Nasal bridling decreases feeding tube dislodgment and may increase caloric intake in the surgical intensive care unit: a randomized, controlled trial

AGA Clinical Practice Update on Endoscopic Enteral Access: Commentary

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update is to facilitate understanding and improve the clinical practice of endoscopic enteral access.

METHODS

This expert commentary was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology.

Assessment by finite element analysis modelling of tissue strains associated with the use of two different nasogastric tube securement devices

OBJECTIVES

Nasogastric tube use can lead to pressure injury. Some nasogastric tube securement devices (NG-SD) include hard plastic components. In the current study, we assessed the differences in strain profiles for two NG-SD, one with hard segments and one without hard segments, using finite element analysis (FEA) to measure strain and deformation occurring at the nasogastric tube-tissue interface.

METHODS

FEA in silico models of devices were based on device mechanical test data and clinically relevant placements. Peak strain values were determined by modelling different scenarios using Abaqus software whereby the tubing is moved during wear.

RESULTS

The modelling showed peak strains ranging from 52% to 434% for the two NG-SD depending on the tubing placement and device type. Peak strain was always higher for the hard plastic device. Tissue strain energy was a minimum of 133.8 mJ for the NG-SD with no hard parts and a maximum of 311.6 mJ for the NG-SD with hard parts.

CONCLUSIONS

This study provided evidence through in silico modelling that NG-SD without hard components may impart less strain and stress to tissues which may provide an option for tube securement that is less likely to cause medical device-related pressure injury.

Timing and Outcomes of Percutaneous Endoscopic Gastrostomy After Ischemic Stroke

Background

Guidelines recommend using percutaneous endoscopic gastrostomy (PEG) for dysphagia after 2 weeks of stroke onset. We aimed to study the impact of PEG timing on outcomes in patients with ischemic stroke.

Methods

In this retrospective study of patients with ischemic stroke and PEG between 2014 and 2019, early PEG was defined as PEG tube placed within 14 days of stroke and late PEG after 14 days. Outcomes of 30-day mortality, PEG-related complications, and functional swallow recovery were compared between early and late PEG. Logistic regression model assessed factors associated with PEG timing.

Results

The median time of PEG tube placement after stroke was 10.9 days. Of the 161 included patients, 60.9% had early PEG, and its associated patient factors were nursing facility discharge (adjusted odds ratio (OR): 3.4, confidence interval (CI): 1.48 - 7.82) and infection (OR: 0.32, CI: 0.139 - 0.178). Late PEG had 3.27 times greater odds of swallowing recovery, but mortality and complications were not significantly different between early and late PEG.

Conclusions

Skilled nursing facility disposition and lack of infection were predictors of early PEG, constituting the majority of PEG placed for ischemic stroke-related dysphagia. Although better odds of swallowing recovery were seen with late PEG, likely implicating better patient selection, overall, the timing of PEG tube placement did not impact short-term mortality and complications.

Heterogeneity of surrogate outcome measures used in critical care studies: A systematic review

BACKGROUND

The choice of outcome measure is a critical decision in the design of any clinical trial, but many Phase III clinical trials in critical care fail to detect a difference between the interventions being compared. This may be because the surrogate outcomes used to show beneficial effects in early phase trials (which informed the design of the subsequent Phase III trials) are not valid guides to the differences between the interventions for the main outcomes of the Phase III trials. We undertook a systematic review (1) to generate a list of outcome measures used in critical care trials, (2) to determine the variability in the outcome reporting in the respiratory subgroup and (3) to create a smaller list of potential early phase endpoints in the respiratory subgroup.

METHODS

Data related to outcomes were extracted from studies published in the six top-ranked critical care journals between 2010 and 2020. Outcomes were classified into subcategories and categories. A subset of early phase endpoints relevant to the respiratory subgroup was selected for further investigation. The variability of the outcomes and the variability in reporting was investigated.

RESULTS

A total of 6905 references were retrieved and a total of 294 separate outcomes were identified from 58 studies. The outcomes were then classified into 11 categories and 66 subcategories. A subset of 22 outcomes relevant for the respiratory group were identified as potential early phase outcomes. The summary statistics, time points and definitions show the outcomes are analysed and reported in different ways.

CONCLUSION

The outcome measures were defined, analysed and reported in a variety of ways. This creates difficulties for synthesising data in systematic reviews and planning definitive trials. This review once again highlights an urgent need for standardisation and validation of surrogate outcomes reported in critical care trials. Future work should aim to validate and develop a core outcome set for surrogate outcomes in critical care trials.

Safety and effectiveness of the nasal bridle securement device to retain feeding tubes in adult patients in the intensive care unit: An observational study

BACKGROUND

Nasal bridle securement devices were introduced to our adult intensive care unit (ICU) in October 2016 as an alternative for securing small-bore feeding tubes in patients at higher risk of inadvertent tube dislodgement.

