Ultrasound-guided nasogastric feeding tube placement in critical care patients

Abdominal ultrasound and VExUS score in critical care

The use of ultrasound while caring for critically ill patients has been increasing exponentially in the last two decades and now is an essential component of intensive care practice. Abdominal ultrasound is an established technique in other specialties, but its use in intensive care has lagged behind other ultrasound modalities. However, its potential role in the diagnosis and management of patients will make it an invaluable tool for intensivists. The main use of abdominal ultrasound at the bedside is for free fluid detection in trauma patients. But abdominal ultrasound can also help us diagnose patients with abdominal pain, hypovolemia or anuria, and it can guide us during procedures such as paracentesis or bladder catheter and gastric tube placement.

Successful Medical Management of Bilateral Pneumothorax Due to Nasogastric Tube Misplacement in a Cat

A 7 yr old female spayed domestic shorthair was evaluated for suspected lily ingestion and acute vomiting. The cat had vomited suspected lily plant material before presentation, and a nasogastric tube (NGT) was placed to continue to administer activated charcoal. The NGT was passed with sedation and limited restraint. To confirm placement, a single lateral radiograph was taken, which showed that the tube was in the trachea, bronchus, through the pulmonary parenchyma, and extending into the region of the craniodorsal retroperitoneal space. The tube was subsequently removed, resulting in a tension pneumothorax. Bilateral thoracostomy tubes were placed and attached to continuous suction. The pneumothorax resolved after 2 days, the thoracostomy tubes were removed, and the cat was discharged on day 3 after admission. To the authors' knowledge, this is the first described pneumothorax complication with successful medical management secondary to routine nasogastric tube placement in a cat. This case report underscores the importance of preparedness for thoracostomy tube placement before removal of any NGT that has been confirmed to be placed through the pulmonary parenchyma.

Usefulness of ultrasound in confirming the correct placement of Ryle's tube compared to the traditional method of auscultation in normal versus overweight and obese patients

Background and Aims

Auscultation to verify Ryle's tube position is difficult in obese patients. We compared the usefulness of ultrasonography (USG) versus auscultation in confirming the correct Ryle's tube placement in normal versus overweight or obese patients, time taken for confirmation, and incidence of reinsertion.

Material and Methods

A prospective, observational study was carried out on 80 patients. Patients with a body mass index (BMI)>25 kg/m2 formed group O and those with BMI <25 kg/m2 constituted group N. After Ryle's tube insertion correct placement was first confirmed by auscultation. The presence of a gurgling sound over the epigastrium was graded (definite/doubtful/absent). During USG evaluation, if Ryle's tube was not visualized at the subxiphoid region, 20mL of air was injected, looking for dynamic fogging in the stomach. If auscultation yielded doubtful or absent results and USG also failed to confirm, Ryle's tube was repositioned and confirmed.

Results

Group O had a significantly higher BMI. Auscultation time and the time taken for USG confirmation were significantly longer in group O. The percentage of patients with definite auscultatory signs was significantly higher in group N. Significantly higher number of patients in group O had doubtful/absent auscultatory signs. Ryle's tube and fogging visualization with USG and the requirement of reinsertion were comparable in both groups. The percentage of patients with definite auscultatory confirmation and definite USG confirmation were comparable in group N. However, in group O, significantly lesser patients had definite auscultatory confirmation compared to definite USG signs.

Conclusion

Confirmation of the correct placement of Ryle's tube using ultrasound is easier than auscultation in overweight and obese patients. In normal patients, both techniques are equally useful.

Comparison of 4 point-of-care techniques to detect correct positioning of nasogastric tubes in dogs (2020-2021)

OBJECTIVE

To compare 4 point-of-care (POC) techniques to assess nasogastric (NG) tube placement versus radiographs as a reference standard. POC methods included air inflation with auscultation, fluid aspiration with pH measurement, ultrasonography, and capnography.

DESIGN

Prospective observational study in hospitalized dogs between 2020 and 2021.

SETTING

University teaching hospital.

ANIMALS

Fifty-one dogs requiring NG tube placement as part of their normal care.

INTERVENTIONS

After standard blind NG tube placement, each POC method was performed following standardized instructions. All POC methods were scored as to whether the investigator believed the tube to be in the gastrointestinal tract (as indicated by positive auscultation of borborygmus during insufflation, positive fluid aspiration with pH ≤5, presence of hyperechoic shadow in the esophagus, or absence of capnographic waveform). Subsequently, radiographs were taken to determine NG tube position as a gold standard. The sensitivity, specificity, and accuracy of each test as compared to 2-view thoracic radiographs were determined.

