Stroke: ineffective tube securement reduces nutrition and drug treatment.

Stroke patients with dysphagia often depend on nutrition, hydration and medication via nasogastric (NG) feeding tubes. Securing tubes using tape is associated with repeated tube loss. In this study, the authors determined cause and effect by auditing tube placement methods, delays incurred, duration and costs. Of 202 NG tube placements in 75 patients, 67 placements occurred in 17 patients over a full course of enteral nutrition (EN) and 40 of these placements were tracked. Tubes were secured by tape in 100%, mittens 31% and special observation 5.4%. However, over an EN course, inadvertent tube loss occurred in 82% of patients and was associated with age (p=0.049) and mitten use (p<0.001): 64% of tubes were lost due to patients and 9% slipped. Average 'tube life' was 2 days, less than 25% of the EN episode (p<0.001). While tube placement occurred within 2.55 hours of request, X-ray confirmation led to a delay in feed and drugs of 8-9 hours per tube placement and loss of 18.8% of feeding time per EN episode. Delays exceeded the 1-hour and 4-hour limits for antibiotics and other medicines in 20% and 80%, respectively. In the 17 tracked patients, it was estimated that 55% of the £5979 direct costs could be saved by nasal bridle use. In conclusion, most tubes studied were lost to inadvertent tube removal, leading to clinically significant delays to nutrition, hydration and drug treatments; this may impair recovery. Reducing tube loss is likely to reduce patient distress, treatment cost and enhance recovery.

A randomised controlled feasibility and proof-of-concept trial in delayed gastric emptying when metoclopramide fails: We should revisit nasointestinal feeding versus dual prokinetic treatment: Achieving goal nutrition in critical illness and delayed gastric emptying: Trial of nasointestinal feeding versus nasogastric feeding plus prokinetics.

BACKGROUND & AIMS: Delayed gastric emptying (DGE) commonly limits the use of enteral nutrition (EN) and may increase ventilator-associated pneumonia. Nasointestinal feeding has not been tested against dual prokinetic treatment (Metoclopramide and Erythromycin) in DGE refractory to metoclopramide. This trial tests the feasibility of recruiting this 'treatment-failed' population and the proof of concept that nasointestinal (NI) feeding can increase the amount of feed tolerated (% goal) when compared to nasogastric (NG) feeding plus metoclopramide and erythromycin treatment. METHODS: Eligible patients were those who were mechanically ventilated and over 20 years old, with delayed gastric emptying (DGE), defined as a gastric residual volume ≥250 ml or vomiting, and who failed to respond to first-line prokinetic treatment of 3 doses of 10 mg IV metoclopramide over 24 h. When assent was obtained, patients were randomised to receive immediate nasointestinal tube placement and feeding or nasogastric feeding plus metoclopramide and erythromycin (prokinetic) treatment. RESULTS: Of 208 patients with DGE, 77 were eligible, 2 refused assent, 25 had contraindications to intervention, almost exclusively prokinetic treatment, and it was feasible to recruit 50. Compared to patients receiving prokinetics (n = 25) those randomised to nasointestinal feeding (n = 25) tolerated more of their feed goal over 5 days (87-95% vs 50-89%) and had a greater area under the curve (median [IQR] 432 [253-464]% vs 350 [213-381]%, p = 0.026) demonstrating proof of concept. However, nasointestinally fed patients also had a larger gastric loss (not feed) associated with the NI route but not with the fluid volume or energy delivered. CONCLUSIONS: This is first study showing that in DGE refractory to metoclopramide NI feeding can increase the feed goal tolerated when compared to dual prokinetic treatment. Future studies should investigate the effect on clinical outcomes. EU CLINICAL TRIALS REGISTER: EudraCT number: 2012-001374-29.