A multicenter, prospective study of the placement of transpyloric feeding tubes with assistance of a magnetic device. The Magnet-Guided Enteral Feeding Tube Study Group

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.

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.

Electromagnetically guided bedside placement of post-pyloric feeding tubes in critical care

Post-pyloric feeding is recommended in critically ill patients with gastro-intestinal intolerance. However, traditional placement methods are logistically difficult and carry potential risks. The authors retrospectively compared the position of post-pyloric feeding tubes (PPFTs) using an electromagnetic device that demonstrated by X-ray and analysed the complication rates, proportion of lung placements avoided and the time taken to establish enteral feeding. Forty placements in 37 mechanically ventilated patients were analysed; there was a success rate of 87.5%. Sensitivity and specificity were 77% (95% CI 59.9-89.6%) and 100% (95% CI 48.0-100%). Five lung placements were identified in real time and therefore avoided. The mean (SD) time from PPFT placement to X-ray was 134 minutes (± 139 minutes) and, to feeding, 276 minutes (± 213 minutes). In conclusion, placement of PPFT using an electromagnetic device carries a high success rate, is safe and feasible to undertake at the bedside in mechanically ventilated patients.

Devices and Techniques for Bedside Enteral Feeding Tube Placement

Enteral feedings are an integral part of care for many hospitalized patients. Accessing the gastrointestinal (GI) tract safely and in a timely manner can be challenging. Various techniques and devices to enhance the safety of bedside feeding tube placement are available for clinicians. Three specific devices are highlighted, including the colorimetric CO(2) detector (CCD), a magnetically guided feeding tube (MGFT), and the electromagnetic tube placement device (ETPD). The CO(2) detector is applied to detect the presence or absence of CO(2), thus assisting in correct placement of the feeding tube tip into the GI tract vs the lung. The MGFT uses a magnetic device to manipulate the feeding tube through the GI tract into the small intestine. The ETPD provides real-time visualization of the feeding tube as it progresses into the small intestine. Training and repetition are essential for safe and successful feeding tube placement, and the highlighted devices can contribute to both of these goals.

A randomised controlled feasibility and proof-of-concept trial in delayed gastric emptying when metoclopramide fails: We should revisit nasointestinal feeding versus dual prokinetic treatment: Achieving goal nutrition in critical illness and delayed gastric emptying: Trial of nasointestinal feeding versus nasogastric feeding plus prokinetics

BACKGROUND & AIMS

Delayed gastric emptying (DGE) commonly limits the use of enteral nutrition (EN) and may increase ventilator-associated pneumonia. Nasointestinal feeding has not been tested against dual prokinetic treatment (Metoclopramide and Erythromycin) in DGE refractory to metoclopramide. This trial tests the feasibility of recruiting this 'treatment-failed' population and the proof of concept that nasointestinal (NI) feeding can increase the amount of feed tolerated (% goal) when compared to nasogastric (NG) feeding plus metoclopramide and erythromycin treatment.

METHODS

Eligible patients were those who were mechanically ventilated and over 20 years old, with delayed gastric emptying (DGE), defined as a gastric residual volume ≥250 ml or vomiting, and who failed to respond to first-line prokinetic treatment of 3 doses of 10 mg IV metoclopramide over 24 h. When assent was obtained, patients were randomised to receive immediate nasointestinal tube placement and feeding or nasogastric feeding plus metoclopramide and erythromycin (prokinetic) treatment.

RESULTS

Of 208 patients with DGE, 77 were eligible, 2 refused assent, 25 had contraindications to intervention, almost exclusively prokinetic treatment, and it was feasible to recruit 50. Compared to patients receiving prokinetics (n = 25) those randomised to nasointestinal feeding (n = 25) tolerated more of their feed goal over 5 days (87-95% vs 50-89%) and had a greater area under the curve (median [IQR] 432 [253-464]% vs 350 [213-381]%, p = 0.026) demonstrating proof of concept. However, nasointestinally fed patients also had a larger gastric loss (not feed) associated with the NI route but not with the fluid volume or energy delivered.

CONCLUSIONS

This is first study showing that in DGE refractory to metoclopramide NI feeding can increase the feed goal tolerated when compared to dual prokinetic treatment. Future studies should investigate the effect on clinical outcomes.

EU CLINICAL TRIALS REGISTER

EudraCT number: 2012-001374-29.

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.

Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice

Malnutrition is common in critically ill patients and is associated with poor outcomes for patients and increased health care spending. Enteral nutrition is the method of choice for nutrition delivery. Enteral nutrition delivery practices vary widely, and underfeeding is widespread in critical care. Interruptions in enteral nutrition due to performance of procedures, positioning, technical issues with feeding accesses, and gastrointestinal intolerance contribute to underfeeding. Strategies such as head-of-bed positioning, use of prokinetic agents, tolerance of higher gastric residual volumes, consideration of postpyloric feeding access, and use of a nutrition support protocol may decrease time spent without nutrition.

