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Taylor SJ, Karpasiti T, Milne D. Safety of blind versus guided feeding tube placement: Misplacement and pneumothorax risk. Intensive Crit Care Nurs 2023; 76:103387. [PMID: 36657250 DOI: 10.1016/j.iccn.2023.103387] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/04/2023] [Accepted: 01/07/2023] [Indexed: 01/19/2023]
Abstract
Most intensive care unit patients require a feeding tube, but misplacement risk is high due to the presence of artificial airways and because unconsciousness reduces clinical warnings. Predominantly, tubes are placed 'blindly', where position is not known throughout placement. The result is that 1.6% enter the lung, 0.5% cause pneumothorax and potentially 5% are left in the oesophagus. Guided placement, by identifying tube position in real time, may prevent these problems, but undetected misplacements still occur. We review the safety of guided methods of confirming tube position, including rates of pneumothorax, in the context of current unguided methods. During blind tube placement, tube position can only be tracked intermittently. Excepting X-ray and ultra-sound, most methods of checking position are simple. Conversely, guided tube placement can track tube position from the nose to small intestine (IRIS®), or oesophagus to jejunum (Cortrak™, ENvue®). However, this requires expertise. Overall, guided placement is associated with lower rates of pneumothorax. Unfortunately, for Cortrak, low-use centres have higher rates of undetected misplacement compared with blind placement whereas Cortrak use in high-use centres had lower risk compared with blind placement and low use centres. Because guided placement requires high-level expertise manufacturer training packages have been developed but currently appear insufficient. Specifically, Cortrak's package is less accurate in determining tube position compared to the 'gastrointestinal flexure' system. Validation of an evidence-based guide for IRIS placement is underway. Recommendations are made regarding the training of new operators, including minimum numbers of placements required to achieve expertise.
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Affiliation(s)
- Stephen J Taylor
- Department of Nutrition & Dietetics, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, United Kingdom.
| | - Terpsi Karpasiti
- Department of Nutrition & Dietetics, Royal Brompton and Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, SW3 6NP, United Kingdom
| | - Danielle Milne
- Department of Nutrition & Dietetics, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, United Kingdom
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Wood T, Sabol V, Engel J, Allen DH, Thompson JA, Yap TL. Using an Electromagnetic Guidance System for Placement of Small-Bowel Feeding Tubes to Reduce Feeding Start Times. Crit Care Nurse 2023; 43:52-58. [PMID: 36720278 DOI: 10.4037/ccn2023847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cardiothoracic surgery patients have an increased risk for aspiration and may require enteral access for nutrition. LOCAL PROBLEM In a cardiothoracic intensive care unit, feeding start times were delayed because of scheduling conflicts with support services. An electromagnetic device (Cortrak 2 Enteral Access System, Avanos Medical) was introduced to allow advanced practice providers (nurse practitioners and physician assistants) to independently establish postpyloric access and reduce dependence on ancillary services. METHODS A quality improvement study was performed. Pre- and postimplementation data included order time, service arrival, tube placement time, tube positioning, and feeding start times for 207 placements. Pre- and postimplementation surveys were conducted to evaluate advanced practice provider satisfaction with enteral tube placement practices. RESULTS Feeding start time for initial placement decreased by 35.5% (15.6 hours to 10 hours); for subsequent placement, by 55.2% (15.5 hours to 7.0 hours). Assistance by support services decreased by 80.4% (before implementation, 100 of 100 placements [100%]; after implementation, 21 of 107 placements [19.6%]; P < .001; ϕ = 0.815). Overall, advanced practice provider satisfaction increased. Most participants said that using the electromagnetic device was faster, nutrition was delivered sooner, and implementation was a valuable practice change. CONCLUSIONS Using an electromagnetic device decreased feeding start times, reduced the need for support services, and increased advanced practice provider satisfaction with small-bowel feeding tube placement practices.
