Gastric Route Research Articles

Successful blind placement of nasojejunal tubes in paediatric intensive care: impact of training and audit

This paper is a report of a study to monitor continuing nasojejunal tube placement success rate and to evaluate a training programme for staff placing these tubes at the bedside. Gastric delivery of enteral feeds is frequently poorly tolerated due to impaired gastric motility in critically ill children. Consequently, there has been an increased interest in the use of the nasojejunal feeding route. Nasojejunal tubes are both safe and well-tolerated, but placements of these tubes are notoriously difficult and therefore often avoided. Consequently, a blind bedside technique was developed, with a placement success of 96%. A training programme using this technique was developed for nursing staff on the unit. This included one-to-one training of key nurses of the nasojejunal tube placement technique and a supervised nasojejunal placement with either the senior nurse or dietitian. This practice was audited in 100 consecutive patients in 2001 and 2004. Patient demographics, diagnosis, time taken for placement and reasons for unsuccessful placements were documented. The 2001 audit (n = 100) indicated that the nasojejunal route was used in 19% of all cases, with 1% and 80% of patients fed via the parenteral and nasogastric route respectively. In 2004 (n = 94), 18% of patients were fed via the nasojejunal route, 3% parenterally and 79% via the gastric route. Placement success continued to be between 94.5-95% in 2001 and 2004. Continued successful placement of blind nasojejunal feeding tubes can be achieved through a well-monitored education programme, regular audit cycles and multidisciplinary team support.

CONTINUOUS INTRA-ABDOMINAL PRESSURE MONITORING

Background: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) can develop within 12 hours of ICU admission in high-risk patients. Until recently the intermittent intra-abdominal pressure (IAP) measurement via the urinary catheter was the clinical standard. This is a relatively labour intensive technique and its intermittent nature could prevent timely recognition of significant changes in IAP. The historical continuous IAP (CIAP) measurements were poorly reproducible (gastric route) or invasive/impractical (direct measurement). The aim of this paper is to review the current evidence on CIAP monitoring.Methods: A broad Medline search of the English literature was performed using the terms of “intra abdominal pressure” and “continuous”. This result was analysed based on the title and abstract. Only original clinical studies with continuous IAP measurement were considered in this review. New techniques of CIAP monitoring evaluated in large animal models are discussed as potential future directions.Results: There is a growing evidence of measuring (monitoring) CIAP using several techniques (gastric, direct abdominal, inferior vena cava, and urinary bladder. The strongest evidence supports the direct abdominal, the gastric and the bladder route. From these three techniques the CIAP monitoring via the bladder has excellent agreement with the current standard of intermittent bladder pressure measurement. While the direct measurement could be very accurate it is an invasive method and feasible in patient who underwent laparotomy or laparoscopy.Conclusions: Until a better technique is available the CIAP monitoring via the bladder or stomach should be considered as the standard for continuous monitoring of the IAP. It is a less labour intensive, safe, less invasive and reliable method.

Evaluation of a technique for blind placement of post-pyloric feeding tubes in intensive care: application in patients with gastric ileus

To evaluate a blind 'active' technique for the bedside placement of post-pyloric enteral feeding tubes in a critically ill population with proven gastric ileus. An open study to evaluate the success rate and duration of the technique in cardiothoracic and general intensive care units of a tertiary referral hospital. 20 consecutive, ventilated patients requiring enteral nutrition, where feeding had failed via the gastric route. Previously described insertion technique-the Corpak 10-10-10 protocol-for post-pyloric enteral feeding tube placement, modified after 20 min if placement had not been achieved, by insufflation of air into the stomach to promote pyloric opening. A standard protocol and a set method to identify final tube position were used in each case. In 90% (18/20) of cases tubes were placed on the first attempt, with an additional tube being successfully placed on the second attempt. The median time for tube placement was 18 min (range 3-55 min). In 20% (4/20) insufflation of air was required to aid trans-pyloric passage. The previously described technique, modified by insufflation of air into the stomach in prolonged attempts to achieve trans-pyloric passage, proved to be an effective and cost efficient method to place post-pyloric enteral feeding tubes. This technique, even in the presence of gastric ileus, could be incorporated by all critical care facilities, without the need for any additional equipment or costs. This approach avoids the costs of additional equipment, time-delays and necessity to transfer the patient from the ICU for the more traditional techniques of endoscopy and radiographic screening.

