Determination of a practical pH cutoff level for reliable confirmation of nasogastric tube placement

Background: Enteral feeding is a common method of nutrition support when oral intake is inadequate. Confirmation of correct nasogastric (NG) tube placement is essential. Risks of morbidity/mortality associated with misplacement in the lung are well documented. Studies indicate that pH ≤4 confirms gastric aspirate, but in pediatrics, a pH of gastric aspirate is often >4. The goal of this study was to determine a reliable and practical pH value to confirm NG tube placement, without increasing the risk of not identifying a misplaced NG tube. Methods: Pediatric inpatients older than 4 weeks receiving enteral nutrition (nasogastric or gastrostomy) were recruited over 9 months. Aspirate samples were pH tested at NG tube placement and before feedings. If pH >4, NG tube position was confirmed by chest radiograph or further investigations. In addition, intensive care unit (ICU) patients who required endotracheal suctioning were recruited, and endotracheal aspirate samples were pH tested. Results: A total of 4,330 gastric aspirate samples (96% nasogastric) were collected from 645 patients with a median (interquartile range [IQR]) age of 1.0 years (0.3–5.2 years). The mean (standard deviation [SD]) pH of these gastric samples was 3.6 (1.4) (range, 0–9). pH was >4 in 1,339 (30.9%) gastric aspirate samples, and of these, 244 were radiographed, which identified 10 misplaced tubes (1 with pH 5.5). A total of 65 endotracheal aspirate samples were collected from 19 ICU patients with a median (IQR) age of 0.6 years (0.4–5.2 years). The mean (SD) pH of these samples was 8.4 (0.8) (range, 6–9.5). Conclusion: Given that the lowest pH value of endotracheal aspirate sample was 6, and a misplaced NG tube was identified with pH 5.5, it is proposed that a gastric aspirate pH ≤5 is a safer, reliable, and practical cutoff in this population.     

Comparison of tolerance and change of intragastric pH between early nasogastric and nasojejunal feeding following resection of colorectal cancer

BACKGROUND: Early feeding after injury has been suggested to decrease morbidity and mortality in many studies. Intrajejunal feeding has been preferred over intragastric feeding due to earlier return of peristalsis following laparotomy. Few reports, however, have focused on the tolerance and change in pH inside the stomach after intragastric and intrajejunal feeding. The aim of the present study was the assessment of (1) the postoperative tolerance of intragastric and intrajejunal feeding, and (2) the effect of intragastric and intrajejunal feeding on intragastric pH value. MATERIALS AND METHODS: From April 1998 to October 2002, 140 patients underwent colon resection for colorectal cancer entered the study. The patients were divided into seven groups of 20 patients each. Group I was kept on NPO for 1 week. Groups II, III, and IV were fed through a nasogastric (NG) tube from the second to the sixth postoperative day (POD) with low residual (Osmolite-HN), high-fat (Pulmocare), and glutamine-containing (AlitraQ) enteral formulas, respectively. Groups V, VI, and VII were fed through a nasojejunal (NJ) tube from the second to the sixth POD with Osmolite-HN, Pulmocare, and AlitraQ, respectively. Feeding started at 500 kcal/500 cm(3)/d. If the patient tolerated the formula well, feeding increased to 1,500 kcal/1,500 cm(3)/d the following day. Intragastric pH was measured preoperatively and then twice daily until the sixth POD. RESULTS: Poor tolerance occurred in 14 patients (23%) with NG tube feeding and 18 patients (30%) with NJ tube feeding. The pH value of intragastric juice increased significantly once NG feeding started (3.67+/-1.33 on the third POD; 4.28+/-1.26 on the sixth POD). However, the pH value remained low after NJ feeding was started (2.09+/-1.46 on the third POD; 2.14+/-1.49 on the sixth POD). CONCLUSIONS: This series suggests that (1) the majority of patients can tolerate early feeding well following resection of colorectal cancer, and NJ feeding is not necessarily better tolerated than NG feeding; (2) early NG, but not the NJ feeding, can significantly elevate the intragastric pH value in patients who underwent resection of colorectal cancer. NG may be more effective than NJ feeding in preventing stress-induced gastropathy by elevating the pH value of intragastric juice.     

