Efficacy of erythromycin for postpyloric placement of feeding tubes in critically ill children: a randomized, double-blind, placebo controlled study

BACKGROUND: Erythromycin enhances gastric emptying and has been suggested to facilitate nasoenteric feeding tube placement in adults. Our primary objective was to evaluate the effect of erythromycin on the transpyloric passage of feeding tubes in critically ill children, and second, to evaluate the effect of erythromycin on the distal migration of duodenal feeding tubes. METHODS: Seventy-four children were randomly assigned to receive erythromycin lactobionate (10 mg/kg) IV or equal volume of saline placebo 60 minutes before passage of a flexible weighted tip feeding tube. Abdominal radiographs were obtained 4 hours later to assess tube placement. If the tube was proximal to the third part of the duodenum, two additional doses of erythromycin/placebo were administered 6 hours apart. Those receiving additional doses had repeat radiographs 14 to 18 hours after tube placement. RESULTS: The number of postpyloric feeding tubes was similar in the erythromycin and placebo treated groups 4 hours after tube insertion (23/37 vs 27/37, p = .5). Of those with prepyloric tubes at 4 hours, none in the erythromycin group and 3 in the placebo group had the tube migrate to the postpyloric position by 14 to 18 hours (p < .05). Of those with postpyloric tubes proximal to the third part of the duodenum at 4 hours, additional doses of erythromycin did not cause more tubes to advance further into the intestine than did placebo (p = .6). CONCLUSIONS: Erythromycin does not facilitate transpyloric passage of feeding tubes in critically ill children. The distal migration of duodenal tubes further into the small bowel is also not enhanced by erythromycin.     

A randomized trial of endoscopic and fluoroscopic placement of postpyloric feeding tubes in critically ill patients

BACKGROUND: Early postpyloric feeding is considered the accepted method of nutrition support in critically ill patients. Endoscopic and fluoroscopic techniques are associated with the highest percentage of successful placement. The purpose of this study was to compare endoscopic vs fluoroscopic placement of postpyloric feeding tubes in critically ill patients. METHODS: This is a randomized prospective clinical trial. Forty-three patients were randomized to receive feeding tubes by endoscopic or fluoroscopic technique. All procedures were performed at the bedside in the critical care unit. A soft small-bore nonweighted feeding tube was used in all cases. Successful placement was confirmed by either an abdominal x-ray for endoscopic technique or a fluoroscopic radiograph for fluoroscopic technique. RESULTS: Postpyloric feeding tubes were successfully placed in 41 of 43 patients (95%). The success rate using endoscopic technique was 96% (25 of 26), whereas the rate using fluoroscopy was 94% (16 of 17). The average time of successful placement was 15.2 +/- 2.9 (mean +/- SEM) minutes for endoscopic placement and 16.2 +/- 3.2 minutes for fluoroscopic placement, which was not statistically significant (p > .05). CONCLUSIONS: Endoscopic and fluoroscopic placement of postpyloric feeding tubes can safely and accurately be performed at the bedside in critically ill patients. Our results showed no significant difference in the success rate or time of placement between endoscopic vs fluoroscopic placement of postpyloric feeding tubes.     

Transnasal endoscopic placement of feeding tubes in the intensive care unit

BACKGROUND: There is an increasing demand for enteral feeding in intensive care unit (ICU) patients. However, gastroparesis is common, and jejunal placement with gastric decompression leads to delays in feeding. In an attempt to minimize delays, we describe our technique and results with transnasal endoscopic placement of double-lumen gastric aspiration, jejunal feeding tubes (DLFT). METHODS: Fifty-one consecutive ICU patients referred for nutrition support were studied; 29% had respiratory failure, 28% acute head injury, and 33% acute pancreatitis. A 5.8-mm ultraslim video endoscope was used to place a guidewire through the nose terminating beyond the Ligament of Treitz. After withdrawal of the endoscope, a DLFT was passed over the wire. Final position of the tube was checked and adjusted under direct vision by reendoscopy though the opposite nasal passage. RESULTS: Initial placement of the guidewire and DLFT was successful in 46 of 51 patients. Massive gastric dilatation and acute pancreatitis complicated by duodenal compression impeded full duodenoscopy in 5 patients, necessitating fluoroscopy for correct guidewire deployment. In confirming correct tube placement, there was near perfect concordance between reendoscopy and x-ray (45/46). Previously unrecognized upper gastrointestinal tract pathology was detected in most patients, with acute gastritis in 47, superficial gastric ulceration in 24, and erosive esophagitis in 5. CONCLUSIONS: Transnasal endoscopic placement of feeding tubes in the ICU is quick, effective, and minimally disruptive of intensive therapy. In addition, it can reveal unrecognized pathology, which potentially could lead to improvements in overall medical care.     

