Bedside sonographic control for positioning enteral feeding tubes: a controlled study in intensive care unit patients

Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study

INTRODUCTION

Patients using a nasogastric tube (NGT) are vulnerable to adverse events, therefore proper assessment of these patients, verification of the correct tube placement and constant monitoring by the nursing staff are strategies that can reduce adverse events and risks associated with the care. The aim of this study will be to assess the accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement compared with the X-ray method. A further aim will be to measure and provide evidence for the direct costs of each method of confirming NGT placement and to evaluate the impact of each method on the mean direct cost of the patient.

METHODS AND ANALYSIS

This is a prospective, single-centre study of diagnostic accuracy. Data will be collected in the clinical and surgical wards, intensive care unit and coronary care unit of a Brazilian teaching hospital. The sample will consist of 385 assessments, performed in adult patients that agree to participate in the study and that receive an NGT. The combined method and the ultrasound will be the index tests and will be performed on all study participants for later comparison with an X-ray examination, considered the reference standard and the gold standard to distinguish between gastric and pulmonary placement. Sensitivity, specificity, positive predictive value and negative predictive value will be calculated to assess the diagnostic accuracy of the methods investigated in this study, with Cohen's kappa analysis used to evaluate the degree of concordance.

ETHICS AND DISSEMINATION

The study was approved by the Research Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing, registration number: 83087318.4.0000.5393. The findings will be reported through academic journals, seminars and conference presentations, social media, print media, the internet and community/stakeholder engagement activities.

4-Point ultrasonography to confirm the correct position of the nasogastric tube in 114 critically ill patients

PURPOSE

Nasogastric feeding tube is routinely positioned in intensive care units. The complications of misplacement are rare but very dangerous for the patients. The aim of this study is to estimate the diagnostic accuracy of this new technique, 4-point ultrasonography to confirm nasogastric tube placement in intensive care.

METHODS

One hundred fourteen critical ill patients monitored in ICU were included. The intensivist provided in real time to perform the exam in four steps: sonography from either the right or left side of the patient's neck to visualize the esophagus, sonography of epigastrium to confirm the passage through the esophagogastric junction and the positioning in antrum, sonography of the fundus. Finally, gastric placement of the nasogastric feeding tube was confirmed with thorax radiograph.

RESULTS

One hundred fourteen of the gastric tubes were visualized by sonography in the digestive tract and all were confirmed by radiography (sensitivity 100%). The entire sonographic procedure, including the longitudinal and transversal scan of the esophagus, the esophagogastric junction, the antrum and the fundus, took 10 min.

CONCLUSIONS

Our pilot study demonstrated that not weighted-tip gastric tube routinely used in Intensive Care is visible with the sonography. The pilot study confirmed the high sensitivity of the sonography in the verify correct positioning of gastric tube in the adult ICU patients. The ultrasound examination seems to be easy and rapid even when performed by a intensivist whit a sonographic training of only 40 h. The sonographic exam at the bedside was performed in a shorter time than the acquisition and reporting of the X-ray.

Computed Tomography-Guided Percutaneous Gastrostomy/Jejunostomy for Feeding and Decompression

BACKGROUND

An effective method for long-term enteral feeding or stomach decompression is the use of a percutaneous gastrostomy (PEG) or sometimes jejunostomy (PEJ). Under certain circumstances (eg, inadequate transillumination), endoscopic placement of PEG/PEJ tubes is impossible. In these cases, computed tomography (CT)-guided PEG/PEJ may represent an alternative technique. In this study, we evaluate indications, results, and complications of CT-guided PEG/PEJ.

MATERIALS AND METHODS

A total of 102 consecutive referred patients were enrolled in the study. Patients came to the endoscopy unit of our department to undergo a CT-guided PEG/PEJ for long-term intragastric/intrajejunal feeding (n = 57) or decompression (n = 45). The majority (n = 98) received a pull-through PEG/PEJ with simultaneous gastroscopy/jejunoscopy. Dose length product and the effective dose for every patient were calculated.

RESULTS

PEG/PEJ tube placement was successful in 87.3% (89 of 102). Feeding PEG/PEJ tube placement was successfully completed in 91.2% (52 of 57); decompressive PEG/PEJ tube placement was likewise successfully completed in 82.2% (37 of 45). No procedure-related mortality was observed. Minor complications (eg, tube dysfunction, local bleeding, minimal leakage, local skin infection) were observed in 13 patients. The complication rate was similar between the feeding and decompression groups ( P = .9).

CONCLUSIONS

CT-guided PEG/PEJ is a feasible and safe method with a low procedure-related morbidity rate for patients where endoscopic placement via transillumination is not successful. Thus, the procedure is an attractive alternative to surgical tube placement. Long-term complications, mainly tube disturbances, can be treated easily.

Naso-enteric Tube Placement: A Review of Methods to Confirm Tip Location, Global Applicability and Requirements

BACKGROUND

The insertion of a tube through the nose and into the stomach or beyond is a common clinical procedure for feeding and decompression. The safety, accuracy and reliability of tube insertion and methods used to confirm the location of the naso-enteric tube (NET) tip have not been systematically reviewed. The aim of this study is to review and compare these methods and determine their global applicability by end-user engagement.

METHODS

A systematic literature review of four major databases was performed to identify all relevant studies. The methods for NET tip localization were then compared for their accuracy with reference to a gold standard method (radiography or endoscopy). The global applicability of the different methods was analysed using a house of quality matrix.

RESULTS

After applying the inclusion and exclusion criteria, 76 articles were selected. Limitations were found to be associated with the 20 different methods described for NET tip localization. The method with the best combined sensitivity and specificity (where n > 1) was ultrasound/sonography, followed by external magnetic guidance, electromagnetic methods and then capnography/capnometry. The top three performance criteria that were considered most important for global applicability were cost per tube/disposable, success rate and cost for non-disposable components.

CONCLUSION

There is no ideal method for confirming NET tip localisation. While radiography (the gold standard used for comparison) and ultrasound were the most accurate methods, they are costly and not universally available. There remains the need to develop a low-cost, easy-use, accurate and reliable method for NET tip localization.

Endoscopic position control of nasoenteral feeding tubes by transnasal re-endoscopy: a prospective study in intensive care patients

OBJECTIVES

In critically ill patients, correct placement of enteral feeding tubes is usually controlled by X-ray. A bedside method without radiation exposure would be preferable. This study aimed to demonstrate the feasibility and value of endoscopic position control for enteral feeding tubes by transnasal re-endoscopy.

METHODS

A total of 120 consecutive examinations in critically ill patients were analyzed. Immediately after transnasal endoscopic placement of a feeding tube, the correct position was determined by re-endoscopy. In cases of incorrect position, replacement was performed instantly until the correct position was achieved. Abdominal X-ray with contrast was performed thereafter and served as the gold standard.

RESULTS

In 95 patients (79%), endoscopic control showed correct position. In 25 patients, position was incorrect and endoscopic placement was repeated (one attempt in 22 patients, two attempts in 3 patients). Radiological control showed correct position in 118 patients (98%). In two cases, the feeding tube was displaced in the meantime. The sensitivity and positive predictive value of endoscopic position control was 100% (95% confidence interval, CI; 97-100%) and 98% (95% CI; 94-99%), respectively. The cost savings per case ranged from $281 to $302, depending on different cost assumptions.

CONCLUSIONS

Endoscopic position control of enteral feeding tubes by re-endoscopy is feasible, very accurate, leads to a high rate of successful feeding tube placements, and has the potential of substantial cost-savings.