BEDSIDE SONOGRAPHIC-GUIDED VERSUS BLIND NASOENTERIC FEEDING TUBE PLACEMENT IN CRITICALLY ILL PATIENTS

Objective: To compare a blind manual bedside method for placing feedin g tubes into the small bowel vs, a sonographic bedside technique in cr itically ill patients. Design: Prospective study with a random sample. Setting: Multidisciplinary intensive care unit in a tertiary care uni versity hospital. Patients: Thirty-five adult patients. All patients w ere hemodynamically stable, mechanically ventilated, and required a na soenteric tube placement for short-term enteral feeding due to impaire d gastric emptying. Interventions: A well-known, blind, manual, bedsid e method for postpyloric tube placement was always attempted first in all cases. The technique was considered successful when a postpyloric location of the tip of the tube was achieved as shown by abdominal roe ntgenogram. However, if after 30 mins we failed to enter the small bow el, a radiologist attempted a sonographic bedside technique for postpy loric tube insertion. finally, when the feeding tube was in place, bef ore starting enteral nutrition, a nasogastric tube was inserted into t he stomach. Measurements and Main Results: The blind manual method was successful in nine (25.7%) of the 35 patients and the final location of these feeding tubes was the proximal jejunum. The average time for placement of the feeding tubes with this manual technique was 13.9 +/- 7.4 mins (range 5 to 30). The sonographic technique was succesful in 22 (84.6%) of the remaining patients and the final location of the fee ding tubes was three (11%) tubes in the second portion of the duodenum , eight (31%) tubes in the third portion of the duodenum, and 11 (42%) tubes in the proximal jejunum. The average time for placement with th e sonographic technique was 18.3 +/- 8.2 mins (range 5 to 35). The pyl oric outlet was sonographically akinetic or severely hypokinetic in 13 patients, and in four of them, we were unable to achieve postpyloric tube placement. In these four patients, the tubes were subsequently pl aced by endoscopy. Conclusions: The sonographic bedside technique for placing feeding tubes into the small bowel in critically ill patients has a success rate of 84.6% (confidence interval 71% to 98%) after the failure of the blind bedside manual method, proving that the former i s significantly more successful. This sonographic technique facilitate s the insertion of the tubes in patients who cannot be moved and in th ose patients with severe impairment of the peristaltic activity of the stomach.