Transpyloric feeding tube placement in critically ill patients using electromyogram and erythromycin infusion

Abstract

Study objectives: Transpyloric feeding is desirable in critically ill patients who often have gastroparesis; however, correct placement is difficult, requiring fluoroscopy, endoscopy, or time-consuming blind attempts. This study evaluated the success rate and time required to place transpyloric tubes using erythromycin infusion and GI electromyogram (EMG) signal.

Design: Observational trial.

Setting: University hospital medical ICU.

Patients: Thirty-nine patients receiving mechanical ventilation for respiratory failure (n = 13), pancreatitis (n = 9), ARDS (n = 8), neurologic disease (n = 4), major surgery (n = 3), and GI disease (n = 2) were enrolled (25 men and 14 women; mean age, 48.4 years; range, 21 to 82 years).

Interventions: Unweighted Flexiflo 10F feeding tubes were modified by the placement of an electrode 4 to 8 cm from the tip to record electromyogram (EMG) signals (Ross Products Division; Columbus, OH). Gastric signals are high amplitude with a frequency of 3 cycles per minute, while the duodenum and jejunum are low amplitude and 11 to 13 cycles per minute. Erythromycin was infused at a dose of 3 mg/kg to enhance gastric motor activity and emptying. The transpyloric tube was placed in the stomach, and its position was confirmed by EMG, then slowly advanced until duodenal EMG was detected. Tube position was determined by abdominal radiography.

Measurements and results: Thirty-one of 39 placements were immediately successful (initial success rate, 80%), 23 jejunal and 8 duodenal, requiring an average 7.8 min (range, 3 to 31 min). Six attempts in five patients were initial failures but were repeated, reaching the duodenum in one patient and the jejunum in four patients.

Conclusion: Erythromycin infusion and EMG guidance can facilitate rapid transpyloric feeding tube placement in critically ill patients at the bedside.