Outcomes of Infants With Home Tube Feeding: Comparing Nasogastric vs Gastrostomy Tubes

Background: The aim of this study was to determine the tube‐related complications and feeding outcomes of infants discharged home from the neonatal intensive care unit (NICU) with nasogastric (NG) tube feeding or gastrostomy (G‐tube) feeding. Materials and Methods: We performed a chart review of 335 infants discharged from our NICU with home NG tube or G‐tube feeding between January 2009 and December 2013. The primary outcome was the incidence of feeding tube–related complications requiring emergency department (ED) visits, hospitalizations, or deaths. Secondary outcome was feeding status at 6 months postdischarge. Univariate and multivariate analyses were conducted. Results: There were 322 infants discharged with home enteral tube feeding (NG tube, n = 84; G‐tube, n = 238), with available outpatient data for the 6‐month postdischarge period. A total of 115 ED visits, 28 hospitalizations, and 2 deaths were due to a tube‐related complication. The incidence of tube‐related complications requiring an ED visit was significantly higher in the G‐tube group compared with the NG tube group (33.6% vs 9.5%, P < .001). Two patients died due to a G‐tube–related complication. By 6 months postdischarge, full oral feeding was achieved in 71.4% of infants in the NG tube group compared with 19.3% in the G‐tube group (P < .001). Type of feeding tube and percentage of oral feeding at discharge were significantly associated with continued tube feeding at 6 months postdischarge. Conclusion: Home NG tube feeding is associated with fewer ED visits for tube‐related complications compared with home G‐tube feeding. Some infants could benefit from a trial home NG tube feeding.     

Self‐Insertion of a Nasogastric Tube for Home Enteral Nutrition

Background: Enteral tube feeding can be a source of discomfort and reluctance from patients. We evaluated for the first time the tolerability of self‐insertion of a nasogastric (NG) tube for home enteral nutrition (EN). Materials and Methods: All patients requiring enteral tube feeding for chronic diseases were enrolled in a therapeutic patient education (TPE) program at Nancy University Hospital. Results: In our department, between November 2008 and August 2012, 66 patients received EN with an NG tube. Twenty‐nine of 66 had self‐insertion of the NG tube (median age, 44 years), 17 had an anatomical contraindication, and 20 were excluded because of cognitive disability or language barrier or refusal. Twenty‐eight of 29 patients completed the TPE program. One patient died of pancreatic cancer in palliative care during the study. Median follow‐up was 20 months (interquartile range [IQR], 4–31). Median gain weight was 3.1 kg (IQR, 1.8–6.0) (P = .0002). Median duration of self‐insertion of the NG tube was 3 months (IQR, 2–5), and it was well tolerated by all 29 patients. Two patients described minor adverse events: abdominal pain and nausea for 1 patient and epistaxis leading to temporary discontinuation of EN for another patient. A group of 10 consecutive patients previously had a long‐term NG tube for EN. If they had the choice between a self‐inserted NG tube and a long‐term NG tube, all 10 patients reported they would prefer to start again with the self‐inserted NG tube. Conclusion: This pilot study suggests that self‐insertion of an NG tube may be efficacious and well tolerated in patients receiving EN for chronic conditions.     

Audit of nasogastric feeding practice at two acute hospitals: is early enteral feeding associated with reduced mortality and hospital stay?

