Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: a critical review

Introduction: A critical review of the pulmonary complications associated with blind placement of narrow‐bore nasoenteric tubes (NETs) is discussed. Preventive measures and placement techniques are addressed to decrease patient morbidity and mortality. Methods: A thorough database review was conducted to identify all randomized controlled and retrospective trials specifically addressing pulmonary complications from narrow‐bore NET placement. Five unique studies, comprising more than 9900 NET placements, were identified. On the basis of the literature reviewed, the authors identified 3 major complications associated with blind NET placement: patient mortality directly resulting from NET misplacement, incidence of tracheopulmonary malpositioning, and correlation between NET misplacement and mechanical ventilation. Results: Of the 9931 NET placements reviewed, there were 187 total improper tube placements in the tracheobronchial tree, which translates to a 1.9% mean overall malposition rate. Of these 187 misplacements, there were 35 (18.7%) reported pneumothoraces, at least 5 of which resulted in patient death. NET malpositioning was reported in 13%–32% of subsequent repositioning attempts. This increased risk exposes the patient population to a cumulative mortality from tracheobronchial malpositioning approaching >20%. Unexpectedly, of the 187 total misplacements, 113 (60.4%) of the patients were mechanically ventilated. Conclusions: Practitioners need to be aware of the potential for pulmonary complications associated with blind NET placement. Changes in institutional protocol should be considered to minimize unnecessary risks. As with any procedure, experienced personnel should be primarily used for tube placement and responsible for assisting others with less familiarity to learn the proper methods.     

2092例肠内营养置管方法分析

目的比较不同肠内营养置管方法的优缺点。方法1996年9月-2008年6月,共有2092例患者接受肠内营养支持。肠内营养置管方法包括床旁经鼻置螺旋型鼻肠管、X线引导下经鼻置鼻肠管、胃镜引导下经鼻置鼻肠管、术中经鼻置鼻肠管、空肠切开造口置空肠管、空肠穿刺造口置空肠管、胃切开造口术及内镜引导下经皮胃穿刺造口术。结果床旁经鼻置肠管32例,第2天23例鼻肠管的远端通过幽门到达小肠,另9例鼻肠管盘曲在胃腔内。X线引导下直接经鼻置鼻肠管61例,顺利通过幽门57例,另4例鼻肠管盘曲胃腔内。胃镜引导下经鼻置鼻肠管186例,术后经x线检查显示177例鼻肠管的远端位于小肠。腹部手术时,经鼻放置鼻肠管1628例,7例鼻肠管远端离开手术时放置的位置。空肠切开术放置空肠营养管56例,术后出现不全性肠梗阻2例、肠瘘1例。空肠穿刺造口术98例,2例空肠穿刺管移位脱出小肠。传统胃切开造口术19例,出现胃瘘1例。胃穿刺造口术12例,无并发症。结论肠内营养置管的方法有多种,具体采取哪种方法,需根据患者的原发病以及营养支持的时间决定。经鼻置鼻肠管是一种安全、简便、实用的方法。经皮穿刺胃造口术、空肠穿刺造口术将逐步替代传统的造口方法。     

可视气管导管用于颈部外伤手术插管的效果研究

目的：探讨可视气管导管用于颈部外伤手术插管效果。方法：选取本院76例颈部外伤手术患者,按随机数字表法将其分为试验组和对照组各38例,试验组采用可视气管导管插管,对照采用普通型加强导管插管,比较两组患者的插管时间、插管次数、插管过程中患者生命体征、插管并发症和导管置入后通气效果等指标的差异。结果：所有患者插管过程中生命体征平稳,无并发症发生,置入导管后通气效果良好。两组的生命体征指标比较差异均无统计学意义（P〉0.05）;试验组平均插管时间明显低于对照组,一次性插管成功率明显高于对照组,差异均有统计学意义（P〈0.05）。结论：可视气管导管用于颈部外伤手术插管效果满意,有助于提高患者一次性插管成功率,降低插管时间。     

Acute complications associated with bedside placement of feeding tubes.

