American Gastroenterological Association technical review on tube feeding for enteral nutrition

Role of endoscopy in enteral feeding

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. A previous guideline related to this topic (ASGE Publication No. 1017, Gastrointest Endosc 1998;48:699-701). Since that time, new information has become available that requires an update of this statement and its recommendations. In preparing this update, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from the recommendations of expert consultants. When inadequate data existed from well-designed prospective trials, emphasis was given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance from these recommendations.

Erythromycin and early enteral nutrition in mechanically ventilated patients

OBJECTIVE

To determine whether erythromycin facilitates early enteral nutrition in mechanically ventilated, critically ill patients.

DESIGN

Prospective, randomized, placebo-controlled, single-blind trial.

SETTING

General intensive care unit in a university-affiliated general hospital.

PATIENTS

Forty consecutive critically ill patients receiving invasive mechanical ventilation and early nasogastric feeding.

INTERVENTIONS

Patients were assigned randomly to intravenous erythromycin (250 mg/6 hrs; n = 20) or a placebo (intravenous 5% dextrose, 50 mL/6 hrs; n = 20) for 5 days. The first erythromycin or 5% dextrose injection was given at 8 am on the day after intubation. One hour later, a daily 18-hr enteral nutrition regimen via a 14-Fr gastric tube was started. Residual gastric volume was aspirated and measured every day at 9 am, 3 pm, 9 pm, and 3 am. Enteral nutrition was discontinued if residual gastric volume exceeded 250 mL or the patient vomited.

MEASUREMENTS AND MAIN RESULTS

On the first day, residual gastric volume was smaller in the erythromycin than in the placebo group (3 pm, 15 +/- 7 mL vs. 52 +/- 14 mL, p <.05; 9 pm, 29 +/- 15 mL vs. 100 +/- 20 mL, p <.001; 3 am, 11 +/- 4 mL vs. 54 +/- 13 mL, p <.05). With erythromycin, residual gastric volume at 9 pm was smaller on the second day (33 +/- 11 mL vs. 83 +/- 19 mL, p <.01) and residual gastric volume at 3 pm was smaller on the third day (39 +/- 15 mL vs. 88 +/- 19 mL, p <.05) than with placebo. On the fourth and fifth days, the differences in residual gastric volume were not significant. Enteral nutrition was discontinued before the end of the 5-day period in seven of the 20 erythromycin patients and 14 of the 20 placebo patients (p <.001).

CONCLUSION

In critically ill patients receiving invasive mechanical ventilation, erythromycin promotes gastric emptying and improves the chances of successful early enteral nutrition.

Supportive therapy of elderly cancer patients

Elderly cancer patients often require supportive care due to the physiologic decline of organs and apparatus linked with the aging process per se, and for the effects of tumor or of anticancer treatments. Pain and nutritional deficits are some clinical aspects requiring supportive care. Lack of studies on these latter topics does not allow an in depth analysis of the problem. The present review deals with literature concerning pain and nutritional problems in the general cancer population with emphasis on aspects typical for elderly cancer subjects. Physiologic and cancer-related changes in body composition, physical function and cognitive capacity of the elderly are presented and, when appropriate, linked with pathogenetic factors of pain and malnutrition, as well as their treatment. Pain demographic data, pain intensity evaluation and currently available techniques to provide pain relief such as etiologic treatment, analgesic pharmacotherapy and invasive analgesic procedures, are extensively discussed. Causes and assessment of malnutrition as well as available nutritional approaches such as oral, enteral and parenteral nutrition are also debated.

A prospective evaluation of outcome in patients referred for PEG placement

BACKGROUND

PEG feeding is not recommended for short-term use because the 30-day mortality after PEG placement is substantial. The primary aim of this study was to prospectively identify factors predictive of survival in patients referred for PEG placement.

METHODS

All patients for whom gastroenterology consultation was sought for feeding PEG placement were prospectively studied. Demographic data, Charlson comorbidity index, and functional status were recorded at entry. After PEG placement, patients were followed for up to 12 months.

RESULTS

Of the 67 patients for whom consultation was requested, 58 were eligible for the study and 50 underwent PEG placement. The 7-day and 30-day mortality rates in the PEG placement group were 4% and 20%, respectively. In multivariate analysis, only the Charlson index > or =4 was associated with decreased survival time (relative hazard = 2.9: 95% CI [1.20, 7.21], p = 0.019). Median survival in patients with Charlson comorbidity index > or =4 was significantly shorter than that in patients with Charlson index < 4 (p = 0.013).

CONCLUSIONS

A Charlson comorbidity index > or =4 was significantly associated with shorter patient survival after initial consultation. Careful consideration of predictive factors of survival may improve patient selection for feeding PEG placement.

Gastric feeding with erythromycin is equivalent to transpyloric feeding in the critically ill

OBJECTIVE

To determine whether adding erythromycin to a gastric feeding regimen could render it as effective in meeting nutritional needs as transpyloric feeding.

DESIGN

Randomized, controlled study.

SETTING

University hospital medical, surgical, and neurologic care intensive care units.

PATIENTS

Critically ill patients, requiring a projected 96 hrs of enteral feeding, who had no specific indication for tube location (gastric or transpyloric). Eighty patients were randomized.

INTERVENTIONS

Patients were randomized to gastric feeding with erythromycin (200 mg iv) given every 8 hrs or feeding through a transpylorically placed feeding tube. Goal rate and feeding advancement were determined by protocol.

