e132

Chapter

37Feeding Tube PlacementLawrence J. caruso and DanieL r. Layon

InTroducTIon

Critically ill patients will almost invariably require nutri-tional intervention. Current guidelines support the prefer-ential use of enteral nutrition over parenteral nutrition (1). While parenteral nutrition can effectively deliver protein and calories, it does not prevent intestinal mucosal atrophy (2,3). It is now well recognized that the healthy gut mucosal layer provides a barrier to pathogen invasion (4,5). Micro-bial invasion through the gut into the systemic circulation is thought to represent a major cause of the nosocomial sepsis, and possibly the multiple organ dysfunction, seen with critical illness (6–9).

Enteral nutrition is preferable to parenteral in terms of cost, complications, gut mucosal maintenance, and metabolic and immune function (10–13). However, feeding the patient via the gastrointestinal tract is not without challenges. Enteral feed-ing is commonly frustrated by gastric dysmotility, aspiration, diarrhea, and occasionally intestinal ileus (14). Feeding intol-erance, fluid restrictions, and metabolic derangements further limit attempts to establish total enteral support. Appropriate gastrointestinal access can also be challenging to obtain and maintain, and may require surgical placement. Often, after successful access placement, feeding tubes become occluded by inspissated feeds or medications, become dislodged, or are inadvertently removed.

Mechanical complications of feeding tube placement can be life threatening. In deeply sedated or comatose patients, inad-vertent placement of a nasoenteral tube into the bronchial tree is not uncommon. Percutaneous tube placement can be compli-cated by bowel perforation or insertion site infection. Thought-ful consideration of the appropriate tube placement method as well as careful technique will minimize complications.

Fortunately, there are a multitude of commercially available tube designs and a variety of placement techniques to meet most needs. The choice of tube type, access site, and place-ment technique will depend on a number of considerations including each patient’s unique requirements, clinician prefer-ence, and even available resources. This chapter will review the assortment of tube types, the differences between gastroin-testinal placement sites, and the variety of access options avail-able. In addition, it will describe the decision-making process required for choosing the best combination of tube, site, and method of placement.

deTermInIng The mosT APProPrIATe Tube TyPe, sITe, And PlAcemenT TechnIque

When considering the initiation of enteral feeding, the clini-cian must first decide on the most appropriate type of tube

to employ, the region in the gastrointestinal tract in which to place the tube, and the technique to access the lumen. Several factors influence the ultimate decision (15).• Duration of enteral feeding• Current status of the patient• Coexisting medical conditions• Functional status of the gastrointestinal tract• Previous abdominal surgeries• Tube brands in stock• Availability of radiologic, gastroenterologic, and surgical

support

Duration of Enteral Feeding

The initial consideration is the anticipated duration of enteral feeding. Based on the patient’s current status and comorbid-ity, it must be estimated whether the access requirement is to be short, intermediate, or long term. The distinction between the three classifications is somewhat artificial and there are no absolute time separations.

Short Term

Short term usually implies the need for enteral feeding for up to 2 weeks in duration. Short-term enteral feeding is com-monly used for patients who tend to be free of significant underlying medical conditions, such as trauma victims and younger patients who undergo uncomplicated major surgery. In most of these patients, access requirements can be satisfied by placing the tube into the gastrointestinal tract using the nasal approach. These tubes are considered to be temporary in that they can be easily removed when they are no longer required. Placement techniques tend to be relatively inexpen-sive and minimally invasive, and carry a low complication rate. Although these tubes easily dislodge, replacement is usu-ally straightforward.

Long Term

Long-term enteral access can be defined as the need to admin-ister enteral nutritional support for an extended period of time or even permanently. Some authors describe long-term support as that requiring access for more than 4 to 6 weeks (16,17). Regardless of the time, the important consider-ation for these patients is that the tube needs to be more permanently secured. In most cases, nasally placed tubes are not adequate. For this subgroup of patients, tube place-ment tends to be more invasive and more expensive and has greater potential for complications. It also usually requires surgical or percutaneous procedures. Patients requiring long-term enteral nutrition are those whose illness is such that recovery will be delayed or permanently incomplete. These patients typically are older, have significant comorbid condi-tions or end-stage organ dysfunction, and have had a serious acute event.

LWBK1580_C37e_p132-140.indd 132 31/07/17 5:36 PM

Chapter 37 Feeding Tube Placement e133

Intermediate Duration

Intermediate duration is also a relative term but encompasses all patients with requirements for enteral feeding access for greater than 2 weeks but less than 6 to 8 weeks. These patients can be served by any of the available access routes. Though nasally placed tubes are less secure, the ease of replacement can often extend their use for the duration of their necessity. Tubes placed percutaneously or surgically tend to be consid-ered permanent but can be removed without much difficulty should feeding access no longer be necessary. In most cases, the decision can be based on factors such as previous abdominal surgery and the availability of resources.

Site of Tube Placement and Technique

Although the patient’s current medical status and comorbid conditions indirectly influence the choice of tube by their effects on the duration of tube utilization, these factors also directly impact the choice of placement site and technique. The more critically ill patients are less likely to tolerate a surgical or endoscopic procedure. In these patients, if enteral feeding is desired, less invasive techniques such as nasal access can be used temporarily until conditions are more conducive to long-term access placement. Patients with complications such as intestinal fistulae, laparotomy wound infections, open abdo-mens, or sepsis from other sources also may be inappropriate for surgically or percutaneously placed tubes. Other groups at increased risk for complications with surgically or percu-taneously placed tubes include obese patients and those with diabetes, cancer, malnutrition, immunocompromised condi-tions, end-stage liver disease, cirrhosis, ascites, renal failure, uremia, thrombocytopenia, coagulopathy states, and significant heart disease.

