insertion. The average time for tube insertion was 5.9±2.2 min, with a mean insertion depth of 108.8±12.5 cm. The EN tolerance score was 0.79±0.98. Following 7 days of EN therapy, the patients showed significant improvement in serum albumin levels compared to baseline (36.42 vs. 33.66 g/L, P<0.001).

Conclusions

The improved endoscopically guided NJ tube placement technique is a rapid and safe procedure with excellent patient tolerance. It significantly improves the nutritional status of critically ill patients and facilitates the administration of EN, which requires further validation through randomized controlled trials.

Effect of post-pyloric Dobhoff tube retention during gastrojejunostomy for reduction of fluoroscopic time and radiation dose

The purpose of this study was to determine whether retention of a post-pyloric Dobhoff tube (DHT) in position to serve as a visual guide through the pylorus during gastrojejunostomy (GJ) tube placement results in a reduction in fluoroscopy time, procedure time, and estimated radiation dose. A retrospective study evaluated patients who underwent GJ tube placement or gastric to GJ conversion from January 1, 2017, to April 1, 2021. Demographic and procedural data were collected, and results were evaluated using descriptive statistics and hypothesis testing through an unpaired Student's t-test. Of the 71 GJ tube placements included for analysis, 12 patients underwent placement with a post-pyloric DHT in position, and 59 patients underwent placement without a post-pyloric DHT in position. The mean fluoroscopy time and estimated radiation dose were significantly reduced in patients who underwent GJ tube placement with a post-pyloric DHT in position compared with those without (7.08 min vs. 11.02 min, P = 0.004; 123.12 mGy vs. 255.19 mGy, P = 0.015, respectively). The mean total procedure time was also reduced in patients who underwent GJ tube placement with a post-pyloric DHT in position compared with those who had no post-pyloric DHT, but this finding lacked statistical significance (18.55 min vs. 23.15 min; P = 0.09). Post-pyloric DHT retention can be utilized during GJ tube placement to reduce radiation exposure to both the patient and interventionalist.

Potentially inappropriate medications with older people in intensive care and associated factors: a historic cohort study

BACKGROUND

The epidemiology of potentially inappropriate medications (PIMs) in critical care units remains limited, especially in terms of the factors associated with their use.

OBJECTIVE

To estimate the incidence and factors associated with PIMs use in intensive care units.

DESIGN AND SETTING

Historical cohort study was conducted in a high-complexity hospital in Brazil.

METHODS

A retrospective chart review was conducted on 314 patients aged ≥ 60 years who were admitted to intensive care units (ICUs) at a high-complexity hospital in Brazil. The dates were extracted from a "Patient Safety Project" database. A Chi-square test, Student's t-test, and multivariable logistic regression analyses were performed to assess which factors were associated with PIMs. The statistical significance was set at 5%.

RESULTS

According to Beers' criteria, 12.8% of the identified drugs were considered inappropriate for the elderly population. The incidence rate of PIMs use was 45.8%. The most frequently used PIMs were metoclopramide, insulin, antipsychotics, non-steroidal anti-inflammatory drugs, and benzodiazepines. Factors associated with PIMs use were the number of medications (odds ratio [OR] = 1.17), length of hospital stay (OR = 1.07), and excessive potential drug interactions (OR = 2.43).

CONCLUSIONS

Approximately half of the older adults in ICUs received PIM. Patients taking PIMs had a longer length of stay in the ICU, higher numbers of medications, and higher numbers of potential drug interactions. In ICUs, the use of explicit methods combined with clinical judgment can contribute to the safety and quality of medication prescriptions.

Examination of the effectiveness of bedside nasojejunal tube placement using a portable imaging device with a flat panel detector

Transporting pediatric patients with severe cardiovascular complications to the fluoroscopy room can be difficult. Therefore, we started using a portable imaging device with a flat panel detector (FPD) for nasojejunal tube (NJT) placement. The purpose of this study was to investigate the differences in length of time of NJT placement and dosage of radiation exposure using a portable imaging device with FPD versus fluoroscopy. Pediatric patients who underwent NJT placement between April 2016 and December 2018 were identified retrospectively from the clinical records. The age, sex, body weight, and height of each child at the time of the procedure as well as the procedure time, outcomes of the procedure, and dosage of radiation exposure was compared between the two groups. In 76 cases of NJT placement (41 patients), there was no significant difference in the success rate of NJT placement between the FPD (90%) and fluoroscopy groups (95%). However, the NJT placement time was significantly longer in the FPD group than in the fluoroscopy group (488 s vs 291 s). According to our calculations, the radiation dosage was lower in the FPD group than in the fluoroscopy group (136 μGy per procedure vs 2819 μGy per procedure). These results suggest that NJT placement using a portable imaging device with an FPD can be an effective method for children who are difficult to transport with an equal success rate and lower dosage of radiation exposure compared with conventional fluoroscopy.

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.

Ventilator-associated pneumonia prevention in the Intensive care unit using Postpyloric tube feeding in China (VIP study): study protocol for a randomized controlled trial

BACKGROUND

Ventilator-associated pneumonia is a challenge in critical care and is associated with high mortality and morbidity. Although some consensuses on preventing ventilator-associated pneumonia are reached, it is still somewhat controversial. Meta-analysis has shown that postpyloric tube feeding may reduce the incidences of ventilator-associated pneumonia, which still desires high-quality evidence. This trial aims to evaluate the efficacy and safety profiles of postpyloric tube feeding versus gastric tube feeding.

METHODS/DESIGN

In this multicenter, open-label, randomized controlled trial, we will recruit 924 subjects expected to receive mechanical ventilation for no less than 48 h. Subjects on mechanical ventilation will be randomized (1:1) to receive postpyloric or gastric tube feeding and routine preventive measures simultaneously. The primary outcome is the proportion of patients with at least one ventilator-associated pneumonia episode. Adverse events and serious adverse events will be observed closely.

