Postpyloric Feeding Tube Placement Research Articles

What is the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement?

What is the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement?

Electromagnetic-guided versus endoscopic-guided postpyloric placement of nasoenteral feeding tubes.

For people who are malnourished and unable to consume food by mouth, nasoenteral feeding tubes are commonly used for the administration of liquid food and drugs. Postpyloric placement is when the tip of the feeding tube is placed beyond the pylorus, in the small intestine. Endoscopic-guided placement of postpyloric feeding tubes is the most common approach. Usually, an endoscopist and two or more medical professionals perform this procedure using a guidewire technique. The position of the tube is then confirmed with fluoroscopy or radiography, which requires moving people undergoing the procedure to the radiology department. Alternatively, electromagnetic-guided placement of postpyloric nasoenteral feeding tubes can be performed by a single trained nurse, at the bedside and with less equipment than endoscopic-guided placement. Hence, electromagnetic-guided placement may represent a promising alternative to endoscopic-guided placement, especially in settings where endoscopy and radiographic facilities are unavailable or difficult to access. To assess the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement. We searched the Cochrane Library, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and OpenGrey until February 2021. We screened the reference lists of relevant review articlesand current treatment guidelines for further literature. We contacted the study authors for missing data. We included randomised trials comparing electromagnetic-guided placement with endoscopic-guided placement of nasoenteral feeding tubes. We excluded prospective cohort studies, retrospective cohort studies, (nested) case-control studies, cross-sectional studies, and case series or case reports. Two review authors independently assessed the methodological quality of potentially eligible trials and extracted data from the included trials. The primary outcomes were technical success in insertion and aspiration pneumonitis. The secondary outcomes were the time for postpyloric placement of nasoenteral feeding tubes, direct healthcare costs, and adverse events. We performed a random-effects meta-analysis. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs) with 95% CIs for continuous outcomes. We evaluated the certainty of evidence based on the GRADE approach. We identified four randomised controlled trials with 541 participants which met our inclusion criteria. All trials had methodological limitations, and lack of blinding of participants and investigators was a major source of bias. We had 'some concerns' for the overall risk of bias in all trials. Electromagnetic-guided postpyloric placement of nasoenteral feeding tubes may result in little to no difference in technical success in insertion compared to endoscopic-guided placement (RR 1.09, 95% CI 0.88 to 1.35; I2 = 81%; low-certainty evidence). Electromagnetic-guided placement may result in a difference in the proportion of participants with aspiration pneumonitis compared to endoscopic-guided placement, but these results are unclear (RR 0.24, 95% CI 0.03 to 2.18; I2 = 0%; low-certainty evidence). Electromagnetic-guided placement may result in little to no difference in the time for postpyloric placement of nasoenteral feeding tubes compared to endoscopic-guided placement (MD 4.06 minutes, 95% CI -0.47 to 8.59; I2 = 97%; low-certainty evidence). Electromagnetic-guided placement likely reduces direct healthcare costs compared to endoscopic-guided placement (MD -127.69 US dollars, 95% CI -135.71 to -119.67; moderate-certainty evidence). Electromagnetic-guided placement likely results in little to no difference in adverse events compared with endoscopic-guided placement (RR 0.78, 95% CI 0.41 to 1.49; moderate-certainty evidence). We found low-certainty evidence that electromagnetic-guided placement at the bedside results in little to no difference in technical success in insertion and aspiration pneumonitis, compared to endoscopic-guided placement. The heterogeneity of the healthcare professionals who performed the procedures and the small sample sizes limited our confidence in the evidence. Future research should be based on large studies with well-defined endpoints to potentially elucidate the differences between these two procedures.

Intravenous Metoclopramide to Improve the Success Rate of Blind Bedside Post-pyloric Placement of Feeding Tube in Critically Ill Children: A Randomized, Double-Blind, Placebo-Controlled Study.

