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      A secure ”double-check” technique of bedside post pyloric feeding tube placement using transnasal endoscopy

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          Abstract

          Enteral feeding has become an important means of providing nutritional support to seriously ill patients. Placement of the feeding tube through the pyloric ring and past the ligament of Treitz into the proximal jejunum is critical to reduce the risk of gastroesophageal regurgitation and microaspiration. We started utilizing transnasal endoscopy for intestinal feeding tube placement, placing enteral tubes for 40 patients between March 2008 and February 2009. Although we achieved a high success rate comparable to previous reports, we experienced several cases of failure, which was corrected with repeated endoscopy. Based on these experiences, we modified our method by adding a ”double-check” transnasal endoscopy through the other nasal passage. After April 2010, we have placed the feeding tube by ”double-check” method for all patients (more than 40 patients) who required transnasal endoscopic feeding tube placement. We have not experienced any misplacement in all these patients after 24 h later with 100% successful rate since the introduction of ”double-check” procedure. We describe our experience with ”double-check” transnasal endoscopic feeding tube placement, which we found to be a helpful adjunct, for patients in intensive care unit.

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          Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis.

          F A Moore, D V Feliciano, R J Andrassy … (1992)
          This two-part meta-analysis combined data from eight prospective randomized trials designed to compare the nutritional efficacy of early enteral (TEN) and parenteral (TPN) nutrition in high-risk surgical patients. The combined data gave sufficient patient numbers (TEN, n = 118; TPN, n = 112) to adequately address whether route of substrate delivery affected septic complication incidence. Phase I (dropouts excluded) meta-analysis confirmed data homogeneity across study sites, that TEN and TPN groups were comparable, and that significantly fewer TEN patients experienced septic complications (TEN, 18%; TPN, 35%; p = 0.01). Phase II meta-analysis, an intent-to-treat analysis (dropouts included), confirmed that fewer TEN patients developed septic complications. Further breakdown by patient type showed that all trauma and blunt trauma subgroups had the most significant reduction in septic complications when fed enterally. In conclusion, this meta-analysis attests to the feasibility of early postoperative TEN in high-risk surgical patients and that these patients have reduced septic morbidity rates compared with those administered TPN.
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            Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis.

            A C Windsor, S Kanwar, A G Li … (1998)
            In patients with major trauma and burns, total enteral nutrition (TEN) significantly decreases the acute phase response and incidence of septic complications when compared with total parenteral nutrition (TPN). Poor outcome in acute pancreatitis is associated with a high incidence of systemic inflammatory response syndrome (SIRS) and sepsis. To determine whether TEN can attenuate the acute phase response and improve clinical disease severity in patients with acute pancreatitis. Glasgow score, Apache II, computed tomography (CT) scan score, C reactive protein (CRP), serum IgM antiendotoxin antibodies (EndoCAb), and total antioxidant capacity (TAC) were determined on admission in 34 patients with acute pancreatitis. Patients were stratified according to disease severity and randomised to receive either TPN or TEN for seven days and then re-evaluated. SIRS, sepsis, organ failure, and ITU stay, were globally improved in the enterally fed patients. The acute phase response and disease severity scores were significantly improved following enteral nutrition (CRP: 156 (117-222) to 84 (50-141), p < 0.005; APACHE II scores 8 (6-10) to 6 (4-8), p < 0.0001) without change in the CT scan scores. In parenterally fed patients these parameters did not change but there was an increase in EndoCAb antibody levels and a fall in TAC. Enterally fed patients showed no change in the level of EndoCAb antibodies and an increase in TAC. TEN moderates the acute phase response, and improves disease severity and clinical outcome despite unchanged pancreatic injury on CT scan. Reduced systemic exposure to endotoxin and reduced oxidant stress also occurred in the TEN group. Enteral feeding modulates the inflammatory and sepsis response in acute pancreatitis and is clinically beneficial.
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              Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial.

              Ben N M Lam, Raymond Novak, J Drover … (2001)
              To determine the extent to which postpyloric feeding reduces gastroesophageal regurgitation and pulmonary microaspiration in critically ill patients. Randomized trial. A medical/surgical intensive care unit at a tertiary care hospital. Intensive care unit patients were expected to remain ventilated >72 hrs. We excluded patients with esophageal, gastric, or small bowel surgery in the last week and patients with overt or clinically significant gastrointestinal bleeding. We studied 33 patients; 42.4% were female, mean age (sd) was 59.2 (+/- 16.8) yrs, and mean Acute Physiology and Chronic Health Evaluation II score was 22.5 (7.8). Patients were randomized to gastric or postpyloric enteral feeds. Technetium 99-sulphur colloid was added to the feeds for 6 hrs of each of the first 3 days on study. We sampled the oropharynx and trachea hourly for the 6 hrs per day that patients received radioisotope-labeled enteral feeds, and the level of radioactivity in these specimens was measured. We defined an episode of gastroesophageal regurgitation and microaspiration as an increase in radioactivity >100 counts per minute/g. Patients fed into the stomach had more episodes of gastroesophageal regurgitation (39.8% vs. 24.9%, p =.04) and trended toward more microaspiration (7.5% vs. 3.9%, p =.22) compared with patients fed beyond the pylorus. When the logarithmic mean of the radioactivity count was compared across groups, there was a trend toward an increase in gastroesophageal regurgitation (3.7 vs. 2.9 counts/g, p =.22) and a trend toward increased microaspiration (1.9 vs. 1.4 counts/g, p =.09) in patients fed into the stomach. Patients who had gastroesophageal regurgitation were much more likely to aspirate than patients who did not have gastroesophageal regurgitation (odds ratio: 3.2; 95% confidence interval: 1.36, 7.77). Feeding beyond the pylorus is associated with a significant reduction in gastroesophageal regurgitation and a trend toward less microaspiration.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Clin Biochem Nutr
                Journal ID (iso-abbrev): J Clin Biochem Nutr
                Journal ID (publisher-id): JCBN
                Title: Journal of Clinical Biochemistry and Nutrition
                Publisher: the Society for Free Radical Research Japan (Kyoto, Japan )
                ISSN (Print): 0912-0009
                ISSN (Electronic): 1880-5086
                Publication date (Print): November 2012
                Publication date (Electronic): 12 July 2012
                Volume: 51
                Issue: 3
                Pages: 213-215
                Affiliations
                [1]Department of Emergency and Critical Care Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo 663-8501 Japan
                Author notes
                *To whom correspondence should be addressed. E-mail: kotanijo@ 123456attglobal.net
                Article
                Publisher ID: jcbn12-35
                DOI: 10.3164/jcbn.12-35
                PMC ID: 3491246
                PubMed ID: 23170049
                SO-VID: 32c8fc73-4abd-42d0-a638-b6f59e95f1c0
                Copyright © Copyright © 2012 JCBN
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 17 March 2012
                Date accepted : 10 April 2012
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Biochemistry
                Keywords: complication,intestinal tubing,transnasal,endoscope,enteral feeding
                Data availability:
                ScienceOpen disciplines: Biochemistry
                Keywords: complication, intestinal tubing, transnasal, endoscope, enteral feeding

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