Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique?

BACKGROUND: Registered dietitian/registered nurse (RD/RN) teams were created to place small bowel feeding tubes (SBFT) at the bedside in intensive care unit (ICU) patients using an electromagnetic tube placement device (ETPD). The primary objective of this study was to evaluate the safety of placing feeding tubes at the ICU bedside using an ETPD. Secondary outcomes included success rate, cost, and timeliness of feeding initiation. METHODS: Data were collected prospectively on 20 SBFT blind placements in ICU patients (control group). After implementing a protocol for RD/RN teams to place SBFTs with an ETPD, 81 SBFTs were placed (study group). Complications, success rate, number of x-rays after tube placement, x-ray cost, and time from physician order to initiation of feedings were compared between the groups. RESULTS: No adverse events occurred in either group. Successful SBFT placement was 63% (12/19) in the control group and 78% (63/81) in the study group (not significant, NS). The median time between physician order for tube placement and feeding initiation decreased from 22.3 hours (control group) to 7.8 hours (study group, p = .003). The median number of x-rays to confirm correct placement was 1 in the study group compared with 2 in the control group (p = .0001), resulting in a 50% decrease in the mean cost for x-rays. CONCLUSIONS: No adverse events occurred with the implementation of bedside feeding tube placement using an ETPD. In addition, SBFT placement with an ETPD by designated ICU RD/RN teams resulted in lower x-ray costs and more timely initiation of enteral feedings compared with blind placement.     

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.     

Verification of an electromagnetic placement device compared with abdominal radiograph to predict accuracy of feeding tube placement

Background: Use of an electromagnetic placement device (EMPD) facilitates placement of feeding tubes at the bedside. Standard practice for verification of feeding tube placement is via radiographic confirmation. The purpose of this research study was to assess the accuracy of placement of small‐bore feeding tubes (SBFTs) as determined by EMPD interpretation compared with that of abdominal radiograph verification by a radiologist. Methods: This multicenter prospective study enrolled patients requiring bedside feeding tube placement. SBFTs were placed by an experienced investigator using the EMPD. Two abdominal radiographs were then obtained: one after initial SBFT placement and an additional radiograph after injection of contrast. Documentation of location based on clinician interpretation using the EMPD was then compared with radiologist interpretation. Results: The final sample size was 194 patients, including 18 pediatric patients. Patient age ranged from 12 days to 102 years. Median time for tube placement was 12 minutes. Of the 194 patients, only 1 patient had data showing discrepancies between the original EMPD verification and the final abdominal radiograph interpretation, providing a 99.5% agreement. No patient experienced complications during SBFT placement, and 15 patients had inadvertent airway placement that was avoided with the use of the EMPD. Conclusions: There was a high percentage of agreement between EMPD and radiologic interpretation after contrast injection. The EMPD aided in avoiding inadvertent airway placement, with no patient complications. This device can be used safely at the bedside to facilitate placement of feeding tubes, leading to the delivery of early enteral nutrition.     

Implementation of an electromagnetic imaging system to facilitate nasogastric and post-pyloric feeding tube placement in patients with and without critical illness

Background:  Artificial nutrition support is required to optimise nutritional status in many patients. Traditional methods of placing feeding tubes may incur clinical risk and financial costs. A technique facilitating placement of nasogastric and post-pyloric tubes via electromagnetic visual guidance may reduce the need for X-ray exposure, endoscopy time and the use of parenteral nutrition. The present study aimed to audit use of such a system at initial implementation in patients within an acute NHS Trust.
Methods:  A retrospective review was undertaken of dietetic and medical records for the first 14 months of using the Cortrak® system. Data were collected on referral origin, preparation of the patient prior to insertion, placement success rates and need for X-ray. Cost analysis was also performed.
Results:  Referrals were received from primary consultants or consultant intensivists, often on the advice of the dietitian. Fifty-nine percent of patients received prokinetic therapy at the time of placement. Thirty-nine tube placements were attempted. Sixty-nine percent of referrals for post-pyloric tube placement resulted in successful placement. X-ray films were requested for 22% of all attempted post-pyloric placements. Less than half of nasogastric tubes were successfully passed, although none of these required X-ray confirmation. The mean cost per tube insertion attempt was £111.
Conclusions:  This system confers advantages, particularly in terms of post-pyloric tube placement, even at this early stage of implementation. A reduction in clinical risk and cost avoidance related to X-ray exposure, the need for endoscopic tube placement and parenteral nutrition have been achieved. The implementation of this system should be considered in other centres.     

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.     

床旁放置经鼻小肠管的新方法

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

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.     

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.     

Early initiation of enteral feeding after percutaneous endoscopic gastrostomy tube placement.

