Intravenous Metoclopramide to Improve the Success Rate of Blind Bedside Post-pyloric Placement of Feeding Tube in Critically Ill Children: A Randomized, Double-Blind, Placebo-Controlled Study

Objective: Impaired gastric emptying is a common cause of delayed feeding in critically ill children. Post-pyloric feeding may help improve feeding intolerance and nutritional status and, hence, contribute to a better outcome. However, post-pyloric feeding tube insertion is usually delayed due to a technical difficulty. Therefore, prokinetic agents have been used to facilitate blind bedside post-pyloric feeding tube insertion. Metoclopramide is a potent prokinetic agent that has also been used to improve motility in adults and children admitted to intensive care units. The objective of this study was to determine the efficacy of intravenous metoclopramide in promoting the success rate of blind bedside post-pyloric feeding tube placement in critically ill children.Design: The design of this study is randomized, double blind, placebo controlled.Setting: The setting of the study is a single-center pediatric intensive care unit.Patients: Children aged 1 month−18 years admitted to the pediatric intensive care unit with severe illness or feeding intolerance were enrolled in this study.Intervention: Patients were randomly selected to receive intravenous metoclopramide or 0.9% normal saline solution (the placebo) prior to the tube insertion. The study outcome was the success rate of post-pyloric feeding tube placement confirmed by an abdominal radiography 6–8 h after the insertion.Measurements and Main Results: We found that patients receiving metoclopramide had a higher success rate (37/42, 88%) of post-pyloric feeding tube placement than the placebo (28/40, 70%) (p = 0.04). Patients who received sedative drug or narcotic agent showed a tendency of higher success rate (p = 0.08).Conclusion: Intravenous metoclopramide improves the success rate of blind bedside post-pyloric placement of feeding tube in critically ill children.Trial Registration: Thai Clinical Trial Registry TCTR20190821002. Registered 15th August 2019.

Superior mesenteric artery syndrome treated successfully by endoscopy-assisted jejunal feeding tube placement

We report the case of a 31-year-old man with superior mesenteric artery syndrome after reoperation due to postoperative complications from rectal cancer. Although initial total parenteral nutrition (TPN) therapy failed, he underwent endoscopy-assisted feeding tube placement without complications instead of surgery. After 2 weeks of dual feeding (enteral feeding and TPN), he improved, gaining 6 kg; and an oral diet was advanced.

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).

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.