Nonradiographic assessment of enteral feeding tube position

OBJECTIVE: To determine whether a clinical, nonradiographic criterion can be used to predict when the tip of a blindly placed feeding tube is in the small intestine. DESIGN: Prospective sample. SETTING: Pediatric intensive care unit at a tertiary care children's hospital. PATIENTS: Critically ill children requiring transpyloric feeding. INTERVENTIONS: The small bowel was intubated, using a blind, bedside transpyloric feeding tube placement protocol. The feeding tube was considered to be in the small bowel when <2 mL of a 10- mL aliquot of insufflated air could be aspirated from the feeding tube. This clinical criterion was confirmed with an abdominal radiograph. MEASUREMENTS AND MAIN RESULTS: Patient age ranged from 1 month to 19 yrs (median 6 months). Weight ranged from 2.2 to 60 kg (median 4.9). Median time to feeding tube placement was 10 mins (range 5 to 60). Eighty-nine percent of the patients were mechanically ventilated, while 28% of these patients were pharmacologically paralyzed. Seventy-five feeding tubes were inserted. There were no known complications. Ninety-nine (74/75) percent of the feeding tubes were positioned in the small bowel. The inability to aspirate insufflated air correctly predicted small bowel intubation with 99% certainty (Sequential Probability Ratio Test, p = .05 and power = .80). This test incorrectly predicted the position of only one feeding tube, the 26th, which was in the stomach. Of the 74 feeding tubes positioned in the small bowel, 13 feeding tubes were in the duodenum and 61 were in the jejunum. CONCLUSIONS: The inability to aspirate insufflated air confirms the transpyloric position of a feeding tube. Other clinical criteria did not successfully predict small bowel intubation. Use of this single test may obviate confirmatory abdominal radiographs in carefully selected patients and may lead to more cost-effective and timely initiation of enteral feedings.     

A randomized study of a pH sensor feeding tube vs a standard feeding tube in patients requiring enteral nutrition

RATIONALE AND OBJECTIVES: A survey of chief residents of academic radiology programs is conducted annually on behalf of the American Association of Academic Chief Residents in Radiology (A3CR2). Data are obtained to improve the training of diagnostic radiology residents and to increase the understanding of radiologists and their associates about issues of interest to radiologists in training. METHODS: Questionnaires were mailed to 133 accredited programs in the United States and Canada. A wide variety of demographic and common interest questions were asked. The analysis took into account geographic location of the responders and the size of the residency program. Comparisons were made to the data from prior years. RESULTS: Completed surveys from 93 programs (70%) were returned. The percentage of women residents is increasing. Important regional and size variations exist in several areas including salary, workload, prior clinical training, resident/fellow ratios, post residency plans, and call schedules. Although many chief residents feel knowledgeable about the health care system, opinions about the future of radiology and medical care are tentative. CONCLUSIONS: This survey provides important demographic information about academic radiology residency programs. The summary information regarding plans for fellowship training, resident call schedules, and opinions about socioeconomic issues may be useful for chief residents, program directors, and departmental chairmen.     

Outcome of long-term enteral feeding

In the past two decades, many technical advances have made tube enteral feeding much more comfortable and acceptable to patients and their families. This has greatly expanded the use of this therapy, both in clinical conditions where it was traditionally prescribed and in many other diagnoses. This expanded use raises important questions about how much enteral nutrition is being used, the medical outcome in different clinical conditions, and the quality of life experienced by long-term therapy users. This article addresses these outcome issues for patients in the nonhospital setting.     

Feeding tubes for tube feeding

Several techniques are available for the provision of enteral nutritional support. Nasal tubes, gastrostomy tubes and jejunostomy tubes can be distinguised. Nasal tubes are used for short-term support, gastrostomy tubes (preferably via a percutaneous endoscopic gastrostomy) for long-term support (over 4 to 6 weeks), while (needle catheter) jejunostomy tubes are most often used to provide early enteral nutrition immediately after operations on the proximal gastrointestinal tract. The most frequent complications are: with the nasal tube dislodging, clogging and aspiration, with the gastrostomy tube peristomal infection and with the jejunostomy tube, obstruction. It should further be noted that the quantity of enteral nutrition prescribed and that actually administered may differ substantially so that patients with a feeding device may even become malnourished. With proper patient selection and secure control of the energy balance, feeding tubes are simple (temporary) devices that improve the patient's health and quality of life.     

