Agreement Between Epigastric Auscultation and pH Measurement in the Confirmation of Nasoenteral Tube Placement

AIM

This study aimed to evaluate the agreement between epigastric auscultation and pH measurement in the confirmation of nasoenteral tube placement.

METHOD

A cross-sectional study carried out in a medium-sized private hospital in the interior of the state of São Paulo. Forty-nine patients who were submitted to ninety insertion procedures and confirmation of tube placement. aimed at evaluating the agreement of clinical methods used by nurses to confirm the positioning of a nasoenteral tube inserted blindly at the bedside, by measuring the parameters of sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

The epigastric auscultation was the method that presented the highest sensitivity (100.0%), but lower specificity (2.0%). The measurement of the pH presented lower sensitivity (63.0%) than the auscultation, however, higher specificity (58%). Moreover, the positive predictive value of the pH measurement was 55% and the negative predictive value was 66%. There was no agreement between the epigastric auscultation and the pH measurement with the radiography.

CONCLUSION

The pH measurement did not allow for distinguishing between gastric and enteric positioning, due to the similarity of the esophageal and pulmonary pH with the pH of the intestine. Furthermore, external factors such as the use of medication and reduced fasting time may interfere with the pH value.

The accuracy of methods for determining the internal length of a nasogastric tube in adult patients: a systematic review

BACKGROUND

Blind insertion of nasogastric (NG) tubes is performed for several reasons: nutrition and medication administration, gastric aspiration/decompression, and other, diagnostic reasons. Accidental intraesophageal and intestinal placement is common, and increases the risk of serious complications. Therefore, accurate determination of the internal length of the NG tube before placement is considered a prerequisite for achieving correct gastric positioning.

OBJECTIVES

We aimed to identify, assess, and summarize the evidence on the accuracy of methods for determining the internal length of an NG tube in adults.

METHODS

Cochrane Library, Excerpta Medica database (EMBASE), PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science were searched up to 31 January, 2022. Studies were eligible when reporting data on the accuracy of methods for determining internal NG tube length in adults. Study selection, risk-of-bias assessment, and data extraction were performed independently by 2 investigators. Risk-of-bias was assessed using the Cochrane Risk-of-Bias Tool and the Joanna Briggs Institute Critical Appraisal Checklist for Cross Sectional Studies. A narrative synthesis of the results was then conducted.

RESULTS

Twelve articles were included in this review. All studies were observational, cross-sectional in nature, except for 1 randomized controlled trial. Ten methods for determining the internal length of an NG tube were described. Correctly positioned NG tubes ranged from 13% to 99%. Results showed that the tip of the nose-earlobe-xiphoid distance (NEX) + 10 cm (mean: 59.9-60.7 cm) and (NEX × 0.38696) + 30.37 + 6 cm (mean: 56.6-56.7 cm) could potentially result in accuracy as high as 97.4% and 99.0%, respectively.

CONCLUSIONS

Current data do not provide conclusive evidence of 100% accuracy in finding a correctly placed NG tube when using a method for determining the internal length. Blind placement, using any of the documented methods, cannot be considered safe without additional verification of tube tip positioning. Furthermore, using any of these 10 methods does not reduce the risk of pulmonary intubation.This systematic review was registered at https://www.crd.york.ac.uk/PROSPERO/ as CRD42021243180.

Nasogastric tube insertion difficulty in a patient with a large goiter: A case report

Airway management under anesthesia is given special attention in patients who have large goiters. Nasogastric tube insertion may be difficult in intubated patients with large goiters. Several methods have been proposed to facilitate the insertion of nasogastric tubes in patients with endotracheal intubation; however, a standard insertion method has not been established. A 33-year-old man was admitted to our otolaryngology department for right thyroid lobectomy to remove a larger goiter. A thyroid computed tomography scan revealed a huge cystic mass with tracheal displacement. Although difficult intubation was expected, endotracheal intubation was performed successfully. An anesthesiologist attempted nasogastric tube insertion via the right nostril; however, this was not successful. Next, an angiography catheter was placed in a nasogastric tube, and the nasogastric tube was gently inserted with the patient’s neck in mild flexion. This attempt also failed. Finally, the nasogastric tube was gently inserted via anterior displacement of the cricoid cartilage. The nasogastric tube advanced up to 60 cm. Surgery was performed, and the patient was discharged with no complications on postoperative day 8.