Enteral nutrition delivery and energy expenditure in medical intensive care patients

Delivery of enteral nutrition (EN) in critical illness is often inadequate. This prospective observational study addresses the implementation of enteral feeding in critically ill medical patients and its relation to energy expenditure. All admissions to a university medical ICU over a period of one year were screened. Patients receiving EN for at least 7 days were followed up. The caloric target was a minimum of 20 kcal/kg/day. The feeding volume was increased daily by 500 ml and a maximum of 2000 ml/day was targeted to be achieved by day 4 of admission. Energy expenditure was measured with indirect calorimetry on day 3 or 5. Two hundred and thirtyone patients required artificial nutrition, of which 61 patients were enterally fed for 7 days. This group was followed for a total of 750 feeding days. The gastric route was used at the start, with a post-pyloric feeding required during follow-up in 36.1% of patients due to high gastric residual. EN was interrupted in 32.1% of the feeding days. The daily administered volume was 86.2 +/- 30.4% of the prescribed. The mean enteral caloric supply in relation to energy expenditure was between 39.2 +/- 34.6% on day 1 and 83.1 +/- 31.1% on day 6. The targeted maximum feed volume was achieved on day 4 in 75.4% of the patients. Patients with a delayed target time had a higher mortality rate than those with a target time of <4 days (73.3% vs. 26.1%), A high delivery-to-prescription rate could be achieved with a standardized enteral feeding protocol in critically ill medical patients. However, caloric delivery is much less than measured energy expenditure. Enteral feeding intolerance is associated with a high mortality rate.

Variation in enteral nutrition delivery in mechanically ventilated patients

Objective We determined the variability in enteral feeding practices in mechanically ventilated patients in four adult intensive care units of a tertiary-care, referral hospital. Methods Patients who had been mechanically ventilated for at least 48 h and received enteral nutrition were prospectively followed. Results Fifty-five of 101 consecutive mechanically ventilated patients received enteral nutrition; in 93% of patients, feedings were infused into the stomach. Patients who were cared for in the medical intensive care unit, where a nutritional protocol was operational, received enteral nutrition earlier in their ventilatory course ( P = 0.004) and feedings were advanced to target rates faster ( P = 0.043) than those who received care in other units. The number ( P = 0.243) and duration ( P = 0.668) of interruptions in feeding did not differ by patient location. On average, patients received only 50% to 70% of their targeted caloric goals during the first 6 days of enteral nutrition. Most feeding discontinuations (41%) were secondary to procedures. Gastrointestinal intolerances, including vomiting, aspiration, abdominal distention, and increased gastric residuals, were uncommon despite allowing gastric residuals up to 300 mL. Conclusions The practice of providing enteral feeds to mechanically ventilated patients varies widely, even within one hospital. A protocol enhanced early initiation of enteral feeds and advancement to target feeding rates but did not alter the number or duration of interruptions in enteral feedings. Procedures represented the most common reason for stopping enteral feeds, and gastrointestinal intolerances (vomiting, aspiration, and increased gastric residuals) caused few feeding interruptions. The gastric route was safe and well tolerated for early enteral feeding in most mechanically ventilated patients.

Gastric and postpyloric total enteral nutrition

The provision and maintenance of good nutrition in patients with acute and chronic illness is a fundamental part of standard medical and surgical care. Recently, there is great interest in using enteral nutritional support to reverse the morbidity and mortality associated with malnutrition. Enteral nutrition is preferred over parenteral nutrition because it is more physiologic, maintains intestinal structure and function, limits bacterial translocation, has less morbidity, has fewer complications, and is less expensive. However, the decision to feed into the stomach or into the small bowel (postpyloric) continues to be a matter of some debate and continued clinical investigation. Although the gastric route of enteral feeding is easier and less expensive, some physicians worry that gastric feeding may predispose to aspiration and pneumonia, especially in critically ill patients who frequently have delayed gastric transit. In these critically ill patients, small bowel function usually remains relatively intact and placement of a postpyloric feeding tube may permit more effective delivery of nutrients. However, it should be noted that placement of postpyloric feeding tubes can be challenging, and this may lead to a delay in initiation of nutritional support.