MEASUREMENTS AND MAIN RESULTS

During the 96-hr period, the gastric group received 74% of their goal calories and the transpyloric group received 67%. The only day on which gastric feedings were superior was the first study day, where the gastric group attained 55% of their goal, compared with 44% in the transpyloric group. This 1-day difference was the result of an initial failure of tube placement in some subjects. Exclusion of these patients did not change overall results. Nutritional indexes, length of stay in the intensive care unit, ventilator dependence, and survival were not different between the two groups.

CONCLUSIONS

Gastric feeding with erythromycin as a prokinetic is equivalent to transpyloric feeding in meeting the nutritional goals of the critically ill.

Use of percutaneous gastrojejunostomy feeding tubes in the rehabilitation of stroke patients

OBJECTIVE

To determine the characteristics of and complications in the rehabilitation of stroke patients in whom percutaneous gastrojejunostomy (PGJ) feeding tubes have been placed.

DESIGN

Retrospective cohort study.

SETTING

A rehabilitation unit in a tertiary care hospital.

PARTICIPANTS

Stroke patients (n = 563) admitted to a tertiary care hospital over a 10-year period.

INTERVENTION

PGJ feeding tubes.

MAIN OUTCOME MEASURES

Evidence of aspiration in all videofluoroscopic modified barium swallow (VMBS) studies was noted. For patients with a PGJ feeding tube, the following were recorded: stroke location; results of subsequent VMBS reports; length of time from stroke onset to PGJ feeding tube insertion; total time the PGJ feeding tube remained in situ; discharge disposition; and concurrent feeding status. Follow-up was at 1-year poststroke. Complications during the inpatient stay attributable to the PGJ feeding tube were recorded.

RESULTS

Thirty-two of all 563 (5.7%) stroke patients admitted and 28 of the 115 (24.3%) proven aspirators, as shown on VMBS studies, had a PGJ feeding tube inserted. Twenty-one of the 563 (3.7%) stroke patients were discharged to the community with PGJ feeding tubes in place. The tubes were inserted on average 37 days after stroke onset. Seventeen of all 88 (19.3%) brainstem stroke patients and 15 of all 29 (51.7%) brainstem stroke patients with documented aspiration had feeding tubes inserted, whereas only 15 of 475 (3.2%) hemispheric stroke rehabilitation patients received a tube. Eleven of 32 (34.3%) patients with a feeding tube were able to resume oral feedings at discharge; within 1 year of discharge, 24 of 32 (75%) had done so. Although there were no serious complications resulting from tube insertions, minor complications were documented in more than 50% of the cases. The tubes were associated with prolonged institutionalization in only 1 case; most patients were discharged on a home tube-feeding program.

CONCLUSIONS

PGJ feeding tubes were placed in approximately 1 of every 20 of our stroke rehabilitation patients. One third of the tubes were removed before the patients were discharged from rehabilitation and 75% were removed within 1 year. Insertion of the tubes was most common in patients with evidence of aspiration and in patients with brainstem strokes. Complications caused by the tube were minor and all patients but 1 who were discharged with feeding tubes were able to manage the home tube-feeding program.

Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications

OBJECTIVE

To study the frequency of and risk factors for increased gastric aspirate volume (GAV) and upper digestive intolerance and their complications during enteral nutrition (EN) in critically ill patients.

DESIGN

Prospective observational study.

SETTING

Intensive care unit (ICU) in a general hospital.

PATIENTS

A total of 153 patients with nasogastric tube feeding.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Upper digestive intolerance was considered when GAV was between 150 and 500 mL at two consecutive measurements, when it was >500 mL, or when vomiting occurred. Forty-nine patients (32%; 95% confidence interval [CI], 25%-42%) presented increased GAV after a median EN duration of 2 days (range, 1-16 days), and 70 patients (46%; 95% CI, 38%-54%) presented upper digestive intolerance. Independent risk factors for high GAV were GAV >20 mL before the start of EN (odds ratio [OR], 2.16; 95% CI, 1.11-4.18; p =.02), GAV >100 mL during EN (OR, 1.49; 95% CI, 1.01-2.19; p <.05), sedation during EN (OR, 1.78; 95% CI, 1.17-2.71; p =.007), use of catecholamines during EN (OR, 1.81; 95% CI, 1.21-2.70; p =.004). Complications related to high GAV were a lower feed intake (15 +/- 7 vs. 19 +/- 8 kcal/kg/day; p =.0004) and vomiting (53% vs. 23%; p =.0002). Complications related to upper digestive intolerance were the development of pneumonia (43% vs. 24%; p =.01), a longer ICU stay (23 +/- 21 vs. 15 +/- 16 days; p =.007), and a higher ICU mortality (41% vs. 25%; p =.03), even after adjustment for Simplified Acute Physiology Score II (OR, 1.48; 95% CI, 1.04-2.10; p =.028).

CONCLUSION

In ICU patients receiving nasogastric tube feeding, high gastric aspirate volume was frequent, occurred early, and was more frequent in patients with sedation or catecholamines. High gastric aspirate volume was an early marker of upper digestive intolerance, which was associated with a higher incidence of nosocomial pneumonia, a longer ICU stay, and a higher ICU mortality.

