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1.
Nasal Feeding Tubes Are Associated with Fewer Adverse Events than Feeding via Ostomy in Hospitalized Patients Receiving Enteral Nutrition.
Bowman, CA, Hutchins, E, Burgermaster, M, Sant, V, Seres, DS
The American journal of medicine. 2022;(1):97-102.e1
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Abstract
BACKGROUND Surgical feeding ostomies (eg, gastrostomy) have become required by many nursing facilities for all patients receiving enteral nutrition, whether for short- or long-term use. These policies lack supportive evidence. Comparisons of adverse event rates between surgical and natural orifice tubes are few and lacking in the inpatient setting. Additionally, we hypothesize that adverse events related to feeding tubes are underreported. We sought to quantify adverse events to test the relative safety of surgical feeding ostomies and natural orifice (eg. nasogastric or orogastric) feeding tubes in hospitalized patients. METHODS This was a prospective observational cohort study of enterally fed inpatients using semiweekly focused physical examination, scripted survey, and chart review. RESULTS All tube-fed patients admitted to a large, urban, academic hospital received semiweekly bedside evaluation and chart review over a 9-week period (n = 226 unique patients, mean 6.25 visits each, total 1118 observations). Demographics were comparable between 148 subjects with natural orifice and 113 subjects with surgical feeding tubes. A higher incidence of adverse events was observed with surgical tubes (3.34 vs 1.25 events per 100 subject days, P < .001). Only 50% of all adverse events were documented in the medical record. More patients with surgical tubes were discharged to skilled nursing facilities (58% vs 24%). CONCLUSIONS Surgical feeding tubes are associated with significantly higher in-hospital adverse event rates when compared with natural orifice (nasal or oral) feeding tubes. Policies requiring surgical feeding ostomies should be reevaluated.
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Small-bore feeding tube versus large-bore sump tube for early enteral nutrition in mechanically ventilated patients: A nationwide inpatient database study.
Ohbe, H, Matsui, H, Fushimi, K, Yasunaga, H
Clinical nutrition (Edinburgh, Scotland). 2021;(6):4113-4119
Abstract
BACKGROUND & AIMS When physicians start nasogastric tube feeding in mechanically ventilated patients, they have two choices of feeding tube device: a large-bore sump tube or a small-bore feeding tube. Some physicians may prefer to initiate enteral nutrition via the large-bore sump tube that is already in place, and others may prefer to use the small-bore feeding tube. However, it remains unknown whether small-bore feeding tubes or large-bore sump tubes are better for early enteral nutrition. The present study aimed to compare outcomes between these two types of feeding tubes in mechanically ventilated patients. METHODS Using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018, we identified adult patients who underwent invasive mechanical ventilation for ≥2 days in intensive care units and received nasogastric tube feeding within 2 days of starting mechanical ventilation. We categorized these patients as receiving early enteral nutrition via small-bore feeding tube (8- to 12-Fr single-lumen tubes) or via large-bore sump tube. Propensity score-matched analyses were performed to compare 28-day in-hospital mortality and hospital-acquired pneumonia between the two groups. RESULTS A total of 79,656 patients were included. Of these patients, 20,178 (25%) were in the small-bore feeding tube group. One-to-one propensity score matching created 20,061 matched pairs. Compared with those in the large-bore sump tube group, patients in the small-bore feeding tube group had significantly higher 28-day in-hospital mortality (17.0% versus 15.6%; hazard ratio, 1.08; 95% confidence interval, 1.03 to 1.14) and a significantly higher prevalence of hospital-acquired pneumonia (9.3% versus 8.5%; odds ratio, 1.11; 95% confidence interval, 1.02 to 1.21). CONCLUSIONS This nationwide observational study suggests that small-bore feeding tubes may not be associated with better clinical outcomes but rather with increased mortality and hospital-acquired pneumonia. Because of the uncertainty regarding the mechanism of our findings, further studies are warranted.
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Enteral Nutrition by Nasogastric Tube in Adult Patients under Palliative Care: A Systematic Review.
