Use of a nasal bridle prevents accidental nasoenteral feeding tube removal

Reinserting feeding tubes that are accidentally removed exposes patients to risk and consumes hospital resources. We were interested to know if using a bridle to secure tubes would be more effective than tape at preventing accidental tube removal. This was a quality improvement project with a before-and-after design. Between May 2007 and August 2007, we prospectively followed 90 tubes (50 tape, 40 bridle). Tubes were followed up daily until accidental tube removal, ICU discharge, or planned tube removal. Our primary endpoint was accidental tube removal. We compared the 2 groups on the following: (1) proportion of tubes accidentally removed; (2) rate of accidental tube removal (per 100 tube-days); and (3) Kaplan-Meier survival analysis. Survival analysis data were right-censored at ICU discharge or planned tube removal. There were no significant differences between groups in any demographics. The proportion of tubes accidentally removed was 36% (18 of 50) in the tape group and 10% (4 of 40) in the bridle group; P<.05. The rate of accidental tube removal (per 100 tube-days) was 6.4 (18 in 281 tube-days) in the tape group and 1.6 (4 in 248 tube-days) in the bridle group; P<.05. Survival analysis showed a significant difference between the groups with a log-rank test for equality of survivor function of P<.05. Using a bridle to secure feeding tubes significantly reduces the proportion and rate of accidental tube removal and results in increased tube survival by Kaplan-Meier analysis.     

A technique for positioning nasoenteral feeding tubes

The use of nasoenteral alimentation in many neurologically depressed patients is a common practice. These patients are also at increased risk of sustaining feeding tube malplacement. The morbidity and mortality involving feeding tube malposition in these debilitated patients is high. In this paper, we present four case reports of morbidity, with one resultant mortality, associated with small-bore nasoenteral tube malposition. We are also suggesting a nasoenteral intubation protocol which we feel will decrease the incidence of feeding tube malplacement.     

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.     

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.     

Inadvertent dislodgement of nasoenteral feeding tubes: incidence and prevention

The introduction of soft, small-bore nasoenteral feeding tubes has improved our ability to provide nutritional support to patients in a more comfortable, safe, and cost-effective manner. A retrospective study reveals, however, that 40% of patients receiving nasoenteral tube feeding experienced inadvertent dislodgement of their feeding tubes. All of the patients with dislodged feeding tubes were confused, disoriented, or obtunded periodically. Various means for preventing this problem are discussed. In view of both the considerable time and effort required to place nasoenteral feeding tubes properly and the potential complications due to inadvertent tubes dislodgement, it is recommended that nasoenteral feeding tubes be secured more effectively, particularly in confused or obtunded patients.     

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.     

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.     

Clogging of feeding tubes

This is a report of an in vitro study evaluating clotting ability of some formulas with intact protein and hydrolyzed protein sources in a series of buffers ranging from a pH of 1 thru 10. The following 10 products were tested: Ensure Plus, Ensure, Enrich, Osmolite, Pulmocare, Citrotein, Resource, Vivonex TEN, Vital, and Hepatic Acid II. Protein (10 and 20 g/liter) was added to Citrotein and Ensure Plus. All formulas were tested at full and some at half strength. Clotting occurred only in premixed intact protein formulas (Pulmocare, Ensure Plus, Osmolite, Enrich, Ensure) and in Resource. No clotting was observed for Citrotein (intact protein formula in powder form), Vital, Vivonex TEN, and Hepatic Aid II. Adding protein did not cause or increase clotting. In summary, clotting of some liquid formula diet appears to be an important factor causing possible gastric feeding tube occlusion. The following measures may help in preventing this problem: flushing before and after aspirating for gastric residuals to eliminate acid precipitation of formula in the feeding tube, advance the nasogastric feeding tube into the duodenum if possible, and avoid mixing these products with liquid medications having a pH value of 5.0 or less.     

Declogging small-bore feeding tubes

Nine substances (Pancrease, Viokase, pork pancreatin, bromelain, papain, cranberry juice, Coca-Cola, chymotrypsin, and distilled water) were tested every half-hour for 4 hr using 900 mm of water pressure to determine their effectiveness in declogging small-bore feeding tubes. At the end of 4 hr the tubes were irrigated with air using a 50-cc syringe. None of the substances tested were effective within 4 hr. Three substances allowed for successful syringe irrigation at the end of 4 hr. They were: chymotrypsin, papain, and distilled water.     

Clinical indications for weighted enteral feeding tubes

Simple unweighted fine bore feeding tubes have been used by our Nutritional Support Team for routine nasogastric feeding with success in large numbers of patients. Three clinical situations where mercury or tungsten weighted tubes offer advantages over fine bore tubes have been defined. Significant advantages in patients with concurrent endotracheal intubation, gastric atony and severe oesophageal stricturing are described.     

