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

Procedures for a Transpyloric Feeding Tube Inserted Into Newborns and Infants: A Systematic Review

BACKGROUND

Enteral feeding by a transpyloric tube in critically ill infants is indicated when there is a failure in gastric feeding. However, there is a wide variability regarding the insertion technique.

PURPOSE

To perform a systematic review of the methods for inserting a transpyloric feeding tube in newborns and infants.

DATA SOURCES

Nine databases, without date or language restrictions, accessed in September 2021.

STUDY SELECTION

A systematic review of experimental and nonexperimental studies, according to the "Patient/problem; Intervention; Comparison; Outcome" strategy and the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. The clinical question was about the measurement and insertion techniques, as well as the success rates of properly placing a transpyloric tube in newborns and infants.

DATA EXTRACTION

Two authors (N.M.Q. and J.F.S.) analyzed 6 observational descriptive prospective studies, all of them published in peer-reviewed indexed medical journals and one in the official journal of the National Association of Neonatal Nurses.

RESULTS

The success rate varied between 70% and 100%. There was an important variability in the type of tube, measurement method, and insertion techniques. It was found that the most common strategies to achieve proper positioning were glabella-calcaneal measurements, gastric air insufflation, and right lateral decubitus.

IMPLICATIONS FOR PRACTICE

A transpyloric catheter insertion protocol needs to be established in each neonatal unit, according to the literature findings.

IMPLICATIONS FOR RESEARCH

Randomized controlled studies that evaluate the gastric air insufflation technique and other adjuvant measures could elucidate the knowledge gap concerning the correct positioning of transpyloric tubing in newborns and infants.

Ultrasound-Assisted versus Endoscopic Nasojejunal Tube Placement for Acute Pancreatitis: A Retrospective Feasibility Study

Objective

The optimal technique for nasojejunal tube (NJT) placement in terms of facilitating early enteral nutrition (EN) in patients with acute pancreatitis (AP) is unclear. In this study, we aimed to evaluate the impact of two common techniques on EN implementation and clinical outcomes in a group of AP patients.

Methods

This is a retrospective study. All the data were extracted from an electronic database from August 2015 to October 2017. Patients with a diagnosis of AP requiring NJT placement were retrospectively analyzed. The primary outcome was the successful procedural rate.

Results

A total of 53 eligible patients were enrolled, of whom 30 received an ultrasound-assisted technique and the rest received the endoscopy method (n = 23). There was no difference in success rates of initial placement procedures between the two groups (93.3% and 95.7% in the ultrasound-assisted group and endoscopy group, respectively). The mean amount of EN delivery within the first three days after NJT placement was significantly higher in the ultrasound-assisted group (841.4 kcal (95% CI: 738.8, 944 kcal) vs. 652.5 kcal (95% CI: 562.5, 742.6 kcal), P = 0.018). Moreover, a slight increased postprocedural intra-abdominal pressure (IAP) was observed in patients undergoing endoscopic procedures, but not in the ultrasound-assisted group, especially at 6 hours after NJT placement (0.35 vs. -2.01 from baseline, P < 0.05). For clinical outcomes, we observed no difference between groups.

Conclusion

Compared with endoscopic procedures, ultrasound-assisted NJT placement possesses the acceptable success rates of initial placement procedures.

Host-Microbiome Interactions Mediated by Phenolic Metabolites in Chronically Critically Ill Patients

The community structure and metabolic potential of gut microbiome is not well investigated, especially in chronically critically ill patients with prolonged dependence on support systems after severe brain disorders. Microbial phenolic metabolites can target the brain function by the direct and indirect modulation of inflammation. The aim of this study was to investigate the features of the gut microbiota and profile of certain metabolites in the progression and reversibility of neurological disorders in chronically critically ill patients. Fecal samples were collected in dynamics from such patients (n = 44) and analyzed using 16S rRNA sequencing. Serum microbial and mitochondrial metabolites were measured by GC-MS and compared with the biomarkers and clinical neurological scores. The identified associations between specific bacterial taxa in fecal samples, neurological status and serum levels of metabolites suggest that impacts on specific members of the gut microbiota and their metabolism might be a promising tool for regulating brain function in future.