Decisions for enteral access in the intensive care unit

When making decisions regarding nutrition support, many factors must be considered before committing a patient to receive parenteral or enteral nutrition. Parenteral nutrition (PN) is more expensive and technically more difficult to administer than enteral nutrition (EN). The charge for PN can range from US 200 dollars to 1000 dollars per day, where a standard hospital diet or enteral tube feedings might cost less than US 25 dollars/d. PN is also associated with a much higher incidence of biochemical complications such as hyperglycemia and other electrolyte abnormalities and catheter-related complications such as infection, thrombosis, or pneumothorax. For many years PN was preferred to EN because it was believed to be unwise to feed a critically ill patient into the gut. It has now been shown in multiple studies that it is not only feasible to feed critically ill patients early, but also it may be immunologically advantageous to feed enterally. The cost effectiveness of the nutrition support team approach to monitoring PN and EN should not be underestimated by hospital administrators. If enteral therapy can be instituted, significant patient-care cost savings may be realized. This presentation will discuss decisions that must be addressed in the intensive care unit. With more physician education, protocols can be designed to provide the most advantageous use of nutrition support for the benefit of the hospitalized patient.

Does the supplementation of the formula with fibre increase the risk of gastro-oesophageal reflux during enteral nutrition? A human study

BACKGROUND & AIMS

Fibre-supplements in enteral feeding could increase the risk of gastro-oesophageal reflux (GOR). The aim of this study was to assess in humans the physiological effects of the supplementation of the enteral diet with different types of dietary fibre on gastro-oesophageal reflux episodes, gastric acidity and gastric emptying.

METHODS

pH profiles were compared in 12 healthy volunteers between three different formula (500 kcal, 250 mL x h-1) delivered in a random order and containing either no fibre, either soy polysaccharide fibre only or mixed fibre from pea and inuline. Enteral diets were instilled through a nasogastric tube. Oesophageal and gastric pH recordings were combined with the ultrasound measurement of gastric antral area during the infusion.

RESULTS

More GOR were observed with a fibre-free diet (median 4, range 1-10) than with a mixed (median 1.5, range 0-5) (P=0.04) or soy polysaccharide fibre (median 1.5, range 0-5) (P=0.04) diet. The median duration of GOR was longer with the mixed fibre (median 3.6, range 1.8-7.2) than with the fibre-free diet (mean 1.8 min, range 1-3.6) (P<0.05). The number of GOR episodes lasting more than 5 min, the duration of the longest GOR and the percent of time under pH 4 were not significantly different with the three diets. The intragastric pH profile and the ultrasound antral area were not different with all three diets.

CONCLUSIONS

Addition of fibre to the enteral formula had limited effects on the onset of GOR episodes. It decreased the number of GOR but increased their duration. These effect were more pronounced with the formula containing soluble fibre. At variance, the addition of fibre had no significant effect on gastric emptying and gastric acid secretion.

Outcome of patients treated with home enteral nutrition

BACKGROUND

The aims of this study were to prospectively analyze the 1-month mortality and long-term outcome of home enteral nutrition (HEN) patients in order to determine the benefits of this treatment.

METHODS

Between 1990 and 1996, 417 patients, aged 64 +/- 25 years, were discharged on HEN and followed up until December 31, 1998, when outcome was assessed, which allowed us to determine survival probabilities and conditions associated with survival.

RESULTS

The mean duration of HEN was 242 +/- 494 days, with a 24- to 103-month follow-up. Probabilities of being alive at 1 month, 1 year, and 5 years were 80%, 41.7%, and 25%, respectively. Factors associated with death were dementia, neurologic disease, head and neck cancer, AIDS, and age over 70 years. A total of 5.5% of patients remained dependent on HEN, 32.6% resumed full oral nutrition, 20.2% of patients died during the first month on HEN, and 35% died after more than 1 month on HEN (219 +/- 257 days). A total of 6.7% of patients stopped HEN for other reasons.

CONCLUSIONS

HEN provides well-tolerated long-term nutritional support in many patients. However, because of their likelihood of being old and the nature of the underlying disease, these patients as a group tend to have a modest prognosis. This calls for the determination of more accurate selection criteria, and the measurement of the impact of HEN on quality of life.

Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit

Enteral nutrition through a nasogastric tube is a technique often used with hospitalized patients when they present problems with oral nutrition. Patients receiving enteral nutrition show several kinds of complications such as diarrhoea, vomiting, constipation, lung aspiration, tube dislodgement, tube clogging, hyperglycaemia and electrolytic alterations. We present a prospective and observational study carried out in an Internal Medicine Unit with 64 patients who were fed by a nasogastric tube. From the results it can be seen that older people represented a majority (the average age was 76.2 years), and difficulty in swallowing was the main reason for beginning enteral nutrition. The complications which appeared were: tube dislodgement (48.5%); electrolytic alterations (45.5%); hyperglycaemia (34.5%); diarrhoea (32.8%); constipation (29.7%); vomiting (20.4%); tube clogging (12.5%); and lung aspiration (3.1%). We discuss the possible relationship between the different factors associated with the enteral nutrition procedure and the occurrence of these complications. Finally, some nursing interventions are suggested, such as: checking the gastric residue periodically; attempting to place the tube in the duodenum in unconscious patients; and the use of protective mittens in disturbed patients.