Enteral feeding tubes: are insertion techniques and positioning based on anatomical evidence?

Patients in whom oral energy intake is insufficient for daily needs may develop malnutrition and its complications, such as increased infection rates, increased length of hospitalization, and death. Enteral feeding is beneficial for these patients. However, this therapy is not without complications related to the insertion and placement of enteral feeding tubes. This review aims to identify from the literature different techniques for insertion and the methods used to evaluate the placement of enteral feeding tubes.

Perioperative care following complex laryngotracheal reconstruction in infants and children

Laryngotracheal reconstruction (LTR) involves surgical correction of a stenotic airway with cartilage interpositional grafting, followed by either placement of a tracheostomy and an intraluminal stent (two-stage LTR) or placement of an endotracheal tube with postoperative sedation and mechanical ventilation for an extended period of time (singlestage LTR). With single-stage repair, there may be several perioperative challenges including the provision of adequate sedation, avoidance of the development of tolerance to sedative and analgesia agents, the need to use neuromuscular blocking agents, the maintenance of adequate pulmonary toilet to avoid perioperative nosocomial infections, and optimization of postoperative respiratory function to facilitate successful tracheal extubation. We review the perioperative management of these patients, discuss the challenges during the postoperative period, and propose recommendations for the prevention of reversible causes of extubation failure in this article. Optimization to ensure a timely tracheal extubation and successful weaning of mechanical ventilator, remains the primary key to success in these surgeries as extubation failure or the need for prolonged postoperative mechanical ventilation can lead to failure of the graft site, the need for prolonged Pediatric Intensive Care Unit care, and in some cases, the need for a tracheostomy to maintain an adequate airway.

[Postpyloric feeding tubes for surgical intensive care patients. Pilot series to evaluate two methods for bedside placement]

Bedside placement of postpyloric feeding tubes in surgical intensive care patients: a pilot series to evaluate two methods. Early enteral feeding is thought to be a key factor in maintaining the integrity of the gastrointestinal tract mucosal barrier associated with less bacterial translocation and decreased stimulation of the systemic inflammatory response and subsequent improved outcome in intensive care patients. Thus enteral feeding by nasogastric tubes is the preferred route of nutritional support for most surgical intensive care patients. However, intensive care patients with delayed gastric emptying and poor intestinal motility may not tolerate gastric feeding and may therefore benefit from postpyloric feeding. Postpyloric feeding tube placement may be achieved by endoscopic procedures or different bedside techniques with variable success. In the present study two feeding tubes for bedside postpyloric placement without endoscopic assistance were compared. The time to successful positioning was compared for jejunal feeding tubes from the companies Cook (Tiger 2™) and PortaMedical (Corflo-Tube®). The description for the Tiger 2™ states that because of its design slight residual peristalsis can cause it to migrate from the stomach to the jejunum. The Corflo-Tube® is also positioned at the bedside with the help of a detector and a monitor which maps the movements of the magnetic tip of the mandrin as it is pushed forward. Patients receiving early enteral nutrition through a gastric tube and exhibiting enhanced reflux, in spite of the head of the bed being raised and the administration of prokinetics randomly received either a Tiger 2™ or a Corflo-Tube®. The study included 41 patients from an intensive care ward for surgical patients and 13 out of 20 Tiger 2™-Tubes (65%) and 16 out of 21 Corflo-Tubes® (76%) were successfully positioned (p>0.05). The median time to successful positioning with the Corflo-Tubes® was 0.83 h (range 0.06-2.5 h), which was significantly shorter than the 24 h (range 2-72 h) found with the Tiger 2™ (p<0.001). There was no significant difference between the groups with respect to the period between the insertion of the tubes and the attainment of complete enteral nutrition, corresponding to the calculated individual calorie requirements. These tubes offer a good alternative to more demanding procedures as they are easy to handle and rapidly available. They confer clinical and cost advantages in terms of the early establishment of enteral feeding, no routine X-ray confirmation in the case of the Corflo-Tube® and avoidance of endoscopic guidance for tube placement or parenteral nutrition. In addition they are always justified in the event of a lack of endoscopic positioning.

Enteral nutrition access devices

The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, performing a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such situations, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the ASGE Governing Board. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to endoscopy in patients requiring enteral feeding access by using the keywords "endoscopy," "percutaneous," "gastrostomy," "jejunostomy," "nasogastric," "nasoenteric," "nasojejunal," "transnasal," "feeding tube," "enteric," and "button." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Nasoenteral feeding tube placement by nurses using an electromagnetic guidance system (with video)

BACKGROUND

The early institution of feeding in patients who need postpyloric feeding tubes is often hampered by a limited availability of endoscopists experienced in safe tube positioning.

