Placement Of Nasoenteric Feeding Tubes Research Articles

Electromagnetic guided bedside placement of nasoenteral feeding tubes by nurses versus endoscopic placement by gastroenterologists (CORE): A randomized controlled non-inferiority multicenter trial

Electromagnetic guided bedside placement of nasoenteral feeding tubes by nurses versus endoscopic placement by gastroenterologists (CORE): A randomized controlled non-inferiority multicenter trial

Electromagnetic Sensor-Guided Enteral Access Systems: A Literature Review.

Enteral feeding is the nutritional support of choice for acutely ill patients with functional gastrointestinal tracts who are unable to swallow. Several benefits including reduced mortality and length of hospital stay have been associated with early initiation of enteral feeding. However, misplacement of conventional nasoenteric tubes is relatively common and can result in complications including pneumothorax. In addition, the need to confirm the position by X-ray can delay the start of using the tube. Eliminating these delays can help patients start feeding, and minimise the adverse impact on initiating hydration and medication. The purpose of this review was to critically examine whether electromagnetic sensor-guided enteral access systems (EMS-EAS) can help overcome the challenges of conventional nasoenteric feeding tube placement and confirmation. The Royal Society of Medicine’s library performed two searches on Medline (1946–March 2014) and Embase (1947–March 2014) covering all papers on Cortrak or electromagnetic or magnetic guidance systems for feeding tubes in adults. Results from the literature search found an agreement between the radiographic and EMS-EAS confirmation of placement. EMS-EAS virtually eliminated the risk of misplacement and pneumothorax was not reported. In addition, studies showed a small decrease in the number of X-rays with EMS-EAS and a reduced average time to start feeding compared with blind placement. This review suggests that EMS-EAS reduces several complications associated with the misplacement of nasoenteric feeding tubes, and that there could be considerable improvements in mortality, morbidity, patient experience and cost if EMS-EAS is used instead of conventional methods.

Electromagnetic guided bedside or endoscopic placement of nasoenteral feeding tubes in surgical patients (CORE trial): study protocol for a randomized controlled trial.

BackgroundGastroparesis is common in surgical patients and frequently leads to the need for enteral tube feeding. Nasoenteral feeding tubes are usually placed endoscopically by gastroenterologists, but this procedure is relatively cumbersome for patients and labor-intensive for hospital staff. Electromagnetic (EM) guided bedside placement of nasoenteral feeding tubes by nurses may reduce patient discomfort, workload and costs, but randomized studies are lacking, especially in surgical patients. We hypothesize that EM guided bedside placement of nasoenteral feeding tubes is at least as effective as endoscopic placement in surgical patients, at lower costs.Methods/DesignThe CORE trial is an investigator-initiated, parallel-group, pragmatic, multicenter randomized controlled non-inferiority trial. A total of 154 patients admitted to gastrointestinal surgical wards in five hospitals, requiring nasoenteral feeding, will be randomly allocated to undergo EM guided or endoscopic nasoenteral feeding tube placement. Primary outcome is reinsertion of the feeding tube, defined as the insertion of an endoscope or tube in the nose/mouth and esophagus for (re)placement of the feeding tube (e.g. after failed initial placement or dislodgement or blockage of the tube). Secondary outcomes include patient-reported outcomes, costs and tube (placement) related complications.DiscussionThe CORE trial is designed to generate evidence on the effectiveness of EM guided placement of nasoenteral feeding tubes in surgical patients and the impact on costs as compared to endoscopic placement. The trial potentially offers a strong argument for wider implementation of this technique as method of choice for placement of nasoenteral feeding tubes.Trial registrationDutch Trial Register: NTR4420, date registered 5-feb-2014Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-0633-1) contains supplementary material, which is available to authorized users.

Metoclopramide for post-pyloric placement of naso-enteral feeding tubes.

