Bedside transpyloric tube placement in the pediatric intensive care unit.

BACKGROUND: The purpose of this study was to demonstrate the feasibility of placing transpyloric feeding tubes at the bedside without fluoroscopy in critically ill pediatric patients. METHODS: The patient population consisted of 90 patients (ages 1 week to 15 years, median age 9 months) admitted to a 26-bed pediatric intensive care unit in a university-affiliated pediatric hospital. Patient weights ranged from 2.4 to 100 kg with a median weight of 7.5 kg. Seventy-six patients were endotracheally intubated and mechanically ventilated; one patient had a tracheotomy. A total of 24 patients were pharmacologically paralyzed; 38 patients were receiving catecholamine infusions, and 17 patients had intracranial monitoring devices in place. All had concurrent nasogastric suctioning. Nonweighted Silicone Rubber 6F or 8F nasoenteric tubes were inserted at the bedside using metoclopramide, air insufflation and positioning to achieve transpyloric passage. Blue-dyed water was instilled in 58 patients to test for reflux and confirm transpyloric position. RESULTS: Successful nonfluoroscopic bedside transpyloric (duodenal or jejunal) tube placement was verified radiographically in 84 (93%) patients; seven of these patients were less than 4 weeks of age. One patient had blue dye in the nasogastric fluids, consistent with duodenogastric reflux or failure of transpyloric passage. The abdominal radiographs confirmed the results of the blue dye test in all 58 patients. There were six (6.7%) unsuccessful attempts at transpyloric bedside tube placement: four were a result of hemodynamic instability, one was a result of oropharyngeal trauma, and one was due to intestinal malrotation. The average time for placement was 15 minutes with a range of 5 to 45 minutes. No complications from tube placement were observed. CONCLUSIONS: Bedside placement of transpyloric feeding tubes is a safe and effective method to institute enteral feedings in critically ill pediatric patients.

Early enteral feeding in the pediatric intensive care unit.

BACKGROUND: The purpose of this study was to evaluate the feasibility and safety of early enteral feedings of critically ill pediatric patients. METHODS: The subject population of 42 critically ill patients ranged in age from 5 days to 18 years (mean 5.8 years), mean weight 17 kg. Transpyloric nasoenteric tubes were placed in all patients by a nonfluoroscopic bedside technique. All subjects were mechanically ventilated; 32 (76%) were on one or more vasoactive medications. Six (15%) patients were fed for more than 13 days while on vasoactive support and pharmacological paralysis. RESULTS: There were no documented complications of early enteral feeding, including aspiration. All patients were able to achieve caloric goals within 48 hours of beginning enteral feedings. All patients developed regular stool patterns despite periodic absence of bowel sounds. Enteral feedings replaced 256 days of total parenteral nutrition. Estimated patient charge savings averaged $425 for each day of enteral feedings. CONCLUSIONS: Early enteral feedings are feasible, well tolerated, and cost effective in critically ill pediatric patients.

Physiologic monitoring of infants and children.

Accurate and safe monitoring of infants and children requires knowledge of their unique physiology, especially cardiovascular function, pulmonary physiology, and metabolic function. These individual features influence the equipment selection, as well as data interpretation. Although some adult equipment is adaptable for pediatric use, many specifications must be tailored to pediatric needs. Vascular monitoring in pediatric patients requires specific knowledge of insertion procedures and complications, fluid maintenance, and hemodynamic norms, indexed to body surface area. Valid data interpretation requires an understanding of the distinctive clinical responses intrinsic to the pediatric patient. Likewise, maintenance care for pediatric patients always includes attention to precise fluid balance, thermoregulation, and metabolic needs. Finally, all pediatric patients require constant vigilance to protect the integrity of their monitoring systems and, ultimately, the safety of these patients. Failure to address these concerns may result in complications or invalid data.