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.     

Successful Identification of Anatomical Markers and Placement of Feeding Tubes in Critically Ill Patients via Camera‐Assisted Technology with Real‐Time Video Guidance

Background: Enteral feeding via feeding tube (FT) provides essential nutrition support to critically ill patients or those who cannot intake adequate nutrition via the oral route. Unfortunately, 1%–2% of FTs placed blindly at bedside enter the airway undetected (as confirmed by x‐ray), where they could result in adverse events. Misplaced FTs can cause complications including pneumothorax, vocal cord injury, bronchopleural fistula, pneumonia, and death. X‐ray is typically performed to confirm FT placement before feeding, but may delay nutrition intake, may not universally identify misplacement, and adds cost and radiation exposure. Methods: A prospective case series was conducted to evaluate a novel FT with a camera to provide real‐time visualization, guiding placement. The primary end point was the clinician's ability to identify anatomical markers in the gastrointestinal tract and/or airway using the camera. Results: The Kangaroo Feeding Tube with IRIS Technology tube was placed in 45 subjects with 1 misplaced tube; 3 placements were postpyloric, with the remainder gastric. Clinicians correctly identified the stomach in 44 of 45 placements at a median depth of 60.0 cm (range 45.0–85.0 cm). A stomach image was obtained in 42 subjects (93.3%). Agreement between camera image and radiographic confirmation of placement was 93% (P = .014) with small deviations in recognizing stomach vs small bowel. No device‐related adverse events occurred. Conclusions: Direct visualization of the stomach using a camera‐equipped FT can assist with FT placement, help avoid misplacements, and with further studies to evaluate the safety of eliminating confirmatory x‐ray before feeding, could potentially preclude the need for radiographic confirmation.     

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.     

Treating Delayed Gastric Emptying in Critical Illness

Background: We describe experience using the Cortrak nasointestinal feeding tube and prokinetics in critically ill patients with delayed gastric emptying. Methods: Patient cohorts fed via a Cortrak electromagnetically guided nasointestinal tube (EGNT) or 14 French‐gauge nasogastric tube plus prokinetics were retrospectively compared. Results: Of 69 EGNT placements in 62 patients, 87% reached the small intestine. The median percentage of the enteral nutrition goal increased from 19% pre‐EGNT to 80%–100% between days 1 and 10 post‐insertion and was greater than in 58 patients prescribed metoclopramide (40%–87%: days 1–2, 5–7, P ≤ .018) or 38 patients prescribed erythromycin (48%–98%; days 1 and 5, P < .0084). Up to day 10, the cumulative feeding days lost were lower for EGNT (1.06) than for metoclopramide (2.6, P < .02) or erythromycin (3.1, P < .02). The EGNT group had a lower use of prokinetics and lower treatment cost. Conclusion: Most bedside EGNT placements succeed and, compared to nasogastric feeding plus prokinetics, increase enteral nutrition delivery and reduce both cumulative feeding days lost and prokinetic use.     

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.     

Comparative Analysis of the Efficacy and Complications of Nasojejunal and Jejunostomy on Patients Undergoing Pancreaticoduodenectomy

Background: The efficacy and feeding‐related complications of a nasojejunal feeding tube and jejunostomy after pancreaticoduodenectomy (PD) was investigated with a randomized, controlled clinical trial at the Affiliated Drum Tower Hospital. Methods: Sixty‐eight patients who underwent PD in the Department of Hepatobiliary Surgery were randomly divided into 2 groups: 34 patients received enteral feeding via a nasojejunal tube (NJT group) and 34 patients received enteral feeding via a jejunostomy tube (JT group). The assessment of clinical outcome was based on postoperative investigation of complications. The second part of the assessment included tube related complications and an index on catheter efficiency. Results: There were 15 cases with infectious complications in the JT group and 13 cases in the NJT group, and there was no significant difference in the rate of infectious complications between the 2 groups. The rate of intestinal obstruction and delayed gastric emptying was significantly decreased in the NJT group (P < .05). Catheter‐related complications were more common in the JT group as compared with the NJT group (35.3% vs 20.6%, P < .05). The time for removal of the feeding tube and nasogastric tube was significantly decreased in the NJT group. The postoperative hospital stay in the NJT group was significantly decreased (P < .05), and there was no hospital mortality in this study. Conclusion: Nasojejunal feeding is safer than jejunostomy, and it is associated with only minor complications. Nasojejunal feeding can significantly decrease the incidence of delayed gastric emptying and shorten the postoperative hospital stay.     