MEASUREMENTS AND MAIN RESULTS

Sensitivity, specificity, and accuracy for each POC technique were as follows: air auscultation (84.4%, 50.5%, and 80.4%, respectively), neck ultrasound (95.6%, 83.3%, and 94.1%, respectively), capnography (91.1%, 33.3%, and 84.3%, respectively), and fluid aspiration with pH measurement (22.2%, 100%, and 31.4%, respectively).

CONCLUSIONS

Among the 4 techniques evaluated, neck ultrasound had the best overall performance for assessing NG tube placement. Fluid aspiration with pH measurement might also have potential due to perfect specificity, but its clinical utility may be limited by low sensitivity and accuracy. Nonetheless, 2-view thoracic radiography should still be considered the standard method for confirmation of NG tube placement as none of the 4 POC techniques investigated showed both high sensitivity and perfect specificity.

Performance of Point-of-Care Ultrasonography in Confirming Feeding Tube Placement in Mechanically Ventilated Patients

BACKGROUND

A feeding tube (FT) is routinely placed in critically ill patients, and its correct placement is confirmed with a chest X-ray (CXR), which is considered the gold standard. This study evaluated the diagnostic accuracy of ultrasonography (USG) in verifying FT placement compared to a CXR in an intensive care unit (ICU).

METHOD

This was a prospective single-blind study conducted on patients admitted to the ICU of a tertiary hospital in Malaysia. The FT placements were verified through a fogging test and USG at the neck and subxiphoid points. The results of confirmation of FT placement through USG were compared with those obtained using CXRs.

RESULTS

A total of 80 patients were included in this study. The FT positions were accurately confirmed by overall USG assessments in 71 patients. The percentage of FT placements correctly identified by neck USG was 97.5%, while the percentage of those identified by epigastric USG was 75%. The corresponding patients' CXRs confirmed correct FT placement in 76 patients. The overall USG assessment had a sensitivity of 92.11% and specificity of 75%, a positive predictive value of 98.59%, and a negative predictive value of 33.33%. The USG findings also showed a significant association between FT size and BMI. FTs with a size of 14Fr were better visualized (p = 0.008), and negative USG findings had a significantly higher BMI (p < 0.001).

CONCLUSION

USG is a simple, safe, and reliable bedside assessment that offers relatively high sensitivity in confirming correct FT placement in critically ill patients.

Ultrasound to Verify Gastric Tube Position in Infants and Children: A Systematic Review

BACKGROUND

Placement of gastric tubes is commonly performed in infants and children but malpositioning is common and is associated with significant complications.

OBJECTIVE

The aim of this systematic review is to identify the evidence on the use of ultrasound to verify correct gastric tube placement in infants and children and gaps in the research.

METHODS

This review was performed using CINAHL, PUBMED, EMBASE and Web of Science databases. Studies were included if they used an empirical study design, were published in English, included infants or children, and evaluated the use of ultrasound to verify correct gastric tube placement compared to radiograph. Sensitivity, specificity, positive and negative predictive values were evaluated.

RESULTS

Four articles were included in the review. Sensitivity estimates were 0.88 to 1.00 and a positive predictive value of 0.99 was reported in one study. Specificity was not reported in any of the included studies. Ultrasound may be an important method to correctly identify gastric tube placement in infants and children with less radiation exposure and cost.

IMPLICATIONS FOR PRACTICE

Ultrasound could be a used to verify gastric tube positioning in infants and children for both initial placement and continued verification leading to reduced radiation exposure and cost.

IMPLICATIONS FOR RESEARCH

Research should focus on evaluating ultrasound specificity and the clinical feasibility of using ultrasound as a standard practice, including cost and time required to complete the exam, as well as the ability of ultrasound to verify gastric tube placement in infants weighing less than 1500 grams.

Point-of-care ultrasonography-assisted nasogastric tube placement in the emergency department: a randomized controlled trial

BACKGROUND

The complications of a blind procedure for gastric tube placement are well documented. POCUS has been widely used to confirm the position of blindly inserted gastric tubes, and it does not prevent complications caused by the blind method. We performed a randomized controlled trial to compare gastric tube insertion with real-time oesophagus visualization using POCUS to the standard technique.

OBJECTIVE

The primary goal of this study was to compare the accuracy of real-time POCUS-guided nasogastric tube (NGT) insertion and confirmation to that of the standard technique.

