Postpyloric enteral feeding costs for patients with severe head injury: Blind placement, endoscopy, and PEG/J versus TPN

This study describes the advantages and disadvantages of several forms of e nteral nutrition for patients with severe head injury (Glasgow Coma Scale S core [GCS], <12). included in the study are nasoenteric nutrition delivery using blind, endoscopic, percutaneous endoscopic gastrostomy (PEG) and PEG with jejeunostomy (PEG/J), and open jejeunostomy tube placement methods. Th ese methods are compared with parenteral delivery of nutrition. The study c onstituted a retrospective analysis of the success rate of early enteral fe edings by blind, endoscopic PEG and PEG/J and by open jejeunostomy placemen t of small-bowel feeding tubes for 57 patients with severe head injury. The delivery cost of enteral nutrition per intensive care unit day was compare d to the delivery cost of parenteral nutrition per intensive case unit day in the same group of patients. Fifty-three percent of patients were adequat ely maintained nutritionally with nasoenteric delivery alone and did not re quire parenteral feeding. The average number of days for initiation of eith er enteral or parenteral feedings was 1.8 +/- 0.2 days from injury [standar d error of mean (SEM); range, 0-10 days]. An average of 3.3 days (range, 0- 23 days) was required for feeding tube placement in all patients. For 70% o f patients, tube placement was completed within 48 h after injury. Full-str ength, full-rate enteral feedings were achieved by a mean of 4.9 days after injury. A total of 128 feeding tubes were placed while the patients were i n the intensive care unit (ICU; 2.2 +/- 0.2 tubes per patient). Blind place ment of feeding tubes into the small bowel was rarely achieved without repo sitioning. Endoscopic tube placement into the duodenum was achieved in 50% of patients, into the jejunum for 33% of patients, and into the stomach for 18% of patients. While in the intensive care unit, patients received an av erage of 77 +/- 2% of their measured energy expenditure (range, 57-114%). E leven percent of patients experienced severe gastrointestinal problems. Oth er problems were associated with the inability to achieve or maintain acces s: dislodged tubes (30%), clogged or kinked tubes (21%), and mechanical acc ess problems (7%). Seventy-one percent of patients in barbiturate coma were able to tolerate early nasoenteric feedings. Aspiration pneumonitis occurr ed equally among patients fed nasogastrically and those fed nasoenterically . The overall aspiration rate was 14%. The cost of acute enteral feeding wa s $170 per day and that for parenteral feeding, $308 per day. We conclude t hat blind transpyloric feeding tube placement is difficult to achieve in pa tients with severe head injury; endoscopically guided placement is a better option. Endoscopic feeding tube placement most consistently allows for ear ly enteral nutritional support in severe head injured patients. Limitations include the inability to establish and/or maintain enteral access, increas ed intracranial pressure, unstable cervical spinal injuries, facial fractur es, and dedication of the physician to tube placement and monitoring.