Experience of post-pyloric feeding in seriously ill patients in clinical practice

BACKGROUND: Maintaining nutrition is an integral part of patient care and when it is possible enteral nutrition is regarded as superior to parenteral nutrition. Post-pyloric feeding may enable enteral feeding to be maintained in patients who cannot tolerate nasogastric feeding. The success of post-pyloric feeding in routine clinical practice is uncertain. METHODS: One hundred and forty six consecutive patients who had 150 separate episodes of post-pyloric feeding were identified. Casenotes were reviewed to assess indication for post-pyloric feeding, prior use of alternative methods of feeding, success of achieving nutritional requirements and patient outcome. RESULTS: A post-pyloric tube was successfully placed in 138 (92%) and nutritional requirements were met by post-pyloric feeding alone in 124 (83%). Post-pyloric feeding was used for between 2 and 254 days (median 14 days). Conditions for which post-pyloric feeding was used to administer nutritional support included burn injury, pancreatitis, sepsis, post-operative gastric stasis, bone marrow transplantation and chemotherapy induced vomiting. Fifty (33%) patients had an attempt at nasogastric feeding and 33 (22%) were on total parenteral nutrition before post-pyloric feeding was commenced. There was one major complication of a jejunal ulcer bleed in the series. Minor complications included displacement of the nasojejunal tube and failure to absorb feed related to gastrointestinal dysfunction. CONCLUSIONS: Post-pyloric feeding can be successfully used to maintain enteral nutrition in patients who would otherwise require parenteral nutrition.     

Nasoenteral feeding tube insertion via fiberoptic endoscope for enteral hyperalimentation.

Total parenteral nutrition can maintain good nutritional status in selected patients. However, it can be accompanied by serious complications. It is generally agreed that enteral alimentation is more economical and safer. Gut should be used for nutritional replenishment whenever feasible. However, large-bore nasogastric feeding tubes can cause problems. Even fine-bore nasogastric tubes can cause aspiration pneumonia in obtunded and debilitated patients. In some patients it is clearly desirable to have the tip of the feeding tube in the distal duodenum or proximal jejunum. Previously described methods for placement of nasoenteral tubes may be unsatisfactory. We describe a safe, simple, and reliable method for endoscopic insertion of fine-bore nasoenteral feeding tube. We have used this method on 15 patients without complication.     

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.     

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.     

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.     

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.     

Serum paracetamol concentration: an alternative to X-rays to determine feeding tube location in the critically ill

BACKGROUND: Placement of enteral feeding tubes is an important clinical issue. Previous studies suggest that paracetamol absorption is very fast after jejunal administration. The aim was to determine whether paracetamol serum concentration measured by immunoassay can determine the tip position of the feeding tube. METHODS: Thirty-three critically ill patients requiring enteral nutrition with either gastric or post-pyloric feeding tubes were enrolled prospectively in the surgical intensive care unit of a university hospital. Paracetamol was administered in the feeding tube (15 mg/kg) after a baseline blood sample (T0). Thereafter, 8 blood samples were taken between 2.5 and 240 minutes. Paracetamol was analyzed using an automated homogenous immunoassay. RESULTS: The patients did not differ with respect to age or severity of disease. Peak paracetamol concentrations were significantly higher after post-pyloric administration with 42.6 +/- 13.5 versus 20.5 +/- 7.5 mg/L (p < .0001). Time-to-peak paracetamol concentration was significantly shorter with post-pyloric tubes (median, 5 versus 60 minutes; p < .0001). The receiver operating characteristic (ROC) curves showed the highest sensitivity and specificity at 5 minutes with 94.1% and 100%, respectively, for discriminating between gastric and post-pyloric location. CONCLUSIONS: Because of paracetamol's rapid absorption after jejunal administration, the test seems to be a safe and inexpensive alternative to X-ray control for assessment of the enteral feeding tube location. Its value in clinical practice remains to be established.     