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Affiliation(s)
- Teresa Wood
- Teresa Wood is a nurse practitioner at Duke University Hospital, Durham, North Carolina
| | - Valerie Sabol
- Valerie Sabol is a clinical professor and Interim Vice Dean at Duke University School of Nursing, Durham, North Carolina
| | - Jill Engel
- Jill Engel is the Service Line Vice President for Heart & Vascular at Duke University Health System, Durham, North Carolina
| | - Deborah H Allen
- Deborah H. Allen is a clinical nurse scientist and Director of Nursing Research and EBP at Duke University Health System
| | - Julie A Thompson
- Julie A. Thompson is a consulting associate at Duke University School of Nursing
| | - Tracey L Yap
- Tracey L. Yap is an associate professor at Duke University School of Nursing
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Xu J, Li S, Chen X, Tan B, Chen S, Hu B, Nie Z, Ye H, Sun C, Chi R, Chen C. 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. Front Med (Lausanne) 2022; 9:875298. [PMID: 35646990 PMCID: PMC9134184 DOI: 10.3389/fmed.2022.875298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/26/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Jing Xu
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Sinian Li
- Neurological Intensive Care Unit, Maoming People's Hospital, Maoming, China
| | - Xiangyin Chen
- Surgical Intensive Care Unit, Maoming People's Hospital, Maoming, China
| | - Bo Tan
- Department of Emergency, Maoming People's Hospital, Maoming, China
| | - Shenglong Chen
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Bei Hu
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhiqiang Nie
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Heng Ye
- Department of Critical Care Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Cheng Sun
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruibin Chi
- Department of Critical Care Medicine, Xiaolan People's Hospital of Zhongshan, Zhongshan, China
| | - Chunbo Chen
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Critical Care Medicine, Maoming People's Hospital, Maoming, China
- *Correspondence: Chunbo Chen
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Shain LM, McHale L, Ahmed T. Hemothorax Following Traumatic Dobhoff Tube Insertion. Cureus 2021; 13:e13097. [PMID: 33728119 PMCID: PMC7935303 DOI: 10.7759/cureus.13097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Dobhoff tube is a specialized small-bore and flexible nasogastric tube that makes it more comfortable for placement than a usual nasogastric tube. Dobhoff tube insertion is commonly considered a relatively safe bedside procedure, but it is not without its associated risks. Inadvertent tracheobronchial placement of Dobhoff tube has been associated with severe complications, most notably pneumothorax. We present a rare cause of right-sided hemothorax following tracheobronchial insertion of a Dobhoff tube with a prolonged and arduous clinical course.
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Affiliation(s)
| | - Leslie McHale
- Internal Medicine, University of Kentucky, Lexington, USA
| | - Taha Ahmed
- Internal Medicine, University of Kentucky, Lexington, USA
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Bourgault AM, Powers J, Aguirre L. Pneumothoraces Prevented With Use of Electromagnetic Device to Place Feeding Tubes. Am J Crit Care 2020; 29:22-32. [PMID: 31968083 DOI: 10.4037/ajcc2020247] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND A US Food and Drug Administration safety letter warned about the risk for pneumothoraces during feeding tube insertion despite the use of electromagnetic placement devices that provide real-time visualization of feeding tube position. OBJECTIVES To systematically assess pulmonary placement and pneumothoraces in CORTRAK-assisted feeding tube insertions. METHODS CINAHL, MEDLINE, and Cochrane databases were searched for studies of CORTRAK-assisted feeding tube insertion. Thirty-two studies documenting pulmonary placement and/or complications of feeding tube insertion were found. RESULTS Operators recognized pulmonary placement on insertion tracings during 202 CORTRAK-assisted feeding tube insertion procedures, resulting in the immediate withdrawal of 199 feeding tubes. One pneumothorax was identified later by radiography. Seven pulmonary placements were not recognized by CORTRAK operators at the time of feeding tube insertion, resulting in 2 pneumothoraces. The incidence of pneumothorax for CORTRAK-assisted feeding tube insertions was 0.02% (3 of 17039). Of the feeding tubes inserted into the pulmonary system - either found during or after the procedure -1.4% (3 of 209) resulted in pneumothoraces (as opposed to the 19% to 28% incidence of pneumothorax for blind feeding tube insertions. Operators recognizing pulmonary placement on CORTRAK insertion tracings may have prevented 97% (202 of 209) of feeding tubes from being inserted farther into the respiratory tract. CONCLUSIONS Feeding tube insertion with an electromagnetic placement device is advantageous over blind feeding tube insertion because the operator can recognize pulmonary placement early and withdraw the feeding tube, thus decreasing the risk of pulmonary complications.
