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.     

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.     

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

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

Acute complications associated with bedside placement of feeding tubes.

Several types of feeding tubes can be placed at a patient's bedside; examples include nasogastric, nasointestinal, gastrostomy, and jejunostomy tubes. Nasoenteral tubes can be placed blindly at bedside or with the assistance of placement devices. Nasoenteric tubes can also be placed via fluoroscopy and endoscopy. Gastrostomy and jejunostomy tubes can be placed using endoscopic techniques. This paper will describe the indications and contraindications for different types of tubes that can be placed at the bedside and complications associated with tube placement. Complications associated with nasoenteral tubes include inadvertent malpositioning of the tube, epistaxis, sinusitis, inadvertent tube removal, tube clogging, tube-feeding-associated diarrhea, and aspiration pneumonia. Complications from percutaneous gastrostomy and jejunostomy tube placements include procedure-related mishaps, site infection, leakage, buried bumper syndrome, tube malfunction, and inadvertent removal. These complications will be reviewed, along with a discussion of incidence, cause, treatment, and prevention approaches.     

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.     

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.     

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.     

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.     

Feeding Tube Insertion and Placement Confirmation Using Electromagnetic Guidance: A Team Review

Background

Challenges for bedside placement of small‐bore feeding tube (SBFT) include iatrogenic injury, multiple exposures to x‐rays, and prolonged placement times. In 2011, the study facility began a feeding tube placement team (FTPT) using the CORTRAK system (CS) in the adult intensive care unit (ICU) and medical‐surgical populations. In 2013, a protocol was implemented using the CS to determine final SBFT location.

Methods

Serial retrospective reviews were done of patients with SBFT placement by the FTPT during July 2011–December 2012 and 2015. Measures included pulmonary deviation, tube location, placement agreement beyond chance for CS tracing and confirmation radiography (CR), x‐ray frequency, and placement time intervals.

Results

A total of 6290 SBFT placements were completed for 4239 patients. First‐attempt SBFT locations were 12.78% gastric, 13.39% first through fourth portion of duodenum, and 73.83% ligament of Treitz/jejunum, with zero placements in esophagus or lung. In 2015, staff avoided 68 lung placements by recognizing proximal pulmonary deviation. X‐ray preprotocol vs protocol (mean [SD]: 1.02 [0.15] vs 0.26 [0.44]) resulted in 74% x‐ray reduction and cost avoidance of $346,000. Time intervals (mean [SD]; N = 6290) were 14.90 (12.74) minutes for insertion, 46.04 (13.80) minutes for placement event, and 3.85 (2.23) hours for consult conclusion. Agreement for n = 1692 placements was 85.28%, with k score of 0.622 (95% confidence limit: 0.582, 0.661; P = .0005).

Conclusions

Team management of SBFT placement using the CS optimizes patient safety, standardizes practice, and decreases cost. Using the CS to determine final SBFT location is a safe alternative to CR.     

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.     

Bedside enteral feeding tube placement into duodenum and jejunum

A bedside method for placement of nasoenteric feeding tubes is described utilizing gravity and corkscrewing of the feeding tube to pass the pylorus and then air injection to verify position of the tube from the location and character of transmitted sounds to the stethoscope. Twenty-eight of 31 consecutive patients requiring enteral feeding had tubes successfully placed past the pylorus using this method, 25 on the first attempt and three on the second. This method is an effective and inexpensive alternative to endoscopic or fluoroscopic feeding tube placement.     

