Adequacy of different measurement methods in determining nasogastric tube insertion lengths: An observational study.

BACKGROUND: Distance from the tip of the nose to earlobe to xiphisternum is commonly used to determine the length of nasogastric tube to be inserted. However, it is not evidence-based and frequently leads to improper positioning. OBJECTIVES: This study evaluated four formulae and the distance from the tip of the nose to earlobe to xiphisternum in estimating the internal length of nasogastric tube required for optimal positioning. DESIGN: Observational Study. SETTINGS: Tertiary hospital in Singapore involving patients from the medical and surgical intensive care units and a neurosurgical ward. PARTICIPANTS: Inclusion criteria were patients who required a nasogastric tube insertion and age > = 21 years old and =<85 years old. Patients who required an orogastric tube insertion or did not require a chest x-ray post nasogastric tube insertion were excluded. METHODS: Upon nasogastric tube insertion, the external length of the tube was measured and the corresponding internal length calculated. Several anatomical measurements were taken as required in the formulae below: 1. ((Distance from tip of nose to earlobe to xiphisternum-50 cm)/2) + 50 cm. 2. 29.38 + 4.53*gender+0.34*distance from nose to umbilicus with head flat on bed-0.06*weight (gender = 1 for male, and 0 for female). 3. Distance from xiphisternum to earlobe to nose + 10 cm. 4. Distance from earlobe to xiphisternum to umbilicus-distance from tip of the nose to earlobe. Post insertion chest x-rays were examined to evaluate the position of the nasogastric tube. For those with optimal positioning, the distance from tip of the nose to earlobe to xiphisternum and the four formulae were compared to determine which provided the least difference with the internal length of the nasogastric tube. RESULTS: Ninety-two participants were recruited. The average age of the cohort was 62.9 years old with 54% being male. Twenty-five had nasogastric tubes in optimal position; 13 had it too short and 54 had it too long. For nasogastric tubes in optimal position, distance from xiphisternum to earlobe to nose + 10 cm provided the best estimate of the internal length. Average difference between the distance from xiphisternum to earlobe to nose + 10 cm and internal length of the nasogastric tubes in optimal position was only 1.8 cm which was by far the least difference compared to other formulae. CONCLUSION: This study found distance from xiphisternum to earlobe to nose + 10 cm to provide the best estimate for the internal length of nasogastric tube required. However, even this formula could result in placement that is not optimal due to anatomical differences.

External Validation of Hematoma Expansion Scores in Spontaneous Intracerebral Hemorrhage in an Asian Patient Cohort.

BACKGROUND: Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage (ICH) and is known to be a strong predictor of neurological deterioration as well as poor functional outcome. This study aims to externally validate three risk prediction models of HE (PREDICT, 9-point, and BRAIN scores) in an Asian population. METHODS: A prospective cohort of 123 spontaneous ICH patients admitted to a tertiary hospital (certified stroke center) in Singapore was recruited. Logistic recalibrations were performed to obtain updated calibration slopes and intercepts for all models. The discrimination (c-statistic), calibration (Hosmer-Lemeshow test, le Cessie-van Houwelingen-Copas-Hosmer test, Akaike information criterion), overall performance (Brier score, R2), and clinical usefulness (decision curve analysis) of the risk prediction models were examined. RESULTS: Overall, the recalibrated PREDICT performed best among the three models in our study cohort based on the novel matrix comprising of Akaike information criterion and c-statistic. The PREDICT model had the highest R2 (0.26) and lowest Brier score (0.14). Decision curve analyses showed that recalibrated PREDICT was more clinically useful than 9-point and BRAIN models over the greatest range of threshold probabilities. The two scores (PREDICT and 9-point) which incorporated computed tomography (CT) angiography spot sign outperformed the one without (BRAIN). CONCLUSIONS: To our knowledge, this is the first study to validate HE scores, namely PREDICT, 9-Point and BRAIN, in a multi-ethnic Asian ICH patient population. The PREDICT score was the best performing model in our study cohort, based on the performance metrics employed in this study. Our findings also showed support for CT angiography spot sign as a predictor of outcome after ICH. Although the models assessed are sufficient for risk stratification, the discrimination and calibration are at best moderate and could be improved.