Migration of Feeding Tubes Assessed by Using an Electromagnetic Device: A Cohort Study

BACKGROUND

Bedside methods to verify placement of a feeding tube are not accurate for detecting placement within the gastrointestinal tract, increasing risk of pulmonary aspiration. Current guidelines recommend verifying placement every 4 hours, yet the rationale for this recommendation is unknown.

OBJECTIVE

To assess spontaneous migration of small-bore feeding tubes in critically ill adults.

METHODS

A prospective, repeated-measures cohort study was performed in 2 intensive care units. An electromagnetic placement device was used to assess distal feeding tube location every 24 hours for 7 days. Tube migration between zones-esophageal, gastric, and postpyloric- was considered clinically significant.

RESULTS

Feeding tubes were analyzed in 20 patients. Interrater agreement was substantial for round 2 of a blinded analysis of insertion tracings (g = 0.78); 100% agreement was achieved after unblinding. Among 62 outcomes (migration assessments), 4 feeding tubes migrated 8 times (3 forward and 5 retrograde). All migrations occurred in the postpyloric zone and none were clinically significant. Within 24 hours of insertion, 50% of feeding tubes had migrated forward. Repeated-measures analysis showed a greater likelihood of migration in patients with an endotracheal tube (relative risk, 3.46 [95% CI, 1.14-10.53]; P = .03).

CONCLUSIONS

No tubes migrated retrograde into the stomach or esophagus, challenging the practice of verifying placement every 4 hours. Verification every 24 hours may be adequate if migration is not suspected. Also, lack of visible anatomical structures on insertion tracings from an electromagnetic placement device make subtle changes in postpyloric placement difficult to identify accurately.

Taxonomic dysbiosis of gut microbiota and serum biomarkers reflect severity of central nervous system injury

The term “chronic critical illness” (CCI) refers to patients with prolonged dependence on intensive care. In most patients, CCI is triggered by severe brain injury. Ever more studies researching the microbiota in pathologic conditions are published every year, but a lot is yet to be elucidated about the composition of the gut microbiota in CCI. The aim of this study was to investigate possible correlations between changes in the taxonomic abundance of the gut microbiota, levels of proinflammatory and neurological serum biomarkers and the severity of central nervous system injury in patients with CCI. Our prospective observational pilot study included 29 patients with CCI. Using real-time PCR allowed us to detected changes in the taxonomic abundance of the gut microbiota. The correlation analysis of serum biomarkers and the taxonomic composition of the gut microbiota revealed statistically significant correlations between cortisol levels and the abundance of F. prausnitzii (r = ‒0.62; p < 0.05) and B. thetaiotaomicron (r = ‒0.57; p < 0.05) in vegetative state patients; between the CRP/albumin ratio and the abundance of S. aureus (r = 0.72; p < 0.05); between the abundance of B. fragilis group/F. prausnitzii and S100 levels (r = 0.45; p <0.05) in conscious patients; between Glasgow coma scale scores and the abundance of Enterococcus spp. (r = ‒0.77; p <0.05) in both groups. Thus, the association between the changes in the taxonomic composition of the gut microbiota and the severity of neurologic deficit can be evaluated using PCR-based diagnostic techniques and blood serum biomarkers. This approach will help to optimize antibacterial treatment regimens and/or develop alternative strategies to minimize the aggressive effect of antibiotics on the gut microbiota.

Erythromycin versus metoclopramide for post-pyloric spiral nasoenteric tube placement: a randomized non-inferiority trial

Purpose

To determine whether erythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs) in critically ill patients.

Methods

A prospective, multicenter, open-label, parallel, and non-inferiority randomized controlled trial was conducted comparing erythromycin with metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients admitted to intensive care units (ICUs) of eight tertiary hospitals in China. The primary outcome was procedure success defined as post-pyloric placement (spiral NETs reached the first portion of the duodenum or beyond confirmed by abdominal radiography 24 h after tube insertion).