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Affiliation(s)
- Annette M. Bourgault
- Annette M. Bourgault is an assistant professor, University of Central Florida College of Nursing, Orlando, Florida, and a nurse scientist, Orlando Health, Orlando, Florida
| | - Jan Powers
- Jan Powers is director of nursing research and professional practice, Parkview Health System, Fort Wayne, Indiana
| | - Lillian Aguirre
- Lillian Aguirre is clinical nurse specialist trauma/burn critical care, Orlando Regional Medical Center, Orlando Health
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Bear DE, Smith E, Barrett NA. Nutrition Support in Adult Patients Receiving Extracorporeal Membrane Oxygenation. Nutr Clin Pract 2018; 33:738-746. [DOI: 10.1002/ncp.10211] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Danielle E. Bear
- Department of Nutrition and Dietetics; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Department of Critical Care; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Lane Fox Research Clinical Respiratory Physiology Research Centre; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Centre for Human and Applied Physiological Sciences; King's College London; London United Kingdom
| | - Elizabeth Smith
- Department of Nutrition and Dietetics; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Department of Critical Care; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
| | - Nicholas A. Barrett
- Department of Critical Care; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Lane Fox Research Clinical Respiratory Physiology Research Centre; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Centre for Human and Applied Physiological Sciences; King's College London; London United Kingdom
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Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill. Nutr Clin Pract 2018; 34:23-36. [PMID: 30294835 DOI: 10.1002/ncp.10199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
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Affiliation(s)
- Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Stephen A McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Anton Emmanuel
- Department of Neuro-Gastroenterology, University College London, London, UK
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MacGowan L, Smith E, Elliott-Hammond C, Sanderson B, Ong D, Daly K, Barrett NA, Whelan K, Bear DE. Adequacy of nutrition support during extracorporeal membrane oxygenation. Clin Nutr 2018; 38:324-331. [PMID: 29395370 DOI: 10.1016/j.clnu.2018.01.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/20/2017] [Accepted: 01/05/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND The use of veno-venous extracorporeal membrane oxygenation (vv-ECMO) is increasing in adults with severe respiratory failure. Observational data suggest that there are significant challenges to providing adequate nutrition support for patients on vv-ECMO. We aimed to describe firstly the nutrition support practices in a large single-centre providing vv-ECMO to adults and secondly any association with clinical outcome. METHODS We conducted a retrospective review of patients receiving vv-ECMO on the Intensive Care Unit (ICU) of a large London teaching hospital. Adult patients admitted to the ICU with severe respiratory failure between December 2010 and December 2015 were included. Daily energy and protein delivery were compared with estimated targets and reasons for feeding interruptions were collected from electronic medical records. Adequate feeding was defined as 80-110% of estimated targets. RESULTS We analysed 203 eligible patients. Median duration of ICU stay was 21.0 (IQR, 15.0-33.0) days and vv-ECMO 10.0 (IQR, 7.0-16.0) days. Although median energy (89.8% (IQR, 80.5-96.0%)) and protein (84.7% (IQR, 74.0-96.7%)) delivery was adequate, underfeeding of either energy or protein occurred on nearly one third (28.3%) of nutrition support days. A higher admission severity of illness score was associated with inadequate protein delivery (p = 0.040). Patients with more severe organ dysfunction on the first day of vv-ECMO received inadequate energy (p = 0.026). The most common reasons for interrupted feeding were medical procedures (39.1%) followed by poor gastric motility (22.8%). CONCLUSION Adequate energy and protein delivery during vv-ECMO is possible but underfeeding is still common, especially in those who are more severely ill or who have more severe organ dysfunction. Patients with inadequate energy or protein delivery did not differ in ICU and 6-month survival. Prospective studies investigating optimal feeding in this patient cohort are required.
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Affiliation(s)
- Liisa MacGowan
- King's College London, Department of Nutritional Sciences, 150 Stamford Street, London SE1 9NH, United Kingdom
| | - Elizabeth Smith
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom; Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
| | - Charmaine Elliott-Hammond
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
| | - Barnaby Sanderson
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
| | - Dennis Ong
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
| | - Kathleen Daly
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
| | - Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
| | - Kevin Whelan
- King's College London, Department of Nutritional Sciences, 150 Stamford Street, London SE1 9NH, United Kingdom
| | - Danielle E Bear
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom; Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom.
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