ABSTRACT
The COVID-19 pandemic presented clinical and logistical challenges in the delivery of adequate nutrition in the critical care setting. The use of neuromuscular-blocking drugs, presence of maxilla-facial oedema, strict infection control procedures, and patients placed in a prone position complicated feeding tube placement. We audited the outcomes of dietitian-led naso-jejunal tube (NJT) insertions using the IRIS (Kangaroo, USA) device, before and during the COVID-19 pandemic. NJT placement was successful in 78% of all cases (n = 50), and 87% of COVID-19 cases. Anaesthetic support was only required in COVID-19 patients (53%). NJT placement using IRIS was more difficult but achievable in patients with COVID-19.Copyright © The Intensive Care Society 2023.
ABSTRACT
Introduction: Sufficient nutrition has been repeatedly demonstrated to be a vital part of recovery from critical illness.1 Nutrition is often delivered in the intensive care setting via a Nasoenteral (NE) tube if oral diet is impractical or inadequate;this is first line as per ESPEN guidance.2 It has been observed that patients in the intensive care unit (ICU), particularly those who have been intubated due to COVID-19, are at high risk of agitation and delirium which can lead to accidental NE displacement. Nasal Loop Bridles (NLB) are amedical device which can be placed at bedside and are used to reduce the risk of NE tube displacement. The usage of NLBs varies between Trusts. Insertion of a NLB is a medical procedure which should be consented for where possible and clearly documented. Objectives: To identify all patients who had a NLB placed during the second wave of the COVID-19 pandemic at Royal Surrey Hospital (RSH) ICU, ascertain their reason for insertion, and identify any nutritional deficits incurred prior to NLB insertion. Secondary objectives include assessing quality of documentation of NLB insertion. Methods: A literature review was undertaken regarding the safety and efficacy of NLBs. This was followed by a retrospective observation of patients admitted to RSH ICU between December 2020 and March 2021. Data was collected on patients who required a NLB, including accrued nutritional deficit prior to placement and adverse incidents. Documentation of NLB rationale and placement was also noted. Results: 10 patients met inclusion criteria. The most common indications for insertion were delirium and previous tube displacement. Two NLBs were placed prior to any NE displacements therefore resulted in no nutritional losses. In the remaining patients a range of 1-5 NE tubes were accidentally displaced prior to NLB insertion (mean 2.7 tubes). 6-117 hours of feeding were lost prior to NLB placement resulting in a deficit of 744-6843kcal. Two patients were unable to have a NLBwhen indicated due to stock shortages, resulting in a deficit of 4140 and 6480kcal. No standard documentation was utilised for NLB placement. No major incidents occurred in relation to NLBs. Conclusion: This study highlights the benefits of NLBs in respect to nutritional delivery in patients who have undergone emergency sedation and ventilation and are at risk of delirium. It has also highlighted the need for improved documentation of this medical procedure. Inferences made from this study, and work by other centres identified in the literature review, suggest that it may be beneficial to consider early or prophylactic NLB placement in this cohort. Further local research could test criteria for use of NLBs including hyperactive delirium, difficulty of initial NE tube insertion and number of previous displaced tubes, in order to elucidate the most effective timing and indication for their use.