Bevacizumab-Associated Implant Presence-Triggered Osteonecrosis: A Case Report and Literature Review.

The effect of bevacizumab-related osteonecrosis of the jaw on previously osseointegrated dental implants has not been adequately studied. Here, we report a case of osteonecrosis of the jaw detected around dental implants placed before bevacizumab therapy. A 66-year-old woman undergoing bevacizumab therapy for metastatic triple-negative breast cancer developed malocclusion after buccal gingival swelling and pain in the #18, #19, and #20 tooth region. The patient visited a local dental clinic, where existing implants in relation to #19 and #20 were removed. Subsequently, the patient visited our department, and intraoral examination revealed necrotic bone in the region corresponding to #19 and #20. Radiographic examination showed a pathologic fracture in this region that was considered to result from osteonecrosis of the jaw. Bevacizumab therapy was suspended temporarily until the acute inflammation had subsided. In addition, treatment with antibacterial agents and conservative surgery was considered. Complete soft tissue coverage was observed 14 days after surgery. In recent years, the number of patients receiving bevacizumab treatment has increased. Because bevacizumab-related osteonecrosis of the jaw could occur around previously osseointegrated dental implants as well, this case report suggests an effective treatment regimen based on a combination of antibacterial agents and conservative surgery.

Factors associated with viral clearance periods from patients with COVID-19: A retrospective observational cohort study.

INTRODUCTION: Knowledge is limited on the virologic course of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, particularly the time taken for viral clearance and the optimal time to discontinue isolation. This study aims to identify the clinical and demographic factors influencing the time taken for viral clearance in patients with COVID-19 to determine the optimal isolation period. METHODS: This two-center retrospective observational cohort study was conducted between March 1 and June 31, 2020. Patients with COVID-19, which was confirmed by real-time reverse transcription polymerase chain reaction, were included. Data were extracted from medical records. The positive duration, which was defined as the period from the day of symptom onset to the negative conversion day, was assessed using a generalized linear model. RESULTS: We included 63 patients. The mean positive duration was 20 days. The positive duration was significantly shorter for patients younger than 30 years of age and those between 30 and 60 years of age than for patients older than 60 years of age. We observed a more scattered distribution of the positive duration in older patients than in younger patients. CONCLUSIONS: Younger patients who recovered from COVID-19 took less time to clear SARS-CoV-2 than older patients; thus, a classification of the isolation periods based on age could be considered. A uniform viral clearance period for older patients may be difficult to determine because of biases such as underlying medical conditions. Further surveillance measures are recommended to determine the viral clearance time and the optimal isolation period.

A novel method for transpulmonary pressure estimation using fluctuation of central venous pressure.

The objective of the study is to develop a correction method for estimating the change in pleural pressure (ΔPpl) and plateau transpulmonary pressure (PL) by using the change in central venous pressure (ΔCVP). Seven children (aged < 15 years) with acute respiratory failure (PaO2/FIO2 < 300 mmHg), who were paralyzed and mechanically ventilated with a PEEP of < 10 cmH2O and had central venous catheters and esophageal balloon catheters placed for clinical purposes, were enrolled prospectively. We compared change in esophageal pressure (ΔPes), ΔCVP, and ΔPpl calculated using a corrected ΔCVP (cΔCVP-derived ΔPpl). cΔCVP-derived ΔPpl was calculated as κ × ΔCVP, where κ was the ratio of the change in airway pressure (ΔPaw) to ΔCVP during the occlusion test. cΔCVP-derived ΔPpl correlated better than ΔCVP with ΔPes (R2 = 0.48, p = 0.08 vs. R2 = 0.14, p = 0.4) with lesser bias and precision in Bland-Altman analysis. The plateau PL calculated using the cΔCVP-derived ΔPpl (17.6 ± 2.6 cmH2O) correlated well with the ΔPes-derived plateau PL (18.1 ± 2.3 cmH2O) (R2 = 0.90, p = 0.001). Our correction method can estimate ΔPpl and plateau PL from ΔCVP with a reasonable accuracy in paralyzed and mechanically ventilated pediatric patients with respiratory failure.

[Delayed discharge from the intensive care unit].