Magnetically Guided Nasoenteral Feeding Tubes: A New Technique

Our objective was to evaluate a new technique for the bedside placement of nasoenteral feeding tubes into the duodenum using an external hand-held magnet to maneuver the tube from the stomach to the distal duodenum. We conducted a prospective case series of 20 consecutive patients requiring nasoenteral tube feeding in the intensive care units of a university-affiliated hospital. Twenty patients were entered into the study after the attending physician requested assistance in tube placement. A flexible nasoenteral feeding tube (12 F), modified to include a magnet and a magnetic field sensor in the distal tip connected by a thin insulated wire to a small light at the proximal end, was passed per nares into the stomach. A larger hand-held magnet held over the epigastrium was used to magnetically “capture” the tube tip, indicated by the illumination of the proximal light. The tube tip was then maneuvered by the hand-held magnet along the lesser curvature of the stomach, through the pylorus, and into the duodenum. Procedure time and anatomic location of the tube tip as determined by an abdominal radiograph was recorded. The 12 men and eight women had a mean age of 60 years (range 30–84). The procedure time averaged 9.6 minutes (range 1–30). In 19 of the 20 patients (95%) radiographs revealed successful placement of the tip of the feeding tube into the duodenum. There were no complications related to the procedure. Using a novel magnetically guided nasoenteral feeding tube transpyloric tube placement was achieved in 95 per cent of cases with an average procedure time of 9.6 minutes. This new and inexpensive bedside technique will allow prompt and safe initiation of enteral nutrition.

Gastrointestinal problems in the chronically critically ill patient

In summary, a variety of gastrointestinal processes may occur in the chronically critically ill patient population, usually as consequence of the primary systemic process. The clinical presentation is frequently nonclassic and there often is a substantial delay in diagnosis, resulting in increased morbidity and mortality.

Enteral versus parenteral nutrition: a pragmatic study

Controversy persists as to the optimal means of providing adjuvant nutritional support. The aim of this study was to compare enteral nutrition (EN) and parenteral nutrition (TPN) in terms of adequacy of nutritional intake, septic and nonseptic morbidity, and mortality. This was a prospective pragmatic study, whereby the route of delivery of nutritional support was determined by the attending clinician's assessment of gastrointestinal function. Patients considered to have inadequate gastrointestinal function were given TPN (group 1), while those deemed to have a functioning gastrointestinal tract received EN (group 2). Patients in whom there was reasonable doubt as to the adequacy of intestinal function were randomized to receive either TPN (group 3) or EN (group 4). The trial setting was a large district general hospital with a dedicated nutrition team. A total of 562 patients were included in the study (331 males; median age 67 y). Gastrointestinal function on entry into the study was considered inadequate in 267 patients who were given TPN (group 1) and adequate in 231 whom received EN (group 2). There was clinical uncertainty about the adequacy of gut function in 64 patients (11.4%) who were randomized to receive either TPN (group 3, 32 patients) or EN (group 4, 32 patients). The incidence of inadequate nutritional intake was significantly higher in group 4 compared with group 3 (78.1% versus 25%, P < 0.001). Complications related to the delivery system and other feed-related morbidity were significantly more frequent in both EN groups compared with the respective TPN groups. EN was associated with a higher overall mortality in both nonrandomized and randomized patients. There were no significant differences observed in the incidences of septic morbidity between patients receiving TPN and those given EN. EN is associated with a higher incidence of inadequate nutritional intake, complications related to the delivery system, and other feed-related morbidity than TPN. There is no evidence from this study to support a difference between the two modalities in terms of septic morbidity. Patients in whom there is reasonable doubt as to the adequacy of gastrointestinal function should be fed by the parenteral route.

Intolerance to intragastric enteral nutrition in critically ill patients: complications and management

Compared with parenteral nutrition, early administration of enteral nutrition (EN) to critically ill patients improves clinical outcomes and reduces infection rates. Intragastric EN often is complicated by intolerance, as indicated by elevated volumes of aspirated gastric residuals. Conflicting data are available for the volume of residual that represents intolerance, but most clinicians use 150-200 ml to signify gastrointestinal motility dysfunction. Intolerance is associated with mortality. Data support an association between intragastric EN and aspiration pneumonia, but little information is available regarding the contributory effect of intolerance. Transpyloric migration of the feeding tube may facilitate tolerance but does not reduce the likelihood of aspiration pneumonia. Prokinetic agents (cisapride, erythromycin, metoclopramide) promote gastric emptying. Results of most studies are limited because patients did not receive or tolerated intragastric EN. Metoclopramide is the agent of choice for treating intolerance. Further studies are necessary before prokinetic drugs can be recommended for preventing intragastric EN-associated aspiration pneumonia.

How do fiber-supplemented formulas affect antroduodenal motility during enteral nutrition? A comparative study between mixed and insoluble fibers

BACKGROUND

Fiber supplementation during enteral nutrition has been recommended, but the effect of soluble compared with insoluble fiber supplements on antroduodenal motility is unknown.

OBJECTIVE

The objective of this study was to compare antroduodenal motor patterns in 8 healthy volunteers during and after gastric infusion of 3 different diets: a fiber-free diet, an insoluble-fiber diet, and a mixed-fiber diet (50% soluble fiber and 50% insoluble fiber).

DESIGN

Manometric studies with the 3 different diets (2100 kJ) were performed in random order. Antroduodenal motility was monitored continuously for 6 h by using a pneumohydraulic system to calculate the number, amplitude, and duration of the pressure waves; the area under the curve (AUC); and the percentage of time occupied by motor activity before, during, and after each type of infusion. Variations in antral areas were measured by ultrasonography.