METHODS

It was a prospective, parallel-group, open-label randomized controlled trial with a superiority design. All patients requiring NGT were screened for inclusion and exclusion criteria, and 120 patients were randomly assigned to one of two groups: POCUS ( n = 60) or control ( n = 60). Following the procedures, confirmatory chest radiographs were obtained in both groups.

RESULTS

As per protocol, 118 patients were analyzed. In POCUS group, the oesophagus was visualized on POCUS in 56 of 58 patients (96.5%). In 55 of 58 cases (94.8%), an NGT was inserted in real time. Despite visualizing the oesophagus, we fail to insert the tube in one (1.8%). The oesophagus could not be seen on the scan in two cases (3.4%). Chest radiographs confirmed the tube in the stomach in 55 (98.2%). The chest radiograph revealed the tip of the NGT in the stomach in 52 of 60 (86.6%) patients. In seven cases (11.7%), we were unable to insert NGT. On a chest radiograph, one (1.6%) tip of the tube was seen in the right lung and was safely removed. The ultrasound-guided gastric tube insertion had a sensitivity of 96.5% (95% CI, 88-99.6%) and a positive predictive value (PPV) of 98.2% (95% CI, 98.1-98.3%). The conventional technique had 88% (95% CI, 77-95%) sensitivity and a PPV of 98% (95% CI, 97.9-98.2%).

CONCLUSION

POCUS enables real-time insertion of a gastric tube with high sensitivity, in a short time with high first-attempt success rate and limited passage-related complications. POCUS should be utilized for NGT insertion whenever expertise is available on the bedside.

Ultrasound-guided post-pyloric feeding tube insertion in peri-operative cardiac infants

Delivery of enteral nutrition in critical infants post-paediatric cardiac surgery is sometimes hampered, necessitating direct feeding into the small intestine. This study is highlighting the role of ultrasound-guided post-pyloric feeding tube insertion performed by the paediatric cardiac ICU intensivist in critically ill infants.

METHODS

We carried out a prospective pilot observational experimental study in peri-operative cardiac infants with feeding intolerance between 2019 and 2021. Feeding tube insertion depends on a combination of ultrasound and gastric insufflation with air-saline mixture. Insertion was confirmed by bedside abdominal X-ray.

RESULTS

Out of 500 peri-operative cardiac infants, 15 needed post-pyloric feeding tube insertion in median 15 postoperative day. All were under 6 months of age with average weight of 3 ± 0.2 kg. Median Risk Adjustment for Congenital Heart Surgery Categories was 4. Median insertion time was 15 minutes. No complications have been reported. First pass success rate was 87%, while a second successful insertion attempt was needed in 2 cases (13%). Target daily calorie intake was achieved within average of 3.5 ± 0.4 days. Mean post-pyloric feeding tube stay was 20 ± 3 days. Out of 15 infants, 3 patients died, 1 patient needed gastrostomy tube, and 11 patients were discharged home on oral feeds.

CONCLUSIONS

Ultrasound-guided post-pyloric feeding tube insertion using gastric insufflation with air-saline mixture in peri-operative cardiac infants with feeding intolerance is a useful and practical bedside tool, and it can be performed by a trained paediatric cardiac ICU intensivist. It may have potential positive effects on morbidity and outcome.

Ultrasonographic Confirmation of Nasogastric Tube Placement in the COVID-19 Era

Background: Nasogastric tube (NGT) placement is a daily routine in the Intensive Care Unit (ICU), and misplacement of the NGT can cause serious complications. In COVID-19 ARDS patients, proning has emerged the need for frequent NGT re-evaluations. The gold standard technique, chest X-ray, is not always feasible. In the present study we report our experience with the use of ultrasonographic confirmation of NGT position. Methods: A prospective study in 276 COVID-19 ARDS patients admitted after intubation in the ICU. Ultrasonographic evaluation was performed using longitudinal or sagittal epigastric views. Examinations were performed during the initial NGT placement and every time the patients returned to the supine position after they had been proned or whenever critical care physicians or nurses considered that reconfirmation was necessary. Results: Ultrasonographic confirmation of correct NGT placement was feasible in 246/276 (89.13%) patients upon ICU admission. In 189/246 (76.8%) the tube could be visualized in the stomach (two parallel lines), in 172/246 (69.9%) the ultrasonographic whoosh test (“flash” due to air instillation through the tube, seen with ultrasonography) was evident, while in 164/246 (66.7%) both tests confirmed correct NGT placement. During ICU stay 590 ultrasonographic NGT evaluations were performed, and in 462 (78.14%) cases correct NGT placement were confirmed. In 392 cases, a chest X-ray was also ordered. The sensitivity of ultrasonographic NGT confirmation in these cases was 98.9%, specificity 57.9%, PPV 96.2%, and NPV 3.8%. The time for the full evaluation was 3.8 ± 3.4 min. Conclusion: Ultrasonographic confirmation of correct NGT placement is feasible in the initial placement, but also whenever needed thereafter, especially in the COVID-19 era, when changes in posture have become a daily practice in ARDS patients.