Ethical issues in instituting and discontinuing enteral feeding

The authors present the results of a study to determine the serological prevalence of the enzootic bovine leukosis virus among dairy cows in the Sabana de Bogotá region and the Ubaté and Chiquinquirá Valleys, the principal dairying areas of Colombia. Samples were taken from 919 animals selected at random from 420 farms in 51 municipalities, in accordance with a statistical sampling procedure developed previously, based on the cattle census maintained by the Animal Health and Disease Control Office of the Instituto Colombiano Agropecuario, and the recommendations for prevalence studies of the Pan American Health Organization. The double gel diffusion technique with gp-51 antigen was used. Serological prevalence averaged 45.28% (ranging from 42.07% to 48.49%) with a confidence level of 95%. In addition, a survey was conducted to determine how much those in charge of herds knew about the disease, and to establish the incidence of certain risk factors possibly associated with distribution of the causal agent. Data obtained from 232 completed questionnaires showed that only 54.6% of farms received professional assistance. Of these, 6.6% received constant assistance, 4.4% received visits every fortnight, 51.8% received monthly visits, 14% received visits every other month and 22.95% received occasional visits.     

A primate model for enteral nutrition by tube

To establish an animal model for the controlled study of enteral nutrition by tube, five adult chair-adapted primates (Macaca fasicularis) had gastrostomy and jejunostomy tubes placed for the delivery of a modified protein isolate diet. Following 7 days of postoperative depletion with a hypocaloric infusion of dextrose (20 kcal, 0 g N/kg/day), the animals were repleted for 10 days with tube feedings (124 kcal, 0.73 g N/kg/day). There was no operative mortality or morbidity and each animal demonstrated conversion to anabolism by significant weight gain, positive nitrogen balance, and net protein synthesis as determined by [15N]glycine protein turnover rates. Significant correlation was found between caloric intake and nitrogen balance at the level of nitrogen provided in this diet (r = 0.88, p less than 0.05). This model was found to be well suited for the surgical and nutritional techniques required for the long-term study of enteral nutrition by tube.     

Clinical experience with early enteral feeding in very-low-birth-weight infants

We investigated dorsal shift and anteroposterior spinal cord diameter after expansive open-door laminoplasty, comparing pre- and postoperative computed tomographic myelographic images to clarify the relationships between surgical outcome and these changes. Dorsal shift occurred at the midcervical spine in cervical spondylotic myelopathy (CSM) but was less extensive in ossification of the posterior longitudinal ligament (OPLL). Spinal cord anteroposterior diameter expanded for OPLL but did not for CSM. Correlation of outcome and dorsal shift was not significant for OPLL or CSM. Correlation of outcome and expansion was significant for OPLL, but not for CSM.     

Early postoperative enteral feeding following major upper gastrointestinal surgery

For a variety of reasons, enteral feeding is frequently delayed following major abdominal surgery. The purpose of this study was to evaluate prospectively the feasibility and tolerance of early jejunal feeding following major upper gastrointestinal surgery. Beginning on postoperative day 1, patients (n = 167) received a full-strength enteral formula at the rate of 25 ml/hr through a jejunal feeding tube. Diets were advanced to the calculated target rate (25 kcal/kg/day) by postoperative day 4. Complications of tube feeding, calories received, and patient symptoms were recorded daily. There were no major complications or deaths resulting from placement of a jejunal tube or from early enteral feeding. Patients had abdominal symptoms such as cramping, distention, nausea, and diarrhea on 9%, 18%, 4%, and 24% of all feeding days, respectively. The majority of these symptoms, with the exception of diarrhea, were graded as mild. Patients undergoing surgery for pancreatic malignancy had significantly more diarrhea than patients undergoing esophagectomy or gastrectomy. Despite these differences in symptoms, patients received an average of 78% of their targeted caloric goal by postoperative day 4 and maintained this level throughout the study. Early enteral feeding for patients undergoing esophageal, gastric, or pancreatic resections is both safe and feasible despite the occurrence of predominantly mild gastrointestinal symptoms.     

Simplified insertion of a transpyloric feeding tube

Placement of a transpyloric feeding tube is a common procedure done through a previous gastrostomy site. Conventional fluoroscopic and endoscopic methods can be tedious because of the difficulty in cannulating the pylorus. Described here is a simplified method to place a transpyloric feeding tube under fluoroscopy.     