建立一种简易的大鼠肠内营养支持模型

目的:研究和建立一种简易可靠的EN支持大鼠模型。方法:将32只大鼠剖腹建立急性胰腺炎模型,术中经胃放置EN管至Treitz韧带以下5 cm。在导管入口处、胃体、腹膜、颈背部和尾部5处缝合固定导管,用一次性静脉输液管与营养管连接,调节输液管上滑轮,连续匀速输注EN液。结果:所有大鼠均置管成功,平均输液时间为7 d,均耐受良好,无腹泻等症状。TEN支持3～4 d后开始获得正氮平衡。导管无脱出、折曲和泄漏等。结论:该EN支持模型简易、牢固、可靠,所用器材价廉易得,可同时大规模进行,能满足小动物EN支持研究的需求。     

Lung perforation by nasogastric feeding tubes

Endotracheal misdirection of narrow bore nasogastric feeding tubes resulted in perforation of the lung, pneumothorax and hydrothorax in two intensive care patients. Both were intubated with cuffed endotracheal low pressure tubes, one patient was on respirator therapy with neuromuscular relaxation. Feeding tubes were inserted by experienced personnel with the assistance of a steel stylet without difficulties. Aspiration of fluid was misinterpreted as proof of correct positioning, the liquid being however pleural effusion and not gastric juice. Similarly auscultation of gurgling sounds in the upper epigastrium was not a reliable sign of intragastric position. Insertion of nasoenteric feeding tubes may be complicated by perforation of the upper gastrointestinal tract and lung in poorly responsive patients with cuffed endotracheal devices during neuromuscular blockage. In these patients a laryngoscope and forceps should be used to ensure free passage of the tube into the oesophagus. R?ntgenographic confirmation of correct positioning of the tube immediately after insertion is mandatory.     

Pleural complications of nasoenteric feeding tubes

Pliable, small-bore, feeding tubes are inserted frequently in critically ill patients. The use of wire stylets to facilitate passage of these tubes has increased the chances of unrecognized tracheal intubations, particularly in obtunded patients. Five patients with depressed sensoria had inadvertent transbronchial insertions of feeding tubes into their pleural spaces over a 28-month period. The incidence of this complication among intensive care unit patients was 0.3%. Sequellae included pneumothoraces in four patients, pleural effusions in three patients, and pneumonia with a pulmonary abscess in one patient. The presence of cuffed endotracheal tubes did not prevent this complication in patients with depressed cough reflexes. Inexperience of feeding tube insertors may have contributed to pleural intubations in four of the patients. In patients with depressed sensoria, adequate confirmation of feeding tube location in the stomach or duodenum requires both chest and abdominal roentgenograms.     

Unclogging feeding tubes with pancreatic enzyme

Occlusion of small-bore feeding tubes (Dobbhoff, 8 French) was observed at our institution in 32 of 90 patients (35%) over an 8-month period. The purpose of this study was to evaluate possible causes of tube occlusion and to assess the efficacy of an activated pancreatic enzyme solution to clear obstructed feeding tubes. A Drum cartridge catheter was inserted into the occluded feeding tube to displace any liquid formula and to apply the enzyme solution close to the obstruction site. Water was injected first and served as control. The feeding tubes of 32 patients occluded 60 times during an 8-month period and declogging was attempted in 44 instances. Water was able to clear the obstruction in 12 cases. In the remaining 32 cases, the activated pancreatic enzyme was injected, and the obstruction was cleared in 23 cases (72%). The causes of failure to clear the obstruction were determined in seven cases: tablet impaction (three cases), knotted feeding tube (two cases), tomato seed occluded the feeding port (one case), formula clot in two-third length of the tube for 24-hr (one case). Thus, the pancreatic enzyme solution was successful in restoring tube patency in 23 of 24 instances (96%) where formula clotting was the likely cause of occlusion and Coke or water had failed.     

Detection of improperly positioned feeding tubes

This article describes potentially disastrous outcomes associated with failure to determine when nasally inserted feeding tubes are improperly positioned. It also presents information that is important for risk managers to consider when developing protocols for testing placement of newly inserted feeding tubes.     

Improved design of nasogastric feeding tubes

Disappointed with the overall performance of weighted and unweighted nasogastric feeding tubes, a design programme was initiated which resulted in the development of two new nasogastric tubes, one weighted and one unweighted. The tubes were manufactured with polyurethane rather than polyvinylchloride (PVC) which permitted an increase in diameter of the internal lumen which in turn was coated with water activated lubricant to ease removal of the introducer wire. A specially modelled outflow port was incorporated into the tips of both tubes. The performance of the two new polyurethane nasogastric feeding tubes was assessed under controlled trial condition using as a reference a widely used PVC unweighted open ended tube. While intubation times were similar in patients without concurrent endotracheal intubation, it took a significantly shorter time to intubate patients with concurrent endotracheal intubation with the new weighted tube. Following tube intubation, it was possible to aspirate gastric contents significantly more often through the new polyurethane tubes (p < 0.001) than through the PVC tube, and the unweighted polyurethane tube stayed in situ longer (p < 0.05) than the PVC tube. The newly designed polyurethane nasogastric feeding tubes are the first tubes that have been shown to have advantages over the simpler type of open ended, unweighted PVC nasogastric feeding tubes.     

Bacterial colonization of enteral feeding tubes

An in-vitro model system was used to determine the number of bacteria infused into a 'patient' when three types of polyurethane enteral feeding-tubes that had been experimentally contaminated with feed containing K . aerogenes on day I, were then perfused with sterile feed for periods of 8 h on three consecutive days (days 2–4). The tubes were syringed with 20 ml sterile water at regular intervals. Viable counts were made on syringe washings, feed collected from the ends of the tubes and feed from the nutrient containers.
On day 1, the total number of K . aerogenes in feed samples collected from the nutrient containers and the ends of the tubes rose from 10² to 103–10⁴ cfu ml^-1 over 8 h. On days 2–4 no organisms were detected in the feed samples from the nutrient containers whereas viable counts on feed samples collected from the tubes and syringe washings rose from 10⁴ to 10⁷ and from 10¹ to 10⁷ cfu ml^-1 respectively.
It can be concluded that a single incidence of feed contamination could lead to a patient receiving contaminated feed from an enteral feeding-tube colonized with bacteria which will not be detected by normal monitoring of the remainder of the system.