RESULTS

The gastric motor response was significantly higher, whatever the diet, in the distal antral recording site than in the 2 more proximal sites. In the proximal but not the distal antrum, the number of waves, the AUC, and the percentage of time occupied by motor activity were higher (P: < 0.04) with the mixed-fiber than with the insoluble-fiber diet. No significant differences in variations of antral area were observed among the 3 diets. In the duodenum, motor variables were not significantly different among the 3 diets.

CONCLUSIONS

A gastric infusion induced a greater motor response in the distal than in the proximal antrum. A mixed-fiber diet was associated with significantly greater proximal antral motility than was an insoluble-fiber diet. There was no significant difference among the 3 formulas in duodenal motor variables or in variations in antral area as measured by ultrasound.

Nutrition

The use of nutrition for the medical patient, in the inpatient setting and at home, will likely continue to increase in the future. Each patient should be evaluated in an individualized but systematic fashion. Each patient in whom malnourishment is suspected should undergo a thorough assessment for the presence and degree of malnutrition with an accurate calculation of nutritional requirements. It is important to choose the correct method of delivery of nutrition, to monitor and recognize any complications or problems that may arise, and to tailor the nutritional therapy to the unique diseases that are encountered in medicine. Although increasingly new advances and changes are occurring in the field of nutrition, nutritional support and therapy are best delivered and supplied to the patient with a network of health care workers, including the physician, the nurse, the dietitian, the social worker, and pharmacist.

Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: a multicenter randomized trial

Steroids are recommended in severe alcohol-induced hepatitis, but some data suggest that artificial nutrition could also be effective. We conducted a randomized trial comparing the short- and long-term effects of total enteral nutrition or steroids in these patients. A total of 71 patients (80% cirrhotic) were randomized to receive 40 mg/d prednisolone (n = 36) or enteral tube feeding (2,000 kcal/d) for 28 days (n = 35), and were followed for 1 year or until death. Side effects of treatment occurred in 5 patients on steroids and 10 on enteral nutrition (not significant). Eight enterally fed patients were prematurely withdrawn from the trial. Mortality during treatment was similar in both groups (9 of 36 vs. 11 of 35, intention-to-treat) but occurred earlier with enteral feeding (median 7 vs. 23 days; P =.025). Mortality during follow-up was higher with steroids (10 of 27 vs. 2 of 24 intention-to-treat; P =. 04). Seven steroid patients died within the first 1.5 months of follow-up. In contrast to total enteral nutrition (TEN), infections accounted for 9 of 10 follow-up deaths in the steroid group. In conclusion, enteral feeding does not seem to be worse than steroids in the short-term treatment of severe alcohol-induced hepatitis, although death occurs earlier with enteral nutrition. However, steroid therapy is associated with a higher mortality rate in the immediate weeks after treatment, mainly because of infections. A possible synergistic effect of both treatments should be investigated.

Effect of high ambient temperature on contamination and physical stability of one-liter ready-to-hang enteral delivery systems

The effect of high ambient temperature on the physical stability and bacterial contamination of 1-L, prefilled, closed enteral feeding systems was examined under simulated clinical conditions. One hundred Jevity Ready-to-Hang enteral feeding systems (Abbott Park, IL, USA) were placed in a 37 degrees C incubator for 24 h. The Ready-to-Hang formula containers were visually inspected at 0 and 24 h. Formula samples were collected from the containers at 24 h and plated on trypticase soy agar. Two samples had insignificant bacterial growth of one colony-forming unit per milliliter that was not demonstrated in repeat culture. No growth was observed for any other sample. Additional samples collected from the two apparently contaminated delivery sets showed no growth. No set showed signs of formula instability, such as coagulation, clumping, or curdling. These findings suggest that, even at a high ambient temperature of 37 degrees C, the risk of bacterial contamination or compromised physical integrity is very low with the use of 1-L, prefilled, closed enteral feeding systems.

Minimally invasive surgery. Bedside tracheostomy and gastrostomy

Minimally invasive surgical techniques have gathered tremendous momentum. Most patient benefit is realized in the ambulatory setting. Smaller incisions result in less pain and earlier return to activities. Critically ill patients typically do not benefit from minimally invasive techniques in this manner; however, they do benefit from other aspects of minimally invasive tracheostomy and gastrostomy. Small tracheostomy wounds are associated with reduced wound problems (infection and breakdown). The small stab wounds of minimally invasive gastrostomy are associated with less pain and with an absence of fascial dehiscence. Furthermore, because these procedures are performed easily and safely at the bedside, transport and operating room costs are avoided. Although these procedures are minimally invasive, they are major procedures. Devastating complications can become life-threatening. Attention to detail is required to avoid or respond promptly to complications. In this way, patients receive maximal benefit at minimal risk.

Intestinal obstruction secondary to enteral feedings in burn trauma patients

BACKGROUND

Enteral feeding is preferred for maintaining gut integrity and providing nutrition in trauma patients. Recent reports suggest that use of early enteral feeds is successful and that complications are rare. A recent burn patient, who suffered apparent bowel obstruction and perforation secondary to enteral feedings, led us to review our experience with mechanical complications of tube feedings.

METHODS

We searched our registry of patients treated for acute burn trauma injury and identified patients treated for acute bowel obstruction in the past 3 years.