Hospital malnutrition is common and thought to be a cause of morbidity and mortality. Nasogastric (NG) feeding is the most commonly used invasive technique of nutritional support used at the acute Bolton hospitals. A prospective observational study was initiated to audit the use of NG feeding in patients in whom oral energy intake was virtually nil at the time of commencement of tube feeding.
Patients who were starved for 0–5 days prior to commencement of NG feeding had a lower mortality than patients starved >5 days (a) during their feeding episode and (b) during their hospital stay subsequent to cessation of oral intake. The difference in mortality was not related to age or sex. However, in patients of <65 years mortality was only non-significantly higher in patients starved >5 days compared with those starved 0–5 days. In patients of >64 years the difference in mortality between those starved 0–5 vs. >5 days remained significant: (a) during the feeding episode and (b) during the hospital stay. The fact that starvation has a disproportionate effect on mortality in old patients may indicate that older patients are more susceptible to starvation. In surviving patients there was a positive correlation between the length of starvation and: (a) the duration of the NG feeding episode and (b) hospital stay subsequent to cessation of oral intake. Disease severity was not measured therefore its effect on outcome and speed of rehabilitation cannot be excluded.
The study indicates a possible relationship between the duration of starvation and mortality, the duration of NG feeding and the length of hospital stay. Definitive testing of this association would require a prospective trial which controls for age and disease severity.     

Noninvasive verification of nasogastric tube placement using a magnet-tracking system: a pilot study in healthy subjects

BACKGROUND: Fluoroscopic verification of nasogastric (NG) feeding tube placement is inconvenient and involves radiation exposure. We tested whether the position of an NG tube can be assessed reliably by a recently introduced magnet-tracking system. METHODS: A small permanent magnet was attached at the end of an NG tube and its position was monitored using an external sensor array connected to a computer. NG tube trajectory, spontaneous movements of the magnet, and its position relative to the lower esophageal sphincter (LES) and xiphisternum were assessed in 22 healthy subjects and compared with esophageal manometry. In 12 subjects, localization of the magnet was also compared with fluoroscopy. RESULTS: Magnet-tracking displayed NG tube tip movement reproducibly as it moved vertically in the esophagus and then laterally into the stomach. Compared with manometry, the accuracy and sensitivity of magnet tracking for localization of the NG tube tip, above or below the diaphragm, were 100%. Compared with fluoroscopy, the accuracy of NG tube localization by magnet tracking was 100%. With the magnet in the stomach, but not in the esophagus or LES, low amplitude displacements at a frequency of 3 per minute, consistent with gastric slow wave activity, were observed. CONCLUSIONS: Magnet tracking allows accurate, real-time, 3-dimensional localization of an NG tube with respect to anatomic landmarks. Recorded motor patterns are indicative of the position of the NG tube. Magnet tracking may be a useful tool for bedside placement of nasogastric and enteral feeding tubes.     

Magnetic Resonance–Guided Nasogastric Feeding Tube Placement for Neonates: A Preclinical Study

Background: Establishing postnatal nutrition delivery is challenging in neonates with immature sucking and swallowing ability. Enteral feeding is the gold standard for such patients, but their small size and fragility present challenges in nasogastric (NG) feeding tube placement. Feeding tubes are typically placed with x‐ray guidance, which provides minimal soft tissue contrast and exposes the baby to ionizing radiation. This research investigates magnetic resonance (MR) guidance of NG feeding tube placement in neonates to provide improved soft tissue visualization without ionizing radiation. Materials and Methods: A novel feeding tube incorporating 3 solenoid coils for real‐time tracking and guidance in the MR environment was developed. The feeding tube was placed 5 times in a rabbit with conventional x‐ray guidance to assess mechanical stability and function. After x‐ray procedures, the rabbit was transferred to a neonatal MR system, and the tube was placed 5 more times. Results: In procedures guided by x‐ray and MR, the feeding tube provided sufficient mechanical strength and functionality to access the esophagus and stomach of the rabbit. MR imaging provided significantly improved soft tissue contrast versus x‐ray, which aided in proper tube guidance. Moreover, MR guidance allowed for real‐time placement of the tube without the use of ionizing radiation. Conclusions: The feasibility and benefits offered by an MR‐guided approach to NG feeding tube placement were demonstrated. The ability to acquire high‐quality MR images of soft tissue without ionizing radiation and a contrast agent, coupled with accurate 3‐dimensional device tracking, promises to have a powerful impact on future neonatal feeding tube placements.     