Nasoenteric tube doppler guided insertion. A case report and review of literature

Nasoenteric tube placement is needed in patients with gastric enteral feeding intolerance or high risk of aspiration. Several techniques are described. Ultrasound is used more commonly for gastric tube placement, but also is described in enteral tube feeding placement. Doppler technique with cold water injection is not described in the literature. We describe a new and easy to realize technique. A case of a 65 years old male patient in the intensive care unit (ICU) with gastroparesis is described. Before beginning a prokinetic drug was administered. In this technique gastric tube placement was bedside assessed with ultrasound, and then the tube was progressed with cold water injection. Duodenal position was confirmed with doppler ultrasound. Ultrasound and doppler technique for nasoenteric tube placement could be a feasible technique to use in the ICU. More studies are needed to assess the effectiveness of the technique.

Nurse-performed ultrasound assessment of gastric residual volume and enteral nasogastric tube placement in the general intensive care unit

OBJECTIVE

Ultrasonography is an essential imaging modality in the critical care population and has been increasingly utilized to check gastric residual volume . Various studies have shown that intensive care unit nurses untrained in ultrasound can easily be trained in its accurate interpretation. We prospectively analyzed nurse-performed repeated measurements of gastric residual volume and nasogastric tube positioning via an ultrasound technique in the intensive care unit.

DESIGN

This was a single-center, cross-sectional prospective study. Four intensive care unit nurses, evenly divided into two groups (teams A and B), underwent four hours of formal ultrasound training by three critical care staff physicians. The trained nurses provided bedside ultrasound assessments of gastric residual volume and nasogastric tube positioning which were compared to a standard protocol of syringe aspiration.

RESULTS

Ninety patients were recruited to the study. Four measurements per patient were performed, for a total of 360 assessments. The ultrasound gastric residual volume assessments were correlated with the syringe aspiration protocol and demonstrated high Intraclass Correlation Coefficient rates of 0.814 (0.61-0.92) for team A and 0.85 (0.58-0.91) for team B. Nasogastric tube placement was successfully and independently verified by ultrasound in most of the critically ill patients (78% of team A and 70% of team B). The comparative ultrasound assessments of tube positioning demonstrated good correlation of 0.733 (0.51-0.88) between each team's two independent observers.

CONCLUSION

Our study demonstrated a strong correlation between US utilization for assessment of gastric residual volume and nasogastric tube positioning and standard protocol methods, suggesting it is a safe, simple and effective practice for intensive care unit nurses.

Point-of-Care Ultrasound for Confirmation of Nasogastric and Orogastric Tube Placement in Pediatric Patients

OBJECTIVES

The aim of the study was to investigate the role of point-of-care ultrasound (POCUS) as an alternative imaging modality to confirm proper placement for nasogastric tubes (NGTs) and orogastric tubes (OGTs) in pediatric patients.

METHODS

This was a prospective descriptive study performed at a tertiary care free-standing children's hospital. Patients 21 years and younger requiring radiographic confirmation of NGT or OGT placement were eligible for enrollment. Bedside ultrasonography examination of the epigastric area was performed by a blinded pediatric emergency medicine physician. An abdominal radiograph was obtained to confirm NGT or OGT placement in all patients.

RESULTS

A total of 26 patients with a mean age of 2.6 years (standard deviation, 3.9 years) were enrolled. All 26 patients had x-ray confirmation of NGT and OGTs correctly placed in the stomach. Confirmation of NGT or OGT placement by ultrasound was obtained in 23 patients. For these 23 patients, POCUS agreed with radiographic findings. For 3 patients, the NGT and OGT was unable to be identified by ultrasound. The sensitivity of ultrasound for detecting a properly placed tube was 88% (95% confidence interval, 70.0%-97.6%).

CONCLUSIONS

This pilot study described ultrasound confirmation of NGT or OGT placement. If confirmed in larger studies, POCUS can be used as an objective tool for the confirmation of NGT or OGT placement in pediatric patients and limit the need for routine x-ray confirmation.