Results

A total of 5688 patients were admitted to the ICUs. Of these, in 355 patients there was a plan to insert a nasoenteric feeding tube, of whom 332 were randomized, with 167 patients assigned to the erythromycin group and 165 patients assigned to the metoclopramide group. The success rate of post-pyloric placement was 57.5% (96/167) in the erythromycin group, as compared with 50.3% (83/165) in the metoclopramide group (a difference of 7.2%, 95% CI − 3.5% to 17.9%), in the intention-to-treat analysis, not including the prespecified margin of − 10% for non-inferiority. The success rates of post-D1 (reaching the second portion of the duodenum or beyond), post-D2 (reaching the third portion of the duodenum or beyond), post-D3 (reaching the fourth portion of the duodenum or beyond), and proximal jejunum placement and the incidence of any adverse events were not significantly different between the groups.

Conclusions

Erythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients. The success rates of post-D1, post-D2, post-D3, and proximal jejunum placement were not significantly different.

The History of Nonsurgical Enteral Tube Feeding Access

Specialized nutrition support, particularly enteral feeding, has been used for centuries. Technologic advancements have affected the provision of enteral feeding. Feeding solutions and devices, as well as the techniques to place the feeding devices, have evolved. This article reviews the history of bedside placement methods for short-term enteral access devices.

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.

Motilin: towards a new understanding of the gastrointestinal neuropharmacology and therapeutic use of motilin receptor agonists

The gastrointestinal hormone motilin has been known about for >40 years, but after identification of its receptor and subsequent development of new tools and methods, a reappraisal of its actions is required. Firstly, it is important to note that motilin and ghrelin receptors are members of the same family (similar genomic organization, gastrointestinal distribution and abilities to stimulate gastrointestinal motility), yet each fails to recognize the ligand of the other; and whereas ghrelin and ghrelin receptors are widespread outside the gastrointestinal tract, motilin and its receptors are largely restricted to the gastrointestinal tract. Secondly, although some studies suggest motilin has activity in rodents, most do not, and receptor pseudogenes exist in rodents. Thirdly, motilin preferentially operates by facilitating enteric cholinergic activity rather than directly contracting the muscle, despite the relatively high expression of receptor immunoreactivity in muscle. This activity is ligand-dependent, with short-lasting actions of motilin contrasting with longer-lasting actions of the non-selective and selective motilin receptor agonists erythromycin and GSK962040. Finally, the use of erythromycin (also an antibiotic drug) to treat patients requiring acceleration of gastric emptying has led to concerns over safety and potential exacerbation of antibiotic resistance. Replacement motilin receptor agonists derived from erythromycin (motilides) have been unsuccessful. New, non-motilide, small molecule receptor agonists, designed to minimize self-desensitization, are now entering clinical trials for treating patients undergoing enteral feeding or with diabetic gastroparesis. Thus, for the translational pharmacologist, the study of motilin illustrates the need to avoid overreliance on artificial systems, on structural information and on animal studies.

LINKED ARTICLES

This article is part of a themed section on Neuropeptides. To view the other articles in this section visit http://dx.doi.org/10.1111/bph.2013.170.issue-7.

A novel method of post-pyloric feeding tube placement at bedside

PURPOSE

Post-pyloric feeding tube placement is often difficult, and special equipment or peristalsis agents are used to aid insertion. Although several reports have described blind techniques for post-pyloric feeding-tube placement, no general consensus about method preference has been achieved.

MATERIALS AND METHODS

The technique is performed as follows: via the nostril, a stylet-tipped feeding tube is advanced about 70 cm; to confirm tip location to the right of the epigastric area, towards the right hypochondriac region, 5 mL shots of air are injected to enable touch detection of bubbling; finally, the tube is advanced to a length of 100 cm, during which the strength of bubbling seems to diminish under palpation.

RESULTS

We prospectively enrolled consecutive patients whose oral intake was expected to be difficult for 48 hours in the intensive care unit. Forty-one patients were enrolled and the rate of successful placement at first attempt was 95.1%. Mean duration for successful placement was 15 minutes.

CONCLUSIONS

With a novel technique, from the bedside, without special tools or drugs, we successfully placed post-pyloric feeding tubes. Essential points when inserting the tube are confirmation of the location of the tube tip by palpation of injected air, and to avoid deflection and looping.