Objective: Impaired gastric emptying is a common cause of delayed feeding in critically ill children. Post-pyloric feeding may help improve feeding intolerance and nutritional status and, hence, contribute to a better outcome. However, post-pyloric feeding tube insertion is usually delayed due to a technical difficulty. Therefore, prokinetic agents have been used to facilitate blind bedside post-pyloric feeding tube insertion. Metoclopramide is a potent prokinetic agent that has also been used to improve motility in adults and children admitted to intensive care units. The objective of this study was to determine the efficacy of intravenous metoclopramide in promoting the success rate of blind bedside post-pyloric feeding tube placement in critically ill children.Design: The design of this study is randomized, double blind, placebo controlled.Setting: The setting of the study is a single-center pediatric intensive care unit.Patients: Children aged 1 month−18 years admitted to the pediatric intensive care unit with severe illness or feeding intolerance were enrolled in this study.Intervention: Patients were randomly selected to receive intravenous metoclopramide or 0.9% normal saline solution (the placebo) prior to the tube insertion. The study outcome was the success rate of post-pyloric feeding tube placement confirmed by an abdominal radiography 6–8 h after the insertion.Measurements and Main Results: We found that patients receiving metoclopramide had a higher success rate (37/42, 88%) of post-pyloric feeding tube placement than the placebo (28/40, 70%) (p = 0.04). Patients who received sedative drug or narcotic agent showed a tendency of higher success rate (p = 0.08).Conclusion: Intravenous metoclopramide improves the success rate of blind bedside post-pyloric placement of feeding tube in critically ill children.Trial Registration: Thai Clinical Trial Registry TCTR20190821002. Registered 15th August 2019.

The feasibility of electromagnetic sensing aided post pyloric feeding tube placement (CORTRAK) in patients with thrombocytopenia with or without anticoagulation on the intensive care unit.

The successful initiation of enteral nutrition is frequently hampered by various complications occurring in patients treated in the intensive care unit (ICU). Successful placement of a nasojejunal tube by CORTRAK enteral access system (CEAS) has been reported to be a simple bedside tool for placing the postpyloric (PP) feeding tube. We evaluated the efficacy and side effects using CEAS to establish EN in patients with critical illness, thrombocytopenia, and/or anticoagulation. Fifty-six mechanically ventilated patients were analyzed. Twenty-four of them underwent prior hematopoietic stem cell transplantation (SCT). Sixteen patients received extracorporeal membrane oxygenation treatment because of acute respiratory distress syndrome. The median platelet count at PP placement was 26g/L (range, 4-106g/L); 16 patients received therapeutic anticoagulation (activated partial thromboplastin time, 50-70s). CEAS-assisted placement of a PP nasojejunal tube was performed successfully in all patients. The most frequent adverse event was epistaxis in 27 patients (48.2%), which was mostly mild (Common Terminology Criteria for Adverse Events grade 1, n=21 [77.8%], and grade 2, n=6). A significant association between a low platelet count and bleeding complications was observed (P<0.001). Performed by an experienced operator, CEAS is a simple, rapidly available, and effective bedside tool for safely placing PP feeding tubes for EN in patients with thrombocytopenia, even when showing an otherwise-caused coagulopathy in the ICU. Higher-grade bleeding complications were not observed despite their obvious correlation to thrombocytopenia. A prospective study is in preparation.

Multivariate analysis of factors associated with first-pass success in blind placement of a post-pyloric feeding tube: a retrospective study

