Blind bedside insertion of small bowel feeding tubes

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Placement of a Magnetic Small Bowel Feeding Tube at the Bedside

BACKGROUND

Current methods of achieving postpyloric enteral access for feeding are fraught with difficulties, which can markedly delay enteral feeding and cause complications. Bedside tube placement has a low success rate, often requires several radiographs to confirm position, and delays feeding by many hours. Although postpyloric enteral tubes can reliably be placed in interventional radiology (IR), this involves greater resource utilization, delays, cost, and inconvenience. We assessed the utility of bedside enteral tube placement using a magnetic feeding tube (Syncro-BlueTube; Syncro Medical Innovations, Macon, GA, USA) as a means to facilitate initial tube placement.

METHODS

We recorded the time to insertion, location of tube, success rate, and need for radiographs in a series of patients given magnetic feeding tubes (n = 46) inserted by our hospitalist service over an 8-month interval.

RESULTS

Of the 46 attempted magnetic tube placements, 76% were successfully placed in the postpyloric position, 13% were in the stomach, and 11% could not be placed. In 83% of the magnetic tubes, only 1 radiograph was needed for confirmation. The median time to placement was 12 minutes (range, 4-120 minutes).

CONCLUSION

The use of a magnetic feeding tube can increase the success rate of bedside postpyloric placement, decrease the time to successful placement, and decrease the need for supplemental radiographs and IR.

Rhubarb to Facilitate Placement of Nasojejunal Feeding Tubes in Patients in the Intensive Care Unit

BACKGROUND

Prokinetic agents are sometimes needed to aid in the placement of nasojejunal feeding tubes in patients at risk of malnutrition. The objective of the present study was to evaluate the feasibility of rhubarb as a new prokinetic agent to replace metoclopramide and erythromycin in the placement of nasojejunal feeding tubes.

MATERIALS AND METHODS

Ninety-four patients who required jejunal feeding tube insertion were included. They were divided into rhubarb (n = 34), metoclopramide (n = 31), and erythromycin groups (n = 29), depending on the use of rhubarb, metoclopramide, and erythromycin as the prokinetic agent. The jejunal feeding tube insertions were performed at the bedside. An abdominal x-ray was taken as the gold standard to determine the position of the tube. Cases in which insertion failed in either group were subjected to a second insertion attempt using rhubarb as the prokinetic agent.

RESULTS

The success rates in the rhubarb, metoclopramide, and erythromycin groups were 91.2%, 87.1%, and 89.7%, respectively. The difference in the success rates was not statistically significant (P = .916). The insertion times in the rhubarb, metoclopramide, and erythromycin groups were 16.0 ± 1.9 minutes, 18.0 ± 1.9 minutes, and 18.8 ± 2.2 minutes, respectively. The insertion time in the rhubarb group was significantly shorter than those in metoclopramide and erythromycin groups (P < .001). No side effects were noted in the rhubarb group.

CONCLUSIONS

Rhubarb could serve as an effective prokinetic agent to promote the insertion of nasojejunal feeding tubes.

A pilot study to explore the safety of perioperative postpyloric enteral nutrition

BACKGROUND

The practice of holding enteral nutrition (EN) 8 hours prior to surgery is common. We hypothesized that it was safe to continue postpyloric EN, and we developed an institutional practice pattern to investigate our hypothesis.

METHODS

Our pilot study included intubated patients in the surgical intensive care unit at Froedtert Memorial Lutheran Hospital who received EN via a nasojejunal (NJ) feeding tube and underwent 1 or more surgical procedures. Demographic, illness, and injury information were collected as well as length of time to NJ placement, time to initiation of EN, EN interruptions, and complications. Additional hours of EN were calculated by totaling the number of hours a patient received EN past midnight on the day of surgery.

RESULTS

A total of 14 patients with mean (SD) age 44.3 (19.9) were included. Patients had a mean (SD) Injury Severity Score (ISS) of 26.1 (9.2) on admission and underwent a total of 38 operations following placement of a feeding tube. The most frequent operation performed was an orthopedic procedure (n = 17; 46.1%). The mean (SD) length of EN interruptions for a single procedure was 222.4 (206.9) minutes. Patients received an additional 11.9 (4.7) hours of EN over the course of their hospitalization and an additional 1064.9 (490) kcal/d per operation. There were no adverse events.

CONCLUSION

Perioperative continuation of postpyloric EN is feasible in some critically ill surgical patients and can result in additional calories provided. A multidisciplinary approach and an institutional policy can increase the likelihood of meeting nutrition goals in these patients.

A transatlantic survey of nutrition practice in acute pancreatitis

BACKGROUND

Many guidelines exist for the nutritional management of acute pancreatitis; however, little is known regarding current practice. We aimed to investigate feeding practices, including the use of parenteral/enteral nutrition.

METHODS

The study design was a cross-sectional, descriptive survey. Electronic surveys were sent to dietitians in the UK, the Republic of Ireland and Canada. Of 253 dietitians surveyed, 204 saw patients with acute pancreatitis regularly or occasionally and were included in the analyses.

RESULTS

Most dietitians (92.8%) considered early feeding to mean <48 h after presentation. Over half (54.2%) favoured early feeding in severe disease, less in obesity (42%) and more with pre-existing malnutrition (81.9%). There was a tendency to feed earlier in university hospitals (P = 0.015), especially in obesity (P = 0.011). There was a tendency towards enteral (versus parenteral) nutrition in university hospitals (P = 0.000). The majority preferred the jejunal route (64.2%), although this was lower in the UK (43.8%) than in Canada (77.8%) or Ireland (54.2%). Under one-quarter of UK dietitians (23.2%) reported the existence of a pancreatic multidisciplinary team in their institutions, although this was lower in Ireland and Canada.

CONCLUSIONS

Despite guidelines, there are gaps in the nutritional management of acute pancreatitis, including a continued reliance on parenteral feeding.