BACKGROUND: Delayed discharge from ICU to the general ward can exert an adverse effect. We researched whether patients are discharged smoothly from our ICU to the general ward. METHODS: We defined that patients were eligible for discharge if they are without administration of catecholamine, being assisted by mechanical ventilation and having blood purification therapy. RESULTS: Average time from actual discharge to the time patient was considered eligible for discharge was fifteen hours. This study was retrospective. CONCLUSIONS: We need to investigate further the reasons why delayed discharge occurred. It is im portant that patients are discharged from the ICU to the general ward properly. Delayed discharge can delay the recovery and expose the patient to multi-resistant microorganisms. We studied whether patients are discharged smoothly from the ICU to the general ward.

Chorioamnionitis and early pregnancy loss caused by ampicillin-resistant non-typeable Haemophilus influenzae.

Haemophilus influenzae can cause intra-amniotic infection and early pregnancy loss. The mode of transmission and risk factors for H. influenzae uterine cavity infections are unknown. Here, we present the case of chorioamnionitis caused by ampicillin-resistant H. influenzae in a 32-year-old Japanese woman at 16 weeks of gestation. Despite empirical treatment, including ampicillin, as recommended by the current guidelines, she had fetal loss. The antimicrobial regimen was changed to ceftriaxone, and the treatment was completed without complications. Although the prevalence and risk factors for chorioamnionitis caused by ampicillin-resistant H. influenzae are unknown, clinicians need to recognize H. influenzae as a potentially drug-resistant and lethal bacterium for pregnant women.

Estimation of change in pleural pressure in assisted and unassisted spontaneous breathing pediatric patients using fluctuation of central venous pressure: A preliminary study.

BACKGROUND: It is important to evaluate the size of respiratory effort to prevent patient self-inflicted lung injury and ventilator-induced diaphragmatic dysfunction. Esophageal pressure (Pes) measurement is the gold standard for estimating respiratory effort, but it is complicated by technical issues. We previously reported that a change in pleural pressure (ΔPpl) could be estimated without measuring Pes using change in CVP (ΔCVP) that has been adjusted with a simple correction among mechanically ventilated, paralyzed pediatric patients. This study aimed to determine whether our method can be used to estimate ΔPpl in assisted and unassisted spontaneous breathing patients during mechanical ventilation. METHODS: The study included hemodynamically stable children (aged <18 years) who were mechanically ventilated, had spontaneous breathing, and had a central venous catheter and esophageal balloon catheter in place. We measured the change in Pes (ΔPes), ΔCVP, and ΔPpl that was calculated using a corrected ΔCVP (cΔCVP-derived ΔPpl) under three pressure support levels (10, 5, and 0 cmH2O). The cΔCVP-derived ΔPpl value was calculated as follows: cΔCVP-derived ΔPpl = k × ΔCVP, where k was the ratio of the change in airway pressure (ΔPaw) to the ΔCVP during airway occlusion test. RESULTS: Of the 14 patients enrolled in the study, 6 were excluded because correct positioning of the esophageal balloon could not be confirmed, leaving eight patients for analysis (mean age, 4.8 months). Three variables that reflected ΔPpl (ΔPes, ΔCVP, and cΔCVP-derived ΔPpl) were measured and yielded the following results: -6.7 ± 4.8, - -2.6 ± 1.4, and - -7.3 ± 4.5 cmH2O, respectively. The repeated measures correlation between cΔCVP-derived ΔPpl and ΔPes showed that cΔCVP-derived ΔPpl had good correlation with ΔPes (r = 0.84, p< 0.0001). CONCLUSIONS: ΔPpl can be estimated reasonably accurately by ΔCVP using our method in assisted and unassisted spontaneous breathing children during mechanical ventilation.

Effect of High-Flow Nasal Cannula on Thoraco-Abdominal Synchrony in Pediatric Subjects After Cardiac Surgery.

BACKGROUND: We previously reported the effects of high-flow nasal cannula (HFNC) oxygen therapy on thoraco-abdominal synchrony. This study was designed to clarify the effect of HFNC on thoraco-abdominal synchrony in pediatric subjects after cardiac surgery and to investigate HFNC optimal flow in this population. METHODS: Thoraco-abdominal synchrony was evaluated with respiratory inductive plethysmography. After extubation, we delivered oxygen via face mask for 30 min to subjects with mild to moderate respiratory failure. Each subject then randomly received either 1 or 2 L/kg/min via HFNC for 30 min, followed by the other flow level via HFNC for 30 min. After HFNC, face mask delivery was resumed. Rib cage and abdominal movement were converted into volumes and 2 quantitative indexes: maximum compartmental amplitude/tidal volume (VT) ratio and phase angle. RESULTS: Ten subjects of median (interquartile range) age 7 (6-14) months and weighing 6.5 (5.3-8.8) kg were enrolled. Compared with the first delivery via face mask, breathing frequency, maximum compartmental amplitude/VT, phase angle, and minute volume significantly decreased at 2 L/kg/min (P < .05 for all) but not at 1 L/kg/min. PaCO2 did not differ among oxygen therapies. None of the measured variables differed between first and second face mask periods. CONCLUSIONS: After cardiac surgery, HFNC oxygen therapy at 2 L/kg/min improved thoraco-abdominal synchrony and decreased breathing frequency in pediatric subjects. (Clinical trial registration: UMIN000023426.).

