Summary of the Best Evidence for Tube Feeding Intolerance in Critically Ill Children

Objective:To summarize the evidence of tube feeding intolerance in critically ill children,aiming to provide evidence-based information for clinical nursing staff.Methods:Evidence search was done in Chinese and English databases to guide network and professional associations at home and abroad.The search time limit was from January 2014 to January 2024,nearly 10 years of relevant literature,mainly including guidelines,consensus,expert advice,best practice,evidence summary,system evaluation,and meta-analysis.Literature quality evaluation and evidence extraction were independently performed by two researchers.Results:This paper included 13 articles,including three guidelines,three systematic evaluations,three expert opinions,and four expert consensus.Twenty-six pieces of evidence were summarized from 10 aspects of feeding intolerance definition,team building,nutritional assessment,nutritional preparation,feeding protocol,feeding route,feeding management,pipeline management,gastric residual volume,and drug application.Conclusion:This paper summarized the evidence of tube feeding intolerance in critically ill children,which can provide evidence-based information for clinical practice.The abdominal signs should be closely observed when evaluating feeding intolerance,focusing on the prevention and reduction of feeding interruption.

Gastroenteric tube feeding: Techniques, problems and solutions

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake,chronic neurological or mechanical dysphagia or gut dysfunction,and patients who are critically ill.However,despite the benefits and widespread use of enteral tube feeding,some patients experience complications.This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding,together with associated complications and special aspects.We conducted an extensive literature search on PubMed,Embase and Medline using index terms relating to enteral access,enteral feeding/nutrition,tube feeding,percutaneous endoscopic gastrostomy/jejunostomy,endoscopic nasoenteric tube,nasogastric tube,and refeeding syndrome.The literature showed common routes of enteral access to include nasoenteral tube,gastrostomy and jejunostomy,while complications fall into four major categories:mechanical,e.g.,tube blockage or removal;gastrointestinal,e.g.,diarrhea;infectious e.g.,aspiration pneumonia,tube site infection;and metabolic,e.g.,refeeding syndrome,hyperglycemia.Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route,gastrointestinal complications are without doubt the most common.Complications associated with enteral tube feeding can be reduced by careful observance of guidelines,including those related to food composition,administration rate,portion size,food temperature and patient supervision.

Blindly inserted nasogastric feeding tubes and thoracic complications in intensive care

Purpose of review: This article reviews the thoracic complications from malpositioned blindly inserted nasogastric feeding tubes in mechanically ventilated patients in intensive care and the methods to check the position and promote safe placement of the feeding tubes. Recent findings: Malpositioned feeding tubes are not included in risk management databases. The reported incidence is 1-3% and more than half occur in mechanically ventilated patients. Eighty three mechanically ventilated patients were reported with malpositioned nasogastric tubes and 66% of them developed serious thoracic complications. Pneumothoraces accounted for 80% of thoracic complications that were evenly distributed between tubes with and without stylet. Repeated misplacements appear to increase the risk. Non-radiological confirmation of the position of the tube has suboptimal performance. Protocols to place feeding tubes and new technology are promising candidates. Summary: Malpositioned nasogastric feeding tubes are underreported and associated with serious thoracic complications in mechanically ventilated patients. We need more data to answer whether we can afford to prevent them.

Postoperative complications and weight loss following jejunostomy tube feeding after total gastrectomy for advanced adenocarcinomas