Inadequate gastric emptying is common in critically ill patients, occurring in roughly half of general intensive care unit (ICU) patients and up to 80% of patients with traumatic brain injury (18–20). Interleukin-1, a cytokine released dur-ing stressed states, has been shown to delay gastric emptying when administered to rats (21). Many underlying conditions such as diabetes mellitus, medication use, gastritis, sepsis, and electrolyte abnormalities also affect gastric emptying (22). Due to concerns about inadequate gastric emptying and potential aspiration, many physicians feel compelled to place the tip of the feeding tube in the small bowel. However, while postpylo-ric feeding has a lower incidence of gastroesophageal regurgi-tation and a trend toward less aspiration compared to gastric feeding (23), evidence that postpyloric feeding improves out-comes is somewhat lacking.

The Canadian Critical Care Nutrition Guidelines recom-mended feeding in the small bowel whenever feasible (1). Small bowel feeding improves nutrient delivery and may reduce the risk of pneumonia, although there is no difference in ventilator days or mortality compared to gastric feeding (24). Given this data, it seems reasonable to place the feeding tube postpyloric whenever feasible. However, attempts at postpyloric place-ment should not unduly delay the start of enteral nutrition, as gastric feedings are often well tolerated.

The extra workload and cost to place the feeding beyond the pylorus is not trivial. While nasogastric tubes can typically be placed fairly easily, placement of postpyloric tubes has his-torically involved multiple attempts, usually with each attempt

followed with a radiograph. If the tube cannot be properly positioned with a blind technique, endoscopy or fluoroscopy may be required, the latter requiring a trip out of the unit with the associated costs and personnel requirements. Recently developed bedside techniques that improve the success of tube placement are discussed below.

bedsIde TechnIques

Motility Agents

If gastric feeding is used, the addition of a promotility agent may be helpful. Metoclopramide increases upper gastroin-testinal motility by blocking dopamine receptors. It has been shown to improve gastric emptying and decrease gastric resid-ual volumes in ICU patients (25–27). Erythromycin, a macro-lide antibiotic that is also a motilin agonist, increases gastric emptying and tolerance to gastric feeding (27–29). The com-monly used dose is 200 mg, but 70 mg may be just as effective (30). Unfortunately, patients often develop tachyphylaxis to the drugs after several days, requiring close monitoring of gas-tric volumes and feeding tolerance (27). Safety concerns should be taken into account when using motility agents. Metoclo-pramide is associated with movement disorders, which may be irreversible. Erythromycin can prolong the Q-T interval and has many drug interactions.

Functional Status of Gastrointestinal Tract

The functional status of the gastrointestinal tract also may influence the technique of tube placement in other ways. Gas-troesophageal disease or obstruction may preclude the ability to pass tubes nasally and may also make percutaneous tube placement using the endoscopic approach difficult or impos-sible. Adhesions from previous upper abdominal surgeries or the anatomic alterations seen after procedures such as gastrec-tomy or pancreaticoduodenectomy diminish the likelihood of endoscopic and radiologic placement and may make a surgical placement more complicated.

Hospital Resources

Hospital resources—both supplies and personnel—also influ-ence the decision-making process. Hospitals may have a limited selection of tube products, as the cost has become a significant determinant of hospital purchasing. Because many tube designs are similar, substitutions can be successful, and the inability to obtain a specific tube should not preclude the use of enteral nutrition. Human resources also vary from facil-ity to facility. Not all hospitals offer equal expertise in each of the support services required. The choice between radiologic, gastroenterologic, or surgical support may be based to some degree on the strength and weaknesses of these departments within the hospital.

Summary

The selection of the most appropriate tube type, access site, and placement technique for the critically ill is based on the consideration of these interrelated factors. Therefore, the final decision varies from patient to patient. Success is never

LWBK1580_C37e_p132-140.indd 133 31/07/17 5:36 PM

e134 SeCtion 4 Techniques, ProceDures, anD TreaTmenTs

ensured but occurs most often when all of the dependent variables are considered and the approach is flexible to allow for change when the situation warrants creativity. To aid in the decision-making process, a useful algorithm is provided (Fig. 37.1).

Tube oPTIons And desIgns

Currently, a large variety of tube designs are commercially available. For nasal placement, tubes tend to be thin, soft, and flexible. Most are polyvinyl chloride, silicone, or polyurethane. Many are weighted at the tip with mercury, whereas others are unweighted. Most contain a thin metal stylet to assist in place-ment. All are radiopaque to enable confirmation of position by radiographic study. Their soft, flexible construction and nar-row diameter enables these tubes to be well tolerated by the patient. However, these tubes are prone to occlusion, particu-larly if feeding is interrupted without irrigating the tube free of formula and when the tube is used for the delivery of crushed or dissolved medications.

Percutaneous

Percutaneously placed tubes also come in a variety of com-mercially prepared designs. These tubes tend to be wider in diameter than those used for nasal placement, which decreases but does not completely eliminate the likelihood of occlusion. Placement requires fluoroscopic or endoscopic assistance to direct the tube into the appropriate lumen after skin puncture. These tubes are less likely to dislodge but can leak, cause pain at the insertion site, and induce a local soft tissue infection. With long-term use, they also may begin to deteriorate. Some models have separate ports for simultaneous jejunal feeding and gastric decompression. Most are secured from within the

lumen of the viscus by a small flange or balloon contained within the tip; removal may require endoscopy.

Surgical

The choices for surgical access are also extensive. Balloon- and mushroom-tipped soft rubber tubes are commonly used for gastrostomy tubes. These have a wide bore and are flex-ible. Like their percutaneously placed counterparts, they may leak, cause pain at the insertion site, and induce a local soft tissue infection. The rubber tubes also have been known to deteriorate with time. Some models on the market have mul-tiple lumens and ports to allow for gastric decompression and jejunal nutrient infusion.

