Successful blind placement of nasojejunal tubes in paediatric intensive care: impact of training and audit

Postpyloric Feeding Access in Infants and Children: A State of the Art Review

Achieving postpyloric feeding access is a clinical challenge faced by the pediatric gastroenterologist in everyday practice. Currently, there is limited literature published on the topic. This article provides a practical summary of the literature on the different methods utilized to achieve postpyloric feeding access including bedside, fluoroscopic, endoscopic and surgical options. Indications and complications of these methods are discussed as well as a general approach to infants and children that require intestinal feeding.

Bedside Methods for Transpyloric Feeding Tube Insertion in Hospitalized Children: A Systematic Review of Randomized and non-Randomized Trials

PROBLEM

Enteral nutrition is a critical component of therapy for many hospitalized children. Some children, especially those with critical illness, require post-pyloric enteral nutrition, but placement of post-pyloric feeding tubes poses challenges, necessitating costly fluoroscopy procedures and delaying initiation of enteral nutrition. There is no established standard method for pediatric transpyloric tube placement at the bedside.

ELIGIBILITY CRITERIA

We searched for trials that assessed the efficacy of methods for transpyloric tube placement at the bedside. Studies that evaluated gastric insufflation, prokinetic agents, pH guided devices, and electromagnetic devices with an objective of bedside transpyloric tube placement in children ages one month to 18 years were included.

RESULTS

After each author independently reviewed the search results, we agreed on fourteen articles for inclusion, consisting of six randomized controlled trials, five quasi-experimental studies, and three cohort studies. Intervention protocols varied, both within and between studies, with most trials incorporating more than one variable in the intervention.

CONCLUSIONS

The heterogeneity of the research does not provide clear direction about best practices. All interventions demonstrated some efficacy, with the exception of erythromycin. Gastric insufflation, the most prevalent intervention studied, is safe and at least moderately effective. The research demonstrates the positive impact of a small, trained team of personnel for the insertion of a transpyloric tube.

IMPLICATIONS

High quality studies with clear protocols evaluating a single variable are needed in order to establish a bedside transpyloric tube placement protocol. We recommend studies on the efficacy of a dedicated team for this procedure.

Postpyloric feeding tube placement at the bedside: Complication rate and impact on length of stay

BACKGROUND

Postpyloric feeding tube (PPFT) placement is essential for the ongoing nutrition care of critically ill children requiring noninvasive and invasive ventilation. PPFTs are placed by a variety of providers, including advanced practice nurses (APNs), surgeons, gastroenterologists, and radiologists. Complication rates, time to enteral nutrition (EN) following placement, and association with length of stay (LOS) have not been well documented.

METHODS

A query of the electronic medical record identified patients in the pediatric intensive care unit (PICU) in whom PPFTs were placed. A retrospective chart review was performed to identify patient demographics; PPFT placement provider, indication, and duration; PICU LOS; hospital LOS; and patient pediatric risk of mortality (PRISM) scores.

RESULTS

A total of 452 PPFTs were placed in 346 patients , with 318 placed by APNs. There was only one complication in 452 placed PPFTs. PRISM scores between patient groups for APN-placed PPFTs and non-APN-placed PPFTs were not significantly different. Mean time from hospital admission to PPFT placement was 1.5 days (APN) to 2.0 days (non-APN) (P < .02). Spearman correlation coefficients demonstrated shorter hospital and PICU LOS were associated with shorter duration to insertion.

CONCLUSION

Overall complication rates of PPFT insertion is very low and do not significantly differ between provider type , even in patients with higher PRISM scores. Additionally, early time to insertion of PPFT is associated with decreased hospital and PICU LOS. Further research is needed to determine if the earlier time to insertion of PPFTs is associated with the achievement of goal feeds.

Efficacy and safety of a modified method for blind bedside placement of post-pyloric feeding tube: a prospective preliminary clinical trial

Objective

To compare the efficacy and safety of a new modified method of bedside post-pyloric feeding tube catheterization with the Corpak protocol versus electromagnetic-guided catheterization.

