Postpyloric Feeding Tube Research Articles

Blind versus endoscopy-guided postpyloric feeding tube placement in adults with ischemic stroke: A retrospective cohort study.

This study compared the one-time success rate of blind and endoscopy-guided postpyloric feeding tube placement after implementing a comprehensive nursing scheme of intestinal blind placement for patients with ischemic stroke. This retrospective cohort study included 179 patients with blind bedside placement and 118 with endoscopy-guided placement. The primary outcome was the one-time success rate of radiologically confirmed postpyloric placement. The secondary endpoints included the position of the tube tip, length of insertion, time of placement, and expenses. The safety endpoints were the incidence of complications caused by placement. The results showed that the method of tube placement did not significantly affect the outcome of the first tube placement (odds ratio [OR] = 0.41; 95% CI = 0.137-1.207; P = 0.105). Compared with endoscopy-guided placement, blind placement was half the cost. We also found that a history of abdominal surgery (OR = 0.003; 95% CI = 0.000-0.059; P < 0.001) and longer intensive care unit (ICU) days (OR = 0.94; 95% CI = 0.903-0.981; P = 0.004) were inversely associated with the one-time success rate. Our study suggested that blind intestinal feeding tube placement has an equivalent one-time success rate compared with endoscopy-guided placement in hospitalized patients with ischemic stroke if operators can be trained well. However, the expenses of endoscopy-guided placement were twice those of blind bedside methods. We also found that patients with abdominal surgery history and longer ICU stay were more likely to fail at the first placement. Further research is needed to replicate our single-center observations in a larger population of patients.

Tutorial on adult enteral tube feeding: Indications, placement, removal, complications, and ethics.

Enteral nutrition, generally preferred to parenteral nutrition, is indicated when patients cannot meet their energy and metabolic demands. Gastrostomy tubes are placed directly into the stomach (either endoscopically, surgically, or radiologically) through the abdominal wall. Routine gastrostomy tube care is important to maintain well-functioning tubes. Postpyloric feeding tubes are preferable to gastric feeding tubes if patients have a history of aspiration, gastroesophageal reflux, severe gastroparesis, and/or recurrent nausea and vomiting. Feeding jejunostomy tubes are placed surgically and are indicated if gastric feeding is unsafe or impossible. Dual-lumen gastrojejunostomy tubes are used when both gastric decompression and feeding are desired. The general risks of enteral tube feeding include diarrhea, metabolic derangements, and aspiration. Additional complications for gastrostomy tubes, which can arise at any time, include tube dysfunction (clogging or deterioration), infection, bleeding, peristomal leakage, ulceration, gastric outlet obstruction, and accidental removal. After percutaneous endoscopic gastrostomy placement, there are also early or late complications that may occur. Multiple factors should be considered in the decision-making process for feeding tube placement. It is important to be realistic about the patient's prognosis and goals and to discuss the risks and benefits ahead of time. Consultation with palliative care or clinical ethics specialists should be considered in certain clinical scenarios.

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.

Use of an electromagnetic-guided device to assist with post-pyloric placement of a nasoenteral feeding tube: A systematic review and meta-analysis.

Background and study aims While endoscopic-guided placement (EGP) of a post-pyloric nasoenteral feeding tube may improve caloric intake and reduce the risk of bronchoaspiration, an electromagnetic-guided placement (EMGP) method may obviate the need for endoscopic procedures. Therefore, the primary aim of this study was to perform a systematic review and meta-analysis of randomized trials comparing the efficacy and safety of EMGP versus EGP of a post-pyloric feeding tube. Methods Protocolized searches were performed from the inception through January 2021 following PRISMA guidelines. Only randomized controlled trials were included comparing EMGP versus EGP. Study outcomes included: technical success (defined as appropriate post-pyloric positioning), tube and patient associated adverse events (AEs), time to enteral nutrition, procedure-associated cost, and procedure time. Pooled risk difference (RD) and mean difference (MD) were calculated using a fixed-effects model and heterogeneity evaluated using Higgins test (I 2 ). Results Four randomized trials (n = 536) were included. A total of 287 patients were included in the EMGP group and 249 patients in the EGP group. There was no difference between EMGP versus EGP regarding technical success, tube-related AEs, patient-related AEs, procedure time, and time in the right position. Time to enteral nutrition favored EMGP (MD: –134.37 [–162.13, –106.61]; I 2 = 35 %); with significantly decreased associated cost (MD: –127.77 ($) [–135.8–119.73]; I 2 = 0 %). Conclusions Based on this study, EMGP and EGP were associated with similar levels of technical success and safety as well as time to complete the procedure. Despite this, EMGP was associated with reduced cost and time to initiation of nutrition.

