Search

Electromagnetic (EM) guided enteral tube placement may reduce lung misplacement to almost zero in expert centres, but more than 60 undetected misplacements had occurred by 2016 resulting in major morbidity or death. Aim: Determine the accuracy of manufacturer guidance in trace interpretation against what is referred to as the ‘GI flexure system’. Methods: The authors prospectively observed the accuracy of the ‘GI flexure system’ of trace interpretation against manufacturer guidance in primary nasointestinal (NI) tube placements. Findings: Contrary to manufacturer guidance, 33% of traces deviated >5 cm from the sagittal midline and 26.5% were oesophageal when entering the lower left quadrant, incorrectly indicating lung and gastric placement, respectively. Conversely, the GI flexure system identified ≥99.4% of GI traces when they reached the gastric body flexure; 100% at the superior duodenal flexure. All lung misplacements were identified by the absence of GI flexures. Conclusion: Current manufacturer guidance should be updated to the GI flexure system of interpretation.

Background: Blind (unguided) feeding tube placement results in 0.5% of patients suffering major complications mainly due to lung misplacement detected prior to feeding. Electromagnet-guided (Cortrak) tube placement could pre-empt such complications but undetected misplacements still occur due to incorrect trace interpretation. By identifying gastrointestinal (GI) flexures from the trace, ‘the GI flexure system’, it has been proposed that tube position can be interpreted. Aims: To audit agreement between standards of interpreting tube position: the Cortrak ‘GI flexure’ system versus X-ray. Methods: In 185 primary nasointestinal tube placements tube position determined by Cortrak trace interpretation (GI flexure) was retrospectively compared with radiological position in a blinded study. Findings: Radiological and Cortrak interpretation agreed in 92.2–98.3% of placements at different GI flexures. Discrepancy mainly occurred because some radiological images were unclear or did not cover all anatomical points. Conclusion: The GI flexure method of Cortrak interpretation appears safe but would necessitate prospective radiological investigation to definitively test equivalence.

Background: In a previous audit, 81% of enteral protein prescriptions failed to meet protein guidelines. To address this, a very high-protein enteral formula and protein supplements were introduced, and protein prescriptions were adjusted to account for nonnutrition energy sources displacing enteral formula. This follow-up audit compared protein provision in critically ill adults requiring exclusive enteral nutrition (EN), first, with local and international guidelines, and second, after changes to practice, with the previous audit in the same intensive care unit (ICU). Methods: Data were collected from 106 adults consecutively admitted to the ICU of a U.K. tertiary hospital and requiring exclusive EN ≥3 days. Protein targets based on local guidelines (1.25, 1.5, or 2.0 g/kg/d), nutrition prescription, and delivery were recorded for 24 hours between days 1–3, 5–7, 8–10, and 18–20 post-ICU admission. Results:The proportion of day 1–3 protein prescriptions meeting protein targets increased from 19% in 2015 to 69% in 2017 (P Conclusion: The proportion of protein prescriptions meeting guideline targets was higher after changes to practice.

Electromagnetic (EM)-guided tube placement has been successfully used to pre-empt lung misplacement, but undetected misplacements continue to occur. The authors conducted an audit to investigate whether official Cortrak or local guidance enabled differentiation of gastrointestinal (GI) from lung traces. X-ray, pH or an EM trace beyond the gastric body were used to independently confirm gastric position. The authors undertook 596 nasointestinal (NI) tube placements, of which 361 were primary GI placements and 41 lung misplacements. Official guidance that in GI traces a midline deviation is absent cannot differentiate GI from lung traces because deviation is common in both. However, when comparing a trace in the same patient, midline deviation during lung misplacement always occurred >18 cm above the horizontal line compared with only 33% of the subsequent GI deviation (p

Stroke patients with dysphagia often depend on nutrition, hydration and medication via nasogastric (NG) feeding tubes. Securing tubes using tape is associated with repeated tube loss. In this study, the authors determined cause and effect by auditing tube placement methods, delays incurred, duration and costs. Of 202 NG tube placements in 75 patients, 67 placements occurred in 17 patients over a full course of enteral nutrition (EN) and 40 of these placements were tracked. Tubes were secured by tape in 100%, mittens 31% and special observation 5.4%. However, over an EN course, inadvertent tube loss occurred in 82% of patients and was associated with age (p=0.049) and mitten use (p

Over 50 % of tape-secured feeding tubes are inadvertently lost. The impact of nasal bridle securement on nasogastric (NG) and nasointestinal (NI) tube loss, outcome and duration of use was determined from 1 October 2014 (NG) and 1 January 2010 respectively to 31 December 2017. From this and published data, the potential impact of nasal bridles on major complications was determined. Use of nasal bridles was independently associated with: an 80% reduction in inadvertent NI tube loss (odds ratio (OR): 95% confidence interval (CI): 0.2: 0.12-0.33, p