Gastric residual volumes in critically ill paediatric patients: A comparison of feeding regimens

This study examined the effect of gastric feeding regimens, either continuous or intermittent, on fourth hourly gastric residual volumes (GRV) in a group of critically ill paediatric patients where delayed gastric emptying is defined as a GRV greater than 5ml/kg. A randomised controlled trial was conducted in a tertiary paediatric intensive care unit (PICU), with 45 participants being randomly assigned to either the continuous (n=22) or intermittent (n=23) gastric feeding groups. Participants remained in the assigned group for the duration of the study and, fourth hourly, GRV were assessed to monitor the incidence of delayed gastric emptying. Both groups were similar in age, weight, gender, diagnosis, paediatric index mortality (PIM) score, and usage of pharmacological agents known to affect the gastrointestinal tract. No differences emerged in study duration or the volume of administered enteral formula (ml/kg/day). The intermittent feeding group commenced enteral feeding earlier in the PICU admission (13.0 hours versus 18.5 hrs, p=0.05). Repeated measures analysis revealed no overall difference in median GRV/kg values between treatment groups over the 72 hour study period. Additionally, the incidence of fourth hourly GRV, greater than 5ml/kg, was not different between the continuous and intermittent feeding groups. The provision of enteral nutrition via the gastric route is a common treatment in the PICU, and GRV are frequently used as a measure of gastric tolerance. The result of this analysis provides some support for the theoretical definition of delayed gastric emptying being >5ml/kg. However, further work is required to confirm this finding and to determine its relevance when providing enteral nutrition to the critically ill paediatric patient.

Systematic review of transpyloric versus gastric tube feeding for preterm infants

Aim: To determine if enteral tube feeding by the transpyloric versus the gastric route improves feeding tolerance, and growth and development, without increasing adverse events, in preterm infants. Methods: Systematic...

Gastric Feeding in Critically Ill Children: A Randomized Controlled Trial

Provision of enteral nutrition via the gastric route is a common nursing procedure in pediatric intensive care units. Little research, however, has focused on children's tolerance of different types of gastric feeding regimens. To examine the relationship between 2 gastric feeding regimens, continuous and intermittent, and children's tolerance as measured by the number of stools and prevalences of diarrhea and vomiting. A randomized controlled trial was conducted in an Australian pediatric intensive care unit; 45 children were randomly assigned to either the continuous or the intermittent gastric feeding groups. Participants remained in the assigned feeding group for the duration of the study, and values of variables used to monitor patients' tolerance were recorded. Both feeding groups were similar with respect to Pediatric Index Mortality score, age, weight, sex, diagnosis, and use of pharmacological agents known to affect the gastrointestinal tract. Additionally, the 2 groups did not differ in study duration or the daily volume of administered enteral formula per kilogram of body weight. The number of stools per day and the prevalences of diarrhea and vomiting did not differ significantly between the 2 groups. Continuous and intermittent gastric feeding regimens have similar outcomes with respect to the number of stools per day and the prevalence of diarrhea and vomiting in pediatric intensive care patients. Further gastric feeding studies and the development of enteral feeding guidelines for critically ill children are needed.

Long-term influence of an initial exposure to alcohol on the rat hypothalamic-pituitary axis.

We have previously shown that adult male rats injected with alcohol daily for 3 consecutive days displayed a significantly blunted ACTH to a second alcohol injection, given 3 to 7 days later. The purpose of the present work was to determine the maximum duration over which the ACTH response remained blunted after an initial alcohol treatment. Male rats were exposed to alcohol (intragastrically or via vapors for 4 hr) on three consecutive days, starting when they were 22 (group A), 34 (group B), or 50 days old (group C). Control animals were injected with the vehicle intragastrically or kept in chambers through which normal air was circulated. At 60 days of age, the animals were injected with the vehicle or alcohol (4.5 g/kg intragastrically) to determine whether the initial treatment had long-term consequences on the ACTH response to a second alcohol challenge. Rats of group C, pretreated with alcohol via intragastric injections or vapors, all exhibited a blunted ACTH response to the second acute alcohol challenge. In contrast, the second alcohol challenge only attenuated ACTH responses in rats of group B that had received intragastric injections, but not vapors. Group A showed a comparable response to acute intragastric alcohol injection at 60 days of age regardless of whether they had been preexposed to the drug. This was not due to a lack of neuroendocrine response because alcohol vapors significantly increased plasma ACTH levels and up-regulated paraventricular nucleus neuronal activity regardless of the age at which it was initially administered. Repeated (daily for 3 consecutive days) administration of alcohol by the gastric route induces a long-lasting (up to 24 days) but not permanent blunting of the ACTH response to a second (acute) alcohol challenge. The fact that alcohol delivered by inhalation only caused a relatively brief (</=8 days) decrease in the ability of a second intragastric alcohol challenge to release ACTH suggests that the mode of alcohol delivery influences its long-term consequences.

