Early nutritional therapy: the role of enteral and parenteral routes.

PURPOSE OF REVIEW: Early nutrition is defined as the initiation of nutritional therapy within 48 h of either hospital admission or surgery. However, optimal timing for initiation of nutritional therapy through either enteral or parenteral routes remains poorly defined with the existing data. We reviewed the recent literature investigating the role of early enteral and parenteral nutrition in critical illness and perioperative care. RECENT FINDINGS: Recent studies in both trauma/surgical and nonsurgical patients support the superiority of early enteral over early parenteral nutrition. However, late commencement of enteral feeding should be avoided if the gastrointestinal tract is functional. Both prolonged hypocaloric enteral feeding and hypercaloric parenteral nutrition should be avoided, although the precise caloric target remains controversial. SUMMARY: Early enteral nutrition remains the first option for the critically ill patient. However, there seems to be increased favor for combined enteral-parenteral therapy in cases of sustained hypocaloric enteral nutrition. The key issue is when the dual regimen should be initiated. Although more study is required to determine the optimal timing to initiate a combined enteral-parenteral approach, enteral nutrition should be initiated early and parenteral nutrition added if caloric-protein targets cannot be achieved after a few days.

Clinical costs of feeding tube placement.

BACKGROUND: Although small-bore tube placement is common, insertion can lead to serious complications. We investigated the use of radiographs, fluoroscopy, feeding tubes, and complications associated with blind feeding-tube placement. METHODS: The electronic and paper records of adult patients receiving a small-bore feeding tube in 2005 were retrospectively reviewed for the following variables: demographics, desired location (gastric or postpyloric), number of radiographs, number of tubes per individual, time interval between medical prescription, tube placement and delivery of the diet, complications, transport for fluoroscopy, and hospital location of placement (intensive care unit vs floor). RESULTS: We identified 1822 tubes placed into 729 patients (male: 449, 61.6%; female: 280, 38.4%; median age: 59 years old, range 18-98). All tubes were placed by nurses unless fluoroscopically placed in radiology or placed after head and neck surgery in the operating room. An average of 2.5 (range 1-20) tubes was used per patient. A total of 2696 radiographs were obtained for an average of 3.7 (range 0-32) films per patient and 1.5 (range 0-11) per feeding tube. Successful placement was higher for intragastric (93.3%) than for postpyloric position (60.4%; p < .001). Fluoroscopy was needed in 18.6% of the patients, mostly for postpyloric insertion (p < .001). Respiratory tree misplacement occurred in 23 (3.2%) patients; 9 (1.2%) had a pneumothorax and 4 (0.5%) died. Patients with a malpositioned feeding tube underwent more tube insertions (6.8 +/- 5.4; range 2-20) than patients without complications (2.2 +/- 1.8; range 1-18; p < .001). CONCLUSIONS: The incidence of airway misplacement of feeding tubes (3.2%) at a major tertiary referral university hospital was alarming. Mandatory radiographs may eliminate the risk of respiratory administration of feedings but not misplacements. The associated costs of radiographs, unsuccessful placements, fluoroscopy, and complications are significant. A solution to this problem will require focused attention and development of specific protocols, possibly using new technologies.

Use of small-bore feeding tubes: successes and failures.

PURPOSE OF REVIEW: Early enteral nutrition is the preferred option for feeding patients who cannot meet their nutrient requirements orally. This article reviews complications associated with small-bore feeding tube insertion and potential methods to promote safe gastric or postpyloric placement. We review the available bedside methods to check the position of the feeding tube and identify inadvertent misplacements. RECENT FINDINGS: Airway misplacement rates of small feeding tubes are considerable. Bedside methods (auscultation, pH, aspirate appearance, air bubbling, external length of the tube, etc.) to confirm the position of a newly inserted small-bore feeding tube have limited scientific basis. Radiographic confirmation therefore continues to be the most accurate method to ascertain tube position. Fluoroscopic and endoscopic methods are reliable but costly and are not available in many hospitals. Rigid protocols to place feeding tubes along with new emerging technology such as CO2 colorimetric paper and tubes coupled with signaling devices are promising candidates to substitute for the blind placement method. SUMMARY: The risk of misplacement with blind bedside methods for small-bore feeding tube insertion requires a change in hospital protocols.