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

Blind versus endoscopy-guided postpyloric feeding tube placement in adults with ischemic stroke: A retrospective cohort study

BACKGROUND

This study compared the one-time success rate of blind and endoscopy-guided postpyloric feeding tube placement after implementing a comprehensive nursing scheme of intestinal blind placement for patients with ischemic stroke.

METHODS

This retrospective cohort study included 179 patients with blind bedside placement and 118 with endoscopy-guided placement. The primary outcome was the one-time success rate of radiologically confirmed postpyloric placement. The secondary endpoints included the position of the tube tip, length of insertion, time of placement, and expenses. The safety endpoints were the incidence of complications caused by placement.

RESULTS

The results showed that the method of tube placement did not significantly affect the outcome of the first tube placement (odds ratio [OR] = 0.41; 95% CI = 0.137-1.207; P = 0.105). Compared with endoscopy-guided placement, blind placement was half the cost. We also found that a history of abdominal surgery (OR = 0.003; 95% CI  = 0.000-0.059; P < 0.001) and longer intensive care unit (ICU) days (OR = 0.94; 95% CI = 0.903-0.981; P = 0.004) were inversely associated with the one-time success rate.

CONCLUSION

Our study suggested that blind intestinal feeding tube placement has an equivalent one-time success rate compared with endoscopy-guided placement in hospitalized patients with ischemic stroke if operators can be trained well. However, the expenses of endoscopy-guided placement were twice those of blind bedside methods. We also found that patients with abdominal surgery history and longer ICU stay were more likely to fail at the first placement. Further research is needed to replicate our single-center observations in a larger population of patients.

Application of a downward tract adherence method in the manual bedside placement of post-pyloric tubes in the intensive care unit

BACKGROUND

At present, there are few studies on the technical requirements of manual bedside placement of post-pyloric tube in Intensive Care Unit patients.

OBJECTIVE

To investigate the application value of downward tract adherence method in the manual bedside placement of jejunal tubes.

METHODS

In the downward group, 160 patients underwent manual bedside placement of jejunal tubes by a downward tract adherence method. In the conventional group, 144 patients were treated with conventional gas injection during the placement. The success rate, average time, and adverse reactions of the placement in the two groups were investigated and compared.

RESULTS

The success rate of the placement in the downward group was significantly higher (95% vs. 75%, P< 0.001) and the average time for the successful placement was shortened (23 ± 5.91 min vs. 26 ± 5.49 min, P= 0.025) than that in the conventional group. No treatment-related adverse reactions occurred in either group, and there were also no significant differences in vital sign changes.

CONCLUSIONS

The use of the downward tract adherence method in the manual bedside placement of postpyloric tubes for the intensive care patients at the bedside has a higher success rate, effectivity and safety.

Agreement Between Epigastric Auscultation and pH Measurement in the Confirmation of Nasoenteral Tube Placement

AIM

This study aimed to evaluate the agreement between epigastric auscultation and pH measurement in the confirmation of nasoenteral tube placement.

METHOD

A cross-sectional study carried out in a medium-sized private hospital in the interior of the state of São Paulo. Forty-nine patients who were submitted to ninety insertion procedures and confirmation of tube placement. aimed at evaluating the agreement of clinical methods used by nurses to confirm the positioning of a nasoenteral tube inserted blindly at the bedside, by measuring the parameters of sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

The epigastric auscultation was the method that presented the highest sensitivity (100.0%), but lower specificity (2.0%). The measurement of the pH presented lower sensitivity (63.0%) than the auscultation, however, higher specificity (58%). Moreover, the positive predictive value of the pH measurement was 55% and the negative predictive value was 66%. There was no agreement between the epigastric auscultation and the pH measurement with the radiography.

CONCLUSION

The pH measurement did not allow for distinguishing between gastric and enteric positioning, due to the similarity of the esophageal and pulmonary pH with the pH of the intestine. Furthermore, external factors such as the use of medication and reduced fasting time may interfere with the pH value.

Application of visual placement of a nasojejunal indwelling feeding tube in intensive care unit patients receiving mechanical ventilation

Background

Compared with nasogastric nutrition, nasojejunal nutrition may prevent some complications of critically ill patients by maintaining better nutritional status, and blind placement of nasojejunal dwelling feeding tubes is widely used. However, the visual placement seems to be safer and more effective than the blind placement, and is still seldom reported.

Objective

We tried to develop visual placement of a nasojejunal feeding tube in intensive care unit patients.