Inspiratory Tube Condensation During High-Flow Nasal Cannula Therapy: A Bench Study.

BACKGROUND: High-flow nasal cannula (HFNC) therapy provides better humidification than conventional oxygen therapy. To allay loss of vapor as condensation, a servo-controlled heating wire is incorporated in the inspiratory tube, but condensation is not completely avoidable. We investigated factors that might affect condensation: thermal characteristics of the inspiratory tube, HFNC flow, and ambient temperature. METHODS: We evaluated 2 types of HFNC tubes, SLH Flex 22-mm single tube and RT202. Both tubes were connected to a heated humidifier with water reservoir. HFNC flow was set at 20, 40, and 60 L/min, and FIO2 was set at 0.21. Air conditioning was used maintain ambient temperature at close to either 20 or 25°C. We weighed the tubes on a digital scale before (0 h) and at 3, 6, and 24 h after, turning on the heated humidifier, and calculated the amount of condensation by simple subtraction. The amount of distilled water used during 24 h was also recorded. RESULTS: At 25°C, there was little condensation, but at 20°C and HFNC flow of 20, 40, and 60 L/min for 24 h, the amount of condensation with the SLH was 50.2 ± 10.7, 44.3 ± 17.7, and 56.6 ± 13.9 mg, and the amount with the RT202 was 96.0 ± 35.1, 72.8 ± 8.2, and 64.9 ± 0.8 mg. When ambient temperature was set to 20°C, condensation with the RT202 was statistically significantly greater than with the SLH at all flow settings (P < .001). CONCLUSIONS: Ambient temperature statistically significantly influenced the amount of condensation in the tubes.

Neurally adjusted ventilatory assist improves patient-ventilator synchrony in a patient with tetanus and unstable diaphragmatic electrical activity.

A 79-y-old man with generalized tetanus was admitted to the ICU. A left-forearm wound was surgically debrided, and the wound was closed. On postoperative day 1, after the patient experienced opisthotonos and convulsions, endotracheal intubation was performed. Propofol and diazepam were infused but failed to stop the convulsions. Morphine, midazolam, dantrolene, and rocuronium were used to ameliorate the muscle spasms. Magnesium sulfate was also infused. On postoperative day 15, patient-ventilator asynchrony was apparent. The patient showed recurrent tachypnea and bradypnea, which seemed typical of Cheyne-Stokes respiration. A neurally adjusted ventilatory assist (NAVA) catheter was inserted transnasally, and electrical activity of the diaphragm (Edi) was monitored. Readings showed regular attempts to breathe at 40-50 breaths/min with periodic changes in Edi amplitude. NAVA mode improved patient-ventilator synchrony. Periodic breathing continued for 2 weeks. We stopped monitoring Edi on postoperative day 39. He began respiratory rehabilitation and was transferred to a hospital for rehabilitation on postoperative day 80. We encountered periodic respiration in a patient with tetanus. Edi monitoring revealed periodic amplitude change. The cause of the periodic breathing pattern in this patient could not be determined but may be attributable to side effects of the pharmacologic interventions or the natural history of the disease itself. NAVA mode improved patient-ventilator synchrony.

Performance of ventilators compatible with magnetic resonance imaging: a bench study.