A new technique for post-pyloric feeding tube placement by palpation in lean critically ill patients

Various techniques have been described for blind bedside placement of a post-pyloric feeding tube. However, there is no universal method and the technique depends on the local institutional resources and expertise. The purpose of this study was to evaluate a simple new technique for the bedside placement of a post-pyloric feeding tube in an intensive care unit using palpation to confirm tube position. We studied 47 consecutive ventilated patients (mean body mass index 22.4 ± 4.2 kg/m(2)) requiring enteral tube feeding for nutritional support. We monitored the maximum intensity point of injected air 'bubbling' by palpation and estimated tube position. We monitored the movement of the maximum intensity point from the left upper quadrant to the right upper quadrant. If the maximum intensity point on the right upper quadrant diminished or weakened, we considered the tube had proceeded beyond the pylorus. By palpation, we could feel the bubbling of the injected air in all patients, but four patients were excluded because of failure to complete the protocol. The overall success rate including the four excluded cases was 85.1% (40/47) on the first attempt and 91.5% (43/47) when we included the second attempt. The median time for 40 successful tube placements on the first attempt was 10 (7 to 23) minutes. Our new palpation technique can successfully detect the position of a feeding tube in the stomach and help guide the tube to the correct location in the post-pyloric portion of the stomach in lean critically ill patients.

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.

Jejunal tube placement in critically ill patients: A prospective, randomized trial comparing the endoscopic technique with the electromagnetically visualized method

OBJECTIVE

Head-to-head comparison of the success rate of jejunal placement of a new electromagnetically visualized jejunal tube with that of the endoscopic technique in critically ill patients.

DESIGN

: Prospective, randomized clinical trial.

SETTING

Two intensive care units at a university hospital.

PATIENTS

: A total of 66 critically ill patients not tolerating intragastric nutrition.

INTERVENTIONS

Patients were randomly assigned (2:1 ratio) to receive an electromagnetically visualized jejunal feeding tube or an endoscopically placed jejunal tube. The success rate of correct jejunal placement after 24 hrs was the main outcome parameter.

MEASUREMENTS AND MAIN RESULTS

The correct jejunal tube position was reached in 21 of 22 patients using the endoscopic technique and in 40 of 44 patients using the electromagnetically visualized jejunal tube (95% vs. 91%; relative risk 0.9524, confidence interval 0.804-1.127, p = .571). In the remaining four patients, successful endoscopic jejunal tube placement was performed subsequently. The implantation times, times in the right position, and occurrences of nose bleeding were not different between the two groups. The electromagnetically visualized technique resulted in the correct jejunal position more often at the first attempt. Factors associated with successful placement at the first attempt of the electromagnetically visualized jejunal tube seem to be a higher body mass index and absence of emesis. This trial is registered at ClinicalTrials.gov, number NCT00500851.

CONCLUSIONS

In a head-to-head comparison correct jejunal tube placement using the new electromagnetically visualized method was as fast, safe, and successful as the endoscopic method in a comparative intensive care unit patient population.

A new technique for bedside placement of enteral feeding tubes: a prospective cohort study

Introduction

To accomplish early enteral feeding in the critically ill patient a new transnasal endoscopic approach to the placement of postpyloric feeding tubes by intensive care physicians was evaluated.

Methods

This was a prospective cohort study in 27 critically ill patients subjected to transnasal endoscopy and intubation of the pylorus. Attending intensive care physicians were trained in the handling of the new endoscope for transnasal gastroenteroscopy for two days. A jejunal feeding tube was advanced via the instrument channel and the correct position assessed by contrast radiography. The primary outcome measure was successful postpyloric placement of the tube. Secondary outcome measures were time needed for the placement, complications such as bleeding and formation of loops, and the score of the placement difficulty graded from 1 (easy) to 4 (difficult). Data are given as mean values and standard deviation.

Results

Out of 34 attempted jejunal tube placements, 28 tubes (82%) were placed correctly in the jejunum. The duration of the procedure was 28 ± 12 minutes. The difficulty of the tube placement was judged as follows: grade 1: 17 patients, grade 2: 8 patients, grade 3: 7 patients, grade 4: 2 patients. In three cases, the tube position was incorrect, and in another three cases, the procedure had to be aborted. In one patient bleeding occurred that required no further treatment.