METHOD

We assessed high-risk ICU patients from October 2014 to March 2019 to address three objectives. First, we prospectively monitored ICU patients with a nasal bridle for all types of adverse events. Second, we used propensity score methods to create a (1:1) matched historical comparison group (ie, tape group). We then compared the number of inadvertent tube dislodgements and the caloric intake between the tape and nasal bridle groups.

RESULTS

In the prospective group (n = 64), there were 20 adverse events, 12 of which were inadvertent tube dislodgements. Forty-eight participants in the nasal bridle group were matched with participants in the historical group. Thirty-five percent (17/48) of patients in the tape group had at least one inadvertent tube dislodgement; in the nasal bridle group, 48% (23/48) had at least one inadvertent tube dislodgement, although this only occurred in 7 of 48 (15%) patients after the nasal bridle had been inserted. The tape group achieved a lower median percentage of total caloric intake received (66.0%) compared with that of the nasal bridle group (86.1%; P = 0.017).

CONCLUSIONS

In the subpopulation of ICU patients with a small-bore feeding tube who demonstrate a higher risk of inadvertent tube dislodgement, use of the nasal bridle may be associated with a higher caloric intake, even though it does not completely prevent tube dislodgement.

Nasal Tube Securement: Randomized Controlled Trial in Pediatric Hospitalized Patients

PURPOSE

The aim of this study was to compare accidental dislodgement rates of nasal gastric tubes secured with standard methods or a nasal tube securement device in pediatric patients.

DESIGN

A randomized controlled trial was conducted.

METHODS

Participants ( n = 43) were randomized into standard securement or nasal tube securement device using block randomization to control for age and diagnosis. Surveys were collected from staff and caregivers on device ease of use and satisfaction.

RESULTS

There were a similar number of tube dislodgements for patients in the nasal tube securement device group ( n = 6) and the standard practice group ( n = 7). The median hospital length of stay was higher for the standard practice group (13 days vs. 9 days).

CONCLUSION

Use of the nasal tube securement device did not significantly decrease the rate of tube dislodgements compared with standard practice.

CLINICAL RELEVANCE TO REHABILITATION NURSING

The study provides information for pediatric rehabilitation nurses in choosing securement options for nasal gastric tubes.

Enteral Nutrition Overview

Enteral nutrition (EN) provides critical macro and micronutrients to individuals who cannot maintain sufficient oral intake to meet their nutritional needs. EN is most commonly required for neurological conditions that impair swallow function, such as stroke, amytrophic lateral sclerosis, and Parkinson’s disease. An inability to swallow due to mechanical ventilation and altered mental status are also common conditions that necessitate the use of EN. EN can be short or long term and delivered gastrically or post-pylorically. The expected duration and site of feeding determine the type of feeding tube used. Many commercial EN formulas are available. In addition to standard formulations, disease specific, peptide-based, and blenderized formulas are also available. Several other factors should be considered when providing EN, including timing and rate of initiation, advancement regimen, feeding modality, and risk of complications. Careful and comprehensive assessment of the patient will help to ensure that nutritionally complete and clinically appropriate EN is delivered safely.

Nasogastric Bridles are Associated with Improved Tube-Related Outcomes in Children

OBJECTIVE

To compare tube-related outcomes in children with standard tape versus nasal bridle securement of nasogastric tubes (NGTs).

STUDY DESIGN

Single-center, retrospective, correlational study of outcomes from the time of NGT placement until full oral feeds or durable-tube placement. Outcomes of interest included NGT dislodgements, length of stay, emergency department (ED) encounters, radiographic exposures, and adverse skin outcomes. Negative binomial regression and logistic regression were used to analyze differences between groups.

RESULTS

582 children had NGTs secured traditionally [43% female; age at therapy initiation 2.6 months (SD 8.1)] and 173 received nasal bridles [55.5% female; age at therapy initiation 8.4 months (SD 11.8)]. Children with bridled NGTs were 16.67 times less likely to experience ≥1 dislodgement (OR=0.06, 95% CI 0.04, 0.09); 2.5 times less likely to have one more ED visit (OR=0.4, 95% CI 0.19, 0.82), and 4.76 times less likely to require one more radiographic exposure (OR=0.21, 95% CI 0.14, 0.33) than their non-bridled NGT counterparts (all p values <0.02). The mean initial hospital length of stay was 28 and 54 days in the bridled and standard care group respectively (p<0.001). Overall, 62.4% children with bridled NGTs and 77.1% children with unbridled NGTs progressed to full oral feedings and required no further therapy (p<0.001). Adverse skin outcomes were rare in both groups.

CONCLUSION

Children with bridled NGTs experienced fewer dislodgements, days in the hospital, ED encounters, and radiographic exposures than children with traditionally secured NGTs. The majority of children in both groups progressed to full oral feedings. This article is protected by copyright. All rights reserved.