BACKGROUND: Magnetic resonance imaging (MRI) is indispensable for diagnosing brain and spinal cord abnormalities. Magnetic components cannot be used during MRI procedures; therefore, patient support equipment must use MRI-compatible materials. However, little is known of the performance of MRI-compatible ventilators. METHODS: At commonly used settings, we tested the delivered tidal volume (V(T)), F(IO2), PEEP, and operation of the high-inspiratory-pressure-relief valves of 4 portable MRI-compatible ventilators (Pneupac VR1, ParaPAC 200DMRI, CAREvent MRI, iVent201) and one ICU ventilator (Servo-i). Each ventilator was set in volume control/continuous mandatory ventilation mode. Breathing frequency and V(T) were tested at 10 breaths/min and 300, 500, and 700 mL, respectively. The Pneupac VR1 has fixed V(T) and frequency combinations, so it was tested at V(T) = 300 mL and 20 breaths/min, V(T) = 500 mL and 12 breaths/min, and V(T) = 800 mL and 10 breaths/min. F(IO2) was 0.6 and 1.0. At the air-mix setting, F(IO2) was fixed at 0.5 with the Pneupac VR1, 0.45 with the ParaPAC 200DMRI, and 0.6 with the CAREvent MRI. PEEP was set at 5 and 10 cm H2O, and pressure relief was set at 30 and 40 cm H2O. RESULTS: V(T) error varied widely among ventilators (-28.1 to 25.5%). As V(T) increased, error decreased with the Pneupac VR1, ParaPAC 200DMRI, and CAREvent MRI (P < .05). F(IO2) error ranged from -13.3 to 25.3% at 0.6 (or air mix). PEEP error varied among ventilators (-29.2 to 42.5%). Only the Servo-i maintained V(T), F(IO2), and PEEP at set levels. The pressure-relief valves worked in all ventilators. CONCLUSIONS: None of the MRI-compatible ventilators maintained V(T), F(IO2), and PEEP at set levels. Vital signs of patients with unstable respiratory mechanics should be monitored during transport and MRI.

Hyperoxemia in mechanically ventilated, critically ill subjects: incidence and related factors.

BACKGROUND: Excessive supplemental oxygen causes injurious hyperoxemia. Before establishing the best P(aO2) targets for mechanically ventilated patients, it is important to understand the incidence of hyperoxemia and related factors. We investigated oxygenation in mechanically ventilated subjects in our ICU and evaluated factors related to hyperoxemia (P(aO2) > 120 mm Hg) at 48 h after initiation of mechanical ventilation. METHODS: We retrospectively reviewed the medical records of patients admitted to our ICU from January 2010 to May 2013. Inclusion criteria were 15 y of age or older and administration of mechanical ventilation for > 48 h. Patients at risk of imminent death on admission or who had received noninvasive ventilation were excluded. We collected subject demographics, reasons for mechanical ventilation, and during mechanical ventilation, we collected arterial blood gas data and ventilator settings on the first day of intubation (T1), 48 h after initiation of mechanical ventilation (T2), and on the day of extubation (T3). Multivariable logistic regression analysis was performed to clarify independent variables related to hyperoxemia at T2. RESULTS: For the study period, data for 328 subjects were analyzed. P(aO2) statistically significantly increased over time to 90 (interquartile range of 74-109) mm Hg at T1, 105 (89-120) mm Hg at T2, and 103 (91-119) mm Hg at T3 (P < .001), coincident with decreases in F(IO2) of 0.4 (0.3-0.5) at T1, 0.3 (0.3-0.4) at T2, and 0.3 (0.3-0.35) at T3 (P < .001). Hyperoxemia occurred in 15.6% (T1), 25.3% (T2), and 22.4% (T3) of subjects. Multivariable logistic regression analysis revealed that hyperoxemia was independently associated with age of < 40 y (odds ratio 2.6, 95% CI 1.1-6.0), Acute Physiology and Chronic Health Evaluation II scores of ≥ 30 (odds ratio 0.53, 95% CI 0.3-1.0), and decompensated heart failure (odds ratio 1.9, 95% CI 1.1 to 3.5). CONCLUSIONS: During mechanical ventilation of critically ill subjects, P(aO2) increased, and F(IO2) decreased. One in 4 subjects were hyperoxemic at T2, and hyperoxemia persisted until T3.

Complete bronchial obstruction by granuloma in a paediatric patient with translaryngeal endotracheal tube: a case report.

INTRODUCTION: Although continuous or frequent stimuli in tracheostomized patients may cause tracheal granulomas, little is known about management of patients with translaryngeal intubation. CASE PRESENTATION: A 1-month-old Japanese boy, weighing 3.5kg, was admitted to our hospital owing to cardiac failure caused by an atrial septal defect and intractable arrhythmia. To treat his unstable cardiovascular status, surgery was performed to close his atrial septal defect. After the operation, stenosis was detected by auscultation and flow limitation worsened. A bronchoscopy revealed granulomas completely obstructing his right bronchus and partially obstructing his left bronchus. Dexamethasone infusion partially reduced the mass, after which removal by yttrium aluminium garnet laser was tried. The airway obstruction was not resolved, however, because of granuloma reproliferation. Budesonide (aerosol liquid) inhalation was started, and tissue was reduced using an yttrium aluminium garnet laser and physically removed using forceps. After continued budesonide inhalation, he was successfully liberated from the ventilator. CONCLUSIONS: Life-threatening airway obstruction by granulomas developed in a translaryngeally intubated paediatric patient. The granuloma was detected after a couple of weeks of intubation. A bronchial granuloma is rare in paediatric patients. It should be suspected with evidence of bronchial obstruction. Treatment with corticosteroids and surgery using a laser maybe indicated.

