Large Duodenal Hematoma Causing an Ileus after an Endoscopic Duodenal Biopsy in a 6-Year-Old Child: A Case Report

Intramural duodenal hematoma (IDH) in children is a rare complication after esophagogastroduodenoscopy. It is commonly described in patients with additional disorders or risk factors, such as coagulopathy. We present a case of a previously healthy 6-year-old boy with a large obstructing intramural duodenal hematoma and concomitant pancreatitis after an elective esophagogastroduodenoscopy. The patient presented with typical symptoms of an IDH, such as abdominal pain and distension, nausea and vomiting. IDH was diagnosed using ultrasound and magnetic resonance imaging examination. Conservative management with gastric decompression using a nasogastric feeding tube, bowel rest, total parenteral nutrition and analgesia was performed. After three weeks, the patient was discharged from the hospital without any complaints. Interventional management of IDH in pediatric patients with a lack of response to conservative therapy or complicating IDH should be discussed in an interdisciplinary team.

Bolus Versus Continuous Nasogastric Feeds for Infants With Bronchiolitis: A Randomized Trial

BACKGROUND AND OBJECTIVES: Infants hospitalized with bronchiolitis are commenced on nasogastric feeding to maintain hydration. Feeding strategies vary according to physician or institution preference. The current study hypothesized that continuous nasogastric feeding would prolong length of stay (LOS) when compared to bolus feeding. METHODS: A randomized, parallel-group, superiority clinical trial was performed within an Australian children’s hospital throughout 2 bronchiolitis seasons from May 2018 to October 2019. Infants <12 months hospitalized with bronchiolitis and requiring supplemental nasogastric feeding were randomly assigned to continuous or bolus nasogastric regimens. LOS was the primary outcome. Secondary outcome measures included pulmonary aspirations and admissions to intensive care. RESULTS: The intention-to-treat analysis included 189 patients: 98 in the bolus nasogastric feeding group and 91 in the continuous group. There was no significant difference in LOS (median LOS of the bolus group was 54.25 hours [interquartile range 40.25–82] and 56 hours [interquartile range 38–78.75] in the continuous group). A higher proportion of admissions to intensive care was detected in the continuous group (28.57% [26 of 91] of the continuous group vs 11.22% [11 of 98] of the bolus group [P value 0.004]). There were no clinically significant pulmonary aspirations or statistically significant differences in vital signs between the groups within 6 hours of feed initiation. CONCLUSIONS: No significant difference in LOS was found between bolus and continuous nasogastric feeding strategies for infants hospitalized with bronchiolitis. The continuous feeding group had a higher proportion of intensive care admissions, and there were no aspiration events.

Development and validation of ester impregnated pH strips for locating nasogastric feeding tubes in the stomach—a multicentre prospective diagnostic performance study

Background NG (nasogastric) tubes are used worldwide as a means to provide enteral nutrition. Testing the pH of tube aspirates prior to feeding is commonly used to verify tube location before feeding or medication. A pH at or lower than 5.5 was taken as evidence for stomach intubation. However, the existing standard pH strips lack sensitivity, especially in patients receiving feeding and antacids medication. We developed and validated a first-generation ester-impregnated pH strip test to improve the accuracy towards gastric placements in adult population receiving routine NG-tube feeding. The sensitivity was improved by its augmentation with the action of human gastric lipase (HGL), an enzyme specific to the stomach. Methods We carried out a multi-centred, prospective, two-gate diagnostic accuracy study on patients who require routine NG-tube feeding in 10 NHS hospitals comparing the sensitivity of the novel pH strip to the standard pH test, using either chest X-rays or, in its absence, clinical observation of the absence of adverse events as the reference standard. We also tested the novel pH strips in lung aspirates from patients undergoing oesophageal cancer surgeries using visual inspection as the reference standard. We simulated health economics using a decision analytic model and carried out adoption studies to understand its route to commercialisation. The primary end point is the sensitivity of novel and standard pH tests at the recommended pH cut-off of 5.5. Results A total of 6400 ester-impregnated pH strips were prepared based on an ISO13485 quality management system. A total of 376 gastric samples were collected from adult patients in 10 NHS hospitals who were receiving routine NG-tube feeding. The sensitivities of the standard and novel pH tests were respectively 49.2% (95% CI 44.1‑54.3%) and 70.2% (95% CI 65.6‑74.8%) under pH cut-off of 5.5 and the novel test has a lung specificity of 89.5% (95% CI 79.6%, 99.4%). Our simulation showed that using the novel test can potentially save 132 unnecessary chest X-rays per check per every 1000 eligible patients, or direct savings of £4034 to the NHS. Conclusions The novel pH test correctly identified significantly more patients with tubes located inside the stomach compared to the standard pH test used widely by the NHS. Trial registration http://www.isrctn.com/ISRCTN11170249, Registered 21 June 2017—retrospectively registered

Malposition of a Nasogastric Feeding Tube Into the Right Pleural Cavity of a Nasopharyngeal Carcinoma Patient After Radiotherapy and Chemotherapy: A Case Report

Background: Nasogastric feeding tube plays an important role in nutrition intake, drug administration, and stomach emptying for patients with severe dysphagia. However, inserting nasogastric tubes is not absolutely harmless. Inadvertent malposition into the trachea or the pleural cavity could result in severe pulmonary complications. Case presentation: We present a case of a 67-year-old patient with a history of nasopharyngeal carcinoma and after the treatment of radiotherapy and chemotherapy. Nasogastric tubes have to be placed for enteral nutrition and avoiding aspiration owing to his severe dysphagia. Unfortunately, he experienced a malposition of nasogastric tube into the right pleura cavity after blind replacement by nurse, whereas the nurses and physicians did not recognize this fault, even the bedside chest radiography (X-ray) was performed twice after intubation. A week later, his condition deteriorated so rapidly that he had to undergo tracheotomy, and the tube was finally found in his trachea.Conclusions: The Nasopharyngeal carcinoma patients after radiotherapy and chemotherapy should be fully evaluated before the nasogastric tube placement whether the blind insertion is suitable or not. Meanwhile, we should not feed immediately unless we have a radiograph to verify the right position of NG tube. Furthermore, careful monitoring of both typical and untypical symptoms of malposition is essential during tube feeding.

