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A new technique for post-pyloric feeding tube placement by palpation in lean critically ill patients.

Enteral nutrition is the preferred method of feeding critically ill patients and is an important method to counteract the catabolic state induced by severe disease (1). Gastric feeding is the most common method of enteral feeding and is more physiological than other methods. However, gastrointestinal complications are relatively common, including high gastric residual volume, abdominal distension, vomiting and regurgitation. These problems may, in part, be due to delayed gastric emptying in critically ill patients. Feeding beyond the stomach into the duodenum or jejunum has been suggested to reduce the risk of aspiration and improve the adequacy of nutrient delivery. It has been recommended that patients should be fed via an enteral access tube placed in the small bowel if the patient is at high risk for aspiration or shows intolerance to gastric feeding (2).

Placement of the post-pyloric feeding tube is difficult and is traditionally performed under endoscopy or radiological monitoring at considerable risk and expense. On the other hand, various techniques have been described for blind bedside placement, including gastric air insufflation (3), the use of prokinetic agents such as metoclopramide (4) and erythromycin (5) and self-propelled tubes (6). Furthermore, there are a number of methods that can be used to estimate tube position during these procedures, such as auscultation (4,5), measuring pH (5,7), ultrasound (8), electromyography (9), electrocardiography (10) and electromagnetic guidance (11,12). However, these methods for blind bedside placement of a post-pyloric feeding tube may be technically difficult and time-consuming and are often ineffective. Moreover, some techniques require specialised equipment. As a result, there is no universal method to place enteral feeding tubes and the technique is also dependent on local institutional resources and expertise (13). If it is possible to determine the position of the tip of enteral feeding tube with a precision comparable to fluoroscopy without using special techniques or instruments, such methods should become standard techniques.

The purpose of this study was to evaluate a simple blind technique for bedside placement of a postpyloric feeding tube in an intensive care unit using palpation to determine the tube's position.

MATERIALS AND METHODS

Patient selection

We studied 47 consecutive patients in the general intensive care unit of Nagasaki University Hospital between April 2008 and April 2009. All of the patients were sedated or in a coma and intubated, and were likely to require invasive ventilation for more than 48 hours. Written informed consent was obtained from each relative and the study was approved by the Institutional Ethical Committee. Eligible patients exhibited one or more of the following indications for post-pyloric feeding in our institution: evidence of delayed gastric emptying with high gastric aspirates, history of pulmonary aspiration of tube feed or at high risk for aspiration, inability to remain in a semisitting position (e.g. orthopaedic reasons and burn patients) or acute pancreatitis. Exclusion criteria were history of current haemodynamic instability with or without pressor agents, active gastrointestinal bleeding or recently active gastric or oesophageal varices, severe thrombocytopenia, gastric outlet or intestinal obstruction or history of gastric surgery.

Feeding tube placement procedure

All feeding tubes were placed by two staff intensivists at our institution. The intensivists had performed this technique at least three times before this study. All patients were placed in the supine position and a standard nasogastric tube was inserted into the stomach before the procedure and was used for de-aeration. Metoclopramide (10 mg) was administered intravenously 10 minutes before inserting the feeding tube. A 10-French 120 cm enteral feeding tube with an internal stylet (New Enteral Feeding Tube, Covidien Japan, Japan) was inserted via the nose and placement was confirmed in the stomach by auscultation following air injection. The intensivist then placed his palm on the left upper quadrant. Air (10 ml) was injected with a syringe and the point corresponding to the maximum intensity of air 'bubbling' was determined (Figure 1). Every 10 cm advance was followed by confirmation of the point of maximum intensity by palpation until the point had moved to the right upper quadrant (Figure 2). If any resistance was felt and/or the maximum intensity point did not move, the tube was withdrawn and the procedure was repeated. This resistance can be characterised by the feeling that the guide wire is 'popping' when it is pulled back (14). The tube is likely to be coiled not only in the stomach, but also in the oral cavity. Therefore, the oral cavity was carefully checked if we felt any resistance. Furthermore, it is necessary to be very attentive when the stomach is over-inflated with injected air. Although the pyloric opening is stimulated by air insufflation into the stomach (3), it becomes difficult to feel bubbling by palpation. Therefore, in such settings, the stomach was de-aerated via the feeding tube or the nasogastric tube. After confirming the tube was placed in the right upper quadrant, it was slowly advanced to 105 cm. If the maximum intensity point on the right upper quadrant diminished or weakened, we considered the tube to have proceeded beyond the pylorus. We also checked the volume of aspirated air after injecting 10 ml of air. Air is easily insufflated and aspirated when the tip of the tube is in the stomach, but not when the tube is in the transpylorus (15). We found it difficult to estimate the correct position of the tube in the duodenum, a retroperitoneal organ, but we could often feel weak bubbling around the umbilicus (Figure 2). If the maximum intensity point did not move in the right upper quadrant, the tube was withdrawn and the procedure was repeated. After checking that the feeding tube was not coiled in the oral cavity, we withdrew the stylet to end the procedure. We did not measure the pH of the fluids aspirated from the tube or perform auscultation to confirm whether the tube was in correct position in this study.