Home Nasogastric Feeds

Background: Home enteral nutrition (HEN) is a safe method for providing nutrition to children with chronic diseases. Advantages of HEN include shorter hospitalizations, lower cost, and decreased risk of malnutrition‐associated complications. Follow‐up after hospital discharge on HEN is limited. The purpose of this study was to look at children discharged on nasogastric (NG) feeds to assess follow‐up feeding status and impact on growth. Methods: A retrospective chart review was conducted of pediatric patients discharged from Mount Sinai Medical Center on NG feeds between January 2010 and March 2013. Results: A total of 87 patients were included. Average age was 1.2 years. The most common diagnoses were congenital heart disease (47%), metabolic disease (17%), neurologic impairment (10%), liver disease (9%), prematurity (8%), and inflammatory bowel disease (6%). At most recent follow‐up, 44 (50.6%) were on full oral feeds, 8 (9.2%) were still on NG feeds, 9 (10.3%) had a gastrostomy tube placed, 9 (10.3%) were deceased, and 17 (19.5%) had transferred care or were lost to follow‐up. Average time to discontinuation of NG feeds was 4.8 months. Change in body mass index from hospital discharge to follow‐up visit 6 to 12 weeks after discharge was statistically significant, from a mean (SD) of 13.78 (2.82) to 14.58 (2.1) (P = .02). Change in weight z score was significant for neurologic impairment (?1.35 to ?0.04; P = .03). Height z score change was significant for prematurity (?3.84 to ?3.34; P = .02). There was no significant change in height or weight z scores for the other diagnoses. Conclusions: NG feeds can help to improve short‐term growth after hospital discharge in children with chronic illnesses.     

Nutritional factors associated with survival following enteral tube feeding in patients with motor neurone disease

Background:  Motor neurone disease (MND) is a progressive neurodegenerative disease leading to limb weakness, wasting and respiratory failure. Prolonged poor nutritional intake causes fatigue, weight loss and malnutrition. Consequently, disease progression requires decisions to be made regarding enteral tube feeding. The present study aimed to investigate the survival, nutritional status and complications in patients with MND treated with enteral tube feeding. Methods:  A retrospective case note review was performed to identify patients diagnosed with MND who were treated with enteral tube feeding. A total of 159 consecutive cases were identified suitable for analysis. Patients were treated with percutaneous endoscopic gastrostomy (PEG), radiologically inserted gastrostomy (RIG) or nasogastric feeding tube (NGT). Nutritional status was assessed by body mass index (BMI) and % weight loss (% WL). Serious complications arising from tube insertion and prescribed daily energy intake were both recorded. Results:  Median survival from disease onset was 842 days [interquartile range (IQR) 573–1263]. Median time from disease onset to feeding tube was PEG 521 days (IQR 443–1032), RIG 633 days (IQR 496–1039) and NGT 427 days (IQR 77–781) (P = 0.28). Median survival from tube placement was PEG 200 (IQR 106–546) days, RIG 216 (IQR 83–383) days and NGT 28 (IQR 14–107) days. Survival between gastrostomy and NGT treated patients was significant (P ≤ 0.001). Analysis of serious complications by nutritional status was BMI (P = 0.347) and % WL (P = 0.489). Conclusions:  Nutritional factors associated with reduced survival were weight loss, malnutrition and severe dysphagia. Serious complications were not related to nutritional status but to method of tube insertion. There was no difference in survival between PEG and RIG treated patients.     