Enteral nutrition by feeding tube is a common and efficient method of providing nutritional support to prevent malnutrition in hospitalised patients who have adequate gastrointestinal function but who are unable to eat. Gastric feeding may be associated with higher rates of food aspiration and pneumonia than post-pyloric naso-enteral tubes. Thus, enteral feeding tubes are placed directly into the small intestine rather than the stomach, and the use of metoclopramide, a prokinetic agent, has been recommended to achieve post-pyloric placement, but its efficacy is controversial. Moreover, metoclopramide may include adverse reactions, which with high doses or prolonged use may be serious and irreversible. To determine the effect of intravenous metoclopramide on post-pyloric placement of the naso-enteral tube in adults. Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10) which includes the CUGPD group's specialised register of trials, MEDLINE (1996 to 21 October 2014), EMBASE (1988 to 21 October 2014), LILACS (2005 to 21 October 2014) We did not confine our search to English language publications. Searches in all databases were updated originally in January 2005, then in November 2008 and again in October 2014. No new studies were found in 2008 or in 2014. We selected randomised controlled trials of adults needing enteral nutrition, who received intravenous or intramuscular metoclopramide to aid placement of transpyloric naso-enteral feeding tubes, compared to placebo or no intervention. We used standard methodological procedures expected by The Cochrane Collaboration. All analyses were performed according to the intention-to-treat method. We present risk ratios (RR) with 95% confidence intervals (CI). Four studies, with a total of 204 participants were included and analysed. The trials compared metoclopramide with placebo (two trials) or with no intervention (two trials). Metoclopramide was investigated at doses of 10 mg (two trials) and 20 mg (two trials). There was no statistically significant difference between metoclopramide versus placebo or no intervention administered to promote tube placement (RR 0.82, 95% CI 0.61 to 1.10). Metoclopramide at doses of 10 mg (RR 0.82, 95% CI 0.60 to 1.11) and 20 mg (RR 0.62, 95% CI 0.15 to 2.62) were equally ineffective in facilitating post-pyloric intubation when compared with placebo or no intervention. In this review, we found only four studies that fitted our inclusion criteria. These were small, underpowered studies, in which metoclopramide was given at doses of 10 mg and 20 mg. Our analysis showed that metoclopramide did not assist post-pyloric placement of naso-enteral feeding tubes.Ideally randomised clinical trials should be performed that have a significant sample size, administering metoclopramide against control, however, given the lack of efficacy revealed by this review it is unlikely that further studies will be performed.

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

BackgroundNasoenteral tube feeding is often required in surgical patients, mainly because of delayed gastric emptying. Bedside electromagnetic (EM)-guided tube placement by specialized nurses might offer several advantages (e.g., reduced patient discomfort and costs) over conventional endoscopic placement. The aim of this study was to compare the success rate of EM-guided to endoscopic placement of nasoenteral feeding tubes in surgical patients. Materials and MethodsA retrospective cohort study was performed in 267 adult patients admitted to two gastrointestinal surgical wards who received a nasoenteral feeding tube by EM-guidance or endoscopy. Eighteen patients were excluded because of insufficient data. Patients were categorized according to the primary tube placement method. Subgroup analysis was performed in patients with altered upper gastrointestinal anatomy. Primary endpoint was successful tube placement at or beyond the duodenojejunal flexure. ResultsA total of 249 patients were included, of which 90 patients underwent EM-guided and 159 patients underwent endoscopic tube placement. Both groups were comparable for baseline characteristics. Primary tube placement was successful in 74/90 patients (82 %) in the EM-guided group versus 140/159 patients (88 %) in the endoscopic group (P = 0.20). In patients with altered upper gastrointestinal anatomy, success rates were significantly lower in the EM-guided group (58 vs. 86 %, P = 0.004). There were no significant differences in tube-related complications such as dislodgement or tube blockage. ConclusionsBedside EM-guided placement of nasoenteral feeding tubes by specialized nurses did not differ from endoscopic placement by gastroenterologists regarding feasibility and safety in surgical patients with unaltered upper gastrointestinal anatomy.