Transpyloric versus gastric tube feeding for preterm infants.

Enteral feeding tubes for preterm infants may be placed in the stomach (gastric tube feeding) or in the upper small bowel (transpyloric tube feeding). There are potential advantages and disadvantages to both routes. In preterm infants who require enteral tube feeding, does feeding via the transpyloric route versus the gastric route improve feeding tolerance, and growth and development, without increasing adverse consequences? The standard search strategy of the Cochrane Neonatal Review Group was used. This included electronic searches of MEDLINE and EMBASE (up to December 2001) and of The Cochrane Controlled Trials Register in The Cochrane Library (Issue 3, 2001), and searches of the references in previous reviews including cross references. Randomised or quasi-randomised controlled trials comparing transpyloric with gastric tube feeding in preterm infants. Data were extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk and weighted mean difference. Data from eight trials were available. We did not find any evidence of an effect on growth rates: short term weight gain, weighted mean difference -0.7 g/week (95% confidence interval -25.2, 23.8); short term increase in crown heel length, weighted mean difference -0.7 mm/week (95% confidence interval -2.4, 1.0); short term increase in head circumference, weighted mean difference 0.6 mm/wk (95% confidence interval -0.9, 2.1). Longer term growth was reported in one study. There were not any statistically significant differences between the groups in the mean body weight or occipitofrontal head circumference at three months or at six months corrected age. None of the included studies provided data on neurodevelopmental outcomes during infancy or beyond. Transpyloric feeding was associated with a greater incidence of gastro-intestinal disturbance, RR 1.45, 95% CI 1.05, 2.09. There was some evidence that feeding via the transpyloric route increased mortality, RR 2.46, 95% CI 1.36, 4.46; however, the outcomes of the study that contributed most to this finding were likely to have been affected by selective allocation of the less mature and sicker infants to transpyloric feeding. We did not detect any statistically significant differences in the incidence of other adverse events, including necrotising enterocolitis, intestinal perforation, and aspiration pneumonia. We did not find any evidence of benefit, but did find evidence of adverse effects, of transpyloric feeding in preterm infants. Feeding via the transpyloric route cannot be recommended for preterm infants.

Oral transmission of Chagas disease: importance of Trypanosoma cruzi biodeme in the intragastric experimental infection.

Oral transmission of Trypanosoma cruzi has been suspected when epidemic episodes of acute infection were observed in areas devoid of domiciled insect vectors. Considering that the distribution of T. cruzi biodemes differs in sylvatic and domestic cycles, results of studies on biodemes can be of interest regarding oral transmission. The infectivity of T. cruzi strains of different biodemes was tested in mice subjected to infection by the digestive route (gavage). Swiss mice were infected either with the Peruvian strain (Biodeme Type I, Z2b) or the Colombian strain (Biodeme Type III, Z1, or T. cruzi I); for control, intraperitoneal inoculation was performed in a group of mice. The Colombian strain revealed a similar high infectivity and pathogenicity when either route of infection was used. However, the Peruvian strain showed contrasting levels of infectivity and pathogenicity, being high by intraperitoneal inoculation and low when the gastric route was used. The higher infectivity of the Colombian strain (Biodeme Type III) by gastric inoculation is in keeping with its role in the epidemic episodes of acute Chagas disease registered in the literature, since strains belonging to Biodeme III are most often found in sylvatic hosts.

Gastric or rectal instillation of short-chain fatty acids stimulates epithelial cell proliferation of small and large intestine in rats.