Jejunostomy Tubes

Feeding tubes used for jejunal access tend to be smaller in diameter than surgically placed gastrostomy tubes but larger than the nasally inserted models. In the early 1970s, the needle catheter jejunostomy was introduced (31). This consisted of a tube similar in design to those used for nasal insertion in that it was extremely narrow in diameter. Although easy to insert, the needle catheter jejunostomy has fallen from favor because it is a poor conduit for most enteral formulas. The small tube size employed was prone to kinking and frequently was too nar-row to allow rapid flow of the more viscous feeding solutions (15,32), and the small diameter did not allow for medication administration through the tube. Other acceptable options for jejunostomy placement include soft rubber tubes and biliary T tubes. Their wider internal diameter improves infusion and decreases the likelihood of occlusion. Red rubber or Robin-son catheters are excellent choices. Unfortunately, these tubes are prone to dislodgement and need to be secured diligently. Balloon- and mushroom-tipped tubes are less susceptible to

Blind passage

Nutrition support indicated

Enteral nutrition

Parenteral nutrition

Nasogastric tube

Short-term

Endoscopic Radiographic

Percutaneous gastrostomy

Open Laparoscopic

Endoscopic Radiographic

Open Laparoscopic

Surgical gastrostomy

Blind passage Fluoroscopic Endoscopic Other methods (see text)

Nasoenterictube

Percutaneous jejunostomy

Surgical jejunostomy

Poor gastric emptying or increased risk for aspiration

Gut can be used

Yes

Yes

No

No

Intermediate Long-term Short-term Intermediate Long-term

FIgure 37.1 algorithm for deter-mining appropriate enteral access for the critically ill.

LWBK1580_C37e_p132-140.indd 134 31/07/17 5:36 PM

Chapter 37 Feeding Tube Placement e135

inadvertent removal because their tips are wider than their shafts and anchor them in place. Although popular with some, these tubes are disdained by many. The widened tip can poten-tially obstruct the narrow lumen or erode the wall of the jeju-num. The biliary T tube provides some of the security of the balloon- and mushroom-tipped tubes with less risk of intes-tinal obstruction or erosion, but must be fashioned for easy removal. As with the gastric tubes, tube deterioration, leakage, and site infection may occur.

PlAcemenT TechnIque oPTIons

The myriad techniques available for feeding tube placement ensure the potential for obtaining enteral access in nearly all critically ill patients. As stated earlier, the many factors involved in choosing the most appropriate tube type and access site also determine the technique for placement.

Nasogastric

The least complicated and quickest feeding access is the naso-gastric tube. Although the stiffer, wider tubes used for gastric decompression also can be used for feeding, it may be prefer-able to replace these tubes with the thin, softer, more flexible tubes. Placement is similar to that of the drainage sump tubes. The tube is lubricated and then passed blindly through a nos-tril. It travels down the posterior pharynx into the esophagus and then into the stomach. Placement is aided by wire stylets or weighted tips. Complications are similar to those of the sump tube, such as epistaxis, rhinitis, esophageal perforation or hemorrhage, pneumothorax, and inadvertent placement into the trachea or bronchus.

Nasoduodenal and Nasojejunal

Zaloga (33) found that only 5% of weighted small-bore feed-ing tubes pass spontaneously through the pylorus. Manually passing the soft, thin, flexible tube across the length of the stomach and beyond the pylorus is often challenging. Often, the tube coils back into the fundus or cannot easily be negoti-ated through the antrum and pylorus. In most cases, the dif-ficulty in tube advancement into the duodenum is related to the blind nature of the passage and to the inability to steer or guide the tube (Fig. 37.2). Success varies from 49% to 92% (33,34).

Several techniques have been described to aid in passage. Some authors have reported improved success with simple maneuvers such as placing the patient in the right lateral decu-bitus position, giving the tube a gentle clockwise twist as it is being passed, or bending the tip of the stylet (33,35). Using a dedicated feeding tube placement service, Zaloga reported a success rate of 92% with such a technique. House officers who learned the technique were able to achieve placement rates of 70% to 80%. Instillation of 10 mL/kg of air into the stomach increased the success rate of small bowel positioning on the first attempt from 44% to 92% in pediatric patients (36).

The use of ultrasound (37) or electrocardiogram (38) for locating the tip of the tube during insertion have all been described and may decrease the time of insertion and the num-ber of confirmatory radiographs. However, these techniques do not actually guide the tube in its course. A technique using

an industrial magnet to guide a magnet-tipped tube into the duodenum has also been described (39). All these techniques have reported success rates above 75%, but large trials com-paring them to other techniques are lacking.

Another approach to postpyloric feeding tube placement involves the administration of a promotility agent just prior to tube insertion. Metoclopramide and erythromycin have been commonly used to increase upper gastrointestinal motility. In one study of 10 patients, metoclopramide, 20 mg IV, given 10 minutes before insertion increased the success rate of transpy-loric feeding tube placement compared to placebo (40). How-ever, a larger study using 10 mg of metoclopramide showed no benefit (41). Kittinger et al. (42) found that when meto-clopramide was given after tube insertion into the stomach, it improved tube passage only in diabetic patients. The data for erythromycin are limited but more consistent. Administration of erythromycin 200 mg or 500 mg IV prior to feeding tube insertion has been shown to increase the success of postpylo-ric placement and to decrease the time needed for insertion (43,44).

pH monitoring has been described to facilitate passage by enabling recognition of the tube tip location (41,45). Gener-ally, lower pH values are found in the stomach compared with the duodenum, even in patients receiving H2-receptor antago-nists (33). This device may obviate the need for radiographic confirmation of tube location. Serial or continuous pH moni-toring also can be used to indicate if the tube has migrated back into the stomach. Strong et al. (45) reported a 100% correlation between the radiographic documentation of tube location with the measured pH in eight patients. However, the ability to use pH values to determine location may be less accurate in the setting of H2-blocker administration or with achlorhydria, where the stomach has less acid production and, hence, higher than normal pH readings. Despite the advan-tages of knowing tube tip location, Heiselman et al. (41) were still only 79% successful in getting the tip of the tube beyond the pylorus.

FIgure 37.2 nasoenteric feeding tube.

