Feeding Tube Placement and Verification: Best Practices Needed Now.

Routine feeding tube (FT) placement during pancreaticoduodenectomy (PD) has not reduced complication rates. Nonetheless, FTs are often selectively placed in patients with poor nutritional status such as those with significant weight loss or hypoalbuminemia, based on the assumption that the benefits outweigh the risks. This study examined whether FT placement reduced complications in at-risk nutritional subgroups. This retrospective cohort study used data from the National Surgical Quality Improvement Program (NSQIP) database (2017-2020). Patients undergoing PD were grouped according to nutritional status as follows: (1) weight Loss >10%, (2) albumin <30g/L, (3) weight loss or low albumin, (4) both weight loss and low albumin, and (5) neither. Five propensity score matching (PSM) models were utilized, each adjusted for perioperative variables, and postoperative outcomes between patients with and without FTs across these groups were compared. Each subgroup analysis served as an independent evaluation of the potential benefits of FT placement in the defined populations. Among 16,780 patients with PD, 742 (4.4%) received FTs. PSM analyses showed that FT placement did not reduce complications in any subgroup, but significantly increased delayed gastric emptying rates, especially in patients with low albumin and weight loss (29.4% vs 16.0%, P < 0.0001). FT placement also led to longer hospital stays (11 vs 8d, P < 0.0001) and higher reoperation rates in 2 groups. In nutritionally at-risk patients undergoing pancreaticoduodenectomy, the risks of feeding tube placement appear to outweigh the benefits, as no reduction in complications was observed, and morbidity was increased.

Recent evidence suggests that enteral nutrition offers significant advantages over parenteral nutrition in critically ill patients. However, gastric emptying is impaired in many critically ill patients [1]. Thus, feeding through a nasogastric tube may endanger many critically ill patients, in that it can lead to large gastric residues and aspiration. Feeding through a nasoduodenal or nasojejunal tube is an alternative, but postpyloric placement of a feeding tube may be difficult, particularly in critically ill patients. Blind placement of a feeding tube into the duodenum or jejunum in ICU patients is frequently not successful.

The techniques for placement of feeding tubes using fiberscopes are described and an evaluation of the results obtained in the last 12 months is made. The techniques are discussed and compared with other methods of enteral feeding known at present. It is concluded that placement of feeding tubes by endoscopy can be achieved easily, that it is possible to choose the site of enteric liberation of nutrients under conditions which previously represented contraindications, and that this procedure is free of complications even during long periods of time.

Using Prediction Uncertainty to Identify Reliable Predictions for a Deep Learning Model that Predicts the Need for Early Feeding Tube Placement

We aim to explore how health surrogates of patients with dementia proceed in decision making, which considerations are decisive, and whether family surrogates and professional guardians decide differently. We conducted an experimental vignette study using think aloud protocol analysis. Thirty-two family surrogates and professional guardians were asked to decide on two hypothetical case vignettes, concerning a feeding tube placement and a cardiac pacemaker implantation in patients with end-stage dementia. They had to verbalize their thoughts while deciding. Verbalizations were audio-recorded, transcribed, and analyzed according to content analysis. By experimentally changing variables in the vignettes, the impact of these variables on the outcome of decision making was calculated. Although only 25% and 31% of the relatives gave their consent to the feeding tube and pacemaker placement, respectively, 56% and 81% of the professional guardians consented to these life-sustaining measures. Relatives decided intuitively, referred to their own preferences, and focused on the patient's age, state of wellbeing, and suffering. Professional guardians showed a deliberative approach, relied on medical and legal authorities, and emphasized patient autonomy. Situational variables such as the patient's current behavior and the views of health care professionals and family members had higher impacts on decisions than the patient's prior statements or life attitudes. Both the process and outcome of surrogate decision making depend heavily on whether the surrogate is a relative or not. These findings have implications for the physician-surrogate relationship and legal frameworks regarding surrogacy.

Initiation of early nutrition therapy and providing adequate caloric needs in burn patients has been shown to maintain gut integrity, reduce nosocomial infections, decrease disease severity, and achieve nitrogen balance earlier. Failure to meet nutrition needs impairs wound healing, increases risk for infection, and leads to cellular dysfunction. Our Performance Improvement Program monitors several metrics relating to nutrition. These include the time from admission to the placement of feeding tubes, the time it takes to achieve goal tube feeding rates, and the percentage of daily caloric needs met on all patients that meet the criteria for a feeding tube. We reviewed performance improvement data from January 2016 to December 2017. All patients on a ventilator and admitted during this period were included with the exception of patients extubated within 24 hours of admission to the burn unit. Our feeding tube placement protocol calls for post-pyloric placement of feeding tubes with the rationale of a decreased risk for aspiration and the ability to continue tube feeds in the operating room thus decreasing the incidence of not meeting daily caloric needs. If nursing was unable to advance the feeding tube, the GI service was consulted to complete the procedure. During the review period, we had 596 admissions with 50 feeding tube placements. The mean time from admission to tube placement was 5.5 hours. The mean time from admission to initiation of feeding was 11 hours. The mean time from admission to goal rate achieved was 19.5 hours. The percentage of successful post-pyloric placement of feeding tubes by nursing was 75.5%. The average daily caloric needs met was 100.5%. With early small bowel feeding tube placement, we are able to meet caloric needs quickly and consistently to prevent graft loss, reduce infections, decrease LOS, and contribute to positive patient outcomes. We attribute our success in these nutritional matrices to our vigilant Performance Improvement process. In which all of these matrices are monitored and obstructions to nutrition goals are identified in real-time and resolved.

