7 g weighted versus unweighted polyurethane nasoenteral tubes--spontaneous transpyloric passage and clinical performance: a controlled randomised trial

A proportion of patients requiring enteral nutrition is at increased risk of regurgitation or pulmonary aspiration of enteral diet as a result of gastric atony or paresis. The positioning of the distal end of an enteral feeding tube beyond the pylorus into duodenum or jejunum may reduce this risk. It has been postulated that by suitable lengthening of feeding tubes and by altering the distal end tip profile or by the addition of a weight, spontaneous passage of a tube through the pylorus after pernasal insertion may be achieved. In a recent controlled trial we were unable to demonstrate any advantage to a) modifying the tip profile or b) the addition of a 2.4 g weight. This prospective controlled clinical study examined the difference between an unweighted polyurethane tube which had performed optimally in the previous study and a new 7 g weighted tube similar in all other respects. In both cases less than 50% of tubes had passed spontaneously through the pylorus when assessed at 24 h, with no significant difference in performance (p = 0.38). When comparing overall length of time that each tube remained in situ, there was similarly no significant difference between the 7 g weighted and unweighted tubes (p = 0.277). We conclude that the addition of a 7 g weight to a suitably lengthened enteral feeding tube confers no advantage on either incidence of spontaneous transpyloric passage or in prolonging tube usage. If post-pyloric feeding is indicated for a patient, positioning by either fluoroscopic or endoscopic techniques should be undertaken.     

Clearing obstructed feeding tubes

This is a report of an in vitro study evaluating the ability of six solutions to dissolve clotted enteral feeding, which can cause feeding tube occlusion. The following clotted enteral feeding products were tested: Ensure Plus, Ensure Plus with added protein (Promod 20 g/liter), Osmolite, Enrich, and Pulmocare. Clot dissolution was then tested by adding Adolf's Meat Tenderizer, Viokase, Sprite, Pepsi, Coke, or Mountain Dew. Distilled water served as control. Dissolution score for each mixture was assessed blindly. Best dissolution was observed with Viokase in pH 7.9 solution (p less than 0.01). Similar results were obtained when feeding tube patency was restored in eight in vitro occluded feeding tubes (Dobbhoff, French size 8) by using first Pepsi (two/eight successful) and then Viokase in pH 7.9 (six/six successful). We also report our experience in the first 10 patients with occluded feeding tubes using this Viokase solution injected through a Drum catheter into the feeding tube. In seven patients, this method proved to be successful, and the reasons for failure in three patients include a knotted tube, impacted tablet powder, and a formula clot fo 24 hr duration and 45 cm in length.     

Bedside placement of small bowel feeding tubes in hospitalized patients: a new role for the dietitian

OBJECTIVE: The benefits of enteral nutrition when compared with parenteral nutrition are well established. However, provision of enteral nutrition may not occur for several reasons, including lack of optimal feeding access. Gastric feeding is easier to initiate, but many hospitalized patients are intolerant to gastric feeding, although they can tolerate small bowel feeding. Many institutions rely on costly methods for placing small bowel feeding tubes. Our goal was to evaluate the effectiveness of a hospital-developed protocol for bedside-blind placement of postpyloric feeding tubes. METHODS: The Surgical Nutrition Service established a protocol for bedside placement of small bowel feeding tubes. The protocol uses a 10- or 12-French, 110-cm stylet containing the feeding tube; 10 mg of intravenous metoclopramide; gradual tube advancement followed by air injection and auscultation; and an abdominal radiograph for tube position confirmation. In a prospective manner, consults received by the surgical nutrition dietitian for feeding tube placements were followed consecutively for a 10-mo period. The registered dietitian recorded the number of radiograph examinations, the final tube position, and the time it took to achieve tube placement. RESULTS: Because all consults were included, feeding tube placements occurred in surgical and medical patients in the intensive care unit and on the ward. Of the 135 tube placements performed, 129 (95%) were successfully placed postpylorically, with 84% (114 of 135) placed at or beyond D3. Average time for tube placement was 28 min (10 to 90 min). One radiograph was required for 92% of the placements; eight of 135 (6%) required two radiographs. No acute complications were associated with the tube placements. CONCLUSIONS: Hospitalized patients can receive timely enteral feeding with a cost-effective feeding tube placement protocol. The protocol is easy to implement and can be taught to appropriate medical team members through proper training and certification.     