DISCUSSION

The VIP study is a large-sample-sized, multicenter, open-label, randomized, parallel-group, controlled trial of postpyloric tube feeding in China and is well-designed based on previous studies. The results of this trial may help to provide evidence-based recommendations for the prevention of ventilator-associated pneumonia.

TRIAL REGISTRATION

Chictr.org.cn ChiCTR2100051593 . Registered on 28 September 2021.

A Two-Stage Bedside Intubation Method to Improve Success Rate of Post-pyloric Placement of Spiral Nasoenteric Tubes in Critically Ill Patients: A Multi-Center, Prospective Study

Backgrounds

Prokinetic agents could improve the success rate of post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs), and bedside blind technique might apply as a rescue therapy subsequent to spontaneous transpyloric migration failure. The objective of this study was to investigated the validity and safety of these two bedside intubation methods as a sequential procedure for post-pyloric placement of spiral NETs in critically ill patients.

Methods

The multicenter, prospective study was conducted in intensive care units of four tertiary hospitals (June 2020 to January 2021). Eligible patients received self-propelled spiral NET placements, promoted by prokinetic agents (Stage 1). An abdominal X-ray performed 24 h post-intubation confirmed the position of the tube tip. Patients with a failed transpyloric migration entered Stage 2, where beside blind intubation was conducted (reconfirmed by X-ray). The primary end point was the overall success rate of post-pyloric placement.

Results

The overall success rate of post-pyloric placement of the spiral NET was 91.1% (73.4% in the third portion of the duodenum [D3] or beyond). The total adverse event rate was 21.0%, without any serious adverse events. In Stage 1, 55.6% of participants achieved transpyloric migration, of these, 44.4% migrated to D3 or beyond. The median time from decision to intubate to the initiation of enteral nutrition (EN) was 25 h. In Stage 2, 83.0% of patients had successful post-pyloric intubation (67.9% in D3 or beyond). The median time from decision to EN initiation after the two-stage process was 36 h.

Conclusions

Prokinetic agents-assisted self-propelled intubation and remedial bedside blind technique as a sequential procedure for post-pyloric placement of spiral NETs were effective and safe, and this two-stage process did not affect the implementation of early EN in critically ill patients.

Trial Registration

Chinese Clinical Trial Registry, ChiCTR1900026381. Registered on 6 October 2019.

Endoscopic- versus x-ray-guidance for placement of nasojejunal tubes in critically ill patients: a systematic review and meta-analysis of randomized controlled trials

Nasojejunal tubes (NJTs) are increasingly used in critically ill patients. NJT insertion with endoscopic- or x-ray-guidance can be achieved with success rates above 90%. This systematic review and meta-analysis of randomized controlled trials (RCTs) compares the efficiency and safety of these two methods in critically ill patients. We searched Chinese and English databases for RCTs comparing endoscopy- and x-ray-guided NJT placement published up to July 5, 2021. Meta-analyses were performed using RevMan5 software to compute mean differences (MDs) and odds ratios (ORs). Eleven RCTs (n=676) were included. The endoscopic group had a higher procedure success rate (OR=2.14, 95% CI [1.19, 3.85], Z=2.52, P=0.01) and shorter insertion time (MD=-3.70 min, 95% CI [-6.90, -0.50], Z=2.27, P=0.02) than the x-ray group. NJT indwelling time and post-insertion complications were similar between groups. The x-ray group had fewer complications during placement (OR=8.08, 95% CI [3.58, 18.22], Z=5.03, P<0.00001]; on subgroup analysis, only gastrointestinal non-bleeding adverse events differed significantly between groups (OR=2.78, 95% CI [1.43, 5.39], Z=3.03, P=0.002). Visual analog scale discomfort scores were better in the x-ray group (MD=4.10, 95% CI [3.57, 4.63], Z=15.07, P<0.00001). Compared with x-ray-guided NJT placement, endoscopy-guided placement was faster, had a higher success rate, and was associated with fewer gastrointestinal non-bleeding adverse events and less discomfort during insertion. Endoscopic guidance is recommended for NJT placement in critically ill patients to improve placement efficiency. X-ray guidance is a good alternative, depending on the hospital setting, as it is convenient, economical, and potentially safer.

Multivariate analysis of factors associated with first-pass success in blind placement of a post-pyloric feeding tube: a retrospective study

BACKGROUND

Trans-jejunal nutrition via a post-pyloric enteral feeding tube has a low risk of aspiration or reflux; however, placement of the tube using the blind method can be difficult. Assistive devices, such as fluoroscopy or endoscopy, are useful but may not be suitable for patients with hemodynamic instability or severe respiratory failure. The aim of this study was to explore factors associated with first-pass success in the blind placement of post-pyloric enteral feeding tubes in critically ill patients.

METHODS

Data were obtained retrospectively from the medical records of adult patients who had a post-pyloric enteral feeding tube placed in the intensive care unit between January 1, 2012, and December 31, 2018. Logistic regression analysis was performed to assess the association between first-pass success and the independent variables. For logistic regression analysis, the following 13 variables were defined as independent variables: age, sex, height, fluid balance from baseline, use of sedatives, body position during the procedure, use of cardiac assist devices, use of prokinetic agents, presence or absence of intestinal peristalsis, postoperative cardiovascular surgery, use of renal replacement therapy, serum albumin levels, and position of the greater curvature of the stomach in relation to spinal levels L1 - L2.

RESULTS

Data obtained from 442 patients were analyzed. The first-pass success rate was 42.8% (n = 189). Logistic regression analysis demonstrated that the position of the greater curvature of the stomach cephalad to L1 - L2 was only associated with successful placement (odds ratio for first-pass success, 0.62; 95% confidence interval: 0.40 - 0.95).

CONCLUSIONS

In critically ill patients, the position of the greater curvature of the stomach caudal to L1 - L2 may be associated with a lower first-pass success rate of the blind method for post-pyloric enteral feeding tube placement. Further studies are needed to verify our results because the position of the stomach was estimated by radiographs after enteral feeding tube placement.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry (UMIN000036549; April 20, 2019).