Conclusions

Fast and reliable transnasal insertion of postpyloric feeding tubes can be accomplished by trained intensive care physicians at the bedside using the presented procedure. This new technique may facilitate early initiation of enteral feeding in intensive care patients.

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.

Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition

Enteral nutrition support (ENS) involves both the delivery of nutrients via feeding tubes and the provision of specialised oral nutritional supplements. ENS is indicated in a patient with at least a partially functioning digestive tract when oral intake is inadequate or intake of normal food is inappropriate to meet the patients' needs. The aim of this comment by the Committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition is to provide a clinical practice guide to ENS, based on the available evidence and the clinical expertise of the authors. Statements and recommendations are presented, and future research needs highlighted, with a particular emphasis placed on a practical approach to ENS.Among the wide array of enteral formulations, standard polymeric feeds based on cow's-milk protein with fibre and age adapted for energy and nutrient content are suitable for most paediatric patients. Whenever possible, intragastric is preferred to postpyloric delivery of nutrients, and intermittent feeding is preferred to continuous feeding because it is more physiological. An anticipated duration of enteral nutrition (EN) exceeding 4 to 6 weeks is an indication for gastrostomy or enterostomy. Among the various gastrostomy techniques available, percutaneous endoscopic gastrostomy is currently the first option. In general, both patients and caregivers express satisfaction with this procedure, although it is associated with a number of well-recognised complications. We strongly recommend the development and application of procedural protocols that include scrupulous attention to hygiene, as well as regular monitoring by a multidisciplinary nutrition support team to minimise the risk of EN-associated complications.

Jejunal feeding tubes can be efficiently and independently placed by intensive care unit teams

BACKGROUND

Nutrition support is an important therapeutic measure in critically ill patients. Several studies have shown that the enteral route is preferable to the parenteral route. Insertion of a feeding tube beyond the ligament of Treitz combined with continuous gastric drainage will reduce regurgitation and probably also the rate of nosocomial pneumonia. This study was conducted to assess the safety, success rate, and time required to establish jejunal nutrition by the fluoroscopy-guided technique in intensive care unit (ICU) patients.

METHODS

This was a prospective observational study in the ICUs of a 300-bed and a 600-bed community hospital. Indications were large gastric residuals during attempted gastric feeding, severe acute pancreatitis, or recurrent aspiration. Feeding tubes were introduced by the ICU staff at bedside under fluoroscopic guidance (a senior ICU physician and a resident or a registered ICU nurse). The correct jejunal position was documented by the application of a radiopaque contrast medium through the tube. After confirmation of the correct position, jejunal tube feeding was immediately started.

RESULTS

The insertion procedure in 38 patients lasted a median of 17 minutes. The median time from decision to place the tube until start of enteral feeding was 141 minutes. The success rate was 84.2%. No adverse events were observed.

CONCLUSIONS

Fluoroscopic placement of a jejunal feeding tube at the bedside is fast, is safe, and has a high success rate when performed by well-trained ICU staff. Using this method makes the ICU team more self-sufficient when critically ill patients require enteral nutrition and no gastroenterologist is available.

A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients

Introduction

To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU).

Methods

Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically.

Results

A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the post-pyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 - 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 - 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 - 13.0 hours) compared to 12.3 hours (8.9 - 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 - 288 Kcal) and 3.5 g (0 - 15 g) compared to 167 Kcal (70 - 411 Kcal) and 6.5 g (2.8 - 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar.

Conclusions

Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complications

Trial Registration

Clinical Trial: anzctr.org.au:ACTRN12606000367549

Insertion of Post-Pyloric Feeding Tubes in the ICU is Not as Difficult as we Thought

Post-pyloric feeding has been shown to be beneficial compared to gastric feeding in terms of calories delivered, length of intensive care unit stay and possibly rates of ventilator-associated pneumonia and mortality. It has often been disregarded as taking too long or requiring expensive equipment, but we have established a rapid, safe, cheap and reliable technique for inserting post-pyloric feeding tubes.

Fluoroscopically guided nasojejunal enteral tube placement in infants and young children

OBJECTIVE

The purpose of this study was to evaluate the feasibility, clinical effectiveness, and safety of fluoroscopically guided placement of a nasojejunal enteral tube in infants and young children.

