Small Bowel Feeding Research Articles

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.

Practicalities of nutrition support in the intensive care unit

Nutrition support improves clinical outcomes in the critically ill and our understanding of its effects has advanced significantly over the last few years. Three recently published evidence-based guidelines have made generally consistent and thorough recommendations to assist clinicians in providing nutrition support. This review will focus on various aspects of these recommendations, concentrating on the practicalities of nutrition support in the intensive care unit, such as its optimal mode and composition. Enteral nutrition is preferred to parenteral nutrition unless there is a major gut condition which will delay commencement of enteral nutrition. Nasogastric feeding should begin within 24 h, but if intolerance develops, small bowel feeding or pro-motility drugs (erythromycin or metoclopramide) should be attempted before resorting to supplementary parenteral nutrition. Enteral nutrition should not routinely be supplemented with arginine or glutamine, but it should contain a package of eicosapentaenoic acid, gamma-linolenic acid and antioxidants if the patient has acute lung injury or sepsis. Parenteral nutrition should be glutamine supplemented and the prescription should be limited in energy to avoid hyperglycemia. Whether using enteral nutrition or parenteral nutrition, most patients should receive intravenous selenium, and may also need zinc and copper supplementation. Intensive care unit patients should have nutrition support based on recent evidence-based guidelines with a preference for nasogastric feeding. If intolerance occurs, pro-motility drugs and small bowel feeding should be attempted. Clinicians should also consider carefully the composition of the nutrition support regimen with regard to lipid content (especially eicosapentaenoic acid and gamma-linolenic acid), antioxidants, glutamine and other micronutrients.

XV. Steroids

XV. Steroids

Therapeutic effects of artificial nutrition in intensive care patients: New insights

Summary Nutritional support has become a routine part of the care of critically ill patients and it is now widely accepted for the treatment and prevention of malnutrition and related complications. Most positive effects of artificial nutrition on the outcome of the critically ill patient result from controlling complex physiologic changes that lead to catabolism and loss of body cell mass. The knowledge of metabolic requirements is essential to define an appropriate artificial nutritional regimen, according to guideline recommendations. There is a general agreement that enteral nutrition (EN) is better than parenteral since it is safer, preserves gut function and is more cost effective. Most comparative studies of EN and PN, however, show that outcomes are comparable with either route. Evidence supports early initiation of nutrition support and debate is ongoing over whether gastric feedings or small-bowel feedings are best. Immunonutrition refers to the potential to modulate the activity of the immune system by interventions with specific nutrients (arginine, glutamine, n-3 fatty acids, antioxidants agents) and thereby to attempt to further improve the clinical outcome of selected critically ill patients. The emerging discipline of nutrigenomics (speculative branch of genes-nutrition interaction) has tremendous potential to change the future of our knowledge and intervention strategies on artificial nutrition.

Gastric vs Small-Bowel Feeding in Critically Ill Children Receiving Mechanical Ventilation: A Randomized Controlled Trial

Gastric vs Small-Bowel Feeding in Critically Ill Children Receiving Mechanical Ventilation: A Randomized Controlled Trial

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.

Effect of Feeding‐Tube Properties on Residual Volume Measurements in Tube‐Fed Patients

The effect of feeding tube size and port configuration on the ability to measure gastric residual volume (GRV) is poorly understood. In addition, there is confusion about the need to measure GRVs during feedings into the small bowel. This study sought to (1) compare the volume of gastric contents obtained from small-diameter feeding tubes and large-diameter sump tubes concurrently positioned in the stomach and (2) describe the distribution of GRVs during small-bowel feedings. For the first objective, GRV measurements were made from 10-Fr tubes (n = 645) and 14-Fr or 18-Fr sump tubes (n = 645) concurrently present in 62 critically ill patients. Sixty-milliliter syringes were used to measure GRVs from the 10-Fr tubes; the fluid was returned to the stomach and measurements were repeated from the large-diameter sump tubes. To address the second research objective, 890 GRV measurements were made from 14-Fr or 18-Fr gastric sump tubes (not connected to suction) in 75 critically ill patients who were receiving small-bowel feedings. When GRVs were >50 mL, a linear regression equation indicated that volumes obtained from the large-diameter sump tubes were about 1.5 times greater than those obtained from the small-diameter tubes concurrently present in the stomach, p < .001. Gastric volumes > or =100 mL were found in 11.6% of the 890 measurements made in patients receiving small-bowel feedings; volumes > or =150 mL were found in 5.4% of the measurements. The findings suggest that GRVs obtained from large-diameter sump tubes are about 1.5 times greater than those obtained from 10-Fr tubes. Large GRVs occur in at least 5% of patients receiving postpyloric feedings.