Association of enteral feeding with microaspiration in critically ill adults

AimThis study explored relationships between enteral feeding and tracheal pepsin A. BackgroundMechanically ventilated (MV) patients receiving enteral feeding are at risk for microaspiration. Tracheal pepsin A, an enzyme specific to gastric cells, was a proxy for microaspiration of gastric secretions. MethodsSecondary analysis of RCT data from critically ill, MV adults was conducted. Microaspiration prevention included elevated head of bed, endotracheal tube cuff pressure management, and regular oral care. Tracheal secretions for pepsin A were collected every 12 h. Microaspiration was defined as pepsin A ≥ 6.25 ng/mL. Positive pepsin A in >30 % of individual tracheal samples was defined as abundant microaspiration (frequent aspirator). Chi-squared, Fisher's Exact test, and generalized linear model (GLM) were used. ResultsTracheal pepsin A was present in 111/283 (39 %) mechanically ventilated patients and 48 (17 %) had abundant microaspiration. Enteral feeding was associated with tracheal pepsin A, which occurred within 24 h of enteral feeding. Of the patients who aspirated, the majority received some enteral feeding 96/111 (86 %), compared to only 15/111 (14 %) who received no feeding. A greater number of positive pepsin A events occurred with post-pyloric feeding tube location (55.6 %) vs. gastric (48.6 %), although significant only at the event-level. Frequent aspirators (abundant pepsin A) had higher pepsin A levels compared to infrequent aspirators. ConclusionsOur findings confirmed the stomach as the microaspiration source. Contrary to other studies, distal feeding tube location did not mitigate microaspiration. Timing for first positive pepsin A should be studied for possible association with enteral feeding intolerance.

Ventilator-associated pneumonia prevention in the Intensive care unit using Postpyloric tube feeding in China (VIP study): study protocol for a randomized controlled trial

BackgroundVentilator-associated pneumonia is a challenge in critical care and is associated with high mortality and morbidity. Although some consensuses on preventing ventilator-associated pneumonia are reached, it is still somewhat controversial. Meta-analysis has shown that postpyloric tube feeding may reduce the incidences of ventilator-associated pneumonia, which still desires high-quality evidence. This trial aims to evaluate the efficacy and safety profiles of postpyloric tube feeding versus gastric tube feeding.Methods/designIn this multicenter, open-label, randomized controlled trial, we will recruit 924 subjects expected to receive mechanical ventilation for no less than 48 h. Subjects on mechanical ventilation will be randomized (1:1) to receive postpyloric or gastric tube feeding and routine preventive measures simultaneously. The primary outcome is the proportion of patients with at least one ventilator-associated pneumonia episode. Adverse events and serious adverse events will be observed closely.DiscussionThe VIP study is a large-sample-sized, multicenter, open-label, randomized, parallel-group, controlled trial of postpyloric tube feeding in China and is well-designed based on previous studies. The results of this trial may help to provide evidence-based recommendations for the prevention of ventilator-associated pneumonia.Trial registrationChictr.org.cn ChiCTR2100051593. Registered on 28 September 2021

Outcomes of Continuous Enteral Vancomycin Infusion in Intensive Care Unit Patients: A Novel Treatment Modality for Severe Clostridium Difficile Colitis.

Background and objectiveSevere Clostridium difficile (C. difficile) infection (CDI)-related colitis is associated with high morbidity and mortality. Current guidelines recommend oral vancomycin plus intravenous metronidazole as the first-line treatment and early total colectomy in case of medication failure. In critically ill patients at high surgical risk and with multiple comorbidities, loop ileostomy creation and enteral vancomycin infusion have been employed albeit with limited success. We hypothesized that continuous enteral vancomycin (CEV) infusion via a postpyloric feeding tube would provide a less invasive, efficacious, and safer route to treat high surgical risk patients.MethodsAll adult (>18 years) non-pregnant patients admitted to the ICU for severe CDI from October 2012 to October 2016 and received CEV after the failure of conventional therapy were included. Vancomycin was prepared as a 1-2-mg/ml enteral solution and run continuously through a feeding pump at 42 ml/hour via a post-pyloric feeding tube. The primary efficacy endpoint was clinical improvement defined as (a) decrease in stool output, (b) decreased vasopressor requirement, or (c) improved leukocytosis, and the secondary endpoint was treatment failure defined as the need for total colectomy or death due to severe CDI.ResultsOur cohort comprised 11 patients in total. The median age of the participants was 64 years, and there were more females (67%) than males (36%). Clinical improvement was seen in seven patients (63%); treatment failure documented as the need for total colectomy was observed in two patients (18%), and death attributable to CDI occurred in three patients (27%).ConclusionCEV resulted in clinical improvement in most patients with severe CDI who were at high surgical risk. Sustained intestinal vancomycin delivery may increase luminal concentration and bactericidal effect. The use of a feeding tube and pump provides an effective and less invasive route of vancomycin delivery in critically ill patients.