Objective： Patients undergoing total gastrectomy for cancer are at risk of malnourishment. The aim of this self- controlled study was to examine the effect of jejunostomy tube feeding （JTF） and other factors on postoperative weight and the incidence of jejunostomy-related complications in patients undergoing total gastrectomy for cancer. Methods： All consecutive patients who underwent total gastrectomy for gastric cancer with jejunostomy plaeement were included from a prospective single-center database （2003-2014）. Jejunostomy-related complications and postoperative weight changes were evaluated up to 12 months after surgery. Multivariable linear regression analysis was performed to identify factors associated with weight loss 12 months after gastreetomy. Results： Of 113 patients operated in the study period, 65 received JTF after total gastrectomy for a median duration of 18 d [interquartile range （IQR）, 10-55 d]. Jejunostomy-related complieations occurred in 11 （17%） patients, including skin leakage （n=3） and peritoneal leakage （n=2）, luxation （n=3）, occlusion （n=2）, infection （n=l） and torsion （n=l）. In 2 （3%） patients, a reoperation was needed due to jejtmostomy-related complications. The mean preoperative weight of patients was 71.8 kg （100%）, and remained stable during JTF （73.9 kg, 103%, P=0.331）. After JTF was stopped, the mean weight of patients decreased to 64.9 kg （90%） at 12 months after surgery （P〈0.001）. A high preoperative body mass index （BMI） （〉_25 kg/m2） was associated with high postoperative weight loss compared to patients with a low BMI （〈25 kg/m2） （16.3% vs. 8.6%, P=0.016）. Conclusions： JTF can prevent weight loss in the early postoperative phase. However, this is at the prize of possible complications. As weight loss in the long term is not prevented, routine JTF should be re-evaluated and balanced against the selected use in preoperatively malnourished patients. Special attention should be paid to patients with a high preoperative BMI, who are at risk of more postoperative weight loss.

Evaluation of a new method for placing nasojejunal feeding tubes

AIM:To compare fluoroscopic, endoscopic and guide wire assistance with ultraslim gastroscopy for placement of nasojejunal feeding tubes. METHODS:The information regarding nasojejunal tube placement procedures was retrieved using the gastrointestinal tract database at Tongji Hospital affiliated to Tongji Medical College. Records from 81 patients who underwent nasojejunal tubes placement by different techniques between 2004 and 2011 were reviewed for procedure success and tube-related outcomes. RESULTS:Nasojejunal feeding tubes were successfully placed in 78 (96.3%) of 81 patients. The success rate by fluoroscopy was 92% (23 of 25), by endoscopic technique 96.3% (26 of 27), and by guide wire assistance (whether via transnasal or transoral insertion)100% (23/23, 6/6). The average time for successful placement was 14.9 ± 2.9 min for fluoroscopic placement, 14.8 ± 4.9 min for endoscopic placement, 11.1 ± 2.2 min for guide wire assistance with transnasal gastroscopic placement, and 14.7 ± 1.2 min for transoral gastroscopic placement. Statistically, the duration for the third method was significantly different (P < 0.05) compared with the other three methods. Transnasal placement over a guidewire was significantly faster (P < 0.05) than any of the other approaches. CONCLUSION:Guide wire assistance with transnasal insertion of nasojejunal feeding tubes represents a safe, quick and effective method for providing enteral nutrition.

Endoscopic nasojejunal feeding tube placement in patients with severe hepatopancreatobiliary diseases:a retrospective study of 184 patients

BACKGROUND: Total parenteral nutrition (TPN) has been recognized as the mainstay of nutritional support in patients with severe hepatopancreatobiliary (HPB) diseases for decades. However, recent studies advocate the utilization of endoscopic nasojejunal feeding tube placement (ENFTP), rather than the conventional approach. This study was designed to compare the clinical value of ENFTP and TPN in patients with severe HPB diseases. METHODS: Two groups of patients with severe HPB diseases were analyzed retrospectively. One group of 88 patients received ENFTP, and the other 96 received TPN. Routine blood levels, serum glucose and prealbumin, hepatic and renal function, serum lipid, and calcium were measured at baseline and after 1, 2, and 4 weeks of nutritional support. Also, complication rate, mortality, nutritional support time, mechanical ventilation time, mean length of time in intensive care unit, and duration of hospital stay were analyzed. RESULTS: After 4 weeks of nutritional support, the degree of recovery of red blood cells, prealbumin, and blood glucose was greater in the ENFTP than in the TPN group (P<0.05). Furthermore, the ENFTP group showed a lower incidence of septicemia, multiple organ dysfunction syndrome, peripancreatic infection, biliary infection, and nosocomial infection, in addition to shorter nutritional support time and hospital stay (P<0.05). CONCLUSIONS: ENFTP is much more effective than TPN in assisting patients with severe HPB diseases to recover from anemia, low prealbumin level, and high serum glucose, as well as in decreasing the rates of various infections (pulmonary infection excluded), multiple organ dysfunction syndrome rate, nutrition support time, and length of hospital stay. Therefore, ENFTP is safer and more economical for clinical application.