Small-bowel necrosis associated with jejunal tube feeding

OBJECTIVE: This paper reports the results of a prospective randomized double-blind trial on the effects of pre-operative clonidine on platelet aggregation. METHODS: Thirty adult (ASA I-II) patients undergoing elective minor orthopaedic surgery were randomly allocated into three groups of ten patients each. In group I clonidine 2 microg x kg(-1), in group II clonidine 4 microg x kg(-1) and in group III saline placebo was administered intravenously before the induction of anaesthesia. Anaesthesia was induced with propofol and vecuronium and maintained with halothane-nitrous oxide. Platelet counts and aggregation tests were performed before (t0) and 1 h (t1) and 24 h (t24) after administration of the study drug. RESULTS: Changes in platelet counts among the groups and values over time were not significant. Both maximum rate and intensity of collagen-induced aggregation in both clonidine groups and maximum intensity of adenosine 5'-diphosphate (ADP)-induced aggregation in the high-dose clonidine group increased significantly at t1. However, all these increases in aggregation were within the normal ranges. CONCLUSION: The effects of both low and high doses of clonidine on platelet aggregation appeared to be minor, and we did not observe any increases above the normal ranges.     

Enteral tube feeding of small animals in practice: nasoesophageal tube and percutaneous gastrostomy tube

Enteral force feeding via a feeding tube is a widely accepted, but rarely used technique in practice. Two simple methods are discussed: the nasoesophageal tube, which can be positioned quickly without the need of general anaesthesia for diseases of predictably short duration and the percutaneous gastrostomy tube, which is placed blindly under short general anaesthesia without endoscopic or surgical procedures and which is designed for month long force feeding.     

Plasmapheresis in the treatment of inadvertent intravenous infusion of an enteral feeding solution

This 50-year-old man was on enteral full-strength Ensure through the jejunostomy tube. The enteral feed was accidentally infused through the peripheral intravenous line. He went into a septic state with hypotension, hypoxemia, and increased pulmonary shunting requiring ventilatory and inotropic support. We instituted two cycles of plasmapheresis in an attempt to remove any foreign antigen and toxins present. This resulted in improved oxygenation, rapid recovery, and discharge from intensive care. His blood culture grew Klebsiella species that was consistent with the organism grown from the culture of the Ensure feeds.     

Decisions about prostate cancer screening in managed care

The primary object of this research project was to establish the amount of incisor retraction to be expected during full fixed mechanotherapy and to generate regression models that could provide more accurate prediction of each of the three most popular combinations of symmetrical premolar extractions, where extraoral anchorage would not be used. Pretreatment and posttreatment records of 73 cases that had their four first premolars extracted (group 44), 74 cases with four second premolar extractions (group 55), and 59 cases with upper first and lower second premolar extractions (group 45) were selected. All these cases were treated by one orthodontist, who used the same edgewise technique throughout. The results indicate that, on average, maxillary retraction in relation to the facial plane (N Po) differed only slightly between group 55 (mean 4.2 +/- 2.4 mm) and group 44 (mean 4.7 +/- 2.3 mm), with relatively more retraction for group 45 (mean 6.6 +/- 2.5 mm; p < 0.05). In contrast, the mandibular incisors were retracted slightly more in group 44 than in the other two groups (p < 0.05). The regression models that were developed could be useful as an additional tool to assist the practitioner in the selection of which teeth to extract for a particular case.     

Endoscopic nasoenteral feeding tube placement following cardiothoracic surgery

Intraluminal incision is often used for the treatment of strictures of both the upper and the lower urinary tracts. The depth of the stricture and the location of surrounding structures such as blood vessels are important factors in guiding the incision. Endoluminal ultrasonography has been shown to be effective in defining periureteral anatomy accurately. A new device is described that combines an endoluminal ultrasound transducer and cutting device (electrocautery or laser fiber) in 9F catheter. This catheter was evaluated in two live anesthetized pigs (four kidneys) and four ex-vivo kidneys. Incisions were made at the ureteropelvic junction and middle and distal ureter. The ability to image the periureteral structures and to direct the location and the adequacy of the incision were assessed. Endoluminal ultrasound imaging was excellent, and the electrocautery wire was well seen. Well-defined, limited, full-thickness incisions were made using this device and could be directed accurately toward or away from periureteral vessels. This study demonstrates the potential for endoluminal ultrasound guidance of intraluminal incisions.