Nasogastric tube placement under sonographic observation: A comparison study of ultrasound and chest radiography in mechanically ventilated patients

BACKGROUND

Nasogastric tube insertion in the intensive care setting is common. Placement verification is required to avoid complications of bronchotracheal misplacement that range from aspiration of infused contents to death from associated causes. The gold standard of practice is chest radiography. Ultrasound is a growing modality and is readily available in most intensive care units.

OBJECTIVE

The objective of this study was to examine the diagnostic accuracy of ultrasound imaging of nasogastric tube placements by nonradiologists compared with chest radiography in mechanically ventilated patients.

METHODS

This is a dual-centre prospective, single-blind study. Correct placement was captured with a hyperechoic ultrasound image of a nasogastric tube in the oesophagus and epigastrium, which was compared with chest radiography. Patient enrolment included general adult intensive care unit admissions who were mechanically ventilated and required a nasogastric tube for either the treatment or monitoring of their illness.

RESULTS

A total of 25 patients were enrolled (15 men, 10 women), and their mean age was 68.1 ± 13.8 years. Outcome measures were the percentage of correctly identified nasogastric tubes in the oesophagus and epigastrium. The sensitivity of oesophagus ultrasound was 88%, and the positive predictive value was 100%. The subxiphoid sensitivity was 64%, and the positive predictive value was 100%. Comparison sensitivity and specificity of oesophagus versus subxiphoid ultrasound was 64% and 33%, respectively. There was a positive predictive value of 88% and a negative predictive value of 11%. The results showed a variance in detection sensitivity in the ultrasound scans of the oesophagus (0.88) and subxiphoid (0.64) (N = 25, p = 0.012).

CONCLUSION

Nasogastric tube placement verification via ultrasound in critically ill mechanically ventilated patients conducted by nonradiologists with minimal training is associated with diagnostic accuracy. These results add to the limited evidence in the current literature; however, they should be considered with awareness that placement in the stomach in this study was detected in 64% of cases, alongside the missed captured evidence of the sonographer's ability to identify misplacement.

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.

Bedside Abdominal Ultrasound in Evaluating Nasogastric Tube Placement: A Multicenter, Prospective, Cohort Study

BACKGROUND

Chest radiography is universally accepted as the method of choice to confirm correct positioning of a nasogastric tube (NGT). Considering also that radiation exposure could increase with multiple insertions in a single patient, bedside abdominal ultrasound (BAU) may be a potentially useful alternative to chest radiography in the management of NGTs.

RESEARCH QUESTION

What is the accuracy of BAU in confirming the correct positioning of an NGT?

STUDY DESIGN AND METHODS

After a specific course consisting of 10 h of training, the authors studied, in a prospective multicenter cohort, the validity of BAU to confirm correct NGT placement. All patients were also evaluated by auscultation (whoosh test) and by chest radiography. Every involved operator was blind to each other. Interobserver agreement and accuracy analyses were calculated.

RESULTS

This study evaluated 606 consecutive inpatients with an indication for NGT insertion. Eighty patients were excluded for protocol violation or incomplete examinations and 526 were analyzed. BAU was positive, negative, and inconclusive in 415 (78.9%), 71 (13.5%), and 40 (7.6%), respectively. The agreement between BAU and chest radiography was excellent. Excluding inconclusive results, BAU had a sensitivity of 99.8% (99.3%-100%), a specificity of 91.0% (88.5%-93.6%), a positive predictive value of 98.3% (97.2%-99.5%), and a negative predictive value of 98.6% (97.6%-99.7%). The accuracy of BAU slightly changed according to the different assignments of the uncertain cases and was improved by the exclusion of patients with an altered level of consciousness.

INTERPRETATION

These results suggest that BAU has a good positive predictive value and may confirm the correct placement of NGTs when compared with chest radiography. However, considering its suboptimal specificity, caution is necessary before implementing this technique in clinical practice.

Validation of sonographic assistance for placement of a nasogastric tube in pediatric patients

PURPOSE

Enteral access via nasogastric tube (NGT) placement can be essential in the provision of care in pediatric patients. Methods exist to confirm correct placement with success rates between 80% and 85%. Radiographic confirmation remains the "gold-standard," however; it exposes patients to ionizing radiation and fails to provide "real-time" information. In this study, we determined the feasibility of using sonography to assist in the placement of NGT insertions in pediatric patients that have difficulty cooperating.