Magnets in the GI tract

Magnets in the GI tract

Endoscopic Clip-Assisted Feeding Tube Placement Reduces Repeat Endoscopy Rate: Results from a Randomized Controlled Trial

To determine whether endoscopic clip-assisted nasoenteral feeding tube placement is more effective than standard feeding tube placement with transnasal endoscopy. Between August 2009 and February 2011, 143 patients referred for endoscopic nasoenteral feeding tube placement were randomized between clip-assisted and standard nasoenteral tube placement. Endoscopies were performed in the endoscopy unit and intensive care unit in a tertiary referral center in the Netherlands. For the clip-assisted procedure, the feeding tube was introduced with a suture fixed to the tip, picked up in the stomach with an endoclip and attached (as distal as possible) to the duodenal wall. In the standard group, a guide wire was placed in the duodenum using a transnasal endoscope, followed by blind insertion of a feeding tube over the guide wire. Primary end point was a repeat endoscopy for incorrect tube placement or spontaneous retrograde tube migration. Secondary end points were incorrect tube placement, spontaneous migration of feeding tube, directs medical costs, and procedure-related (serious) adverse event (SAE). Of the 143 patients included, 71 were randomly assigned to clip-assisted tube placement, and 72 to standard tube placement. Four (5.6%) repeat endoscopies were performed in the clip-assisted group vs. 19 (26.4%) in the standard group (relative risk reduction (RRR) 0.79; 95% confidence interval (CI) 0.40-0.92). The number needed to clip to avoid one repeat endoscopy was 4.8 (95% CI 3.1-11.3). Repeat endoscopies were mostly performed for incorrectly placed tubes, 3 (4.2%) in the clip-assisted group vs. 16 (22.2%, RRR 0.81; 95% CI 0.38-0.94) in the standard group. Spontaneous retrograde tube migration occurred in one (1.4%) clip-assisted placement and three (4.2%) standard tubes. Median costs were higher for clip-assisted tube placement (€519 vs. €423, P<0.01). Four (5.6%) SAEs occurred after clip-assisted feeding tube placement vs. one (1.4%) after standard feeding tube placement (P=0.21). Clip-assisted endoscopic nasoenteral feeding tube placement results in fewer repeat endoscopies than standard endoscopic nasoenteral tube placement, due to a higher success rate of initial placement. When tubes are adequately placed, retrograde tube migration rarely occurs.

Transnasal esophagogastroduodenoscopy for placement of nasoenteric feeding tubes in patients with severe upper gastrointestinal diseases

To evaluate the feasibility and efficacy of small-caliber transnasal esophagogastroduodenoscopy for the placement of nasoenteric feeding tubes (NET) in patients with severe upper gastrointestinal (GI) diseases. Between January 2007 and March 2010, 51 patients underwent transnasal endoscopy for the placement of NET in Peking University Third Hospital. Indications for NET included esophageal stricture or gastric outlet obstruction because of corrosive esophagitis or gastritis, partial obstruction due to malignancy, stenosis in stoma or efferent loop, gastroparesis, metallic stent in upper GI tract, tracheoesophageal fistula, severe acute pancreatitis, anorexia nervosa and intensive care patients. The tubes were endoscopically placed using the guidewire technique. The position of the tube was confirmed by the immediate second endoscopy or abdominal X-ray. If the initiate placement was not correct, an adjustment or a second placement was conducted immediately. Initial post-pyloric placement of NET was achieved in 43 of 51 patients (84.3%), but the total success rate reached 98.0% (50/51) after the second placement. The time required for the procedure ranged from 10 to 35 min, with a median time of 20.4 min. Epistaxis occurred in 2 patients. There were no complications of hemorrhage, perforation or aspiration. The transnasal endoscopic placement of NET was feasible in patients with upper GI diseases, especially in those with changed anatomy.