RESULTS

Four patients were identified, ages 22 to 44, with burns of 6 to 92% total body surface area. Each required intubation and ventilatory support during initial treatment, complicated by adult respiratory distress syndrome and sepsis. We began enteral feeds 1 to 3 days after admission. At approximately 14 days after admission, each patient deteriorated clinically, which led to emergent abdominal exploration; the tube feedings caused bowel obstruction and associated complications. Each patient improved with laparotomy.

CONCLUSION

Bowel obstruction, ischemic necrosis, or both, secondary to early and aggressive nutrition with a fiber supplemented enteral feeding is an uncommon, life-threatening complication. Understanding and early recognition of this potential complication are essential to prevention or successful treatment.

The cup is half full

BACKGROUND

The clinical outcomes following feeding tube procedures are infrequently studied because most patients have other incurable conditions.

METHODS

Multiple electronic databases were used to track clinical outcomes following all gastrostomies and jejunostomies performed at a single institution from October 1, 1992, through December 31, 1995. Preoperative risk factors and postoperative morbidity were available for all 104 cases; long-term status was available for all but 2 of 104.

RESULTS

The in-hospital mortality was 11.4%. Mortality was lower in those receiving feeding tubes as primary procedures (7.4%) than in those who had a feeding tube placed during other major procedures (24%, P <0.05). Postoperative pneumonia was frequent (24.7%), and was associated with preoperative gastroesophageal reflux (odds ratio 4.2, P = 0.01) and history of aspiration (odds ratio 3.9, P = 0.01). Although 14.5% of the patients were newly discharged to care facilities, the majority (74%) returned to their previous residence. Median survival was just over 6 months, with 18% surviving more than 2 years. Survival was inversely related to do-not-resuscitate status (odds ratio 4.6, P <0.001), metastatic tumor (odds ratio 2.7, P <0.001), dementia (odds ratio 2.3, P = 0.005), and unresectable tumor (odds ratio 2.1, P <0.001), but was unrelated to type of feeding tube.

CONCLUSIONS

Significant morbidity and mortality follow feeding enterostomies, but the majority of patients benefit and can return to their previous residence. Am J Surg. 1999;178:406-410. 1999 by Excerpta Medica, Inc.

Enteral nutrition access devices

During the past decade a concerted effort has been made to use enteral nutrition instead of parenteral nutrition for hospitalized patients. Enteral nutrition has major advantages over parenteral nutrition in terms of cost and fewer serious complications. A clinician interested in initiating enteral nutrition may be limited by a lack of familiarity with the variety of options for enteral access and the difficulty of choosing among them. This paper reviews the different enteral access routes and devices available to the clinician.

Preoperative issues in clinical nutrition

Allowing a patient's nutritional state to deteriorate through the perioperative period adversely affects measureable outcome related to nosocomial infection, multiple organ dysfunction, wound healing, and functional recovery. Careful preoperative nutritional assessment should include a determination of the level of stress, an evaluation of the status of the GI tract, and the development of specific plans for securing enteral access. Patients already demonstrating compromise of nutritional status (defined by > 10% weight loss and serum albumin level < 2.5 g/dL) should be considered for a minimum of 7 to 10 days of nutritional repletion prior to surgery. Widespread use of total parenteral nutrition in unselected patients is unwarranted, may actually worsen outcome, and should be reserved for preoperative nutritional support only in severely malnourished patients in whom the GI tract is unavailable. Compared with the parenteral route, use of perioperative enteral feeding has been shown to provide more consistent and beneficial results, and can be expected to promote specific advantages in long-term morbidity and mortality.

Appropriate use, complications and advantages demonstrated in 500 consecutive needle catheter jejunostomies

BACKGROUND

The ability to deliver nutrition enterally after operation has been a significant advance in managing patients after major intra-abdominal operations.

METHODS

The experience of a single surgeon at a tertiary referral hospital over a 10-year period with insertion and use of 500 consecutive needle catheter jejunostomies (NCJs) was reviewed critically from prospectively collected data.

RESULTS

The NCJ was used to deliver nutrition in 93 per cent, fluid and electrolytes in 95 per cent, and various medications in the postoperative period in the majority of patients. There were three major complications: small bowel obstruction and pneumatosis intestinalis in one and two patients respectively. Minor complications included diarrhoea (15 per cent), abdominal distension (15 per cent), abdominal cramps (3 per cent), subcutaneous infection at the insertion site (1 per cent) and catheter occlusion precluding use (1 per cent). In 16 patients, the NCJ was replaced percutaneously with a larger-bore catheter for more prolonged enteral feeding at home after discharge.

CONCLUSION

Through the experience gained, indications are offered for the placement of NCJs and cautions are provided concerning appropriate use of an NCJ to provide nutritional support, fluid and electrolyte replacement or maintenance, and safe enteral administration of medication. Overall, an NCJ appears to allow safer, cheaper and equally effective delivery of nutrition compared with total parenteral nutrition after major intra-abdominal operations.

