Comparison of Gravity Flow Rates Between ENFit and Legacy Feeding Tubes

Background: Misconnections between enteral supplies and other access devices have led to significant morbidity and mortality. To reduce misconnections, a standard small‐bore connector has been developed (International Organization for Standards 80369‐8; ENFit). The full impact of transition to this connector is not known, however. Method: Working with major manufacturers and Food and Drug Administration, we obtained ENFit and comparative legacy tubes of variable sizes (low‐profile, 14F, 18F, 20F, and 24F balloon gastrostomies). Gravity enteral feeding was simulated with an empty bolus syringe attached to the feeding tube to be tested. The tube was clamped and filled to the 60‐mL mark with liquid (water, Jevity 1 Cal, Isosource HN, Isosource 1.5 Cal, Two Cal HN, and Nourish). The clamp was released, and time for formula to leave the syringe was recorded. Results: There was no difference in flow rate between the aggregate legacy and ENFit tubes for the low‐profile, 18F, and 20F sizes. The ENFit 14F tubes had a lower flow rate vs the legacy tubes, largely due to the low flow rates seen with the 1 ENFit tube. Similarly, 24F ENFit tubes with some formulas yielded lower flow rates as opposed to legacy. Conclusion: Overall, for the low‐profile, 18F, and 20F sizes, the ENFit tubes had similar flow rates when compared with the legacy tubes. For the 14F and 24F sizes, the flow rate of ENFit tubes was significantly lower, which could result in longer EN delivery for patients who are using these tubes to provide gravity feeding.     

Effects of Force Feeding

Rats eating ad libitum have less body fat than those force fed the same amount of feed. Force feeding produces a threefold increase in activity of enzymes involved in lipogenesis.     

Warfarin Bioavailability With Feeding Tubes and Enteral Formula

Background: Earlier literature showed reduced efficacy of warfarin when co‐administered with enteral nutrition formulas through feeding tubes. This study used an in vitro model for gastric administration of warfarin through a feeding tube to evaluate potential causes for reduced warfarin absorption when administered through feeding tubes. Methods: There were 2 phases of the study. The first phase used an artificial stomach model with or without the infusion of enteral nutrition formula. Warfarin was added to the contents either directly into the vessel or passed through a feeding tube. Warfarin tablet dissolution was compared to the injectable formulation, which served as a control. The second phase used chopped feeding tube material added to beakers containing warfarin in increasing amounts. Results: Warfarin injection and tablet formulations showed decreased solubility when combined with acid. The warfarin solubility was higher when enteral formula was added. Warfarin concentration dropped by 35% when the drug was passed through a feeding tube, as opposed to added directly to the flask. In the second study, the warfarin levels were lower in the beakers containing feeding tubes. Doubling the amount of warfarin added did not raise levels to that of the initial dissolved. Doubling the amount of feeding tube material further reduced the concentration dissolved. Conclusions: Feeding‐tube administration compromises the total amount of warfarin reaching patients. It appears, from this in vitro study, that the mechanism of the interaction of warfarin may be a result of direct binding to the feeding tube.     

配药注射器使用时间与细菌污染相关性研究

目的研究临床配药注射器使用后细菌污染状况,明确注射器启封后的有效使用时间。方法对10个临床科室的700具注射器于启封后随机分为配制抗菌药物药液组与非抗菌药物药液组,并于7h内每隔1h随机采样进行细菌检测。结果启封后配制抗菌药物药液组和非抗菌药物药液组4h内均无细菌生长,配制抗菌药物药液组5、6、7h阳性率分别为2.00%、8.00%、22.56%(P0.05);配制非抗菌药物药液注射器5、6、7h阳性率分别为28.00%、40.45%、62.00%(P0.05)。结论配药注射器使用后细菌污染与使用时间有明显的相关性,配药注射器启封后短时间内使用是安全的。     

Dual‐Purpose Gastric Decompression and Enteral Feeding Tubes Rationale and Design of Novel Nasogastric and Nasogastrojejunal Tubes