Tu1727 Nasoenteral Feeding Tube Placement Using Ultra-Thin Endoscopy in Daily Clinical Practice Is Associated With Low Success Rates

Nasoenteral Feeding Tube Placement Using Ultra-Thin Endoscopy in Daily Clinical Practice Is Associated With Low Success Rates Meike M. Hirdes*, Lily Nagtzaam, Elisabeth M. Mathus-Vliegen, Frank P. Vleggaar, Jan J. Koornstra, Peter D. Siersema, Jan F. Monkelbaan Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, Netherlands; Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, Netherlands; Gastroenterology & Hepatology, University Medical Center Groningen, Groningen, Netherlands Background and Aim: In case of short term intolerance to gastric feeding, nasoenteral feeding tubes are commonly used to provide nutritional support. Tube placement over a guide wire using transnasal endoscopy is a minimally invasive technique for post-pyloric feeding tube placement at the bedside, with a reported success rate of 90% in experienced hands. In daily clinical practice, transnasal endoscopic tube placement is often performed by less experienced trainee endoscopists, which may affect success rates. The aim of this study was to determine success rate of transnasal endoscopic feeding tube placement in teaching hospitals and to identify independent patient and procedure-related predictors of successful tube placement. Methods: From January October 2011, all consecutive patients referred for first nasoenteral feeding tube placement with ultra-thin endoscopy were included. Exclusion criteria were altered anatomy of the upper gastrointestinal tract, alternative strategy of endoscopic tube placement, and no abdominal X-ray made within 3 hours after endoscopy. Abdominal X-rays were evaluated by radiologists not involved in the study. Multivariable logistic regression analysis was performed to identify independent predictors of successful tube placement. Successful nasoenteral tube placement was defined as a post-pyloric location of the tip of the feeding tube on abdominal radiograph. Results: In total, 175 patients (95 males, mean age 59 17 years) were included from 3 Dutch teaching hospitals. Patients were mostly admitted to the ward (48%) or intensive care unit (ICU, 36%). Common indications for nasoenteral tube feeding included gastroparesis due to critical illness (31%) or surgery (21%). Most endoscopic tube placements were performed by trainee endoscopists (81%) and under conscious sedation (74%). Radiographic control revealed that 26% of the tubes were placed in the stomach, 9% in the proximal duodenum, 16% in the distal duodenum and 49% in the jejunum. Multivariable logistic regression showed that use of sedation was the only independent predictor of successful feeding tube placement (OR 2.4 (95% CI 1.1-5.1)). Tube placement by a trainee instead of staff endoscopist, ICU admission or the presence of large gastric residuals ( 300 cc) were not associated with an increased risk of incorrect tube placement. Conclusions: In daily clinical practice, success rate of endoscopic nasoenteral feeding tube placement is much lower than reported in previous ‘study settings,’ however, this cannot be explained by the difference in experience between staff and trainee endoscopists. We recommend routine use of an abdominal X-ray after transnasal endoscopic tube placement to verify correct placement. The use of sedation can be considered as this may prevent incorrect tube placement.

Nasoenteral feeding tube placement by nurses using an electromagnetic guidance system (with )

The early institution of feeding in patients who need postpyloric feeding tubes is often hampered by a limited availability of endoscopists experienced in safe tube positioning. To test the feasibility of having nurses place postpyloric feeding tubes by using a universal path finding system device. Prospective study. Academic hospital. The success rate and learning curve of a senior nurse placing postpyloric feeding tubes in 50 patients was studied, followed by a study in 160 patients on the success rates and learning curves of 4 inexperienced nurses instructed by the senior nurse. Finally, the success rate of postpyloric feeding tube placement by the senior nurse in 50 critically ill patients was investigated. Postpyloric feeding tube positioning by nurses using an electromagnetic universal path-finding system device enabling them to follow the path of the tip of the feeding tube on a monitor screen. Success was defined by postpyloric positioning of the feeding tube. The ultimate aim was to reach at least the duodenojejunal flexure. In the first part, the senior nurse was successful in 72% of cases. There was a clear learning curve. In the second part, the 4 newly instructed nurses had a success rate of 89.4% without an evident learning curve. In the third part, successful feeding tube positioning was achieved in 78% of critically ill patients. Of the 217 successfully positioned tubes, 74% reached at least the duodenojejunal flexure. In half of the unsuccessful cases, an explanation for the failure was found at endoscopy. No complications were seen. The generalization to less-specialized hospitals should be investigated. Postpyloric positioning of feeding tubes by nurses at the bedside without endoscopy is feasible and safe. Nurses may take over some of the tasks of doctors in a time of high endoscopic needs.