BackgroundTrans-jejunal nutrition via a post-pyloric enteral feeding tube has a low risk of aspiration or reflux; however, placement of the tube using the blind method can be difficult. Assistive devices, such as fluoroscopy or endoscopy, are useful but may not be suitable for patients with hemodynamic instability or severe respiratory failure. The aim of this study was to explore factors associated with first-pass success in the blind placement of post-pyloric enteral feeding tubes in critically ill patients.MethodsData were obtained retrospectively from the medical records of adult patients who had a post-pyloric enteral feeding tube placed in the intensive care unit between January 1, 2012, and December 31, 2018. Logistic regression analysis was performed to assess the association between first-pass success and the independent variables. For logistic regression analysis, the following 13 variables were defined as independent variables: age, sex, height, fluid balance from baseline, use of sedatives, body position during the procedure, use of cardiac assist devices, use of prokinetic agents, presence or absence of intestinal peristalsis, postoperative cardiovascular surgery, use of renal replacement therapy, serum albumin levels, and position of the greater curvature of the stomach in relation to spinal levels L1 − L2.ResultsData obtained from 442 patients were analyzed. The first-pass success rate was 42.8% (n = 189). Logistic regression analysis demonstrated that the position of the greater curvature of the stomach cephalad to L1 − L2 was only associated with successful placement (odds ratio for first-pass success, 0.62; 95% confidence interval: 0.40 − 0.95).ConclusionsIn critically ill patients, the position of the greater curvature of the stomach caudal to L1 − L2 may be associated with a lower first-pass success rate of the blind method for post-pyloric enteral feeding tube placement. Further studies are needed to verify our results because the position of the stomach was estimated by radiographs after enteral feeding tube placement.Trial registration: University Hospital Medical Information Network Clinical Trials Registry (UMIN000036549; April 20, 2019).

Video-assisted placement of enteral feeding tubes using the Integrated Real-Time Imaging System (IRIS)-technology in critically ill patients

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.

Postpyloric feeding tube placement at the bedside: Complication rate and impact on length of stay.

Postpyloric feeding tube (PPFT) placement is essential for the ongoing nutrition care of critically ill children requiring noninvasive and invasive ventilation. PPFTs are placed by a variety of providers, including advanced practice nurses (APNs), surgeons, gastroenterologists, and radiologists. Complication rates, time to enteral nutrition (EN) following placement, and association with length of stay (LOS) have not been well documented. A query of the electronic medical record identified patients in the pediatric intensive care unit (PICU) in whom PPFTs were placed. A retrospective chart review was performed to identify patient demographics; PPFT placement provider, indication, and duration; PICU LOS; hospital LOS; and patient pediatric risk of mortality (PRISM) scores. A total of 452 PPFTs were placed in 346 patients , with 318 placed by APNs. There was only one complication in 452 placed PPFTs. PRISM scores between patient groups for APN-placed PPFTs and non-APN-placed PPFTs were not significantly different. Mean time from hospital admission to PPFT placement was 1.5 days (APN) to 2.0 days (non-APN) (P < .02). Spearman correlation coefficients demonstrated shorter hospital and PICU LOS were associated with shorter duration to insertion. Overall complication rates of PPFT insertion is very low and do not significantly differ between provider type , even in patients with higher PRISM scores. Additionally, early time to insertion of PPFT is associated with decreased hospital and PICU LOS. Further research is needed to determine if the earlier time to insertion of PPFTs is associated with the achievement of goal feeds.

Bedside postpyloric enteral tube placement using Kangaroo IRIS technology: a single-center case series

ObjectivesPostpyloric enteral feeding tubes (PPTs) are often placed endoscopically. This carries cost and capacity implications for hospitals with additional strain on endoscopy units during the SARS-CoV-2 pandemic. The Kangaroo Feeding Tube with IRIS Technology (IRIS) uses optical visualization to guide bedside placement, obviating the need for endoscopy. We describe a case series of bedside postpyloric enteral feeding tube placement using the IRIS tube. MethodsThis was a prospective, single-center case series over 12 mo. Conscious and sedated adult participants were included. Exclusion criteria were altered anatomy and need for endoscopy for other indications. IRIS placement was confirmed by contrast radiograph. ResultsTwenty attempts were made in 19 participants (13 women). The primary indication was intolerance of gastric feeding. The overall success rate was 75%. In sedated participants, 5 (83%) of 6 tubes were successful in 5 participants. In conscious participants, 10 (71%) of 14 tubes were successful in 14 participants. Placement failure in conscious participants was due to intolerance of the camera tip during nasal passage. The median procedure time was 13.5 min. In all cases, correct position as deemed by the operator was confirmed with contrast radiograph. No complications were observed. ConclusionsTo our knowledge, this is the largest single series of bedside postpyloric enteral feeding tube placement using the IRIS tube to date. The success rate and safety profile reported here, together with the potential benefits (reduced feeding delays, costs, and need for endoscopy) suggest that further, large-scale studies are warranted.