Sánchez-Sánchez, E, Ruano-Álvarez, MA, Díaz-Jiménez, J, Díaz, AJ, Ordonez, FJ
Nutrients. 2021;(5)
Abstract
Nutritional management of patients under palliative care can lead to ethical issues, especially when Enteral Nutrition (EN) is prescribed by nasogastric tube (NGT). The aim of this review is to know the current status in the management of EN by NG tube in patients under palliative care, and its effect in their wellbeing and quality of life. The following databases were used: PubMed, Web of Science (WOS), Scopus, Scielo, Embase and Medline. After inclusion and exclusion criteria were applied, as well as different qualities screening, a total of three entries were used, published between 2015 and 2020. In total, 403 articles were identified initially, from which three were selected for this review. The use of NGT caused fewer diarrhea episodes and more restrictions than the group that did not use NG tubes. Furthermore, the use of tubes increased attendances to the emergency department, although there was no contrast between NGT and PEG devices. No statistical difference was found between use of tubes (NGT and PEG) or no use, with respect to the treatment of symptoms, level of comfort, and satisfaction at the end of life. Nevertheless, it improved hospital survival compared with other procedures, and differences were found in hospital stays in relation to the use of other probes or devices. Finally, there are not enough quality studies to provide evidence on improving the health status and quality of life of the use of EN through NGT in patients receiving palliative care. For this reason, decision making in this field must be carried out individually, weighing the benefits and damages that they can cause in the quality of life of the patients.
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Auscultation-assisted bedside postpyloric placement of feeding tube in critically ill patients: a prospective, observational study.
Xiao, J, Mao, Z, Hua, M, Chen, T, Liu, H, Hu, P, Tang, S, Kang, H, Zhou, F
Asia Pacific journal of clinical nutrition. 2019;(3):435-441
Abstract
BACKGROUND AND OBJECTIVES To assess the efficacy and safety of auscultation-assisted bedside postpyloric feeding tube (ABPFT) placement in early enteral nutritional support for critically ill patients. METHODS AND STUDY DESIGN A prospective observational study was conducted and 92 critically ill patients who met the inclusion criteria undergoing ABPFT placement after the intravenous injection of 10 mg of metoclopramide were included. Abdominal X-ray was performed to confirm the location of the catheter tip. End points investigated were the success rate of tube placement, rate of jejunal tube placement, duration of the procedure, length of insertion, and number of attempts. Operational-related adverse events or complications were also documented and evaluated. RESULTS The total success rate of postpyloric feeding tube implantation was 97.8% (90/92), among which, 89.1% (82/92) of the tubes were placed proximal to the jejunum. The first-attempt success rate was 91.3% (84/92) and the mean attempt per individual patient was 1.11±0.38 times. The mean operation time was 28.6±17.7 minutes, and the mean insertion length of tube was 106±9.6 cm. A total of 27 adverse events occurred in 19.6% (18/92) patients and there was no serious adverse events or complications during the study period. CONCLUSIONS Assistance by auscultation can significantly improve the success rate of nasal feeding tube placement. This simple, safe and fast approach is feasible for the application among health practitioners in the intensive care unit.
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Adequacy of different measurement methods in determining nasogastric tube insertion lengths: An observational study.
Fan, PEM, Tan, SB, Farah, GI, Cheok, PG, Chock, WT, Sutha, W, Xu, D, Chua, W, Kwan, XL, Li, CL, et al
International journal of nursing studies. 2019;:73-78
Abstract
BACKGROUND Distance from the tip of the nose to earlobe to xiphisternum is commonly used to determine the length of nasogastric tube to be inserted. However, it is not evidence-based and frequently leads to improper positioning. OBJECTIVES This study evaluated four formulae and the distance from the tip of the nose to earlobe to xiphisternum in estimating the internal length of nasogastric tube required for optimal positioning. DESIGN Observational Study. SETTINGS Tertiary hospital in Singapore involving patients from the medical and surgical intensive care units and a neurosurgical ward. PARTICIPANTS Inclusion criteria were patients who required a nasogastric tube insertion and age > = 21 years old and =<85 years old. Patients who required an orogastric tube insertion or did not require a chest x-ray post nasogastric tube insertion were excluded. METHODS Upon nasogastric tube insertion, the external length of the tube was measured and the corresponding internal length calculated. Several anatomical measurements were taken as required in the formulae below: 1. ((Distance from tip of nose to earlobe to xiphisternum-50 cm)/2) + 50 cm. 2. 29.38 + 4.53*gender+0.34*distance from nose to umbilicus with head flat on bed-0.06*weight (gender = 1 for male, and 0 for female). 3. Distance from xiphisternum to earlobe to nose + 10 cm. 4. Distance from earlobe to xiphisternum to umbilicus-distance from tip of the nose to earlobe. Post insertion chest x-rays were examined to evaluate the position of the nasogastric tube. For those with optimal positioning, the distance from tip of the nose to earlobe to xiphisternum and the four formulae were compared to determine which provided the least difference with the internal length of the nasogastric tube. RESULTS Ninety-two participants were recruited. The average age of the cohort was 62.9 years old with 54% being male. Twenty-five had nasogastric tubes in optimal position; 13 had it too short and 54 had it too long. For nasogastric tubes in optimal position, distance from xiphisternum to earlobe to nose + 10 cm provided the best estimate of the internal length. Average difference between the distance from xiphisternum to earlobe to nose + 10 cm and internal length of the nasogastric tubes in optimal position was only 1.8 cm which was by far the least difference compared to other formulae. CONCLUSION This study found distance from xiphisternum to earlobe to nose + 10 cm to provide the best estimate for the internal length of nasogastric tube required. However, even this formula could result in placement that is not optimal due to anatomical differences.