Objectives Determine why Cortrak-guided, undetected tube misplacement may occur in relation to the system of trace interpretation used. Methodology From 2010 to 2017 we obtained seven of the eight Cortrak traces from the United Kingdom where misplacement was undetected and the patient received feed. Seven suffered serious harm. Each misplacement was interpreted by three systems: screen position, manufacturer guidance and gastrointestinal (GI) flexures. Setting National and local records. Main outcome measures Ability to identify misplacement. Results Traces that were later identified as misplacements, could not be differentiated from GI position when they wholly or partially: a) overlapped with the GI screen area plotted from historical records (57–71%) or b) met both manufacturer guidance criteria or were confused with receiver misplacement or unusual anatomy and reached the lower left quadrant (14–71%). Conversely, all lung misplacements were identified as unsafe using the GI flexure system. All three systems failed to detect the intra-peritoneal trace. Traces were inconsistently stored by healthcare centres. Conclusion Trace file storage should be mandated by and accessible to relevant health authorisation bodies to improve safety research. Screen position alone and manufacturer guidance fail to consistently differentiate the shape of safe from unsafe traces. GI flexure interpretation appears safer but requires testing in larger studies.

Relatively high protein input has been associated with improved clinical outcome in critical illness. However, until recently differences in clinical outcome have been examined in terms of the energy goal-versus under-feeding. Most studies failed to set the energy goal by an accurate measure or estimate of expenditure or independently set protein prescription. This leads to under-prescription of protein, possibly adversely affecting outcome. We determined whether an enteral nutrition prescription could meet local and international protein guidelines.Protein prescriptions of consecutive patients admitted to Southmead Hospital ICU and requiring full enteral nutrition were audited against local and international guidelines. Prescriptions were designed to not exceed energy expenditure based on a validated estimation equation, minus non-nutritional energy, and protein requirements were based on local or international guidelines of between 1.2 and 2.5 g protein/kg/d or 2-2.5/kg ideal body weight (Hamwi ideal body weight)/d.From 15/1/15 to 12/4/15 139 ICU patients were prescribed full enteral nutrition. Protein prescriptions failed to meet local guidelines in 75% (p 0.001) and international guidelines in 45-100%. Prescriptions meeting at least 90% of protein guidelines and 130 g of carbohydrate could be increased from between 0 and 55%, depending on the guideline, to between 53 and 94% using a protein supplement and 82 and 100% using a protein plus glucose supplement. Non-nutritional energy (NNE) proportionately reduces feed protein prescription and contributed 19% of energy expenditure in 10% of patients.We need feeds with a lower non-protein energy: nitrogen (NPE:gN) ratio and/or protein supplementation if prescriptions are to meet protein guidelines for critical illness. NNE must be adjusted for in prescriptions to ensure protein needs are met.

Rowan Clemente, Specialised Dietitian, and Stephen Taylor, Research Dietitian, North Bristol NHS Trust, consider the current UK pH stick threshold and whether it might be putting vulnerable patients at risk

Gastric confirmation by pH is only achievable in approximately 50% of placements and X-rays are expensive and may be misinterpreted. Bedside electromagnetic (EM) guidance offers real-time confirmation. The authors determined the accuracy of guidance in predicting gastric body position from the EM trace using official Cortrak guidance (the EM trace reaches the bottom left quadrant of the anterior screen) compared with local guidance (detailed anterior-depth description of the GI flexures). X-ray, pH or an EM trace beyond the gastric body were used to independently confirm gastric position. Of 496 EM traces, 49% of tubes were in the oesophagus on entry to the lower left quadrant whereas 12% had already reached the gastric body in the upper left quadrant. Overall, predicting position by quadrant was 70% accurate whereas differentiating the pre-gastro-oesophageal junction (pre-GOJ) from the gastric body flexure was 100% accurate. Confirming gastric position by the anterior trace quadrant appears to be unsafe whereas expert differentiation of the pre-GOJ and gastric body flexures was reliable. The authors invite Corpak Medsystems (now owned by Halyard Health) to update its guidance in view of these findings.

Background: safe placement and securement of feeding tubes are essential to establishing early enteral nutrition. Nasogastric or nasojejunal feeding tubes are often inadvertently removed, and using a nasal bridle can reduce the number of tube replacements required. Aim: to review current nasal bridle practices on one intensive care unit. Over a 3-month period, nasal bridle use was recorded to measure unintentional tube loss and tube duration (the time a tube remained in situ). Method: an observational service evaluation. Findings: 109 patients were recruited; 205 tubes were passed and 77 bridles were inserted, with 42% (n=46) of the bridles placed on day 1. Tubes secured with tape were more likely to be dislodged than tubes secured with a bridle, P=0.0001. Duration of tubes remaining in situ was significantly longer in patients who had a bridle fitted on day 1, P=0.0001 compared with tubes secured with tape. Conclusion: securing a tube with a nasal bridle from day 1 is independently associated with reduced tube loss, increased duration of tube use, and likelihood that the tube would reach redundancy when it was no longer required.