Small Bowel Feeding Tubes Research Articles

Electromagnetically Navigated Tube Placement Device for Bedside Placement of Small Bowel Feeding Tube on Patients with Acute Severe Pancreatitis: Comparative Study.

A developing approach for the bedside installation of feeding tubes is the Electromagnetic Navigation-assisted Tube Placement Device (ENTPD). The ENTPD monitors the tip position of feeding tubes when they are inserted into the digestive tract. It aids in the avoidance of airway misalignment and allows placing into the small bowel. Several recent exploratory studies have shown that ENTPD for nasojejunal feeding tube installation can improve success rates, lower costs, and allow for a more rapid beginning of enteral nutrition. The aim of this study was to compare the effect of using an ENTPD for bedside placement of small bowel feeding tubes with blind placement on patients with acute severe pancreatitis and to see how well the electromagnetic navigation trajectory image (ENTI) and X-ray agreed on the location of the tube tip after placement. The study was done prospectively using randomized and single-blind methods. The 65 cases used electromagnetic navigation-assisted placement, and 58 cases were blind placement. For judging the tube tip location, we compared the success rate, median time, number of repeat placements, complications, and agreement of ENTI vs. X-ray. The blind placement group's success rate was 86.21% compared to the ENTPD's 95.38%, P = 0.075. The median time was significantly longer in the blind placement group (116.55 ± 68.62 min vs. 25.37 ±12.63 min, P=0.000); the average number of repeating placements was 3.02 ± 1.21 vs. 1.16 ± 0.31 (Blind placement vs. ENTPD, P = 0.002). It provided a high degree of agreement between ENTI and X-ray after contrast, κ=0.752 [95% confidence interval, 0.67-0.84]. No complications occurred in the two groups. ENTPD was used safely and effectively at the bedside to help patients with acute severe pancreatitis get feeding tubes. It not only improved the high successful rate of placement, decreased the time and reduced the exposure to X-ray, but it was also very convenient for bedside placement because of the portable equipment.

Using an Electromagnetic Guidance System for Placement of Small-Bowel Feeding Tubes to Reduce Feeding Start Times.

Cardiothoracic surgery patients have an increased risk for aspiration and may require enteral access for nutrition. In a cardiothoracic intensive care unit, feeding start times were delayed because of scheduling conflicts with support services. An electromagnetic device (Cortrak 2 Enteral Access System, Avanos Medical) was introduced to allow advanced practice providers (nurse practitioners and physician assistants) to independently establish postpyloric access and reduce dependence on ancillary services. A quality improvement study was performed. Pre- and postimplementation data included order time, service arrival, tube placement time, tube positioning, and feeding start times for 207 placements. Pre- and postimplementation surveys were conducted to evaluate advanced practice provider satisfaction with enteral tube placement practices. Feeding start time for initial placement decreased by 35.5% (15.6 hours to 10 hours); for subsequent placement, by 55.2% (15.5 hours to 7.0 hours). Assistance by support services decreased by 80.4% (before implementation, 100 of 100 placements [100%]; after implementation, 21 of 107 placements [19.6%]; P < .001; ϕ = 0.815). Overall, advanced practice provider satisfaction increased. Most participants said that using the electromagnetic device was faster, nutrition was delivered sooner, and implementation was a valuable practice change. Using an electromagnetic device decreased feeding start times, reduced the need for support services, and increased advanced practice provider satisfaction with small-bowel feeding tube placement practices.

Developing and Maintaining an RDN‐Led Bedside Feeding Tube Placement Program

Registered dietitian nutritionists (RDNs), like other healthcare professionals, are often searching for ways to improve their skills and advance their practice. One way RDNs have expanded their skills is by learning to place small bowel feeding tubes (SBFTs). However, it is also important that staffing RDNs to place SBFTs makes sense for their institution and their patient population. Although it is unknown how many RDNs place SBFTs, feeding tube placements by RDNs have been in practice for almost 2 decades, and it is within the RDN scope of practice. This article is a review of the literature, including indications for SBFT, possible benefits of RDNs placing SBFTs, development and maintenance of an RDN-led SBFT program, and assessment of clinical and institutional outcomes for this procedure.