Association between Domperidone Administered via Feeding Tube and Feeding Success in Critically Ill Patients with Enteral Feeding Intolerance

One nutritional challenge in critically ill patients is enteral feeding intolerance (EFI), but current prokinetic agents have uncertain efficacy and safety profiles. We conducted a longitudinal, single-center, retrospective study to evaluate the efficacy and safety of domperidone administered via the feeding tube versus intravenous (IV) metoclopramide among adult patients with EFI. The primary outcome was feeding success, defined as the proportion of patients with average percentage of daily protein prescription >80% of the target dose. The secondary outcomes were safety endpoints. Among 28,814 intensive care unit (ICU) admissions, 552 patients with EFI were included, 38 receiving IV metoclopramide and 514 receiving tube feeding domperidone. The proportion of feeding success in patients receiving tube feeding domperidone and IV metoclopramide was 42.02% and 21.05%, respectively. After 1:2 matching (IV metoclopramide to tube feeding domperidone), the proportion of feeding success was 40.79% in patients receiving tube feeding domperidone. Basically, after matching, there were no differences in any safety endpoints (mortality and length of stay during ICU and hospitalization, organ-support-treatment free days) or adverse events (recurrence of EFI, electrolyte disturbance, abdominal and other symptoms) between the two groups (p > 0.05). A logistic regression analysis in the matched cohort indicated that domperidone administered via the feeding tube was independently associated with feeding success. We found that tube feeding domperidone was efficient in increasing enteral nutrition delivery performance among critically ill adult patients with EFI.

Is metoclopramide beneficial for the postpyloric placement of nasoenteric tubes? A systematic review and meta-analysis of randomized controlled trials

Background

Metoclopramide is frequently prescribed as an adjuvant for the postpyloric placement of nasoenteric tubes (NETs). However, a recent meta‐analysis showed that metoclopramide was not beneficial in adults. Thus, this study aimed to reevaluate the effect of metoclopramide on the postpyloric placement of NETs.

Methods

A systematic search of PubMed, Embase, the Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), and Wanfang data was conducted up to August 2020 for randomized controlled trials (RCTs) comparing metoclopramide with placebo or no intervention. Trial sequential analysis (TSA) was used for the primary outcomes (the success rate of the postpyloric placement of NETs).

Results

Seven eligible RCTs that included 520 participants were identified. The results of the pooled effect sizes showed that metoclopramide significantly facilitated the postpyloric placement of NETs (relative risk [RR], 1.48; 95% CI, 1.11–1.97; P = .007; I² = 37%). However, the risk‐of‐bias assessment and the TSA results indicated that the qualities of the RCTs and the sample sizes were insufficient to confirm the efficacy of metoclopramide. Further subgroup analysis revealed that successful postpyloric placement was more pronounced in studies in which spiral NETs were employed (RR, 1.85; 95% CI, 1.41–2.43; P < .001; I² = 0%). Additionally, overall adverse events were minimal.

Conclusions

The evidence accumulated so far was not strong enough to demonstrate metoclopramide's beneficial effects on the postpyloric placement of NETs. Further high‐quality, large‐sample RCTs are required to elucidate the effects of metoclopramide.

Can domperidone decrease transit time of pediatric video capsule endoscopy? A randomized controlled trial

BACKGROUND

The complete examination rate of video capsule endoscopy can be increased by reduced gastric transit time (GTT) and or small bowel transit time (SBTT). This study aims to examine whether the prokinetic domperidone reduces GTT and/or SBTT in pediatric patients undergoing video capsule endoscopy (VCE).

METHODS

We performed a single-center randomized controlled trial (n=200) to evaluate the effect of domperidone on GTT and SBTT among pediatric patients in a tertiary university-affiliated hospital for children. We explored whether patients randomized to domperidone had increased GTT, SBTT (primary outcomes) or higher complete examination rate (secondary outcome). The safety outcomes were the adverse effects in the domperidone group. This study was registered on ClinicalTrials.gov (NCT03662113).

RESULTS

Demographic features including gender and age were similar between the 100 patients of the domperidone group and the 100 patients of the control group. The median GTT was 67.5 minutes (44.8-117.5) in the domperidone group and 80.0 minutes (42.0-128.0) in the control group, while the median SBTT was 317 minutes (231-436) and 323 minutes (225-426), respectively. There were no significant differences in GTT (P=0.49) and SBTT (P=0.52) between the two groups. The complete examination rate was 97% and 98% in the domperidone and control groups, respectively (P=1.00).

CONCLUSIONS

Domperidone shows no effect on GTT, SBTT and complete examination rate in pediatric patients receiving VCE.

Intravenous Metoclopramide to Improve the Success Rate of Blind Bedside Post-pyloric Placement of Feeding Tube in Critically Ill Children: A Randomized, Double-Blind, Placebo-Controlled Study

Objective: Impaired gastric emptying is a common cause of delayed feeding in critically ill children. Post-pyloric feeding may help improve feeding intolerance and nutritional status and, hence, contribute to a better outcome. However, post-pyloric feeding tube insertion is usually delayed due to a technical difficulty. Therefore, prokinetic agents have been used to facilitate blind bedside post-pyloric feeding tube insertion. Metoclopramide is a potent prokinetic agent that has also been used to improve motility in adults and children admitted to intensive care units. The objective of this study was to determine the efficacy of intravenous metoclopramide in promoting the success rate of blind bedside post-pyloric feeding tube placement in critically ill children. Design: The design of this study is randomized, double blind, placebo controlled. Setting: The setting of the study is a single-center pediatric intensive care unit. Patients: Children aged 1 month-18 years admitted to the pediatric intensive care unit with severe illness or feeding intolerance were enrolled in this study. Intervention: Patients were randomly selected to receive intravenous metoclopramide or 0.9% normal saline solution (the placebo) prior to the tube insertion. The study outcome was the success rate of post-pyloric feeding tube placement confirmed by an abdominal radiography 6-8 h after the insertion. Measurements and Main Results: We found that patients receiving metoclopramide had a higher success rate (37/42, 88%) of post-pyloric feeding tube placement than the placebo (28/40, 70%) (p = 0.04). Patients who received sedative drug or narcotic agent showed a tendency of higher success rate (p = 0.08). Conclusion: Intravenous metoclopramide improves the success rate of blind bedside post-pyloric placement of feeding tube in critically ill children. Trial Registration: Thai Clinical Trial Registry TCTR20190821002. Registered 15th August 2019.