Hygrometric properties of inspired gas and oral dryness in patients with acute respiratory failure during noninvasive ventilation.

BACKGROUND: Because noninvasive ventilation (NIV) delivers medical gas at high flow, inadequate humidification may cause oral dryness and patient discomfort. Heated humidification can be used during NIV, but little has been reported about the effects on the hygrometric conditions inside an oronasal mask and oral dryness during 24 hours on NIV. METHODS: We measured absolute humidity (AH) inside oronasal masks on subjects with acute respiratory failure during 24 hours on NIV. A single-limb turbine ventilator and oronasal mask with an exhalation port were used for NIV. Oral moistness was evaluated using an oral moisture-checking device, and 3 times during the 24 hours the subjects subjectively scored the feeling of dryness on a 0-10 scale in which 10 was the most severe dryness. RESULTS: Sixteen subjects were enrolled. The mean ± SD AH inside the mask was 30.0 ± 2.6 mg H2O/L (range 23.1-33.3 mg H2O/L). The median oral moistness was 19.2% (IQR 4.4-24.0%), and the median oral dryness score was 5.5 (IQR 4-7). AH and inspired gas leak correlated inversely, both within the subjects (r = -0.56, P < .001) and between the subjects (r = -0.58, P = .02). AH and oral moistness correlated within the subjects (r = 0.39, P = .04). Oral breathing was associated with reduced oral moistness (P = .001) and increased oral dryness score (P = .002). CONCLUSIONS: AH varied among the subjects, and some complained of oral dryness even with heated humidifier. Oral breathing decreased oral moistness and worsened the feeling of dryness.

Effect of high-flow nasal cannula on thoraco-abdominal synchrony in adult critically ill patients.

BACKGROUND: High-flow nasal cannula (HFNC) creates positive oropharyngeal airway pressure and improves oxygenation. It remains unclear, however, whether HFNC improves thoraco-abdominal synchrony in patients with mild to moderate respiratory failure. Using respiratory inductive plethysmography, we investigated the effects of HFNC on thoraco-abdominal synchrony. METHODS: We studied 40 adult subjects requiring oxygen therapy in the ICU. Low-flow oxygen (up to 8 L/min) was administered via oronasal mask for 30 min, followed by HFNC at 30-50 L/min. Respiratory inductive plethysmography transducer bands were circumferentially placed: one around the rib cage, and one around the abdomen. We measured the movement of the rib-cage and abdomen, and used the sum signal to represent tidal volume (V(T)) during mask breathing, and at 30 min during HFNC. We calculated the ratio of maximum compartmental amplitude (MCA) to V(T), and the phase angle. We assessed arterial blood gas and vital signs at each period, and mouth status during HFNC. We used multiple regression analysis to identify factors associated with improvement in thoraco-abdominal synchrony. RESULTS: During HFNC, breathing frequency significantly decreased from 25 breaths/min (IQR 22-27 breaths/min) to 21 breaths/min (IQR 18-24 breaths/min) (P < .001), and MCA/VT (P < .001) and phase angle (P = .047) significantly improved. CONCLUSIONS: HFNC improved thoraco-abdominal synchrony in adult subjects with mild to moderate respiratory failure.

Humidification performance of two high-flow nasal cannula devices: a bench study.

