Jejunal tubes – a missed opportunity? New methods of placement · Enteral nutrition is superior...
Transcript of Jejunal tubes – a missed opportunity? New methods of placement · Enteral nutrition is superior...
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ESPEN Congress Vienna 2009
Jejunal tubes – a missed opportunity?
New methods of placement
C. Madl (Austria)
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Jejunal tubes – a missed opportunity?
New methods of placement
Christian Madl, MDDepartment of Gastroenterology and EndoscopyHospital RudolfstiftungVienna, [email protected]
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„Critical illness“
Acute Stress Response
Trauma/Infection
Immunological
Response
Neuroendocrine Response
Metabolic Response
Iatrogenic Factors
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Nutrition in critically ill patients
Enteral nutrition is superior to parenteral nutrition
Preserves gut integrity
Reduces infection rate
Less expensive
Improves outcome
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Nutrition in critically ill patients
Early (within 24 to 48h) enteral nutrition is beneficial
→ up to 63% have intolerance of enteral nutrition: large gastric volumes vomiting abdominal distension
→ interuption of enteral nutrition
→ Guidelines: intestinal feeding via jejunal tubes
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Placement of jejunal feeding tubes
Endoscopic guided technique Grasping the tube tip using a foreceps Placement through the endoscope
Self-propelling tubes
Tubes under fluoroscopic guidance
Unguided „blinded“ jejunal tubes
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Endoscopic guided technique of jejunal feeding tubes
• n = 60, success rate of jejunal placement: 90%
• n = 34; success rate of jejunal placement: 98%
• n = 51; success rate of jejunal placement: 90%
Schwab, Gastrointest Endosc 2002; Davies, Crit Care Med 2002; O`Keefe, JPEN 2003
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Endoscopic guided technique of jejunal feeding tubes
24%
38%
28%
10%0-10min11-20min21-30min30-60min
Duration of jejunal tube placement (n=108; success rate: 97%)
Number of attempts until correct jejunal position
57%19%
14%10%
1 attempt2 attempts3 attempts4 attempts
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Endoscopic guided technique –a „new“ jejunal tube
Freka® Easy In Tube: Double lumen jejunal feeding tube for placement through the working channel of an endoskop.
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„Self-propelling“ tube –Bengmark naso-intestinal feeding tube
Berger, Intensive Care Med 2002; Lai, Clin Nutr 2003; Karsenti, Gastroenterol Clin Biol 2003
• n = 105, success rate of jejunal placement: 49%
• n = 30; success rate regular peristalis: 78%reduced peristalis: 57%
• n = 16; success rate of jejunal placement: 75%
The distal end: 2.5 loops, which are straightened during insertion with a guidewire; after removal of the guidewire, the spiral allows transpyloric passage via peristalis
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„Self-propelling“ tube –„Tiger Tube®”; jejunal feeding tube
14 french, 155 cm long, single lumen tube with small plastic flaps; In gastric position: manually advanced 10cm/hour until the 100cm mark
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Problems: single lumen “Self-propelling” tubes
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Comparison of a new unguided self-advancing jejunal tube with the endoscopic guided technique: a prospective, randomized study.
Holzinger; Intensive Care Med. 2009 Sep;35(9):1614-8.
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Comparison of a new unguided self-advancing jejunal tube with the endoscopic guided technique: a prospective, randomized study.
Holzinger; Intensive Care Med. 2009 Sep;35(9):1614-8.
P = 0,008P < 0,001
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Comparison of a new unguided self-advancing jejunal tube with the endoscopic guided technique: a prospective, randomized study.
Holzinger; Intensive Care Med. 2009 Sep;35(9):1614-8.
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X-ray - single lumen self-propelling “Tiger Tube® “
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New jejunal feeding tube using an electromagnetic sensing technique to visualize the placement process on a bedside monitor
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Jejunal feeding tube using an electromagnetic guided system (Cortrak™)
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Jejunal feeding tube using an electromagnetic guided system (Cortrak™)
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Jejunal feeding tube using an electromagnetic guided system (Cortrak™)
Mathus-Vliegen E, DDW 2009, Abstract ID 590237
N=250;placement by nurses overall success rate:85%
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Endoscopic guided technique
Electromagnetic guided technique
p-value
N= (randomization 1:2) 22 44 0,25
SAPS II Score 50 ± 16 52 ± 20 0,66
Success rate (%) 95 91 0,65
Time until correct placement (min)
17 ± 9 15 ± 13 0,60
Days in correct position (d)
15 ± 8 14 ± 14 0,82
Holzinger U, Intensive Care Med 2009, Abstract in press
Comparison of the electromagnetic guided system with the endoscopic guided technique:
a prospective, randomized study
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Conclusion
Placement of jejunal feeding tubes allows continuation of enteral nutrition in more than 90% of all patients
The endoscopic guided technique is still the „gold standard“ for jejunal feeding tube placement with a success rate of approx. 95%
New self propelling techniques or electromagnetic guided systems are simple alternatives