Materials and Methods

We conducted a single-center, single-blinded, prospective clinical trial. Sixty-three patients were treated with a non-gravity type gastrointestinal feeding tube using different procedures: modified bedside post-pyloric feeding tube placement (M group), the conventional Corpak protocol (C group), and standard electromagnetic-guided tube placement (EM group).

Results

The success rate in the M group, C group, and EM group was 82.9% (34/41), 70.7% (29/41), and 88.2% (15/17), respectively, with significant differences among the groups. The time required to pass the pylorus was significantly shorter in the M group (26.9 minutes) than in the C group (31.9 minutes) and EM group (42.1 minutes). The proportion of pylorus-passing operations completed within 30 minutes was significantly higher in the M group than in the C group and EM group. No severe complications occurred.

Conclusion

This modified method of bedside post-pyloric feeding tube catheterization significantly shortened the time required to pass the pylorus with no severe adverse reactions. This method is effective and safe for enteral nutrition catheterization of patients with dysphagia and a high risk of aspiration pneumonia.

Intravenous Metoclopramide to Improve the Success Rate of Blind Bedside Post-pyloric Placement of Feeding Tube in Critically Ill Children: A Randomized, Double-Blind, Placebo-Controlled Study

Objective: Impaired gastric emptying is a common cause of delayed feeding in critically ill children. Post-pyloric feeding may help improve feeding intolerance and nutritional status and, hence, contribute to a better outcome. However, post-pyloric feeding tube insertion is usually delayed due to a technical difficulty. Therefore, prokinetic agents have been used to facilitate blind bedside post-pyloric feeding tube insertion. Metoclopramide is a potent prokinetic agent that has also been used to improve motility in adults and children admitted to intensive care units. The objective of this study was to determine the efficacy of intravenous metoclopramide in promoting the success rate of blind bedside post-pyloric feeding tube placement in critically ill children. Design: The design of this study is randomized, double blind, placebo controlled. Setting: The setting of the study is a single-center pediatric intensive care unit. Patients: Children aged 1 month-18 years admitted to the pediatric intensive care unit with severe illness or feeding intolerance were enrolled in this study. Intervention: Patients were randomly selected to receive intravenous metoclopramide or 0.9% normal saline solution (the placebo) prior to the tube insertion. The study outcome was the success rate of post-pyloric feeding tube placement confirmed by an abdominal radiography 6-8 h after the insertion. Measurements and Main Results: We found that patients receiving metoclopramide had a higher success rate (37/42, 88%) of post-pyloric feeding tube placement than the placebo (28/40, 70%) (p = 0.04). Patients who received sedative drug or narcotic agent showed a tendency of higher success rate (p = 0.08). Conclusion: Intravenous metoclopramide improves the success rate of blind bedside post-pyloric placement of feeding tube in critically ill children. Trial Registration: Thai Clinical Trial Registry TCTR20190821002. Registered 15th August 2019.

Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit

BACKGROUND

Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program.

METHODS

In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined.

RESULTS

The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction.

CONCLUSION

Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.

Nasojejunal tube feeding in children: knowledge and practice

Nasojejunal tubes (NJ) are used in small numbers of children outside of neonatal and paediatric intensive care units. There is limited evidence on which to base practice aside from insertion techniques. Ongoing care and management is largely based on historical practice and extrapolation from nasogastric tube practice. This paper presents the historical caseload data for 36 babies and children over a five year period. The children ranged from 0 to 13 years of age, and 95% were less than 2 years old. They had a median of 4 tubes each (range 1 - 46). The paper presents data from two surveys of health professionals that demonstrate a lack of consistency in practice. There are concerns about ongoing position checks and about the radiation burden in these children. Local practice is described that aims to reduce dependence on x-ray procedures and to stimulate debate. Finally, an argument is made for a better evidence base for future practice.

Bedside Placement of the Postpyloric Tube in Infants

BACKGROUND

Patients in the neonatal intensive care unit are a vulnerable population with specific nutritional requirements, which include increased protein and caloric needs for adequate growth. Some infants cannot tolerate gastric feeds and need to have postpyloric feeds to grow. Placement of a postpyloric tube can be done by gastric insufflation. Gastric insufflation is a technique where air is inserted into the stomach as a nasogastric tube is advanced through the pylorus to the duodenum. There is research to support this technique in pediatrics, but scant evidence exists for placement of postpyloric tubes in the infant population.