Web-based teaching module improves success rates of postpyloric positioning of nasoenteric feeding tubes

Background: Bedside protocols improve success rates of postpyloric nasoenteric tube (NET) placement by nutrition teams and experienced individuals. However, many hospitals require novice practitioners to perform these procedures and often choose fluoroscopy, endoscopy, or newer alternative devices to achieve success. Little is known about the ability to train inexperienced practitioners or the effectiveness of the methods used to implement these protocols. Web‐based learning is a potential tool to improve knowledge and procedural skills. The authors created a self‐directed Web‐based teaching module (WBTM) to educate and standardize placement of postpyloric NETs. Methods: Forty‐three first‐, second‐, or third‐year residents or medical or physician assistant students took pretests for knowledge and confidence surveys, viewed the WBTM, placed NET at the bedside, then took a posttest and confidence survey while awaiting confirmation of tube position by abdominal radiograph. Success was acknowledged if the tip of the NET was beyond the pylorus. A retrospective chart review was used to determine a historical success rate, which was used as a control. Results: Knowledge and confidence significantly improved. Overall success rate of postpyloric NET placement for all participants on first attempt was 74.4% vs 46.7% in the control (P = .005). Improvement occurred in all subgroups, including those with no prior experience, who were successful 70.4% of the time (P = .009). Conclusions: This WBTM is simple to implement, inexpensive, and resource efficient. The improvement in postpyloric NET placement, especially among novice practitioners, demonstrates the benefit and applicability of this method of standardized education.     

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.     

Feasibility of self-propelling nasojejunal feeding tube in patients with acute pancreatitis

BACKGROUND & AIMS: To assess the success rate of a self-propelling nasojejunal feeding tube in patients with acute pancreatitis. METHODS: All patients admitted for acute pancreatitis were included. A self-propelling nasojejunal feeding tube was introduced into the stomach, and gastrointestinal motility was stimulated using metoclopramide. If the tube failed to advance to the ligament of Treitz, a nasojejunal tube was placed endoscopically. RESULTS: A total of 108 patients, 94 with necrotizing pancreatitis (Balthazar D/E) and 14 with nonnecrotizing pancreatitis (Balthazar B/C), were referred for artificial nutrition. In 11 cases, ileus persisted and parenteral nutrition was initiated. Among the remaining 97 patients, 5 refused tube placement. The self-propelling feeding tube was inserted in 92 patients with successful migration to the ligament of Treitz in 61% (n = 56) and failure in 39% (n = 36). Of the 36 patients with an initial failed placement, endoscopic placement of a nasojejunal tube was successful 80% of the time (29 patients). The success rate of a nasojejunal self-propelling feeding tube placement correlated directly with the severity of the acute pancreatitis (92% in B/C vs 61% in D vs 48% in E; P < .05). CONCLUSIONS: Use of a self-propelling nasojejunal tube is a simple technique that can be successfully performed in the majority of patients with acute pancreatitis. The utility of this procedure in the most severe cases of acute pancreatitis continues to pose a challenge.     

Placement of nasoenteral feeding tubes using external magnetic guidance

BACKGROUND: Enteral feeding is preferred over parenteral methods, and feeding into the duodenum is preferred over gastric feeding in certain groups of critically ill patients. However, with current techniques, feeding tubes often coil in the stomach, exposing patients to the risk of aspiration. This study investigated whether a nasoenteral feeding tube can be guided beyond the pyloric sphincter, using external magnetic guidance. METHODS: This is a case series of 288 critically ill patients who needed placement of an enteral feeding tube, carried out in the intensive care units and wards of a university-affiliated community hospital. A 12-French polyurethane nasoduodenal feeding tube was modified by placing a small magnet in the distal tip. After inserting the tube through the nares into the esophagus, an external magnet was used to draw the tube tip beyond the pyloric sphincter and further into the duodenum or jejunum. Placement was verified by plain abdominal x-ray, and the depth of insertion (stomach, proximal duodenum, distal duodenum, or jejunum) was recorded. RESULTS: Three hundred twenty-nine intubations were performed in 288 patients (mean procedure time 15 minutes). In 293 cases (89.1%), the tube was placed beyond the pyloric sphincter. In 139 insertions (42.2%), the tube tip was in the distal portion of the duodenum or the jejunum. There were no significant complications. CONCLUSIONS: This case series demonstrates that external magnetic guidance achieves transpyloric placement of an enteral feeding tube in 89.1% of cases. This reliable bedside technique is superior to other methods described in the literature.     

