Crit Care Nurse 2003 Feb; 23(1): 16-24
Clinical Article
CE Online
Bedside Placement of Small-Bowel Feeding Tubes
In the Intensive Care Unit
Jan Powers, RN, MSN, CCRN
Rick Chance, RN
Lawrence Bortenschlager, MD
Jama Hottenstein, RD, CNSD
Karen Bobel, RD
Jane Gervasio, PharmD
George H. Rodman, Jr, MD
Tom Stone McNees, MS, RD, CNSD
All authors are employed at Clarian Health Partners, Methodist Hospital, Indianapolis, Ind.
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Nutritional support for critically ill or injured patients is a routine and vital part of therapy in the intensive care unit (ICU). Nutritional therapy is recommended to treat and prevent nutrient deficiencies and malnutrition and to improve patients’ outcomes.1 Nutritional support can be delivered enterally via the gastrointestinal system or parenterally with total parenteral nutrition (TPN).
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Justification for Enteral Nutrition
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Enteral nutrition can provide essential energy intake and protein, and the enteral route of administration is preferred for nutritional needs in critically ill patients.2–5 Enteral feeding is more physiological than is parenteral nutrition and maintains the digestive and barrier functions of the gut.2–5 Compared with TPN, enteral nutrition is associated with preservation of the gut’s barrier and immune functions, reduction in sepsis and other infectious complications, and higher survival rates1,4–9 (Table 1
). In a prospective, randomized study, Kudsk et al4 found that patients with abdominal trauma had fewer complications and lower infection rates when managed with enteral nutrition rather than TPN.3 Many studies3,6,10–12 have indicated the benefits of enteral nutrition, such as a shorter stay in the ICU for critically ill patients. Moore and Jones10 reported a decrease of 3.3 days in length of stay for patients with abdominal trauma given enteral feedings (mean 25.3 [SD 5.8] days) versus the control group given TPN (mean 28.6 [SD 6.1] days) and a mean decrease in cost of $2794 per patient for patients in the enteral nutrition group compared with patients in the TPN group. Grahm et al11 also reported a shorter ICU stay, with a median stay of 7 days (range 4–19 days) for the group given enteral feedings versus 10 days for the control group. Grahm et al also found a decrease in infectious complications for patients with head injuries who received early enteral feeding into the jejunum. Hedberg et al13 reported that patients receiving enteral feedings within 12 hours after bowel resection had a 2-day decrease in hospital length of stay, fewer infectious complications, and lower costs of care than did patients receiving TPN. In this randomized, prospective study13 of 225 patients undergoing surgery for small-bowel resection, the mean cost savings was $2598 per patient in the group whose feedings were initiated within 12 hours after surgery.
Published data support starting enteral feeding as soon as possible after admission to the ICU.1 However, critically ill patients may not tolerate gastric delivery of enteral nutrients because of impaired gastric motility due to medications routinely used in the ICU, thus increasing the risk of aspiration. Postpyloric feeding minimizes the risk of aspiration and provides a safe and effective means for delivery of nutrients. When nutrients are administered distal to the pylorus, audible bowel sounds are not a necessary prerequisite. Bowel sounds are caused by the movement of air and fluids in the colon and stomach, and absence of the sounds does not suggest that the small intestine will not accept feedings. Therefore, enteral nutrition can be used in patients with gastric and colonic ileus that leads to the absence of bowel sounds,1 and small-bowel feedings can be an effective means of enteral delivery of nutrients to critically ill patients.
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Barriers to Early Enteral Feeding
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When small-bowel enteral nutrition is necessary, it is not always initiated in a timely manner because of difficulty in placement of the feeding tube. Placement of small-bowel feeding tubes may be costly and time-consuming and requires specialized technical skills (eg, fluoroscopy).
Magnuson et al3 described several barriers to transpyloric placement of feeding tubes, including delayed gastric motility, difficulties in placement of feeding tubes, and increased intracranial pressure. Difficulties in placement of feeding tubes are related to blind placement and may be alleviated by using fluoroscopic or endoscopic guidance.