Knot formation in the feeding jejunostomy tube:A case report and review of the literature

Jejunostomy feeding tubes provide surgeons with an excellent method for providing nutritional support, but there are several complications associated with a tube jejunostomy, including complications resulting from placement of the tube, mechanical problems related to the location or function and development of focally thickened small-bowel folds. A 76-year old man who presented with multiple medical diseases was admitted to our hospital due to aspiration pneumonia with acute respiratory failure and septic shock. He underwent exploratory laparotomy with feeding jejunostomy using a 14-French nasogastric tube for nutritional support. However, occlusion of the feeding tube was found 30 d after operation, and a rare complication of knot formation in the tube occurred after a new tube was replaced. On the following day, the tube was removed and replaced with a similar tube, which was placed into the jejunum for only 15 cm. The patient's feedings were maintained smoothly for two months. Knot formation in the feeding tube seems to be very rare. To our knowledge, this is the third case in the literature review. Its incidence is probably related to the length of the tube inserted into the lumen.

Uncommon complication of nasoenteral feeding tube:A case report

BACKGROUND The jejunal nutrition tube has increasingly been used in clinical practice,and the results in frequent complications.CASE SUMMARY We present the case of a 74-year-old male patient who had been admitted to the intensive care unit for aspiration pneumonia and respiratory failure.When confirming the position of the jejunal tube by X-ray,we found that the feeding tube had been placed into the chest.The complications was a disaster,though the misplacement of jejunal feeding tube are uncommon.CONCLUSION We introduced a way of ultrasound-guided jejunum feeding tube placement to avert the disaster,which was convenient and economical.

Jejunostomy Feeding Tube Placement in Gastrectomy Procedures: A Systematic Review

Many nutritional interventions have been developed to improve nutritional outcomes following upper gastrointestinal surgery. The aim of this systematic review was to investigate whether or not the routine use of intraoperative jejunostomy feeding tubes in partial and total gastrectomy procedures is warranted when assessing complications and nutritional benefits such as improved chemotherapy tolerance. An electronic search of MEDLINE, Web of Science, Embase and CINAHL databases was performed to identify studies which reported complications and/or post-operative outcomes of patients who received an intraoperative jejunostomy feeding tube in gastrectomy procedures. Five articles met the inclusion criteria (n = 636) with four retrospective cohort studies and one RCT. Studies varied in regards to the complications and nutritional outcomes reported. Jejunostomy feeding tube insertion may carry a risk of increased infectious complications but appears to reduce patient post-operative weight-loss and may improve chemotherapy tolerance. Due to the lack of high-quality studies, it is unclear if the routine use of an intraoperative jejunostomy feeding tube is indicated for all patients undergoing gastrectomy procedures or only those at a high-risk of post-operative malnutrition. More comprehensive research is recommended, particularly on the usefulness of home enteral nutrition post-gastrectomy.

Continuous versus bolus nasogastric tube feeding in premature neonates: Randomized controlled trial

Background: Whether premature infants should be fed by bolus or continuous gavage feeding, is still a matter of debate. A recent Cochrane analysis revealed no difference. Study design and methods: We carried out a randomized controlled trial in premature infants on continuous versus bolus nasogastric tube feeding, to search for differences with respect to number of incidents, growth, and time to reach full oral feeding. In total, 110 premature neonates (gestational age 27 - 34 weeks) were randomly assigned to receive either continuous or bolus nasogastric tube feeding. Basic characteristics were comparable in both groups. Results: No significant difference in weight gain could be detected between the two groups, mean weight gain amounting 151.6 (108.9 - 194.3) and 152.4 (102.2 - 202.6) grams per week in the continuous and bolus group, respectively. No significant differences were found between both groups in the time needed to achieve full oral feeding (8 oral feedings per day), full oral feeding being achieved at day 31 (range 19 - 43) and day 29 (range 18 - 40) of life in the continuous and bolus group, respectively. We also found no significant differences in the number of 'incident-days' (three or more incidents a day): 3.5 (0 - 9) versus 2.7 (0 - 6.5) days in the continuous and bolus group, respectively. Conclusion: No significant differences were found in weight gain, time to achieve full oral feeding and number of incident-days between preterm infants enterally fed by nasogastric tube, according to either the bolus or continuous method.