Methods

A total of 122 patients receiving mechanical ventilation were admitted to the Department of Critical Care Medicine of the Fifth Affiliated Hospital of Wenzhou Medical University and received the placement of nasojejunal feeding tubes. These patients were randomly and evenly assigned into two groups, one group receiving visual placement of nasojejunal dwelling feeding tubes and another group receiving blind placement. Actual tube placement was confirmed by X-ray. The primary outcome included the success rates of first placement of feeding tubes. The secondary outcome included the time of tube placement, complications, the total cost, heart rates and respiratory rates.

Results

The primary outcome showed that the success rates of first placement were 96.70% (59 cases/61 cases) in the visual placement group, and two cases failed due to pyloric stenosis and gastroparesis. The success rates were 83.6% (51 cases/61 cases) in the blind placement group and 10 cases failed due to either wrong placement or retrograde tube migration. The success rates in the visual placement group were higher than that in the blind placement group (P = 0.015). The secondary outcome showed that the time of tube placement in the visual placement group was shorter than that in the blind placement group (P < 0.0001). The cost of tube placement in the visual placement group was higher than that in the blind placement group (P < 0.0001). The statistical differences in complications, heart and respiratory rates were insignificant between the two groups (P > 0.05).

Conclusion

Compared with the blind placement, the visual placement shortened the time of nasojejunal tube placement and increased success rates of first placement. The visual placement was more efficient, easy to operate, safe, and has potential clinical applications.

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.

Small bowel feeding: do you pay the price for bypassing the stomach?

PURPOSE OF REVIEW

Hydration and nutritional support is a vital part of medical care, thus a clear understanding of the optimal approach is vital for medical professionals. This is a particularly pertinent issue for patients admitted to a critical care setting. This article aims to define the advantages and disadvantages of gastric and postpyloric feeding in the critical care setting, thus aiding decision-making for clinicians.

RECENT FINDINGS

Within the article, the main themes covered are those relating to enteral feeding tube placement, the impact of enteral feeding route on ventilator-associated pneumonia, optimization of enteral tube feeding in critical care and the impact that a chosen route may have upon gastrointestinal function.

SUMMARY

The value of enteral feeding in critical illness is proven beyond doubt and the simplest approach has long been 'if the gut works, use it'. If gastric feeding is not able to be established or is not tolerated then jejunal feeding should be considered as a preferable alternative to parenteral nutrition. Improving access to service or techniques for postpyloric tube placement would assist in optimizing nutritional support in the critical care setting.

Development and Validation of a Nomogram Incorporating Colloid Osmotic Pressure for Predicting Mortality in Critically Ill Neurological Patients

Backgrounds: The plasma colloid osmotic pressure (COP) values for predicting mortality are not well-estimated. A user-friendly nomogram could predict mortality by incorporating clinical factors and scoring systems to facilitate physicians modify decision-making when caring for patients with serious neurological conditions.

Methods: Patients were prospectively recruited from March 2017 to September 2018 from a tertiary hospital to establish the development cohort for the internal test of the nomogram, while patients recruited from October 2018 to June 2019 from another tertiary hospital prospectively constituted the validation cohort for the external validation of the nomogram. A multivariate logistic regression analysis was performed in the development cohort using a backward stepwise method to determine the best-fit model for the nomogram. The nomogram was subsequently validated in an independent external validation cohort for discrimination and calibration. A decision-curve analysis was also performed to evaluate the net benefit of the insertion decision using the nomogram.

Results: A total of 280 patients were enrolled in the development cohort, of whom 42 (15.0%) died, whereas 237 patients were enrolled in the validation cohort, of which 43 (18.1%) died. COP, neurological pathogenesis and Acute Physiology and Chronic Health Evaluation II (APACHE II) score were predictors in the prediction nomogram. The derived cohort demonstrated good discriminative ability, and the area under the receiver operating characteristic curve (AUC) was 0.895 [95% confidence interval (CI), 0.840–0.951], showing good correction ability. The application of this nomogram to the validation cohort also provided good discrimination, with an AUC of 0.934 (95% CI, 0.892–0.976) and good calibration. The decision-curve analysis of this nomogram showed a better net benefit.

Conclusions : A prediction nomogram incorporating COP, neurological pathogenesis and APACHE II score could be convenient in predicting mortality for critically ill neurological patients.

Cost-effectiveness analysis of nasojejunal tube feeding for the prevention of pneumonia in critically ill adults

BACKGROUND

Nasojejunal tube (NJT) feeding has demonstrated value in reducing pneumonia in critically ill adults who require enteral nutritional (EN) support. This study discusses whether EN support via nasojejunal tube (NJT) feeding is more cost-effective than nasogastric tube (NGT) feeding in reducing pneumonia.