LWBK1580_C37e_p132-140.indd 135 31/07/17 5:36 PM

e136 SeCtion 4 Techniques, ProceDures, anD TreaTmenTs

Fluoroscopic guidance is an excellent method for placing the tip of the feeding tube beyond the pylorus (46). Because the tubes are radiopaque, they are easily seen under fluo-roscopy. Tube passage can then be guided by “direct vision.” Though this technique increases the likelihood of success, it has several drawbacks: the critically ill patient must be trans-ported to the radiology department or the radiography equip-ment must be brought to the ICU. The technique also exposes the patient to radiation. Endoscopy provides an alternate means of delivering the tube past the pylorus, but it is also the most invasive. After positioning the tube into the stomach, an esophagogastroscopy is performed. The tip of the tube, or a suture secured to the tip, can then be grasped with a biopsy forceps that was passed through the endoscope and dragged into the duodenum. Although this technique is effective, the tube may get pulled back into the stomach by the withdrawal of the endoscope, and the procedure places the patient at risk for all of the complications associated with endoscopy, includ-ing injury to the esophagus, stomach, or duodenum; perfora-tion; bleeding; and aspiration. Nasoenteric tubes also can be placed at the time of laparotomy for patients requiring tempo-rary jejunal access.

There is no consensus in the literature as to whether weighted or unweighted tubes pass into the duodenum more often. Levenson et al. (47) demonstrated that there was no apparent difference in the likelihood of tube passage between weighted and unweighted tubes. Lord et al. (48) found that with the addition of preinsertion metoclopramide, unweighted tubes were significantly more likely to pass than weighted (84% vs. 36%, respectively). In contrast, Whatley et al. (40) found that 80% of weighted tubes passed when metoclo-pramide was given before insertion.

Placement of a nasoduodenal tube using an electromag-netic transmitter is a relatively new technique with success rates similar to those of fluoroscopically and endoscopically placed tubes (49). A specialized stylet transmits a signal that is detected in real time by a receiver that is placed over the patient’s xiphoid process. A tracing on a monitor allows the course of the tube to be followed, providing early detection of incorrect positioning and allowing the final placement to be confirmed (50). This technology provides several potential advantages, including early detection of the tube tracking into a bronchus, quicker placement, and earlier initiation of feed-ing (51).

Complications of nasoenteric or oroenteric feeding tubes are not uncommon and can range from nuisances such as mild bleeding to life-threatening events. Inadvertent place-ment of tubes into the tracheobronchial tree has been reported to occur in 1.3% to 2.4% of insertions (52,53). Patients at increased risk of malpositioning are those who are intubated and/or sedated and those with neurologic injury (53). Tracheo-bronchial placement can cause pneumothorax, which may be life threatening. There are also reports of tracheobronchial positioning being misinterpreted as an enteric position, with subsequent instillation of tube feedings resulting in devastat-ing consequences (54,55). Enteric perforation has also been reported (54). Limiting tube insertion depth to 35 cm and then taking a radiograph to confirm esophageal rather than bronchial placement before further advancement significantly reduced procedure-related pneumothorax (52).

It has been suggested that the electromagnetic feeding tube (EMFT) technique may allow confirmation of proper

positioning without x-ray confirmation. Several studies have reported the safety of this practice (56,57). However, search of the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database demonstrates a much more concerning picture (58). While a MEDLINE search revealed no pneumo-thoraces or undetected airway placement in 1,725 patients between 2007 and 2012, review of the MAUDE database over the same time period revealed 20 bronchopulmonary place-ments, with 17 pneumothoraces and 2 deaths. Given that the MAUDE database relies on voluntary reports, the true number of adverse events is likely significantly higher.

Even after successful nasoenteric placement, tubes easily can be inadvertently removed or pulled back into the stomach. A nasal bridle is a fairly effective method to secure the naso-enteric tube and prevent dislodgement. This device is typically a string, umbilical tape, or soft tube that goes in one nostril, wraps around the nasal septum, and comes out the other nos-tril. The ends of the string are tied to the tube. In a random-ized study, bridling of a nasojejunal feeding tube resulted in lower rates of unintentional dislodgement (18% vs. 63%) and a higher percentage of goal calories (78% vs. 62%) (59).

Percutaneous Gastrostomy

Although surgically placed gastrostomy tubes were long the gold standard for obtaining stable, long-term gastric luminal access, numerous published reports demonstrate that percuta-neous placement offers all of the same advantages but with a significantly lower complication rate. This technique involves the placement of an access tube into the gastric lumen using a direct puncture of the skin and abdominal and gastric walls. Endoscopic or radiographic assistance is essential. Percutane-ous endoscopic gastrostomy (PEG) tube placement generally requires one of two techniques, termed push and pull. There are numerous commercially available insertion kits that con-tain the tube and the equipment necessary for placement. A formal esophagogastroduodenoscopy is performed first to rule out upper gastrointestinal disease that precludes tube place-ment. The endoscope is then steered against the anterior gas-tric wall to transilluminate the stomach’s position through the abdominal wall and skin. If successful, a small needle is then passed through a skin puncture into the gastric lumen. With the pull technique, a long nylon guidewire is inserted through the needle and grabbed with a snare that was fed through the endoscope. The guidewire is then dragged out of the patient’s mouth and used to guide the tube down the esophagus, into the stomach, and out through the skin. With the push method, the catheter is passed directly over the guidewire with a peel-away sheath.