Successful postpyloric feeding tube insertion using prokinetic drugs for nasoenteric tube placement: A network meta-analysis.

The objective was to compare the effects of prokinetic drugs on the success of postpyloric nasoenteric tube placement using network meta-analysis methods. Articles from PubMed, Embase, and the Cochrane Library were retrieved up to April 18, 2021. Eligible studies were randomized controlled trials (RCTs) that investigated the effect of prokinetic drugs on postpyloric nasoenteric tube placement. Reviews, retrospective studies, observational studies, letters to the editors, and conference abstracts were excluded. Biases in each study were identified by using the tool recommended by the Cochrane Collaboration. Stata14.0 software were used to process the network meta-analysis. A total of 12 eligible RCTs with 777 patients receiving postpyloric nasoenteric tube placement were finally included for analysis. Patients receiving the following drugs appeared to have significant success with postpyloric feeding tube insertion compared with placebo: metoclopramide (odds ratio [OR] = 2.27; 95% CrI, 1.53-3.37), erythromycin (OR = 1.88; 95% CrI, 1.17-3.19), and domperidone (OR = 2.39; 95% CrI, 1.31-4.35). The surface under the cumulative ranking of placebo, erythromycin, metoclopramide, and domperidone were respectively 9.8%, 73.0%, 62.6%, and 54.6%. Erythromycin had an advantage over the other treatments in success postpyloric feeding tube insertion. Erythromycin may have the greatest possibility to improve success postpyloric feeding tube insertion.

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.

Ultrasound-guided post-pyloric feeding tube insertion in peri-operative cardiac infants.

We carried out a prospective pilot observational experimental study in peri-operative cardiac infants with feeding intolerance between 2019 and 2021. Feeding tube insertion depends on a combination of ultrasound and gastric insufflation with air-saline mixture. Insertion was confirmed by bedside abdominal X-ray. Out of 500 peri-operative cardiac infants, 15 needed post-pyloric feeding tube insertion in median 15 postoperative day. All were under 6 months of age with average weight of 3 ± 0.2 kg. Median Risk Adjustment for Congenital Heart Surgery Categories was 4. Median insertion time was 15 minutes. No complications have been reported. First pass success rate was 87%, while a second successful insertion attempt was needed in 2 cases (13%). Target daily calorie intake was achieved within average of 3.5 ± 0.4 days. Mean post-pyloric feeding tube stay was 20 ± 3 days. Out of 15 infants, 3 patients died, 1 patient needed gastrostomy tube, and 11 patients were discharged home on oral feeds. Ultrasound-guided post-pyloric feeding tube insertion using gastric insufflation with air-saline mixture in peri-operative cardiac infants with feeding intolerance is a useful and practical bedside tool, and it can be performed by a trained paediatric cardiac ICU intensivist. It may have potential positive effects on morbidity and outcome.

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).

S2181 Jejunostomy Feeding in Refractory Hyperemesis Gravidarum - A Case Report and Review of Literature