The exact tube position was confirmed by abdominal radiography. A contrast dye was flushed through the feeding tube before taking the radiographs. The position of the tube tip on the abdominal radiograph (stomach, antrum/first portion of the duodenum, second, third or fourth segments of the duodenum or proximal jejunum) was determined by a radiologist. We determined the success rate of tube placement into or beyond the second portion of the duodenum and the time required for this procedure. The duration of the procedure was recorded as the time from placing the feeding tube in the stomach to withdrawal of the stylet.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Statistical analysis

Data are expressed as mean [+ or -] standard deviation or proportions, as appropriate. The duration of the procedure is expressed as the median and interquartile range.

RESULTS

A total of 47 patients were recruited in this study, including 30 men and 17 women (mean age: 62.4 [+ or -] 19.0 years). Thirty patients exhibited evidence of delayed gastric emptying with high gastric aspirates, 11 patients were unable to remain in a semi-sitting position, five patients exhibited pulmonary aspiration of the tube feed and one patient had pancreatitis. The mean body mass index (BMI) of the patients was 22.4 [+ or -] 4.2 kg/[m.sup.2] and their characteristics are summarised in Table 1. The protocol was completed in 43 patients. We could feel bubbling of injected air by palpation in all cases, but four patients were excluded because of failure to complete the protocol. In these four patients, the procedure was continued for 60 minutes or more. The reasons for failure to complete the protocol were an inability to insert the tube to a sufficient length because of resistance. Although bubbling of air was felt in all cases, it was felt on the left upper quadrant in two cases and on the right upper quadrant in the other two cases. The BMI of these four cases was 20.4, 22.6, 23.4 and 24.6 kg/[m.sup.2] respectively.

The overall success rate on the first attempt was 85.1% (40/47) when we included the four excluded cases (intention to treat analysis) and 91.5% (43/47) when we included the second attempt. Of the 43 tubes successfully positioned post-pylorically, seven (16.3%) were placed in the second portion, five (11.6%) in the third portion and five (11.6%) in the fourth portion of the duodenum, while 26 (60.5%) tubes were placed in the jejunum past the ligament of Trietz. The median (interquartile range) time for 40 successful tube placements on the first attempt was 10 (7 to 23) minutes. The times for the first/second attempts of three cases that failed on the first attempt were 34/15, 20/14 and 14/16 minutes. The BMI of these three cases was 19.5, 23.0 and 21.0 kg/[m.sup.2] respectively. No major complications were observed during any of the procedures.

DISCUSSION

In this study, we estimated tube position by palpation. In all cases, we could feel the bubbling of air injected from the feeding tube. It was possible to feel the tube position, and this technique did not need to be done repeatedly to detect tube position unlike auscultation, because it was easy to feel and identify the point of maximum intensity of bubbling by palpation. Accordingly, this technique is simple and can quickly and accurately estimate the position of the tube in the stomach, with a high success rate for correct tube placement. We believe that this palpation technique is an effective method of estimating tube position during blind bedside feeding tube placement in critically ill patients.

To estimate the correct tube position, auscultation and measuring pH are commonly used alone or in combination, because these techniques can be done easily and do not require specialist equipment. Heiselman et [al.sup.4] used auscultation alone to determine tube position in patients given metoclopramide in a control group, with success rates of 54% and 46% respectively. Griffith et [al.sup.5] used auscultation in addition to measuring pH. They used these techniques to place the tube in the post-pyloric region and the success rate was 55% in the control group (without erythromycin). These results suggest that auscultation does not accurately indicate the position of the tube tip. Auscultation needs to be done repeatedly to confirm the point at which the sound is most audible and the operator needs to be able to recognise the resulting changes in tone (5). This procedure may also be time-consuming and the operator needs to be experienced to achieve accurate tube placement. Thus, we believe that this is an advantage for our palpation technique compared with auscultation.