Electromagnetic guided versus endoscopic guided postpyloric placement of nasoenteral feeding tubes

Electromagnetic guided versus endoscopic guided postpyloric placement of nasoenteral feeding tubes

Efficacy and safety of a modified method for blind bedside placement of post-pyloric feeding tube: a prospective preliminary clinical trial.

ObjectiveTo compare the efficacy and safety of a new modified method of bedside post-pyloric feeding tube catheterization with the Corpak protocol versus electromagnetic-guided catheterization.Materials and MethodsWe conducted a single-center, single-blinded, prospective clinical trial. Sixty-three patients were treated with a non-gravity type gastrointestinal feeding tube using different procedures: modified bedside post-pyloric feeding tube placement (M group), the conventional Corpak protocol (C group), and standard electromagnetic-guided tube placement (EM group).ResultsThe success rate in the M group, C group, and EM group was 82.9% (34/41), 70.7% (29/41), and 88.2% (15/17), respectively, with significant differences among the groups. The time required to pass the pylorus was significantly shorter in the M group (26.9 minutes) than in the C group (31.9 minutes) and EM group (42.1 minutes). The proportion of pylorus-passing operations completed within 30 minutes was significantly higher in the M group than in the C group and EM group. No severe complications occurred.ConclusionThis modified method of bedside post-pyloric feeding tube catheterization significantly shortened the time required to pass the pylorus with no severe adverse reactions. This method is effective and safe for enteral nutrition catheterization of patients with dysphagia and a high risk of aspiration pneumonia.

Ultrasound-Guided Postpyloric Feeding Tube Placement in Critically Ill Pediatric Patients.

Various methods to insert postpyloric feeding tubes at the bedside have been reported, but the optimal method remains controversial. The objective of this study was to evaluate the effect of ultrasound-guided postpyloric feeding tube placement in critically ill children. Single-center retrospective observational study. PICU of tertiary children's hospital. Children under the age of 16 who underwent postpyloric feeding tube placement in our PICU between September 2017 and August 2019. None. A total of 115 patients were included in this study: 30 patients underwent ultrasound-guided postpyloric feeding tube placement and 85 patients underwent blind postpyloric feeding tube placement; the insertion attempts were 32 and 93, respectively. There were no significant differences in patient demographics between the ultrasound-guided group and the blind group. The first-pass success rate of the ultrasound-guided group was higher than that of the blind group (94% [30/32] vs 57% [53/93]; p < 0.001). The median insertion time in the ultrasound-guided group with successful postpyloric feeding tube insertion was 18 minutes (interquartile range, 15-25; range, 8-45; n = 21). There were no complications or adverse events during the placement. In this single-center study, ultrasound-guided postpyloric feeding tube placement was feasible and a significantly high first-pass success rate was observed for critically ill children. Additional investigation with a larger pool of operators and randomized controlled patient assignment is required.

Electromagnetic-guided versus endoscopic placement of post-pyloric feeding tubes: a systematic review and meta-analysis of randomised controlled trials

BackgroundCurrent evidence supporting the utility of electromagnetic (EM)-guided method as the preferred technique for post-pyloric feeding tube placement is limited. We conducted a meta-analysis to compare the performance of EM-guided versus endoscopic placement.MethodsWe searched several databases for all randomised controlled trials evaluating the EM-guided vs. endoscopic placement of post-pyloric feeding tubes up to 28 July 2020. Primary outcome was procedure success rate. Secondary outcomes included reinsertion rate, number of attempts, placement-related complications, tube-related complications, insertion time, total procedure time, patient discomfort, recommendation scores, length of hospital stay, mortality, and total costs.ResultsFour trials involving 536 patients were qualified for the final analysis. There was no difference between the two groups in procedure success rate (RR 0.97; 95% CI 0.91–1.03), reinsertion rate (RR 0.84; 95% CI 0.59–1.20), number of attempts (WMD − 0.23; 95% CI − 0.99–0.53), placement-related complications (RR 0.78; 95% CI 0.41–1.49), tube-related complications (RR 1.08; 95% CI 0.82–1.44), total procedure time (WMD − 18.09 min; 95% CI − 38.66–2.47), length of hospital stay (WMD 1.57 days; 95% CI − 0.33–3.47), ICU mortality (RR 0.80; 95% CI 0.50–1.29), in-hospital mortality (RR 0.87; 95% CI 0.59–1.28), and total costs (SMD − 1.80; 95% CI − 3.96–0.36). The EM group was associated with longer insertion time (WMD 4.3 min; 95% CI 0.2–8.39), higher patient discomfort level (WMD 1.28; 95% CI 0.46–2.1), and higher recommendation scores (WMD 1.67; 95% CI 0.24–3.10).ConclusionsNo significant difference was found between the two groups in efficacy, safety, and costs. Further studies are needed to confirm our findings.Systematic review registrationPROSPERO (CRD42020172427)