Validation of the Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients: Results of a prospective observational study*

Recently, evidence-based clinical practice guidelines for the provision of nutrition support in the critical care setting have been developed. To validate these guidelines, we hypothesized that intensive care units whose practice, on average, was more consistent with the guidelines would have greater success in providing enteral nutrition. Prospective observational study. Fifty-nine intensive care units across Canada. Consecutive cohort of mechanically ventilated patients. In May 2003, participating intensive care units recorded nutrition support practices on a consecutive cohort of mechanically ventilated patients who stayed for a minimum of 72 hrs. Sites enrolled an average of 10.8 (range, 4-18) patients for a total of 638. Patients were observed for an average of 10.7 days. We examined the association between five recommendations from the clinical practice guidelines most directly related to the provision of nutrition support (use of parenteral nutrition, feeding protocol, early enteral nutrition, small bowel feedings, and motility agents) and adequacy of enteral nutrition. We defined adequacy of enteral nutrition as the percent of prescribed calories that patients actually received. Across sites, the average adequacy of enteral nutrition over the observed stay in intensive care unit ranged from 1.8% to 76.6% (average 43.0%). Intensive care units with a greater than median utilization of parenteral nutrition (>17.5% patient days) had a much lower adequacy of enteral nutrition (32.9 vs. 52.7%, p < .0001). Intensive care units that used a feeding protocol tended to have a higher adequacy of enteral nutrition than those that did not (44.9 vs. 38.5%, p = .03). Intensive care units that initiated enteral nutrition on >50% of their patients within the first 48 hrs had a higher adequacy of enteral nutrition than those that did not (48.1 vs. 34.4%, p < .0001). Intensive care units that had a >50% utilization of motility agents and/or any small bowel feedings in patients with high gastric residuals tended to have a higher adequacy of enteral nutrition than those intensive care units that did not (45.6 vs. 39.2%, p = .04, and 48.4 vs. 41.8%, p = .16, respectively). Intensive care units that were more consistent with the Canadian clinical practice guidelines were more likely to successfully feed patients via enteral nutrition. Adoption of the Canadian clinical practice guidelines should lead to improved nutrition support practice in intensive care units. This may translate into better outcomes for critically ill patients receiving nutrition support.

Gastric vs Small-Bowel Feeding in Critically Ill Children Receiving Mechanical Ventilation: A Randomized Controlled Trial

To determine the effect of feeding tube position (gastric vs small bowel) on adequacy of nutrient delivery and feeding complications, including microaspiration, in critically ill children. Randomized controlled trial. Pediatric ICU in a university teaching hospital. Seventy-four critically ill patients < 18 years of age receiving mechanical ventilation were randomized to receive gastric or small-bowel feeding. All feeding tubes were inserted at the bedside. Color, pH, and bilirubin concentration of the feeding tube aspirates were used to guide placement. Final tube position was confirmed radiographically. Continuous feedings were advanced to achieve a caloric goal based on age and body weight. Tracheal secretions were collected daily and tested for gastric pepsin by immunoassay. Thirty-two patients were randomized to the gastric group, and 42 patients were randomized to the small-bowel group. Twelve patients exited the study because a small-bowel tube could not be placed at the bedside, leaving 30 patients in the small-bowel group. Gastric and small-bowel groups were similar at baseline in age, sex, percentage of ideal body weight, serum prealbumin concentration, and pediatric risk of mortality score. The percentage of daily caloric goal achieved was less in the gastric group compared to the small-bowel group (30 +/- 23% vs 47 +/- 22%, p < 0.01). No difference was found in the proportion of tracheal aspirates positive for pepsin between the gastric and small-bowel groups (50 of 146 aspirates vs 50 of 172 aspirates, respectively; p = 0.3). No differences were found in the frequency of feeding tube displacement, abdominal distension, vomiting, or diarrhea between groups. Small-bowel feeds allow a greater amount of nutrition to be successfully delivered to critically ill children. Small-bowel feeds do not prevent aspiration of gastric contents.

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.