A Guide to Enteral Drug Administration in Palliative Care

Enternal feeding is indicated in patients unable to ingest sufficient nutrients but whose gastrointestinal function is adequate for digestion and absorption. Indications in palliative care include patients with radical esophageal surgery, upper gastrointestinal tract obstruction, anorexia, and dysphagia. As the oral route is the preferred method of palliative drug delivery, the enternal feeding tube can become an important tool for drug administration. A number of questions must be asked before a drug is considered for enteral administration. Firstly, is the drug in a suitable dosage form for administration? If not, can a different dosage form (or drug) be substituted or can the physical form of the original product be altered? Secondly, is the drug compatible with the enteral feed? Finally, are there any complicating factors that may affect drug absorption or clearance? This review attempts to answer these questions, provide easily understood guidelines for the successful enteral administration of medications, and discuss clinical implications for palliative care.

Comparison of absorption of nutrients and secretion of water between oligomeric and polymeric enteral diets in pigs

In patients who require enteric tube-feeding the osmolality of the formulas is assumed to play an important role. There is the dilemma that osmolality increases as the digestibility of formulas is enhanced by means of degradation of the nutrients. Hitherto there have been no reports of whether there are differences in nutrient absorption and water fluxes between iso-osmotic polymeric and hyperosmotic oligomeric diets. We therefore investigated absorption of nutrients and net fluxes of water during perfusion of a 1.5 m jejunal segment with oligomeric, polymeric and commercial oligopeptide diets either in the absence of pancreatic juice or with concomitant infusion of pancreatic enzymes. In the absence of pancreatic juice the absorption rates of the polymeric diet and the commercial oligopeptide diets reached 58.0 and 84.5% respectively of that of a completely-hydrolysed hyperosmotic oligomeric diet. The concomitant infusion of pancreatic enzymes with the polymeric and oligopeptide diets significantly increased the absorption rates of nutrients and energy. The highest absorption rate of energy occurred with the commercial formula Survimed (Fresenius, Bad Homburg, Germany), probably due to an optimal composition of the macronutrients. The increase in absorption due to the degradation of nutrients by pancreatic enzymes was associated with an increase in net water secretion and flow-rate, reaching similar values to those with the hyperosmotic oligomeric diet. It may be concluded that iso-osmotic oligopeptide formulas require further pancreatic hydrolysis for optimum absorption. In patients with normal pancreatic secretion, oligopeptide formulas have no advantage over polymeric diets. In patients with reduced pancreatic secretion, either completely-hydrolysed hyperosmotic oligomeric diets or polymeric diets supplemented with pancreatic enzymes are appropriate.

Home enteral and parenteral nutrition in children

The prevalence of home enteral and parenteral nutrition programmes is rising rapidly all over the world, in children as in adults. Home artificial nutrition, especially parenteral nutrition, is an expensive technology but is life-saving for many patients. The only possible alternative to home treatment is keeping patients in hospital, and cost-benefit studies have demonstrated that home nutrition is about 70% more cost-effective than hospital-based therapy. Although home nutrition is usually considered by children and families to lead to an improvement in their quality of life, the complications of these techniques, including psychological consequences, have to be carefully assessed and prevented.

Nutrition and cystic fibrosis

Cystic fibrosis is commonly associated with energy deficiency in children and adults. Chronic undernutrition will lead to failure to thrive, wasting, and stunting of linear growth; nutrition and survival are intimately related in cystic fibrosis. These problems can simply be considered as energy imbalance, and management centers on restoration of energy balance. Specific nutrient deficiencies, such as fat soluble vitamins, are common in cystic fibrosis. Recent work has highlighted problems with bone density and also the prevalence of vitamin K deficiency. Management of nutritional problems can be complex, and injudicious treatment can further worsen the situation, as the relationship between high daily doses of pancreatic enzymes and the development of fibrosing colonopathy illustrates.

Home artificial nutritional support in gastrointestinal disease

Recent studies in the area of home artificial nutrition have shown that the prevalence of home enteral and parenteral nutrition programmes is rising rapidly all over the world. Other features of the past few years are the shift from non-malignant towards malignant indications and the increasing number of geriatric patients.

Nutrition support for patients in long-term acute care and subacute care facilities

Long-term acute care and subacute care facilities (also transitional care facilities) have evolved from the need to decrease costs associated with acute care in the hospital. As the length of stay in many medical centers has been reduced, patients are admitted to transitional care facilities to continue recovery and rehabilitation. Rehabilitation and recovery can be enhanced with the provision of optimal medical nutrition therapy. Nutrition screening is essential in identifying patients who are at risk of malnutrition or are malnourished. Nutrition assessment verifies the risk or presence of malnutrition followed by the development, implementation, and monitoring of nutrition intervention. Nutrition screening and intervention promote recovery from illness, minimize morbidity and mortality, and enhance quality of life. The goals of nutrition support are to prevent starvation-associated malnutrition, preserve lean tissue mass, support metabolic functions, and improve clinical outcomes. Oral nutrition is the preferred method of nourishment; however, specialized nutrition support is considered for patients unable to meet their nutrient requirements adequately. Enteral nutrition support is recommended when providing nutrition support however, parenteral nutrition support is used when the gastrointestinal tract can not be safely used. With appropriate intention, administration, and monitoring, nutrition support can be safely administered.

Enteral feeding techniques

Major technical advances in enteral nutrition include the use of erythromycin or magnetic guidance for the placement of the feeding tube into the duodenum, the development of new enteral tubes, and bedside methods to control the tube position. Percutaneous endoscopic jejunostomy is becoming a safe procedure with a high success rate. Specialized diets offer little or no clinical advantages when compared with standard polymeric diets.