Approach to Enteral Feeding in the PICU

The pediatric intensive care unit (PICU) environment poses unique challenges to achieving enteral nutrition (EN) goals for the critically ill child. Nutrition support in the PICU is often in conflict with the complexity of care provided to acutely ill children. A significant proportion of eligible patients do not receive optimal enteral nutrition for avoidable reasons. Early institution of EN is recommended and the gastric route is preferred because of ease of administration and reduced costs compared with the transpyloric route. In patients with poor gastric emptying or in cases where a trial of gastric feeding has failed, transpyloric or postpyloric feeding may be used to decrease the risk of aspiration and to improve enteral feed tolerance. However, there is no evidence of benefit for routine use of small bowel feeding in all patients admitted to the PICU. The placement of blind nasoenteric feeding tubes can be technically challenging, is not without complications, and requires local expertise and experience for successful placement and maintenance. A protocolized approach to selecting the optimal route and advancing enteral feedings may optimize EN delivery. Institutional practice guidelines based on consensus, available evidence, and national guidelines may decrease time to reaching caloric goal, improve protein balance, and potentially affect clinical outcomes. The rationale and challenges to the delivery and maintenance of optimal EN, and strategies to achieve optimal EN during critical illness, are discussed.

Transnasal Route: New Approach to Endoscopy

Transnasal esophagogastroduodenoscopy (TN-EGD) has recently become one of the frequently used methods of upper gastrointestinal endoscopy in some countries. Changes in blood pressure, heart rate, and oxygen saturation are smaller for TN-EGD than for conventional transoral esophagogastroduodenoscopy, making it a safer procedure. Lower pain and gag reflex enable TN-EGD to be performed without conscious sedation. TN-EGD is applied in various gastrointestinal (GI) procedures such as percutaneous endoscopic gastrostomy, nasoenteric feeding tube placement, endoscopic retrograde cholangiopancreaticography with nasobiliary drainage and lithotripsy, long intestinal tube placement in small-bowel obstruction, esophageal manometry, foreign body removal, botulinum toxin injection for achalasia, esophageal varix evaluation with the aid of endoscopic ultrasonography, and the double-scope technique for endoscopic submucosal dissection. The establishment of standard training programs and nationwide guidelines, the dissemination of educational information, the improvement in endoscopy devices and accessories, and the availability of insurance coverage for the procedure will obviously further widen the adoption of TN-EGD.

Use of a Colorimetric Carbon Dioxide Sensor for Nasoenteric Feeding Tube Placement in Critical Care Patients Compared With Clinical Methods and Radiography

Misplacement of nasoenteric feeding tubes (NFTs) into the airway instead of the esophagus leads to complications. Healthcare providers have relied on clinical methods, devices such as carbon dioxide (CO(2)) sensors, and radiography (the gold standard) to evaluate NFT placements. Most institutions include radiographs in their protocols for NFT insertions, making it expensive and cumbersome. A new commercial CO(2) sensor was developed to assist in these procedures, and the authors evaluated its use. Nurses performing NFT placement completed questionnaires following each procedure. The nurses recorded the clinical methods used to determine proper insertion and, based on them, where the NFT was located. Nurses then evaluated NFT insertion with the CO(2) sensor; from the readings, they recorded where the tube was located. Confirmation of tube placement was performed radiographically. The authors evaluated 424 NFT insertions. Of these, 15 (3.5%) were incorrectly placed into the airway, and 409 were correctly placed into the esophagus. The CO(2) sensor correctly assessed NFT placement in 421 (99%) of the 424 cases. The authors found the device to have a sensitivity of 86.7% and a specificity of 99.8%. The CO(2) sensor is a helpful bedside tool to use in conjunction with clinical methods during NFT insertions. However, there is insufficient evidence to abandon the use of radiographs to confirm tube placement.