PURPOSE

The aim of this quality improvement practice project was to determine whether the current practice for postpyloric tube placement by the bedside nurses in the neonatal intensive care unit is safe and effective.

METHODS

Data were prospectively collected on 38 infants requiring placement of 60 postpyloric tubes over an 8-week period.

RESULTS

The results indicate a success rate of 95.6% for tube placement when a subset of infants diagnosed with congenital diaphragmatic hernia (CDH) (n = 15) was excluded. Six (40%) of the 15 infants with CDH had postpyloric tubes placed successfully. Nursing years of experience did not affect successful postpyloric tube placement.

IMPLICATIONS FOR PRACTICE

The postpyloric tube placement policy was modified as a result of findings from this project. Placement of a postpyloric tube with one attempt by the bedside nurse was safe and effective in most preterm infants in our care excluding patients with CDH. The new policy reduced infants' exposure to radiation due to a decrease in the number of x-rays in comparison to interventional radiology placement.

IMPLICATIONS FOR RESEARCH

Further research should be done by units that primarily care for low birth-weight premature infants.

The activities of a dietitian-led gastroenterology clinic using extended scope of practice

Background

Extending the scope of practice of allied health professionals has been a strategy adopted in the United Kingdom to address issues within the health system.

Australia’s health system is currently undermined by similar issues, heightening government interest in adopting the extended scope health care model. The aim of the current study was to describe the activities and outcomes of a dietitian-led gastroenterology clinic which operated under an extended scope of practice model in an outpatient gastroenterology department at a tertiary hospital in regional Queensland, Australia, and to assess patient satisfaction with the initiative.

Methods

A descriptive, cross-sectional case series undertaken over 50 clinics involving 82 category 2 and 3 patients with suspected/confirmed coeliac disease or inflammatory bowel disease; low haemoglobin; gastroesophageal reflux disease, or; malnutrition. Data was analysed using Microsoft Excel 2010, and presented as descriptive statistics.

Results

Sixty out of 82 selected patients (median age 51 years) attended an initial appointment with the dietitian. Twenty-four review appointments were attended. Average waiting period for an initial appointment was 148 days (range 31–308 days). A total of 149 management strategies were provided, and 94 (63 %) of these involved the dietitian utilising extended scope of practice. The dietitian managed 47 (78 %) patients without need for gastroenterologist referral, and 25 (42 %) were discharged after dietetic management.

Patients reported high levels of satisfaction with the clinic.

Conclusions

Seventy-eight percent of category 2 and 3 patients referred to the gastroenterologist could be managed exclusively in the dietitian-led clinic. This extended scope model of care could potentially benefit the efficiency and acceptability of Australia’s public health system.

Dietitians and small bowel feeding tube placement

Some advanced practice nutrition support dietitians have added small bowel feeding tube placement to their scope of responsibility. This is due, in part, to the challenges of gaining early enteral access in patients with functioning GI tracts. Emerging literature supports the practice of skilled practitioners placing feeding tubes at bedside. A variety of methods can be used to place tubes at the bedside. The nutrition support dietitian must understand licensure and liability considerations to perform this invasive procedure. This article will review literature reports of dietitians placing feeding tubes and provide information on the methods used, training and competencies required, and legal issues involved.

The impact of enteral feeding protocols on nutritional support in critically ill children

BACKGROUND

Studies have shown that feeding protocols may assist in achieving optimal nutritional care in critically ill children. The present study aimed to assess the impact of enteral feeding protocols on nutritional support practices through a continuous auditing process over a defined period.

MATERIALS AND METHODS

A prospective audit on nutritional practice was initiated in 1994-1995 on all ventilated patients who were admitted for more than a complete 24-h period in the paediatric intensive care unit. The audit was repeated 1997-1998, 2001 and 2005. The collection of data on outcomes included the time taken to initiate nutritional support, the proportion of patients fed via the enteral versus parenteral route, and the proportion of children reaching 50% and 70% of the estimated average requirement (EAR) by day 3. Feeding algorithms and protocols were introduced after each audit with a view to improving practices.