METHODS

Thirty patients requiring NGT placement were stratified into three age groups. Upon NGT insertion, transverse and longitudinal ultrasound images were acquired to visualize tube progression through the esophagus. Subsequently, a focused ultrasonographic exam of the gastric antrum and body were performed. If amenable, an air bolus (1 mL/kg) was injected in the stomach if the NGT was not directly visualized. Following intubation, standard guidelines for NGT position confirmation were performed.

RESULTS

The NGT was visualized in all esophageal views and 52% of gastric views. Subgroup analysis showed that successful visualization of tube placement in the stomach ranged from 40% (7-18 years) to 70% (3-6 years). Eighty percentage of air boluses injected were visualized.

CONCLUSION

The use of ultrasonography may assist NGT placement in pediatric patients and reduce the incidence of suboptimal placement during insertion. We demonstrated successful NGT visualization through the esophagus regardless of age. NGT visualization in the stomach was challenging; however, injection of an air bolus may improve visualization. Further studies are required to improve the success rate of obtaining gastric views of the NGT.

GASTROINTESTINAL TUBE INSERTION TECHNIQUES IN CRITICAL PATIENTS: SCOPING REVIEW

ABSTRACT Objective to map the production of knowledge about the different techniques of gastrointestinal tube insertion in critically ill and/or coma patients. Method scope review carried out in December 2020 in ten data sources, following the assumptions established by the Joanna Briggs Institute (2020) and the PRISMA-ScR protocol. Results 25 studies were selected and analyzed, identifying as the main techniques for insertion of gastrointestinal tube in critically ill and/or coma patients: techniques without the aid of instrumentals, such as head flexion, lateral neck pressure, tube freezing, measurement with corrected formula of the tip of the ear-lobe tip-xiphoid process, Sellick´s maneuver, cricoid cartilage compression, SORT maneuver and gastric insufflation. In addition to techniques with the aid of instruments, such as the use of laryngoscopes and video laryngoscopes. It is noteworthy that, in order to facilitate insertion, the use of ultrasound examination, radiological, endoscopic and fluoroscopy were also identified. Conclusions the evidence analyzed reveals that there is no specific gastrointestinal tube insertion technique for universally accepted critically ill patients.

Emergency department approach to gastric tube complications and review of the literature

Nasogastric and orogastric tubes (NGT/OGT) are commonly used in emergency and critical care settings, with indications including medicinal administration, gastric decompression, and enteral feeding. Previous studies have highlighted a variety of complications associated with tube placement. These range from minor occurrences such as nose bleeds and sinusitis, to more severe cases highlighting tracheobronchial perforation, tube knotting, asphyxia, pulmonary aspiration, pneumothorax, and even intracranial insertion. Patients who suffer from these complications face additional obstacles including increased time spent in intensive care settings, healthcare associated costs, and nosocomial infections. Various bedside tests have been developed to reduce the risk of these complications, and current clinical protocol has characterized radiographic imaging as the gold standard. However, air insufflation, CO2 detection (capnography), aspirate pH testing, and point of care ultrasound (POCUS) have all been implemented with varying degrees of utility. Here we present a case involving a 60-year-old male who was brought to the ED and suffered a right sided pneumothorax (PTX) following improper OGT placement. In this case, air insufflation was utilized, but was ineffective in detecting the properly placed tube; leakage of an endotracheal tube cuff served as a lead for misplacement while imaging was conducted. The purpose of this study is not only to highlight the numerous complications that are possible with NGT and OGT placement, but also to propose the use of multiple bedside tests (pH testing, CO2 detection, POCUS) as an alternative to radiographic imaging to increase sensitivity and specificity for detection of improperly placed tubes.

The Use of Ultrasonography for Verifying Gastric Tube Placement in Newborns

BACKGROUND

The use of gastric tubes in newborns admitted to a neonatal intensive care unit is fairly high, and there is a risk of serious complications related to this procedure.

PURPOSE

Considering the need to find a method that does not involve the patient's exposure to radiation, this study aimed to evaluate the diagnostic accuracy of ultrasonography for verifying gastric tube placement in newborns.

METHODS

This was a prospective, double-blind, observational study performed in a neonatal intensive care unit, in which 159 infants had gastric intubation using ultrasound examination and radiological imaging, to verify positioning. Results were analyzed in terms of diagnostic accuracy.

RESULTS

The tubes were correctly positioned in 157 cases (98.7%), according to radiological images, and in 156 cases (98.1%), according to ultrasound. The sensitivity analysis was 0.98 and the positive predictive value was 0.99. It was not possible to perform a specificity analysis, as there were not enough negative cases in the sample.