Short-chain fatty acids stimulate gut epithelial cell proliferation in vivo, although the difference between oral and rectal routes is unknown. Accordingly, we examined the effect of oral or rectal administration of these acids. We instilled a mixture of acetic acid, propionic acid, and n-butyric acid (150, 60, and 60 mmol/liter, respectively; pH 6.5) or saline (270 mM, pH 6.5) into the stomach (2 ml) or rectum (1 ml) three times daily for five days in rats fed an elemental diet. We measured crypt cell production rate of the jejunum, ileum, and distal colon of these rats. The crypt cell production rate of these segments was higher in rats with gastric or rectal instillation of short-chain fatty acids than in saline controls. The rectal route was slightly more effective than the gastric route. The above results indicated that the instillation of short-chain fatty acids orally or rectally stimulated gut epithelial cell proliferation.

New variant Creutzfeldt-Jakob disease

Since the report of new variant Creutzfeldt-Jakob disease (nvCJD) in humans last year, the search was on for direct evidence to link the condition to Bovine Spongiform Encephalopathy (BSE). The first case nvCJD was noted 10 years after the recognition of BSE in UK cattle. a direct link is now established. There are, however, some ‘protective’ mechanisms, the most important of which are the inefficiency of the gastric route of introducing the infected material, the species barrier and genetic ‘predisposition’. None of these is full proof and time will tell whether feeding ruminants with their own species will turn out to be a major public health disaster?

Influence of inoculation route on the carrier state of Salmonella choleraesuis in swine

This study was designed to investigate the carrier state of swine infected with Salmonella choleraesuis. Thirty-five pigs were divided into 3 groups. Groups 1 ( n = 15) and 2 ( n = 16) were challenged with 10 8 CFU of S. choleraesuis intranasally or by gastric route, respectively. Group 3 ( n = 4) served as uninoculated controls. Pigs were necropsied at 2, 4, 6, and 12 weeks post inoculation. Clinical signs and microscopic lesions were more severe for group 1. Salmonella choleraesuis was recovered from a greater percentage of tissue samples for group 1 versus group 2 at 2, 4, and 6 weeks post inoculation. No differences were observed between groups at 12 weeks post inoculation. Regardless of route of inoculation, S. choleraesuis was most often recovered from the ileocolic junction, ileocolic lymph node, cecal contents, tonsil, lung and colon. Both groups shed S. choleraesuis in the feces sporadically throughout the 12 week period indicating that a carrier state is maintained for at least 12 weeks. However, group 1 shed higher numbers of S. choleraesuis initially. Serum IgG, IgM, and IgA antibody responses to S. choleraesuis lipopolysaccharide and heat extract antigens were observed for both groups. Higher serum IgG antibody titers to S. choleraesuis lipopolysaccharide were observed for group 2. Intestinal antibody responses for both groups included IgG and IgM responses but not an IgA response. Both routes of inoculation stimulated peripheral blood B-cells while the intranasal route (group 1) was more effective at stimulating peripheral blood T-cells. The reduction in levels of tissues infection and shedding observed for both groups coincided with the development of the host immune response. These data indicate that route of inoculation affects the development of humoral and cellular immunity, influences levels of Salmonella shed into the environment and the distribution of Salmonella within tissue.

Lower esophageal sphincter dysfunction precludes safe gastric feeding after head injury.

Early nutrition is advocated for patients with head injury to counter the postinjury hypermetabolic state. The gastric route of feeding often leads to vomiting and aspiration pneumonitis. This study was designed to identify the role of lower esophageal sphincter (LES) function in this complication. The LES function was assessed within 72 hours of admission in 16 patients with a head injury and a Glasgow Coma Scale (GCS) score less than 12 (range, 3-11). Other admission assessments included an APACHE II score of 11.7, Injury Severity Score (ISS) of 30.5, and a Revised Trauma Score (RTS) of 6.4. These studies were repeated 1 week postinjury in five patients. Dysfunction of the LES was present in all 16 patients; the average gastric-to-esophageal pressure difference was -0.49 mm Hg (range, -0.59 to 2.5) compared with a normal value of greater than 20 mm Hg. The five patients restudied at 1 week had a gastric-to-esophageal pressure difference of 13.3 mm Hg (range, -3.4 to 36.6 mm Hg). The single patient with a GCS score below 12 at 1 week had a low LES tone. These data show that LES dysfunction accompanies acute head injury and contributes to aspiration pneumonitis after early gastric feeding. Nutrition in patients with low GCS scores should be parenteral or via the jejunum.