Reining in Nasogastric Tubes: Implementation of a Pediatric Bridle Program

Nasogastric tubes (NG) used for enteral nutrition support of medically complex children (MCC) are often inadvertently removed, risking frequent replacements. Bridles have been shown to provide a safe securement method for NGs in adult patients, but are not widely used in pediatrics. Furthermore, nutritional management of MCC is often fragmented. We established a pediatric NG bridle program to bridge the gap amongst disciplines and improve patient outcomes. In January 2018, a multidisciplinary work group involving nurses, physicians, clinical dietitians, advanced practice providers, and speech-language pathologists was established to develop criteria for patient referral and policies, procedures, and order sets for nutritional management of MCC children with bridled NG tubes. Formal teaching sessions engaged clinicians and administrators to participate in building a successful program. Relevant outcomes of interest are tracked continuously for process performance improvement measures and are reviewed quarterly by the core work group. Patient enrollment began in May 2018 and to date, 244 patients have been enrolled. Adhering to strict enrollment criteria, competency modules and review of patient status provided a solid core for the program and process review. Successful implementation of an NG Bridle program was achieved. Outcomes of interest continue to be monitored for process improvement. Balancing measures are also being tracked for potential downstream effects.

Nasogastric Tube Feeding in Older Patients: A Review of Current Practice and Challenges Faced

Nasogastric tube feeding is an essential way of delivering enteral nutrition when the oral route is insufficient or unsafe. Malnutrition is recognised as a reversible factor for sarcopenia and frailty. It is therefore crucial that malnutrition is treated in older inpatients who have dysphagia and require enteral nutrition. Despite five National Patient Safety Alerts since 2005, “Never Events” related to nasogastric feeding persist. In addition to placement errors, current practice often leads to delays in feeding, which subsequently result in worse patient outcomes. It is crucial that tube placement is confirmed accurately and in a timely way. Medical advancements in this area have been slow to find a solution which meets this need. In this paper, we provide an updated review on the current use of feeding nasogastric tubes in the older population, the issues associated with confirming correct placement, and innovative solutions for improving safety and outcomes in older patients.

Percutaneous Gastrostomy in Necrotizing Pancreatitis: Friend or Foe?

BACKGROUND

Enteral nutrition plays a central role in managing necrotizing pancreatitis (NP). Although the nasojejunal (NJ) route is widely used, percutaneous gastrostomy (PEG-J) is an alternative technique that is also applied commonly. We hypothesized that NJ and PEG-J had similar morbidity in the setting of NP.

METHODS

All patients receiving preoperative enteral nutrition before surgical debridement for NP (2005-2015) were segregated into NJ or PEG-J.

RESULTS

A total of 242 patients had complete data for analysis (155 men/87 women; median age 54 years; 47% biliary and 16% alcohol-related pancreatitis). NJ was used exclusively in 187 patients (77%); 25 patients (10%) were fed exclusively by PEG-J; the remaining 30 patients (13%) had NJ first, followed by PEG-J. Equal proportions of NJ and PEG-J patients reached enteral feeding goal (67% vs. 68%, p ≈ 1) and increased serum albumin (39% vs. 36%, p = 0.87). No difference was seen in rate of pancreatic necrosis infection (NJ 53% vs. PEG-J 49%, p = 0.64). NJ patients had significantly more complications compared to PEG-J (51%vs.27%,p = 0.0015). However, NJ patients had more grade I/II complication, compared to PEG-J patients, who had more grade III/IV complication (Grade I/II: NJ 51%vs. PEG-J 16%; Grade III/IV NJ 0%vs. PEG-J 11%, p < 0.0001).

CONCLUSION

In necrotizing pancreatitis, NJ and PEG-J both delivered enteral nutrition effectively. Patients with NJ feeding had significantly more complications than those with PEG-J; however, NJ complications were less severe.

Nasal Bridles for Securing Nasoenteric Feeding Tubes: A Review of Clinical Effectiveness and Potential Complications

Nasal bridle is a feeding tube retaining device that is now increasingly used worldwide. While common complications tend to be minor, it is important to remain vigilant for newer adverse events. We hereby delineate the case of an elderly female who required nasoenteric feeding tube following simultaneous liver-kidney transplantation. Nasal bridle placement was warranted owing to her significant frailty and poor mentation. Due to her extreme agitation during the procedure, bridle insertion could not be completed. Upon removal of the probe, unprompted detachment of the magnetic tip was noted. Radiological workup revealed the dislodged magnet in the sphenoid sinus. Subsequently, she underwent an uneventful endoscopic sinus surgery, resulting in successful retrieval of the magnet. This paper highlights the spontaneous magnet avulsion from a bridling system and serves the purpose of community awareness regarding this unusual procedural complication. Additionally, we aim to evaluate the efficacy of the nasal bridle, further accentuating its advantages and possible complications.

Efficacy of commercial nasal bridle use in reducing feeding tube dislodgements in pediatric patients following double stage laryngotracheoplasty

INTRODUCTION

Maintaining placement of the nasogastric feeding tube (NGT) is imperative in the double stage laryngotracheoplasty (dsLTP) patient because of concerns for adequate nutrition and hydration in the postoperative period. Additionally, multiple reinsertions due to displacement potentiate surgical morbidities. The purpose of this study was to compare NGT dislodgment rates in children with and without a commercial nasal bridle following a dsLTP surgical procedure and to determine if the use of a commercial nasal bridle decreases accidental tube dislodgements.