How to Promote Bedside Placement of the Postpyloric Feeding Tube

Background: The optimal method of achieving fast, safe, and accurate postpyloric tube placement at the bedside remains controversial. This study investigated whether facilitating techniques of bedside placement would improve the rate of successful placement of postpyloric tubes when compared with the standard technique and whether strategies should be confined to adult or pediatric patients. Methods: We searched electronic databases for eligible literatures that compared different methods of postpyloric tube placement, evaluating the successful rate of postpyloric tube placement. Two reviewers reviewed the quality of the studies and performed data extraction independently. Pairwise and network meta‐analyses were performed to integrate the efficacy. Results: Fourteen clinical trials involving 753 patients were included. Pairwise meta‐analyses demonstrated that prokinetic agents (odds ratio [OR], 2.263; 95% confidence interval [CI]: 1.140–4.490; P = .02) were associated with a higher success rate as compared with the standard technique, and gastric air insufflation was associated with a higher success rate as compared with prokinetic agents (OR, 3.462; 95% CI, 1.63–7.346; P = .001) in adult patients. In network analyses, prokinetic agents and gastric air insufflation were also consistently associated with a higher success rate in adult patients. Trend analyses of rank probabilities revealed gastric air insufflation had the cumulative probability of being the most efficacious strategy (78%), especially in adult patients (88%). Conclusions: Gastric air insufflation seems to be clinically better for promoting bedside placement of postpyloric feeding tubes in adults. Clinicians should no longer use prokinetic agents in pediatric patients or patients without impaired motility.     

Technique for intraduodenal placement of transnasal enteral feeding catheters.

Timely initiation of enteral feeding requires efficient placement of nasoenteric feeding tubes. It is generally agreed that postpyloric placement of feeding tubes reduces the risk of regurgitation and aspiration of feeding formulas. The authors describe a simple, economic method of achieving postpyloric placement of feeding tubes in most patients.     

自制镍钛记忆合金支架在幽门十二指肠恶性梗阻中的应用

目的:探讨幽门十二指肠恶性梗阻时镍钛记忆合金支架置入的操作技术及其临床疗效。方法:本组30例患者,胃窦癌5例,胃窦癌术后吻合口狭窄5例,贲门癌术后复发伴幽门梗阻6例,结肠癌晚期伴胆管、十二指肠恶性梗阻2例,胰头癌浸润十二指肠7例,十二指肠癌5例。所有病人均行胃镜和上消化道碘剂造影以证实梗阻部位及其程度,选择合适的支架。经胃镜插入导丝,在X线监视下将导丝送至梗阻远端,沿导丝进行球囊扩张;在X线监视下沿导丝用支架推送器将支架送至狭窄远端2cm,其中4例支架经内镜活检孔送入。术后观察病人腹胀、呕吐等临床症状的改善情况。结果:本组支架一次置入成功29例,成功率96.67%。其中有7例为双支架置入(同时置胆总管支架)。支架置入后1周,患者腹胀消失率为21/30(70%),呕吐消失率为23/30(76.67%)。未发生与操作相关的近期并发症。结论:采用自制镍钛记忆合金幽门支架治疗幽门恶性狭窄,能明显改善患者生存质量,是一种安全有效的治疗方法。     

Do weighted nasoenteric feeding tubes facilitate duodenal intubations?

A widely held assumption is that postpyloric intubations occur more often with weighted than with unweighted nasally inserted feeding tubes. This randomized, prospective study compared the frequency of duodenal intubations using weighted and unweighted nasoenteric feeding tubes. One hundred sixteen patients had either weighted (61 patients) or unweighted (55 patients) 10F silicone elastomer feeding tubes inserted nasally 85 cm. Tubes were placed with wire stylets. Tube positions were verified radiographically within 4 hr after insertions. Radiographs were repeated daily for 3 days or until duodenal intubation occurred. Successful duodenal intubations were achieved in 35 patients (57%) with weighted feeding tubes and in 37 patients (67%) with unweighted feeding tubes. This difference was not significant. Weighted nasoenteric feeding tubes offer no advantage over unweighted tubes in achieving duodenal intubations.     