CONCLUSION

Fluoroscopically guided placement of a nasojejunal enteral tube is feasible, effective, and safe for infants and young children.

Comparison of a new unguided self-advancing jejunal tube with the endoscopic guided technique: a prospective, randomized study

OBJECTIVE

To compare the success rate of correct jejunal placement of a new self-advancing jejunal tube with the gold standard, the endoscopic guided technique, in a comparative intensive care unit (ICU) patient population.

DESIGN

Prospective, randomized study.

SETTING

Two medical ICUs at a university hospital.

PATIENTS

Forty-two mechanically ventilated patients with persisting intolerance of intragastric enteral nutrition despite prokinetic therapy.

METHODS

Patients were randomly assigned to receive an unguided self-advancing jejunal feeding tube (Tiger Tube) or an endoscopic guided jejunal tube (Freka Trelumina). Primary outcome measure was the success rate of correct jejunal placement after 24 h.

RESULTS

Correct jejunal tube placement was reached in all 21 patients using the endoscopic guided technique whereas the unguided self-advancing jejunal tube could be placed successfully in 14 out of 21 patients (100% versus 67%; P = 0.0086). In the remaining seven patients, successful endoscopic jejunal tube placement was performed subsequently. Duration of tube placement was longer in the unguided self-advancing tube group (20 +/- 12 min versus 597 +/- 260 min; P < 0.0001). Secondary outcome parameters (complication rate, number of attempts, days in correct position with accurate functional capability, days with high gastric residual volume, length of ICU stay, ICU mortality) were not statistically different between the two groups. No potentially relevant parameter predicting the failure of correct jejunal placement of the self-advancing tube could be identified.

CONCLUSIONS

Success rate of correct jejunal placement of the new unguided self-advancing tube was significantly lower than the success rate of the endoscopic guided technique.

A novel endoscopic delivery system for placement of a duodenal-jejunal implant for the treatment of obesity and type 2 diabetes

The EndoBarrier Delivery System is a unique product capable of reliably delivering an implant into the small intestine. Further improvements to the product can likely be made to facilitate tracking and improved navigation through the small bowel. This unique system and its related technology may have additional applications where access to the small bowel is desired such as drug delivery, diagnostic and therapeutic endoscopy and small bowel stent delivery.

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.

Motilin, ghrelin and related neuropeptides as targets for the treatment of GI diseases

Motilin and ghrelin are released from the upper gut during fasting, to stimulate gastric motility. Additional actions of ghrelin (e.g. changes in appetite, nausea or endocrine functions) improve the possibility of using ghrelin receptor agonists to treat complex disorders such as functional dyspepsia. However, changes in endocrine functions increase the risk of unacceptable side effects. By comparison, the more restricted prokinetic activity of motilin limits the therapeutic possibilities but improves the risk:benefit ratio. Compounds targeting both receptors are in development. Recently, additional peptides have been identified from preproghrelin (obestatin) and prepromotilin. These exert biological activity but their pathophysiological significance is unknown.

Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique?

BACKGROUND

Registered dietitian/registered nurse (RD/RN) teams were created to place small bowel feeding tubes (SBFT) at the bedside in intensive care unit (ICU) patients using an electromagnetic tube placement device (ETPD). The primary objective of this study was to evaluate the safety of placing feeding tubes at the ICU bedside using an ETPD. Secondary outcomes included success rate, cost, and timeliness of feeding initiation.

METHODS

Data were collected prospectively on 20 SBFT blind placements in ICU patients (control group). After implementing a protocol for RD/RN teams to place SBFTs with an ETPD, 81 SBFTs were placed (study group). Complications, success rate, number of x-rays after tube placement, x-ray cost, and time from physician order to initiation of feedings were compared between the groups.

RESULTS

No adverse events occurred in either group. Successful SBFT placement was 63% (12/19) in the control group and 78% (63/81) in the study group (not significant, NS). The median time between physician order for tube placement and feeding initiation decreased from 22.3 hours (control group) to 7.8 hours (study group, p = .003). The median number of x-rays to confirm correct placement was 1 in the study group compared with 2 in the control group (p = .0001), resulting in a 50% decrease in the mean cost for x-rays.