Intra-abdominal nasogastric tube placement following inadvertent nasopharyngeal perforation

We report the case of a patient who had a nasogastric tube inserted following cardiac surgery that was determined to be appropriately sited on chest X-ray. Following initiation of nasogastric feeding, however, the patient became acutely unwell. Subsequent computed tomography imaging demonstrated that the nasogastric tube had perforated through the posterior nasopharynx and passed through the mediastinum into the abdominal cavity. A laparotomy and washout was required, and following a prolonged intensive care stay with multiple further interventions, the patient ultimately survived to discharge. Pharyngeal wall perforation is a rare but serious complication of attempted nasogastric tube insertion. Risk factors include the need for repeated attempts and patients with an altered mental state. The appropriate steps in confirming the position of nasogastric tubes both clinically and radiologically are reviewed in the context of this rare and serious complication.

Enteral Nutrition via Nasogastric Tube for Refeeding Patients With Anorexia Nervosa: A Systematic Review

Weight restoration is an important first step in treating patients with anorexia nervosa (AN), because it is essential for medical stabilization and reversal of long-term complications. Tube feeding may help facilitate weight restoration, but its role in treatment remains unclear. This study aimed to review the literature describing the efficacy, safety, tolerance, and long-term effects of nasogastric (NG) refeeding for patients with AN. Four electronic databases were systematically searched through May 2018. Boolean search terms included "anorexia nervosa," "refeeding," and "nasogastric tube feeding." Ten studies were eligible for inclusion: 8 retrospective chart reviews, 1 prospective cohort, and 1 randomized controlled trial. Nine of the studies were performed in-hospital. In 8 studies, NG nutrition resulted in an average rate of weight gain exceeding 1 kg/wk. In 4 of 5 studies including an oral-only control group, mean weekly weight gain and caloric intake were significantly higher in tube-fed patients. Six studies provided prophylactic phosphate supplementation, all with <1% occurrence rate of refeeding hypophosphatemia. Seven studies reported on other physiological disturbances, 6 evaluated medical and gastrointestinal side effects, 3 considered psychological outcomes, and 4 assessed patients postdischarge. Results indicated that NG feeding was not associated with an increased risk for adverse outcomes. Overall, in these studies, NG nutrition was considered safe and well tolerated, and effectively increased caloric intake and rate of weight gain in patients with AN. However, results are limited by weaknesses in study designs, and more rigorous methods are needed for development of evidence-based, standardized refeeding protocols.

Comparison of Two Methods for Estimating the Tip Position of a Nasogastric Feeding Tube: A Randomized Controlled Trial

BACKGROUND

Several studies have shown that the nose-earlobe-xiphoid distance (NEX) is inadequate to estimate the insertion length of nasogastric tubes. An alternative approach tested in these studies, which leads to > 90% well-placed nasogastric tubes, used a corrected calculation of the NEX: (NEX × 0.38696) + 30.37. The primary aim of this study was to determine whether using the corrected NEX was more successful than the NEX in determining the insertion length. The secondary aim was to investigate the likelihood to successfully obtain gastric aspirate.

METHODS

Adult patients in a general hospital (N = 215) needing a nasogastric tube were randomized to the control (NEX) or intervention group (corrected NEX). Tip positioning was verified using X-ray. Correct tip positioning was defined as between 3 and 10 cm under the lower esophageal sphincter (LES).

RESULTS

In >20% of all patients, both methods underestimated the required tube length for correct positioning. The NEX showed an overestimation (17.2%) of the insertion length (>10 cm under the LES) compared with the corrected NEX (4.8%). There was no difference (P = 0.938) between the 2 groups in obtaining gastric aspirate (55.6% vs 56%). However, correct tip positioning resulted in a fourfold increase of obtaining gastric aspirate.

CONCLUSIONS

Both methods resulted in a high risk of incorrectly placed tubes due to malposition of the tip near the LES or distal esophagus. This may increase the risk of reflux and pulmonary aspiration. Based on these results, the development of more reliable methods requires consideration.

Enteral Nutrition: Options for Short-Term Access

The preferred method of nutrition support in the presence of a functional gastrointestinal tract is enteral nutrition (EN). Many factors contribute to the selection process for the type of enteral access device to be used. Short-term enteral access tubes are placed into the nares or, sometimes, orally, usually at bedside. The short-term access provides a means to meet patient nutrient needs and can provide a chance to assess tolerance of the tube feedings if more permanent long-term placement is determined to be required. Access for nutrition support does not come without a risk; it can be challenging, requiring an individualized approach for each patient. The selection type and access location can greatly impact the success of EN. The most advantageous tube choice must be determined carefully, taking into account the multiple considerations reviewed in this paper.