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The Use of Ultrasonography for Verifying Gastric Tube Placement in Newborns.
Dias, FSB, Alvares, BR, Jales, RM, Franco, APV, Silva, JEFD, Fabene, SMS, Caldas, JPS, Carmona, EV
Advances in neonatal care : official journal of the National Association of Neonatal Nurses. 2019;(3):219-225
Abstract
BACKGROUND The use of gastric tubes in newborns admitted to a neonatal intensive care unit is fairly high, and there is a risk of serious complications related to this procedure. PURPOSE Considering the need to find a method that does not involve the patient's exposure to radiation, this study aimed to evaluate the diagnostic accuracy of ultrasonography for verifying gastric tube placement in newborns. METHODS This was a prospective, double-blind, observational study performed in a neonatal intensive care unit, in which 159 infants had gastric intubation using ultrasound examination and radiological imaging, to verify positioning. Results were analyzed in terms of diagnostic accuracy. RESULTS The tubes were correctly positioned in 157 cases (98.7%), according to radiological images, and in 156 cases (98.1%), according to ultrasound. The sensitivity analysis was 0.98 and the positive predictive value was 0.99. It was not possible to perform a specificity analysis, as there were not enough negative cases in the sample. IMPLICATIONS FOR PRACTICE The use of ultrasonography to identify correct positioning of gastric tubes in infants and newborns shows good sensitivity. IMPLICATIONS FOR RESEARCH It was not possible to evaluate the ultrasonography specificity; further studies with greater samples are probably necessary, so that this objective can be achieved.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=29&autoPlay=true.
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Endoscopic Insertion of Nasojejunal Feeding Tube at Bedside for Critically Ill Patients: Relationship between Tube Position and Intragastric Countercurrent of Contrast Medium.
Tatsumi, H, Akatsuka, M, Kazuma, S, Katayama, Y, Goto, Y, Monma, K, Yoshida, S, Masuda, Y
Annals of nutrition & metabolism. 2019;(3):163-167
Abstract
UNLABELLED Background and Oblectives: We evaluated the success rate of endoscopically positioned nasojejunal feeding tubes and the intragastric countercurrent of contrast medium thereafter. METHOD This retrospective observational study investigated patients who were admitted to a single intensive care unit and required endoscopic placement of a post-pyloric feeding tube between January 2010 and June 2016. The feeding tube was grasped with forceps via a transoral endoscope and inserted into the duodenum or jejunum. Thereafter, we assessed the position of the tube and the intragastric countercurrent using abdominal radiography with contrast medium. RESULTS The tube tip was inserted at the jejunum and the duodenal fourth portion in 55.8 and 33.6% of patients, respectively. The tip of the inserted tube had moved into the jejunum of 71.7% of patients by the following day. The countercurrent rate was significantly lower among patients with a tube inserted into the duodenal fourth portion or more distal than among those with tubes inserted more proximally (8.4 vs. 45.4%, p = 0.0022). CONCLUSIONS The endoscopic insertion and positioning of a nasojejunal feeding tube seemed effective because the rate of tube insertion into the duodenal fourth portion or more distal was about 90%. The findings of intragastric countercurrents indicated that feeding tubes should be inserted into the duodenal fourth portion or beyond to prevent vomiting and the aspiration of enteral nutrients.
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Evaluation of a Home-Based Behavioral Treatment Model for Children With Tube Dependency.
Taylor, S, Purdy, SC, Jackson, B, Phillips, K, Virues-Ortega, J
Journal of pediatric psychology. 2019;(6):656-668
Abstract
OBJECTIVE To evaluate a home-based behavioral treatment model for children with tube dependency. METHODS Nine children (aged 4-14 years) dependent on nasogastric and gastrostomy tubes were consecutively admitted into a home-based behavioral treatment program. A psychologist specializing in applied behavior analysis led the assessment and treatment phases with the support of caregivers and a multidisciplinary team. Caregivers participated in a caregiver training program and continued the intervention once the service was discontinued. We conducted follow-up visits up to 12 months after treatment. The program was evaluated with a multiple-baseline across participants design. We computed on-treatment and intention-to-treat effects according to the Hedges-Pustejovsky-Shadish model. We monitored behavioral (food acceptance and swallowing) and nutritional outcomes (body weight, oral intake, and tube intake), treatment acceptability and satisfaction, caregiver stress, and estimated treatment cost savings. RESULTS Food acceptance, swallowing, oral intake, and tube intake demonstrated large treatment gains relative to pretreatment levels (effect size range of the intention-to-treat analysis = 0.74-2.1). All participants maintained or increased their body weight. Follow-up effect sizes indicated further improvements. By the final follow-up assessment, six out of the nine children had ceased tube feeding, and one had tube feeds reduced. Caregivers and health professionals provided strong ratings of treatment satisfaction. The cost-savings analysis suggested that a home-based treatment may be a cost-effective alternative to prolonged tube feeding as well as to other treatment approaches. CONCLUSIONS This study provides evidence supporting home-based multicomponent behavioral interventions in the treatment of pediatric feeding disorders. CLINICAL TRIAL IDENTIFIER ACTRN12614001127695, https://goo.gl/XSQ4ZH.
