Ultrasonography for nasogastric tube placement verification: an additional reference

Verification of Nasogastric Tube Positioning Using Ultrasound by an Intensive Care Nurse: A Pilot Study

Placing a nasogastric tube (NGT) is a frequent nursing technique in intensive care units. The gold standard for its correct positioning is the chest X-ray due to its high sensitivity, but it represents a radiation source for critically ill patients. Our study aims to analyze whether the ultrasound performed by an intensive care nurse is a valid method to verify the NGT's correct positioning and to evaluate the degree of interobserver agreement between this nurse and an intensive care physician in the NGT visualization using ultrasound. Its correct positioning was verified by direct visualization of the tube in the stomach and indirect visualization by injecting fluid and air through the tube ("dynamic fogging" technique). A total of 23 critically ill patients participated in the study. A sensitivity of 35% was achieved using direct visualization, increasing up to 85% using indirect visualization. The degree of interobserver agreement was 0.88. Therefore, the indirect visualization of the NGT by an intensive care nurse using ultrasound could be a valid method to check its positioning. However, the low sensitivity obtained by direct visualization suggests the need for further training of intensive care nurses in ultrasonography. According to the excellent degree of agreement obtained, ultrasound could be performed by both professionals.

An improved biologically transparent illumination system that increases the accuracy of detecting the correct position of a nasogastric tube in the stomach

The aim of this study was to determine whether an improved biologically transparent illumination system results in more reliable detection of the correct position of the nasogastric tube in surgical patients. In total, 102 patients undergoing general surgery were included in this prospective observational study. After general anesthesia, all patients were inserted a nasogastric tube equipped with an improved biologically transparent illumination catheter. Identification of biologically transparent light in the epigastric area indicated successful insertion of the nasogastric tube into the stomach. The position of the tube was confirmed by X-ray examination, and its findings were compared with those of the biologically transparent illumination system. We observed biologically transparent light in epigastric area in 87 of the 102 patients. X-ray examination revealed that the nasogastric tube was placed in the stomach in all of these 87 patients. Light was not observed in the remaining 15 patients; the tube position was confirmed in the stomach in 11 of these patients but not in the other 4 by X-ray examination. Illumination had a sensitivity of 88.8% and a specificity of 100%. Our results suggest that this improved biologically transparent illumination system increased the accuracy of detecting the correct position of a nasogastric tube in the stomach. X-ray examination is required to check the position of the nasogastric tube in patients when biologically transparent illumination light is negative.

Diagnostic accuracy of using capnography in verification of nasogastric tube placement among adult patients in hospital settings: Protocol of a diagnostic study

OBJECTIVE

To determine the diagnostic accuracy of end-tidal carbon dioxide (ETCO2) detection using capnography for verifying the correct placement of nasogastric tubes (NGTs) among adult patients in hospital settings.

MATERIALS AND METHODS

A prospective observational diagnostic study will be conducted. Patients ≥ 18-year-old and requiring the insertion of an NGT will be recruited using a convenience sampling method from 39 general medical and geriatric wards, intensive care units, accident and emergency departments, and subacute/rehabilitation/infirmary wards in 21 acute or subacute/convalescent/extended care hospitals. ETCO2 detection by sidestream capnography, which indicates an airway intubation of an NGT when a capnogram waveform or an ETCO2 level > 10mmHg (1.33 kPa) occurs, will serve as the index test. The reference standards will be the X-ray performed and pH value of gastric aspiration (pH ≤ 5.5) after the index test. Each participant will be included only once. Sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve of capnography will be calculated to assess the diagnostic performance of capnography. The variability in diagnostic accuracy in participants with different characteristics will be explored by using chi-squared or Fisher's exact tests. The time spent and the cost of the tests will be compared using the paired t-test. All statistical tests will be two-sided with a level of significance set at 0.05.

DISCUSSION

This study will provide evidence on the diagnostic accuracy of capnography in verifying NGT placement and its applicability to patients in hospitals settings, since this evidence is limited in the current literature. In addition, it will help identify the optimal combination of tests in verifying the correct placement of NGTs and inform the update of clinical practice guidelines and stakeholders' decisions on the adoption of ETCO2 detection as a routine method for verifying NGT placement.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05817864.