METHODS

Medical records of pediatric patients with NGT insertion for dsLTP between Jan 1, 2012 and June 15, 2018 were reviewed for nasal bridle use, demographics, feeding tube and bridle complications, x-rays to check NGT placement, length of stay (LOS), length of bridle use and accidental feeding tube dislodgements.

RESULTS

A total of 67 patients (34 unbridled and 33 bridled) received an NGT after dsLTP. No differences in demographics were noted, except the bridled group was older (median age 6.5 [IQR: 3.7, 14.3] than the unbridled group (median age 3.2 [IQR: 2.2, 6.8], p = 0.05). There were 24 episodes of NGT dislodgement in 16 patients in the unbridled group and zero displacements in the bridled patients resulting in an incidence of 9.4 [95%CI: 6.0, 14.0] and 0.0 [95%CI: 0.0, 1.9] pullouts per 100 days for unbridled versus bridled patients, respectively. Those with displacement had significantly more x-rays to check placement (p = 0.0004) and LOS was longer (p = 0.06) with a mean (SD) of 10.9 (7.0) vs. no displacement 7.0 (3.6) days. Of those bridled, 67% were discharged with a bridle and 86% returned with the NGT and bridle in place (mean bridle placement of *** ± days) at the time of stent removal. No feeding tube or bridle complications were reported for either group.

CONCLUSION

The commercial nasal bridle significantly reduced NGT displacements without complication in the examined pediatric sample s/p dsLTP. Bridle use was associated with decreased radiology exposure and LOS and was successfully used in the outpatient setting.

Observation of inadvertent tube loss in ICU: effect of nasal bridles

Background:

safe placement and securement of feeding tubes are essential to establishing early enteral nutrition. Nasogastric or nasojejunal feeding tubes are often inadvertently removed, and using a nasal bridle can reduce the number of tube replacements required.

Aim:

to review current nasal bridle practices on one intensive care unit. Over a 3-month period, nasal bridle use was recorded to measure unintentional tube loss and tube duration (the time a tube remained in situ).

Method:

an observational service evaluation.

Findings:

109 patients were recruited; 205 tubes were passed and 77 bridles were inserted, with 42% (n=46) of the bridles placed on day 1. Tubes secured with tape were more likely to be dislodged than tubes secured with a bridle, P=0.0001. Duration of tubes remaining in situ was significantly longer in patients who had a bridle fitted on day 1, P=0.0001 compared with tubes secured with tape.

Conclusion:

securing a tube with a nasal bridle from day 1 is independently associated with reduced tube loss, increased duration of tube use, and likelihood that the tube would reach redundancy when it was no longer required.

Usability study of pH strips for nasogastric tube placement

AIMS

(1) To model the process of use and usability of pH strips (2) to identify, through simulation studies, the likelihood of misreading pH strips, and to assess professional's acceptance, trust and perceived usability of pH strips.

METHODS

This study was undertaken in four phases and used a mixed method approach (an audit, a semi-structured interview, a survey and simulation study). The three months audit was of 24 patients, the semi-structured interview was performed with 19 health professionals and informed the process of use of pH strips. A survey of 134 professionals and novices explored the likelihood of misinterpreting pH strips. Standardised questionnaires were used to assess professionals perceived usability, trust and acceptance of pH strip use in a simulated study.

RESULTS

The audit found that in 45.7% of the cases aspiration could not be achieved, and that 54% of the NG-tube insertions required x-ray confirmation. None of those interviewed had received formal training on pH strips use. In the simulated study, participants made up to 11.15% errors in reading the strips with important implications for decision making regarding NG tube placement. No difference was identified between professionals and novices in their likelihood of misinterpreting the pH value of the strips. Whilst the overall experience of usage is poor (47.3%), health professionals gave a positive level of trust in both the interview (62.6%) and the survey (68.7%) and acceptance (interview group 65.1%, survey group 74.7%). They also reported anxiety in the use of strips (interview group 29.7%, survey group 49.7%).

CONCLUSIONS

Significant errors occur when using pH strips in a simulated study. Manufacturers should consider developing new pH strips, specifically designed for bedside use, that are more usable and less likely to be misread.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis

BACKGROUND

There is conflicting evidence about the relationship between the dose of enteral caloric intake and survival in critically ill patients. The objective of this systematic review and meta-analysis is to compare the effect of lower versus higher dose of enteral caloric intake in adult critically ill patients on outcome.

METHODS

We reviewed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from inception through November 2015. We included randomized and quasi-randomized studies in which there was a significant difference in the caloric intake in adult critically ill patients, including trials in which caloric restriction was the primary intervention (caloric restriction trials) and those with other interventions (non-caloric restriction trials). Two reviewers independently extracted data on study characteristics, caloric intake, and outcomes with hospital mortality being the primary outcome.