Introduction: Hyperemesis gravidarum (HG) is intractable vomiting experienced by < 1% of pregnant women causing dehydration, significant weight loss and electrolyte disturbances requiring hospital admission. HG is distinguished from nausea/vomiting in pregnancy by ketonuria and loss of >5% of prepregnancy weight. Nutritional support in early pregnancy reduces potential complications associated with HG. We present a patient with severe HG who failed all pharmacological treatment and had a jejunostomy (J) tube placed for nutrition. Case Description/Methods: A 31-year-old G3P1 female presented in her 21stweek of pregnancy with intractable vomiting ( >20 episodes/day) and 13-lb weight loss in 2months. Symptoms began in her 6thweek and she failed a trial of scheduled Ondansetron, Promethazine, Vitamin B1/B6 and Famotidine. Patient later agreed to complete a regimen of IV Methylprednisolone followed by Prednisone taper; however, symptoms persisted. She continued to lose weight and developed protein-calorie malnutrition with ketonuria by her 24thweek. Enteral versus parenteral feeding options were reviewed and she agreed to endoscopic nasojejunal (NJ) tube placement. Tube feeds were uptitrated gradually, however her NJ tube dislodged after 2days due to vigorous vomiting. She subsequently had central line placed and was started on parenteral nutrition. To prevent long-term complications, we opted for J-tube placement laparoscopically to avoid puncturing the uterus during the procedure. Tube feeds were restarted and increased as tolerated to reach nutritional goals. The J-tube will remain in place until she delivers. Discussion: Currently, antiemetics are recommended for HG as there are no superior treatments available with proven efficacy based on the latest Cochrane review. Glucocorticoids or Droperidol are tried for refractory cases, while smaller studies have reported benefits with Gabapentin and Mirtazapine. Early enteral or parenteral feeding should be initiated in parallel for better outcomes. Generally, post-pyloric feeding tubes are preferred due to the changing anatomy in pregnancy. Extensive literature review only revealed 1 case series reporting jejunostomy feeding in 5 patients with HG. In 2 patients, the J-tube was removed or dislodged while the remainder kept it until delivery. All patients successfully delivered at term without maternofetal complications. Though J-tubes appear to be well-tolerated, further large-scale studies are required to assess the actual benefits and risks involved.

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.

Postprandial rise of essential amino acids is impaired during critical illness and unrelated to small‐intestinal function

BackgroundPostprandial rise of plasma essential amino acids (EAAs) determines the anabolic effect of dietary protein. Disturbed gastrointestinal function could impair the anabolic response in critically ill patients. Aim was to investigate the postprandial EAA response in critically ill patients and its relation to small‐intestinal function.MethodsTwenty‐one mechanically ventilated patients and 9 healthy controls received a bolus containing 100 ml of a formula feed (Ensure) and 2 g of 3‐O‐Methyl‐d‐glucose (3‐OMG) via postpyloric feeding tube. Fasting and postprandial plasma concentrations of EAAs, 3‐OMG, total bile salts, and the gut‐released hormone fibroblast growth factor 19 (FGF19) were measured over a 4‐hour period. Changes over time and between groups were assessed with linear mixed‐effects analysis. Early (0–60 minutes) and total postprandial responses are summarized as the incremental area under the curve (iAUC).ResultsAt baseline, fasting EAA levels were similar in both groups: 1181 (1055–1276) vs 1150 (1065–1334) μmol·L−1, P = .87. The early postprandial rise in EAA was not apparent in critically ill patients compared with healthy controls (iAUC60, −4858 [−6859 to 2886] vs 5406 [3099–16,853] µmol·L−1·60 minutes; P = .039). Impaired EAA response did not correlate with impaired 3‐OMG response (Spearman ρ 0.32, P = .09). There was a limited increase in total bile salts but no relevant FGF19 response in either group.ConclusionPostprandial rise of EAA is blunted in critically ill patients and unrelated to glucose absorption measured with 3‐OMG. Future studies should aim to delineate governing mechanisms of macronutrient malabsorption.