Gastroparesis in the Hospital Setting

Gastroparesis (GP) is commonly seen in hospitalized patients. Refractory vomiting and related dehydration, electrolyte abnormalities, and malnutrition are indications for hospital admission. In addition, tube feeding intolerance is a common sign of gastric dysmotility in critically ill patients. The diagnosis and management of GP in the hospital setting can be quite challenging. Diagnostic tests are often deferred because of patient intolerance of the oral meal for standard scintigraphy or severity of the primary disease. The diagnosis of GP is often established on the basis of clinical scenario and risk factors for gastric motor dysfunction. Medical therapy in GP is directed toward controlling nausea and vomiting by prokinetic and antinausea medications and correcting nutrition risks or treating malnutrition with nutrition therapy. Enteral nutrition is the preferred nutrition intervention for patients with GP. Delayed gastric emptying in critically ill patients has a negative impact on the timely delivery of enteral feeding and meeting the energy and protein goals. Measures to improve gastric tolerance or provide feeding beyond the stomach are often needed, since early enteral nutrition has been an important target of therapy for critically ill patients. This review will address the current understanding of the mechanisms of GP and feeding intolerance in critical illness, diagnostic workup, drug therapies, and interventions to improve the provision of enteral nutrition in hospital settings when gastric dysmotility is present or suspected.

Metoclopramide Reduces Fluoroscopy and Procedure Time during Gastrojejunostomy Tube Placement: A Placebo-Controlled Trial

PURPOSE

To determine whether a single 10-mg intravenous dose of the promotility agent metoclopramide reduces the fluoroscopy time, radiation dose, and procedure time required for gastrojejunostomy (GJ) tube placement.

METHODS

This prospective, randomized, double-blind, placebo-controlled trial enrolled consecutive patients who underwent primary GJ tube placement at a single institution from April 10, 2018, to October 3, 2019. Exclusion criteria included age less than 18 years, inability to obtain consent, metoclopramide allergy or contraindication, and altered pyloric anatomy. Average fluoroscopy times, radiation doses, and procedure times were compared using t-tests. The full study protocol can be found at www.clinicaltrials.gov (NCT03331965).

RESULTS

Of 110 participants randomized 1:1, 45 received metoclopramide and 51 received placebo and underwent GJ tube placement (38 females and 58 males; mean age, 55 ± 18 years). Demographics of the metoclopramide and placebo groups were similar. The fluoroscopy time required to advance a guide wire through the pylorus averaged 1.6 minutes (range, 0.3-10.1 minutes) in the metoclopramide group versus 4.1 minutes (range, 0.2-27.3 minutes) in the placebo group (P = .002). Total procedure fluoroscopy time averaged 5.8 minutes (range, 1.5-16.2 minutes) for the metoclopramide group versus 8.8 minutes (range, 2.8-29.7 minutes) for the placebo group (P = .002). Air kerma averaged 91 mGy (range, 13-354 mGy) for the metoclopramide group versus 130 mGy (range, 24-525 mGy) for the placebo group (P = .04). Total procedure time averaged 16.4 minutes (range, 8-51 minutes) for the metoclopramide group versus 19.9 minutes (range, 6-53 minutes) for the placebo group (P = .04). There were no drug-related adverse events and no significant differences in procedure-related complications.

CONCLUSIONS

A single dose of metoclopramide reduced fluoroscopy time by 34%, radiation dose by 30%, and procedure time by 17% during GJ tube placement.

The "Silk Road": A novel method for inserting transpyloric feeding tubes in low resource settings

INTRODUCTION

Transpyloric tube (TPT) feeding is used in a multitude of conditions including gastroesophageal reflux disease. We here describe a new simple method to insert TPTs.

METHODS

6 French feeding tube is premeasured nose to xiphisternum, and then another 7cm of length is added and 3-5 silk (4-0) ties are applied to the end of the tube spaced 0.5-1cm apart. The knots are placed in different radial directions, and multiple throws are placed on each knot so as to add bulkiness. The tube is then inserted transnasally to the premeasured length and secured. The child is given a single dose of metoclopramide and placed on his right side for 4h. A plain abdominal x-ray is then performed to confirm adequate TP placement. Following correct placement the patient is tube fed with small volumes every 15-20min. Descriptive data was prospectively collected.

RESULTS

34 patients were recruited, median age 3.5months. All presented with vomiting, and 26 had failure to thrive. 24had successful TP tube placement from the first attempt, 6 from the second attempt, 2 on third attempt, and in 2 placement was unsuccessful. In 28 patients vomiting almost stopped completely. 9 patients had fundoplication, and 1 had gastrostomy placement. 3 patients died during the study because of unknown reasons.

CONCLUSION

The silk tie technique is a safe and simple way to treat persistent vomiting and may prove useful in low resourced environments.

LEVEL OF EVIDENCE

IV.

Blinded, Double-Dummy, Parallel-Group, Phase 2a Randomized Clinical Trial to Evaluate the Efficacy and Safety of a Highly Selective 5-Hydroxytryptamine Type 4 Receptor Agonist in Critically Ill Patients With Enteral Feeding Intolerance

Background

Delayed gastric emptying is the leading cause of enteral feeding intolerance (EFI) in critical illness. This phase 2a study compared TAK‐954, a selective agonist of 5‐hydroxytryptamine type 4 receptors, with metoclopramide in critically ill patients with EFI (NCT01953081).

