The learning curve in blind bedside postpyloric placement of spiral tubes: data from a multicentre, prospective observational study.

OBJECTIVE: This study sought to quantify the learning curve for the blind bedside postpyloric placement of a spiral tube in critically ill patients. METHODS: We retrospectively analysed 127 consecutive experiences of three intensivists who performed comparable procedures of blind bedside postpyloric placement of a spiral tube subsequent to failed self-propelled transpyloric migration in a multicentre study. Each intensivist's cases were divided chronologically into two groups for analysis. The assessment of the learning curve was based on efficiency and safety outcomes. RESULTS: All intensivists achieved postpyloric placement for over 80% of their patients. The junior intensivist showed major improvement in both efficiency and safety outcomes, and the learning curve for both outcomes was approximately 20 cases. The junior intensivist showed a significant increase in the success rate of proximal jejunum placement and demonstrated a substantial decrease in the major adverse tube-associated events rate. The time to insertion significantly decreased in each intensivist as case experience accumulated. CONCLUSIONS: Blind bedside postpyloric placement of a spiral tube involves a significant learning curve, indicating that this technique could be readily acquired by intensivists with no previous experience using an adequate professional training programme.

Establishing Decision Trees for Predicting Successful Postpyloric Nasoenteric Tube Placement in Critically Ill Patients.

BACKGROUND: Despite the use of prokinetic agents, the overall success rate for postpyloric placement via a self-propelled spiral nasoenteric tube is quite low. METHODS: This retrospective study was conducted in the intensive care units of 11 university hospitals from 2006 to 2016 among adult patients who underwent self-propelled spiral nasoenteric tube insertion. Success was defined as postpyloric nasoenteric tube placement confirmed by abdominal x-ray scan 24 hours after tube insertion. Chi-square automatic interaction detection (CHAID), simple classification and regression trees (SimpleCart), and J48 methodologies were used to develop decision tree models, and multiple logistic regression (LR) methodology was used to develop an LR model for predicting successful postpyloric nasoenteric tube placement. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of these models. RESULTS: Successful postpyloric nasoenteric tube placement was confirmed in 427 of 939 patients enrolled. For predicting successful postpyloric nasoenteric tube placement, the performance of the 3 decision trees was similar in terms of the AUCs: 0.715 for the CHAID model, 0.682 for the SimpleCart model, and 0.671 for the J48 model. The AUC of the LR model was 0.729, which outperformed the J48 model. CONCLUSION: Both the CHAID and LR models achieved an acceptable discrimination for predicting successful postpyloric nasoenteric tube placement and were useful for intensivists in the setting of self-propelled spiral nasoenteric tube insertion.

Blind bedside postpyloric placement of spiral tube as rescue therapy in critically ill patients: a prospective, tricentric, observational study.

BACKGROUND: Various special techniques for blind bedside transpyloric tube placement have been introduced into clinical practice. However, transpyloric spiral tube placement facilitated by a blind bedside method has not yet been reported. The objective of this prospective study was to evaluate the safety and efficiency of blind bedside postpyloric placement of a spiral tube as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients. METHODS: This prospective, tricentric, observational study was conducted in the intensive care units (ICUs) of three tertiary hospitals. A total of 127 consecutive patients with failed spontaneous transpyloric spiral tube migration despite using prokinetic agents and still required enteral nutrition for more than 3 days were included. The spiral tube was inserted postpylorically using the blind bedside technique. All patients received metoclopramide intravenously prior to tube insertion. The exact tube tip position was determined by radiography. The primary efficacy endpoint was the success rate of postpyloric spiral tube placement. Secondary efficacy endpoints were success rate of a spiral tube placed in the third portion of the duodenum (D3) or beyond, success rate of placement in the proximal jejunum, time to insertion, length of insertion, and number of attempts. Safety endpoints were metoclopramide-related and major adverse tube-associated events. RESULTS: In 81.9% of patients, the spiral feeding tubes were placed postpylorically; of these, 55.1% were placed in D3 or beyond and 33.9% were placed in the proximal jejunum, with a median time to insertion of 14 min and an average number of attempts of 1.4. The mean length of insertion was 95.6 cm. The adverse event incidence was 26.0%, and no serious adverse event was observed. CONCLUSIONS: Blind bedside postpyloric placement of a spiral tube, as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients, is safe and effective. This technique may facilitate the early initiation of postpyloric feeding in the ICU. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR-OPN-16008206 . Registered on 1 April 2016.