Warfarin resistance and enteral feedings

Nutritional support via enteral feeding tubes may interfere with the response to medications by a number of mechanisms. A 31-year-old, white man was admitted after sustaining a gunshot wound to the chest and mandible. Subsequently, the patient developed pulmonary emboli documented by angiography. Attempts at anticoagulation with oral warfarin were unsuccessful while the patient was receiving 50-100 ml/hr of Osmolite through an Entriflex feeding tube and intermittent oral Ensure Plus supplements. Discontinuation of the Osmolite resulted in a prompt prolongation of the prothrombin time. The Ensure Plus was continued and adequate prothrombin times were achieved on 7.5 to 10 mg of warfarin daily. The total amount of vitamin K received from the enteral feedings ranged from 50 to 115 micrograms/day, which is less than the normal daily intake of 300 to 500 micrograms. Previous reports of warfarin resistance implicated older enteral feeding products with a much higher vitamin K content. Difficulty with anticoagulation may still be experienced with the newer formulations. It is unknown whether the vitamin K content or malabsorption of warfarin is the mechanism of resistance.     

Subjective distress during continuous enteral alimentation: superiority of silicone rubber to polyurethane

A small-bore feeding tube of silicone rubber was developed in order to improve the acceptance of enteral feeding. The insertion procedure was facilitated by providing a double guidewire which allows continuous adjustment of tip rigidity. The usefulness of this tube was tested in a short-term and a long-term volunteer study as well as in a prospective follow-up of patients receiving enteral nutrition. The volunteer study showed that the newly developed tube significantly reduced subjective distress (rank value 14) when compared to a conventional tube made of polyurethane (rank value 20). In the patient study, 131 silicone rubber tubes were used in 85 patients who received enteral nutrition for a total period of 2080 days and complained about foreign-body feeling and rhinorrhea in only 3.7% and 0.5% of the days, respectively. The rate of inadvertent removals was relatively low (32%), mainly due to restricted mental status of the patients.     

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.     

Establishing Early Enteral Nutrition With the Use of Self‐Advancing Postpyloric Feeding Tube in Critically Ill Children

Introduction: Early nutrition support is an integral part of the care of critically ill children. Early enteral nutrition (EN) improves nitrogen balance and prevents bacterial translocation and gut mucosal atrophy. Adequate EN is often not achieved as gastric feeds are not tolerated and placing postpyloric feeding tubes can be difficult. Spontaneous transpyloric passage of standard feeding tubes without endoscopic intervention or use of anesthesia can range from 30%?80%. The authors report on their experience with a 14Fr polyurethane self‐advancing jejunal feeding tube in a pediatric population. These tubes have been used in the adult population with success, but to the authors’ knowledge, there have been no reports of its use in the pediatric age group. Case Series: The authors present 7 critically ill patients 8–19 years old, admitted to the pediatric intensive care unit, in whom prolonged recovery, inability to tolerate gastric feeds, and dependence on ventilator were predicted at the outset. The jejunal feeding tube was successfully placed on first attempt at the bedside in all 7 patients within the first 24 hours without the use of a promotility agent or endoscopic intervention. Nutrition goal achieved within 48 hours of feeding tube placement was reported for each patient. This case series demonstrates that children fed via the small bowel reached their nutrition goal earlier and did not require parenteral nutrition. Conclusion: The self‐advancing jejunal feeding tube can be used effectively to establish early EN in critically ill children.     

Quantifying amount of adsorption of levothyroxine by percutaneous endoscopic gastrostomy tubes

BACKGROUND: It has been the authors' clinical experience that hypothyroid patients who achieve a euthyroid state on a steady dose of oral levothyroxine often become hypothyroid over time if the medication is given via a feeding tube. The authors hypothesize that the tubing and enteral feeds may adsorb a significant percentage of the levothyroxine and thereby reduce its bioavailability. To the authors' knowledge, no previous research has been reported on this subject. They therefore performed an in vitro assessment of the degree of levothyroxine adsorption to quantify the amount of drug adsorbed to the percutaneous endoscopic gastrostomy (PEG) tube and how enteral tube feeds mitigate or exacerbate this adsorption. METHODS: Using levothyroxine radiolabeled with an I 125 tracer, a known dose of levothyroxine was passed through 60 new PEG tubes. One-half of the tubes were pretreated with Jevity feeds, and the other half were not. The authors measured the activity of the radiolabeled levothyroxine before and after it had passed through the tubes and, using a subtraction analysis, inferred the amount of thyroxine left within the tube. RESULTS: Tubes presoaked with feeds had a greater uptake in radioactivity by 326.4 cpm (95% confidence interval, 226.7-426.1), corresponding to a 45.08% relative increase in uptake compared with virgin PEG tubes without feeds. CONCLUSIONS: Although the authors found statistically significant differences in mean drug concentrations, they conclude that the amount of uptake of levothyroxine by PEG tubes and adsorption of levothyroxine by PEG tubes is probably clinically insignificant. The differences found may be attributed to the amount of drug lost during crushing and transfer.     