28 Timing of Enteral Nutrition Initiation in Severely Burned Patients

Abstract Introduction Early initiation of enteral nutrition (EN) for severely burned patients (pts) has been found to be associated with decreased catabolism, decreased wound infections, lower sepsis rates, shorter intensive care unit (ICU) days and hospital days, and improved mortality. The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends initiating EN within 4–6 hrs of injury for critically ill adult burn pts; however, they also recommend waiting for hemodynamic stability to be achieved before starting EN in all critically ill pts. The objectives of this performance improvement project (PIP) were to evaluate the timing of EN initiation and reasons for delays in initiating EN in our critically ill burn pts. Methods We performed a retrospective evaluation on pts admitted to our ICU in 2019 with at least 20% TBSA burns. Exclusion criteria were death within 72 hrs of admission, oral nutrition, and admission over 1 calendar day after injury. This PIP was approved by our regulatory compliance division. We clinically defined hemodynamic stability as lactate levels less than 3 mmol/L with vasopressor requirements of less than 10 mcg/min norepinephrine. Demographic data were collected along with timing of EN and reasons for delays in EN initiation. Results EN was initiated 28 ± 17 hrs after admission for the 19 included pts with the following characteristics: 44 ± 16 years old, 38 ± 16% TBSA burn, all required mechanical ventilation on admission. These pts had 16 ± 10 mechanical ventilator days and 42% mortality. The shortest time to EN initiation was 9 hrs after admission. EN was delayed for initial hemodynamic instability for 10 ± 17 hrs after admission. Other delays in EN initiation after initially achieving hemodynamic stability included time to feeding tube placement (1 ± 2 hrs) and x-ray confirmation (4 ± 9 hrs), and time to EN orders (8 ± 10 hrs). EN was initiated 6 ± 6 hrs after the preceding events occurred. Some of the delays in placement of EN orders and for EN initiation after the above criteria were met included procedures (2 ± 2 hrs), becoming hemodynamically unstable again (5 ± 7 hrs), and placement of a small bore, post-pyloric feeding tube when an orogastric or nasogastric feeding tube was already available for use (2 ± 4 hrs). We were not able to retrospectively identify reasons for delays during 5 ± 6 hrs per patient. Conclusions As a result of this PIP, we found EN was not initiated in any of our critically ill burn pts within the timeline recommended by ASPEN/SCCM. The primary reasons for delays included hemodynamic instability, feeding tube placement and confirmation, adding a post-pyloric feeding tube, and procedures.

Implementation and Maintenance of a Pediatric Severe Burn Guidelines Quality Improvement Project.

Critically injured pediatric burn patients require specialized management, yet few verified pediatric burn centers exist in the United States. Many pediatric hospitals have resources to care for severely burned patients but lack standardized care guidelines, which improve outcomes. To improve the morbidity and mortality of severely burned pediatric patients admitted to the pediatric intensive care unit, we created a specialized burn team. We implemented Pediatric Severe Burn Guidelines, focusing on improving fluid resuscitation accuracy and providing timely nutritional support. This investigation is of a 9-year (2010-2019) retrospective preintervention and postintervention study of the effect of the formation of a multidisciplinary burn leadership committee and development and implementation of Pediatric Severe Burn Guidelines. The primary outcome measures are increasing the accuracy of fluid resuscitation and improving the timely administration of nutritional support. The process measure is the percentage of time the electronic health record power plan was used for burn admissions with burn leadership review of the cases. Balancing measures are pediatric intensive care unit and hospital length of stay. Preprotocol patients received acceptable fluid resuscitation 25% (5/20) of the time compared to 61.5% (8/13) of the time in postprotocol patients (P = 0.04). In postprotocol patients, there is an improvement in the timely placement of postpyloric feeding tube and initiation of feeds 48 hours after admission. Extensive guidelines for standardized care require careful implementation and monitoring of adherence gaps. Creating a specialized burn team and implementing clinical guidelines standardize care leading to improvement in critical patient outcomes.

Ultrasonography-guided post-pyloric feeding tube insertion in medical intensive care unit patients.

In this study, we investigated placement rate, complication rate and time spent of successful post-pyloric enteral feeding (PPEF) tube insertion procedure guided by ultrasonography (USG). The patients who required enteral nutrition and who admitted to medical intensive care unit (MICU) of Gazi University Hospital were included to this single-center, prospective, cohort study. It was aimed to insert the enteral feeding tube into the proximal duodenum as the post-pyloric area by ultrasonography guidance. During the PPEF tube insertion procedure, the linear probe was used to display the proximal esophagus and the convex probe was used to display the post-pyloric area, antrum and pyloric channel. 33 patients were included in this study. The median age was 68 [IQR 52-79] years. There were 17 (51.5%) woman and 22 (66.7%) intubated patients. The enteral feeding tube was successfully passed into the post-pyloric area in 29 (87.9%) patients with this technique. The median time of successful feeding tube insertion was 14 [IQR 10-25] min. The median level of the enteral feeding tube was 74 [IQR 70-76] cm. in successful placement. There was no significant difference in insertion time according to gender (female vs male; 10 [IQR 8-20] min. vs 17 [IQR 12-25] min., p = 0.052) and endotracheal intubation status (intubated vs non-intubated; 14 [IQR 10-25] min. vs 12 [IQR 10-25] min., p = 0.985). Only one complication was seen during study (self-limiting epistaxis in one patient). PPEF tube insertion under USG guidance could ensure the initiation of enteral feeding safely and rapidly without exposure to radiation in ICU patients.