Electromagnetic Versus Blind Guidance of a Postpyloric Feeding Tube in Critically Ill Children

Postpyloric feeding tube placement is a time-consuming procedure associated with multiple attempts and radiation exposure. Our objective with this study is to compare the time, attempts, and radiation exposure using the electromagnetic versus blind method to place a postpyloric feeding tube in critically ill children. Our hypothesis is that using electromagnetic guidance decreases the procedure time, number of x-rays, and number of attempts, compared to the blind method. Eleven pediatric nurses participated in a randomized controlled intention-to-treat study at an academic pediatric medical, surgical, and congenital cardiac ICU. University of Texas Health Epidemiology and Biostatistics generated a randomization sequence with sealed envelopes. A standard (2-sided) F-test of association between the electromagnetic and blind method yielded 40 subjects with 86% power. Data were analyzed with Fisher's exact test for categorical variables and the Wilcoxon rank test for continuous variables, with data documented as median (interquartile range [IQR]). We randomly assigned 52 patients to either the electromagnetic (n = 28) or blind method (n = 24). The number of attempts and radiographs was at a median of 2 (IQR: 1-2.25) using the blind method, compared to the electromagnetic method at a median of 1 (IQR: 1.0-1.0; P = .001). Successful guidance was 96.4% with the electromagnetic method, compared to only 66.7% with the blind technique (P = .008). The total time required was 2.5 minutes (IQR: 2.0-7.25) with the electromagnetic method, compared to 19 minutes (IQR: 9.25-27.0) for the blind method (P = .001). Electromagnetic guidance is a superior, faster, and overall safer method to place a postpyloric feeding tube in critically ill children.

409 Early Feeding Tube Placement in Burn Patients and the Impact on Nutritional Outcomes

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.

Auscultation-assisted bedside postpyloric placement of feeding tube in critically ill patients: a prospective, observational study.

To assess the efficacy and safety of auscultation-assisted bedside postpyloric feeding tube (ABPFT) placement in early enteral nutritional support for critically ill patients. A prospective observational study was conducted and 92 critically ill patients who met the inclusion criteria undergoing ABPFT placement after the intravenous injection of 10 mg of metoclopramide were included. Abdominal X-ray was performed to confirm the location of the catheter tip. End points investigated were the success rate of tube placement, rate of jejunal tube placement, duration of the procedure, length of insertion, and number of attempts. Operational-related adverse events or complications were also documented and evaluated. The total success rate of postpyloric feeding tube implantation was 97.8% (90/92), among which, 89.1% (82/92) of the tubes were placed proximal to the jejunum. The first-attempt success rate was 91.3% (84/92) and the mean attempt per individual patient was 1.11±0.38 times. The mean operation time was 28.6±17.7 minutes, and the mean insertion length of tube was 106±9.6 cm. A total of 27 adverse events occurred in 19.6% (18/92) patients and there was no serious adverse events or complications during the study period. Assistance by auscultation can significantly improve the success rate of nasal feeding tube placement. This simple, safe and fast approach is feasible for the application among health practitioners in the intensive care unit.

Postpyloric Versus Gastric Tube Feeding for Preventing Pneumonia and Improving Nutritional Outcomes in Critically Ill Adults.