Methods

A blinded, double‐dummy trial was conducted in mechanically ventilated patients with EFI (>200 mL gastric residual volume within 24 hours before randomization). Patients were randomized to receive either 0.5 mg intravenous TAK‐954 over 1 hour then 0.9% saline injection 4 times/d (sham metoclopramide) or the active comparator 10 mg intravenous metoclopramide 4 times/d and a 1‐hour 0.9% saline infusion. After initial dosing, participants received a radiolabeled meal of liquid nutrient (Ensure; 106 kcal), and gastric emptying was measured (scintigraphy). Adverse events (AEs) were recorded from the time of consent through to day 5; serious AEs were collected to day 30.

Results

Thirteen patients (TAK‐954, n = 7; metoclopramide, n = 6) participated. Five patients in the TAK‐954 group and 4 in the metoclopramide group experienced AEs (2 and 3, respectively, were serious). All AEs except 1 (diarrhea in the metoclopramide group) were considered unrelated to study drug. Following treatment, a greater proportion of patients receiving TAK‐954 had normal gastric retention (<13% retention at 180 minutes) than those receiving metoclopramide (6/7 vs 3/6 patients, respectively).

Conclusion

A single dose of 0.5 mg intravenous TAK‐954 appears to have at least similar efficacy in accelerating gastric emptying to multiple doses of 10 mg metoclopramide and was not associated with increased AEs.

The learning curve in blind bedside postpyloric placement of spiral tubes: data from a multicentre, prospective observational study

Objective

This study sought to quantify the learning curve for the blind bedside postpyloric placement of a spiral tube in critically ill patients.

Methods

We retrospectively analysed 127 consecutive experiences of three intensivists who performed comparable procedures of blind bedside postpyloric placement of a spiral tube subsequent to failed self-propelled transpyloric migration in a multicentre study. Each intensivist’s cases were divided chronologically into two groups for analysis. The assessment of the learning curve was based on efficiency and safety outcomes.

Results

All intensivists achieved postpyloric placement for over 80% of their patients. The junior intensivist showed major improvement in both efficiency and safety outcomes, and the learning curve for both outcomes was approximately 20 cases. The junior intensivist showed a significant increase in the success rate of proximal jejunum placement and demonstrated a substantial decrease in the major adverse tube-associated events rate. The time to insertion significantly decreased in each intensivist as case experience accumulated.

Conclusions

Blind bedside postpyloric placement of a spiral tube involves a significant learning curve, indicating that this technique could be readily acquired by intensivists with no previous experience using an adequate professional training programme.

Development and validation of a nomogram for predicting self-propelled postpyloric placement of spiral nasoenteric tube in the critically ill: Mixed retrospective and prospective cohort study

BACKGROUND & AIMS

Equipment-aided or experience-dependent methods for postpyloric nasoenteric tube placement are not so readily accessible in the critically ill setting. Self-propelled postpyloric placement of a spiral nasoenteric tube can serve as an alternative approach. However, the success rate of this method is relatively low despite using prokinetics. This study aims to develop a user-friendly nomogram incorporating clinical markers to individually predict the probability of successful postpyloric nasoenteric tube placement and facilitate intensivists with improved decision-making before tube insertion.

METHODS

Patients consecutively recruited in the stage between May 2012 through December 2016 constituted the development cohort for retrospective analysis to internally test the nomogram, and patients in the stage between January 2017 through March 2018 constituted the validation cohort for prospective analysis to external validate the nomogram. A multivariate logistic regression analysis was firstly performed in the development cohort by a backward stepwise method to identify the best-fit model, from which a nomogram was obtained. The nomogram was validated in the independent external validation cohort concerning discrimination, calibration. A decision curve analysis was also performed to evaluate the net benefit of insertion decision with the nomogram.

RESULTS

A total of 364 and 119 patients, 52.7% and 55.5% with successful postpyloric placement, were included in the development and validation cohort, respectively. Predictors contained in the prediction nomogram included primary diagnosis, APACHE II score, AGI grade. The derived model showed good discrimination, with an area under the receiver operating characteristic curve (AUROC) of 0.809 (95%CI, 0.765-0.853) and good calibration. Application of the nomogram in the validation cohort also gave good discrimination with an AUROC of 0.776 (95%CI, 0.694-0.859) and good calibration. The decision curve analysis of the nomogram provided better net benefit than the alternate options (insert-all or insert-none).

CONCLUSIONS

A prediction nomogram that incorporates primary diagnosis, together with APACHE II score and AGI grade can be conveniently used to facilitate the pre-insertion individualized prediction of postpyloric nasoenteric tube placement in critically ill patients.

Erythromycin versus metoclopramide for post-pyloric spiral nasoenteric tube placement: a randomized non-inferiority trial

Purpose

To determine whether erythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs) in critically ill patients.

Methods

A prospective, multicenter, open-label, parallel, and non-inferiority randomized controlled trial was conducted comparing erythromycin with metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients admitted to intensive care units (ICUs) of eight tertiary hospitals in China. The primary outcome was procedure success defined as post-pyloric placement (spiral NETs reached the first portion of the duodenum or beyond confirmed by abdominal radiography 24 h after tube insertion).

Results

A total of 5688 patients were admitted to the ICUs. Of these, in 355 patients there was a plan to insert a nasoenteric feeding tube, of whom 332 were randomized, with 167 patients assigned to the erythromycin group and 165 patients assigned to the metoclopramide group. The success rate of post-pyloric placement was 57.5% (96/167) in the erythromycin group, as compared with 50.3% (83/165) in the metoclopramide group (a difference of 7.2%, 95% CI − 3.5% to 17.9%), in the intention-to-treat analysis, not including the prespecified margin of − 10% for non-inferiority. The success rates of post-D1 (reaching the second portion of the duodenum or beyond), post-D2 (reaching the third portion of the duodenum or beyond), post-D3 (reaching the fourth portion of the duodenum or beyond), and proximal jejunum placement and the incidence of any adverse events were not significantly different between the groups.

Conclusions

Erythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients. The success rates of post-D1, post-D2, post-D3, and proximal jejunum placement were not significantly different.