Endoscopic placement of fine bore nasogastric and nasoenteric feeding tubes

In a small proportion of patients requiring enteral nutrition it may not be possible to site nasogastric or nasoenteric feeding tubes using standard intubation techniques. We describe an endoscopic method of tube placement applicable not only for positioning nasogastric feeding tubes in patients with coexisting oesophageal pathology, but also for placement of nasoenteric feeding tubes when disordered gastric emptying is present.     

Enteral feeding tube guidewire—another factor in the retrograde contamination of enteral feeding systems?

Background: In vitro enteral feeding systems were used to investigate the effect that withdrawal of the guidewire from the feeding tube has on bacteria ascending from a patients’ stomach or intestine via the feeding tube to the giving set and nutrient container of the feeding system. Methods: Enteral feeding systems were assembled with the feeding tube running into nutrient broth contaminated with Klebsiella aerogenes. The enteral feeding tubes were held in different orientations (horizontal and vertical) to examine the effect in both prostrate and ambulant patients. The guidewire was removed either prior to or after the enteral feeding tube had been inserted into the K. aerogenes broth. Feed was then run through the systems for 24 h, with feed samples being collected from the distal (patient) end of the giving set at 0 and 24 h. Results: After 24 h, 10^3–108 c.f.u. (colony forming units) K. aerogenes/ml were detected in feed samples taken from the distal end of the giving set in systems where the guidewire had been removed after the enteral feeding tube had been inserted into the contaminated broth (both orientations), but K. aerogenes was not detected in samples from systems in which the guidewire had been removed before the end of the tube was inserted into the broth (both orientations). However, when the latter feed samples were enriched (i.e. incubated at 37 °C for a further 24 h to detect if very low levels of bacteria were present in the original sample), 40% of samples from systems with horizontally orientated tubes, and 20% from systems with vertically orientated tubes were positive for the test organism. K. aerogenes was not detected in any samples of feed taken from the nutrient container or just below the drip chamber. Conclusion: The results demonstrate: (i) that bacteria ascend the feeding tube over a 24-h period (retrograde contamination) and (ii) removal of the guidewire can contribute to the colonization of the lumen of the feeding tube and distal end of the giving set with bacteria from a patients’ own flora.     

Enteral feeding techniques

Major technical advances in enteral nutrition include the use of erythromycin or magnetic guidance for the placement of the feeding tube into the duodenum, the development of new enteral tubes, and bedside methods to control the tube position. Percutaneous endoscopic jejunostomy is becoming a safe procedure with a high success rate. Specialized diets offer little or no clinical advantages when compared with standard polymeric diets.     

X线下放置鼻空肠营养管在危重症早期肠内营养中的应用

目的:探讨X线下放置鼻空肠营养管,在危重症病人早期肠内营养中的临床应用价值.方法:在X线监视下,将带有金属导丝的营养管自鼻腔经胃、十二指肠,置入空肠,拔出导丝,注入造影剂,确认营养管前端已进入Treitz韧带后30 cm以远.结果:X线下可将营养管放置至Treitz韧带30 cm以远的空肠部位,置管成功率为100%,置管时间为10～40(平均20)min.置管后营养管在位良好,喂养过程顺利.结论:X线下放置鼻空肠营养管,是一种操作简便快捷、安全可靠的置管技术,为危重症病人早期肠内营养支持提供了一条更有效的营养途径.     

