Nasogastric tube insertion length measurement and tip verification in adults: a narrative review.

Nasogastric feeding tube insertion is a common but invasive procedure most often blindly placed by nurses in acute and chronic care settings. Although usually not harmful, serious and fatal complications with misplacement still occur and variation in practice still exists. These tubes can be used for drainage or administration of fluids, drugs and/or enteral feeding. During blind insertion, it is important to achieve correct tip position of the tube ideally reaching the body of the stomach. If the insertion length is too short, the tip and/or distal side-openings at the end of the tube can be located in the esophagus increasing the risk of aspiration (pneumonia). Conversely, when the insertion length is too long, the tube might kink in the stomach, curl upwards into the esophagus or enter the duodenum. Studies have demonstrated that the most frequently used technique to determine insertion length (the nose-earlobe-xiphoid method) is too short a distance; new safer methods should be used and further more robust evidence is needed. After blind placement, verifying correct gastric tip positioning is of major importance to avoid serious and sometimes lethal complications.

Prevention and management of minor complications in percutaneous endoscopic gastrostomy.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) was developed by Ponsky-Gauderer in the early 1980s. These tubes are placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition but can also be used for drainage or decompression. The tubes consist of an internal and external retention device. It is a generally safe technique but major or minor complications may arise during and after tube placement. METHOD: A narrative review of the literature investigating minor complications after PEG placement. RESULTS: This review was written from a clinical viewpoint focusing on prevention and management of minor complications and documented with real cases from more than 21 years of clinical practice. CONCLUSIONS: Depending on the literature the incidence of minor complications after gastrostomy placement can be high. To decrease associated morbidity, prevention, early recognition and popper management of these complications are important.

Prevention and management of major complications in percutaneous endoscopic gastrostomy.

BACKGROUND: Percutaneousendoscopic gastrostomy is a commonly used endoscopic technique where a tube isplaced through the abdominal wall mainly to administer fluids, drugs and/orenteral nutrition. Several placement techniques are described in the literaturewith the 'pull' technique (Ponsky-Gardener) as the most popular one.Independent of the method used, placement includes a 'blind' perforation of thestomach through a small acute surgical abdominal wound. It is a generally safetechnique with only few major complications. Nevertheless these complicationscan be sometimes life-threatening or generate serious morbidity. METHOD: Anarrative review of the literature of major complications in percutaneousendoscopic gastrostomy. RESULTS: This review was written from a clinical viewpoint focussing on prevention andmanagement of major complications and documentedscientific evidence with real cases from more than 20 years of clinical practice. CONCLUSIONS: Majorcomplications are rare but prevention, early recognition and popper management areimportant.

Accuracy of the corrected nose-earlobe-xiphoid distance formula for determining nasogastric feeding tube insertion length in intensive care unit patients: A prospective observational study.

BACKGROUND: As nasogastric feeding tube insertion is a frequently applied, non-risk-free nursing technique, a high level of evidence-based nursing care is required. Little evidence is available regarding the accurate determination of the insertion length of nasogastric feeding tubes. The method of using the nose-earlobe-xiphoid distance as measurement is inadequate and not supported by evidence. Findings from a recent randomized trial led to an alternative calculation: the corrected nose-earlobe-xiphoid distance formula: (nose-earlobe-xiphoid distance × 0.38696) + 30.37 + 6 cm. OBJECTIVES: To test the accuracy of the corrected nose-earlobe-xiphoid distance formula for determining the required nasogastric feeding tube insertion length in adults admitted on an intensive care unit and to investigate the probability to successfully obtain gastric aspirate for pH measurement. DESIGN: Prospective, single-center observational study. PARTICIPANTS AND METHODS: Adult intensive care unit patients in a general hospital (N = 218) needing a small-bore nasogastric feeding tube were included between March and September 2018. Correct tip positioning was defined as a tube tip located > 3 cm under the lower esophageal sphincter. Tip positioning was verified using X-ray. RESULTS: All nasogastric feeding tube tips were correctly positioned > 3 cm under the lower esophageal sphincter. The chance of successfully obtaining gastric aspirate within 2 h after placement of the tube was 77.9%. CONCLUSIONS: With all tips positioned > 3 cm in the stomach and zero tubes migrating back into the esophagus, the corrected nose-earlobe-xiphoid distance formula can be considered a more accurate method to determine nasogastric feeding tube insertion length.

Comparison of Two Methods for Estimating the Tip Position of a Nasogastric Feeding Tube: A Randomized Controlled Trial.