Several types of feeding tubes can be placed at a patient's bedside; examples include nasogastric, nasointestinal, gastrostomy, and jejunostomy tubes. Nasoenteral tubes can be placed blindly at bedside or with the assistance of placement devices. Nasoenteric tubes can also be placed via fluoroscopy and endoscopy. Gastrostomy and jejunostomy tubes can be placed using endoscopic techniques. This paper will describe the indications and contraindications for different types of tubes that can be placed at the bedside and complications associated with tube placement. Complications associated with nasoenteral tubes include inadvertent malpositioning of the tube, epistaxis, sinusitis, inadvertent tube removal, tube clogging, tube-feeding-associated diarrhea, and aspiration pneumonia. Complications from percutaneous gastrostomy and jejunostomy tube placements include procedure-related mishaps, site infection, leakage, buried bumper syndrome, tube malfunction, and inadvertent removal. These complications will be reviewed, along with a discussion of incidence, cause, treatment, and prevention approaches.     

Pneumothorax following attempted nasogastric intubation for nutritional support

Nasogastric intubation is a routine procedure, performed daily by both medical and nursing staff. It is a simple procedure, but not without complications which can be life threatening. We present an unusual, life threatening complication which occurred when nasogastric intubation using a no. 8 polyurethane tube with its metal stilet resulted in a pneumothorax after intubation of the endotracheal tree in the presence of a cuffed endotracheal tube. We emphasize that the presence of a cuffed endotracheal tube should not be considered a safeguard against pulmonary intubation during nasogastric placement of a feeding catheter.     

盲探气管插管新技术的系统评价

目的评价盲探气管插管装置相对其他插管方法的效果。方法根据Cochrane Handbook质量评价标准评价纳入文献的质量，用RevMan 4．2软件对研究纳入文献进行Meta分析。结果描述性分析显示盲探气管插管装置与纤维支气管喉镜在插管平均时间、插管成功率及并发症3方面差别无统计学意义，但是前者成本低廉：盲探气管插管装置相对常规盲探插管方法在插管平均时间方面所需时间更短，减轻了患者痛苦。结论从整体角度看，盲探气管插管新技术效果好，并且成本低廉，适合在基层医院推广应用。     

Emergency tracheal intubation without drugs: outcome and one-year survival of medical patients not in cardiac arrest

Non-medicine-assisted tracheal intubation in prehospital trauma is associated with a dismal prognosis. We wished to study the outcome of medical patients who underwent non-medicine-assisted tracheal intubation. This retrospective study of patients attending our university hospital emergency department was conducted over seven years. The tracheal intubation database was analysed to identify medical patients not in cardiac arrest undergoing tracheal intubation without medicines. Intensive care unit, hospital, 12-month mortality and patients' residence at 12 months were recorded. Eighty patients were identified who met inclusion criteria. The most common reason for intubation was definite airway compromise due to decreased conscious level (62.5%), then respiratory failure (26.3%) and finally potentially compromised airway due to a decreased conscious level (11.2%). Eighty-eight percent of patients with a definitely compromised airway were successfully intubated at first attempt compared with 66.7% of patients with a potentially compromised airway or respiratory failure (P= 0.03). Of 75 patients with complete data, 30 (40%) were survivors at 12 months, with all but two (6.7%) living at home. Non-medicine-assisted laryngoscopy leads to an increased first time tracheal intubation failure rate in patients with intact airway reflexes and, therefore, cannot be recommended as best practice.     

A technique for positioning nasoenteral feeding tubes

The use of nasoenteral alimentation in many neurologically depressed patients is a common practice. These patients are also at increased risk of sustaining feeding tube malplacement. The morbidity and mortality involving feeding tube malposition in these debilitated patients is high. In this paper, we present four case reports of morbidity, with one resultant mortality, associated with small-bore nasoenteral tube malposition. We are also suggesting a nasoenteral intubation protocol which we feel will decrease the incidence of feeding tube malplacement.     

943例住院眼外伤病例分析

目的探讨眼外伤的发病率与性别及年龄的关系;眼外伤类型、就诊时间及并发症、后遗症的因果关系。方法对943例患者按年度统计其与眼科住院总数的比例;统计眼外伤性别,职业,各个年龄层的发病率;统计致伤物与眼外伤类型,就诊时间与并发症,后遗症的发病率及严重性。结果显示男性农民,工人发病率最高,20～40岁青壮年占多数,其次为11～20岁青年学生,类型以铁器致眼球穿通伤为最多,因就诊时间太晚,发生眼内炎为最严重的并发症。结论眼外伤患者来自外地各县的例数占80%以上,就诊时间超过3～6天以上超过50%。加强劳保宣传,加强基层眼科技术力量,及时就诊,就地处理,对减少眼外伤的并发症、后遗症很有必要。     