Enteral Feeding and Bowel Necrosis: An Uncommon but Perplexing Problem

This issue of Nutrition in Clinical Practice contains 3 articles focusing on an important problem. I have seen several episodes of small bowel necrosis in patients who seemed indistinguishable from dozens of other patients who tolerated feedings without major problems. This devastating complication of small bowel (and occasionally proximal colonic) necrosis is one that is of concern to all clinicians administering enteral feeding to critically ill or injured patients. Unfortunately (or fortunately), so few cases occur, in such a sporadic manner, that it has been impossible to definitively identify the factor or factors that increase the patient’s risk. Early in my career, I advanced tube feedings aggressively, even in a few hemodynamically unstable patients. I’d become confident after successful use of intragastric feeding in burn patients who required vasopressors for blood pressure and tolerated feedings with low residuals and little gastrointestinal tract intolerance. One advantage of intragastric feedings is that high gastric residuals result if the small intestine doesn’t tolerate feeding. This protective mechanism is bypassed with administration directly into the small bowel. Reflux of tube feedings from the intestine into the stomach is an important sign of gastrointestinal intolerance that warrants discontinuation of tube feedings. However, in some of the reported cases, such warning signs have not been evident. The most common “party line” I’ve heard and I’ve expressed is to avoid direct small bowel feedings in hemodynamically unstable patients, especially those requiring vasopressors. Clearly, as the authors of these articles point out, not all data substantiate a poor physiologic response when the gut is fed in low-flow states. In fact, some studies show that enteral feeding may actually help. The difficulty is interpreting results from the different models of endotoxin, complete mesenteric occlusion, or other artificially induced low-flow states. The fact that some nutrients are deleterious in some circumstances but beneficial in others, or that some pressor agents improve splanchnic blood flow or increase mucosal blood flow, is difficult to apply to an individual patient. One clinical study showed that enteral feeding actually improved flow in select patients with hemodynamic instability. Even more confusing is the recognition that episodes of necrosis can occur after patients have been fed successfully for 5 to 10 days. My few personal episodes occurred within 24 hours of instituting enteral feeding; the patients became tachycardic and hypotensive and spiked a high fever. I know of 1 patient who had been successfully fed (I’m told) for a number of days but suddenly deteriorated. In the operating room, the necrotic small intestine was filled with a pasty residual from tube feedings. The fluid had been absorbed from the feedings and formed a cast of the intestine. The 3 articles presented in this issue review the existing knowledge regarding this uncommon (0.3% to 0.7%) but devastating problem. Unfortunately, no one has the answer, and until we understand this process, I still believe the wisest approach is to delay direct small bowel feedings until there is evidence of adequate splanchnic perfusion and patients are fully resuscitated. Some hemodynamically unstable patients will tolerate feeding, a good example being the burn patients. Unfortunately, it is difficult to predict who will have significant intolerance to small bowel feeding, and by the time it becomes evident, it is too late. Dr. Zaloga’s comment regarding the paucity of this complication in medical patients is very important. It may be that manipulation of the gastrointestinal tract during laparotomy, the transmural placement of the small bowel tube, the presence of intra-abdominal pathology, or some other issues are important etiologic factors. These issues currently are not being tested in animal models. Many randomized prospective studies have demonstrated that there is a significant benefit when nutrients are delivered into the gut of critically ill patients that is not gained when patients are fed IV Correspondence: H4/736 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792.

Inserting guidewires

Inserting guidewires

Nutrition Support for the Mechanically Ventilated Patient

Nutrition support is a hotly debated topic in most intensive care units. Is enteral nutrition or TPN best? Is gastric or small-bowel feeding safer? Are specialized formulas needed? These are only some of the issues, and the fact remains that there is a paucity of clear, solid data. Folklore has become the standard of practice in many areas of medicine; it is richly found in nutrition support. We must be careful not to get caught up in the trappings of our beliefs about nutrition support. Instead, we must continue to evaluate our own practices and fine-tune our skills of clinical assessment and common sense.

Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding.

Strategies that maximize the delivery of enteral nutrition while minimizing the associated risks have the potential to improve the outcomes of critically ill patients. By delivering enteral feeds in the small bowel, beyond the pylorus, the frequency of regurgitation and the risk of aspiration is thought to be decreased while at the same time, nutrient delivery is maximized. The purpose of this paper is to systematically review those studies that compare gastric with small bowel feeding. We searched computerized bibliographic databases, personal files, and relevant reference lists to identify eligible studies. Only randomized, clinical trials of critically ill patients that compared small bowel and gastric feedings were included in this review. In an independent fashion, relevant data on the methodology and outcomes of primary studies were abstracted in duplicate. There were 10 studies that met the inclusion criteria for this review. In 1 study, small bowel feeding was associated with a reduction in gastroesophageal regurgitation and a trend toward reduced pulmonary aspiration. Several studies document that small bowel feeding was associated with an increase in protein and calories delivered and a shorter time to target dose of nutrition. Compared with gastric feeding, when the results of 7 randomized trials were aggregated statistically, small bowel feeding was associated with a reduction in pneumonia (relative risk, 0.76; 95% confidence intervals, 0.59, 0.99). There was no difference in mortality rates between the 2 groups. Small bowel feeding may be associated with a reduction in gastroesophageal regurgitation, an increase in nutrient delivery, a shorter time to achieve desired target nutrition, and a lower rate of ventilator-associated pneumonia.