Performance of Point-of-Care Ultrasonography in Confirming Feeding Tube Placement in Mechanically Ventilated Patients

BACKGROUND

A feeding tube (FT) is routinely placed in critically ill patients, and its correct placement is confirmed with a chest X-ray (CXR), which is considered the gold standard. This study evaluated the diagnostic accuracy of ultrasonography (USG) in verifying FT placement compared to a CXR in an intensive care unit (ICU).

METHOD

This was a prospective single-blind study conducted on patients admitted to the ICU of a tertiary hospital in Malaysia. The FT placements were verified through a fogging test and USG at the neck and subxiphoid points. The results of confirmation of FT placement through USG were compared with those obtained using CXRs.

RESULTS

A total of 80 patients were included in this study. The FT positions were accurately confirmed by overall USG assessments in 71 patients. The percentage of FT placements correctly identified by neck USG was 97.5%, while the percentage of those identified by epigastric USG was 75%. The corresponding patients' CXRs confirmed correct FT placement in 76 patients. The overall USG assessment had a sensitivity of 92.11% and specificity of 75%, a positive predictive value of 98.59%, and a negative predictive value of 33.33%. The USG findings also showed a significant association between FT size and BMI. FTs with a size of 14Fr were better visualized (p = 0.008), and negative USG findings had a significantly higher BMI (p < 0.001).

CONCLUSION

USG is a simple, safe, and reliable bedside assessment that offers relatively high sensitivity in confirming correct FT placement in critically ill patients.

Detecting cervical esophagus with ultrasound on healthy voluntaries: learning curve

BACKGROUND

The objective of this study was to determine the learning curve of tracheal-esophageal ultrasound by prehospital medical and paramedical staff.

METHODS

A single-center prospective study was carried out at a French EMS (SAMU 92). Volunteer participants first received a short theoretical training through e-learning, followed by two separate hands-on workshops on healthy volunteers, spaced one to two months apart. Learners were timed to obtain the tracheal-esophageal ultrasound target image 10 consecutive times. The first workshop was intended to perform a learning curve, and the second was to assess unlearning. The secondary objectives were to compare performance by profession and by previous ultrasound experience.

RESULTS

We included 32 participants with a mean age of 38 (± 10) years, consisting of 56% men. During the first workshop, the target image acquisition time was 20.4 [IQR: 10.6;41] seconds on the first try and 5.02 [3.72;7.5] seconds on the 10th (p < 0.0001). The image acquisition time during the second workshop was shorter compared to the first one (p = 0.016). In subgroup analyses, we found no significant difference between physicians and nurses (p = 0.055 at the first workshop and p = 0.164 at the second) or according to previous ultrasound experience (p = 0.054 at the first workshop and p = 0.176), counter to multivariate analysis (p = 0.02).

CONCLUSIONS

A short web-based learning completed by a hands-on workshop made it possible to obtain the ultrasound image in less than 10 s, regardless of the profession or previous experience in ultrasound.

[Safe position check of gastric tubes: an often underestimated topic to prevent possible severe complications]

The insertion of a gastric tube in the operating room (OR) or in an intensive care unit (ICU) is a routine procedure. Although the tube is often inserted by nursing staff, the indications and selection of the procedure for position control remain the physician's responsibility. For immediate position control, the injection of air through the inserted tube with simultaneous auscultation of the epigastrium is probably the most simple and common clinical method. A typical "bubbling" is often regarded as a sufficiently reliable sign of correct gastric tube position. This procedure can be described as a routine standard both in the OR and the ICU; however, numerous examples from clinical practice and quality reviews show gastric tube mispositioning in esophageal, bronchial, pulmonary or even pleural positions in individual cases. Since auscultation findings are misinterpreted as tracheal, bronchial, or pleural secretions, mispositioning may remain undetected. In addition, adequate documentation of the procedure is lacking. In the worst case, hyperosmolar tube feeding occurs via the malpositioned tube into the lungs or pleural space causing subsequent severe pneumonia or pleuritis, which is often fatal for the patient outcome. In contrast to many other similar procedures in intensive care medicine, such as the installation of central venous catheters or endotracheal intubation, to our knowledge there is no uniform standard for forensic verification of the correct position after gastric tube positioning. The present work provides an overview of existing practices and the scientific background for confirmation of gastric tube positioning without ionizing radiation.