IMPLICATIONS FOR PRACTICE

The use of ultrasonography to identify correct positioning of gastric tubes in infants and newborns shows good sensitivity.

IMPLICATIONS FOR RESEARCH

It was not possible to evaluate the ultrasonography specificity; further studies with greater samples are probably necessary, so that this objective can be achieved.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=29&autoPlay=true.

Verifying the Placement of Nasogastric Tubes at an Emergency Center: Comparison of Ultrasound with Chest Radiograph

The objective of this study was to verify the nasogastric tube position with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture and auscultation and to compare the effectiveness of these methods with chest radiography. This is a single-center, prospective, single-blind study. Patients who were admitted to our emergency department and had an indication of nasogastric tube placement were included. Nasogastric tube localization was verified with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture, auscultation, and direct radiography that was accepted as the ‘gold standard technique'. A total of 49 patients (27 Male, 22 Female) with a mean age of 58.3±22.7 years were included. Sensitivity of neck ultrasound was 91.5%, and positive predictive value was 100%. As for the subxiphoid ultrasound sensitivity was 78.72%. When neck ultrasound + subxiphoid ultrasound and giving water-air mixture were combined sensitivity reached 95.74%. Sensitivity of neck ultrasound + subxiphoid ultrasound + air-water mixture + auscultation was 97.87% and positive predictive value was 100%. In the light of our results, neck and subxiphoid ultrasound seem to be an alternative method for verifying nasogastric tube localization. Combination of the air-water mixture and auscultation with ultrasound improves the sensitivity.

A simple and fast ultrasonographic method of detecting enteral feeding tube placement in mechanically ventilated, critically ill patients

Abdominal X-rays, the diagnostic method for enteral feeding tube (EFT) positioning, are a source of irradiation for the patients and carry a potential risk of adverse effects. Data related to ultrasound (US)-guided EFT placement are scarce. We evaluated 41 patients with 41 EFT insertions with guidewire in place that was maintained until US examination. US detected 38 patients with proper positioning and 3 with inadequate positioning, with a sensitivity of 97% (95% CI 84.9–99.8%) and specificity of 100% (95% CI 19.7–100%). The assessment of EFT position through abdominal US is practical and safe, associated with satisfactory diagnostic accuracy.

Nasogastric tube placement confirmation: where we are and where we should be heading

Background:

Insertion of a tube via the nasal passage is a common procedure which has been practiced for many years. There are various ways to assess the position of the nasogastric tube (NGT).

Objectives:

The objective of this study was to discuss the advantages and limitations of each method of NGT placement confirmation, to identify gaps in literature, and provide suggestions for future research.

Methods:

A search was performed with Pubmed, CINAHL, and Embase. The following keywords were used: “nasogastric,” “tube,” “placement,” “insertion,” and “measurement.” The results were narrowed down to those with full text available, published in the English language, those published within the last 10 years, and those studies done in the adult population. The reference lists of those articles were also referred to and relevant articles were retrieved. A final 26 relevant articles were included in this review, including six that were published more than 10 years ago but still relevant in this review.

Results:

A method to confirm NGT placement that is accurate, affordable, does not require gastric aspirates, and is able to be used not only upon insertion but also at regular intervals is lacking.

Conclusions:

This article provides a summary of the different methods of NGT placement confirmation and discusses their advantages and limitations. Gaps in literature and suggestions for future research were also deliberated.

Ultrasonography for confirmation of gastric tube placement

BACKGROUND

Gastric tubes are commonly used for the administration of drugs and tube feeding for people who are unable to swallow. Feeding via a tube misplaced in the trachea can result in severe pneumonia. Therefore, the confirmation of tube placement in the stomach after tube insertion is important. Recent studies have reported that ultrasonography provides good diagnostic accuracy estimates in the confirmation of appropriate tube placement. Hence, ultrasound could provide a promising alternative to X-rays in the confirmation of tube placement, especially in settings where X-ray facilities are unavailable or difficult to access.

OBJECTIVES

To assess the diagnostic accuracy of ultrasound for gastric tube placement confirmation.

SEARCH METHODS

We searched the Cochrane Library (2016, Issue 3), MEDLINE (to March 2016), Embase (to March 2016), National Institute for Health Research (NIHR) PROSPERO Register (to May 2016), Aggressive Research Intelligence Facility Databases (to May 2016), ClinicalTrials.gov (to May 2016), ISRCTN registry (May 2016), World Health Organization International Clinical Trials Registry Platform (to May 2016) and reference lists of articles, and contacted study authors.