METHODS

A decision tree model was created. The analysis was based on data from a health care provider in China. Model inputs were derived from published data. The endpoints included incremental cost per pneumonia infection avoided, incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB) and incremental net monetary benefit (INMB) associated with prevention of pneumonia. The uncertainty was assessed through one-way and probabilistic sensitivity analysis.

RESULTS

The base case analysis showed that EN support via NJT feeding resulted in 0.7453 quality-adjusted life years (QALYs) at a cost of $3018.83 compared to NGT feeding, which resulted in 0.7354 QALYs at a cost of $4788.76. NJT feeding was better than NGT feeding, providing an INMB of $2,075.09 and an ICER of $-178,813.96 per QALY gained, and the cost per pneumonia infection prevented was $16,808.51. The probabilistic sensitivity analysis indicated that NJT feeding was more cost-effective in 83.4% of the cases, with a cost below the WTP threshold. The NMB and INMB estimation for different WTP thresholds also indicated that NJT feeding is the optimal strategy.

CONCLUSIONS

EN support via NJT feeding was a more cost-effective strategy than NGT feeding in preventing pneumonia in critically ill adults. This article is protected by copyright. All rights reserved.

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.

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.

Fluoroscopic placement of nasojejunal feeding tubes in COVID-19 patients in the prone position

Background

Coronavirus disease 2019 (COVID‐19) has caused an increase in patients requiring enteral feeding access while undergoing proning for severe acute respiratory distress syndrome (ARDS). We investigated the safety and feasibility of fluoroscopy‐guided nasojejunal (NJ) feeding tube placement in the prone position.

Methods

This is a retrospective cohort study of all patients who underwent fluoroscopic placement of NJ feeding tubes at a single institution between March 2020 and December 2020. Primary end points were success rate and number of attempts. Chi‐squared and Fischer exact tests were used to compare prone and supine groups.

Results

A total of 210 patients were included in the study: 53 patients received NJ feeding tubes while prone and 157 while supine. All but one patient in the prone group had ARDS secondary to COVID‐19, whereas 47 (30.3%) had COVID‐19 in the supine group. The rate of successful placement was 94.3% in the prone group and 100% in the supine group. Mean number of attempts was 1.1 (SD, ±0.4) in the prone and 1.0 (SD, ±0.1) in the supine group (P = .14). Prone patients had a longer median fluoroscopy time (69 s, interquartile range [IQR] = 92; vs 48 s, IQR = 43; P < .001) and received a higher radiation dose during the procedure (47 mGy, IQR = 50; vs 25 mGy, IQR = 33; P = .004). No procedural complications were reported.

Conclusion

Fluoroscopy‐guided NJ feeding tube placement in prone patients is feasible and safe. Patient positioning should not delay obtaining postpyloric feeding access.

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.

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.

Simo decoction versus domperidone suspension for post-pyloric spiral nasoenteric tube placement: A multicenter, randomized, non-inferiority trial

BACKGROUND & AIMS

Leveraging prokinetics to facilitate trans-pyloric migration is a conventional strategy. However, due to restrictions on the use of domperidone suspension, oral prokinetics is relatively modest. The study aims to assess the effectiveness of simo decoction as an alternative to domperidone suspension in facilitating post-pyloric placement of spiral nasoenteric tubes.

METHODS

A prospective, open-label, parallel, and non-inferiority randomized controlled trial was performed involving critically ill adults in 6 university hospitals in China between September 2017 and May 2019. Patients were randomly assigned to receive either simo decoction 20 ml q8h, or domperidone suspension 20 mg/20 ml q6h for 24 h. The primary outcome was procedure success defined as post-pyloric placement (spiral nasoenteric tubes reached the first portion of the duodenum or beyond confirmed by abdominal X-ray 24 h after tube insertion).

RESULTS

Of 268 patients assessed for eligibility, 224 patients were enrolled and randomly assigned to the simo decoction group or the domperidone suspension group (n = 112 per group). The success rate of post-pyloric placement was 41.1% (46/112) in the simo decoction group, as compared with 47.3% (53/112) in the domperidone suspension group (a risk difference of -6.3%, 95% CI, -19.2% to 6.7%, adjusted risk difference -3.7%, 95% CI -16.3% to 9.0%), in the intention-to-treat analysis, crossing the prespecified margin of -10% for non-inferiority. There were no differences between groups in 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, the incidences of any adverse events, length of ICU stay or mortality in ICU.

CONCLUSIONS

Non-inferiority of simo decoction to domperidone suspension was not confirmed in facilitating post-pyloric placement of spiral nasoenteric tubes. Registration: The trial was registered with the Chinese Clinical Trial Registry at http://www.chictr.org.cn (registration number ChiCTR-INR-17011311).

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.