Do nasogastric tubes worsen dysphagia in patients with acute stroke?

BACKGROUND: Early feeding via a nasogastric tube (NGT) is recommended as safe way of supplying nutrition in patients with acute dysphagic stroke. However, preliminary evidence suggests that NGTs themselves may interfere with swallowing physiology. In the present study we therefore investigated the impact of NGTs on swallowing function in acute stroke patients. METHODS: In the first part of the study the incidence and consequences of pharyngeal misplacement of NGTs were examined in 100 stroke patients by fiberoptic endoscopic evaluation of swallowing (FEES). In the second part, the effect of correctly placed NGTs on swallowing function was evaluated by serially examining 25 individual patients with and without a NGT in place. RESULTS: A correctly placed NGT did not cause a worsening of stroke-related dysphagia. Except for two cases, in which swallowing material got stuck to the NGT and penetrated into the laryngeal vestibule after the swallow, no changes of the amount of penetration and aspiration were noted with the NGT in place as compared to the no-tube condition. Pharyngeal misplacement of the NGT was identified in 5 of 100 patients. All these patients showed worsening of dysphagia caused by the malpositioned NGT with an increase of pre-, intra-, and postdeglutitive penetration. CONCLUSION: Based on these findings, there are no principle obstacles to start limited and supervised oral feeding in stroke patients with a NGT in place.

Serum procalcitonin in cerebral ventriculitis.

OBJECTIVES: The objective of this study was to test the hypothesis that serum procalcitonin is increased in patients with bacterial cerebral ventricular infections after the insertion of temporary external ventricular drains. PATIENTS AND METHODS: This open, prospective study included patients requiring temporary external ventricular drains for various neurologic conditions such as intracerebral hemorrhage with ventricular hemorrhage or space-occupying lesions in the posterior fossa (cerebellar infarctions or hemorrhages). Patients experiencing primary central nervous system infection or sepsis were excluded. Procalcitonin, C-reactive protein, and white blood cell count were measured daily. Cerebrospinal fluid was investigated every other day, including cerebrospinal fluid cell count, lactate, glucose, and cerebrospinal fluid culture. Results were categorized according to presence of bacterial cerebrospinal fluid infection as determined by positive cerebrospinal fluid cultures. RESULTS: A total of 34 consecutive patients were included. Procalcitonin was significantly higher (4.7 vs. 0.2 ng/mL) in patients with proven bacterial ventriculitis. Cerebrospinal fluid cell count (456 vs. 478 cells/microL) could not distinguish bacterial infection from abacterial reactions, mainly because of blood contamination of the cerebrospinal fluid. CONCLUSION: Cerebrospinal fluid of patients treated with temporary external ventricular drains is frequently characterized by blood contamination because of the insertion procedure, the underlying neurologic disorder such as ventricular hemorrhage, or the presence of an abacterial chemical ventriculitis. Thus, diagnosis of a bacterial ventricular infection requiring immediate antibiotic therapy is less certain. Serum procalcitonin adds to the diagnostic precision in bacterial ventriculitis.