Association between teeth loss and nasogastric tube feeding dependency in older adults from Taiwan: a retrospective cohort study

Background To examine the association between teeth loss and nasogastric tube feeding dependency in older people. Methods The National Health Interview Survey (NHIS) 2005, 2009, and 2013 in Taiwan. Participants were selected by a multistage stratified sampling method and baseline characteristics, including socioeconomic status and health habits, were obtained by well-trained interviewers. The NHIS was linked with the National Health Insurance research database 2000–2016 and the National Deaths Dataset, which contains all the medical information of ambulatory and inpatient care. Cox regression was used to examine the association between the number of teeth lost and nasogastric tube feeding dependency. Results There were 6165 adults older than 65 years old enrolled in the analysis, with 2959 male (48%) and the mean (SD) age was 73.95(6.46) years old. The mean follow-up duration was 6.5(3.3) years. Regarding the teeth loss categories, 1660 (26.93%), 2123 (34.44%), and 2382 (38.64%) of participants were categorized as having no teeth loss, loss of 1–9 teeth, and loss of 10–28 teeth, respectively. During 39,962 person-years of follow-up, new-onset nasogastric feeding dependency was recognized in 220(13.25%), 256(12.06%), and 461(19.35%) participants who were categorized as having no teeth loss, loss of 1–9 teeth, and loss of 10–28 teeth, respectively. Kaplan-Meier curves demonstrated significant findings (Log-rank P < 0.01). After potential confounders were adjusted, compared with those without teeth loss, older adults who had lost 10–28 teeth had significantly increased risks of occurrence nasogastric feeding dependency (AHR, 1.31; 95% CI, 1.05–1.62; p-value = 0.02). Furthermore, a significant dose-response relation between the number of teeth lost and increased risk of nasogastric feeding was found (p for trend< 0.01). Conclusions Older adults who had lost 10–28 teeth had a significantly increased risk of nasogastric tube feeding dependency. Early identification of the oral disease is crucial for the prevention of the occurrence of teeth loss and the following nutrition problems, which would reduce risk of nasogastric tube feeding dependency.

Identification and solution of drug-related problems in the neurology unit of a tertiary hospital in China

Background The prevalence and characteristics of drug-related problems (DRPs) and factors associated with the occurrence of DRPs in the neurology unit in China remain unknown. This study aimed to determine the prevalence, characteristics and severity ratings of DRPs and identify factors associated with the occurrence of DRPs in the neurology unit of a tertiary care and academic teaching hospital in China. Methods A retrospective study of DRPs and pharmacists’ interventions for neurology patients was performed during a non-consecutive 24-month study period. Patient demographics and clinical characteristics, and pharmacist’s intervention records were collected. The characteristics and severity ratings of DRPs were categorized using the Pharmaceutical Care Network Europe (PCNE) DRP classification tool V9.00 and the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) classification respectively. Results A total of 242 DRPs were detected for 974 admitted patients, an average of 0.25 DRPs per patient. Treatment safety was the major type of DRPs (106;43.8%) followed by treatment effectiveness (78;32.2%). The primary causes of DRPs were drug selection (124;44.1%) and dose selection (92;32.7%). Clinical pharmacists provided 525 interventions, and most interventions occurred at the prescriber level (241;45.9%). A total of 91.4% of these interventions were accepted, contributing to solving 93.0% of the identified problems. The majority of DRPs (210;86.8%) were rated at severity categories B to D (causing no patient harm). Multiple logistic regression showed that creatinine clearance, number of medications used, nasogastric feeding, diabetes, and infectious diseases were associated with more frequent DRPs (p < 0.05). Conclusions DRPs are relatively common in the neurology unit in China, with primary causes of drug and dose selection, and clinical pharmacists can effectively reduce and prevent DRPs to optimize medication therapy.

Multichannel esophageal signals to monitor respiratory rate in preterm infants

Background Apnea of prematurity cannot be reliably measured with current monitoring techniques. Instead, indirect parameters such as oxygen desaturation or bradycardia are captured. We propose a Kalman filter-based detection of respiration activity and hence apnea using multichannel esophageal signals in neonatal intensive care unit patients. Methods We performed a single-center observational study with moderately preterm infants. Commercially available nasogastric feeding tubes containing multiple electrodes were used to capture signals with customized software. Multichannel esophageal raw signals were manually annotated, processed using extended Kalman filter, and compared with standard monitoring data including chest impedance to measure respiration activity. Results Out of a total of 405.4 h captured signals in 13 infants, 100 episodes of drop in oxygen saturation or heart rate were examined. Median (interquartile range) difference in respiratory rate was 0.04 (−2.45 to 1.48)/min between esophageal measurements annotated manually and with Kalman filter and −3.51 (−7.05 to −1.33)/min when compared to standard monitoring, suggesting an underestimation of respiratory rate when using the latter. Conclusions Kalman filter-based estimation of respiratory activity using multichannel esophageal signals is safe and feasible and results in respiratory rate closer to visual annotation than that derived from chest impedance of standard monitoring.