Experience with image-guided gastrostomy and gastrojejunostomy tubes in children and adolescents with primary psychiatric illness

OBJECTIVE: To investigate the clinical experience with G/GJ tubes in child and adolescent psychiatry patients with disordered eating. METHOD: Health Records and Image-Guided Therapy databases (1995-2005) identified patients with primary psychiatric illness who received radiologically placed G/GJ tubes for refeeding. Patient charts were reviewed for relevant data. RESULTS: Nine patients who were 11-17 years old had G/GJ tubes inserted for refeeding as a result of their psychopathology. Prior to G/GJ tube insertion, adolescent inpatients were fed by NG/NJ tube for 0.5-7.3 months (mean 3.1 months) and subsequently fed by G/GJ tube for 5-60 months (mean 29 months) on an outpatient basis. No major complications or episodes of intentional tube manipulation/removal occurred. G/GJ tube feeding was effective in restoring and/or maintaining weight. CONCLUSION: Image-guided enterostomy tubes are a safe and well-tolerated method for feeding pediatric patients with psychiatric disorders and food refusal, and allow outpatient management of underlying psychopathology.     

A study of reasons for failure to administer prescribed volume of nasogastric enteral feeds in a district general hospital

Background: A number of studies have demonstrated that the amount of enteral feed delivered is often significantly less than that prescribed (Park, 1992; Reid, 2006), which can impair nutritional status (National Institute for Health and Clinical Excellence, 2006). The aim of this survey was to establish the amount of feed administered versus that prescribed and identify the reasons for patients failing to receive the volume of feed prescribed. Methods: Data were collected prospectively on 20 consecutive patients on medical or surgical wards, who were commenced on nasogastric feeding (NGF). Feed requirements were determined by a clinical dietitian. The volume of feed administered versus that prescribed was calculated from the daily fluid balance charts. Medications and reasons for failure to administer prescribed feed were ascertained from medical, nursing and dietetic records and questioning staff. This was recorded on a data collection form. Results: Data were evaluated for 13 male and seven female patients, mean age 66 years (range 35–91 years) on gastroenterology, oncology and surgical wards. In total, 235 days of NGF were prescribed. Under‐delivery of feed occurred on 70 out of 235 (30%) days. Mean (SD) NGF delivered was 77% (39%) of feed prescribed. No feed was administered on 39 out of 235 days (17%). Fifty‐five percent of patients were on proton pump inhibitors (PPIs). Reasons for not administering feed or administering less than that prescribed are detailed in Fig. 1. Discussion: Inadvertent removal and inability to confirm correct positioning of nasogastric tubes (NGTs) accounted for significant interruptions to feeding resulting in under‐delivery of feed and lost feeding days (27%). Fifty‐five percent of patients were on PPIs because these are known to increase gut pH; this warrants further investigation of the possible cause of obtaining an unsuitable pH. The mean NGF delivered is similar to other studies mentioned. The limitations of this study include the small sample size and the possible inaccuracies of the fluid balance charts. 1 [ Reasons for failure to administer prescribed feed expressed as a percentage (n = 70). ] Conclusions: As a consequence, the nutrition support team is working on improving methods of securing NGTs, investigating aspiration practice, encouraging a review of PPIs and optimising radiography procedures. The study highlights the opportunities for improving practice to ensure that patients receive the feed prescribed. References National Institute of Health and Clinical Excellence (2006) Nutrition support in adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE, Available at http://www.nice.org.uk/guidance/CG32 (accessed on 3 December 2008). Park, R.H.R., Allioson, M.C., Lang J., Spence E., Morris A.J., Danesh B.J.Z., Russell, R.I. & Mills P.R. (1992) Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. BMJ 304 , 1406–1409. Reid, C. (2006) Frequency of under and overfeeding in mechanically ventilated ICU patients: causes and possible consequences. J. Hum. Nutr. Diet. 19 , 13–22.     