OBJECTIVE

To test the feasibility of having nurses place postpyloric feeding tubes by using a universal path finding system device.

DESIGN

Prospective study.

SETTING

Academic hospital.

PATIENTS

The success rate and learning curve of a senior nurse placing postpyloric feeding tubes in 50 patients was studied, followed by a study in 160 patients on the success rates and learning curves of 4 inexperienced nurses instructed by the senior nurse. Finally, the success rate of postpyloric feeding tube placement by the senior nurse in 50 critically ill patients was investigated.

INTERVENTION

Postpyloric feeding tube positioning by nurses using an electromagnetic universal path-finding system device enabling them to follow the path of the tip of the feeding tube on a monitor screen.

MAIN OUTCOME MEASUREMENTS

Success was defined by postpyloric positioning of the feeding tube. The ultimate aim was to reach at least the duodenojejunal flexure.

RESULTS

In the first part, the senior nurse was successful in 72% of cases. There was a clear learning curve. In the second part, the 4 newly instructed nurses had a success rate of 89.4% without an evident learning curve. In the third part, successful feeding tube positioning was achieved in 78% of critically ill patients. Of the 217 successfully positioned tubes, 74% reached at least the duodenojejunal flexure. In half of the unsuccessful cases, an explanation for the failure was found at endoscopy. No complications were seen.

LIMITATIONS

The generalization to less-specialized hospitals should be investigated.

CONCLUSION

Postpyloric positioning of feeding tubes by nurses at the bedside without endoscopy is feasible and safe. Nurses may take over some of the tasks of doctors in a time of high endoscopic needs.

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.

Gastric versus postpyloric feeding

Feeding into the small bowel is often recommended to improve nutrient delivery for critically ill patients, and thus improve outcome and reduce complications associated with enteral feeding. Risks and benefits of gastric feeding, use of motility agents, postpyloric feeding, and obtaining small bowel access are discussed here. Randomized clinical trials directly comparing postpyloric with gastric feeds are also evaluated. These small, underpowered studies demonstrate small but clinically important differences in important outcomes (pneumonia), but are weakened by significant heterogeneity. Current evidence does not support routine use of postpyloric feeding in the critically ill. A standardized approach to optimizing benefits and minimizing risks with enteral nutrition delivery will help clinicians identify patients who would benefit from small bowel feeding.

Nasointestinal intubation with tiger tubes: a case series indicates risk of mucosal damage

Abstract In five intubations using the tiger tube (Cook) two were successfully placed into the small intestine. Two of the three intubation failures were due to early death due to the underlying condition. Nasointestinal placement permitted successful enteral feeding. Unfortunately, both nasointestinal placements were associated with mucosal damage that appears to be related to the tube "flaps". The tiger tube facilitates nasointestinal tube placement but until concerns regarding safety are addressed its clinical use cannot be recommended.

Evaluation of a new technique for endoscopic nasojejunal feeding-tube placement

OBJECTIVES

Multiple techniques for endoscopic nasojejunal tube (NJT) placement exist. However, poor experience with these techniques has limited more routine practice of NJT placement for many endoscopists. We evaluated endoscopic NJT placement with a new stiff jejunal (J)-tube method (push technique).

METHODS

The GI Tract database at the Medical University of South Carolina was queried for NJT-placement procedures. Records of 42 patients who had undergone NJT placement by using the push technique between the years 2001 and 2004 at our institution were reviewed for information regarding procedure success and tube-related outcomes.

RESULTS

The push technique of NJT placement was successful in 41 of 42 patients (97.6%), with an average procedure time of 11.6 minutes (range, 5-50 minutes). Negative outcomes occurred in 61% of properly positioned NJTs and included inadvertent tube removal by the patient or the staff (42.1%), dislodging (10.5%), clogging (5.3%), and kinking (5.3%). The average longevity of the NJT was 7.8 days (range, 1-37 days). Most patients were ultimately converted to a percutaneous enteral access device or to oral feedings.

CONCLUSIONS

Endoscopic placement of NJT by using the push technique is an efficient, reliable method of accessing the small bowel for enteral nutrition.

Transpyloric Feeding Tube Placement in Critically Ill Patients Using Electromyogram and Erythromycin Infusion

STUDY OBJECTIVES

Transpyloric feeding is desirable in critically ill patients who often have gastroparesis; however, correct placement is difficult, requiring fluoroscopy, endoscopy, or time-consuming blind attempts. This study evaluated the success rate and time required to place transpyloric tubes using erythromycin infusion and GI electromyogram (EMG) signal.