Transnasal Endoscopic Placement of Nasoenteric Feeding Tubes: Outcomes and Limitations in Non–Critically Ill Patients

Transnasal endoscopic placement of nasoenteric tubes (NETs) has been demonstrated to be useful in the critical care setting, with limited data on its role in non-critically ill patients. The authors collected data on consecutive patients from a non-critical care setting undergoing transnasal endoscopic NET placement. All NETs were endoscopically placed using a standard over-the-guidewire technique, and positions were confirmed with fluoroscopy. Patients were monitored until the removal of NETs or death. Twenty-two patients (median age = 62.5 years, 36.4% female) were referred for postpyloric feeding, with main indications of persistent gastrocutaneous fistula (n = 6), gastroparesis or gastric outlet obstruction (n = 5), duodenal stenosis (n = 6), acute pancreatitis (n = 4), and gastroesophageal reflux after surgery (n = 1). Postpyloric placement of NET was achieved in 19 of 22 (86.3%) patients, with 36.8% tube positions in the jejunum, 47.4% in the distal duodenum, and 15.8% in the second part of the duodenum. NET placement was least successful in cases with duodenal stenosis. NETs remained in situ for a median of 24 days (range, 2-94), with tube dislodgement (n = 3) and clogging (n = 5) as the main complications. NET feeding resulted in complete healing of gastrocutaneous fistulae in 5 of 6 patients and provision of total enteral nutrition in 3 of 4 cases of acute pancreatitis and 9 of 11 cases of gastroparesis or proximal duodenal obstruction. Transnasal endoscopy has a role in the placement of NET in non-critically ill patients requiring postpyloric feeding. However, there are some limitations, particularly in cases with altered duodenal anatomy.

Transnasal endoscopy for the placement of nasoenteral feeding tubes: does the working length of the endoscope matter?

Transnasal endoscopy with a small-caliber endoscope has been shown to be helpful for the placement of nasoenteral feeding tubes in patients who are critically ill. Success rates were limited by the short working length of the small-caliber endoscopes. To compare the success rate of a 133-cm-long, small-caliber, prototype videoendoscope with a standard 92-cm-long, small-caliber, fiberoptic endoscope for the transnasal placement of feeding tubes. Randomized controlled study. University Hospital of Zurich, Switzerland. Patients who were critically ill were randomly assigned to transnasal feeding tube placement with the standard 92-cm-long, small-caliber, fiberoptic endoscope, or with a new 133-cm-long, small-caliber, prototype videoendoscope. Patient characteristics, procedure time, technical difficulties, patient tolerance, and radiologic tube position were assessed. Success rates of endoscopic placement of enteral feeding tubes. A total of 157 patients were analyzed in 2 groups. The 2 groups were similar with regard to patient characteristics, body length, technical difficulty, and patient tolerance. The 133-cm-long instrument was superior with respect to successful placement of the nasoenteral feeding tube (93.6% vs 74.4%, P = .0008). Patient tolerance, procedure times, and overall technical difficulty were the same in both treatment groups, whereas passage through the duodenum was more difficult with the 133-cm-long instrument (P < .0001). In rare cases, the randomization list could not be followed correctly. This study demonstrated that placement of a nasoenteral feeding tube with a 133-cm-long, small-caliber videoendoscope is feasible, safe, and distinctly more successful than with a 92-cm-long, small-caliber standard instrument.

Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients

Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients

Endoscopic placement of enteral feeding catheters

Critical to realizing increasing benefits of enteral nutrition are techniques for feeding tube placement. Feeding tubes can be placed by bedside, endoscopic, fluoroscopic, and surgical methods. This review encompasses noteworthy studies on endoscopic approaches to enteral feeding published from January 2005 to the present. Studies involving placement of nasoenteric feeding tubes include description of new methods for endoscopic nasoenteric feeding tube placement using a push technique with a stiffened tube, a modification of the 'drag and pull' method using a distal suture tie, and placement using an ultrathin transnasal endoscopic technique compared with fluoroscopic placement. Recent studies involving percutaneous endoscopic gastrostomy tube placement have demonstrated equivalent outcomes of endoscopic and fluoroscopic approaches, description of unsedated placement using transnasal technique, and risk of percutaneous endoscopic gastrostomy site metastasis in head and neck cancer patients. Studies on percutaneous jejunal feeding tubes demonstrate: high complication rate and short functional duration of percutaneous endoscopic gastrojejunostomy and reported outcomes of direct percutaneous endoscopic jejunostomy placement. Enteral nutrition access can be obtained by a variety of methods depending on local expertise and resources. Endoscopic approaches have equivalent or better outcomes than other methods; however, these methods may still have limitations and distinct complications.