A Descriptive Study of Nasogastric Tube Feeding Among Geriatric Inpatients in Malaysia: Utilization,Complications, and Caregiver Opinions

The strong emphasis on feeding in Asian cultures may influence decisions for nasogastric (NG) tube feeding in geriatric inpatients. We evaluated the utility, complications, and opinions of caregivers toward NG tube feeding in an acute geriatric ward in a teaching hospital in Kuala Lumpur. Consecutive patients aged 65 years and older receiving NG tube feeding were included. Sociodemographic, clinical, and laboratory indices were recorded. Opinion on NG tube feeding were evaluated through face-to-face interviews with caregivers, recruited through convenience sampling. Of 432 patients admitted, 96 (22%), age ± standard deviation = 80.8 ± 7.4 years, received NG tube feeding. The complication and mortality rates were 69% and 38%, respectively. Diabetes (odds ratio [95% confidence interval] = 3.34 [1.07, 10.44], aspiration pneumonia (8.15 [2.43, 27.24]), impaired consciousness (3.13 [1.05, 9.36]), and albumin ≤26 g/dl (4.43 [1.46, 13.44]) were independent predictors of mortality. Other relatives were more likely than spouses (23.5 [3.59, 154.2]) and caregivers with tertiary education more likely than those with no formal education (18 Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, etal. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003; 58(5):377–82.[Crossref], [PubMed], [Web of Science ®] , [Google Scholar] [1.23, 262.7]) to agree to NG feeding. Sixty-four percent of caregivers felt NG tube feeding was appropriate at the end of life, mostly due to the fear of starvation. NG tube feeding is widely used in our setting, despite high complication and mortality rates, with likely influences from cultural emphasis on feeding.     

Percutaneous endoscopic gastrostomy–a user's perspective

Sixteen patients receiving percutaneous endoscopic gastrostomy (PEG) feeding following a period of nasogastric (NG) feeding were investigated to assess acceptance and identify problems by means of a questionnaire. PEG was considered to be superior to NG feeding in terms of tolerance and cosmetic acceptance by 81% and 88% of participants respectively ( P < 0.001). Pain was an infrequent problem. Interruptions to feeding were consideed to be more common with NG feeding by 50% of participants; 38% considered interruptions equally common with both PEG and NG, and 12% considered interruptions more common with PEG feeding ( P = NS). The time for care was equivalent for both methods. Seventy-five percent considered PEG to have made a valuable contribution to enteral feeding. Leakage was however considered to be more frequent in PEG feeding by 81% of participants (compared to 12% who considered leakage to be more common with NG feeding; P < 0.001) and leakage was more frequent at die junctions in the catheter rather than from the stoma. Thirty-one percent of patients with PEG had needed systemic antibiotics for stomal infections. All patients with both PEG and NG feeding needed professional help. Sixty-two percent needed professional help more frequently with PEG than with NG feeding (compared to 19% who considered that the NG tube needed professional help more frequently; P <0.05). We conclude that leakage and infections are major problems in PEG enteral feeding.     

The effects of processing of barley-based supplements on rumen pH, rate of digestion of voluntary intake of dried grass in sheep.

1. In one experiment the effect on rumen pH of feeding with restricted amounts of whole or pelleted barley was studied. With whole barley there was little variation in rumen pH associated with feeding time, but with pelleted barley the pH decreased from about 7-0 before feeding to about 5-3, 2--3 h after feeding. 2. The rate of disappearance of dried grass during incubation in the rumens of sheep receiving either whole or pelleted barley was studied in a second experiment. After 24 h incubation only 423 mg/g incubated had disappeared in the rumen of sheep receiving pelleted barley while 625 mg/g incubated had disappeared when it was incubated in the rumen of sheep receiving whole barley. 3. The voluntary intake of dried grass of lambs was studied in a third experiment when they received supplements of either 25 or 50 g whole or pelleted barley/kg live weight 0-75. At the high level, pelleted barley reduced intake of dried grass by 534 g/kg but whole barley reduced it by only 352 g/kg. The digestibility of acid-detergent fibre was reduced more by pelleted barley than by whole barley but there was a tendency for a small increase in digestibility of the barley due to processing. 4. The implications of these findings on supplementation of roughages with cereals are discussed.     