CONCLUSIONS

No adverse events occurred with the implementation of bedside feeding tube placement using an ETPD. In addition, SBFT placement with an ETPD by designated ICU RD/RN teams resulted in lower x-ray costs and more timely initiation of enteral feedings compared with blind placement.

Use of small-bore feeding tubes: successes and failures

PURPOSE OF REVIEW

Early enteral nutrition is the preferred option for feeding patients who cannot meet their nutrient requirements orally. This article reviews complications associated with small-bore feeding tube insertion and potential methods to promote safe gastric or postpyloric placement. We review the available bedside methods to check the position of the feeding tube and identify inadvertent misplacements.

RECENT FINDINGS

Airway misplacement rates of small feeding tubes are considerable. Bedside methods (auscultation, pH, aspirate appearance, air bubbling, external length of the tube, etc.) to confirm the position of a newly inserted small-bore feeding tube have limited scientific basis. Radiographic confirmation therefore continues to be the most accurate method to ascertain tube position. Fluoroscopic and endoscopic methods are reliable but costly and are not available in many hospitals. Rigid protocols to place feeding tubes along with new emerging technology such as CO2 colorimetric paper and tubes coupled with signaling devices are promising candidates to substitute for the blind placement method.

SUMMARY

The risk of misplacement with blind bedside methods for small-bore feeding tube insertion requires a change in hospital protocols.

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.

Important Facts About Intestinal Feeding Tube Placement

Enteral feeding is desirable when the gastrointestinal tract is functional because it allows better use of nutrients, is safer, and is more cost-effective than parenteral nutrition. Feeding through a gastric tube, however, is often not feasible in severely ill adults and children because of gastric paresis leading to recurrent episodes of gastroesophageal reflux with the risk of subsequent aspiration. Feeding into the small intestine (duodenum or jejunum) through a nasointestinal tube, therefore, is preferred. Unfortunately, no method of enteral feeding is risk free. This literature review addresses the following 10 topics: (a) the reasons why nasointestinal tube feeding is better tolerated by some patients, (b) candidates for nasointestinal tube feeding, (c) options for selecting nasointestinal tubes, (d) recommended methods for predicting the distance to insert nasointestinal tubes, (e) recommended methods for placing nasointestinal tubes, (f) how promotility medications work and whether they facilitate nasointestinal tube placement, (g) nasointestinal tube placement error rate, (h) methods of determining the internal location of nasointestinal tubes, (i) complications associated with nasointestinal tube use, and (j) other pertinent issues surrounding feeding through nasointestinal tubes. The available research evidence is summarized and recommendations for future work are suggested.

Evaluation of a technique for blind placement of post-pyloric feeding tubes in intensive care: application in patients with gastric ileus

OBJECTIVE

To evaluate a blind 'active' technique for the bedside placement of post-pyloric enteral feeding tubes in a critically ill population with proven gastric ileus.

DESIGN AND SETTING

An open study to evaluate the success rate and duration of the technique in cardiothoracic and general intensive care units of a tertiary referral hospital.

PATIENTS

20 consecutive, ventilated patients requiring enteral nutrition, where feeding had failed via the gastric route.

INTERVENTIONS

Previously described insertion technique-the Corpak 10-10-10 protocol-for post-pyloric enteral feeding tube placement, modified after 20 min if placement had not been achieved, by insufflation of air into the stomach to promote pyloric opening.

MEASUREMENTS AND RESULTS

A standard protocol and a set method to identify final tube position were used in each case. In 90% (18/20) of cases tubes were placed on the first attempt, with an additional tube being successfully placed on the second attempt. The median time for tube placement was 18 min (range 3-55 min). In 20% (4/20) insufflation of air was required to aid trans-pyloric passage.

CONCLUSIONS

The previously described technique, modified by insufflation of air into the stomach in prolonged attempts to achieve trans-pyloric passage, proved to be an effective and cost efficient method to place post-pyloric enteral feeding tubes. This technique, even in the presence of gastric ileus, could be incorporated by all critical care facilities, without the need for any additional equipment or costs. This approach avoids the costs of additional equipment, time-delays and necessity to transfer the patient from the ICU for the more traditional techniques of endoscopy and radiographic screening.