BACKGROUND: Several studies have shown that the nose-earlobe-xiphoid distance (NEX) is inadequate to estimate the insertion length of nasogastric tubes. An alternative approach tested in these studies, which leads to > 90% well-placed nasogastric tubes, used a corrected calculation of the NEX: (NEX × 0.38696) + 30.37. The primary aim of this study was to determine whether using the corrected NEX was more successful than the NEX in determining the insertion length. The secondary aim was to investigate the likelihood to successfully obtain gastric aspirate. METHODS: Adult patients in a general hospital (N = 215) needing a nasogastric tube were randomized to the control (NEX) or intervention group (corrected NEX). Tip positioning was verified using X-ray. Correct tip positioning was defined as between 3 and 10 cm under the lower esophageal sphincter (LES). RESULTS: In >20% of all patients, both methods underestimated the required tube length for correct positioning. The NEX showed an overestimation (17.2%) of the insertion length (>10 cm under the LES) compared with the corrected NEX (4.8%). There was no difference (P = 0.938) between the 2 groups in obtaining gastric aspirate (55.6% vs 56%). However, correct tip positioning resulted in a fourfold increase of obtaining gastric aspirate. CONCLUSIONS: Both methods resulted in a high risk of incorrectly placed tubes due to malposition of the tip near the LES or distal esophagus. This may increase the risk of reflux and pulmonary aspiration. Based on these results, the development of more reliable methods requires consideration.

Reliability of pH measurement and the auscultatory method to confirm the position of a nasogastric tube.

BACKGROUND: Blind placement of a nasogastric feeding tube is a common nursing procedure. Confirmation of the correct position in the stomach is warranted to avoid serious complications such as misplacement in the lung. Testing pH of aspirate from a tube is one of the techniques to confirm the tip position. The purpose of this study was to evaluate the auscultatory method and pH measurement with a pH cut-off point of 5.5 after tube insertion and to compare this with the 'gold standard': an abdominal X-ray. Also the feasibility of the pH method was evaluated. MATERIALS AND METHODS: Large prospective observational study in a general hospital. In adult hospitalised patients, the positioning of 331 feeding tubes was tested using two different methods to predict tube position in the stomach. RESULTS: In 98.9% (n=178) of aspirate samples with a pH ≤ 5.5, the tube was located in the stomach. If an aspirate could be obtained, the results of pH measurements showed a sensitivity of 78.4% and a specificity of 85.7%. Obtaining aspirate initially after placement was possible in approximately half of cases but after taking additional measures (including administration of air into the tube, side-positioning of the patient and re-aspiration after one hour) this increased to 81.6%. The sensitivity of the auscultatory method was 79% while the specificity was 61%. CONCLUSIONS: A pH of ≤ 5.5 from tube aspirate is adequate to check the position of the tube in the stomach. Additional measures improve the success to obtain an aspirate from the tube. The auscultatory method is unreliable.

Fine needle trucut biopsy in focal liver lesions: a reliable and safe method in identifying the malignant nature of liver lesions.

BACKGROUND AND STUDY AIMS: The correct management of a focal liver lesion, suspected of being malignant, requires tissue for histopathological examination. To this purpose an ultrasonically guided fine needle trucut biopsy technique (FNTCB) can be used, to allow obtaining large tissue samples. The aim of the study is to see that FNTCB is a reliable method in identifying the malignant or benign character of a focal liver lesion. PATIENTS AND METHODS: We retrospectively compared the results of 231 FNTCB of focal liver lesions with the final diagnosis. RESULTS: In 191 lesions a final diagnosis was obtained (164 were malignant, 27 were benign). In our series FNTCB has a sensitivity of 86.6% (142/164), a specificity of 100% (27/27) and an overall accuracy of 88.5% (169/191) in identifying malignancy. There was a correct identification in 79.4% (27/34) of primary liver tumours and 88.5% (115/130) of liver metastases. In 52% (60/115) of liver metastases the primary site was accurately suggested by the pathologist. Correct characterization of benign liver lesions was obtained in 63% (17/27) of the cases. The insufficient sample rate was 3.1% (6/191). In one patient with thrombocytopenia an intraabdominal haemorrhage occurred. CONCLUSIONS: FNTCB is a reliable and safe method in identifying the malignant nature of liver lesions. Due to the large tissue sample, insufficient sample rate is low and an accurate histological identification of benign lesions, primary liver malignancies and metastases can be made. In case of metastases it is often possible to determine the site of the primary tumour.