Prevention of ventilator-associated pneumonia: Current practice in Canadian intensive care units

Objective: To evaluate the current use of strategies to prevent ventilator-associated pneumonia (VAP) and to identify interventions to target for quality-improvement initiatives. Design: Cross-sectional national survey. Setting: Canadian intensive care units (ICUs) with at least 8 beds. Patients: Seven hundred and two patients in 66 ICUs in 10 provinces in Canada. Interventions: None. Measurements and Results: The Canadian Critical Care Trials Group recently developed VAP prevention guidelines. Before these guidelines were disseminated, we documented the extent to which these recommendations were followed in practice by using 3 methods: survey of ICU directors, prospective observation of patients on one day, and retrospective review of patient charts for a 12-day period. According to ICU directors, ventilator circuits were changed only for new patients or if the circuit was soiled in 7 of 66 ICUs (10%), heat and moisture exchangers were used routinely in 53 of 66 ICUs (80%), and closed-suction catheter systems were used in 58 of 66 ICUs (88%). Neither subglottic secretion drainage tubes nor prophylactic antibiotics for VAP were used at all. Of the entire cohort of 702 patients, the average degree of elevation of the head of the bed was 29.9° (range, 0°−90°) and 22 of 702 (3.1%) were observed to be on a kinetic bed. Of the 459 patients receiving any form of mechanical ventilation, 56 (12.2%) were receiving noninvasive or mask ventilation, 262 (57.1%) were orally intubated, 9 (1.9%) were nasally intubated, and 132 (28.8%) had received a tracheostomy. Of the 423 patients who received nutrition support, 373 (88.2%) received enteral nutrition. Small bowel feeding tubes were used during 16.4% of study days on enteral feeds and sucralfate was prescribed for 1.7% of study days. Conclusions: Significant opportunities exist to improve VAP prevention practices in Canada. These strategies include decreasing the frequency of ventilator circuit changes, and increasing the use of non-invasive ventilation, subglottic secretion drainage endotracheal tubes, kinetic bed therapy, small bowel feedings, and elevation of the head of the bed. Copyright 2002, Elsevier Science (USA). All rights reserved.

Gastric versus small-bowel tube feeding in the intensive care unit: A prospective comparison of efficacy*

To compare the outcomes of intensive care unit patients fed through a nasogastric vs. a nasal-small-bowel tube including the time from tube placement to feeding, time to reach goal rate, and adverse events. Sixty patients were prospectively randomized to receive gastric or small-bowel tube feedings. Nursing staff attempted to place a feeding tube in the desired position, and placement was confirmed radiographically after each bedside attempt. After two unsuccessful attempts, the feeding tube was placed under fluoroscopy. Feedings were started at 30 mL/hr and advanced to the patient's specific goal rate. Twenty-bed medical intensive care unit. Sixty medical patients admitted/transferred to the intensive care unit. Tube feeds were held for 2 hrs if any residual was >200 mL. Times were recorded at the initial tube insertion, onset of feeding, achievement of goal rate, and termination of feeding. Adverse outcomes included witnessed aspiration, vomiting, and clinical/radiographic evidence of aspiration. Patients were followed up for the duration of feeding, until leaving the intensive care unit, or for a maximum of 14 days. Patients fed in the stomach received nutrition sooner from initial placement attempt (11.2 hrs vs. 27.0 hrs) and with fewer attempts (one vs. two) than those fed in the small bowel. Patients achieve goal rate sooner (28.8 hrs vs. 43.0 hrs) with gastric feeding compared with small-bowel feeding. There was no difference in aspiration events. Gastric feeding demonstrates no increase in aspiration or other adverse outcomes compared with small-bowel feeding in the intensive care unit. Gastric feeding can be started and advanced to goal sooner with fewer placement attempts than small-bowel feeding.

Gastrointestinal promotility drugs in the critical care setting: a systematic review of the evidence.