Background: The importance of early postoperative nutrition in surgical patients and early institution of enteral nutrition in intensive care unit (ICU) patients have recently been highlighted. Unfortunately, institution of enteral feeding in both groups of patients often has to be postponed due to delayed gastric emptying and the need for gastric decompression. The design of current polyvinylchloride (PVC) gastric decompression tubes (Salem Sump [Covidien, Mansfield, MA] in the United States; Ryles [Penine Health Care Ltd, Derby, UK] in the United Kingdom and Europe) make them unsuitable for their subsequent use as either nasogastric enteral feeding tubes or for continued gastric decompression during postpyloric enteral feeding. To overcome these problems, we have designed a range of polyurethane (PU) dual‐purpose gastric decompression and enteral feeding tubes that include 2 nasogastric tubes (double lumen to replace Salem Sump; single lumen to replace Ryles). Two novel multilumen nasogastrojejunal tubes (triple lumen for the United States; double lumen for the United Kingdom and Europe) complete the range. By using PU, a given internal diameter (ID) and flow area can be incorporated into a lower outside diameter (OD) compared with that achieved with PVC. The ID and lumen and flow area of an 18Fr (OD 6.7 mm) PVC Salem Sump can be incorporated into a 14Fr (OD 4.7 mm) PU tube. The design of aspiration/infusion ports of current PVC and PU tubes invites occlusion by gastrointestinal mucosa and clogging by mucus and enteral feed. To overcome this, we have designed long, single, widened, smooth, and curved edge ports with no “dead space” to trap mucus or curdled diet. Involving up to 214° of the circumference, these ports have up to 11 times the flow areas of the aspiration ports of current PVC tubes. Conclusion: The proposed designs will lead to the development of dual‐purpose nasogastric and nasojejunal tubes that will significantly improve the clinical and nutrition care of postoperative and ICU patients.     

多导丝置管法床边盲插鼻肠喂养管

目的：评价多导丝置管法床边盲插鼻肠喂养管的有效性、安全性。方法：为39例住院患行多导丝法盲插鼻肠喂养管44次。该方法在鼻肠管腔内预置三条导丝以增加刚度。置管时保持轻柔推力，随患呼吸缓慢进管；如遇阻力增加或阻力突然消失，退管后重新进管。最后行美蓝回抽试验及床边X线造影腹部摄片明确管端位置。结果：置管成功率为95％。2次置管失败改在X线透视下成功置管。无呼吸道内置管或消化道穿孔等并发症。结论：多导丝置管法床边盲插鼻肠喂养管是成功率高、安全的置管方法。     

床旁放置经鼻小肠管的新方法

胃排空障碍是影响危重患者肠内营养实施的重要问题,经小肠喂养是解决方法之一。放置小肠营养管的非手术方法主要包括内镜引导和X线辅助,但这两种方法均需要一定的设备和场所,不利于对危重患者进行床旁实施。近年来出现了多种辅助盲探放置小肠管的新方法,本文对这些方法进行综述。     

Rural-Urban Differences in End-of-life Care: The Use of Feeding Tubes

Efforts to improve end-of-life care have increased during the past decade. The goals of these efforts include increasing patient autonomy and reducing or more selectively using intensive medical interventions near the end of life. In this light, examination of community-to-community variations in end-of-life practices may serve to clarify the values and goals of different populations, as well as the roles of patients, families and professionals in bringing about specific patterns of medical care. This study examined the use of feeding tubes among Kansas nursing home residents between Jan. 1, 1994, and June 30, 1998 (n = 78,895), using the Minimum Data Set. Residents with very severe, persistent and irreversible cognitive impairment (n = 4,847) were included in the study population. The location of nursing homes in urban, midsize and rural counties was an independent variable. Feeding tubes were used in 19.3 percent of the urban nursing home residents, 8.0 percent of the residents in midsize counties and 6.4 percent of the rural residents. The rate of feeding tube use was significantly higher in urban counties for most subpopulations, including men, women, whites, nonwhites, and those eligible and ineligible for Medicaid. The observed rural-urban differences in feeding tube use near the end of life may be associated with differences in access to surgical or nursing services, differences in the relationships between providers and consumers of care in different communities or differences in rural and urban cultures. Qualitative research may be useful in clarifying the roles of each of these factors.     

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.     

Placement of Nasoenteral Feeding Tubes Using Magnetic Guidance: Retesting a New Technique

Objective: To study a new technique of intubating the small bowel using a newly developed nasoenteral feeding tube fitted with a magnet in its tip and guided for placement with an external magnet.

Methods: The study was performed in medical and surgical wards of a university-affiliated Department of Veterans Affairs hospital on 42 patients referred by their attending physicians for tube placement. The newly designed feeding tube was inserted per nares into the stomach using traditional technique. As the tube was advanced, movement of the hand-held steering magnet was designed to guide the tip of the magnetic nasoenteral tube along the lesser curvature of the stomach, through the pyloric sphincter, and into the duodenum. Portable abdominal radiography confirmed the anatomic location of the tube tip.

Results: Fifty-one intubations were performed on 42 subjects. In 45 intubations (88%), tubes passed into the duodenum. Twenty-seven (53%) met criteria for optimal placement in the second portion of the duodenum or distally. Six of 11 tubes (55%) that were not optimally placed were advanced to the distal duodenum on repositioning. Median procedure time for the initial intubations was 30 minutes (interquartile range 15–40). Median procedure time for last 10 intubations improved to 13 minutes (interquartile range 5–20). No complications were related to the procedure.

Conclusions: Enteral feeding tube placement using external magnetic guidance is a promising, novel technique which is deserving of further study.     