Measuring the pH of aspirates was performed in many studies (5,7,10). However, gastric and post-pyloric aspirates are not always obtained. Gatt et al (16) reported that a pre-pyloric fluid aspirate was only obtained in 60% of all intubations, with only 44% showing a gastric pH[less than or equal to] 5. Meanwhile, post-pyloric aspirates were obtained in only 5.7% of cases. They concluded that the use of aspirate pH alone is not a reliable indicator of tube tip position.

An electromagnetic guidance device was recently introduced as a minimally invasive bedside technique and achieved a high success rate and rapid placement (11,12). However, like other methods using electromyography or electrocardiography, specialised equipment is required.

In this study, four patients were excluded because we could not complete our protocol. In these patients, we could not advance the tube to a sufficient length because of resistance. The maximum intensity point remained in the left upper quadrant in two patients. In the other two patients, the maximum intensity point on the right upper quadrant did not diminish or weaken and we could not complete the procedure with certainty that the tube was in the post-pyloric position. In fact, radiography confirmed that all of the tubes were located in the stomach or antrum/first portion of the duodenum. Although fluoroscopic techniques can show tube position in real time, the success rate is about 90 to 94% for such techniques (17-19). The reason for this is probably because of anatomical abnormalities such as gastroparesis. In our study, the success rate, including the four excluded patients, was 91.5% (43/47) when we included the second attempt. Thus, we believe that our palpation technique offers similar overall efficacy to fluoroscopy. No major complications were observed in this study and we believe this technique is safe. However, we recommend that we should abandon blind placement if the insertion time takes too long because the success rate is not 100%.

This study has some limitations to discuss. First, although we believe our palpation technique offers advantages such as simplicity and speed of performing the procedure, we did not compare our technique with other techniques, particularly auscultation. Therefore we cannot claim superiority of our technique over other conventional techniques. Second, the patients described in this study had a BMI of 22.4 [+ or -] 4.2 kg/[m.sup.2] By Western standards, the patients would be considered slim. Further studies are needed to determine whether our technique can be used successfully in obese patients. Third, it is difficult to assess the exact tube position after confirmation of placement in the right upper quadrant. Because the duodenum is a retroperitoneal organ, it is difficult to feel bubbling by palpation at this location. We often felt weak bubbling around the umbilicus when the tube was in the duodenum and, if the tube had passed beyond the ligament of Treitz, we could feel bubbling on the left upper quadrant. However, we mistook the position in three patients, despite our certainty that the tube was in the post-pyloric position. Other methods may be needed to supplement our technique to achieve perfect tube placement.

In conclusion, our new palpation technique can successfully detect the position of a feeding tube in the stomach and effectively guide the placement of the feeding tube to the correct position in the post-pyloric region of the stomach in lean critically ill patients. Moreover, the procedure is safe, inexpensive and can be quickly performed in critically ill patients.

ACKNOWLEDGEMENTS

We would like to thank the staff of the Intensive Care Unit and Dr Hideyuki Hayashi, radiologist at our hospital, for their help and advice.

REFERENCES

(1.) Kreymann KG, Berger MM, Deutz NEP, Hiesmayr M, Jolliet P, Kazandjiev G et al. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr 2006; 25:210-223.

(2.) McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009; 33:277-316.

(3.) Salasidis R, Fleiszer T, Johnston R. Air insufflation technique of enteral tube insertion: a randomized, controlled trial. Crit Care Med 1998; 26:1036-1039.

(4.) Heiselman DE, Hofer T, Vidovich RR. Enteral feeding tube placement success with intravenous metoclopramide administration in ICU patients. Chest 1995; 107:1686-1688.

(5.) Griffith DP, McNally AT, Battey CH, Forte SS, Cacciatore AM, Szeszycki EE et al. Intravenous erythromycin facilitates bedside placement of postpyloric feeding tubes in critically ill adults: a double-blind, randomized, placebo-controlled study. Crit Care Med 2003; 31:39-44.

(6.) Berger MM, Bollmann MD, Revelly J-P, Cayeux M-C, Pilon N, Bracco D et al. Progression rate of self-propelled feeding tubes in critically ill patients. Intensive Care Med 2002; 28:1768-1774.

(7.) Dimand RJ, Veereman-Wauters G, Braner DA. Bedside placement of pH-guided transpyloric small bowel feeding tubes in critically ill infants and small children. JPEN J Parenter Enteral Nutr 1997; 21:112-114.