Gastric vs Small Bowel Feeding in Critically Ill Neurologically Injured Patients

Background: To evaluate gastric compared with small bowel feeding on nutrition and clinical outcomes in critically ill, neurologically injured patients. Materials and Methods: International, prospective observational studies involving 353 intensive care units (ICUs) were included. Eligible patients were critically ill, mechanically ventilated with neurological diagnoses who remained in the ICU and received enteral nutrition (EN) exclusively for at least 3 days. Sites provided data, including patient characteristics, nutrition practices, and 60‐day outcomes. Patients receiving gastric or small bowel feeding were compared. Covariates including age, sex, body mass index, and Acute Physiology and Chronic Health Evaluation II score were used in the adjusted analyses. Results: Of the 1691 patients who met our inclusion criteria, 1407 (94.1%) received gastric feeding and 88 (5.9%) received small bowel feeding. Adequacy of calories from EN was highest in the gastric group (60.2% and 52.3%, respectively, unadjusted analysis; P = .001), but this was not significant in the adjusted model (P = .428). The likelihood of EN interruptions due to gastrointestinal (GI) complications was higher for the gastric group (19.6% vs 4.7%, unadjusted model; P = .015). There were no significant differences in the rate of discontinuation of mechanical ventilation (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.66–1.12; P = .270) or the rate of being discharged alive from the ICU (HR, 0.94; 95% CI, 0.72–1.23; P = .641) and hospital (HR, 1.16; 95% CI, 0.87–1.55; P = .307) after adjusting for confounders. Conclusions: Despite a higher likelihood of EN interruptions due to GI complications, gastric feeding may be associated with better nutrition adequacy, but neither route is associated with better clinical outcomes.     

Influence of Age and Type of Underlying Disease on Complications Related to Home Enteral Nutrition

Background: No data about the influence of age and underlying diseases on home enteral nutrition (HEN)–related complications are reported in the literature. Herein, we retrospectively investigated this issue by analyzing HEN‐related complications in a cohort of consecutive patients grouped according to the underlying disease and age. Material and Methods: We reviewed the medical records of 101 patients referring to our team in 2007–2010 to obtain patients’ demographic data, age, nutrition status, duration of HEN treatment, and type of HEN‐related complications. They were divided in cancer and neurologic patients and subgrouped on the basis of their age. HEN‐related complications were expressed as complication rates. Results: Patients with neurological diseases suffered a significantly higher number of complications as compared with cancer patients (P = .04). Age did not significantly influence complication rates. The mechanical complications were the most frequent. The majority of HEN‐related complications were resolved at home. Conclusion: Our data strongly suggest that HEN‐related complications are influenced by underlying diseases and not by age. In neurologic patients, dementia, loss of autonomy, and the different therapies administered by PEG probably play an important role in increasing the number of HEN‐related complications as compared with cancer patients. The most frequent complications can be managed at home, reducing the costs of hospitalizations and discomfort for the patient.     

Post‐pyloric feeding tube placement in critically ill patients: Extending the scope of practice for Australian dietitians

Aim

To determine whether the placement of a post‐pyloric feeding tube (PPFT) can be taught safely and effectively to a critical care dietitian.

Methods

This is a prospective observational study conducted in an adult intensive care unit (ICU). The intervention consisted of 19 attempts at post‐pyloric intubation by the dietitian. The 10 ‘learning’ attempts were performed by the dietitian under the direction of an experienced (having completed in excess of 50 successful tube placements) user. A subsequent nine ‘consolidation’ attempts were performed under the responsibility of the intensive care consultant on duty. The primary outcome measures were success (i.e. tip of the PPFT being visible in or distal to the duodenum on X‐ray) and time (minutes) to PPFT placement. Patients were observed for adverse events per standard clinical practice.

Results

A total of 19 post‐pyloric tube placements were attempted in 18 patients (52 (23–70) years, ICU admission diagnoses: trauma n = 4; respiratory failure n = 3; and burns, pancreatitis and renal failure n = 2 each). No adverse events occurred. Most (75%) patients were sedated, and mechanically ventilated. Prokinetics were used to assist tube placement in 11% (2/19) of attempts, both of which were successful. Placement of PPFT was successful in 58% (11/19) of attempts. Whilst training, the success rate was 40% (4/10) compared with 78% (7/9) once training was consolidated (P = 0.17). In the successful attempts, the mean time to placement was 11.0 minutes (3.9–27.1 minutes).

Conclusions

A dietitian can be trained to safely and successfully place PPFT in critically ill patients.     