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.     

Essential fatty acid status in adult patients receiving soybean-base formula

Essential fatty acid (EFA) status was assessed in 48 normal Thai adults and 6 patients who required tube feeding ro 2-4 wk with commercial soybean-base formula (Sobel, Mead Johnson). Each 1000 kcal of this formula provided 40.2 g protein, 32.8 g fat, 136 g carbohydrate, 13.9 g linoleic acid, 2.9 g linolenic acid, and 0 g arachidonic acid. The linoleic acid status in these patients before receiving soybean-base formula was inadequate, as evidenced by the significantly lower serum 18:2-W6 percentage but higher serum 16:1-W7 and 18:1-W9 percentages than those in normal adults. These changes were reversed while receiving soybean-base formula. A significant positive correlation between linoleic acid intake and its serum level was demonstrated. There was a significant decrease in serum 20:4-W6 percentage while receiving soybean-base formula. This could be related to the absence of this EFA in the formula and suppression of biotransformation of 18:2-W6 to 20:4-W6 in the presence of a significant amount of 18:3-W3. None of the patients had 20:3-W9 in the serum or developed scaly dermatitis throughout the study.     

Severity of illness influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness

BackgroundFew trials have studied the influence of illness severity on clinical outcomes of different tube-feeding routes. Whether gastric or postpyloric feeding route is more beneficial to patients receiving enteral nutrition remains controversial.ObjectiveTo test whether illness severity influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness.DesignA 2-year prospective, randomized, clinical study was conducted to assess the differences between the nasogastric (NG) and nasoduodenal (ND) tube feedings on clinical outcomes.Participants/settingOne hundred one medical adult intensive care unit (ICU) patients requiring enteral nutrition were enrolled in this study.InterventionPatients were randomly assigned to the NG (n=51) or ND (n=50) feeding route during a 21-day study period. Illness severity was dichotomized as “less severe” and “more severe,” with the cutoff set at Acute Physiology and Chronic Health Evaluation II score of 20.Main outcome measuresDaily energy and protein intake, feeding complications (eg, gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, hospital mortality, nitrogen balance, albumin, and prealbumin.Statistical analyses performedTwo-tailed Student t tests and Mann-Whitney U tests were used to analyze significant differences between variables in the study groups. Multiple regression was used to assess the effects of illness severity and enteral feeding routes on clinical outcomes.ResultsAmong less severely ill patients, no differences existed between the NG and ND groups in daily energy and protein intake, feeding complications, length of ICU stay, and nitrogen balance. Among more severely ill patients, the NG group experienced lower energy and protein intake, more tube feeding complications, longer ICU stay, and poorer nitrogen balance than the ND group.ConclusionsTo optimize nutritional support and taking medical resources into account, the gastric feeding route is recommended for less severely ill patients and the postpyloric feeding route for more severely ill patients.     

Changes in circulating concentrations of vitamins and trace elements after cessation of nocturnal enteral tube feeding

BACKGROUND: This study aimed to examine whether circulating concentrations of a range of vitamins and trace elements in patients receiving long-term cyclic enteral tube feeding vary during the day, and whether standardised time points for blood sampling are required for assessment of nutrient status. METHODS: Circulating concentrations or activities of water-soluble vitamins (thiamine, riboflavin, and vitamins B6, B12, folate and C), fat-soluble vitamins (A, D, E) and trace elements (iron, zinc, copper and selenium (assessed by glutathione peroxidase activity), were measured at 0,3,6 and 9-12h after cessation of nocturnal feeding (fasting), in eight clinically stable patients receiving cyclic nocturnal enteral nutrition. RESULTS: The circulating concentrations of the nutrients did not change between the fed and fasted state (repeated-measures-ANOVA) except the following: plasma folate increased progressively from 10.9 (SD 4.6)nmol/l in the fed state to 14.0 (SD 4.4)nmol/l at 9-12 h after cessation of feeding (P<0.05); plasma zinc increased progressively throughout the fasting period by 33.5% (8.57, SD 0.68 vs. 11.44, SD 1.85 micromol/l, in fed state vs. 9-12h fast respectively, P<0.05); and total tocopherol/cholesterol ratio decreased by 9.6% during the study period (P<0.02), while gamma-tocopherol increased by 59.2% (P<0.05). For all analytes, the concentrations in blood samples taken at 3 and 6h after cessation of feeding were not significantly different from those at 9-12h. CONCLUSIONS: Although cessation of nocturnal tube feeding had no significant effect on the circulating concentrations of most micronutrients, it increased plasma folate and zinc concentrations, and decreased the tocopherol/cholesterol ratio. The timing for blood sampling should be standardised when the status of these nutrients is assessed in patients receiving cyclic tube feeding.     