The Impact of Small Bowel Feeding Tube Placement Simulation on Perceived Self-Efficacy of Knowledge and Confidence for Dietetics Education

The Impact of Small Bowel Feeding Tube Placement Simulation on Perceived Self-Efficacy of Knowledge and Confidence for Dietetics Education

Dietitians' Evaluation of Clearing Luminal Occlusions of Gunk (DECLOG): A Pilot Feasibility Study.

Tube clogging is the most frequent mechanical complication associated with enteral nutrition. The objective of this study was to assess the efficacy of a protocol incorporating prophylactic use of a declogging system with enhanced patient education and monitoring to proactively reduce the incidence of tube occlusions in the home care setting. A convenient sample of patients discharged from hospital to home enteral nutrition (HEN) was screened for eligibility and randomized to control group (standard care) or study group (standard care with prophylactic protocol and monitoring). Study patients received 4 enzyme declogging kits before discharge and were instructed to administer them every 7 days for 4 weeks. Seventeen of 49 (35%) patients reported tube occlusions. The incidence of tube occlusion in the control group was not statistically different than in the study group (29% vs 39%, P=0.44). There was no difference between the 2 groups for negative tube outcomes, such as tube occlusion (P=0.44), emergency department visit (P=0.24), tube replacement (P=0.99), or hospital readmission (P=0.33). Continuous feeding method (P=0.037), small-bowel feeding tubes (P=0.016), and tube diameter <14 French (P=0.069) were associated with tube occlusions. A prophylactic protocol using an enzyme declogging system did not lessen the likelihood of tube occlusions when compared with standard care. Multiple factors are associated with tube occlusion. More research investigating the use of a declogging system to prevent clogging incidence in patients receiving HEN is warranted.

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.

Clinical Simulation Learning for Small-Bowel Feeding Tube Insertion.

Clinical simulation training provides a realistic environment for students and healthcare professionals to strengthen and broaden skills and abilities. This type of learning experience creates a controlled environment in which learners may attain new skills or further develop skills that positively impact patient outcomes. Although few studies exist regarding the use of clinical simulation training and nutrition support practitioners, preliminary data following a small-bowel feeding tube (SBFT) insertion workshop for intensive care unit registered nurses and registered dietitian nutritionists showed potential use in this realm. The purpose of this paper is to provide a basic overview of clinical simulation learning, review literature related to clinical simulation in healthcare, and discuss the recent implementation of a SBFT insertion workshop incorporating clinical simulation learning.

Gastric Versus Small Bowel Feeding in Critically Ill Adults.

Critically ill patients often require enteral feedings as a primary supply of nutrition. Whether enteral nutrition (EN) should be delivered as a gastric versus small bowel feeding in the critically ill patient population remains a contentious topic. The Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Parenteral and Enteral Nutrition (ESPEN), and the Canadian Clinical Practice Guidelines (CCPG) are not in consensus on this topic. No research to date demonstrates a significant difference between the two feeding routes in terms of patient mortality, ventilator days, or length of stay in the intensive care unit (ICU); however, studies provide some evidence that there may be other benefits to using a small bowel feeding route in critically ill patients. The purpose of this paper is to examine both sides of this debate and review advantages and disadvantages of both small bowel and gastric routes of EN. Practical issues and challenges to small bowel feeding tube placement are also addressed. Finally, recommendations are provided to help guide the clinician when selecting a feeding route, and suggestions are made for future research.

Bedside placement of small-bowel feeding tube in Intensive Care Unit for enteral nutrition.

Enteral nutrition is the preferred mode of nutrition in critically ill patients whenever feasible as it has a number of advantages over parenteral feeding. Both gastric and small-bowel feeding can effectively deliver calories. In patients with gastroparesis, small-bowel feeding can help avoid parenteral feeding. We carried out a retrospective observational study to assess the ability to insert the Tiger 2 tube into the small bowel at the bedside in 25 patients who failed to tolerate gastric feeds. The time taken, rate of successful insertion, and ability to feed these patients using a standardized feeding protocol were noted. Success rate of insertion was 78% and feeding could be established. This method reduced the delays and risks associated with transportation and dependence on other specialties.

Placement of a Magnetic Small Bowel Feeding Tube at the Bedside.