INTRODUCTION: Delivering heated and humidified medical gas at 20-60 L/min, high-flow nasal cannula (HFNC) creates low levels of PEEP and ameliorates respiratory mechanics. It has become a common therapy for patients with respiratory failure. However, independent measurement of heat and humidity during HFNC and comparison of HFNC devices are lacking. METHODS: We evaluated 2 HFNC (Airvo 2 and Optiflow system) devices. Each HFNC was connected to simulated external nares using the manufacturer's standard circuit. The Airvo 2 outlet-chamber temperature was set at 37°C. The Optiflow system incorporated an O2/air blender and a heated humidifier, which was set at 40°C/3. For both systems, HFNC flow was tested at 20, 40, and 50 L/min. Simulating spontaneous breathing using a mechanical ventilator and TTL test lung, we tested tidal volumes (VT) of 300, 500, and 700 mL, and breathing frequencies of 10 and 20 breaths/min. The TTL was connected to the simulated external nares with a standard ventilator circuit. To prevent condensation, the circuit was placed in an incubator maintained at 37°C. Small, medium, and large nasal prongs were tested. Absolute humidity (AH) of inspired gas was measured at the simulated external nares. RESULTS: At 20, 40, and 50 L/min of flow, respective AH values for the Airvo 2 were 35.3 ± 2.0, 37.1 ± 2.2, and 37.6 ± 2.1 mg/L, and for the Optiflow system, 33.1 ± 1.5, 35.9 ± 1.7, and 36.2 ± 1.8 mg/L. AH was lower at 20 L/min of HFNC flow than at 40 and 50 L/min (P < .01). While AH remained constant at 40 and 50 L/min, at 20 L/min of HFNC flow, AH decreased as VT increased for both devices. CONCLUSIONS: During bench use of HFNC, AH increased with increasing HFNC flow. When the inspiratory flow of spontaneous breathing exceeded the HFNC flow, AH was influenced by VT. At all experimental settings, AH remained > 30 mg/L.

Successful use of extracorporeal membrane oxygenation in the reversal of cardiorespiratory failure induced by atonic uterine bleeding: a case report.

INTRODUCTION: Although extracorporeal membrane oxygenation has made sufficient progress to be considered for the management of life-threatening cardiac and respiratory failure, the risk of hemorrhagic complications may outweigh the benefits for patients with bleeding tendencies. We report, to the best of our knowledge, the first case of successful treatment by extracorporeal membrane oxygenation, without any hemorrhagic complications, of postpartum cardiorespiratory failure after massive uterine bleeding. CASE PRESENTATION: A 25-year-old Japanese woman experienced massive atonic bleeding after delivering her second baby. Recovery from hemorrhagic shock was managed by conservative treatments, but she developed decompensated heart failure and refractory hypoxia. Because we could not obtain hemodynamic stability and proper oxygenation even with high doses of catecholamines and maximal ventilator settings, we administered venoarterial extracorporeal membrane oxygenation, whereupon her hemodynamic status immediately stabilized. After 72 hours of support without major bleeding, extracorporeal membrane oxygenation was successfully withdrawn. CONCLUSION: Even in cases of obstetric bleeding, if clotting status is stringently monitored, extracorporeal membrane oxygenation can be considered as an ultimate means of life support.

Correction: Temperature of gas delivered from ventilators.

[This corrects the article on p. 6 in vol. 1, PMID: 25705400.].

Incidence of bacterial contamination in infusion set needles.

We examined the incidence and types of bacterial contamination in 265 infusion set needles in adult critically ill patients. Bacterial contamination was detected in 15 samples (5.7%), and a total of 17 organisms were isolated. Ten were coagulase-negative staphylococci (CNS) and Staphylococcus aureus, and the remainder were α-Streptococcus, Corynebacterium, and gram-negative rods. Although the contamination was not directly related to catheter-related bloodstream infections exchanging infusion bottles can cause intraluminal contamination and is a possible route of these infections.

A novel method of post-pyloric feeding tube placement at bedside.

PURPOSE: Post-pyloric feeding tube placement is often difficult, and special equipment or peristalsis agents are used to aid insertion. Although several reports have described blind techniques for post-pyloric feeding-tube placement, no general consensus about method preference has been achieved. MATERIALS AND METHODS: The technique is performed as follows: via the nostril, a stylet-tipped feeding tube is advanced about 70 cm; to confirm tip location to the right of the epigastric area, towards the right hypochondriac region, 5 mL shots of air are injected to enable touch detection of bubbling; finally, the tube is advanced to a length of 100 cm, during which the strength of bubbling seems to diminish under palpation. RESULTS: We prospectively enrolled consecutive patients whose oral intake was expected to be difficult for 48 hours in the intensive care unit. Forty-one patients were enrolled and the rate of successful placement at first attempt was 95.1%. Mean duration for successful placement was 15 minutes. CONCLUSIONS: With a novel technique, from the bedside, without special tools or drugs, we successfully placed post-pyloric feeding tubes. Essential points when inserting the tube are confirmation of the location of the tube tip by palpation of injected air, and to avoid deflection and looping.