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

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.

Keywords: Blind bedside; Critically ill patients; Enteral nutrition; Postpyloric placement; Rescue therapy; Spiral nasojejunal tube.

Fig. 1

Method of blind bedside postpyloric spiral tube placement. ^aThe whoosh test was performed by air insufflation with auscultation in the epigastrium, in which a gurgling was regarded as indicative of air entering the stomach while the absence of gurgling suggested the tube tip was located elsewhere (lung, esophagus, pharynx, and so on). ^bThe vacuum test was done by instilling 60 ml air with a 20-ml syringe three times and then aspirated. If the volume of air aspirated was < 20 ml the tube was likely postpyloric, while if the volume of air aspirated was > 40 ml the tube was likely intragastric. ^cThe pH test was taken by measuring the pH value of aspiration with a pH strip. Aspiration of pH <5.0 was deemed intragastric. Aspiration of pH 6 − 7 was deemed to be from the small bowel. ^dThe guide wire withdrawal test was conducted by pulling back the guide wire a little way (within 5 cm). In a coiled tube, the guide wire either could be withdrawn with resistance felt as “popping”, or could be withdrawn easily but was unable to be re-inserted without a degree of force