Survival Effect of Tube Feeding in Patients with Advanced Dementia and Comorbidities

Patients suffering from advanced dementia who have difficulties in eating and swallowing are often tube fed (TF). They suffer, on most occasions, from additional diseases. The effect of tube feeding in advanced dementia patients is controversial and is largely discussed in the medical literature. The purpose of the present study, is to report the effect of tube feeding on the survival time in patients with advanced dementia who suffered from additional diseases. One hundred and forty nine patients with Functional Assessment Stage of Alzheimer Disease (FAST) stage 5>, hospitalized in skilled geriatric nursing department between July 2008 and December 2011 were included in the study. Oral and tub feeding was decided following the evaluation by speech therapists at admission. 99 (66.5%) of the patients were tube fed and 50 (33.5%) received oral feeding at admission. The mean age was 80 ± 11. Sixty four percent of the patients were admitted from general hospitals. Comorbidities were significantly higher in the tube fed group, median survival time was 164 days. The median survival time of the OF group was 78 days (χ2 = 0.94;p = 0.33). Prevalence of tube feeding increased significantly from 53.85% to 90.9% in patients with 3 risk factors such as pressure ulcers, low Hgb and low BMI. The survival time of the tube fed patients was longer compared to patients who were orally fed. Tube feeding in patients with dementia continues to be controversial, and additional researchable data are helpful in the decision to insert a tube.

Knowledge and Tube Feeding Practices for Older Adult Patients among Japanese Registered Nurses

The aim of this study was to examine nurses’ thinking regarding the indications for tube feeding in older adults with eating difficulties and to determine whether the team approach can improve their knowledge and tube feeding practices. We sent self-administered questionnaires to 436 nurses and collected them from November to December 2010 (response rate, 70.0%). The results indicated that approximately 30% of the Japanese nurses thought that older patients with dementia should be on tube feeding and more than half of the nurses answered that tube feeding is indicated for aspiration-prone, frail, older adults. Moreover, our findings showed that nurses who organize multidisciplinary teams performed more interventions for dysphagia before introducing tube feeding than the reference group as analyzed by multivariate adjustment (odds ratio, 2.1-6.6). In conclusion, a multidisciplinary team approach is expected to make better decisions on the treatment and care of older patients with difficulty eating, including the need for tube

Comparison of the Clinical Outcomes of Early Enteral Nutrition Versus Convenience Diet by Tube Feeding Following Laryngectomy in Chinese Patients

The purpose of the present study was to evaluate the efficiency of early enteral nutritional support in patients undergoing laryngectomy. We retrospectively reviewed and analyzed 329 laryngeal cancer patients who underwent total or partial laryngectomy from November 2003 to July 2013 in our hospital. Of those patients, 278 were given enteral nutrition (EN group) with elemental formulations through a nasogastric tube beginning within 24 hours after the surgery, while 51 chose not to receive the elemental formulations and were on a homogenate diet (convenience diet group, CD group), which was also given through a nasogastric tube. The clinical outcomes were compared between the two groups. Thirteen patients in the EN group (13/278, 4.68%) and six patients in the CD group (6/51, 11.76%) developed fistulas. The difference was statistically significant (P < 0.046). The differences in the post-surgical infection rate, average length of hospitalization and other clinical indicators between the two groups were not statistically significant. In conclusion, early enteral nutrition should be recommended in patients undergoing laryngectomy, and convenience diet is not as effective as the commercial formulation in reducing the risk of fistula formation.

