Extemporaneous Compounding: A Possible Trigger Tool to Detect potentially health incidents

Background: Extemporaneous compounding (EC) involves preparation of a therapeutic product to a specific-patient need. However, there is a potential relation between this procedure and the occurrence of health incidents (HI). The use of triggers tool increases HI identification. Objective: This study assessed the performance of EC as trigger to detect potentially health incidents arising from this procedure. Method: A one-month observational and cross-sectional study was performed in internal medicine ward and intensive care unit of medium-sized hospital. Data collection was carried out in 5 stages: all triggered patients with dysphagia or enteral feeding tube with prescription of EC were included; it was observed all EC executed in standardized drugs prescribed; the procedure was compared with the hospital guide and scientific literature; HI monitoring and their evaluation using WHO and NCC MERP algorithms; a search for pharmaceutical alternatives (PA) that would avoid the observed EC. Results: 197 patients were recruited. Almost half of them were triggered by EC from 84 standardized drugs. 48 patients met inclusion criteria. It was identified 28 adverse drug reactions, 01 therapeutic ineffectiveness and 29 medication errors. EC as trigger tool showed a PPV value of 0.38. Finally, only 24 drugs have PA available in the market, that could avoid one third of all observed EC. Conclusion: It was possible to detect potentially HI in one of two patients with enteral feeding tube using EC as trigger tool. The use of EC as a trigger tool contributes to identify potentially HI arising from drugs, which have not gotten pharmaceutical alternatives to be administered via enteral feeding tube.

Multivariate analysis of factors associated with first-pass success in blind placement of a post-pyloric feeding tube: a retrospective study

Background Trans-jejunal nutrition via a post-pyloric enteral feeding tube has a low risk of aspiration or reflux; however, placement of the tube using the blind method can be difficult. Assistive devices, such as fluoroscopy or endoscopy, are useful but may not be suitable for patients with hemodynamic instability or severe respiratory failure. The aim of this study was to explore factors associated with first-pass success in the blind placement of post-pyloric enteral feeding tubes in critically ill patients. Methods Data were obtained retrospectively from the medical records of adult patients who had a post-pyloric enteral feeding tube placed in the intensive care unit between January 1, 2012, and December 31, 2018. Logistic regression analysis was performed to assess the association between first-pass success and the independent variables. For logistic regression analysis, the following 13 variables were defined as independent variables: age, sex, height, fluid balance from baseline, use of sedatives, body position during the procedure, use of cardiac assist devices, use of prokinetic agents, presence or absence of intestinal peristalsis, postoperative cardiovascular surgery, use of renal replacement therapy, serum albumin levels, and position of the greater curvature of the stomach in relation to spinal levels L1 − L2. Results Data obtained from 442 patients were analyzed. The first-pass success rate was 42.8% (n = 189). Logistic regression analysis demonstrated that the position of the greater curvature of the stomach cephalad to L1 − L2 was only associated with successful placement (odds ratio for first-pass success, 0.62; 95% confidence interval: 0.40 − 0.95). Conclusions In critically ill patients, the position of the greater curvature of the stomach caudal to L1 − L2 may be associated with a lower first-pass success rate of the blind method for post-pyloric enteral feeding tube placement. Further studies are needed to verify our results because the position of the stomach was estimated by radiographs after enteral feeding tube placement. Trial registration: University Hospital Medical Information Network Clinical Trials Registry (UMIN000036549; April 20, 2019).

Efficacy of a Viokace Pancreatic Enzyme Protocol for Clearing Occluded Enteral Feeding Tubes: A Quality Assurance Evaluation