What is the effectiveness and safety of postpyloric feeding versus gastric feeding for critically ill adults who require enteral tube feeding?Adequate nutrition is a key component to providing holistic care to critically ill patients. Assessing the need for nutritional support and providing early intervention can have many beneficial outcomes for patients, including improved disease progression and recovery time, improved immune response, and decreased overall complications.1 Early feeding for critically ill patients may be provided via enteral or parenteral routes. According to international guidelines,1–3 enteral feeding is the preferred method for patients who have a functioning gastrointestinal (GI) tract but who cannot maintain adequate oral intake. The advantages of enteral nutrition include prevention of GI atrophy and the systemic spread of GI bacteria.As with any intervention, potential challenges and side effects need to be taken into consideration. One main issue with feeding via the enteral route is the reduction in gastric motility including decreased gastric emptying and weakening of the gastric sphincters. This reduction in gastric motility can in turn can lead to gastroesophageal reflux (GER) and the risk of aspiration pneumonia. In addition, overall caloric intake can be an issue related to gastric intolerance, large residual volumes, and interruptions to continual feeding. Postpyloric feeding, in which the feeding tube is placed directly into the duodenum or the jejunum, could solve these issues by decreasing GER and residual volumes.Although gastric and postpyloric feeding in critical care patients have been compared in several meta-analyses,4 investigators reached different conclusions regarding the benefits and complications of using a postpyloric feeding tube. These discrepancies affect both standard guidelines and clinical practice. The purpose of this systematic review was to evaluate the potential benefits and adverse effects of using early postpyloric feeding in the adult critical care setting.This summary is based on a Cochrane systematic review that included individual patient data from 14 randomized controlled trials, with a total of 1109 participants.4 The systematic review examined both primary and secondary outcomes.The authors independently assessed the risk of bias for each study, including selection bias, performance bias, detection bias, attrition bias, reporting bias, and publication bias. The authors resolved any disagreements by reviewing and discussing the data.Risk ratio (RR) or mean differences (MD) were used as the measure of treatment effect between different comparisons and outcomes. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to provide a level of the quality of evidence for each outcome (very low, low, moderate, or high).5This systematic review and meta-analysis found moderate-quality evidence suggesting that postpyloric feeding decreases incidences of pneumonia by 30% and low-quality evidence suggesting that postpyloric feeding may lead to an increase in the amount of total nutrition delivered compared with gastric tube feeding. This review also found low-quality evidence suggesting that insertion of a postpyloric feeding tube is a safe intervention and is not associated with any more complications such as epistaxis and GI bleeding than gastric tube insertion. Therefore, using a postpyloric feeding tube may be preferred for ICU patients when feasible.Placement of a postpyloric feeding tube, however, can be challenging, often requiring expertise and a variety of radiological devices. Because the findings of this review do not recommend a best method for placing the postpyloric feeding tube, nurses should use their clinical judgment as to which method is best for their clinical scenario. If nurses lack skill in postpyloric feeding tube placement, consider additional training so that placing a postpyloric feeding tube is among the options they can choose from.As nurses caring for critically ill patients, we should advocate for the best evidence-based treatment for our patients. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine if we should implement it in our unit.

Erythromycin for Promoting the Postpyloric Placement of Feeding Tubes: A Systematic Review and Meta-Analysis.

Background Critically ill patients can benefit from enteral nutrition with postpyloric feeding tubes, but the low success rate limits its wide use. Erythromycin could elevate the success rate of tube insertion, but its clinical efficiency still remains controversial. Methods Included studies must be RCTs which assessed the success rate of postpyloric feeding tube insertion using erythromycin. Results 284 patients were enrolled in six studies. Meta-analysis showed that erythromycin significantly increases the rate of successful postpyloric feeding tube placement (RR 1.45, 95% CI (1.12, 1.86)) and did not increase the risk of adverse effects (RR 2.15, 95% CI (0.20, 22.82)). Subgroup analysis showed that unweighted feeding tubes (RR 1.47, 95% CI (1.03, 2.11)) could significantly increase the success rate. Country of study, intravenous route of erythromycin, and year of participant enrollment did not influence these results. Conclusions Erythromycin significantly increases the success rate of postpyloric feeding tube placement. This suggests that erythromycin can be used as an auxiliary method to improve the success rate of bedside insertion.