DESIGN

Observational trial.

SETTING

University hospital medical ICU.

PATIENTS

Thirty-nine patients receiving mechanical ventilation for respiratory failure (n = 13), pancreatitis (n = 9), ARDS (n = 8), neurologic disease (n = 4), major surgery (n = 3), and GI disease (n = 2) were enrolled (25 men and 14 women; mean age, 48.4 years; range, 21 to 82 years).

INTERVENTIONS

Unweighted Flexiflo 10F feeding tubes were modified by the placement of an electrode 4 to 8 cm from the tip to record electromyogram (EMG) signals (Ross Products Division; Columbus, OH). Gastric signals are high amplitude with a frequency of 3 cycles per minute, while the duodenum and jejunum are low amplitude and 11 to 13 cycles per minute. Erythromycin was infused at a dose of 3 mg/kg to enhance gastric motor activity and emptying. The transpyloric tube was placed in the stomach, and its position was confirmed by EMG, then slowly advanced until duodenal EMG was detected. Tube position was determined by abdominal radiography.

MEASUREMENTS AND RESULTS

Thirty-one of 39 placements were immediately successful (initial success rate, 80%), 23 jejunal and 8 duodenal, requiring an average 7.8 min (range, 3 to 31 min). Six attempts in five patients were initial failures but were repeated, reaching the duodenum in one patient and the jejunum in four patients.

CONCLUSION

Erythromycin infusion and EMG guidance can facilitate rapid transpyloric feeding tube placement in critically ill patients at the bedside.

Intravenous erythromycin facilitates bedside placement of postpyloric feeding tubes in critically ill adults: a double-blind, randomized, placebo-controlled study

OBJECTIVE To evaluate the efficacy of intravenous erythromycin as a method to facilitate feeding tube placement into the small intestine in critically ill patients. DESIGN Double blind, randomized, controlled trial. SETTING Medical and surgical intensive care units in an academic medical center. PATIENTS Prospective cohort of 36 consecutive adults requiring intensive care unit care and enteral tube feeding for nutritional support. INTERVENTION Infusion of a single dose of intravenous erythromycin (500 mg) or saline before placement of 10-Fr feeding tubes using a standardized active bedside protocol. MEASUREMENTS AND MAIN RESULTS We determined the success rate of feeding tube placement into or beyond the second portion of the duodenum and the time required for this procedure by experienced nurses. The feeding tube was considered to be postpyloric when the tip was in the second portion of the duodenum or beyond. The predictive value of a serial step-up in gastrointestinal aspirate pH from < or = 5.0 to > or = 6.0 was also determined. Use of intravenous erythromycin significantly improved the rate of feeding tube placement into the duodenum or jejunum (erythromycin group, 13 of 14 patients or 93% vs. the control group, 12 of 22 patients or 55%; p < .03). Erythromycin administration also significantly decreased the procedure time from 25 +/- 3 to 15 +/- 2 mins (p < .04). Feeding tube placement into either duodenum or jejunum was confirmed in all 18 patients with a pH step-up from < or = 5.0 to > or = 6.0.

CONCLUSION

A single bolus dose of intravenous erythromycin facilitates active bedside placement of postpyloric feeding tubes in critically ill adult patients.

Endoscopic placement of nasojejunal tubes: a randomized, controlled, prospective trial comparing suitability and technical success for two different tubes

BACKGROUND

Jejunal feeding is an attractive means for delivering nutrients to critically ill patients. Nasojejunal tubes may have different advantages and disadvantages that may have important clinical implications.

METHODS

To compare the suitability of 2 different nasojejunal feeding tubes (Tube A, Dobbhoff; Tube B, Freka-Trelumina) for use by endoscopists and nursing staff, a randomized, controlled, prospective trial was performed in 60 patients. The primary end point was time required for tube placement. Secondary end points were successful placement and nursing problems encountered during clinical use. Results of upper endoscopy were also recorded.

RESULTS

Placement took significantly longer with Tube A than Tube B (95% CI for median [11.5, 20.0] minutes vs. [5.5, 7.5] minutes; p < 0.001), and was less successful (73.3% vs. 90%; p = 0.18). Nursing problems occurred significantly more often with Tube A compared with Tube B (11 vs. 1; p < 0.001). Tube B stayed in place significantly longer than Tube A (37 days vs. 21 days; p = 0.034). In 45% of the cases, upper endoscopy provided a diagnosis of potential therapeutic relevance.

CONCLUSIONS

Selection of a nasojejunal tube for endoscopic placement has significant implications with respect to time required for placement, duration of tube usage and the practicability for nursing staff. Diagnostic upper endoscopy performed concomitantly often reveals findings of clinical importance.