Background: A previous retrospective study documented restored patency to 48.2% of occluded enteral feeding tubes using alkalinized Creon pancreatic enzyme capsules. In light of the low efficacy rate, the institutional enteral feeding tube clearance protocol was subsequently revised to incorporate a newly marketed non–enteric-coated Viokace pancreatic enzyme tablet, despite the lack of published data for this indication. Objective: This study aims to evaluate the effectiveness of a Viokace-based alkalinized pancreatic enzyme protocol to clear occluded enteral feeding tubes in a university health system. Methods: This retrospective, cohort quality assurance study included adult and pediatric patients receiving a Viokace-based pancreatic enzyme protocol for enteral feeding tube occlusions in a university health system during a 12-month period. The primary outcome was effectiveness in enteral tube clearance as documented in the electronic medical record. Efficacy of the new protocol was also compared with a Creon-based alkalinized solution using historical data. Results: The Viokace protocol successfully cleared 176 of the 277 (63.5%) occluded enteral feeding tubes occurring in 205 patients included in the analysis. The revised protocol was significantly more effective at clearing occluded enteral feeding tubes ( P = 0.0056) than a protocol using Creon pancreatic enzyme capsules. Conclusion: According to this retrospective evaluation, an alkalinized Viokace pancreatic enzyme protocol was effective in clearing 63.5% of occluded enteral feeding tubes. This significantly higher success rate than previously documented with a Creon-based protocol supports the change in pancreatic enzyme formulations in the institutional protocol.

Acute Respiratory Failure After Feeding Tube Placement in ALS: An Underrecognized Problem

Introduction Our objective was to identify parameters to identify Amyotrophic Lateral Sclerosis (ALS) patients at risk of acute respiratory failure after enteral feeding tube (EFT) insertion. Methods Retrospective single-site, IRB-exempt review of 17 patients identified by procedure code 43246 (Esophagogastroduodenoscopy) and ALS (ICD9-335, ICD10-G12.2) between 2015–2019. Spirometry, pre/post-procedure VC, use of non-invasive ventilation, procedure type and type of sedation were reviewed. Statistical significance determined at P ≤ .05. Cohen’s d effect size was done to address impact of the small sample size. Results Procedure selection followed the American Academy of Neurology recommendations using pre-procedure FVC; lowest risk (FVC > 50%) patients were referred for percutaneous enteral gastrostomy (PEG), whereas moderate risk (FVC 30–50%) and high risk (FVC < 30%) patients were referred for radiographically inserted gastrostomy or PEG with endotracheal intubation. Despite appropriate pre-operative risk stratification by FVC, post-procedure vital capacity (VC) acutely and significantly declined in 35% of patients, (mean decline 56%, SD 33), that impacted all procedure types. Conclusion In our case series, 35% of ALS patients developed acute respiratory failure with a marked acute drop in VC after enteral feeding tube placement. Pre-procedure FVC risk stratification into low, moderate or high risk did not identify patients who developed acute procedural respiratory failure, as this was not limited to those patients identified pre-operatively as moderate or high-risk. Post-procedure VC and change from pre-procedure measurements did identify patients who needed increased, inpatient post-procedure respiratory support. Implication of these observations drawn from a retrospective review support the need for additional research, to both confirm the initial findings in a larger sample size, difficult in single center trials with a low prevalence disease; further explore the impact of the type of sedation on post procedure respiratory failure, and determine if this is unique to ALS, or more broadly impacts patients with all forms of neuromuscular respiratory insufficiency.

Preparing and administering medications via enteral feeding tubes: a guideline for clinical pharmacists and multi-professional team

Objective: To identify the most prescribed drugs by enteral feeding tube in a public hospital and to a guideline for safe medication preparation and administration via enteral feeding tubes. Methods: A cross-sectional study with analysis of the daily prescriptions of patients exclusively using an enteral catheter in intensive care units and inpatients of the medical clinic specialty, in which descriptive statistics were used to identify the prevalence of medication use by tube. In a second step, a protocol was developed for the situation in which oral medications are prescribed to patients with a tube in the digestive tract. Results: A total of 1.810 medications prescribed by enteral feeding tube, of these 1.810, 291 (16%) were prescribed in liquid pharmaceutical form (suspension, solution, syrup) e 1.519 (84%) were prescribed in solid pharmaceutical form (tablets, capsule). 52 medications were selected for the protocol, and 14 of them (26.9%) with the recommendation of not crushing and administering via enteral feeding tube. Conclusion: Our results highlights the performance of clinical pharmacist in monitoring patients with enteral feeding tubes and guidance of multi-professional team. The protocol elaboration will guide for preparation and administration medication through the enteral feeding tube, reducing possible adverse events and ensuring the safety and efficacy of drug therapy.