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Placement Methods
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Several techniques for placement of feeding tubes have been reported (Table 2), including the use of fluoroscopy, endoscopy, tube manipulation, and promotility agents.
Placement of feeding tubes with fluoroscopic guidance is a well-accepted technique that ensures accurate placement. However, this procedure is expensive and may be available only during limited hours because of hospital policy and staffing limitations. In critically ill patients, bedside fluoroscopy is preferred but is not available in all institutions, and when bedside fluoroscopy is not available, patients must be transported to the radiology department for fluoroscopy. Moving patients out of the ICU may introduce additional risks and creates the potential for dislodging vital equipment. A nurse must escort the patient to procedures, a practice that not only is time-consuming for the transporting nurse but also increases the workload for the nurses who remain in the unit.
Endoscopy is another option for guiding placement of small-bowel feeding tubes. As with fluoroscopy, tube placement with endoscopic guidance requires expensive equipment and a physician specialist trained in the procedure, characteristics that make it a less cost-effective method of tube placement than the bedside nursing procedure. Endoscopic placement also creates potential risks for patients, such as pharyngeal and esophageal injury and the potential for gastric bleeding and perforation.2
Several techniques for transpyloric placement of feeding tubes without the use of specialized equipment have been reported. Salasidis et al20 described an air insufflation technique in which the tube is placed into the stomach and 500 mL of air is pumped into the stomach. An abdominal flat plate radiograph is obtained 2 hours after placement. The authors reported a 78% success rate after 24 hours and a mean time for placement of 2 to 4 minutes. Even though the placement time is significantly less than that required for other techniques, 2 hours is required for the tube to migrate beyond the pylorus before a radiograph can be obtained, thus delaying initiation of enteral nutrition.
The manufacturers of the Corpak feeding tube (Corpak MedSystems, Wheeling, Ill) promote the "10-10-10" placement technique. In this technique, the patient is given 10 mg of metoclopramide to stimulate gastric peristalsis. Ten minutes later, the feeding tube is placed in a distance equal to that measured from nose to ear to xiphoid process, leaving 10 cm of the tube extending out from the nose. After 4 hours, portable radiography of the abdomen is used to determine tube placement. Lord et al15 reported a success rate of 88% after 4 hours when this technique was used.
Placement of a gastric feeding tube that then spontaneously passes into the duodenum, with and without the use of promotility agents, has also been described. Ahmed et al21 conducted a study on spontaneous tube migration with 3 different types of tubes. The authors reported a 62% rate of transpyloric placement at 72 hours for unweighted tubes and only 32% for weighted tubes. Hernandez-Socorro et al18 reported a 25.7% success rate with blind placement versus a success rate of 84.6% with placement guided by sonography.
Promotility agents such as metoclopramide have been used in placement of feeding tubes, with the idea that stimulating peristalsis will aid in tube migration. Use of metoclopramide does not seem to enhance tube placement17; therefore, this practice is not encouraged at our facility. Heiselman et al17 found no significant difference in success of transpyloric tube placement in patients who received 10 mg of intravenous metoclopramide versus control subjects, who were not given metoclopramide. Whatley et al23 did find an increase in the rate of transpyloric placement when 20 mg of metoclopramide was used, although the sample size was limited to 5 subjects in the control group and 5 in the experimental group. The small sample size in their study precludes generalization of those findings to other groups. As with any medication, promotility agents may have adverse effects. Possible effects include drowsiness, anxiety, agitation, urticaria, supraventricular tachycardia, and hypotension.24
Keidan and Gallagher22 proposed an electrocardiographically guided method wherein electrocardiographic tracings are compared to confirm placement of feeding tubes. With this technique, they achieved 60% success rate of duodenal placement in 24 patients. This method is focused more on accurate verification of placement than on a specific placement technique. Welch19 reported a success rate of 83% when injection of air was used during advancement of the tube into the duodenum. Using a "corkscrew technique," Thurlow14 successfully placed 52 (87%) of 60 tubes, with a mean time for placement of a tube of 2 to 15 minutes. Using this same technique, Zaloga6 achieved a 92% (213 of 231) success rate. However, Zaloga subsequently trained residents in this same technique, and they achieved only 70% to 80% successful placements.
