Electrocardiographic Guidance for the Placement of Gastric Feeding Tubes: A Pediatric Case Series

Abstract

The placement of nasal or oral gastric tubes is one of the most frequently performed procedures in critically ill children; tube malposition, particularly in the trachea, is an important complication. Neurally adjusted ventilatory assist (NAVA) ventilation (available only on the Servo-i ventilator, Maquet Critical Care, Solna, Sweden) requires a proprietary-design catheter (Maquet Critical Care, Solna, Sweden) with embedded electrodes that detect the electrical activity of the diaphragm (EA(di)). The EA(di) catheter has the potential benefit of confirming proper positioning of a gastric catheter, based on and the EA(di) waveforms. In a case series study, our multidisciplinary team used EA(di) guidance for immediate, real-time confirmation of proper nasal or oral gastric tube placement in 20 mechanically ventilated pediatric patients who underwent 23 oral or nasal gastric tube placements. The catheters were placed with our standard practice, with the addition of a team member monitoring the EA(di) waveforms. As the tube passes down the esophagus and posterior to the heart, a characteristic EA(di) pattern is identified and the position of the atrial signal confirms correct placement of the gastric tube. If the EA(di) waveforms indicate incorrect placement, the tube is repositioned until the proper EA(di) waveform pattern is obtained. Then proper tube placement is reconfirmed via auscultation over the stomach while air is injected into the catheter, checking the pH of fluid suctioned from the catheter (gastric pH indicates correct positioning), and/or radiograph. The group's median age was 3 years (range 4 d to 16 y). All 20 patients had successful gastric catheter placement. The EA(di) catheter provided characteristic patterns for correctly placed tubes, tubes malpositioned above or below the gastroesophageal junction, and curled tubes. Proper catheter position was confirmed via radiograph and/or gastric pH in all 20 patients. EA(di) guidance helps confirm proper gastric catheter position, is equivalent to our standard practice for confirming gastric catheter placement, and may reduce the need for radiographs and improve patient safety by avoiding catheter malpositions.