Nasoenteric tube doppler guided insertion. A case report and review of literature

Nasoenteric tube placement is needed in patients with gastric enteral feeding intolerance or high risk of aspiration. Several techniques are described. Ultrasound is used more commonly for gastric tube placement, but also is described in enteral tube feeding placement. Doppler technique with cold water injection is not described in the literature. We describe a new and easy to realize technique. A case of a 65 years old male patient in the intensive care unit (ICU) with gastroparesis is described. Before beginning a prokinetic drug was administered. In this technique gastric tube placement was bedside assessed with ultrasound, and then the tube was progressed with cold water injection. Duodenal position was confirmed with doppler ultrasound. Ultrasound and doppler technique for nasoenteric tube placement could be a feasible technique to use in the ICU. More studies are needed to assess the effectiveness of the technique.

Bedside ultrasonography for the confirmation of nasogastric tube placement: agreement between nurse and physician

ABSTRACT Objective To evaluate the agreement between nurse and physician in verifying the positioning of the nasogastric tube by ultrasonography and describe the difficulties faced by nurse in performing the technique. Method Cross-sectional study conducted in 2021, including critical patients after nasogastric tube insertion who were independently evaluated by a nurse and physician, using bedside ultrasonography. The tube was considered adequately positioned when viewed in infradiaphragmatic location in the topography of the stomach. Results In the 30 peer evaluations there was almost perfect agreement (k = 0.93; 95%CI: 0.65 - 0.99). In only one case the nurse was uncertain about the positioning. Some difficulties were reported: abdominal distention (n=2), gas interposition (n=3) and patient movement during the exam (n=2). Conclusion A trained nurse obtained very similar results to those found by a physician in identifying the nasogastric tube placement by means of ultrasonography, suggesting a reproducible and safe technique.

Ultrassonografia à beira do leito para localização da sonda nasoenteral: concordância entre enfermeiro e médico

RESUMO Objetivo Avaliar a concordância entre enfermeiroe médico na determinação da localizaçãoda sonda enteral por ultrassonografia e descrever as dificuldades encontradas pelo enfermeiro na execução da técnica. Método Estudo transversal, realizado em 2021, incluindo pacientes críticos após a inserção dasondaenteral, avaliados de modo independente por enfermeiro e médico, utilizando ultrassonografia à beira do leito. A sonda foi considerada adequadamente posicionada quando visualizada em posição infradiafragmática na topografia do estômago. Resultados Nos 30 pares de avaliações houve concordância quase perfeita (k = 0,93; IC95%: 0,65 - 0,99). Em apenas um caso houve dúvida do enfermeiro sobre o posicionamento. As dificuldades relatadas foram:distensão abdominal (n=2), interposição de gás (n=3) e movimentação do paciente durante o exame (n=2). Conclusão Um enfermeiro capacitadoobteve resultados semelhantes aos encontrados por um médico na identificação do posicionamento da sondaenteral por meio de ultrassonografia, sugerindo tratar-se de uma técnica reprodutível e segura.

Biologically transparent illumination is a safe, fast, and simple technique for detecting the correct position of the nasogastric tube in surgical patients under general anesthesia

The aim of this study was to evaluate the effectiveness of using biologically transparent illumination to detect the correct position of the nasogastric tube in surgical patients. This prospective observational study enrolled 102 patients undergoing general surgeries. In all cases, a nasogastric tube equipped with a biologically transparent illumination catheter was inserted after general anesthesia. The identification of biologically transparent light in the epigastric area either with or without finger pressure indicated that the tube had been successfully inserted into the stomach. X-ray examination was performed to ascertain the tube position and was compared with the findings of the biologically transparent illumination technique. Biologically transparent light was detected in 72 of the 102 patients. In all of these 72 patients, the position of the nasogastric tube in the stomach was confirmed by X-ray examination. The light was not detected in the other 30 patients; X-ray examination showed that the nasogastric tube was positioned in the stomach in 21 of these 30 patients but not in the other 9. The sensitivity and specificity of the illumination were 77.4% and 100%, respectively. The results suggest that biologically transparent illumination is a useful and safe technique for detecting the correct position of the nasogastric tube in surgical patients under general anesthesia. When the BT light cannot be identified, X-ray examination is mandatory to confirm the position of the nasogastric tube.