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Multidisciplinary Intervention
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Timely, accurate, and cost-effective placement of feeding tubes into the small bowel is challenging. Before bedside placement was available at our institution, patients were transported to the radiology department for fluoroscopy or incurred the cost of bedside fluoroscopy. The fluoroscopic procedures require the availability of a procedure room and the attendance of a radiologist, a technician, or both. Anecdotal reports indicate that placement was often delayed for 24 hours and, in some instances, over a weekend, up to 4 days. For bedside placement, portable C-arm fluoroscopy can be used, but that equipment is not always available when needed to place feeding tubes.
Difficulties in placing feeding tubes by conventional means at our institution delayed initiation of nutritional support and increased the cost of patients’ care. This problem led the nutrition support team at our institution to implement a modified protocol for placement of feeding tubes. With this protocol, nurses place nasoenteric feeding tubes at the bedside without fluoroscopy. The protocol involves the placement technique first described by Thurlow in 1986 and then by Zaloga in 1991. A physician on the nutrition support team who trained under Dr Zaloga taught 3 nurses to place feeding tubes into the small bowel.
An advanced practice nurse was recruited from each ICU area for training in the technique. Because of time constraints on the advanced practice nurse in 1 ICU, a care coordinator was trained in that unit instead of the advanced practice nurse. The nurses chosen were not tied to a bedside nursing assignment, so they could commit time to the placement of feeding tubes throughout their ICUs. Training consisted of working with the physician from the nutrition support team, observing his technique, and placing tubes with supervision. When skill in placing the tubes was validated, the nurses were allowed to place feeding tubes independently, with the team physician available as needed. Competency in tube placement was validated by the team physician, and nurses were generally competent in the technique after placing 7 to 10 feeding tubes. Even after competency was shown, the physician was available for any questions or difficulties encountered. Tube placement was always confirmed by obtaining an abdominal radiograph that was interpreted by a physician.
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Bedside Technique
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The bedside technique involves initial placement of the feeding tube into the stomach either orally or nasally. When the nasal route is used, the mucosa is anesthetized with topical lidocaine jelly. Once gastric placement is confirmed, the patient is positioned on his or her right side at a 30° to 45° angle to promote tube migration. The feeding tube guidewire is removed and bent approximately 2 to 3 cm from the end at a 30° angle to facilitate entry into the pylorus6,21 (Figure 1). The guidewire is then gently reinserted into the tube. Reinsertion of the guidewire is not recommended by the manufacturer of the feeding tube; however, we had no complications with this technique after placement of 357 tubes. The tube is twisted in a clockwise fashion and slowly advanced through the pylorus into the small bowel while the approximate location of the tube tip is assessed intermittently by using air auscultation. A slight resistance may be felt while the tube is being placed as it passes through the pyloric sphincter. If an increased resistance is felt while the tube is being inserted, advancement is stopped, the tube is repositioned or pulled back, and another attempt is made to advance the tube.
Tentative confirmation of small-bowel placement is provided by auscultation and aspiration of secretions. Approximately 5 mL of water is drawn into a 60-mL syringe, with the remainder of the syringe filled with air. The air and water are injected methodically about 10 mL at a time while the epigastric area from along the lower right rib margin to the right midaxillary line is systematically auscultated. Sounds progressively increase in loudness and pitch along this area when proper placement is achieved. Aspiration of small-bowel contents is used as another indication of accurate placement. Gastric aspirate is usually green and contains particulate matter, whereas small-bowel aspirate is clear, golden, and more viscous than gastric aspirate (Figure 2). Once the tube is thought to be in place, portable radiography of the abdomen is used to confirm placement. An abdominal radiograph will show a correctly placed tube crossing the midline with a characteristic "C" shape as the tube enters the duodenum and progresses through the small bowel (Figure 3). The complete procedure for this technique is presented in Table 3.