RESULTS

Twenty-one trials mostly with moderate bias risk were included (2365 patients in the lower caloric intake group and 2352 patients in the higher caloric group). Lower compared with higher caloric intake was not associated with difference in hospital mortality (risk ratio (RR) 0.953; 95 % confidence interval (CI) 0.838-1.083), ICU mortality (RR 0.885; 95 % CI 0.751-1.042), total nosocomial infections (RR 0.982; 95 % CI 0.878-1.077), mechanical ventilation duration, or length of ICU or hospital stay. Blood stream infections (11 trials; RR 0.718; 95 % CI 0.519-0.994) and incident renal replacement therapy (five trials; RR 0.711; 95 % CI 0.545-0.928) were lower with lower caloric intake. The associations between lower compared with higher caloric intake and primary and secondary outcomes, including pneumonia, were not different between caloric restriction and non-caloric restriction trials, except for the hospital stay which was longer with lower caloric intake in the caloric restriction trials.

CONCLUSIONS

We found no association between the dose of caloric intake in adult critically ill patients and hospital mortality. Lower caloric intake was associated with lower risk of blood stream infections and incident renal replacement therapy (five trials only). The heterogeneity in the design, feeding route and timing and caloric dose among the included trials could limit our interpretation. Further studies are needed to clarify our findings.

TAK-242 treatment ameliorates liver ischemia/reperfusion injury by inhibiting TLR4 signaling pathway in a swine model of Maastricht-category-III cardiac death

OBJECTIVES

This study aims to test the effects of TAK-242 on liver transplant viability in a model of swine Maastricht-category-III cardiac death.

METHODS

A swine DCD Maastricht-III model of cardiac death was established, and TAK-242 was administered prior to the induction of cardiac death. The protein and mRNA level of TLR4 signaling pathway molecules and cytokines that are important in mediating immune and inflammatory responses were assessed at different time points following the induction of cardiac death.

RESULTS

After induction of cardiac death, both the mRNA and protein levels of key molecules (TLR4, TRAF6, NF-ϰB, ICAM-1, MCP-1 and MPO), TNF-α and IL-6 increased significantly. Infusion of TAK-242 1h before induction of cardiac death blocked the increase of immune and inflammatory response molecules. However, the increase of TLR4 level was not affected by infusion of TAK-242. Histology study showed that infusion of TAK-242 protect liver tissue from damage during cardiac death.

CONCLUSIONS

These results indicates that TLR4 signaling pathway may contribute to ischemia/reperfusion injury in the liver grafts, and blocking TLR4 pathway with TAk-242 may reduce TLR4-mediated tissue damage.

Regional Comparison of Enteral Nutrition-Related Admission Policies in Skilled Nursing Facilities

BACKGROUND

Nursing home admission policies are one driver of increased and earlier gastrostomy placement, a procedure that is not always medically or ethically indicated among patients needing short-term nutrition support. This important clinical decision should be based upon patient prognosis, goals, and needs. We compared nursing home enteral nutrition-related admission policies in New York City and other regions of the United States. We also explored motivations for these policies.

METHODS

We conducted a telephone survey with skilled nursing facility administrators in New York City and a random sample of facilities throughout the United States about enteral nutrition-related admission policies. Survey data were matched with publically available data about facility characteristics from the Centers for Medicare and Medicaid Services. The relationship between facility location and admission policies was described with regression models. Reasons for these policies were thematically analyzed.

RESULTS

New York City nursing homes were significantly less likely to admit patients with nasogastric feeding tubes than were nursing homes nationwide, after we controlled for facility characteristics (odds ratio = 0.111; 95% CI, 0.032-0.344). Reasons for refusing nasogastric tubes fell into 5 categories: safety, capacity, policy, perception of appropriate level of care, and patient quality of life.

CONCLUSION

Our findings indicate that enteral nutrition-related admission policies vary greatly between nursing homes in New York City and nationwide. Many administrators cited safety and policy as factors guiding their institutional policies and practices, despite a lack of evidence. This gap in research, practice, and policy has implications for quality and cost of care, length of hospital stay, and patient morbidity and mortality.

Brazilian recommendations of mechanical ventilation 2013. Part 2

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Experience in Bedside Placement, Clinical Validity, and Cost-Efficacy of a Self-Propelled Nasojejunal Feeding Tube

BACKGROUND

The procedures needed to insert nasojejunal tubes (NJTs) are often invasive or uncomfortable for the patient and require hospital resources. The objectives of this study were to describe our experience in inserting a self-propelling NJT with distal pigtail end and evaluate clinical validity and cost efficacy of this enteral nutrition (EN) approach compared with parenteral nutrition (PN).