Nasogastric or nasointestinal feeding in severe acute pancreatitis

AIM:To assess the rate of spontaneous tube migration and to compare the effects of naso-gastric and nasointestinal(NI)(beyond the ligament of Treitz) feeding in severe acute pancreatitis(SAP).METHODS:After bedside intragastric insertion,tube position was assessed,and enteral nutrition(EN) started at day 4,irrespective of tube localization.Patients were monitored daily and clinical and laboratory parameters evaluated to compare the outcome of patients with nasogastric(NG) or NI tube.RESULTS:Spontaneous tube migration to a NI site occurred in 10/25(40%) prospectively enrolled SAP patients,while in 15(60%) nutrition was started with a NG tube.Groups were similar for demographics and pancreatitis aetiology but computed tomography(CT) severity index was higher in NG tube patients than in NI(mean 6.2 vs 4.7,P=0.04).The CT index seemed a risk factor for failed obtainment of spontaneous distal migration.EN trough NG or NI tube were similar in terms of tolerability,safety,clinical goals,complications and hospital stay.CONCLUSION:Spontaneous distal tube migration is successful in 40% of SAP patients,with higher CT severity index predicting intragastric retention;in such cases EN by NG tubes seems to provide a pragmatic alternative opportunity with similar outcomes.

Clinical application of dip-assisted endoscopic method for nasoenteric feeding in patients with gastroparesis and gastroesophageal wounds

AIM: To report the clinical experiences in the application of clip-assisted endoscopic method for nasoenteric feeding in patients with gastroparesis and patients with gastroesophageal wounds, and to compare the efficacy of nasoenteric feeding in these two indications. METHODS: From April 2002 to January 2004,21 consecutive patients with gastroparesis or gastroesophageal wounds were enrolled and received nasoenteric feeding for nutritional support. A clip-assisted method was used to place the nasoenteric tubes. Outcomes in the two groups were compared with respect to the successful rate of enteral feeding, percentage of recommended energy intake (REI), and complication rates. RESULTS: The gastroparesis group included 13 patients with major burns (n = 7), trauma (n = 2), congestive heart failure (n = 2) and post-surgery gastric stasis syndrome (n = 2). The esophageogastric wound group included eight patients with tracheoesophageal fistula (n = 2) and wound leakage following gastric surgery (n = 6). Two study groups were similar in feeding successful rates (84.6% vs 75.0%). There were also no differences in the percentage of REI between groups (79.4% vs 78.6%). Additionally, no complications occurred in any of the study groups. CONCLUSION: Nasoenteric feeding is a useful method to provide nutritional support to most of the patients with gastroparesis who cannot tolerate nasogastric tube feeding and to the cases who need bypass feeding for esophageogastric wounds.

Post-pyloric feeding

Postpyloric feeding is an important and promising alternative to parenteral nutrition. The indications for this kind of feeding are increasing and include a variety of clinical conditions, such as gastroparesis, acute pancreatitis, gastric outlet stenosis, hyperemesis (including gravida), recurrent aspiration, tracheoesophageal fistula and stenosis in gastroenterostomy. This review discusses the differences between pre- and postpyloric feeding, indications and contraindications, advantages and disadvantages, and provides an overview of the techniques of placement of various postpyloric devices.

Air flow exploration of abrasive feed tube

An abrasive water-jet cutting process is one in which water pressure is raised to a very high pressure and forced through a very small orifice to form a very thin high speed jet beam. This thin jet beam is then directed through a chamber and then fed into a secondary nozzle, or mixing tube. During this process, a vacuum is generated in the cham- ber, and garnet abrasives and air are pulled into the chamber, through an abrasive feed tube, and mixes with this high speed stream of water. Because of the restrictions introduced by the abrasive feed tube geometry, a vacuum gradient is generated along the tube. Although this phenomenon has been recog- nized and utilized as a way to monitor nozzle condition and abrasive flowing conditions, yet, until now, conditions inside the abrasive feed line have not been completely understood. A possible reason is that conditions inside the abrasive feed line are complicated. Not only compressible flow but also multi- phase, multi-component flow has been involved in inside of abrasive feed tube. This paper explored various aspects of the vacuum creation process in both the mixing chamber and the abrasive feed tube. Based on an experimental exploration, an analytical framework is presented to allow theoretical calculations of vacuum conditions in the abrasive feed tube.