(8.) Hernandez-Socorro CR, Marin J, Ruiz-Santana S, Santana L, Manzano JL. Bedside sonographic-guided versus blind nasoenteric feeding tube placement in critically ill patients. Crit Care Med 1996; 24:1690-1694.

(9.) Levy H, Hayes J, Boivin M, Tomba T. Transpyloric feeding tube placement in critically ill patients using electromyogram and erythromycin infusion. Chest 2004; 125:587-591.

(10.) Slagt C, Innes R, Bihari D, Lawrence J, Shehabi Y. A novel method for insertion of post-pyloric feeding tubes at the bedside without endoscopic or fluoroscopic assistance: a prospective study. Intensive Care Med 2004; 30:103-107.

(11.) Gray R, Tynan C, Reed L, Hasse J, Kramlich M, Roberts S et al. Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique? Nutr Clin Pract 2007; 22:436-444.

(12.) Deane AM, Fraser RJ, Young RJ, Foreman B, O'Conner SN, Chapman MJ. Evaluation of a bedside technique for postpyloric placement of feeding catheters. Crit Care Resusc 2009; 11:180-183.

(13.) Haslam D, Fang J. Enteral access for nutrition in the intensive care unit. Curr Opin Clin Nutr Metab Care 2006; 9:155-159.

(14.) Lee AJ, Eve R, Bennett MJ. Evaluation of a technique for blind placement of post-pyloric feeding tubes in intensive care: application in patients with gastric ileus. Intensive Care Med 2006; 32:553-556.

(15.) Harrison AM, Clay B, Grant MJ, Sanders SV, Webster HF, Reading JC et al. Nonradiographic assessment of enteral feeding tube position. Crit Care Med 1997; 25:2055-2059.

(16.) Gatt M, MacFie J. Bedside postpyloric feeding tube placement: a pilot series to validate this novel technique. Crit Care Med 2009; 37:523-527.

(17.) Foote JA, Kemmeter PR, Prichard PA, Baker RS, Paauw JD, Gawel JC et al. A randomized trial of endoscopic and fluoroscopic placement of postpyloric feeding tubes in critically ill patients. JPEN J Parenter Enteral Nutr 2004; 28:154-157.

(18.) Fang JC, Hilden K, Holubkov R, DiSario JA. Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients. Gastrointest Endosc 2005; 62:661-666.

(19.) Thurley PD, Hopper MA, Jobling JC, Teahon K. Fluoroscopic insertion of post-pyloric feeding tubes: success rates and complications. Clin Radiol 2008; 63:543-548.

M. SEKINO*, O. YOSHITOMI*, T. NAKAMURA*, T. MAKITA ([dagger]), K. SUMIKAWA ([double dagger])

Intensive Care Unit, Nagasaki University Hospital, Nagasaki, Japan

* MD, Staff Intensivist, Division of Intensive Care.

([dagger]) MD, Staff Intensivist and Associate Professor, Division of Intensive Care.

([double dagger]) MD, Professor, Department of Anesthesiology.

Address for correspondence: Dr M. Sekino, Division of Intensive Care, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-859, Japan. Email: m-sekino@nagasaki-u.ac.jp

Accepted for publication on September 16, 2011.
Table 1
Clinical characteristics of the patients

Variable Value

Patients 47
 Gender, M/F 30/17
 Age, y * 62.4 [+ or -] 19.0
 Height, cm * 161.1 [+ or -] 10.1
 Weight, kg * 58.4 [+ or -] 11.5
 BMI, kg/[m.sup.2] * 22.5 [+ or -] 4.2
 SOFA score at tube placement * 9.9 [+ or -] 3.1
Admission diagnosis
 Major vascular surgery 11 (21%)
 Respiratory failure 10 (21%)
 Cardiac surgery 7 (14%)
 Multiple trauma 6 (14%)
 Sepsis 4 (9%)
 Cardiac arrest 2 (5%)
 Poisoning 2 (5%)
 Burn 2 (5%)
 Others 3 (7%)
 Total 47

BMI=body mass index, SOFA=Sequential Organ Failure
Assessment. * Mean [+ or -] SD.
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Article Details
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Author:Sekino, M.; Yoshitomi, O.; Nakamura, T.; Makita, T.; Sumikawa, K.
Publication:Anaesthesia and Intensive Care
Article Type:Report
Geographic Code:8AUST
Date:Jan 1, 2012
Words:3147
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