American Gastroenterological Association technical review on tube feeding for enteral nutrition

Bedside videoscopic placement of feeding tubes: development of fiberoptics through the tube

OBJECTIVE

Transpyloric small intestine feeding tube placement can be difficult and tedious. Currently accepted techniques are associated with disadvantages and risk. The purpose of this study is to describe the development of a new technique: bedside videoscopic placement using fiberoptics through the tube.

DESIGN

Prospective, descriptive case study.

SETTING

Intensive care unit in a teaching hospital.

PATIENTS

Subjects were divided into two groups: a) group 1: eight healthy volunteers (seven male, one female); b) group 2: nine critically ill patients (six male, three female; eight of these patients were intubated).

INTERVENTIONS

Standard 12-Fr (4.0-mm) feeding tubes (n = 19) were placed. Two patients from group 2 had feeding tubes placed on two separate occasions. The feeding tubes were inserted by the oral (n = 8) or nasal (n = 11) route under direct vision, using a 6.7-Fr (2.2-mm) fiberoptic scope through the feeding tube.

MEASUREMENTS AND MAIN RESULTS

We visualized enteric structures clearly through the feeding tube in all subjects and patients. Based on visual landmarks, we advanced the feeding tube through the pylorus and into the duodenum in all individuals. Transpyloric tube placement was confirmed videoscopically (n = 19) and radiographically (n = 18). In three subjects from group 1, the feeding tube entered the first part of the duodenum, while, in the remainder of the subjects, the tube passed into or beyond the second portion of the duodenum. In eight (73%) of 11 attempts on the nine critically ill patients from group 2, the feeding tubes were advanced to the distal duodenum or jejunum. The time required for placement in group 2 ranged from 2 to 43 mins (mean 18 +/- 12 [SD]). The feeding tubes remained in place 10 +/- 4 days and patients met their estimated caloric needs within 24 hrs. Residual volumes of nutrition in the small bowel were < 5 mL. There were no documented episodes of aspiration.

CONCLUSION

This new technique has the potential for rapid, accurate, and safe feeding tube placement in patients requiring nutritional support.

Gastrostomy tube infections in a community hospital

BACKGROUND

Percutaneous gastric feeding tubes are becoming increasingly more common to provide nutrition in debilitated patients, while they decrease the risk of aspiration associated with nasogastric tubes.

METHODS

We reviewed infectious complications of 372 feeding gastrostomy tubes placed in a small urban community hospital over a recent period.

RESULTS

In our study there was an infection rate of 4.8%. Four serious infections occurred: two cases of peritonitis and two deep abscesses, but there were no infectious deaths. The most common infecting organisms were staphylococci, gram negative bacteria, and yeast. Most infections required treatment with parenteral antibiotics, prolonging hospitalization. Two of 17 infected tubes required removal.

CONCLUSION

Percutaneous gastrostomy tubes can produce life threatening infections and deserve serious attention by ICPs in hospitals, long-term care facilities, and home care services. These tubes should only be inserted if they extend meaningful life in patients. Protocols are needed for the care of gastrostomy tubes, and infections must be treated as early and as aggressively as possible to avoid serious consequences.

Evaluation of the safety of nurse-assisted percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) procedures have become a common, nonsurgical approach to providing enteral access to patients who are otherwise unable to meet their nutritional needs by mouth. Historically, two physicians have been required to complete this procedure; the first performed the endoscopy while the second helped to position the PEG tube. As a result of constraints on physicians' time and availability, as well as increased medical costs, this process has changed in some settings where the procedure is accomplished by one physician who performs the endoscopy and directly observes a nurse who acts in the role of the second physician. This research study was designed to evaluate the safety of nurse-assisted PEG procedures by comparing the complications of placement (i.e., infection, hemorrhage, perforation, and ileus) with those complications that occur when two physicians perform the procedure. The current standard of care for placing PEG tube was followed. Results in this small sample show that nurse-assisted PEG procedures are as safe as when two physicians perform this procedure.

Parenteral Nutrition Formulation: An Integral Part of the Endocrinologist’s Metabolic Support Consultation Service

Endocrinologists are uniquely suited to provide consultation in the new field of metabolic support. This specialty incorporates management of electrolyte and mineral disorders, diabetes mellitus, and malnutrition. Principles of formulation of parenteral nutrition are discussed, with an emphasis on distinguishing marasmus from kwashiorkor types of cachexia, disease-specific treatment, nutritional pharmacology, and relevant controversies.