Placement of a Magnetic Small Bowel Feeding Tube at the Bedside

Background: Current methods of achieving postpyloric enteral access for feeding are fraught with difficulties, which can markedly delay enteral feeding and cause complications. Bedside tube placement has a low success rate, often requires several radiographs to confirm position, and delays feeding by many hours. Although postpyloric enteral tubes can reliably be placed in interventional radiology (IR), this involves greater resource utilization, delays, cost, and inconvenience. We assessed the utility of bedside enteral tube placement using a magnetic feeding tube (Syncro‐BlueTube; Syncro Medical Innovations, Macon, GA, USA) as a means to facilitate initial tube placement. Methods: We recorded the time to insertion, location of tube, success rate, and need for radiographs in a series of patients given magnetic feeding tubes (n = 46) inserted by our hospitalist service over an 8‐month interval. Results: Of the 46 attempted magnetic tube placements, 76% were successfully placed in the postpyloric position, 13% were in the stomach, and 11% could not be placed. In 83% of the magnetic tubes, only 1 radiograph was needed for confirmation. The median time to placement was 12 minutes (range, 4–120 minutes). Conclusion: The use of a magnetic feeding tube can increase the success rate of bedside postpyloric placement, decrease the time to successful placement, and decrease the need for supplemental radiographs and IR.     

Examination of Accuracy in the Assessment of Gastric Residual Volume

Background. Increased gastric content from enteral nutrition intolerance is thought to place patients at risk for pulmonary aspiration. Although considered a questionable practice, blind gastric tube aspiration is the most common approach to measure gastric content. This simulated study evaluated the accuracy of residual volume (RV) assessment via tube aspirations made from known volumes by controlling the syringe pull technique, feeding tube properties, fluid viscosity, and placement of tubes in the fluid. Materials and Methods. This study was conducted in a metrology laboratory. Aspirates were obtained using a force measurement test system to control force of the syringe pull technique using 3 different procedures (slow 10 inches per minute [ipm], intermittent 10 ipm, and fast 40 ipm). Four different feeding tubes, 10 Fr and 18 Fr, each made of polyurethane and polyvinyl chloride, were placed in varying depths of 100 mL of either water or formula. The effect of fluid viscosity was also examined. Results. Overall, 108 RVs were analyzed using a force measurement test system. Actual content of RV was underestimated 19% on average and varied across tube size and viscosity. Intermittent and slow syringe pull techniques yielded greater aspirate quantities, although neither technique aspirated the full amount of volume available. The 10 Fr feeding tubes yielded larger RVs in more viscous fluid, yet the 18 Fr tubes performed better with fluids of lower viscosity. Conclusions. Based on this simulation, RV assessment does not accurately reflect the total volume of the contents available and, therefore, the clinical utility of this assessment should be further investigated.     

Spontaneous transpyloric passage and performance of 'fine bore' polyurethane feeding tubes: a controlled clinical trial

Certain groups of patients requiring enteral nutritional support are at increased risk of regurgitation and pulmonary aspiration of feed. Positioning of enteral feeding tubes distal to the pylorus has been advocated as a method of reducing such complications. Various techniques have been suggested to achieve postpyloric siting. Reports have indicated that lengthening the tube or altering the distal end tip configuration, by varying the tip profile or by the addition of a weight, may facilitate spontaneous transpyloric passage of the tube. This prospective controlled clinical study using three new polyurethane tubes demonstrates that the frequency of spontaneous transpyloric passage of the tube is not affected by tip profile or by the addition of a weight. Indeed, with all three tube designs only about one-third had passed spontaneously through the pylorus at 24 hr. Once through the pylorus the unweighted tube stayed in position significantly longer than the weighted tubes (p less than 0.005). We suggest that in those patients requiring post-pyloric feeding, endoscopic or fluoroscopic techniques should be used to position the tubes at the time of insertion, and that an unweighted tube should be used to prolong tube usage.     

Considerations regarding oral medications delivery to patients on nasoenteral tubes

Patients with healthy gastrointestinal tract but not capable to be fed orally may receive their nutrition and medications via enteral feeding tubes, patients who receive nutrition via feeding tubes are often receive medications through the same route. Not all medications are appropriate to be administrated enterally, improper dosage form selection, drug-nutrition interactions and incompatibilities, inadequate dilution, and other types of preparation and administration errors might lead to an unpleasant outcome. Appreciating the complexity of the administration of medications via feeding tube, following proper techniques could help in reducing incidents and improve patient outcomes. The present review covers the most considerations regarding the preparation and administration of oral medications to patients on nasoenteral feeding tubes.     