Current methods of achieving postpyloric enteral access for feeding are fraught with difficulties, which can markedly delay enteral feeding and cause complications. Bedside tube placement has a low success rate, often requires several radiographs to confirm position, and delays feeding by many hours. Although postpyloric enteral tubes can reliably be placed in interventional radiology (IR), this involves greater resource utilization, delays, cost, and inconvenience. We assessed the utility of bedside enteral tube placement using a magnetic feeding tube (Syncro-BlueTube; Syncro Medical Innovations, Macon, GA, USA) as a means to facilitate initial tube placement. We recorded the time to insertion, location of tube, success rate, and need for radiographs in a series of patients given magnetic feeding tubes (n = 46) inserted by our hospitalist service over an 8-month interval. Of the 46 attempted magnetic tube placements, 76% were successfully placed in the postpyloric position, 13% were in the stomach, and 11% could not be placed. In 83% of the magnetic tubes, only 1 radiograph was needed for confirmation. The median time to placement was 12 minutes (range, 4-120 minutes). The use of a magnetic feeding tube can increase the success rate of bedside postpyloric placement, decrease the time to successful placement, and decrease the need for supplemental radiographs and IR.

Elimination of Radiographic Confirmation for Small-Bowel Feeding Tubes in Critical Care

A variety of techniques are used for placement of small-bowel feeding tubes. Standard practice at the study institution is for postpyloric placement using an electromagnetically guided placement device (EMPD). EMPD placement is performed by bedside nurses trained in the placement technique and may reduce radiograph exposures and time to initiation of enteral nutrition. To evaluate how changes in SBFT placement verification procedures in critical care patients-from use of EMPD with radiographic confirmation, to placement verification by using EMPD without radiographic confirmation-influenced successful placement, misinterpretations of locations, and radiographic verification of tube locations. The research was conducted at an 800-bed quaternary care referral hospital located in the Midwest. Nine-hundred four feeding tubes were placed in 632 critical care patients by using bedside EMPD instead of radiographic confirmation as the standard of care. Prospectively collected EMPD audit form data were retrospectively analyzed. Small-bowel (duodenum or jejunum) placement was achieved by bedside nurses in 97.2% of all EMPD placements, with 2.8% placed in the stomach because gastric placement was ordered or small-bowel placement could not be achieved. Radiographic confirmation was required in only 7.7% of placements. No adverse events or pulmonary placements occurred. Use of EMPD technology allowed clinicians to safely and effectively place feeding tubes at the bedside and eliminate radiographs in most cases. EMPD placement was not limited to specialized nurses or teams. This procedure should be easily reproducible in other critical care environments.

Creating a Culture of Clinical Excellence in Critical Care Nutrition

To develop, validate, and implement a system to reward top performers in critical care nutrition practice and to illuminate characteristics of top-performing intensive care units (ICUs). An international, prospective, observational, cohort study conducted in May 2008. 179 ICUs from 18 countries. 2956 consecutively enrolled mechanically ventilated adult patients who stayed in the ICU for at least 72 hours. To qualify for the "Best of the Best" (BOB) award, sites had to have implemented a nutrition protocol and contributed complete data on a minimum of 20 patients. Data on nutrition practices were collected from ICU admission to ICU discharge for a maximum of 12 days. Eligible sites were ranked based on their performance on the following 5 criteria: adequacy of provision of energy, use of enteral nutrition (EN), early initiation of EN, use of promotility drugs and small bowel feeding tubes, and adequate glycemic control. Of the 179 participating ICUs, 81 qualified for the BOB award. Overall, the average nutrition adequacy across sites was 56.2% (site range, 20.3%-90.1%). The top 10 performers were identified and publicly recognized. Regression analysis suggested that the presence of a dietitian in the ICU was associated with a high BOB award ranking, whereas being located in the United States or China, relative to other participating countries, was associated with worst performance. There is variable performance with respect to critical care nutrition practices across the world.