Improved Delivery of Fat From Human Breast Milk via Continuous Tube Feeding

Background: Human breast milk is used sparingly in infants with intestinal failure due to observations from studies using syringe pumps that show loss of macronutrients with continuous feeding. Because of the potential benefits of using human milk, we sought to assess macronutrient losses using human milk as continuous tube feeds as done in the inpatient and home setting using a feeding bag and pump. Methods: Using in vitro simulations of human milk to assess macronutrient losses with continuous tube feeds, hourly samples were analyzed using the SpectraStar Near‐Infrared Analyzer (Unity Scientific, Columbia, MD). Effects of agitation and positional changes of the feeding bag on macronutrient delivery were investigated in 249 total samples. Pairwise comparisons were performed using repeated‐measures analysis of variance. Results: Significant fat losses were observed at all rates at hours 1–4, averaging to 73% at 5 mL/h. Caloric losses correlated strongly with fat losses. Significant gains in the fat content (+116% at hour 4 at 5 mL/h) were seen in the preinfusion aliquots (feeding bags). Horizontal positioning and continuous agitation of the feeding bag only partially limited fat losses. Fat delivery at 5 mL/h was significantly enhanced to 87% when the feeding bag was placed in an inverted position and improved further up to 98% with higher infusion rates. No carbohydrates and proteins losses were seen. Conclusions: Enabling the delivery of the human milk from the top of the feeding bag optimizes fat delivery and limits losses. Such top infusing feeding bags should be developed and could decrease healthcare costs for intestinal rehabilitation programs.     

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.     

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.     

Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit

Background: Factors impeding delivery of adequate enteral nutrition (EN) to trauma patients include delayed EN initiation, frequent surgeries and procedures, and postoperative ileus. We employed 3 feeding strategies to optimize EN delivery: (1) early EN initiation, (2) preoperative no nil per os feeding protocol, and (3) a catch‐up feeding protocol. This study compared nutrition adequacy and clinical outcomes before and after implementation of these feeding strategies. Methods: All trauma patients aged ≥18 years requiring mechanical ventilation for ≥7 days and receiving EN were included. Patients who sustained nonsurvivable injuries, received parenteral nutrition, or were readmitted to the intensive care unit (ICU) were excluded. EN data were collected until patients received an oral diet or were discharged from the ICU. The improvement was quantified by comparing nutrition adequacy and outcomes between April 2014–May 2015 (intervention) and May 2012–June 2013 (baseline). Results: The intervention group (n = 118) received significantly more calories (94% vs 75%, P < .001) and protein (104% vs 74%, P < .001) than the baseline group (n = 121). The percentage of patients receiving EN within 24 and 48 hours of ICU admission increased from 41% to 70% and from 79% to 96% respectively after intervention (P < .001). Although there were fewer 28‐ay ventilator‐free days in the intervention group than in the baseline group (12 vs 16 days, P = .03), receipt of the intervention was associated with a significant reduction in pneumonia (odds ratio, 0.53; 95% confidence interval, 0.31–0.89; P = .017) after adjusting sex and Injury Severity Score. Conclusions: Implementation of multitargeted feeding strategies resulted in a significant increase in nutrition adequacy and a significant reduction in pneumonia.     

Commercial enteral formulas and nutrition support teams improve the outcome of home enteral tube feeding

Background: The benefits of home enteral tube feeding (HETF) provided by nutrition support teams (NSTs) have been questioned recently, given the growing costs to the healthcare system. This study examined the effect of a specialized home enteral nutrition program on clinical outcome variables in HETF patients. Methods: The observational study included 203 patients (103 women, 100 men; mean age 52.5 years) receiving HETF with homemade diets for at least 12 months before starting a specialized home nutrition program for another 12 months consisting of provision of commercial enteral formulas and the guidance of an NST. Both study periods were compared regarding the number of hospital admissions, length of hospital and intensive care unit (ICU) stay, and costs of hospitalization. Results: A specialized HETF program significantly reduced the number of hospital admissions and the duration of hospital and ICU stays. The need for hospitalization and ICU admission was significantly reduced, with odds ratios of 0.083 (95% confidence interval, 0.051–0.133, P < .001) and 0.259 (95% confidence interval, 0.124–0.539, P < .001), respectively. Specialized HETF was associated with a significant decrease in the prevalence of pneumonia (24.1% vs 14.2%), respiratory failure (7.3% vs 1.9%), urinary tract infection (11.3% vs 4.9%), and anemia (3.9% vs 0%) requiring hospitalization. The average yearly cost of hospital treatment decreased from $764.65 per patient to $142.66 per year per patient. Conclusions: The specialized HETF care program reduces morbidity and costs related to long‐term enteral feeding at home.     