Increasing the occupational therapy mental health workforce through innovative practice education: A pilot project

Aim:  This paper describes the evaluation of a pilot trial of two innovative placement models in the area of mental health, namely role emerging and collaborative supervision. The Queensland Occupational Therapy Fieldwork Collaborative conducted this trial in response to workforce shortages in mental health.
Method:  Six occupational therapy students and eight practice educators were surveyed pre- and post-placements regarding implementation of these innovative models.
Results:  Students participating in these placements reported that they were highly likely to work in mental health upon graduation, and practice educators were positive about undertaking innovative placements in future. An overview of the placement sites, trials, outcomes and limitations of this pilot trial is provided.
Conclusion:  Though limited by its small sample size, this pilot trial has demonstrated the potential of innovative placement models to provide valuable student learning experiences in mental health. The profession needs to develop expertise in the use of innovative placement models if students are to be adequately prepared to work with the mental health issues of the Australian community now and in the future.     

Magnetic Resonance–Guided Nasogastric Feeding Tube Placement for Neonates: A Preclinical Study

Background: Establishing postnatal nutrition delivery is challenging in neonates with immature sucking and swallowing ability. Enteral feeding is the gold standard for such patients, but their small size and fragility present challenges in nasogastric (NG) feeding tube placement. Feeding tubes are typically placed with x‐ray guidance, which provides minimal soft tissue contrast and exposes the baby to ionizing radiation. This research investigates magnetic resonance (MR) guidance of NG feeding tube placement in neonates to provide improved soft tissue visualization without ionizing radiation. Materials and Methods: A novel feeding tube incorporating 3 solenoid coils for real‐time tracking and guidance in the MR environment was developed. The feeding tube was placed 5 times in a rabbit with conventional x‐ray guidance to assess mechanical stability and function. After x‐ray procedures, the rabbit was transferred to a neonatal MR system, and the tube was placed 5 more times. Results: In procedures guided by x‐ray and MR, the feeding tube provided sufficient mechanical strength and functionality to access the esophagus and stomach of the rabbit. MR imaging provided significantly improved soft tissue contrast versus x‐ray, which aided in proper tube guidance. Moreover, MR guidance allowed for real‐time placement of the tube without the use of ionizing radiation. Conclusions: The feasibility and benefits offered by an MR‐guided approach to NG feeding tube placement were demonstrated. The ability to acquire high‐quality MR images of soft tissue without ionizing radiation and a contrast agent, coupled with accurate 3‐dimensional device tracking, promises to have a powerful impact on future neonatal feeding tube placements.     

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.     

Enhancing patient safety during feeding-tube insertion: a review of more than 2,000 insertions

BACKGROUND: An intervention to reduce complications from insertion of small-bore nasogastric feeding tubes was performed. METHODS: This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding-tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre- and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology-guided insertion, and implementation of explicit policies and procedures. RESULTS: Of all small-bore nasogastric feeding-tube placements, 1.3%-2.4% resulted in 50 documented cases of feeding-tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly attributed to the feeding-tube malposition. Only 2 of the 13 complications and none of the misplacements had been recorded in the risk management database; most cases were identified from the search of radiology reports. In the 15-month postintervention period, no complications were identified. The control chart showed that after the intervention, there was a significant increase in the "number between" tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project. CONCLUSIONS: Unassisted feeding tube insertion carries significant risk in vulnerable patients, which can be mitigated. Voluntary reporting appears inadequate to capture complications from feeding tube insertion.     

Percutaneous endoscopic gastrostomy in the neurosurgical intensive care unit: complications and outcome