Percutaneous endoscopic gastrostomy in children and adolescents

BACKGROUND

Long-term nasogastric tube feeding is often associated with irritation of the hypopharynx or dislocation of the tube. These pitfalls may be circumvented by percutaneous endoscopic gastrostomy. Although frequently used in adults, there is limited experience with the procedure in children.

METHODS

A series of 139 patients (aged 3 weeks to 36.5 years, mean age, 4.4 years; weight 3.1-60 kg, mean weight, 15 kg) underwent placement of a percutaneous endoscopic gastrostomy because of central dysphagia (n = 103); general dystrophy caused by chronic renal failure, congenital heart disease, neoplasms, or cystic fibrosis (n = 26); requirement for special diets (n = 7); malnutrition related to respiratory insufficiency (n = 2); and gastric volvulus (n = 1).

RESULTS

The percutaneous endoscopic gastrostomy was placed either in the stomach (n = 122) or in the duodenum (n = 15). In two patients a direct percutaneous endoscopic jejunostomy was performed, because duodenal placement proved impossible. Percutaneous endoscopic gastrostomies were placed using intravenous sedation (midazolam, etomidate, or diazepam). None of the patients required general or inhalation anesthesia. We observed 19 complications including: dislocation of the duodenal part into the stomach (n = 5); inflammation at the insertion site (n = 3); perforation of the stomach (n = 2), which healed under conservative treatment; disconnection of the retention disk (n = 4); occlusion of the tube (n = 4), and chronic vomiting (n = 1). Mean lifetime of a percutaneous endoscopic gastrostomy was more than 1 year.

CONCLUSIONS

Percutaneous endoscopic gastrostomy provides a major improvement for children requiring long-term tube feeding. High efficacy and low rates of complication suggest that percutaneous endoscopic gastrostomy should be considered more often, even in infants.

Stopping enteral feeding for arbitrary gastric residual volume may not be physiologically sound: results of a computer simulation model

BACKGROUND

During tube feeding, it is a common practice to check gastric residual volume frequently for indications of pathologic impairment of gastric emptying. The volume threshold standards for holding feedings are applied nonselectively, disregarding slowing of gastric emptying by nutrient-triggered intestinogastric inhibitory feedback. We developed a computer simulation model considering this feedback to test the hypothesis that gastric residual volume increases with slower gastric emptying and faster formula delivery but reaches a plateau volume (equilibrium between input and output) at volumes commonly seen in the postprandial stomach.

METHODS

A computer simulation model using Microsoft Excel 4.0 calculated the cumulative gastric residual volume over time when the input volume into the stomach is 125 mL/h (endogenous secretions)+ 0 to 125 mL/h (formula delivery rate) and the output volume out of the stomach is equal to gastric emptying rates that varied between 0% and 50%/h. The model simulated nasogastric feeding with nine different rates of gastric emptying and six different rates of formula delivery. Measurements consisted of the cumulative gastric residual volume at the end of each hour for a minimum of 48 hours.

RESULTS

(1) Gastric residual volumes 1.5 to 6 times the commonly applied "stop feeding" threshold volume of 150 mL are encountered at gastric emptying rates of 20% to 50%/h; (2) gastric residual volume stabilizes to a plateau of 225 to 900 mL between 3 and 13 hours after start of formula delivery at these rates; and (3) at 0% gastric emptying, gastric residual volume does not reach a plateau.

CONCLUSIONS

At gastric emptying rates expected with nutrient-triggered inhibitory feedback and at formula delivery rates common in nutrition support, gastric residual volume reaches a plateau rapidly and at volumes commonly encountered in normal postprandial stomachs. On the basis of the results of this model, the current practice of stopping enteral feeding when gastric residual volume exceeds an arbitrarily selected volume threshold may not be physiologically sound. Clinical studies are needed to verify this model.

A new technique for placement of nasoenteral feeding tubes using external magnetic guidance

OBJECTIVE

To evaluate a new technique in which a hand-held external magnet is used to maneuver nasoenteral feeding tubes through the pylorus and into the duodenum.

DESIGN

Prospective case series.

SETTING

Critical care units and medical and surgical wards of a university-affiliated community hospital.

PATIENTS

Thirty-five patients were entered into the study after the attending physician requested assistance in tube placement.

INTERVENTIONS

A standard 12-Fr, 114-cm flexible nasoenteral feeding tube was modified by inserting a small magnet into the distal tip. The tube was inserted per nares into the stomach, using traditional technique. Next, an external magnet was placed over the right upper abdominal quadrant, at the midclavicular line to attract the tube tip along the lesser curvature of the stomach, through the pyloric sphincter, and into the duodenum. Portable abdominal radiography performed immediately after the procedure confirmed the anatomic location of the tube tip.

MEASUREMENTS AND MAIN RESULTS

Forty-two intubations were performed in 35 patients (in seven patients, the tube had to be reinserted due to inadvertent removal or surgery). In 37 (88%) of 42 intubations, the tube was passed through the pyloric sphincter and into the duodenum on the first attempt. The mean procedure time was 15 +/- 9 mins (range 10 to 45). There were no complications related to the procedure during the study period.

CONCLUSIONS

This report describes a novel technique of enteral feeding tube placement, using external magnetic guidance. Transpyloric placement was achieved in 88% of cases. This reliable and convenient bedside method for rapid placement of the tube into the duodenum allows prompt and safe initiation of enteral nutrition.