Electromagnetically guided bedside placement of post-pyloric feeding tubes in critical care.

Post-pyloric feeding is recommended in critically ill patients with gastro-intestinal intolerance. However, traditional placement methods are logistically difficult and carry potential risks. The authors retrospectively compared the position of post-pyloric feeding tubes (PPFTs) using an electromagnetic device that demonstrated by X-ray and analysed the complication rates, proportion of lung placements avoided and the time taken to establish enteral feeding. Forty placements in 37 mechanically ventilated patients were analysed; there was a success rate of 87.5%. Sensitivity and specificity were 77% (95% CI 59.9-89.6%) and 100% (95% CI 48.0-100%). Five lung placements were identified in real time and therefore avoided. The mean (SD) time from PPFT placement to X-ray was 134 minutes (± 139 minutes) and, to feeding, 276 minutes (± 213 minutes). In conclusion, placement of PPFT using an electromagnetic device carries a high success rate, is safe and feasible to undertake at the bedside in mechanically ventilated patients.

Safety and Efficacy of Electromagnetic-Guided Bedside Placement of Nasoenteral Feeding Tubes versus Standard Placement

Although enteral feeding in critically ill patients has been shown to be beneficial, reliable postpyloric placement of feeding tubes remains a challenge. The standard of care involves blind placement, frequently requiring multiple attempts, and radiographs. To evaluate the effect of electromagnetic-guided bedside placement in reducing time to establishment of feeding, lung placement, use of radiography, and cost, we initiated a prospective trial using electromagnetic-guided bedside placement and compared them to a retrospective cohort. Fifty-three consecutive placements of nasoenteral feeding tubes were made using electromagnetic-guidance on patients requiring enteral nutrition in a surgical intensive care unit at a tertiary care center. Sixty-three placement attempts in the preceding seven months served as controls. There were no significant differences between the two groups in terms of age, sex, weight, body mass index, hiatal or ventral hernias, or previous esophageal/gastric operations. The number of radiographs needed per patient, need for fluoroscopy, radiology charge per patient for the tube placement, and time from first attempt at placement to confirmation of postpyloric location were lower for the electromagnetic-guided group. Use of electromagnetic guidance allows reliable and cost-effective postpyloric enteral feeding tube placement compared with blind insertion.

Post-pyloric feeding tube placement in critically ill patients: Extending the scope of practice for Australian dietitians.

To determine whether the placement of a post-pyloric feeding tube (PPFT) can be taught safely and effectively to a critical care dietitian. This is a prospective observational study conducted in an adult intensive care unit (ICU). The intervention consisted of 19 attempts at post-pyloric intubation by the dietitian. The 10 'learning' attempts were performed by the dietitian under the direction of an experienced (having completed in excess of 50 successful tube placements) user. A subsequent nine 'consolidation' attempts were performed under the responsibility of the intensive care consultant on duty. The primary outcome measures were success (i.e. tip of the PPFT being visible in or distal to the duodenum on X-ray) and time (minutes) to PPFT placement. Patients were observed for adverse events per standard clinical practice. A total of 19 post-pyloric tube placements were attempted in 18 patients (52 (23-70) years, ICU admission diagnoses: trauma n = 4; respiratory failure n = 3; and burns, pancreatitis and renal failure n = 2 each). No adverse events occurred. Most (75%) patients were sedated, and mechanically ventilated. Prokinetics were used to assist tube placement in 11% (2/19) of attempts, both of which were successful. Placement of PPFT was successful in 58% (11/19) of attempts. Whilst training, the success rate was 40% (4/10) compared with 78% (7/9) once training was consolidated (P = 0.17). In the successful attempts, the mean time to placement was 11.0 minutes (3.9-27.1 minutes). A dietitian can be trained to safely and successfully place PPFT in critically ill patients.