Arg(972) insulin receptor substrate-1 is associated with elevated plasma endothelin-1 level in hypertensives.

OBJECTIVES: To explore the association among Arg(972) insulin receptor substrate-1 (IRS-1), hypertension, insulin resistance, and plasma levels of endothelial nitric oxide synthase (eNOS) and endothelin-1 (ET-1). METHODS: A total of 1030 patients, including 521 healthy controls, 142 patients with both primary hypertension and insulin resistance, 184 patients with primary hypertension but no insulin resistance, and 183 patients with insulin resistance but no hypertension were genotyped for the Arg(972) IRS-1 polymorphism. Serum levels of ET-1 and eNOS were determined by ELISA. Shear stress was applied to human umbilical vein endothelial cells (HUVECs) overexpressing wild type IRS-1 or Arg(972) IRS-1, and the mRNA and secreted protein levels of ET-1 were measured by real-time RT-PCR and ELISA, respectively. RESULTS: There was no significant difference in allelic frequency between patients with and without primary hypertension or insulin resistance, in the hypertensives, heterozygous Arg(972) IRS-1 carriers had significantly higher plasma ET-1 levels and blood pressure (BP) than the homozygous carriers. Although shear stress decreased ET-1 expression in control HUVECs as well as cells transfected with wild type Arg(972) IRS-1, it increased the mRNA dose-dependently and secreted protein levels of ET-1 in cells transfected with Arg(972) IRS-1. CONCLUSIONS: Based on both in-vivo and in-vitro data, we have shown a potential causal association between Arg(972) IRS-1 and elevated plasma ET-1 level in hypertensives, which may account for the aggravated hypertension observed in hypertensives with heterozygous Arg(972) IRS-1. This study for the first time provides insights into the role of Arg(972) IRS-1 in hypertension.

[The feasibility study of using the dual stylet method as a bedside measure in facilitating insertion of the spiral distal end nasal-enteral feeding tube in critically ill patients].

OBJECTIVE: To evaluate the feasibility of using the dual stylet method as a bedside measure after unsuccessful of the spiral distal end nasal-enteral feeding tubes into the duodenum in critically ill patients. METHODS: Spiral distal end nasal-enteral feeding tubes were introduced into the stomach of 50 critically ill patients but unable to pass through the pylorus from July 2005 to March 2007. Under electrocardiographic monitoring, the dual stylet method was used as a bedside measure to facilitate the passage. The duration, successful ratio, and complication of the procedure were recorded. RESULTS: This procedure took an average time of (24.5+/-4.9) minutes. The success rate of passing through the pylorus was 82.0% (41/50). The success rate of the latter 25 cases treated from July 2006 to March 2007 was significantly higher than that of the former 25 cases treated from July 2005 to July 2006 [96.0% (24/25) vs. 68.0% (17/25), P<0.05]. The average insertion distance of the 41 successful cases was (85.3+/-2.9)cm. Heart rate(HR) during the procedure was (116.7+/-18.5) beats per minute, that before insertion was (107.6+/-14.2) beats per minute (P<0.01), respiratory rate (RR) was (22.4+/-4.6)breaths per minute during the procedure and (21.3+/-3.9)breaths per minute (P<0.01) before the procedure and mean arterial pressure (MAP) (86.7+/-10.7) mm Hg during and (82.0+/-7.7)mm Hg (1 mm Hg=0.133 kPa, P<0.01) before the procedure. But there was no change in arterial oxygen saturation (SaO(2)). No severe complication was noted. CONCLUSION: The dual stylet method can be used effectively and safely in critically ill patients as a bedside measure after placement of the spiral distal end nasal-enteral feeding tubes.