Bedside sonographic-guided versus blind nasoenteric feeding tube placement in critically ill patients

Abstract

Objective: To compare a blind manual bedside method for placing feeding tubes into the small bowel vs. a sonographic bedside technique in critically ill patients. Design: Prospective study with a random sample. Setting: Multidisciplinary intensive care unit in a tertiary care university hospital. Patients : Thirty-five adult patients. All patients were hemodynamically stable, mechanically ventilated, and required a nasoenteric tube placement for short-term enteral feeding due to impaired gastric emptying. Interventions : A well-known, blind, manual, bedside method for postpyloric tube placement was always attempted first in all cases. The technique was considered successful when a postpyloric location of the tip of the tube was achieved as shown by abdominal roentgenogram. However, if after 30 mins we failed to enter the small bowel, a radiologist attempted a sonographic bedside technique for postpyloric tube insertion. Finally, when the feeding tube was in place, before starting enteral nutrition, a nasogastric tube was inserted into the stomach. Measurements and Main Results: The blind manual method was successful in nine (25.7%) of the 35 patients and the final location of these feeding tubes was the proximal jejunum. The average time for placement of the feeding tubes with this manual technique was 13.9 +/- 7.4 mins (range 5 to 30). The sonographic technique was succesful in 22 (84.6%) of the remaining patients and the final location of the feeding tubes was three (11%) tubes in the second portion of the duodenum, eight (31%) tubes in the third portion of the duodenum, and 11 (42%) tubes in the proximal jejunum. The average time for placement with the sonographic technique was 18.3 +/- 8.2 mins (range 5 to 35). The pyloric outlet was sonographically akinetic or severely hypokinetic in 13 patients, and in four of them, we were unable to achieve postpyloric tube placement. In these four patients, the tubes were subsequently placed by endoscopy. Conclusions : The sonographic bedside technique for placing feeding tubes into the small bowel in critically ill patients has a success rate of 84.6% (confidence interval 71% to 98%) after the failure of the blind bedside manual method, proving that the former is significantly more successful. This sonographic technique facilitates the insertion of the tubes in patients who cannot be moved and in those patients with severe impairment of the peristaltic activity of the stomach.