Fat‐Modified Enteral Formula Improves Feeding Tolerance in Critically Ill Patients: A Multicenter,Single‐Blind,Randomized Controlled Trial

Background: Improvement of fat digestion and absorption was supposed to relieve feeding intolerance. This trial aimed to evaluate the effect of a fat‐modified enteral formula on feeding tolerance in critically ill patients. Materials and Methods: This trial was conducted in 7 hospitals in China. In total, 144 intensive care unit (ICU) patients with estimated need of enteral nutrition (EN) for at least 5 days were randomly given fat‐modified enteral formula containing medium‐chain triglycerides (MCT), carnitine, and taurine (interventional feed group, n = 71) or standard enteral formula (control feed group, n = 73). EN intake, feeding intolerance (diarrhea, vomiting, gastric retention, and abdominal distension) and outcomes (mechanical ventilator‐free days of 28 days, length of ICU stay, length of hospital stay, and in‐hospital mortality) were collected. Results: Daily calories and protein intake were increased in the interventional feed group compared with the control feed group (P < .01). Total incidence of feeding intolerance was 42.3% in the interventional feed group and 65.7% in the control feed group (P < .001). Daily incidence of feeding intolerance was 11.3%, 18.3%, 14.1%, 25.4%, and 26.1% in the interventional feed group and 31.5%, 32.9%, 34.2%, 34.2%, and 30.4% in the control feed group from study days 1–5 (P = .0083). Incidence of feeding intolerance without abdominal distention was 32.9% in the interventional feed group and 49.3% in the control feed group (P = .047), while the incidence of abdominal distension was 26.8% in the interventional feed group and 43.8% in the control feed group (P = .03). No significant differences existed in outcomes between the 2 groups. Conclusions: The fat‐modified enteral formula containing MCT, carnitine, and taurine may improve feeding tolerance in critically ill patients.     

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.     

Patient and Family Caregivers’ Experiences of Living With a Jejunostomy Feeding Tube After Surgery for Esophagogastric Cancer

Background:Jejunostomy feeding tubes (JFTs) can be used to provide nutrition support to patients who have had surgery for esophagogastric cancer. Although previous research reports how patients cope with a gastrostomy tube, little is known about the impact of having a JFT. The aim of this qualitative study was to explore how patients and their informal caregivers experience living with a JFT in the first months following surgery. Methods: Participants were purposively sampled from a cohort of patients recruited to a trial investigating home enteral nutrition vs standard care after esophagogastric surgery for cancer. The sampling framework considered age, sex, and marital status. Informal caregivers were also invited to participate. Interviews were audio recorded, transcribed verbatim, and anonymized. Inductive thematic analysis was used to identify key themes related to living with a JFT. Results: Fifteen patient interviews were conducted; 8 also included a family caregiver. Analysis of the data resulted in 2 main themes: “challenges” and “facilitators” when living with a JFT. While “physical effects,” “worries” and “impact on routine” were the main challenges, “support,” “adaptation” and “perceived benefit” were what motivated continuation of the intervention. Conclusion: Findings suggest that participants coped well with a JFT, describing high levels of compliance with stoma care and the feeding regimen. Nonetheless, disturbed sleep patterns and stoma‐related problems proved troublesome. A better understanding of these practical challenges, from the patient and family caregiver perspective, should guide healthcare teams in providing proactive support to avoid preventable problems.     

Incidence of gastroesophageal reflux and aspiration in mechanically ventilated patients using small-bore nasogastric tubes

BACKGROUND: Use of a large-bore nasogastric tube (NGT) and patient position are considered key factors in promoting gastroesophageal reflux (GER) and pulmonary aspiration in critically ill patients. The objective of this study was to determine the incidence of GER and pulmonary aspiration of gastric contents in mechanically ventilated (MV) patients using small-bore NGTs. METHODS: We studied 30 patients on mechanical ventilation for acute respiratory failure who tolerated enteral nutrition through a small-bore NGT. Patients were randomly assigned to a group with (n = 16) or without (n = 14) a small-bore NGT and were maintained in a semirecumbent position during the study. GER and aspiration of gastric contents were assessed by a radioisotopic technique. Scans were done 24 hours after technetium-99m administration (n = 30). In 9 patients a dynamic scintigraphy was performed immediately after colloid administration, and samples of blood and tracheal and oropharyngeal secretions were obtained basally, 30 minutes, and 24 hours after technetium administration and analyzed for radioactivity using a gamma counter. RESULTS: Both groups were similar in age, underlying diagnosis, number of days of mechanical ventilation at the day of study, and mortality. There were no GER reaching the oropharynx and aspiration of gastric contents in both groups. CONCLUSIONS: GER and aspiration of gastric contents were not detected in MV patients using small-bore NGTs and may be a simple measure to prevent ventilator-associated pneumonia.