Small bowel feeding tube placement using an electromagnetic tube placement device: accuracy of tip location

Background: An electromagnetic tube placement device (ETPD) monitors tip position of feeding tubes (FT) during placement in the digestive tract. It helps to avoid airway misplacement and permits positioning into the small bowel (SB). This study compares the overall agreement between FT tip location as determined by an ETPD vs an abdominal radiograph of the kidneys, ureter, and bladder (KUB). Methods: Using an ETPD, A nurse placed postpyloric FTs in ICU patients. We included all patients in whom the ETPD was used for FT placement. Data were prospectively recorded for 255 days on the rate of successful postpyloric placement, ETPD estimated tip location, and KUB location. Results: 860 tubes were placed in 616 patients, 719 (83.6%) of which recorded for ETPD and KUB. According to the KUB, 81% of tubes were in the SB; however, ETPD suggested 89% were beyond the pylorus. There was moderate agreement beyond what could be attributed to chance between KUB and ETPD tip locations (475 [66.1%], κ score 0.62 [95% confidence interval 0.58–0.67]). More tubes by KUB were distal (134[18.6%]) vs proximal (110[15.3%]) to the suspected location by ETPD (P < .0001. Tubes in or distal to the second half of the duodenum, according to ETPD were rarely in the stomach (<1%). No tubes were proximal to the stomach or placed into the airway. Conclusions: The strong agreement between KUB and ETPD, when tubes were believed to be in the second part of the duodenum or beyond, suggests that KUB is necessary only when the FT tip is suspected to be in the proximal duodenum.     

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.     

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.     

经内镜十二指肠营养管置放术在重度昏迷气管切开气管插管患者的应用价值

目的探讨经内镜十二指肠营养管置放术在重度昏迷气管切开气管插管患者的应用价值．方法对28例已行气管切开气管插管的重度昏迷患者进行经内镜十二指肠营养管置放术。结果本组28例患者经内镜十二指肠营养管置放术均获成功，术中未发生任何经内镜十二指肠营养管置放术相关性并发症。所有患者在术后立即恢复了胃肠营养=十二指肠营养管置放术最长用时为31min，最短仅8min，平均16min。患者平均带管时间为73(7～218)d。所有患者仅1例发生营养菅堵塞、脱管等现象。无一例出现通过十二指肠营养管注入的营养物或药物的反流。结论对于重度昏迷已行气管切开气管插管的患者，经内镜十二指肠营养管置放术是一种有效、简便、安全的建立胃肠营养的方法。     

A randomized controlled trial comparing three different techniques of nasojejunal feeding tube placement in critically ill children

BACKGROUND: The goal of this study was to compare 3 different techniques used to place nasojejunal (NJ) feeding tubes in the critically ill or injured pediatric patients. This was a randomized, prospective trial in a university-affiliated 12-bed pediatric intensive care unit. Patients were critically ill children requiring placement of an NJ feeding tube. Patient age, weight, medications, use of mechanical ventilation, and patient tolerance were recorded. An abdominal radiograph obtained immediately after the placement determined correct placement. The final placement was recorded, as was the number of placement attempts. METHODS: Patients were randomized to 1 of 3 groups: standard technique, standard technique facilitated with gastric insufflation, and standard technique facilitated with the use of preinsertion erythromycin. To ensure equal distribution, all patients were stratified by weight (<10 kg vs > or =10 kg) before randomization. All NJ tubes were placed by one of the investigators. If unsuccessful, a second attempt by the same investigator was allowed. Successful placement of the NJ tube was defined by confirmation of the tip of the tube in the first part of the duodenum or beyond by a pediatric radiologist blinded to the treatment groups. RESULTS: Seventy-five pediatric patients were enrolled in the study; 94.6% (71/75) of tubes were passed successfully into the small bowel on the first or second attempt. Evaluation of the data revealed no significant association with a specific technique and successful placement (p = .1999). CONCLUSIONS: When placed by a core group of experienced operators, the majority of NJ feeding tubes can be placed in critically ill or injured children on the first or second attempt, regardless of the technique used.     

Efficacy of metoclopramide as an adjunct to duodenal placement of small-bore feeding tubes: a randomized, placebo-controlled, double-blind study

We examined whether metoclopramide would improve the success rate of transpyloric intubation of a weighted Corpak feeding tube when fluoroscopic guidance is not used. Seventy patients were randomized in a prospective, double-blind fashion to receive either placebo (n = 35) or metoclopramide, 10 mg (n = 35) parenterally, administered immediately after the feeding tube was inserted. Tube location was determined independently by two observers who examined radiographs obtained after barium was instilled via the tube. There was no significant increase in the success rate of duodenal intubation in the total group following metoclopramide, 60%, compared to placebo, 49%. However, analysis of subgroups among the placebo-treated patients revealed that diabetes mellitus, but not other medical conditions, decreased the success rate for duodenal intubation, 20 vs 60% (p less than 0.05). Among diabetic patients, metoclopramide resulted in a significant increase in duodenal placement compared to placebo (p less than 0.05). We conclude that parenteral metoclopramide significantly increases the frequency of transpyloric intubation with small feeding tubes without fluoroscopic guidance in diabetic patients but not in nondiabetic 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.