Cost-Effectiveness Analysis: Stress Ulcer Bleeding Prophylaxis with Proton Pump Inhibitors,H2 Receptor Antagonists

ObjectivesProton pump inhibitors (PPIs) and H2-receptor antagonists (H2RAs) present varying pharmacological efficacy in preventing stress ulcer bleeding (SUB) in intensive care units. The literature also reports disparate rates of ventilator-assisted pneumonia (VAP) as side effects of these treatments. We compared the cost-effectiveness of these two prophylactic pharmacological options.MethodsWe constructed a decision tree with a 60-day time horizon for patients at high risk for developing SUB, receiving either PPIs or H2RAs. For each treatment strategy, patients could be in one of three states of health: SUB, VAP, or no complication. Contemporary, clinically relevant probabilities were obtained from a broad literature search. Costs were estimated by using a representative US countrywide database. A third-party payer perspective was adopted. Cost-effectiveness and univariate and multivariate sensitivity analyses were performed.ResultsProbabilities of SUB and VAP were 1.3% and 10.3% for PPIs versus 6.6% and 10.3% for H2RAs, respectively. Lengths of stay and per diem costs were 24 days and US $2764 for SUB, 42 days and US $3310 for VAP, and 14 days and US $2993 for patients without complications. Average costs per no complication were US $58,700 for PPIs and US $63,920 for H2RAs. The H2RA strategy was dominated by PPIs. Sensitivity analysis showed that these findings were sensitive to VAP rates but PPIs remain cost-effective. The acceptability curve shows the stability of the probabilistic results according to varying willingness-to-pay values.ConclusionPPI prophylaxis is the most efficient prophylactic strategy in patients at high risk of developing SUB when compared with using H2RAs.     

Aspiration (of gastric residuals)—a cause of bacterial contamination of enteral feeding systems?

In vitro model enteral feeding systems were used to investigate whether bacteria can travel from the «patient's» stomach or intestine via the enteral feeding tube to the giving set and nutrient container of the feeding system when feed is flowing continuously through the system for 24 h. Further systems were also assembled to examine the effects that aspiration and flushing via the enteral feeding tube and/or the medication (Y) port have on the bacterial contamination of feed and feeding systems. Organisms were detected at levels ranging from 10²–10⁹ CFU/ml (CFU, colony forming units) in feed samples collected from the distal end of the giving set at 0 h immediately after aspirating or aspirating and flushing. Fewer bacteria (10²–10⁵ CFU/ml) were recovered at 0 h in samples from systems where aspiration or aspiration and flushing were carried out via the tube as compared with those where aspiration and flushing took place via the mediport (10⁶–10⁹ CFU/ml). No bacteria were detected at 0 h in samples from systems that had neither been aspirated nor flushed. The test organism, CFU/ml) after 24 h. At no time during the study were K. aerogenes organisms detected in samples of feed taken from the nutrient container or just below the drip chamber at 24 h. The results of this study confirm the hypothesis that one of the contributory factors in the microbial colonisation of enteral feeding tubes and giving sets with organisms from the patients» own flora is the practice of aspirating the stomach or intestinal contents to check the position of the tube.