Nasointestinal tube placement: Techniques that increase success.

Background: Delayed gastric emptying (DGE) is a major cause of undernutrition that can be overcome using nasointestinal (NI) feeding, but tube placement often fails. We analyse which techniques enable successful NI tube placement. Methods: Efficacy of tube technique was determined at each of six anatomical points: Nose, nasopharynx-oesophagus, stomach-upper and -lower, duodenum part-1 and intestine. Results: In 913 first NI tube placements, significant associations with tube advancement were found in the pharynx (head tilt, jaw thrust, laryngoscopy), stomach_upper (air insufflation, 10 cm or 20-30 cm flexible tube tip ± reverse Seldinger manoeuvre), stomach_lower (air insufflation, possibly flexible tip and wire stiffener) and duodenum part-1 and beyond part-2 (flexible tip and combinations of micro-advance, slack removal, wire stiffener or prokinetic drugs). Conclusion: This is the first study to show what techniques are associated with tube advancement and the alimentary tract level they are specific to.

Integrated real-time imaging system, 'IRIS', Kangaroo feeding tube: a guide to placement and image interpretation.

BACKGROUND: Lung complications occur in 0.5% of the millions of blind tube placements. This represents a major health burden. Use of a Kangaroo feeding tubes with an 'integrated real-time imaging system' ('IRIS' tube) may pre-empt such complications. We aimed to produce a preliminary operator guide to IRIS tube placement and interpretation of position. METHODS: In a single centre, IRIS tubes were prospectively placed in intensive care unit patients. Characteristics of tube placement and visualised anatomy were recorded in each organ to produce a guide. RESULTS: Of 45 patients having one tube placement, 3 were aborted due to refusal (n=1) or inability to enter the oesophagus (n=2). Of 43 tubes placed beyond 30 cm, 12 (28%) initially entered the respiratory tract but all were withdrawn before reaching the main carina. We identified anatomical markers for the nasal or oral cavity (97.8%), respiratory tract (100%), oesophagus (97.6%), stomach (100%) and intestine (100%). Organ differentiation was possible in 100%: trachea-oesophagus, oesophagus-stomach and stomach-intestine. Gastric tube position was confirmed by aspiration of fluid with a pH <4.0 and/ or X-ray. Trauma was avoided in 13.6% by identifying that the tube remained in the nasal lumen in the presence of a base of skull fracture (n=3) and in the stomach in the presence of recently bleeding polyps or mucosa (n=3). A systematic guide was produced from records of tube placement and interpretation of anatomical images. CONCLUSION: By permitting real-time confirmation of tube position, direct vision may reduce risk of lung complications. The preliminary operator guide requires validation in larger studies.

Tube placement using 'IRIS': A pilot assessment of its utility and safety.

INTRODUCTION: Most critically ill patients have a feeding tube placed blindly, but 0.5% result in a major lung complication because misplacement is only detected at the end of procedure. Real-time guided tube placement may pre-empt such complications. This clinical effectiveness study examined the ability to visualise anatomy using Kangaroo™ feeding tubes with IRIS technology ('IRIS' tube). METHODS: In a single centre, gastric or intestinal integrated real-time imaging system (IRIS) tubes were prospectively placed in critically ill patients noting the anatomical visualisation. RESULTS: Of 15 placements, 13 were successful gastric placements and used for feeding but one gastric and one intestinal placement failed because of signal loss and inability to find the pylorus, respectively; both tubes were removed. Air insufflation and fluid aspiration were possible with all tubes. Respiratory misplacement was clearly differentiated, prior to reaching the main carina, from gastrointestinal (GI) anatomical markers, permitting removal before causing trauma. Furthermore, non-traumatic placement was visualised in high-risk cases including during advancement through a nostril with a base of skull fracture and into a stomach with a recently haemorrhaging gastric polyp. Individually assessed, direct vision may offer greater safety. X-ray or pH of aspirated fluid confirmed the position of GI tube placements. One adverse event occurred during placement, reversible bradycardia, in a patient previously having bradycardia. Vision was intermittently obscured by bile, mucus or impaction with mucosa. CONCLUSION: 'IRIS' tubes offer real-time guidance regarding anatomical position. Larger studies are needed to establish the best techniques of deploying this equipment and over-coming the difficulties observed.

Cortrak feeding tube placement: accuracy of the 'GI flexure system' versus manufacturer guidance.

Electromagnetic (EM) guided enteral tube placement may reduce lung misplacement to almost zero in expert centres, but more than 60 undetected misplacements had occurred by 2016 resulting in major morbidity or death. AIM: Determine the accuracy of manufacturer guidance in trace interpretation against what is referred to as the 'GI flexure system'. METHODS: The authors prospectively observed the accuracy of the 'GI flexure system' of trace interpretation against manufacturer guidance in primary nasointestinal (NI) tube placements. FINDINGS: Contrary to manufacturer guidance, 33% of traces deviated >5 cm from the sagittal midline and 26.5% were oesophageal when entering the lower left quadrant, incorrectly indicating lung and gastric placement, respectively. Conversely, the GI flexure system identified ≥99.4% of GI traces when they reached the gastric body flexure; 100% at the superior duodenal flexure. All lung misplacements were identified by the absence of GI flexures. CONCLUSION: Current manufacturer guidance should be updated to the GI flexure system of interpretation.