Enteral feeding through the percutaneous endoscopic gastrostomy (PEG) tube is usually initiated about 12 to 24 hours after insertion of the tube. There have been earlier studies evaluating the efficacy of early initiation of enteral feedings that had encouraging results. However, delayed initiation of feeding following PEG placement continues to be practiced widely. We believe that feeding can be done earlier without any increase in associated morbidity or mortality and with obvious reduction in the need for parenteral nutrition and healthcare costs. We evaluated a protocol to initiate enteral nutrition 4 hours after the PEG tube insertion with subsequent discharge of the outpatients on the same day. We conducted a prospective study to assess the efficacy of early initiation of PEG feeding. We enrolled 77 patients in our study who were having PEG tubes placed for enteral feeding. Only patients who had a PEG placed for gastric venting procedures were excluded from our study. During the course of our study, no patient had to be excluded for the latter reason. Patients were evaluated by the physician performing the procedure, 4 hours after the tube was inserted. Their vital signs were checked, and a thorough abdominal examination was performed. Minimal tenderness around the PEG site was the most frequent finding. Otherwise, all the patients had a benign abdominal examination. The tube was flushed with 60 mL of sterile water. Following the examination, orders were given to restart the feedings. These patients were followed for a 30-day period to evaluate complications associated with PEG tube placement and early initiation of PEG feeding. There was one case of aspiration pneumonia (1.3%) and one death that was attributed to the underlying disease out of our 77 patients. Early initiation of enteral feeding after PEG tube placement can be successfully completed with a systematic protocol and close observation. Not only was this protocol found to be safe, it can also have significant cost savings by eliminating the need for inpatient hospitalization for the procedure.     

A multicenter, prospective study of the placement of transpyloric feeding tubes with assistance of a magnetic device. The Magnet-Guided Enteral Feeding Tube Study Group

BACKGROUND: Placement of feeding tubes in the transpyloric position can be helpful in the management of enterally fed patients with pancreatitis, gastric atony, enterocutaneous fistulae, or pulmonary aspiration risk. The attainment of transpyloric position is difficult, and numerous techniques have been proposed to help in achieving this location. Recently, the use of a magnet-tipped feeding tube, dragged into proper position with an external magnet, has been described with an excellent success rate. METHODS: At 10 participating institutions, practitioners were trained in the use of the device. Successful tube placement was determined by abdominal radiograph. RESULTS: One hundred fifty-six tube placements were attempted. Transpyloric position was obtained in 60%. Placement into the third portion of the duodenum or distal was obtained in only 32%. Analysis of the data did not reveal a learning curve at the institutions, and 7 of 10 had a 50% or lower success rate. CONCLUSIONS: Placement of feeding tubes with the assistance of a magnetic device was infrequently successful at the majority of institutions where it was attempted. We report a lower success rate than the original article, which described an 88% success rate of transpyloric intubation. Although this technique has a high failure rate, some individuals seem to be very successful using it, which could reduce the need for endoscopy or transport for the placement of feeding tubes.     

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.     

Use of small-bore feeding tubes: successes and failures

PURPOSE OF REVIEW: Early enteral nutrition is the preferred option for feeding patients who cannot meet their nutrient requirements orally. This article reviews complications associated with small-bore feeding tube insertion and potential methods to promote safe gastric or postpyloric placement. We review the available bedside methods to check the position of the feeding tube and identify inadvertent misplacements. RECENT FINDINGS: Airway misplacement rates of small feeding tubes are considerable. Bedside methods (auscultation, pH, aspirate appearance, air bubbling, external length of the tube, etc.) to confirm the position of a newly inserted small-bore feeding tube have limited scientific basis. Radiographic confirmation therefore continues to be the most accurate method to ascertain tube position. Fluoroscopic and endoscopic methods are reliable but costly and are not available in many hospitals. Rigid protocols to place feeding tubes along with new emerging technology such as CO2 colorimetric paper and tubes coupled with signaling devices are promising candidates to substitute for the blind placement method. SUMMARY: The risk of misplacement with blind bedside methods for small-bore feeding tube insertion requires a change in hospital protocols.     

Pose d’une sonde naso-jéjunale au lit du patient combinant l’érythromycine et le décubitus latéral droit

Gastric enteral nutrition is sometimes limited by moderate to severe gastroparesis with high gastric residuals. In these situations, small bowel nutrition is often a good alternative as, most of the time, the small bowel function remain normal.A blind bedside setting up of a nasojejunal feeding tubes is described, combining erythromycin injection and right side decubitus is reported with 94,9 % post-pyloric feeding tubes and 81,3 % beyond Treitz's angle. Technique results are compared with literature data.     

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.     

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.     

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.     

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.     

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.     

Monitoring feeding tube placement.

The purpose of this literature review is to describe currently available bedside methods to determine feeding tube placement. Described first are methods used at the time of blind insertion to distinguish between gastric and respiratory placement and gastric and small-bowel placement. Discussed next are methods used after feedings are initiated to determine if the tube has remained in the desired position in the gastrointestinal tract. Some of the methods are research-based, whereas others are opinion-based. The level of accuracy of the methods discussed in the review varies widely. No sure non-radiographic method exists to differentiate between respiratory, esophageal, gastric, and small bowel placement of blindly inserted feeding tubes in the fed or unfed state. However, a combination of some of the simpler and more accurate methods may be used to guide feeding tube placement during insertion and help identify the point at which an abdominal radiograph is most likely to confirm the desired location. In addition, methods described in this review can help determine when a radiograph is needed to confirm that a feeding tube has remained in the correct position after the initiation of feedings. Minimizing the number of radiographs taken to assure correct tube placement is important, especially in young children and in the critical care setting where the need for radiographs for other reasons is common.