The incidence of major complications with PEG is gen-erally described as between 1% and 3%, and the reported mortality rate is about 0.5% (60,61). Complications include colonic injury, gastric perforation, hemorrhage, leakage with peritonitis, necrotizing fasciitis, and skin infection (62,63). In addition to having a lower complication rate than the open technique, the PEG procedure has been shown to require less time (10–30 minutes) to perform and has a lower cost over-all (61,64,65). It also can usually be performed under local or intravenous sedation. Conditions that preclude the abil-ity to perform upper endoscopy such as obstruction, varices, and severe Candida esophagitis are contraindications to this procedure. Relative contraindications include ascites—with

LWBK1580_C37e_p132-140.indd 136 31/07/17 5:36 PM

Chapter 37 Feeding Tube Placement e137

its attendant risk of peristomal leakage as well as peritonitis from gastric leakage—and previous upper abdominal surgery, because the adhesions that form after surgery may prevent the stomach from being manipulated up to the abdominal wall. If transillumination cannot be achieved, the procedure should be aborted.

An alternative method for percutaneous gastrostomy is the radiographic approach. The stomach is distended with air using a nasogastric tube. Radiopaque contrast is then instilled in the stomach to enable it to be seen with fluoroscopy. The abdominal wall then can be pressed down onto the stomach. A needle is passed into the lumen and a guidewire inserted through the needle. The tract is dilated to the appropriate diameter and the tube is pushed into the lumen. This technique eliminates the need for endoscopy; however, many of the same contraindications and complications apply. In addition, this method does not allow inspection of the mucosa before tube placement or direct visualization of tube position after it is in place.

Percutaneous Jejunostomy

For patients with a significant risk of aspiration or abnormal gastric motility, specialized two-lumen tubes can be placed through the stomach, with a gastric port for decompression and an extended jejunal limb for feeding. These tubes can be inserted either by the endoscopic technique or with radio-graphic assistance (66). Alternatively, feeding tubes can be placed directly into the jejunum, using a technique similar to that of a PEG. With proper patient selection and experienced providers, percutaneous endoscopic jejunostomy can be a safe and effective procedure. In one center, a 90% success rate was achieved, with a low rate of adverse events and no mortality (67).

While early reports of percutaneous endoscopic jejunos-tomy placement noted high rates of complications (68–70), more recent reports suggest much lower rates (67). Complica-tions include bowel perforation, peristomal infection, leakage around the stoma, bleeding, and tube dysfunction (67,69). Occlusion is often secondary to inspissated feeding solu-tions or the use of the tube to deliver crushed tablets. Proper use and maintenance of the catheters should minimize these problems.

Surgical Gastrostomy

Before the development of safe and effective methods for per-cutaneous tube placement, surgical techniques were the most commonly employed. After entering the abdominal cavity, a large-bore tube is placed directly into the gastric lumen and then pulled through the abdominal wall and out through the skin. The tubes used are usually balloon or mushroom tipped to prevent dislodgement. To minimize the risk of leakage and peritonitis, the tube is secured with two or three concentric purse-string sutures, and the anterior wall of the stomach is tacked to the undersurface of the abdominal wall to obliterate any potential space around the tube. This technique is gener-ally referred to as the Stamm gastrostomy. While traditionally an open procedure, gastrostomy placement may also be per-formed laparoscopically (71).

The overall complication rate varies from 2.5% to 24% in the literature, with a major complication rate of about 10%

(60,61). However, the wide range may be more indicative of the severity of illness of the patient populations than from the procedure itself. In addition to the complications associated with any gastric tube, surgical placement adds the increased risks associated with surgery and anesthesia. For patients requiring laparotomy for other reasons, the gastrostomy tube can be inserted at that time with minimal additional time or morbidity. However, for patients not requiring abdominal sur-gery, this technique requires a laparotomy and an anesthetic. In patients without previous abdominal surgery, the procedure can be brief and limited. The incision type can be either limited vertical midline or small left upper quadrant transverse one. Some surgeons can perform this procedure with local anesthe-sia, which avoids the risk associated with general anesthetics. Patients who have had previous abdominal surgery may pose a greater risk for complications because the procedure may be more involved. Adhesions—scar tissue that forms in the abdominal cavity as a result of surgery—may extend the inci-sion size and the length of time necessary for tube placement. In addition, it increases the likelihood of injury to the stomach or intestines.

Surgical Jejunostomy

Like the surgically placed gastrostomy, the technique for open jejunostomy tube placement is generally safe; however, it can be more risky in patients who have had abdominal surgery, and typically requires general anesthesia. The most commonly employed techniques minimize the risks of leak from the bowel around the tube by either placing a purse-string suture around the tube (Stamm) or creating a serosal tunnel from the bowel wall overlying a portion of the tube (Witzel). After tube insertion into the jejunal lumen, the bowel is plicated to the undersurface of the anterior abdominal wall with three to four silk sutures placed circumferentially around the tube to further minimize the risk of leak and peritonitis (Fig. 37.3). The bowel is also carefully positioned for plication to prevent kinking or tube erosion.

To facilitate tube placement and minimize the risk of leak, the needle catheter jejunostomy technique was developed. It was first described by Delaney et al. (31) in 1973 as a safe and simple alternative to standard jejunostomy tube placement.

FIgure 37.3 Plication of the jejunum to the anterior abdominal wall. By suturing the jejunum to the abdominal wall circumferentially around the tube, the risk of leakage is decreased.

LWBK1580_C37e_p132-140.indd 137 31/07/17 5:36 PM

e138 SeCtion 4 Techniques, ProceDures, anD TreaTmenTs

This method employs a narrow tube that is inserted by needle puncture through the antimesenteric border of the jejunal wall obliquely to create a subserosal tunnel. The tube is secured with a purse-string suture and then passed through the abdom-inal wall and skin. Few major complications were reported with this technique. Page et al. (72) had a 1% major and 1.5% minor complication rate in 199 patients. As stated earlier, these tubes tend to be unreliable and therefore are unpopular with many surgeons.

More commonly used is a large-bore, soft flexible catheter with additional holes placed into the jejunal lumen with a sin-gle purse-string suture. A biliary T tube can also be used for jejunal feeding, and is less likely to dislodge than the straight tube (Fig. 37.4). The limbs are each cut to approximately 3 cm in length and the back of the T limb is slit lengthwise to facilitate removal. After tube insertion into the jejunal lumen, the bowel is plicated as described earlier.