Providing optimal nutritional support on the intensive care unit: key challenges and practical solutions

Many patients in the intensive care unit are malnourished or unable to eat. Feeding them correctly has the potential to reduce morbidity and even mortality but is a very complex procedure. The inflammatory response induced by surgery, trauma or sepsis will alter metabolism, change the ability to utilise nutrients and can lead to rapid loss of lean mass. Both overfeeding and underfeeding macronutrients can be harmful but generally it would seem optimal to give less during metabolic stress and immobility and increase in recovery. Physical intolerance of feeding such as diarrhoea or delayed gastric emptying is common in the intensive care unit. Diarrhoea can be treated with fibre or peptide feeds and anti-diarrhoeal drugs; however, the use of probiotics is controversial. Gastric dysfunction problems can often be overcome with prokinetic drugs or small bowel feeding tubes. New feeds with nutrients such as n-3 fatty acids that have the potential to attenuate excessive inflammatory responses show great promise in favourably improving metabolism and substrate utilisation. The importance of changing nutrient provision according to metabolic and physical tolerance cannot be understated and although expert groups have produced many guidelines on nutritional support of the critically ill, correct interpretation and implementation can be difficult without a dedicated nutrition health care professional such as a dietitian or a multidisciplinary nutritional support team.

Dietitians and Small Bowel Feeding Tube Placement

Some advanced practice nutrition support dietitians have added small bowel feeding tube placement to their scope of responsibility. This is due, in part, to the challenges of gaining early enteral access in patients with functioning GI tracts. Emerging literature supports the practice of skilled practitioners placing feeding tubes at bedside. A variety of methods can be used to place tubes at the bedside. The nutrition support dietitian must understand licensure and liability considerations to perform this invasive procedure. This article will review literature reports of dietitians placing feeding tubes and provide information on the methods used, training and competencies required, and legal issues involved.

Disinhibition Due to Disruption of the Orbitofrontal Circuit Treated Successfully With Carbamazepine: A Case Series

Disinhibition Due to Disruption of the Orbitofrontal Circuit Treated Successfully With Carbamazepine: A Case Series

Blind bedside insertion of small bowel feeding tubes

The use of Naso-Jejunal (NJ) feeding is limited by difficulty in feeding tube placement. Patients have traditionally required transfer to Endoscopy or Radiology for insertion of small bowel feeding tubes, with clear resource implications. We hypothesised that the adoption of a simple bedside procedure would be effective and reduce cost. Clinical nutrition and nurse specialist personnel were trained in the 10/10/10 method of blind bedside NJ insertion. The aims of this prospective study were to evaluate safety, efficaciousness and resource implications of bedside NJ tube insertion. A total of 22 patients had 37 NJ tubes inserted in the study period (12 months). The majority were inserted by either a nurse specialist or clinical nutritionist. Out of the 37 insertions, 32 (86%) were in the correct position. Compared to Endoscopy insertion, this technique saved an estimated €8,353.60 for the duration of the study. This study demonstrates that the bedside insertion of NJ tubes by clinical nutritionists and nurse specialists is safe, efficacious and highly cost effective.

Small bowel endoscopic enteral access

Small bowel endoscopic enteral access is perceived as difficult. However, small bowel access is necessary for patients who are unable to tolerate gastric feedings. This review discusses the successes and challenges involved with endoscopic small bowel tube placement in various populations using a variety of placement techniques. In general, direct percutaneous endoscopic jejunostomy (DPEJ) is becoming a more common procedure performed to obtain small bowel enteral access. BMI may be a useful predictor of DPEJ tube placement success and complication rates. A retrospective review determined that DPEJ tube placement significantly decreased the incidence of aspiration pneumonia in patients with previous recurrent aspiration pneumonia episodes. DPEJ is an effective method of providing enteral nutrition for patients when percutaneous endoscopic gastrostomy is not indicated because of anatomical or gastric function abnormalities. However, there are known complications of DPEJ, including small bowel volvulus. Nasojejunal tubes also can provide enteral access to the small intestine. Endoscopic insertion of nasojejunal tubes promotes decreased length of hospital stay and early initiation of enteral feedings as compared with bedside self-migrating jejunal tubes in patients with severe acute pancreatitis. Endoscopically placed small bowel feeding tubes can safely deliver enteral nutrition to patients when gastric feedings are not indicated. Continued evaluation of endoscopic jejunal tube placement methods and associated clinical outcomes in assorted populations is necessary to determine the safest and most effective technique.

Bedside Electromagnetic‐Guided Feeding Tube Placement: An Improvement Over Traditional Placement Technique?