MATERIALS AND METHODS

Prospective study from July 2009 to December 2010, including hospitalized noncritical patients who required short-term jejunal EN. The tubes were inserted at bedside, using intravenous erythromycin as a prokinetic drug. Positioning was considered correct when the distal end was beyond the ligament of Treitz. Migration failure was considered when the tube was not positioned into the jejunum within 48 hours postinsertion.

RESULTS

Fifty-six insertions were recorded in 47 patients, most frequently in severe acute pancreatitis (69.6%). The migration rates at 18 and 48 hours postinsertion were 73.2% and 82.1%, respectively. There was migration failure in 8.9% of cases, and 8.9% were classified null (the tube was no longer in the gastrointestinal tract at 18 hours). There were no reported or observed complications. The mean duration of the EN was 12 ± 10.8 days. Five different types of EN formula were used. The total study cost was 53.9% lower compared with using PN in all patients.

CONCLUSIONS

Our study demonstrated that bedside insertion of a self-propelling NJT is a safe, cost-effective, and successful technique for postpyloric enteral feeding in at least 73% of the patients, and only 18% of patients could eventually need other placement techniques. It can avoid the need for more aggressive or expensive placement techniques or even PN if we cannot achieve enteral access.

Avulsed Nasoenteric Bridle System Magnet as an Intranasal Foreign Body

Nasoenteric tubes provide short-term nutrition support to patients unable to take an adequate oral diet. Bridling systems may be used to secure tubes to guard against displacement. We present the first case of an avulsed magnet from a bridling system to raise awareness of this potential complication. The primary methods of securing a nasogastric tube are reviewed, and comparative assessment of the 3 main systems is presented. Diagnosis and management of nasal foreign bodies relevant to this case are reviewed and prevention/safety considerations discussed.

Nasal bridles for securing nasoenteric tubes: a meta-analysis

BACKGROUND

Nasoenteric feeding tubes may easily become dislodged due to patient mental status, transfers, or positional changes. Nasal bridles were introduced to provide a better, more reliable system to secure these tubes. This meta-analysis was performed to evaluate the effectiveness of nasal bridles compared with the traditional method of adhesive tape alone in securing enteral feeding tubes.

MATERIALS AND METHODS

Multiple databases were searched (October 2013). All studies that evaluated the use of nasal bridles in adult patients were included in the analysis. Meta-analysis for the outcomes from use of a nasal bridle vs the more traditional method of adhesive tape alone for securing nasoenteric tubes was analyzed by calculating pooled estimates of dislodgement, skin complications, and sinusitis. Statistical analysis was performed using RevMan 5.1.

RESULTS

Six studies (n = 594) met the inclusion criteria. Use of a nasal bridle for securing enteral tubes resulted in a statistically significant reduction in tube dislodgement compared with traditional adhesive tape alone (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.10–0.27; P < .01). The use of nasal bridles was associated with a higher rate of skin complications compared with traditional adhesive tape (OR, 4.27; 95% CI, 1.79–10.23; P < .01). Incidence of sinusitis was no different between the 2 groups (OR, 0.26; 95% CI, 0.03–2.28; P = .22).

CONCLUSION

Nasal bridles appear to be more effective at securing nasoenteric tubes and preventing dislodgement than traditional use of tape alone.

Randomized clinical trial: nasoenteric tube or jejunostomy as a route for nutrition after major upper gastrointestinal operations

BACKGROUND

Curative treatment of upper gastrointestinal tract neoplasms is complex and associated with high morbidity and mortality. In general, the patients are already malnourished, and early postoperative enteral nutrition is recommended. However, there is no consensus concerning the best enteral access route in these cases.

METHODS

A prospective randomized trial was performed from 2008 to 2012 with 59 patients who underwent esophagectomy, total gastrectomy, or pancreaticoduodenectomy. In all, 4 patients declined to participate, and 13 did not meet the inclusion criteria and were excluded. Of the 42 included patients, 21 had nasoenteric tubes, and 21 had a jejunostomy.

RESULTS

The two groups were similar in demographic and clinical aspects. The nasoenteric (NE) and jejunostomy groups underwent early enteral therapy in 71 and 62 % of cases (p > 0.05), respectively. The median length of enteral therapy use was less in the NE group (5.0 vs. 8.5 days), but the difference was not statistically significant. The NE group required introduction of parenteral therapy more frequently than the jejunostomy group (p < 0.05). Complications related to the enteral route occurred in 38.0 and 28.5 % of patients (p > 0.05) in the NE and jejunostomy groups, respectively. In the NE group, there were four losses and four tube obstructions. In the jejunostomy group, there were two losses, four obstructions, and two cases of leakage around the tube. In the latter group, patients who underwent therapy for a longer time had tubal complications (p < 0.05) and longer intensive care unit and hospital stays (p < 0.05).

CONCLUSION

The two enteral routes were associated with the same number of complications. However, the presence of a jejunostomy allowed enteral therapy for longer periods, especially in patients with complications, thus avoiding the need for parenteral nutrition.

