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      Blind bedside postpyloric placement of spiral tube as rescue therapy in critically ill patients: a prospective, tricentric, observational study

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          Abstract

          Background

          Various special techniques for blind bedside transpyloric tube placement have been introduced into clinical practice. However, transpyloric spiral tube placement facilitated by a blind bedside method has not yet been reported. The objective of this prospective study was to evaluate the safety and efficiency of blind bedside postpyloric placement of a spiral tube as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients.

          Methods

          This prospective, tricentric, observational study was conducted in the intensive care units (ICUs) of three tertiary hospitals. A total of 127 consecutive patients with failed spontaneous transpyloric spiral tube migration despite using prokinetic agents and still required enteral nutrition for more than 3 days were included. The spiral tube was inserted postpylorically using the blind bedside technique. All patients received metoclopramide intravenously prior to tube insertion. The exact tube tip position was determined by radiography. The primary efficacy endpoint was the success rate of postpyloric spiral tube placement. Secondary efficacy endpoints were success rate of a spiral tube placed in the third portion of the duodenum (D3) or beyond, success rate of placement in the proximal jejunum, time to insertion, length of insertion, and number of attempts. Safety endpoints were metoclopramide-related and major adverse tube-associated events.

          Results

          In 81.9% of patients, the spiral feeding tubes were placed postpylorically; of these, 55.1% were placed in D3 or beyond and 33.9% were placed in the proximal jejunum, with a median time to insertion of 14 min and an average number of attempts of 1.4. The mean length of insertion was 95.6 cm. The adverse event incidence was 26.0%, and no serious adverse event was observed.

          Conclusions

          Blind bedside postpyloric placement of a spiral tube, as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients, is safe and effective. This technique may facilitate the early initiation of postpyloric feeding in the ICU.

          Trial registration

          Chinese Clinical Trial Registry, ChiCTR-OPN-16008206. Registered on 1 April 2016.

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          Most cited references 34

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          ESPEN Guidelines on Enteral Nutrition: Intensive care.

          Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.
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            Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

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              Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications.

              To study the frequency of and risk factors for increased gastric aspirate volume (GAV) and upper digestive intolerance and their complications during enteral nutrition (EN) in critically ill patients. Prospective observational study. Intensive care unit (ICU) in a general hospital. A total of 153 patients with nasogastric tube feeding. None. Upper digestive intolerance was considered when GAV was between 150 and 500 mL at two consecutive measurements, when it was >500 mL, or when vomiting occurred. Forty-nine patients (32%; 95% confidence interval [CI], 25%-42%) presented increased GAV after a median EN duration of 2 days (range, 1-16 days), and 70 patients (46%; 95% CI, 38%-54%) presented upper digestive intolerance. Independent risk factors for high GAV were GAV >20 mL before the start of EN (odds ratio [OR], 2.16; 95% CI, 1.11-4.18; p =.02), GAV >100 mL during EN (OR, 1.49; 95% CI, 1.01-2.19; p <.05), sedation during EN (OR, 1.78; 95% CI, 1.17-2.71; p =.007), use of catecholamines during EN (OR, 1.81; 95% CI, 1.21-2.70; p =.004). Complications related to high GAV were a lower feed intake (15 +/- 7 vs. 19 +/- 8 kcal/kg/day; p =.0004) and vomiting (53% vs. 23%; p =.0002). Complications related to upper digestive intolerance were the development of pneumonia (43% vs. 24%; p =.01), a longer ICU stay (23 +/- 21 vs. 15 +/- 16 days; p =.007), and a higher ICU mortality (41% vs. 25%; p =.03), even after adjustment for Simplified Acute Physiology Score II (OR, 1.48; 95% CI, 1.04-2.10; p =.028). In ICU patients receiving nasogastric tube feeding, high gastric aspirate volume was frequent, occurred early, and was more frequent in patients with sedation or catecholamines. High gastric aspirate volume was an early marker of upper digestive intolerance, which was associated with a higher incidence of nosocomial pneumonia, a longer ICU stay, and a higher ICU mortality.
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                Author and article information

                Contributors
                gdlvbo@163.com
                hulinhui@live.cn
                13610013473@139.com
                qhubei@hotmail.com
                zylks163@163.com
                yeheng@139.com
                suncheng2008@139.com
                zhangxiunong@126.com
                13682237886@139.com
                +86-20-83827812-61526 , gghccm@163.com
                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                26 September 2017
                26 September 2017
                2017
                : 21
                Affiliations
                [1 ]Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080 Guangdong Province People’s Republic of China
                [2 ]ISNI 0000 0004 1764 3838, GRID grid.79703.3a, School of Medicine, , South China University of Technology, ; Guangzhou Higher Education Mega Center, Guangzhou, 510006 Guangdong Province People’s Republic of China
                [3 ]Department of Critical Care Medicine, Xinjiang Kashgar Region’s First People’s Hospital, 66 Airport Road, Kashgar Region, 844099 Xinjiang Uygur Autonomous Region People’s Republic of China
                [4 ]Department of Critical Care Medicine, Guangzhou Nansha Central Hospital, 105 Fengzhedong Road, Guangzhou, 511457 Guangdong Province People’s Republic of China
                Article
                1839
                10.1186/s13054-017-1839-2
                5615440
                28950897
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: Guangdong Province Hospital Association Scientific Research Foundation
                Award ID: 2014001
                Award Recipient :
                Funded by: Guangdong General Hospital Scientific Research Foundation
                Award ID: 201343
                Award Recipient :
                Funded by: Science and Technology Planning Project of Guangdong Province
                Award ID: 2013B021800158
                Award ID: 2014A020212236
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2017

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