Registered dietitian/registered nurse (RD/RN) teams were created to place small bowel feeding tubes (SBFT) at the bedside in intensive care unit (ICU) patients using an electromagnetic tube placement device (ETPD). The primary objective of this study was to evaluate the safety of placing feeding tubes at the ICU bedside using an ETPD. Secondary outcomes included success rate, cost, and timeliness of feeding initiation. Data were collected prospectively on 20 SBFT blind placements in ICU patients (control group). After implementing a protocol for RD/RN teams to place SBFTs with an ETPD, 81 SBFTs were placed (study group). Complications, success rate, number of x-rays after tube placement, x-ray cost, and time from physician order to initiation of feedings were compared between the groups. No adverse events occurred in either group. Successful SBFT placement was 63% (12/19) in the control group and 78% (63/81) in the study group (not significant, NS). The median time between physician order for tube placement and feeding initiation decreased from 22.3 hours (control group) to 7.8 hours (study group, p = .003). The median number of x-rays to confirm correct placement was 1 in the study group compared with 2 in the control group (p = .0001), resulting in a 50% decrease in the mean cost for x-rays. No adverse events occurred with the implementation of bedside feeding tube placement using an ETPD. In addition, SBFT placement with an ETPD by designated ICU RD/RN teams resulted in lower x-ray costs and more timely initiation of enteral feedings compared with blind placement.

Indicators of Tubesite During Feedings

Nurses are forced to make decisions about feeding tube position at regular intervals during the delivery of tube feedings; failure to detect an improperly positioned feeding tube can have serious consequences. This study was designed to determine the extent to which specific indicators could singularly and collectively differentiate between gastric and small-bowel placement in patients with nasally or orally inserted small-bore feeding tubes. Indicators were the length of tubing extending from the tube's insertion site as well characteristics of aspirates withdrawn from the feeding tube (volume, appearance, and pH). A total of 201 critically ill tube-fed patients participated in the study for a period of 2-3 days. Among the inclusion criteria were an order for the blind insertion of a small-bore feeding tube, orders to start continuous feedings, and radiographic confirmation of tube location. Five times daily, the following variables were measured: (a) length of tubing extending from the insertion site, (b) volume of aspirate from the feeding tube, (c) appearance of the aspirate, and (d) pH of the aspirate. At the time of entry into the study, 85 patients had gastric feeding tubes and 116 patients had small-bowel feeding tubes. A total of 2,754 concurrent measurements of the variables were attempted; sufficient fluid for pH testing and color description was obtained in 74.2% of the attempts from gastric tubes and in 62.2% of the attempts from small-bowel tubes. Univariate analysis showed that all four of the variables described above were able to differentiate between gastric and small bowel tube sites. A multivariate, forced entry, logistic regression model was able to correctly classify tube site in 81% of the predictions. A variety of easy-to-use bedside methods can be used with a moderate degree of confidence to distinguish between gastric and small-bowel tube placement during continuous feedings.

Bedside placement of small bowel feeding tubes in hospitalized patients:: A new role for the dietitian

Objective The benefits of enteral nutrition when compared with parenteral nutrition are well established. However, provision of enteral nutrition may not occur for several reasons, including lack of optimal feeding access. Gastric feeding is easier to initiate, but many hospitalized patients are intolerant to gastric feeding, although they can tolerate small bowel feeding. Many institutions rely on costly methods for placing small bowel feeding tubes. Our goal was to evaluate the effectiveness of a hospital-developed protocol for bedside-blind placement of postpyloric feeding tubes. Methods The Surgical Nutrition Service established a protocol for bedside placement of small bowel feeding tubes. The protocol uses a 10- or 12-French, 110-cm stylet containing the feeding tube; 10 mg of intravenous metoclopramide; gradual tube advancement followed by air injection and auscultation; and an abdominal radiograph for tube position confirmation. In a prospective manner, consults received by the surgical nutrition dietitian for feeding tube placements were followed consecutively for a 10-mo period. The registered dietitian recorded the number of radiograph examinations, the final tube position, and the time it took to achieve tube placement. Results Because all consults were included, feeding tube placements occurred in surgical and medical patients in the intensive care unit and on the ward. Of the 135 tube placements performed, 129 (95%) were successfully placed postpylorically, with 84% (114 of 135) placed at or beyond D3. Average time for tube placement was 28 min (10 to 90 min). One radiograph was required for 92% of the placements; eight of 135 (6%) required two radiographs. No acute complications were associated with the tube placements. Conclusions Hospitalized patients can receive timely enteral feeding with a cost-effective feeding tube placement protocol. The protocol is easy to implement and can be taught to appropriate medical team members through proper training and certification.