Gastrointestinal promotility agents may improve tolerance to enteral nutrition, reduce gastroesophageal reflux and pulmonary aspiration, and therefore have the potential to improve outcomes of critically ill patients. To systematically review and critically appraise studies of promotility agents in the critical care setting. Computerized bibliographic search of published research (1980-2001), citation review of relevant articles, and contact with primary investigators. Randomized trials of critically ill adult patients that evaluated the effect of promotility agents on measures of gastrointestinal motility were included. Relevant methods and outcome data were abstracted in duplicate by independent investigators. We reviewed 60 citations; 18 articles met the inclusion criteria (six studies of feeding tube placement, 11 studies evaluating gastrointestinal function, and one study of clinical outcomes). The heterogeneity of study methods and outcomes measured precluded a quantitative synthesis of the data. Although there are conflicting studies, the larger and more methodologically robust studies suggest that metoclopramide has no effect on feeding tube placement. Erythromycin has been shown to increase success rates with small-bowel tube placement in two studies. Eight of ten studies evaluating the effect of cisapride, metoclopramide, or erythromycin on measures of gastrointestinal transit demonstrated positive effects; the two studies that did not were relatively small (n = 27 and 10) and likely had inadequate power to detect a difference in treatment effect. No study demonstrated a positive effect on clinical outcomes. As a class of drugs, promotility agents appear to have a beneficial effect on gastrointestinal motility in critically ill patients. A one-time dose of erythromycin may facilitate small-bowel feeding tube insertion. Administration of metoclopramide appears to increase physiologic indexes of gastrointestinal transit and feeding tolerance. Concerns about safety and lack of effect on clinically important outcomes preclude strong treatment recommendations.

Bedside Small Bowel Feeding Tube Placement in Critically III Patients Utilizing a Dietitian/Nurse Team Approach

Background: To determine if a previously described protocol for small bowel feeding tube (SBFT) placement would be feasible for use in surgical/trauma/burn intensive care population; if limiting the number of a professionals placing the tubes would achieve a sufficient success rate for cost effectiveness; and to determine the effectiveness of a certified nutrition support dietitian (CNSD)/clinical nurse specialist (CNS) team approach to tube placement. Method: Prospective trial of bedside small bowel feeding tube placement by a CNS/CNSD team. The setting was an university‐affiliated surgical/trauma/burn intensive care unit. A total of 74 patients were included in the study. Results: We successfully placed 64 of 74 (86.4%) SBFTs in our intensive care unit. The CNS successfully placed 32 of 38 tubes and the CNSD placed 32 of 36 tubes. Of the successfully placed tubes 41 (64%) were at or beyond the ligament of Treitz. Of the other 23 (36%), 6 were in the second portion of the duodenum, 12 were in the third portion of the duodenum and 5 were in the fourth portion of the duodenum. Of physicians and nurses surveyed, 100% were more satisfied with bedside SBFT placement vs fluoroscopy SBFT placement. Conclusions: Successful bedside placement of SBFT in a surgical/trauma/burn intensive care setting by a CNSD/CNS team approach is a feasible cost effective alternative to fluoroscopy SBFT placement.

Blind bedside placement of enteric feeding tubes

Early enteral nutrition, especially with immune-modulating formulas, has been shown to improve outcomes in critically ill patients. Early nutrient delivery supports organ function and recovery from illness and modulates inflammation and organ injury. Misconceptions regarding gastrointestinal function and alterations in gastrointestinal function during illness impede early enteral feeding. Bowel sounds, elevated gastric residuals, failure to pass flatus, and diarrhea are not contraindications to enteral nutritional support. Most critically ill patients can be fed into the stomach with minimal risk for aspiration. Promotility agents aid in gastric feeding. When gastric feeding is not possible, most patients will tolerate small intestinal feeding. Because spontaneous passage of feeding tubes into the small bowel in critically ill patients is rare, most feeding tubes can be positioned into the small bowel with blind bedside placement by the clinician (ie, physician, nurse, nutritionist). When such procedures are not successful, x-ray guided or endoscopic placement of feeding tubes into the small bowel are recommended. Occasionally, small bowel feeding tubes will need to be placed surgically.

Bedside placement of postpyloric feeding tubes.

Postpyloric placement of feeding tubes into the duodenum or jejunum is often recommended to support early feeding, improve tolerance of enteral nutrition, and decrease the risk of aspiration pneumonia. Achieving small bowel feeding tube placement can be a difficult, time-consuming, and costly process that may delay the initiation of enteral nutrition. Various bedside techniques, including air insufflation, pH assisted, and spontaneous passage with or without motility agents are available to facilitate transpyloric feeding tube passage. A discussion of these methods is presented in this article, including a hospital-based quality initiative project designed to facilitate early enteral nutrition.