As with gastrostomy tube placement, laparoscopic inser-tion techniques also have been developed. One such procedure attaches the jejunum to the anterior abdominal wall with four specially designed T fasteners. After this is completed, a large-bore needle is inserted into the jejunal lumen. A guidewire is then threaded through the needle and the catheter passed over a guidewire with the use of a peel-away introducer (73).

Jejunostomy tubes often become occluded, leak, or are removed either deliberately or inadvertently. Replacement is most easily performed with fluoroscopic assistance and should be attempted as soon as dislodgement is noted to prevent the tract from closing (67). This technique may even be success-ful for reinserting tubes that have been removed in the distant past. Because the jejunal limb used for the jejunostomy is rou-tinely fixed to the undersurface of the abdominal wall, luminal access can be achieved by passing a needle catheter through the skin site or scar. Once the tip of the needle is in the lumen, a long guidewire is then directed into the lumen and used to direct the tube.

summAry

Enteral nutrition is fully recognized as an important addition to the comprehensive care of the critically ill and the preferred means of nutritional support. However, the successful estab-lishment of secure and dependable enteral feeding access may be challenging. Several factors, including the patient’s current condition, past medical and surgical history, status of the gas-trointestinal tract, and hospital resources available to the clini-cian determine the best tube type, access choice, and placement method. Fortunately, several options are currently available so that there should be few reasons—short of gastrointestinal tract dysfunction—that preclude the use of enteral nutrition.

No single enteral access combination is superior to the oth-ers. Using a flexible strategy based on the unique characteristics of the patient and the patient care environment will maximize the likelihood of success. Persistence also pays dividends. Fail-ure of one attempt should not be a cause to abandon enteral feeding. A fresh new approach, possibly using another access option, may ultimately succeed. Only with patience, determi-nation, and an understanding of the available access options will the greatest number of critically ill patients reap the ben-efits of enteral nutrition.

A

B

FIgure 37.4 a surgically placed jejunostomy tube using a biliary T tube. A: cutaway showing placement. b: in situ.

• The initial consideration for determining the choice of an enteral access system is the anticipated duration of enteral feeding.• Short term: Patients predicted to need enteral feed-

ing for 2 weeks or less are said to have short-term requirements. These patients are best served with bedside placement of a nasoenteric tube.

• Long term: Patients thought to need enteral feeding for greater than 6 to 8 weeks are described as having long-term requirements. Percutaneous or surgically placed tubes are most appropriate for this subgroup of patients.

• Intermediate: Patients with the anticipated need for enteral feeding for greater than 2 weeks but less than 6 to 8 weeks are said to have an intermedi-ate requirement. These patients are well served by nasally, percutaneously, or surgically placed feeding tubes.

• Roughly half of critically ill patients have gastric emp-tying dysfunction. For these patients, enteral tubes may need to be placed beyond the pylorus.

• Several bedside techniques have been described to aid in achieving postpyloric placement of tubes inserted through the nose. These techniques are highly success-ful in experienced hands.

• While fluoroscopic or endoscopic support may be nec-essary for passing the tip of the nasoenteric tube beyond the pylorus, newer techniques such as the use of electro-magnetically guided tubes provide similar success rates. However, even with the assistance of these modalities, success is not guaranteed, and complications still occur.

• Percutaneous gastrostomy has been shown to be less costly and less time consuming, and has fewer compli-cations than surgical gastrostomy.

Key Points

LWBK1580_C37e_p132-140.indd 138 31/07/17 5:36 PM

Chapter 37 Feeding Tube Placement e139

References 1. 2015 Canadian Critical Care Nutrition Clinical Practice Guidelines. Critical

Care Nutrition website. Available at: http://www.criticalcarenutrition.com/index.php?option = com_content&view = category&layout = blog&id = 25&Itemid = 109. Accessed February 15, 2017.

2. Moore FA, Moore EE, Jones TN, et al. TEN versus TPN following major abdominal trauma-reduced septic morbidity. J Trauma. 1989;29:916–922.

3. Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral feeding: effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;215:503–511.

4. Gianotti L, Alexander JW, Nelson JL, et al. Role of early enteral feeding and acute starvation on postburn bacterial translocation and host defense: prospective, randomized trials. Crit Care Med. 1994;22:265–272.

5. Heyland DK, Cook DJ, Guyatt GH. Enteral nutrition in the critically ill patient: a critical review of the literature. Intensive Care Med. 1993;19:435–442.

6. Babineau TJ, Blackburn GL. Time to consider early gut feeding. Crit Care Med. 1994;22:191–193.

7. Grant JP, Snyder BA. Use of L-glutamine in total parenteral nutrition. J Surg Res. 1988;44:506–513.

8. Johnson LR, Copeland EM, Dudrick JT, et al. Structural and hormonal alterations in the gastrointestinal tract of parenterally fed rats. Gastroenter-ology. 1975;68:1177–1183.

9. Wilmore DW, Smith RJ, O’Dwyer ST, et al. The gut: a central organ after surgical stress. Surgery. 1988;104:917–923.

10. Page CP. Edgar J. Poth lecture. The surgeon and gut maintenance. Am J Surg. 1989;158:485–490.

11. Deitch EA. Multiple organ failure: pathophysiology and potential future therapy. Ann Surg. 1992;216:117–134.

12. Carrico J, Meakin JL, Marshall JC, et al. Multiple organ failure syndrome. Arch Surg. 1986;121:196–208.

13. Border JR, Hassett J, LaDuca J, et al. The gut origin septic states in blunt multiple trauma (ISS = 40) in the ICU. Ann Surg. 1987;206:427–448.

14. Marshall JC, Christou NV, Meakins JL. The gastrointestinal tract: the “und-rained abscess” of multiple organ failure. Ann Surg. 1993;218:111–119.

15. Thibault A: Care of feeding tubes. In: Borlase BC, Bell SJ, Blackburn GL, et al., eds. Enteral Nutrition. New York: Chapman & Hall; 1994:197.