Enteral access for nutrition in the intensive care unit

Enteral nutrition is the preferred route for nutrition support in the intensive care unit setting. This is usually delivered through nasoenteric feeding tubes in patients with an otherwise functional gastrointestinal tract. Placement of nasoenteric feeding tubes, however, may be difficult in this setting. Nasoenteric feeding tubes may be placed by multiple methods, each with their particular advantages and disadvantages. This review summarizes the recent literature on different methods of nasoenteric feeding tube placement with emphasis on critically ill patients. Bedside assisted methods using electromyogram, electrocardiogram, and magnetic fields to provide immediate positional feedback to help guide tube advancement appear promising. Bedside methods using specific protocols, modified feeding tubes, prokinetics or magnetic assistance were also successfully reported. None of these methods has been prospectively compared with more commonly practiced methods in large studies. Endoscopic nasoenteric tube placement methods including transnasal approaches using ultra-thin endoscopes have been recently described and appear to be equivalent to fluoroscopic placement. All these recently reported techniques, however, may require more specialized equipment or training than is currently widely available. Feeding tubes can be placed using bedside, fluoroscopic, and endoscopic means. Novel bedside methods have been recently described using immediate positional feedback or new assistive methods. Endoscopic techniques have similar success rates to fluoroscopic techniques and provide data on upper gastrointestinal abnormalities. There is no clear universal standard method. When feeding tube placement is required the technique used depends on local institutional resources and expertise.

Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients

Placement of a nasoenteric feeding tube (NET) beyond the pylorus in critically ill patients is desirable. Bedside methods are unreliable, and fluoroscopic methods require transport and/or radiation exposure. Traditional endoscopic methods require sedation and oronasal transfer techniques. Transnasal techniques of NET placement by using recently developed ultrathin endoscopes have been described. The object of this prospective study was to compare the efficacy of NET placement by using ultrathin transnasal endoscopy vs. fluoroscopic placement. This is a prospective randomized study of endoscopic vs. fluoroscopic NET placement. The settings of the study were intensive care units at academic medical center. The study included 100 consecutive patients who required NET placement. They received endoscopic NET placement at the bedside with a 5.1-mm, ultrathin endoscope by using a transnasal over-the-wire technique vs. fluoroscopic NET placement by using standard techniques. The procedure success was defined as postpyloric (beyond the duodenal bulb) NET placement, jejunal placement success, and procedure time. Tube placement success was not significantly different between endoscopic and fluoroscopic methods (90% with both methods; p = 1.00). The endoscopic procedure duration (12.8 +/- 6.4 minutes) was significantly shorter than fluoroscopic procedure duration (19.3 +/- 12.0 minutes) (p < 0.001). Procedure duration decreased significantly (from 17.3 +/- 6.2 minutes to 8.0 minutes +/- 4.2 minutes, p = 0.04), and jejunal placement increased significantly (from 60% to 100%, p = 0.04) from the first to the last 10 endoscopic procedures. NET placement success with an ultrathin transnasal endoscope is equivalent to fluoroscopic placement with faster procedure times. More distal placement and procedure times improve with increasing experience with the endoscopic technique. Endoscopic NET placement can be performed at the bedside without the need for oronasal transfer, additional sedation, or fluoroscopy.

Nasoenteral feeding tube placement: indications and nurse skills

Nutrition therapy (NT) is a powerful tool to assist the patients' nutritional needs mainly in the ICU, where the patients usually have high energy expenditures. The route mostly used for NT is the nasoenteral feeding tube (NFT), being easier and with lower costs. It can be accomplished by the nursing staff under direct vision by the nasal route (after training) or through endoscopy. The nasoenteral insertion is not free from complications, and these can be classified as: mechanics (obstruction of the probe, accidental exit, migration of the tube), infectious and psychological (anxiety, depression). The NFT is suitable for small and medium periods of NT (about 6 weeks).