Bedside placement of nasojejunal tubes: a randomised-controlled trial of spiral- vs straight-ended tubes

BACKGROUND AND AIMS: The success rate of unguided nasojejunal feeding tube insertion is low, thus often requiring endoscopic or radiological assistance. The spiral end of the Bengmark nasojejunal tube is supposed to aid post-pyloric placement, but no comparative trial has been performed. METHODS: Patients requiring nasojejunal feeding were randomised to have either Medicina (straight) or Bengmark (spiral) nasojejunal tube placed after stratification into those with normal gastric emptying or clinical evidence of delayed gastric emptying. Nasojejunal tubes were placed at the bedside in a standard fashion without radiological guidance by the same person for pre- and/or post-operative feeding. Bolus intravenous metaclopromide (10mg) was given prior to insertion in the abnormal gastric emptying group. Abdominal radiographs were obtained at 4 and 24h, and the primary end-point was jejunal placement at 24h. RESULTS: Forty-seven patients were randomised of which 17 (11 straight, 6 spiral) could not tolerate the nasojejunal tube. Of the 30 remaining patients, 16 had normal gastric emptying. In patients with normal gastric emptying, successful placement at 24h was achieved in 78% (spiral tube), vs 14% (straight tube) (P=0.041). In the abnormal gastric emptying group, success rates were 57% and 0%, respectively (P=0.07). CONCLUSION: Spiral nasojejunal tubes are preferable to straight tubes for bedside unguided post-pyloric feeding in patients with normal gastric emptying.     

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.     

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.     

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.     

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.     

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.     

Peritonitis after gastrostomy tube replacement: a case series and review of literature

Background: The placement of feeding gastrostomy (G) tubes through a percutaneous endoscopic gastrostomy (PEG) technique has become common because of its simplicity and safety. The majority of the serious complications are reported to occur within a few days of initial tube placement and happen in fewer than 3% of cases. Long‐term reported complications of this procedure include occlusion or breakage of the G‐tube, requiring reinsertion. This report describes the complication of intraperitoneal placement and the development of peritonitis after replacement of an established PEG tube and reviews the pertinent world literature. Methods: A retrospective review of cases of intraperitoneal insertion of replacement G‐tubes was done as well as a Medline search for cases of intraperitoneal insertion of replacement G‐tube or development of peritonitis after replacement tube insertion. Results: Three new cases of inadvertent intraperitoneal insertion of a replacement G‐tube in adult patients with mature tracts are reported. An additional 5 cases have been previously described in adults. Significant morbidity was associated with this complication, and 4 deaths were related to it. Methods used to determine whether the replacement G‐tube was intragastric were not uniform. Conclusions: There have been few reports of intraperitoneal insertion of replacement G‐tubes in patients with mature (>30 days) stoma sites. The cases presented in this report highlight for the clinician the importance of considering this complication, particularly if there are any difficulties with the reinsertion. Prospective studies are needed to determine the frequency of this complication and the optimal protocol for PEG replacement.     

Early enteral nutrition after brain injury by percutaneous endoscopic gastrojejunostomy

Twenty-seven patients in a series of 52 patients with severe brain injury (Glasgow Coma Scale score less than or equal to 8) underwent insertion of intestinal feeding tubes at the bedside. The technique required endoscopy with externalization of gastric and intestinal ports through the abdominal wall. Feedings were begun through the intestinal tube with Vital HN within 4 hours of its insertion with simultaneous gastric decompression via the gastric tube. Tubes were placed 2.3 (range 0-5) days after injury. Full caloric intake (3020 kcal/24 h) was achieved by 6.8 (range 2-8) days after injury to 4.2 (range 2-8) days after placement of the feeding tube. Only 1 patient failed to tolerate feedings immediately after tube insertion. Technical inability to insert the tubes occurred in 3 patients and the intestinal tube migrated into the stomach in 2 patients; diarrhea occurred in only 1 patient. With this technique, it was possible to deliver an average daily intake of 1.2 g/kg of protein in 8-day balance periods beginning at the time of tube insertion. These data included 3- to 4-day periods in which feedings were steadily increased. In 16 patients in whom nitrogen balance was measured for 8-day balance periods, average nitrogen balance was -5.7 (range -11.3 to +3.5) g/24 h. The reduction in nitrogen loss by this technique appears equal to or superior to either gastric feeding or TPN. This technique provides the ability to enterally feed a high proportion of brain-injured patients (except those in barbiturate coma) very early after injury using a bedside procedure.(ABSTRACT TRUNCATED AT 250 WORDS)