Colorimetric capnography, a new procedure to ensure correct feeding tube placement in the intensive care unit: An evaluation of a local protocol

Evaluation of a novel platform for placement confirmation of enteral feeding tubes in adults

In critically ill patients, nasogastric (NG) and nasojejunal (NJ) feeding tube placements are standard procedures. However, about 1.9% of blind tube insertions are malpositioned in the tracheopulmonary system, whereas guided procedures may result in a significant delay in nutritional delivery. Guided methods, such as Cortrak and fluoroscopy, have success rates of 82.6-85% and 93% respectively. The current study aims to investigate the performance of video-assisted feeding tube placement in the post-pyloric position using Integrated Real Time Imaging System (IRIS-) technology. A prospective cohort study in patients requiring enteral feeding was conducted in a mixed medical-surgical intensive care unit (ICU). The primary outcome was the post-pyloric placement of IRIS feeding tubes, as confirmed by X-ray. Secondary study objectives included gastric placement, ease of use and adverse events. Thirty-one feeding tubes were placed using IRIS-technology; one patient was excluded for analysis due to protocol violation. One procedure was terminated due to significant bleeding (epistaxis) and desaturation. Only eighteen (58%) feeding tubes were placed in post-pyloric position (including two past the ligament of Treitz). In subjects who needed post-pyloric placement due gastroparesis, IRIS was mostly unsuccessful (success rate of 25%). However, when gastric placement was the primary objective, 96.8% of tubes were correctly placed. During insertion, tracheal visualization occurred in 27% of cases, and the IRIS feeding tube was repositioned early in the procedure without causing patient harm. Real-time video-assisted post-pyloric feeding tube placement in critically ill ICU patients was only successful in 58% of cases and therefore currently cannot be recommended for this indication. However, a high success rate (96.8%) for gastric placement was achieved. IRIS tube placement detected tracheal misplacement immediately and had few adverse events.

Impact of a Proactive Swallowing Rehabilitation Program on Feeding Tube Placement in Patients Treated for Head and Neck Cancer

The use of feeding tubes is common in children with neurologic impairment. Benefits after tube placement include improvements in nutritional status, drooling, secretion management, constipation,1 and ease of caregiver medication administration and feeding.2 A systematic review of the literature in which family experience is described after gastrostomy tube placement revealed both positive and negative outcomes in a variety of domains, including the child’s health and quality of life, parental stress, and family relationships.3 The effect of feeding tube placement on reflux-related outcomes, including aspiration and pneumonia (common issues in this population), remains unclear. In this issue of Pediatrics , Nelson et al4 examine survival and acute health care use after feeding tube placement in a population-based cohort study of children with neurologic impairment. By using an impressively comprehensive and complete health administration data set from the province of Ontario between 1993 and 2015, the authors looked at health care use for an equal time period before and after feeding tube placement with a minimum time of … Address correspondence to K. Jane Lee, MD, MA, Special Needs Complex Care Program, 999 N. 92nd St, Milwaukee, WI 53226. E-mail: kjlee{at}mcw.edu

Systematic review on bedside electromagnetic-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes

Endoscopic Versus Bedside Electromagnetic-Guided Placement of Nasoenteral Feeding Tubes in Surgical Patients

Background:In order to determine the type and incidence of pulmonary complications associated with the placement of narrow-bore enteral feeding tubes we conducted a prospective, descriptive study in the multidisciplinary intensive care unit (ICU) of a university hospital. All patients that had narrow-bore enteral feeding tubes inserted over a 2-year period (1993-1995) were included. The study required no clinical interventions.Results:Seven hundred and forty feeding tubes were inserted during the study period. In 14 cases (2%), the feeding tube was inserted into the tracheopulmonary system. Five patients (0.7%) suffered a major complication, including two (0.3%) who died from complications directly related to the feeding tube placement. All patients had altered consciousness and 13 of the 14 had endotracheal tubes in place. Malposition of the feeding tube was not predictable from clinical signs and auscultation, but was detectable by chest roentgenogram.Conclusions:Inadvertent insertion of enteral feeding tubes into the tracheopulmonary system during placement is associated with significant morbidity and mortality. Clinical signs at the time of insertion are not useful in identifying feeding tubes which are malpositioned. In the ICU patient, a chest roentgenogram is required after all feeding tube insertions prior to the initiation of enteral feeding. In the high-risk patient, alternatives to blind feeding tube insertion should be considered.

Evidence-Based Review and Discussion Points.