注射器和输液泵的匹配问题

讨论了恒速输液泵与注射器之间的匹配问题,对同一输液泵使用13个品牌注射器的实际泵速进行了比较,证明使用非指定注射器可能导致泵注速度较大的误差,给临床及科研工作造成不良影响,认识并重视该问题是目前可行的规避手段。     

母乳喂养与婴儿体格发育关系的多因素分析

广义估计方程的纵向分析显示，哺乳或母乳量对婴儿体格发育呈良好的正向促进作用；典型（典则）相关的横向分析显示，以母乳量为主的蛋白质摄入作用首先使婴儿向高而瘦长的体格发育，支持蛋白质对婴儿生长发育影响较大的理论。喂养方式相同而母乳量不同者，婴儿体格发育水平亦不同，在比较不同喂养方式下的婴儿体格发育时应注意。建议母乳喂养的干预应抓住围产期和生后１～２个月这两个时机，并用健康教育方法促使其改进。     

Consistency Between Parent-Reported Feeding Practices and Behavioral Observation During Toddler Meals

ObjectiveTo assess whether feeding questionnaire responses reflect observed mealtime behavior.DesignCross-sectional associations between self-reported and observed behaviors.SettingParticipants’ homes.ParticipantsParents (n = 75) of toddlers (mean age = 24.7 months) in the US.Main Outcome MeasuresFeeding behavior questionnaires and coded videos of children's dinner meals.AnalysisParents’ questionnaire responses of “never” (or “rarely”) considered consistent with video observation if behavior was not observed; responses of “always” (or “most of the time”) if behavior observed at least once. Proportion (%) of participants observed performing each behavior was calculated for the groups of parents reporting that they “never,” “sometimes,” or “always” used that feeding practice. These were compared across the 3 response groups.ResultsParents reported 6 behaviors consistently (≥70% agreement): allowing child to eat as much as wanted, helping child eat, prompting child to eat, television/screens on during meal, nonfood rewards, and hurrying child. The remaining 8 behaviors fell below the threshold. For many behaviors, all response groups (never, sometimes, always) had similar rates of participants demonstrating the behavior. Only 5 behaviors had observed rates falling in the expected direction (frequency of always > sometimes > never). For some behaviors, the “sometimes” group had a higher (eg, clean plate) or lower (praise) frequency than the other 2 groups.Conclusions and ImplicationsSelf-reported questionnaire responses predicted whether some, but not all, behaviors were observed. Parents’ use of “sometimes” remains difficult to interpret as parents may use “sometimes” inconsistently across behaviors and perhaps to mitigate socially undesirable responses. Self-reports of “sometimes” performing a behavior may have limited utility for prediction of behavior and likely requires additional exploration with the respondent.     

一次性使用输液器、注射器的管理

目的加强一次性使用输液器、注射器临床使用的管理,确保医疗和护理安全. 方法加强采购、验收、储存、领用、发放、回收各环节的管理. 结果通过对各环节的监督管理,形成了订货索证、进货验收、用前核对、用后消毒毁形、以旧换新的管理模式. 结论加强一次性使用输液器、注射器临床使用管理,可有效地预防医院感染的发生,确保医疗和护理安全.     

肺叶切除术后使用不同管径胸腔引流管的临床效果比较

目的探讨肺叶切除术后采用不同管径胸腔引流管的临床效果。方法选取2015年1月至2018年12月我院收治的104例肺叶切除术后胸腔引流患者,随机分为试验组(52例, 16F细管引流)和对照组(52例, 32F粗管引流),比较两组的带管时间、导管故障情况、胸腔积液再穿刺、带管NRS评分与镇痛药物使用情况。结果两组的平均带管时间、导管故障发生率、胸腔积液再穿刺率比较均无统计学差异(P>0.05)。术后第2～4天,试验组的带管NRS评分低于对照组(P <0.05)。带管期间,试验组的止痛药物使用率为17.31%,低于对照组的44.23%(P <0.05)。结论 16F细径导管与32F粗径导管用于肺叶切除术后胸腔引流均可行,其中前者不延长带管时间,不增加导管故障及再穿刺率,效果确切,而且患者的带管疼痛较轻,易于耐受,临床应用更具有优势。     

中美两国医院比较——访华盛顿大学Fred Hutchinson癌症研究中心兼职研究员、华盛顿医疗系统公司董事长廖新生

“大门诊、小病房”使许多服务都可以在门诊完成，包括所有实验室和映像学检查、术前检查、静脉注射和抗生素治疗、输血、输血小板、血浆交换、大多数化疗、60％的外科手术(如胆囊切除、阑尾切除)、心脏导管等等。     

中日血液透析模式比较

本文分别介绍了中国和日本血液透析模式,并且对两者的优缺点进行了比较,指出日本血液透析模式的优越性会越来越明显,这也是未来我国血液透析治疗的发展趋势。