RESULTS

Over the study period, time taken to initiate nutrition support was reduced from 15 h (1994-1995), 8 h (1997-1998), 5.5 h (2001) to 4.5 h (2005). The proportion of patients on parenteral feeds was reduced from 11% (1994-1995) to 4% (2005). An increase was also documented in the percentage of patients receiving a daily energy provision of 50% and 70% of the EAR by day 3 after the initiation of nutritional support (6% in 1994-1995 to 21% in 2005 for 70% of EAR).

CONCLUSION

The present study demonstrates that feeding protocols improve nutritional practices in a paediatric intensive care unit. However, protocol introduction needs to be monitored regularly through audit.

Successful placement of postpyloric enteral tubes using electromagnetic guidance in critically ill children

OBJECTIVES

Initiation of postpyloric feeding is often delayed by difficulties in placement of enteral tubes. We evaluated the effectiveness of bedside postpyloric enteral tube (PET) placement using an electromagnetic (EM)-guided device. We hypothesized that: 1) EM-guided placement of PETs would be successful more often than standard blind placement with a shorter total time to successful placement and 2) the EM-guided technique would have similar overall costs to the standard technique.

DESIGN

Prospective cohort trial with serial control groups in a pediatric intensive care unit at a tertiary care children's hospital.

INTERVENTIONS

We collected data on a cohort of consecutive pediatric intensive care unit patients who underwent PET placement by standard blind technique followed by a cohort who underwent EM-guided placement. The primary outcome measure was successful placement determined by abdominal radiography.

MEASUREMENTS AND MAIN RESULTS

One hundred seven patients were evaluated in the trial: 57 in the standard group and 50 in the EM-guided group. Demographic data, percent intubated, and admission diagnosis were similar in both groups. Forty-one of 50 patients (82%) in the EM-guided group had successful placement compared with 22 of 57 in the standard group (38%) (p < 0.0001). The average time to successful placement was 1.7 vs. 21 hours in the EM-guided group and standard group, respectively (p < 0.0001). Children in the EM-guided group received fewer radiographs (p = 0.007) and were given more prokinetic drugs (p = 0.045). There were no episodes of pneumothorax in either group. After controlling for prokinetic drug use, EM-guided placement was more likely to result in successful placement than the standard blind technique (odds ratio 6.4, 95% confidence interval 2.5-16.3). An annual placement rate of 250 PETs by EM guidance, based on our institution's current utilization rates, is associated with a cost savings of $55.46 per PET placed.

CONCLUSION

EM guidance is an efficient and cost-effective method of bedside PET placement.

Small bowel endoscopic enteral access

PURPOSE OF REVIEW

Small bowel endoscopic enteral access is perceived as difficult. However, small bowel access is necessary for patients who are unable to tolerate gastric feedings. This review discusses the successes and challenges involved with endoscopic small bowel tube placement in various populations using a variety of placement techniques.

RECENT FINDINGS

In general, direct percutaneous endoscopic jejunostomy (DPEJ) is becoming a more common procedure performed to obtain small bowel enteral access. BMI may be a useful predictor of DPEJ tube placement success and complication rates. A retrospective review determined that DPEJ tube placement significantly decreased the incidence of aspiration pneumonia in patients with previous recurrent aspiration pneumonia episodes. DPEJ is an effective method of providing enteral nutrition for patients when percutaneous endoscopic gastrostomy is not indicated because of anatomical or gastric function abnormalities. However, there are known complications of DPEJ, including small bowel volvulus. Nasojejunal tubes also can provide enteral access to the small intestine. Endoscopic insertion of nasojejunal tubes promotes decreased length of hospital stay and early initiation of enteral feedings as compared with bedside self-migrating jejunal tubes in patients with severe acute pancreatitis. Endoscopically placed small bowel feeding tubes can safely deliver enteral nutrition to patients when gastric feedings are not indicated.

SUMMARY

Continued evaluation of endoscopic jejunal tube placement methods and associated clinical outcomes in assorted populations is necessary to determine the safest and most effective technique.