不同部位行静脉PICC置管的临床比较

目的:探讨不同部位行静脉PICC置管的临床疗效比较。方法:搜集2016年7月~2018年9月在本院行PICC治疗的126例长期输液肿瘤患者的病历资料进行回顾性分析,其中将实施肘上部置管的66例患者作为肘上组,60例肘下部置管的患者作为肘下组,观察两组患者在肿瘤科长期输液患者置管过程中的并发症发生率以及患者的舒适度,并进行对比分析。结果:①肘上组置管并发症发生率(12.1%)较肘下组(26.7%)低,P<0.05;②肘上置管组患者舒适度更高,χ~2=20.225,P<0.05。结论:长期输液患者PICC置管中,肘上置管较肘下置管能降低置管并发症、提高患者舒适度,如患者条件适合,可作为PIC置管首选部位。     

Use of Temporary Enteral Access Devices in Hospitalized Neonatal and Pediatric Patients in the United States

Background: Temporary enteral access devices (EADs), such as nasogastric (NG), orogastric (OG), and postpyloric (PP), are used in pediatric and neonatal patients to administer nutrition, fluids, and medications. While the use of these temporary EADs is common in pediatric care, it is not known how often these devices are used, what inpatient locations have the highest usage, what size tube is used for a given weight or age of patient, and how placement is verified per hospital policy. Materials and Methods: This was a multicenter 1‐day prevalence study. Participating hospitals counted the number of NG, OG, and PP tubes present in their pediatric and neonatal inpatient population. Additional data collected included age, weight and location of the patient, type of hospital, census for that day, and the method(s) used to verify initial tube placement. Results: Of the 63 participating hospitals, there was an overall prevalence of 1991 temporary EADs in a total pediatric and neonatal inpatient census of 8333 children (24% prevalence). There were 1316 NG (66%), 414 were OG (21%), and 261 PP (17%) EADs. The neonatal intensive care unit (NICU) had the highest prevalence (61%), followed by a medical/surgical unit (21%) and pediatric intensive care unit (18%). Verification of EAD placement was reported to be aspiration from the tube (n = 21), auscultation (n = 18), measurement (n = 8), pH (n = 10), and X‐ray (n = 6). Conclusion: The use of temporary EADs is common in pediatric care. There is wide variation in how placement of these tubes is verified.     

经肝动脉介入治疗并发胆囊坏死(附3例报告)

目的探讨经肝动脉介入治疗并发胆囊坏死的发生原因和防治措施。方法报告3例经肝动介入治疗并发胆囊坏死的病例,均经手术病理证实。并结合文献资料分析这一并发症发生原因,及治疗措施。结果近几年来我们共做经肝动脉介入治疗700余例次,并胆囊坏死3例(0.4%)。经肝介入治疗并发胆囊坏死是一常见并发症,其发生原因是多方面的。插管困难,反复操作是该并发症发生的主要原因。结论胆囊坏死是经肝动脉介入治疗比较常见的严重并发症之一,在医疗工作中应引起足够的重视,使这一并发症的发生率降至最低限度。     

Peritonitis after gastrostomy tube replacement: a case series and review of literature

Background: The placement of feeding gastrostomy (G) tubes through a percutaneous endoscopic gastrostomy (PEG) technique has become common because of its simplicity and safety. The majority of the serious complications are reported to occur within a few days of initial tube placement and happen in fewer than 3% of cases. Long‐term reported complications of this procedure include occlusion or breakage of the G‐tube, requiring reinsertion. This report describes the complication of intraperitoneal placement and the development of peritonitis after replacement of an established PEG tube and reviews the pertinent world literature. Methods: A retrospective review of cases of intraperitoneal insertion of replacement G‐tubes was done as well as a Medline search for cases of intraperitoneal insertion of replacement G‐tube or development of peritonitis after replacement tube insertion. Results: Three new cases of inadvertent intraperitoneal insertion of a replacement G‐tube in adult patients with mature tracts are reported. An additional 5 cases have been previously described in adults. Significant morbidity was associated with this complication, and 4 deaths were related to it. Methods used to determine whether the replacement G‐tube was intragastric were not uniform. Conclusions: There have been few reports of intraperitoneal insertion of replacement G‐tubes in patients with mature (>30 days) stoma sites. The cases presented in this report highlight for the clinician the importance of considering this complication, particularly if there are any difficulties with the reinsertion. Prospective studies are needed to determine the frequency of this complication and the optimal protocol for PEG replacement.     