Cholesterol-lowering effect of continuous enteral nutrition in man

We have studied the effect of polymeric cholesterol-free enteral nutrition (EN) on serum lipid and apolipoprotein levels in 30 consecutive non-diabetic, non-hyperlipaemic gastrointestinal patients. EN-40 ± (SEM) 2 kcal/kg/day including 35% vegetable lipids (50% highly polyunsaturated fat, 50% medium chain triglycerides)—was delivered continuously (24h) via the gastric route for at least 2 weeks (mean duration: 35 ± 4 days). In the entire group, serum total cholesterol decreased by 10.5% (p < 0.01) on day 7 and 17.5% (p < 0.01) on day 28 (n = 12); this was accompanied by 21% and 20% decreases in LDL-cholesterol and apolipoprotein B (p < 0.05) levels respectively, on day 28. In the 19 patients who were normocholesterolaemic on day 0, serum total cholesterol decreased by 15% (p < 0.01) on day 7 and by 28% (p < 0.05) on day 28 (n = 7). Conversely, in the other 11 patients with a low (<3.7 mmol/L) pre-EN serum total cholesterol level, no significant changes were observed during EN. We conclude that continuous, cholesterol-free EN has, in normocholesterolaemic patients, a marked cholesterol-lowering effect; the respective role of the composition of the diet and the continuous delivery of nutrient within the gut have yet to be investigated.

Immediate Enteral Feeding in Burn Patients Is Safe and Effective W.S. MCDONALD, C.W. SHARP, E.A. DEITCH Annals of Surgery 213:177–183, 1991

Traditionally, it has been taught that a period of ileus occurs after significant burn injury, thus clinicians avoided use of the gut as the primary mode of administering nutrients in patients with major burns. Several studies have suggested early aggressive enteral support may be beneficial. One hundred six patients with burns involving 40 ± 21% of the total body surface area were entered into a study where gastric feeding was begun within 6 hours from the onset of injury. Feedings were administered as boluses and consisted of an intact protein diet. Eighty‐two percent of the patients absorbed at least part of their tube‐fed diet on the day of injury and this reached 95% by hospital day 4. Vomiting was the most frequent complication, occurring in 16 of 106 patients. No patient developed stress gastritis/ulcers and H‐2 blockers were not used. Among those patients who were unable to tolerate early enteral feeding, the mortality rate was significantly higher (38.5% us 9.3%, p &lt; 0.004); these patients also had significantly larger burn size, (60 ± 26% us 35% ± 14%, p &lt; 0.007). Early enteral support via the gastric route is safe and effective in most patients with major burns. More severely injured burn patients may require nasoduodenal tube placement.

The selective shunt for variceal bleeding: A personal perspective

It has been proved that selective decompression of esophageal varices can occur by way of the left gastric venous route or the transsplenic route. The left gastric venacaval shunt functions well over a long postoperative period, if the shunt is technically satisfactory; however, the distal splenorenal shunt (DSRS) can be problematic. Unless the proximal and distal portions of the splenic vein are both entirely isolated from the pancreas, blood flow will be diverted from the portal vein to the distal splenic vein, where the pressure has been lowered by the shunt. This portal malcirculation may lead to portal thrombosis or stenosis on occasion. To prevent this adverse effect, complete isolation of the splenic vein (splenopancreatic disconnection) is necessary. Extensive gastric disconnection is irrelevant in this regard. Although the conventional DSRS has been viewed with disfavor, we must realize that splenopancreatic disconnection makes the DSRS a satisfactory technique. The clinical evidence and theoretic basis of the selective shunt for esophageal varices are described herein.

Disseminated zygomycosis and systemic lupus erythematosus

A young woman with long-standing systemic lupus erythematosus and rheumatic fever presented with deteriorating renal function. She had severe gastritis treated with cimetidine and received methylprednisolone when her blood cultures were repeatedly negative. She developed spontaneous bruising and bleeding from venepuncture sites, leading to clotting studies and a diagnosis of thrombotic thrombocytopenic purpura. At post-mortem, extensive evidence of disseminated zygomycosis was found. The likely portal of entry was the gastric route.