16. Koruda MJ, Guenter P, Rombeau JL. Enteral nutrition in the critically ill. Crit Care Clin. 1987;3:133–153.

17. Minard G. Enteral access. Nutr Clin Pract. 1994;9:172–182. 18. Ritz MA, Fraser R, Edwards N, et al. Delayed gastric emptying in ventilated

critically ill patients: measurement by 13C-octanoic acid breath test. Crit Care Med. 2001;29(9):1744–1749.

19. Tarling MM, Toner CC, Withington PS. A model of gastric emptying using paracetamol absorption in intensive care patients. Intensive Care Med. 1997;23:256–260.

20. Kao CH, ChangLai SP, Chieng PU, Yen TC. Gastric emptying in head-injured patients. Am J Gastroenterol. 1998;93(7):1108–1112.

21. Suto G, Kiraly A, Tache Y. Interleukin 1 beta inhibits gastric emptying in rats: mediation through prostaglandin and corticotropin-releasing factor. Gastroenterology. 1994;106(6):1568–1575.

22. McClave SA, Snider HL, Lowen CC, et al. Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings. JPEN J Parenter Enter Nutr. 1992;16:99–105.

23. Heyland DK, Drover JW, MacDonald S, et al. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med. 2001;29:1495–1501.

24. Deane AM, Dhaliwal R, Day AG. Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis. Crit Care. 2013;17:R125.

25. Jooste CA, Mustoe J, Collee G. Metoclopramide improves gastric motility in critically ill patients. Intensive Care Med. 1999;25:464–468.

26. Calcroft RM, Joynt G, Hung V. Gastric emptying in critically ill patients: a randomized, blinded, prospective comparison of metoclopramide with pla-cebo. Intensive Care Med. 1997;23(Suppl 1):S138.

27. Nguyen NQ, Chapman MJ, Fraser RJ, et al. Erythromycin is more effective than metoclopramide in the treatment of feed intolerance in critical illness. Crit Care Med. 2007;35:483–489.

28. Dive A, Miesse C, Galanti L, et al. Effect of erythromycin on gastric motility in mechanically ventilated critically ill patients: a double-blind, randomized, placebo-controlled study. Crit Care Med. 1995;23:1356–1362.

29. Chapman MJ, Fraser RJ, Kluger MT, et al. Erythromycin improves gastric emptying in critically ill patients intolerant of nasogastric feeding. Crit Care Med. 2000;28:2334–2337.

30. Ritz MA, Chapman MJ, Fraser RJ, et al. Erythromycin dose of 70 mg accel-erates gastric emptying as effectively as 200 mg in the critically ill. Intensive Care Med. 2005;31:949–954.

31. Delaney HM, Carnevale NH, Garvey JW. Jejunostomy by a needle catheter technique. Surgery. 1973;73:786–790.

32. Jones TN, Moore EE, Moore FA. Early postoperative feeding. In: Borlase BC, Bell SJ, Blackburn GL, et al., eds. Enteral Nutrition. New York: Chap-man & Hall; 1994:78.

33. Zaloga GP. Bedside method for placing small bowel feeding tubes in criti-cally ill patients: a prospective study. Chest. 1991;100:1643–1646.

34. Welch SK, Hanlon MD, Waits M, Foulks CJ. Comparison of four bedside indicators used to predict duodenal feeding tube placement with radiogra-phy. JPEN J Parenter Enter Nutr. 1994;18:525–530.

35. Thurlow PM. Bedside enteral feeding tube placement into duodenum and jejunum. JPEN J Parenter Enter Nutr. 1986;10:104–105.

36. Spalding HK, Sullivan KJ, Soremi O, et al. Bedside placement of transpy-loric feeding tubes in the pediatric intensive care unit using gastric insuffla-tion. Crit Care Med. 2000;28(6):2041–2044.

37. Hernandez-Socorro CR, Marin J, Ruiz-Santana S, et al. Bedside sono-graphic-guided versus blind nasoenteric feeding tube placement in critically ill patients. Crit Care Med. 1996;24(10):1690–1694.

38. Keidan I, Gallagher TJ. Electrocardiogram-guided placement of enteral feeding tubes. Crit Care Med. 2000;28:2631–2633.

39. Gabriel SA, Ackermann RJ, Castresana M. A new technique for placement of nasoenteral feeding tubes using external magnetic guidance. Crit Care Med. 1997;25(4):641–645.

40. Whatley K, Turner WW Jr, Dey M, et al. When does metoclopramide facilitate transpyloric intubation? JPEN J Parenter Enter Nutr. 1984;8: 679–681.

41. Heiselman DE, Vidovich RR, Milkovich G, Black LD. Nasointestinal tube placement with a pH sensor feeding tube. JPEN J Parenter Enter Nutr. 1993;17:562–565.

42. Kittinger JW, Sandler RS, Heizer WD. Efficacy of metoclopramide as an adjunct to duodenal placement of small-bore feeding tubes: a random-ized, placebo-controlled, double-blind study. JPEN J Parenter Enter Nutr. 1987;11:33–37.

43. Kalliafas S, Choban PS, Ziegler D, et al. Erythromycin facilitates postpylo-ric placement of nasoduodenal feeding tubes in intensive care unit patients: randomized, double-blinded, placebo-controlled trial. JPEN J Parenter Enteral Nutr. 1996;20(6):385–388.

44. Griffith DP, McNally T, Battey CH, et al. Intravenous erythromycin facili-tates bedside placement of postpyloric feeding tubes in critically ill adults: a double-blind, randomized, placebo-controlled study. Crit Care Med. 2003;31:39–44.

45. Strong RM, Gribbon R, Durling S, et al. Enteral tube feedings utilizing a pH sensor enteral feeding tube. Nutr Suppl Sero. 1988;8:11–25.