肠内肠外营养治疗的并发症的发生及处理

肠内肠外营养支持是近年来广泛开展的治疗措施.然而,在实施中常因技术操作不当或营养物制备不完善而产生多种并发症,主要有:(1)技术性并发症,如气胸、动静脉损伤、导管错位、空气栓塞、静脉血栓形成、导管堵塞等.此类并发症近年已少见.(2)感染.近年加强护理及严格无菌技术其发生率已明显降低.(3)代谢并发症,包括高糖及低糖血症、肝功异常、蛋白代谢及脂代谢紊乱等.只要提高认识加强预防均可避免其发生.     

Clinical audit: optimal positioning of endotracheal tubes in neonates

BACKGROUND: The malposition of endotracheal tubes (ETTs) can be associated with endo-bronchial intubation or accidental extubation. A variety of methods have been reported for predicting insertional length (IL) including weight, nasal-tragus length (NTL) and sternal length (STL) measurements. In our unit no consistent predictor method was being used. AIM: To audit the proportion of endotracheal tubes that required a significant position change after oral intubation. Our standard set was that the endotracheal tube should be in a satisfactory position in > 80% of cases. If not met, practice would then be re-audited after a consistent predictor method had been implemented. METHODS: Data regarding changes in endotracheal tube position were collected. Significant position changes were defined as adjustments > 0.5 cm. RESULTS: Twenty two babies were included in the initial audit, and only 73% of endotracheal tubes had a satisfactory position. Thirty six babies were included in the re-audit and when the nasal-tragus length predictor was used, 94% of endotracheal tubes had a satisfactory position, meeting the standard. CONCLUSION: The nasal-tragus length predictor improved the accuracy of endotracheal tube positioning after oral intubation. It is a simple, fast, reproducible method and can be used in everyday practice to help avoid significant endotracheal tube malposition.     

输卵管内节育器的研究及应用现状

输卵管绝育术是中国育龄人群应用较多的避孕节育方法之一。但绝育术是有创伤手术,存在一定并发症及后遗症,可接受性差。因此,提供高效、安全、可复、微创或无创的女性避孕绝育方法是目前研究的重点。最近,输卵管内节育器（intra-tubal device,ITD）的研究取得了新的进展,ITD为非创伤性手术,不良反应及并发症都很少,使用者如需要再生育,取出ITD即可恢复,其有可能取代传统的输卵管绝育术,为育龄妇女提供一种新的、无创伤性及可逆性的避孕节育方法。     

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.     

Endotracheal intubation skills of medical students.

The ability and confidence of clinical medical students to insert endotracheal tubes correctly and quickly and to recognize oesophageal misplacement was evaluated. Ten (33%) of the medical students intubated the trachea correctly at their first attempt but 14 (47%) incorrectly identified the position of the endotracheal tube. However, recognition improved by their second and third attempts (70% and 80% respectively). Ninety-three percent of students intubated correctly on their third attempt. Although medical students can obtain better results at correct tube placement with repeated attempts under optimum conditions--a practice effect--and do better at recognizing correct tube placement there is still a persistent failure to recognize endotracheal tube misplacement, ie oesophageal intubation. It is the ability to recognize oesophageal intubation promptly that is a life-saving skill. This essential skill should be taught during the introductory anaesthesia programme through the use of clinical patients.     

Monitoring feeding tube placement.

The purpose of this literature review is to describe currently available bedside methods to determine feeding tube placement. Described first are methods used at the time of blind insertion to distinguish between gastric and respiratory placement and gastric and small-bowel placement. Discussed next are methods used after feedings are initiated to determine if the tube has remained in the desired position in the gastrointestinal tract. Some of the methods are research-based, whereas others are opinion-based. The level of accuracy of the methods discussed in the review varies widely. No sure non-radiographic method exists to differentiate between respiratory, esophageal, gastric, and small bowel placement of blindly inserted feeding tubes in the fed or unfed state. However, a combination of some of the simpler and more accurate methods may be used to guide feeding tube placement during insertion and help identify the point at which an abdominal radiograph is most likely to confirm the desired location. In addition, methods described in this review can help determine when a radiograph is needed to confirm that a feeding tube has remained in the correct position after the initiation of feedings. Minimizing the number of radiographs taken to assure correct tube placement is important, especially in young children and in the critical care setting where the need for radiographs for other reasons is common.