Gastric versus postpyloric enteral nutrition in elderly patients (age ≥ 75 years) on mechanical ventilation: a single-center randomized trial

BACKGROUND

The risk of ventilator-associated pneumonia (VAP) is reduced when postpyloric enteral nutrition (EN) is administered compared to when gastric EN is administered in specific populations. In the present study, we tested the hypothesis that postpyloric EN is superior to gastric EN in reducing the incidence of VAP in elderly patients (age ≥ 75 years) who are admitted to the intensive care unit (ICU) and require mechanical ventilation.

METHODS

We performed a single-center randomized clinical trial involving elderly patients (age ≥ 75 years) who were admitted to the ICU and required mechanical ventilation. The patients were randomly assigned to either the postpyloric EN group or the gastric EN group. The primary outcome was the VAP rate.

RESULTS

Of the 836 patients screened, 141 patients were included in the study (70 in the postpyloric EN group and 71 in the gastric EN group). The patients in the postpyloric EN group were 82.0 (75.0-99.0) years old (male 61.4%), and those in the gastric EN group were 82.0 (75.0-92.0) years old (male 63.4%). The Acute Physiology and Chronic Health Evaluation II scores were 28.09 ± 6.75 in the postpyloric EN group and 27.80 ± 7.60 in the gastric EN group (P = 0.43). VAP was observed in 8 of 70 patients (11.4%) in the postpyloric EN group and in 18 of 71 patients (25.4%) in the gastric EN group, which resulted in a significant between-group difference (OR 0.38, 95% CI 0.15-0.94; P = 0.04). In the postpyloric EN group, there were significant reductions in vomiting (12 patients in the postpyloric EN group vs 29 patients in the gastric EN group; OR 0.30, 95% CI 0.14-0.65; P = 0.002) and abdominal distension (18 patients in the postpyloric EN group vs 33 patients in the gastric EN group; OR 0.40, 95% CI 0.20-0.81; P = 0.01). No significant differences were observed between the two groups regarding mortality and other secondary outcomes.

CONCLUSIONS

Our study demonstrated that, compared with gastric EN, postpyloric EN reduced the VAP rate among elderly patients who were admitted to the ICU and required mechanical ventilation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IPR-16008485 . Registered on 17 May 2016.

Evaluation of gastric motility through surface electrogastrography in critically ill septic patients. Comparison of metoclopramide and domperidone effects: A pilot randomized clinical trial

INTRODUCTION AND AIMS

Critically ill patients present with a broad spectrum of gastrointestinal motility disorders that affect the digestive tract. Our aim was to compare the effect of two prokinetic drugs on gastric electrical rhythm in critically ill septic patients, measured through surface electrogastrography (EGG).

MATERIAL AND METHODS

A prospective triple-blinded randomized study was conducted on 36 patients admitted to the intensive care unit (ICU) with the diagnosis of septic shock. They were randomized to receive metoclopramide or domperidone. We assessed dominant frequency (DF), percentage distribution over time, and dominant power (DP), which represents the strength of contraction, before and after administration of the study drugs.

RESULTS

Reliable electrogastrograms were achieved in all patients. In relation to the distribution of DF over time, 64% of patients had dysrhythmia, the mean baseline DF was 2.9 cpm, and the mean DP was 56.5μv After drug administration, 58% of the patients had dysrhythmia, the mean DF increased to 5.7 cpm (P<.05), and the DP did not change (57.4μv²). There were no significant differences between drugs. In the metoclopramide group, the baseline DF was 2.1 cpm and the baseline DP was 26.1μv². The post-drug values increased to 5.4 cpm and 34.1μv², respectively. In the domperidone group, the baseline DF was 3.7 cpm and the baseline DP was 86.9μv². After drug administration, the DF increased to 6.1 cpm and the DP decreased to 83.5μv².

CONCLUSIONS

Both metoclopramide and domperidone similarly increased the DF of gastric pacemaker activity and improved gastric motility by restoring a normogastric pattern. Gastric dysmotility is frequent in septic patients.

Gastrointestinal dysmotility in critically ill patients

Gastrointestinal (GI) motility disorders are commonly present in critical illness. Up to 60% of critically ill patients have been reported to experience GI dysmotility of some form necessitating therapeutic intervention. It has been attributed to various factors, related to both the underlying disease and the therapeutic interventions undertaken. The assessment of motility disturbances can be challenging in critically ill patients, as the available tests used to detect abnormal motility have major limitations in the setting of an Intensive Care Unit. Critically ill patients with GI dysmotility require a multifaceted treatment approach that addresses multiple causes and utilizes multiple pharmacological pathways. In this review, we discuss the pathophysiology, assessment and management of GI dysmotility in critically ill patients.

Establishing Decision Trees for Predicting Successful Postpyloric Nasoenteric Tube Placement in Critically Ill Patients

BACKGROUND

Despite the use of prokinetic agents, the overall success rate for postpyloric placement via a self-propelled spiral nasoenteric tube is quite low.

METHODS

This retrospective study was conducted in the intensive care units of 11 university hospitals from 2006 to 2016 among adult patients who underwent self-propelled spiral nasoenteric tube insertion. Success was defined as postpyloric nasoenteric tube placement confirmed by abdominal x-ray scan 24 hours after tube insertion. Chi-square automatic interaction detection (CHAID), simple classification and regression trees (SimpleCart), and J48 methodologies were used to develop decision tree models, and multiple logistic regression (LR) methodology was used to develop an LR model for predicting successful postpyloric nasoenteric tube placement. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of these models.

RESULTS

Successful postpyloric nasoenteric tube placement was confirmed in 427 of 939 patients enrolled. For predicting successful postpyloric nasoenteric tube placement, the performance of the 3 decision trees was similar in terms of the AUCs: 0.715 for the CHAID model, 0.682 for the SimpleCart model, and 0.671 for the J48 model. The AUC of the LR model was 0.729, which outperformed the J48 model.