Tips and tricks for deep jejunal enteral access: modifying techniques to maximize success

Endoscopic insertion of enteral feeding tubes is a major advance in the delivery of nutrition therapy. Since the first report of percutaneous endoscopic gastrostomy (PEG) in 1980 (Gauderer et al. J Pediatr Surg. 15:872-5, 1980), insertion techniques and equipment have been refined and improved. Despite this progress, deep jejunal enteral access remains a difficult procedure, and many endoscopists do not have experience with the techniques of nasojejunal (NJ) placement, percutaneous endoscopic gastrojejunostomy (PEGJ), or direct percutaneous endoscopic jejunostomy (DPEJ) (Shike and Latkany, Gastrointest Endosc Clin N Am. 8:569-80, 1998). The difference between an exasperating experience and a rewarding procedure lies in mastering the "tips and tricks" that make insertion easy. While the basic techniques are described elsewhere (McClave and Chang 2011), we review several universal basic principles to enhance deep jejunal access, which should promote a more efficient and successful procedure.

Brazilian recommendations of mechanical ventilation 2013. Part 2

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Head and neck surgical patients; is it time for a bridle era?

Early enteral feeding is vital for successful outcomes in patients who have undergone open pharyngeal surgery, with nasogastric tube (NGT) feeding being a safe and accepted method of providing enteral nutrition in the short-term. Securing the NGT is key to ensure adequate caloric consumption and avoid the potential complications of re-siting the tube. The aim of this study was to compare the efficacy of utilising an anterior septal suture to a bridle system for NGT fixation. A sheep's head model was used to represent the nasal cavity of post-operative patients and a fine-bore NGT was passed. The NGT was secured with either an anterior septal suture or bridle system. A pulley system of weights was applied until the NGT slipped or snapped. Each weight and condition was investigated five times. The anterior and posterior septum were examined for evidence of damage for each condition. At 5 kg the anterior septal suture allowed the NGT to slip and the tube began to become distorted. At 5.5 kg the anterior septal suture snapped the NGT. In comparison, the bridle system was able to sustain a weight up to 15.5 kg (Fisher's exact test, p = 0.0079). There was no evidence of damage to the anterior or posterior septum for each condition. The bridle system was able to fix the NGT without slippage or damage at higher weights than the anterior septal suture. This suggests there may be potential benefits of stronger NGT fixation with reduced tube damage using bridle systems in patients, but further research is required in this domain.

Outcomes of nasal bridling to secure enteral tubes in burn patients

BACKGROUND

Reliable securement of nasally inserted enteral tubes is a problem in patients with facial burns that make use of traditional adhesive tape ineffective.

OBJECTIVE

To implement the nasal bridle as a way to decrease inadvertent removal of nasally inserted enteral tubes and improve subsequent patient outcomes.

METHODS

The nasal bridle was implemented in the burn unit of the University of Kansas Hospital, Kansas City, Kansas, as a quality improvement project. Outcomes for the calendar year 2010 were measured in patients treated before use of the bridle (prebridle control group) and in patients for whom the bridle was used. The groups were compared on measures of tube insertions per tube day, abdominal radiographs per tube day, and a number of complications.

RESULTS

A total of 50 patients were studied: 33 in the control group and 17 in the bridle group. Baseline characteristics of age and sex did not differ between the groups. The bridle group had significantly fewer tube insertions and abdominal radiographs per tube day than the control group. Although complications were generally less common in the bridle group, the differences were not statistically significant.

CONCLUSIONS

In burn patients, use of a nasal bridle to secure nasally inserted tubes had clinical advantages over securement with traditional adhesive tape.

Efficacy of nasal bridles in avoiding percutaneous endoscopic gastrostomy placement

OBJECTIVE

The aim of the study was to report the use of nasogastric tube bridles to avoid dislodging of percutaneous endoscopic gastrostomy tubes. Specifically it was intended to see if they reduced feeding time, medical input and costs.

DESIGN

and setting This was a cohort study in a district hospital setting.

PATIENTS

164 patients admitted with conditions causing acutely impaired swallowing.

INTERVENTIONS

140 of 164 patients referred received a NGT bridle.

RESULTS

Of these, 49 (35%) died by 28 days and 68 (48.6%) at 1 year; 73 (52.1%) had regained adequate oral intake at 28 days and 27 (19.2%) had proceeded to PEG. Of those not bridled, nine (37.5%) died by 28 days and 10 (41.7%) at 1 year with the remainder eating. There was no significant difference in mortality between groups. There were no complications attributed to bridles.

CONCLUSION

We conclude that nasogastric bridles are safe and represent an appropriate method to maintain nutrition while seeing if the underlying disease process will stabilise in these critically ill patients. They have the benefits of avoiding unnecessary PEG and the associated complications and cost.

Efficacy and complications of nasojejunal, jejunostomy and parenteral feeding after pancreaticoduodenectomy

BACKGROUND

European nutritional guidelines recommend routine use of enteral feeding after pancreaticoduodenectomy (PD) whereas American guidelines do not. Data on the efficacy and, especially, complications of the various feeding strategies after PD are scarce.