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Results
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During a 12-month period, 357 feeding tubes were placed at our institution in 3 critical care areas where this technique was used. The success rate was 95%, with placement of 339 feeding tubes into the small bowel. No complications of feeding tube placement occurred during this period. Correct placement was confirmed by a physician’s interpretation of abdominal radiographs. Other institutions that use a similar technique have reported success rates from 70% to 92% with placements by physicians.6,14 Welch19 reported a 90% success rate with placement by a certified staff nurse using an air insufflation technique.
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Discussion
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An inherent advantage of this technique for placing feeding tubes into the small bowel is the timely placement. Once the order was received for placement of a feeding tube, nurses responded within a mean of 93 minutes (range 1 minute to 16 hours, with the longest delays for orders placed very late in the day that were completed the next morning). The procedure also was time efficient; a mean of 22 minutes was needed to place a tube in the small bowel (range 5–180 minutes). This timely response and brief placement time allowed enteral feeding to be started sooner than otherwise in ICU patients.
We have not been able to measure exactly the costs associated with fluoroscopically guided bedside placement of feeding tubes, but estimates for charges are in the range of $600 to $900 per procedure, depending on fluoroscopy time. By avoiding the costs associated with fluoroscopy, the institution benefits, with a potential reduction in charges of more than $300 000 annually. With nurses placing small-bowel feeding tubes at the bedside, time to feeding has been shortened from as long as several days to less than 24 hours. Early enteral feeding in critically ill patients shortens length of stay significantly.10,11,13 However, in our project, we did not specifically measure length of stay.
Timely placement of small-bowel feeding tubes in our facility is beneficial to patients and to our organization. We can provide enteral feeding earlier to our critically ill patients, thereby improving quality of care and patients’ outcomes while decreasing potential complications and costs that may have been associated with TPN. During the course of this project, no adverse events related to bedside placement of feeding tubes were noted.
Additional nurses have since been trained to place feeding tubes in order to provide for additional resources as well as weekend coverage for feeding tube placements. These nurses were originally hired to place peripherally inserted central catheters and were later trained to place small-bowel feeding tubes. In the first 6 months after training, the success rate was 92% (176 of 192 tubes). After follow-up training and additional experience during the next 4 months, a 95% success rate was obtained, with successful post-pyloric placement of 139 of 147 tubes. The overall success rate for the entire 10 months was 93%. We have shown that this technique can be consistently used by nursing staff. We have specifically tried to limit the number of people trained in order to increase competence and decrease variation. This strategy has resulted in the continuing, consistent rate of successful tube placements of 93% to 95%.
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Summary
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Early enteral feeding is beneficial to critically ill patients, although it is often a challenge to accomplish. When required, placing feeding tubes into the small bowel can be costly and difficult to carry out in a timely manner, often requiring fluoroscopic or endoscopic guidance. We implemented a modified protocol that enabled nurses to place feeding tubes at the bedside without fluoroscopy. This technique has resulted in timely placement, with initiation of enteral feeding in less than 24 hours. Ninety-five percent of the attempted placements were successfully completed at the bedside. Transport of patients was avoided, and no specialized equipment was required. Therefore, greater satisfaction for patients with less risk was possible, and caregivers benefited as well.
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Acknowledgments
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We thank all members of the nutrition support team at Methodist Hospital in Indianapolis, Ind, for their assistance in developing the protocol for placement of small-bowel feeding tubes. A special thank you also to members of the PICC (peripherally inserted central catheters) team for their support and continued effort in placing small-bowel feeding tubes.
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References
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Justification for Enteral...
Barriers to Early Enteral...