SELECTION CRITERIA

We included studies that evaluated the diagnostic accuracy of naso- and orogastric tube placement confirmed by ultrasound visualization using X-ray visualization as the reference standard. We included cross-sectional studies, and case-control studies. We excluded case series or case reports. Studies were excluded if X-ray visualization was not the reference standard or if the tube being placed was a gastrostomy or enteric tube.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from each of the included studies. We contacted authors of the included studies to obtain missing data.

MAIN RESULTS

We identified 10 studies (545 participants and 560 tube insertions) which met our inclusion criteria.No study was assigned low risk of bias or low concern in every QUADAS-2 domain. We judged only three (30%) studies to have low risk of bias in the participant selection domain because they performed ultrasound after they confirmed correct position by other methods.Few data (43 participants) were available for misplacement detection (specificity) due to the low incidence of misplacement. We did not perform a meta-analysis because of considerable heterogeneity of the index test such as the difference of echo window, the combination of ultrasound with other confirmation methods (e.g. saline flush visualization by ultrasound) and ultrasound during the insertion of the tube. For all settings, sensitivity estimates for individual studies ranged from 0.50 to 1.00 and specificity estimates from 0.17 to 1.00. For settings where X-ray was not readily available and participants underwent gastric tube insertion for drainage (four studies, 305 participants), sensitivity estimates of ultrasound in combination with other confirmatory tests ranged from 0.86 to 0.98 and specificity estimates of 1.00 with wide confidence intervals.For the studies using ultrasound alone (four studies, 314 participants), sensitivity estimates ranged from 0.91 to 0.98 and specificity estimates from 0.67 to 1.00.

AUTHORS' CONCLUSIONS

Of 10 studies that assessed the diagnostic accuracy of gastric tube placement, few studies had a low risk of bias. Based on limited evidence, ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement. However, in settings where X-ray is not readily available, ultrasound may be useful to detect misplaced gastric tubes. Larger studies are needed to determine the possibility of adverse events when ultrasound is used to confirm tube placement.

Intraoperative Gastric Tube Intubation: A Summary of Case Studies and Review of the Literature

Study Objective

Establish complications and risk factors that are associated with blind tube insertion, evaluate the validity of correct placement verification methods, establish the rationales supporting its employment by anesthesia providers, and describe various deployment facilitators described in current literature.

Measurements

An exhaustive literature review of the databases Medline, CINAHL, Cochrane Collaboration, Scopus, and Google Scholar was performed applying the search terms “gastric tube”, “complications”, “decompression”, “blind insertion”, “perioperative”, “intraoperative” in various order sequences. A five-year limit was applied to limit the number and timeliness of articles selected.

Main Results

Patients are exposed to potentially serious morbidity and mortality from blindly inserted gastric tubes. Risk factors associated with malposition include blind insertion, the presence of endotracheal tubes, altered sensorium, and previous tube misplacements. Pulmonary aspiration risk prevention remains the only indication for anesthesia-related intraoperative use. There are no singularly effective tools that predict or verify the proper placement of blindly inserted gastric tubes. Current placement facilitation techniques are perpetuated through anecdotal experience and technique variability warrants further study.

Conclusion

In the absence of aspiration risk factors or the need for surgical decompression in ASA classification I & II patients, a moratorium should be instituted on the elective use of gastric tubes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Does Bedside Sonography Effectively Identify Nasogastric Tube Placements in Pediatric Critical Care Patients?

BACKGROUND

A nasogastric tube (NGT) insertion is a common procedure in intensive care units, with some serious complications that result from the malposition of the NGT tip. This pilot study was designed to investigate the efficiency of ultrasound in verifying correct NGT placement and to compare these results with radiographic findings.

MATERIALS AND METHODS

This was a single-center, double-blind prospective study of patients who had received an NGT in the pediatric critical care unit. Twenty-one patients aged 1 month to 18 years were included in this study. All NGTs were inserted by the same critical care physician. After insertion, the physician first confirmed NGT placement by the auscultation of the epigastrium following the insufflation of air. Confirmation was supplemented with an abdominal radiograph. A radiologist who was unaware of the radiographic findings performed bedside sonography on all patients and verified the location of the NGTs. The findings from these 2 physicians were then compared.

RESULTS

NGTs were inserted without any complications, and none of the NGTs were positioned in the respiratory tract in any of the patients. All NGT tips were visualized by radiography and sonography with a sensitivity of 100%.

CONCLUSION

Bedside sonography performed by a radiologist is an effective and sensitive diagnostic procedure for confirming the correct NGT position in patients in the pediatric critical care unit.