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Enteral Nutrition via Nasogastric Tube for Refeeding Patients With Anorexia Nervosa: A Systematic Review.
Rizzo, SM, Douglas, JW, Lawrence, JC
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2019;(3):359-370
Abstract
Weight restoration is an important first step in treating patients with anorexia nervosa (AN), because it is essential for medical stabilization and reversal of long-term complications. Tube feeding may help facilitate weight restoration, but its role in treatment remains unclear. This study aimed to review the literature describing the efficacy, safety, tolerance, and long-term effects of nasogastric (NG) refeeding for patients with AN. Four electronic databases were systematically searched through May 2018. Boolean search terms included "anorexia nervosa," "refeeding," and "nasogastric tube feeding." Ten studies were eligible for inclusion: 8 retrospective chart reviews, 1 prospective cohort, and 1 randomized controlled trial. Nine of the studies were performed in-hospital. In 8 studies, NG nutrition resulted in an average rate of weight gain exceeding 1 kg/wk. In 4 of 5 studies including an oral-only control group, mean weekly weight gain and caloric intake were significantly higher in tube-fed patients. Six studies provided prophylactic phosphate supplementation, all with <1% occurrence rate of refeeding hypophosphatemia. Seven studies reported on other physiological disturbances, 6 evaluated medical and gastrointestinal side effects, 3 considered psychological outcomes, and 4 assessed patients postdischarge. Results indicated that NG feeding was not associated with an increased risk for adverse outcomes. Overall, in these studies, NG nutrition was considered safe and well tolerated, and effectively increased caloric intake and rate of weight gain in patients with AN. However, results are limited by weaknesses in study designs, and more rigorous methods are needed for development of evidence-based, standardized refeeding protocols.
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10.
Effect of Nasogastric Tube on Aspiration Risk: Results from 147 Patients with Dysphagia and Literature Review.
Kim, G, Baek, S, Park, HW, Kang, EK, Lee, G
Dysphagia. 2018;(6):731-738
Abstract
Nasogastric tube (NGT) is a common feeding strategy for patients at risk of endotracheal aspiration with an oral diet. With NGT feeding, however, swallowing of small amounts saliva cannot be avoided. We investigated whether the aspiration rate when swallowing 1 mL of fluid increased in patients using an NGT in different dysphagia severities. One hundred forty-seven patients who had been receiving NGT feeding underwent a videofluoroscopic swallowing study (VFSS). During VFSS, subjects were offered 1 mL of fluid twice: initially, with the tube inserted (NGT-in) and, subsequently, with the tube removed (NGT-out). Aspiration depth was determined using the 8-point Penetration-Aspiration Scale (PAS) (0 points, no aspiration/penetration; 8 points, aspiration passing the vocal cords with no ejection efforts). PAS-diff was computed (PASNGT-in - PASNGT-out), and a positive PAS-diff (PAS-diff > 0) meant increased aspiration depth in the presence of NGT. After VFSS, diet recommendations were made according to dysphagia severity assessment: non-oral feeding (n = 59), diet modification (n = 74), and diet as tolerated (n = 13). Cognitive level (mini-mental state examination, MMSE) and general functional level (Modified Barthel Index, MBI) were compared between the PAS-diff > 0 and PAS-diff ≤ 0 groups. Aspiration severity did not significantly change after NGT removal (PASNGT-in, 2.45 ± 2.40; PASNGT-out, 2.57 ± 2.58; P = .50). Regardless of recommended diet, PAS-diff values were not significantly different (P = .49). MMSE and MBI were not significantly different (P = .23 and .94) between subjects with PAS-diff > 0 (n = 25) and PAS-diff ≤ 0 (n = 121). In conclusion, the risk of aspirating a small amount of fluid was not significantly different before and after NGT removal, regardless of swallowing function, cognitive level, or general functional level.