BACKGROUND: Even with a functioning gastrointestinal tract, it is not always easy to initiate oral feeding in some neurosurgical patients because of their persistently depressed neurologic status or severe lower cranial nerve palsies. Percutaneous endoscopic gastrostomy (PEG) may be required for long-term feeding in these patients. The purpose of the present study is to report our experience with PEG chosen for establishing an enteral route in patients of neurosurgical intensive care unit (ICU). METHODS: The outcome and complications of PEG in neurosurgical ICU patients of Marmara University Institute of Neurological Science between January 2001 and November 2006 were retrospectively evaluated. RESULTS: Thirty-one patients, with the median age of 51 years (range, 14-78 years) underwent PEG placement. PEG was placed before the craniotomy in 2 patients and after in 29. Indications for PEG were absent gag reflex in 10 patients and low Glasgow Coma Scale score in 21. Before the PEG tube insertion, 18 patients had enteral nutrition by a nasogastric tube and 10 had parenteral nutrition (PN), with a median duration of 14.5 (range, 4-60) and 12 (range, 7-25) days, respectively. Two patients accidentally pulled out the gastrostomy tubes 10 and 11 days after insertion. Buried bumper syndrome developed in 1 patient. Two patients died 8 and 34 days after the procedure in the neurosurgical ICU. Twenty-nine patients were discharged from the hospital while being fed via the PEG tubes. In 11 patients who were able to resume oral feeding, the tube was removed, with a median interval of 62 (range, 25-150) days. Procedure-related mortality, 30-day mortality, and overall mortality of the patients were 0%, 6.4%, and 45%, respectively. CONCLUSION: PEG is a safe and well-tolerated gastrostomy method for neurosurgical ICU patients with depressed neurologic state or severe lower cranial nerve palsies.     

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.     

X线导向下置入鼻空肠管早期肠内营养在重症急性胰腺炎病人的应用

目的:评价X线导向下置入鼻空肠管早期肠内营养(EEN)对重症急性胰腺炎(SAP)病人的临床效果和价值。方法:27例SAP病人入院3~5 d后,通过X线导向,经鼻置入空肠管行EEN支持,持续使用2周,并与同期完全胃肠外营养(TPN)组29例病人进行对照。结果:两组病人营养支持后,血淀粉酶较营养支持前明显下降;EEN组较TPN组下降更加明显(P0.01)。两组病人前清蛋白较营养支持前上升,EEN组较TPN组明显上升(P0.05)。EEN组病人可明显缩短住院时间和降低住院费用。两组病人治愈率和病死率无统计学差异。结论:X线导向下置入鼻空肠管行EEN操作简便、成功率高,对SAP病人疗效好,并节省医疗费用。     

Pre-pyloric versus post-pyloric feeding

Optimal management of the critically ill patient involves the initiation and rapid advancement of early enteral nutrition (EN). Compared to parenteral nutrition or no nutritional support, early enteral feeding favorably impacts patient outcome by reducing infectious morbidity and shortening hospital length of stay. Controversy exists over the true risks and benefits of pre-pyloric versus post-pyloric feeding. Placement of nasogastric tubes is easier than nasojejunal tubes, initiation of EN is more expedient, and intragastric feeds may provide greater physiologic benefits. Post-pyloric feeding, on the other hand, is associated with fewer interruptions once EN has been started, may reach goal calorie provision sooner, and may reduce risk for gastroesophageal reflux and aspiration. Overall differences in outcome between the two methods of feeding, however, are minimal. Thus, the final choice for the practicing clinician on the level of infusion of enteral feeding is based on institutional factors (related to protocols and available expertise) and the degree of risk and potential tolerance of the individual patient.     

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.     

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.     

Loss of income and levels of scholarship support for students on rural clinical placements: A survey of medical, nursing and allied health students

Objective:  To quantify the financial impact of rural clinical placements on medical, nursing and allied health students in rural Australia.
Design:  The Careers in Health Tracking Survey provided data on whether students were employed, usual weekly hours of employment and a range of covariates, such as age, sex, course of study, marital status, dependants and rural or urban origin.
Participants:  A total of 121 students from a range of health professions completed the Careers in Health Tracking Survey while on rural placement at the Northern Rivers University Department of Rural Health.
Outcome measures:  Survey data.
Results:  Forty-one per cent of respondents were working immediately before their clinical placements. Nursing students worked the longest hours by far and were significantly more financially disadvantaged than both medical and allied health students ( P <  0.01). Scholarship support was unevenly distributed, with nursing and allied health students being relatively under-supported in relation to lost earnings.
Conclusion:  Recruitment of students can be an effective strategy to address the rural health workforce shortage throughout Australia. However, there are a number of financial disincentives for students to undertake rural clinical placements. Additional support for some disciplines is needed to provide equitable distribution of scholarship support to offset this financial burden. Establishing an employment scheme for students on rural clinical placements and a scholarship for income replacement where employment is not available would also alleviate income loss.     

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.