Head and Neck Cancer Tumor Seeding at the Percutaneous Endoscopic Gastrostomy Site

The National Institutes of Health National Cancer Institute estimates that over 13,000 new cases of head and neck cancer (HNC) will be diagnosed in 2017. Patients with HNC often require enteral nutrition (EN) via gastrostomy tube to provide nutrition support and hydration because of tumor obstruction of the oropharynx and/or cumulative effects of chemoradiation therapy. The percutaneous endoscopic gastrostomy (PEG) tube has become the preferred technique for EN access because placement is considered a minimally invasive procedure. There are 3 methods of PEG placement: Gauderer-Ponsky "pull," Sachs-Vine "push," and Russell "push" method. The Gauderer-Ponsky "pull" method has become the preferred method of PEG placement. It has been previously reported that the rate of stomal metastasis can be 0.5%-1% of those undergone the Gauderer-Ponsky "pull" method that is consistent with HNC morphology. Other researchers believe the rate may be as high as 0.5%-3%. This article reviews the 3 methods of PEG placement, as well as all potential complications, including metastatic seeding at the PEG site. In addition, 1 additional case of tumor seeding at the PEG site will be reviewed. Consideration for avoidance of the Gauderer-Ponsky pull method of PEG placement or other methods of feeding tube placement where the gastrostomy tube has to pass through the oral cavity before exiting the abdominal wall in patients with squamous cell carcinoma of the head and neck should be considered.

Use of Nasogastric Feeding Tubes for Children at Home: A Template for Caregiver Education

There is a lack of knowledge on the part of caregivers who need to place nasogastric (NG) tubes in children for enteral nutrition therapy. This article provides the rationale, best practices, and a template for caregiver education. Canadian and Australian programs have excellent patient education materials. They have shared these step-by-step procedures for healthcare professionals to provide to caregivers to whom they are teaching placement and care of NG tubes.

Ultrasound-guided nasogastric feeding tube placement in critical care patients

BACKGROUND

Nasogastric feeding tube (NGT) placement is a common practice performed in intensive care units (ICUs). Complications due to the improper placement of NGT are well known. In this prospective descriptive study, the effectiveness of ultrasound (US)-guided NGT placement was investigated.

MATERIALS AND METHODS

Fifty-six mechanically ventilated patients monitored in the ICU were included. A linear US probe was transversely placed just cranial to the suprasternal notch, and the concentric layers of the esophagus were attempted to be viewed on the posterolateral side of the trachea (generally left) by shifting the probe. If the esophagus can be seen, an attempt was made to insert the NGT under real-time visualization of ultrasonography. Furthermore, gastric placement of the NGT tip was confirmed with abdominal radiograph.

RESULTS

A total of 56 patients were included in the study. For 52 (92.8%), the NGT image was obtained during placement within the esophagus. For 3 (5.3%), the esophagus could not be seen by US, and NGT was placed blindly. For 1 patient, we could not detect passing of the NGT into the stomach despite the successful visualization of esophagus. In this patient, NGT was radiographically detected in the trachea after the procedure.

CONCLUSION

This study revealed that passing of the NGT through the esophagus could be visualized at a high rate in real-time US among ICU patients. These data suggest that ultrasonographic visualization of the upper esophagus during NGT insertion can be used as an adjuvant method for confirmation of correct placement.

Nasogastric tube placement and verification in children: review of the current literature

Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is a common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Society for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all healthcare professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.

Confirmation of gastric tube bedside placement with the sky blue method

BACKGROUND

The purpose was to review our experiences and determine if applying the sky blue method is reliable in confirming gastric tube (GT) placement in neonates.

METHODS

The study population consisted of 44 infants (55 placements) who were admitted to the Takeda General Hospital between April 2012 and March 2013 and who required GT exchange. The sky blue method using indigo carmine (IC) was indicated for planned tube exchange only. Diluted IC was injected into the gastric space via the old GT just before the tube exchange. The tube was exchanged using a standard method. Then, we checked whether the diluted IC could be collected through the new GT or not.

RESULTS

The reasons for GT placement were a gestational age of < 35 weeks in 31 (56.4%), poor sucking or swallowing disorders in 17 (30.4%), and respiratory disorders in 7 (12.7%) of the 55 placements. GT placement using the sky blue method was considered successful in 52 placements (94.4%), with the remaining 3 placements (5.6%) considered to be failures due to the inability to obtain IC from the gastric space. No adverse events were observed during the tube exchange period.

CONCLUSION

Based on the results, the sky blue method can be considered to be reliable method for the confirmation of GT placement. These results also suggest that the number of radiologic evaluations performed to confirm correct replacement of the GT in infants can be reduced in the future.