46. Grant JP, Curtas MS, Kelvin FM. Fluoroscopic placement of nasojejunal feeding tubes with immediate feeding using a nonelemental diet. JPEN J Parenter Enter Nutr. 1983;7:299–303.

47. Levenson R, Turner WW, Dyson A, et al. Do weighted nasogastric feed-ing tubes facilitate duodenal intubations? JPEN J Parenter Enter Nutr. 1988;12:135–137.

48. Lord LM, Weser-Maimone A, Pulhamus M, et al. Comparison of weighted vs unweighted enteral feeding tubes for efficacy of transpyloric intubation. JPEN J Parenter Enter Nutr. 1993;17:271–273.

49. Gerritsen A, van der Poel MJ, de Rooij T, et al. Systematic review on bedside electromagnetic-guided, endoscopic, and fluoroscopic placement of nasoen-teral feeding tubes. Gastrointest Endosc. 2015;81;836–847.

50. Roberts S, Echeverria P, Gabriel SA. Devices and techniques for bedside enteral feeding tube placement. Nutr Clin Pract. 2007;22:412–420.

51. Smithard D, Barrett NA, Hargroves D, Elliott S. Electromagnetic sensor-guided access systems: a literature review. Dysphagia. 2015;30: 275–285.

• While bolus gastric feeding may occasionally be used, continuous infusion of enteral feeds is better tolerated than bolus feeding.

• Surgically placed jejunostomy tubes are excellent for long-term infusion feeding, but expose the critically ill patient to the risks and complications of an operative procedure.

LWBK1580_C37e_p132-140.indd 139 31/07/17 5:36 PM

e140 SeCtion 4 Techniques, ProceDures, anD TreaTmenTs

52. Marderstein EL, Simmons RL, Ochoa JB. Patient safety: effect of institu-tional protocols on adverse events related to feeding tube placement in the critically ill. J Am Coll Surg. 2004;199:39–47.

53. Sorokin R, Gottlieb JE. Enhancing patient safety during feeding-tube inser-tion: a review of more than 2000 insertions. JPEN J Parenteral Enter Nutr. 2006;30:440–445.

54. McWey RE, Curry, NS, Schabel SI, Reines D. Complications of nasoenteric feeding tubes. Am J Surg. 1988;155:253–257.

55. Theodore AC, Frank JA, Ende J, et al. Errant placement of nasoenteric tubes: a hazard in obtunded patients. Chest. 1984;86(6):931–933.

56. Powers J, Fischer MH, Ziemba-Davis M, et al. Elimination of radiographic confirmation for small-bowel feeding tubes in critical care. Am J Crit Care. 2013;22:521–527.

57. Rivera R, Campana J, Hamilton C, et al. Small bowel feeding tube place-ment using an electromagnetic tube placement device: accuracy of tip loca-tion. JPEN J Parenter Enteral Nutr. 2011;35:636–642.

58. Metheny NA, Meert KL. Effectiveness of an electromagnetic feeding tube placement device in detecting inadvertent respiratory placement. Am J Crit Care. 2014;23:240–247.

59. Seder CW, Stockdale W, Hale L, Janczyk RJ. Nasal bridling decreases feeding tube dislodgement and may increase caloric intake in the surgi-cal intensive care unit: a randomized, controlled trial. Crit Care Med. 2010;38:797–801.

60. Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endo-scopic gastrostomy: indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology. 1987;93:48–52.

61. Grant JP. Comparison of percutaneous endoscopic gastrostomy with Stamm gastrostomy. Ann Surg. 1988;270:598–603.

62. Peasarini AC, Dittler HJ. Feeding tube perforation as a complication of percutaneous endoscopic gastrostomy. Endoscopy. 1992;24:235.

63. Saltzberg DM, Anand K, Juvan P, Joffe I. Colocutaneous fistula: an unusual complication of percutaneous endoscopic gastrostomy. JPEN J Parenter Enter Nutr. 1987;11:86–87.

64. Dwyer KM, Watts DD, Thurber JS, et al. Percutaneous endoscopic gastros-tomy: the preferred method of elective feeding tube placement in trauma patients. J Trauma. 2002;52:26–32.

65. Kirby DF, Craig RM, Tsang TK, Plotnick BH. Percutaneous endoscopic gastrostomies: a prospective evaluation and review of the literature. JPEN J Parenter Enter Nutr. 1986;10:155–159.

66. Lambiase RE, Dorfman GS, Cronan JJ, et al. Percutaneous alternatives in nutritional support: a radiologic perspective. JPEN J Parenter Enter Nutr. 1988;12:513–520.

67. Lim AH, Schoeman MN, Nguyen NQ. Long-term outcomes of direct per-cutaneous endoscopic jejunostomy: a 10-year cohort. Endosc Int Open. 2015;03:E610–E614.

68. Wolfsen HC, Kozarek RA, Ball TJ, et al. Tube dysfunction follow-ing percutaneous gastrostomy and jejunostomy. Gastrointest Endosc. 1990;36:261–263.

69. DiSario JA, Foutch PG, Sanowski RA. Poor results with percutaneous endo-scopic jejunostomy. Gastrointest Endosc. 1990;36:257–260.

70. Henderson JM, Strudel WE, Gilinsky NH. Limitations of percutane-ous endoscopic jejunostomy. JPEN J Parenter Enter Nutr. 1993;17: 546–550.

71. Mizrahi I, Garg M, Divino CM, Nguyen S. Comparison of laparoscopic versus open approach to gastrostomy tubes. JSLS. 2014;18:28–33.

72. Page CP, Carlton PK, Andrassy RJ, et al. Safe, cost-effective postoperative nutrition: defined formula diet via needle catheter jejunostomy. Am J Surg. 1979;138:939–945.

73. Duh QY, Way LW. Laparoscopic jejunostomy using T-fasteners as retractors and anchors. Arch Surg. 1993;128:105–108.

LWBK1580_C37e_p132-140.indd 140 31/07/17 5:36 PM