CONCLUSION

Both the CHAID and LR models achieved an acceptable discrimination for predicting successful postpyloric nasoenteric tube placement and were useful for intensivists in the setting of self-propelled spiral nasoenteric tube insertion.

Blind bedside postpyloric placement of spiral tube as rescue therapy in critically ill patients: a prospective, tricentric, observational study

Background

Various special techniques for blind bedside transpyloric tube placement have been introduced into clinical practice. However, transpyloric spiral tube placement facilitated by a blind bedside method has not yet been reported. The objective of this prospective study was to evaluate the safety and efficiency of blind bedside postpyloric placement of a spiral tube as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients.

Methods

This prospective, tricentric, observational study was conducted in the intensive care units (ICUs) of three tertiary hospitals. A total of 127 consecutive patients with failed spontaneous transpyloric spiral tube migration despite using prokinetic agents and still required enteral nutrition for more than 3 days were included. The spiral tube was inserted postpylorically using the blind bedside technique. All patients received metoclopramide intravenously prior to tube insertion. The exact tube tip position was determined by radiography. The primary efficacy endpoint was the success rate of postpyloric spiral tube placement. Secondary efficacy endpoints were success rate of a spiral tube placed in the third portion of the duodenum (D3) or beyond, success rate of placement in the proximal jejunum, time to insertion, length of insertion, and number of attempts. Safety endpoints were metoclopramide-related and major adverse tube-associated events.

Results

In 81.9% of patients, the spiral feeding tubes were placed postpylorically; of these, 55.1% were placed in D3 or beyond and 33.9% were placed in the proximal jejunum, with a median time to insertion of 14 min and an average number of attempts of 1.4. The mean length of insertion was 95.6 cm. The adverse event incidence was 26.0%, and no serious adverse event was observed.

Conclusions

Blind bedside postpyloric placement of a spiral tube, as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients, is safe and effective. This technique may facilitate the early initiation of postpyloric feeding in the ICU.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-OPN-16008206. Registered on 1 April 2016.

Prokinetics in the Management of Functional Gastrointestinal Disorders

PURPOSE OF REVIEW

The goal of this review is to review the current status of prokinetics and to place it in historical context. Impaired motility and thus propulsion have long been thought to play important roles in the pathogenesis of a number of gastrointestinal disorders including gastroesophageal reflux disease (GERD), gastroparesis, chronic idiopathic pseudo-obstruction, and constipation. Historically, disordered motility was also thought to contribute to a number of functional gastrointestinal disorders such as functional dyspepsia (FD) and irritable bowel syndrome (IBS).

RECENT FINDINGS

As we learn more of the pathophysiology of FD, IBS, GERD, constipation, and gastroparesis, the limitations of a therapeutic strategy based on the stimulation of motility (i.e., the use of a prokinetic) have become apparent and the disappointments of the past explained. The development of prokinetic drugs has also been hampered by the non-selective nature of many of the agents studied to date which resulted in some unexpected side effects. There is still an unmet need for an effective and safe prokinetic, but drug development in this area must be mindful of the challenges of the area and the need for selectivity for a given target receptor.

Gastrointestinal dysmotility in the critically ill: a role for nutrition

PURPOSE OF REVIEW

The role of enteral nutrition on gastrointestinal dysmotility in the critically ill remains controversial.

RECENT FINDINGS

The mechanisms of gastrointestinal dysmotility during critical illness remain poorly investigated. Low amounts of enteral feeding stimulate motility and have trophic effects. Therefore, enteral feeding is feasible even during gastrointestinal dysmotility as seen in the hemodynamically compromised patient. Rapid 'ramp-up' of administration rate of tube feeding bears the risk of overload and even detrimental ischemic bowel necrosis. The recent American Society for Parenteral and Enteral Nutrition guidelines do not recommend the measurement of gastric residual volume. The use of concentrated enteral solutions with 1.5 kcal/ml may result in greater calorie delivery. Biomarkers like plasma citrulline and plasma or urine intestinal fatty-acid-binding protein reflect the functional integrity of the bowel and may potentially support monitoring.

SUMMARY

To improve enteral nutrition protocols, the definitions of gastrointestinal dysfunction, gastric dysmotility, and feeding intolerance should be clearly defined in the future. In the concept of integrity of the gut, enteral nutrition should not be stopped completely during gastrointestinal dysfunction but restricted to a 'minimal' trophic feeding rate. In malnourished and high-risk patients intolerant to enteral feeding supplemental parenteral nutrition should be started on day 4 or earlier.

The efficacy and safety of prokinetic agents in critically ill patients receiving enteral nutrition: a systematic review and meta-analysis of randomized trials

Background

Intolerance to enteral nutrition is common in critically ill adults, and may result in significant morbidity including ileus, abdominal distension, vomiting and potential aspiration events. Prokinetic agents are prescribed to improve gastric emptying. However, the efficacy and safety of these agents in critically ill patients is not well-defined. Therefore, we conducted a systematic review and meta-analysis to determine the efficacy and safety of prokinetic agents in critically ill patients.

Methods

We searched MEDLINE, EMBASE, and Cochrane Library from inception up to January 2016. Eligible studies included randomized controlled trials (RCTs) of critically ill adults assigned to receive a prokinetic agent or placebo, and that reported relevant clinical outcomes. Two independent reviewers screened potentially eligible articles, selected eligible studies, and abstracted pertinent data. We calculated pooled relative risk (RR) for dichotomous outcomes and mean difference for continuous outcomes, with the corresponding 95 % confidence interval (CI). We assessed risk of bias using Cochrane risk of bias tool, and the quality of evidence using grading of recommendations assessment, development, and evaluation (GRADE) methodology.