A prospective study of tube- and feeding-related complications in patients receiving long-term home enteral nutrition

OBJECTIVES: Percutaneous endoscopic gastrostomy tubes are frequently inserted to facilitate long-term enteral nutrition. There are few studies that address long-term complications related to feeding tubes. The purpose of this study is to examine the long-term complications related to tube malfunction and the effect these have on health care use. METHODS: In this prospective study, 8 patients who were discharged home on long-term home enteral nutrition completed a diary that listed 17 potential complications related to enteral feeding devices. Subjects completed the diary on a weekly basis, noting which of the potential complications they were experiencing and the intervention related to that complication. RESULTS: The 8 patients were followed for a mean of 10.5 months. Common tube-site complications included discharge from the tube site, red or tender stoma, and granulation tissue. Mechanical problems related to tubes plugging, breaking, and falling out were also common. Despite having a dedicated nurse and dietitian to follow these patients, unscheduled health care contacts were frequent and averaged 5.4 contacts over the mean follow-up time of 10.5 months. CONCLUSIONS: In patients receiving long-term home enteral nutrition, tube and tube-feeding complications are frequent and result in significant health care use. Given the increasing use of long-term enteral nutrition, strategies and programs must be developed to assist patients and their families in managing these complications.     

Nasogastric tube feeding and percutaneous endoscopic gastrostomy tube feeding in patients with head and neck cancer

Background: For patients with a diagnosis of head and neck cancer, oral nutrition may not provide adequate nutrition during radical radiotherapy or chemoradiation treatment, resulting in enteral feeding initiation. Enteral feeding may be delivered via a nasogastric tube or by a gastrostomy tube. The present study aimed to determine how different treatment modalities impact on requirement for enteral feeding and which method of enteral feeding provided the most benefit to the patient, as demonstrated by weight loss and the number of unscheduled radiotherapy treatment interruptions. Methods: Patients who were treated with radical radiotherapy or chemoradiation between January 2004 and June 2007 were reviewed retrospectively (n = 196, male = 149, female = 47). Data were collected on demographics, diagnosis, T and N classification, nutritional status, unscheduled radiotherapy treatment interruptions, and type and duration of enteral feeding. Subjects were divided into three subgroups depending on the treatment received. Comparisons were then made between methods of enteral feeding. Results: Combined modality treatment (Induction Chemotherapy and Chemoradiation) results in a higher proportion of patients requiring enteral feeding (66–71% compared to 12% for radiotherapy). Patients fed via a prophylactic percutaneous endoscopic gastrostomy lost the least amount of weight during treatment (?4.6% to +1.4%), although the method of enteral feeding did not statistically influence weight difference at the end of treatment. The enteral feeding method did not influence unscheduled radiotherapy treatment interruptions. Conclusions: Combined modality treatment results in a greater requirement for enteral feeding, with these patient groups having the greatest weight loss. The findings obtained in the present study indicate that the method of enteral feeding did not statistically influence weight loss at the end of treatment or unscheduled radiotherapy treatment interruptions.     

胃镜辅助下放置空肠营养管的方法

目的:探讨内镜下放置空肠营养管的方法.方法:给148例病人放置空肠营养管,116例病人在胃镜下用异物钳钳夹胃腔内空肠营养管,推送胃镜将其送至Treitz韧带以下.32例经鼻超细胃镜放置导丝后,再经导丝放入空肠营养管.结果:两种空肠营养管放置成功率均为100%,其中鼻肠管126例,三腔鼻肠管22例.两组均无严重并发症,1例病人置管后出现血淀粉酶升高.结论:两种空肠营养管放置的方法成功率均高,不良反应小,操作简单安全.     

食管癌手术细管状胃制作及术中肠内营养通路的建立

目的 介绍食管癌手术中细管状胃代食管技术及手术中经鼻或经皮穿刺方式放置空肠营养管的方法.方法 我科从2003年7月至2006年4月,对就诊的食管癌患者(接受两切口及三切口手术)采用传统管状胃代食管技术,2006年5月至2009年11月对就诊的食管癌患者采用细管状胃代食管技术,所有食管癌患者均进行术中空肠营养管置入术,术后早期给予肠内营养支持.结果 围手术期无死亡病例.改进的细管状胃代食管组患者术中管状胃长度较满意,器械吻合操作顺利,两组患者术后生存率差异无统计学意义.结论 在食管癌切除术的处理中,胃大弯侧细管状胃的使用,能提供器械吻合的便利,术中放置空肠营养管有利于术后早期肠内营养支持的开展.