METHODS

Retrospective monocenter cohort study in 144 consecutive patients who underwent PD during a period wherein the routine post-PD feeding strategy changed twice. Patients not receiving nutritional support (n=15) were excluded. Complications were graded according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. Analysis was by intention-to-treat. Primary endpoint was the time to resumption of normal oral intake.

RESULTS

129 patients undergoing PD (111 pylorus preserving) were included. 44 patients (34%) received enteral nutrition via nasojejunal tube (NJT), 48 patients (37%) via jejunostomy tube (JT) and 37 patients (29%) received total parenteral nutrition (TPN). Groups were comparable with respect to baseline characteristics, Clavien ≥II complications (P=0.99), in-hospital stay (P=0.83) and mortality (P=0.21). There were no differences in time to resumption of normal oral intake (primary endpoint; NJT/JT/TPN: median 13, 16 and 14 days, P=0.15) and incidence of delayed gastric emptying (P=0.30). Duration of enteral nutrition was shorter in the NJT- compared to the JT- group (median 8 vs. 12 days, P=0.02). Tube related complications occurred mainly in the NJT-group (34% dislodgement). In the JT-group, relaparotomy was performed in three patients (6%) because of JT-leakage or strangulation leading to death in one patient (2%). Wound infections were most common in the TPN group (NJT/JT/TPN: 16%, 6% and 30%, P=0.02).

CONCLUSION

None of the analysed feeding strategies was found superior with respect to time to resumption of normal oral intake, morbidity and mortality. Each strategy was associated with specific complications. Nasojejunal tubes dislodged in a third of patients, jejunostomy tubes caused few but potentially life-threatening bowel strangulation and TPN doubled the risk of infections.

Nutrition in the stroke patient

Malnutrition is common both before and after stroke, with dysphagia adding to nutrition risk. Many patients require specialized nutrition support in the acute phase and beyond when swallowing function does not improve or return to allow for nutrition autonomy. When neurologic deficits improve, assessment of the swallowing function, introduction of dysphagia diets, and specialized swallowing techniques are used to transition away from enteral feeding tubes to oral diets. This article reviews the evaluation and treatment of dysphagia, use of specialized nutrition support, strategies for weaning enteral tube feedings, and the impact of nutrition on quality of life in the stroke patient population.

Feeding jejunostomy tubes placed during esophagectomy: are they necessary?

BACKGROUND

Jejunostomy tubes (JT) are routinely placed at the time of esophagectomy and can be associated with low--but not insignificant--morbidity. Increased emphasis on evidence-based medicine prompted this critical review of JT use during esophagectomy and factors that predict the absolute need for JT.

METHODS

All esophagectomies performed at one tertiary care institution from 1995 through 2009 were retrospectively reviewed. Statistical analyses were performed to determine preoperative variables that would assist in selecting patients who should receive a JT.

RESULTS

A total of 143 JTs were placed in 151 patients undergoing esophagectomy for carcinoma (83.4%), high-grade dysplasia (13.2%), and perforation (2.6%). Of these, 110 patients (76.9%) had returned to oral intake before discharge (median, 7 days), whereas 33 patients (23.1%) still required tube feedings. Of 8 patients who did not undergo intraoperative JT placement, 6 had resumed oral intake at discharge. Two patients were discharged on total parenteral nutrition. Logistic regression analysis of preoperative variables showed a body mass index of less than 18.5 kg/m2 conferred a likelihood of requiring a JT at discharge (odds ratio, 7.56; p<0.05). Age, sex, albumin level, type of esophagectomy, histology, stage, preoperative neoadjuvant therapy, and type of cancer were not significant predictors of JT need at discharge.

CONCLUSIONS

The only absolute indication for JT placement after esophagectomy was a body mass index of less than 18.5 kg/m2. Other patients may have selective JT placement based on the surgeon's judgment.

An Update on Nutrition Support in the Critically Ill

Nutrition support in the critically ill patient has shifted from adjunctive toward fundamental therapy with the publication of high-grade evidence. Early enteral nutrition (EN) is recommended because it is associated with decreased infectious complications and use of EN is associated with decreased mortality and infections compared with parenteral nutrition (PN). EN is not without risks, such as diarrhea or aspiration, but use of prokinetic agents, head of bed elevation, and use of feeding protocols can maximize benefits and minimize risks. Although recently high-grade evidence on nutrition support in the critically ill population has been published, many controversies still exist. In obese patients, use of hypocaloric feedings with increased protein has been demonstrated to promote weight loss and improved glucose management. In nonobese patients, small studies have demonstrated that providing more than 70% or less than 30% of goal caloric intake may be associated with worse outcomes, but more studies are needed. Additional research is also needed to conclude whether withholding intravenous fat emulsions for the first 7 to 10 days of PN reduces infectious complications. Finally, more high-quality studies are needed to define the role of immune-enhancing nutrients such as arginine, glutamine, omega-3 fatty acids, zinc, and selenium.