神经重症患者留置双腔胃肠营养管护理专家共识

目的形成神经重症患者留置双腔胃肠营养管护理专家共识,推动护士规范、安全、有效地实施双腔胃肠营养管喂养,满足患者营养需求。方法检索、评价和汇总神经重症患者胃肠营养管护理的相关证据,提取相关的推荐意见,形成专家共识初稿,通过1轮专家函询和2轮专家论证会,结合专家意见修改、完善各条目内容,形成专家共识终稿。结果最终形成的专家共识包括神经重症患者双腔胃肠营养管喂养的操作性定义、置管适应证、置管禁忌证、置管及维护、拔管指征5个方面。结论形成的专家共识实用性较强,可为神经重症患者双腔胃肠营养管的临床护理实践和质量控制提供指导依据。

重氮试验在盲插鼻肠管时末端位置判断中的应用效果研究

目的探讨重氮试验在盲插鼻肠管后末端位置判断的应用效果。方法采用便利抽样法,选取2021年9月至2022年1月山东省某三级甲等医院重症监护病房(intensive care unit,ICU)进行盲插鼻肠管术的216名患者为研究对象。采用重氮试验、测pH值、观察回抽液性质三种方式预测鼻肠管末端位置,以X线摄片为判定的金标准,确认鼻肠管末端位置。比较重氮试验及其他两种方式预测的准确率、敏感度、特异度、阳性结果预测值(positive predictive value,PPV)、阴性结果预测值(negative predictive value,NPV)、阳性似然比(positive likelihood ratio,PLR)、阴性似然比(negative likelihood ratio,NLR)等指标。结果pH值判断的敏感度为97.7%、NPV为84.0%、NLR为0.045;回抽液性质判断的特异度为82.9%、PPV为95.5%、PLR为4.912;重氮试验方式的准确率为92.6%、Kappa系数为0.755;受试者操作特征曲线下面积最大为0.870,95%CI(0.793,0.947)。结论重氮试验判断盲插鼻肠管末端位置的准确率、一致性较好,具有较高的临床预测价值。

多感官刺激联合间歇经口至食管管饲法在老年脑卒中吞咽障碍的应用

目的观察多感官刺激联合间歇经口至食管管饲法在老年脑卒中吞咽障碍的应用效果。方法选择2021年2月至2022年10月收治的脑卒中吞咽障碍患者为研究对象,随机分为对照组、观察A组、观察B组,对照组在常规治疗基础上,采用鼻留置胃管管饲;观察A组在常规治疗基础上,采用间歇经口至食管管饲法;观察B组在观察A组基础上,加用多感官刺激方案。3组均干预8周,在干预前和干预8周后观察洼田饮水试验、标准吞咽功能评价量表(SSA)、吞咽困难生活质量量表(SWAL-QOL)、体质指数(BMI)、营养风险筛查表2002(NRS2002)以及舌骨喉复合体动度检查(舌骨上移距离、甲状软骨上移距离、舌骨前移距离、甲状软骨前移距离)。结果干预8周后,除对照组SWAL-QOL评分以外,其余3组洼田饮水试验、SSA评分和SWAL-QOL评分优于干预前(P<0.05)。而观察B组在洼田饮水试验与其余2组差异有统计学意义(P<0.05),SSA评分低于其余2组,SWAL-QOL评分高于对照组(P<0.05),与观察A组差异无统计学意义(P>0.05)。在营养情况方面,干预8周后3组BMI均高于干预前,NRS2002均低于干预前(P<0.05)。组间比较,3组BMI差异无统计学意义(P>0.05);在NRS2002方面,观察A组和观察B组均低于对照组(P<0.05),而观察A组和观察B组之间差异无统计学意义(P>0.05)。在喉复合体动度检查方面,干预8周后,除对照组舌骨上移距离,其余3组各项距离高于干预前(P<0.05)。观察B组舌骨上移距离、舌骨前移距离高于其余2组(P<0.05),甲状软骨前移距离、甲状软骨上移距离仅高于对照组,与观察A组差异无统计学意义(P>0.05)。结论多感官刺激联合间歇经口至食管管饲法作用于脑卒中吞咽障碍患者,能够改善患者的吞咽功能,提高生活质量,值得进一步研究。