Results

Thirteen RCTs (enrolling 1341 patients) met our inclusion criteria. Prokinetic agents significantly reduced feeding intolerance (RR 0.73, 95 % CI 0.55, 0.97; P = 0.03; moderate certainty), which translated to 17.3 % (95 % CI 5, 26.8 %) absolute reduction in feeding intolerance. Prokinetics also reduced the risk of developing high gastric residual volumes (RR 0.69; 95 % CI 0.52, 0.91; P = 0.009; moderate quality) and increased the success of post-pyloric feeding tube placement (RR 1.60, 95 % CI 1.17, 2.21; P = 0.004; moderate quality). There was no significant improvement in the risk of vomiting, diarrhea, intensive care unit (ICU) length of stay or mortality. Prokinetic agents also did not significantly increase the rate of diarrhea.

Conclusion

There is moderate-quality evidence that prokinetic agents reduce feeding intolerance in critically ill patients compared to placebo or no intervention. However, the impact on other clinical outcomes such as pneumonia, mortality, and ICU length of stay is unclear.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1441-z) contains supplementary material, which is available to authorized users.

Bedside placement of small-bowel feeding tube in Intensive Care Unit for enteral nutrition

Enteral nutrition is the preferred mode of nutrition in critically ill patients whenever feasible as it has a number of advantages over parenteral feeding. Both gastric and small-bowel feeding can effectively deliver calories. In patients with gastroparesis, small-bowel feeding can help avoid parenteral feeding. We carried out a retrospective observational study to assess the ability to insert the Tiger 2 tube into the small bowel at the bedside in 25 patients who failed to tolerate gastric feeds. The time taken, rate of successful insertion, and ability to feed these patients using a standardized feeding protocol were noted. Success rate of insertion was 78% and feeding could be established. This method reduced the delays and risks associated with transportation and dependence on other specialties.

Nasogastric Nutrition versus Nasojejunal Nutrition in Patients with Severe Acute Pancreatitis: A Meta-Analysis of Randomized Controlled Trials

Introduction. Previous studies have shown that the nasogastric (NG) route seems equivalent to the nasojejunal (NJ) route in patients with severe acute pancreatitis (SAP). However, these studies used a small sample size and old criteria for diagnosing SAP, which may include some patients with moderate SAP, according to the newly established SAP criteria (Atlanta 2012 classification). Based on the changes in the criteria for classifying SAP, we performed an up-to-date meta-analysis. Method. We reviewed the PubMed, EMbase, China National Knowledge Infrastructure, Wanfang Database, and Cochrane Central Register of Controlled Trials electronic databases. We included randomized controlled trials comparing NG and NJ nutrition in patients with SAP. We performed the meta-analysis using the Cochrane Collaborations' RevMan 5.3 software. Results. We included four randomized controlled trials involving 237 patients with SAP. There were no significant differences in the incidence of mortality, infectious complications, digestive complications, achievement of energy balance, or length of hospital stay between the NG and NJ nutrition groups. Conclusions. NG nutrition was as safe and effective as NJ nutrition in patients with SAP. Further studies are needed to confirm our results.

Endoscopy versus fluoroscopy for the placement of postpyloric nasoenteric tubes in critically ill patients: A meta-analysis of randomized controlled trials

INTRODUCTION

Early postpyloric nasoenteric nutrition is considered an accepted method of nutritional support in critically ill patients. Both endoscopy and fluoroscopy placement of postpyloric nasoenteric tubes (PNTs) have the highest percentages of placement success rate. We aimed to evaluate the differences in efficacy and safety between endoscopy and fluoroscopy methods for the placement of PNTs in critically ill patients.

METHOD

We searched MEDLINE, Embase, and electronic databases of Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing endoscopy and fluoroscopy placement of PNTs in critically ill patients. Two reviewers assessed the quality of each study and collected data independently. We performed the meta-analysis with Cochrane Collaboration RevMan 5.3.

RESULTS

Three randomized controlled trials involving 243 patients were included. There were no significant differences in the placement success rate (RR, 0.99; 95% CI, 0.93, 1.06; z = 0.20, P = .84,) or procedure time (standardized mean difference, -0.08; 95% CI, -6.93, 6.77; z = 0.02, P = .98) between the 2 groups. No severe complications (digestive tract hemorrhage, perforation, respiratory problems, hemodynamic instability, or death) were noted in the three studies. There was a slight difference in the incidence of minor complications (RR, 8.12; 95% CI, 1.07, 61.53; z = 2.03, P = .04) between the 2 groups.

CONCLUSIONS

Endoscopy and fluoroscopy placement of PNTs can be accurately and safely performed in critically ill patients. Endoscopy may be at least equally as safe as fluoroscopy for the placement of PNTs.

Rhubarb to Facilitate Placement of Nasojejunal Feeding Tubes in Patients in the Intensive Care Unit

BACKGROUND

Prokinetic agents are sometimes needed to aid in the placement of nasojejunal feeding tubes in patients at risk of malnutrition. The objective of the present study was to evaluate the feasibility of rhubarb as a new prokinetic agent to replace metoclopramide and erythromycin in the placement of nasojejunal feeding tubes.

MATERIALS AND METHODS

Ninety-four patients who required jejunal feeding tube insertion were included. They were divided into rhubarb (n = 34), metoclopramide (n = 31), and erythromycin groups (n = 29), depending on the use of rhubarb, metoclopramide, and erythromycin as the prokinetic agent. The jejunal feeding tube insertions were performed at the bedside. An abdominal x-ray was taken as the gold standard to determine the position of the tube. Cases in which insertion failed in either group were subjected to a second insertion attempt using rhubarb as the prokinetic agent.

RESULTS

The success rates in the rhubarb, metoclopramide, and erythromycin groups were 91.2%, 87.1%, and 89.7%, respectively. The difference in the success rates was not statistically significant (P = .916). The insertion times in the rhubarb, metoclopramide, and erythromycin groups were 16.0 ± 1.9 minutes, 18.0 ± 1.9 minutes, and 18.8 ± 2.2 minutes, respectively. The insertion time in the rhubarb group was significantly shorter than those in metoclopramide and erythromycin groups (P < .001). No side effects were noted in the rhubarb group.

CONCLUSIONS

Rhubarb could serve as an effective prokinetic agent to promote the insertion of nasojejunal feeding tubes.