TUBES AND OSTOMIES FOR ENTERAL ACCESS K. Boeykens (BE) · ESPEN Congress Krakow 2019 Nutritional...
Transcript of TUBES AND OSTOMIES FOR ENTERAL ACCESS K. Boeykens (BE) · ESPEN Congress Krakow 2019 Nutritional...
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ESPEN Congress Krakow 2019
Nutritional Access
TUBES AND OSTOMIES FOR ENTERAL ACCESS
K. Boeykens (BE)
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KURT BOEYKENS
CLINICAL NUTRITION
NURSE SPECIALIST
Belgium
TUBES AND OSTOMIES
FOR
ENTERAL ACCESS
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Content
SELECTION!
• Short time enteral access
• NG-tube and complications
• Postpyloric enteral access
• Long-term enteral access
• PEG and some complications
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Disclosures
• Invited lectures:
• BAXTER
• FRESENIUS
• NUTRICIA
• HALYARD (AVANOS)
• NESTLE
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Learning objectives
• Know the elements, including duration
and risk of aspiration, behind the choice of
enteral access
• Know the most common methods of
enteral access insertion
• Know the most important complications
of enteral access placement
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Short Time EN Acces
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NG-tube
1. Placement method
• Insertion length
2. Complications
• Misplacement/position check
• Aspiration risk
• (Dislocation)
• (Blockage)
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XEN NEX
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• Four studies found that NEX was most
likely to result in a tube that is positioned
incorrectly, either ending in the
esophagus, in the stomach but too close to
the esophagus, or too far into the stomach
or duodenum.
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2016
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Hanson study 1979
• 99 cadavers
• 5 volunteers
• NEX: 72 % correct
• NEX + Formulas: 91,3% till 92,3%
correct
Hanson RL. Predictive Criteria for Length of Nasogastric Tube Insertion
for Tube Feeding. JPEN. 1979;3:160-63.
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NEX + Formulas
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NEX
2018
HANSON
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Hanson + 6cmNEX
Hanson
NEX + 6
CONEX
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Submitted for publication
CoNEX
78% aspirate
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STEP 1: NEX
STEP 2: CONEX
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NG-tube
1. Placement method
• Insertion length
2. Complications
• Misplacement/position check
• Aspiration risk
• (Dislocation)
• (Blockage)
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Enteral feeding tube misplacements
• Pennsylvania (US)
• Report (2011-2016)
• 166 NGT misplacements
• 60-89 years: 68,7%
• 0-11 years: 6,6%
• 56% serious harm (2 deaths)
• 81 X-rays: 16 misread
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2018
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• 15 published case reports
• 4 children died
• The auscultatory method failed to detect
malpositioned tubes in all seven cases
were it was used
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2014
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Do not rely on the auscultatory method
alone to differentiate between gastric
and respiratory placement or between
gastric and small bowel placement.
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2017
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pH-method
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• At 5.5, the pH test lacks sensitivity towards
oesophageal placements, a major risk
identified by feeding experts
• Under cut-off 5, respiratory feeding was
excluded; oesophageal feeding was kept to
a minimum
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2018
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NG-tube
1. Placement method
• Insertion length
2. Complications
• Misplacement/position check
• Aspiration risk
• (Dislocation)
• (Blockage)
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• Prospective-multicentre
• Pepsin-positive tracheal secretions (a
proxy for the aspiration of gastric content)
• N = 6000 tracheal secretions
• 31,3 % positive
• Pneumonia on day 4 vs NOT:
• 42,2% vs 21,1% (P < 0,001) pepsine-pos!
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2006
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RISK ASPIRATION RISK PNEUMONIA
Low backrest elevation
(p = .024)
Low backrest elevation
(p = .018).
Vomiting
(p = .007)
Aspiration
(p < .001)
Gastric feedings
(p = .009)
Use of paralytic agents
(p = .002),
Glasgow Coma Scale score <9
(p = .021)
High sedation level
(p = .039).
Gastroesophageal reflux disease
(p = .033).
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• 14 trials
• Gastric vs post-pyloric
• N = 1109
• Moderate-quality evidence of a 30% lower
rate of pneumonia
• No sufficient evidence to show that other
clinically important outcomes such as
duration of mechanical ventilation,
mortality and length of stay are influenced28
2015
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• Aspiration as compared with the stomach:
• First portion duodenum: 11.6% lower
• Second/third part: 13.2% lower
• Fourth part and beyond: 18.0% lower
• Pneumonia occurred less often when feedings
were introduced at or beyond the second portion
of the duodenum
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2011
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Nasojejunal (duodenal)
• Blind
• During open surgery
• Endoscopically
• 1,2-3 lumens
• Electromagnetic-guidance
• (Cortrak®)
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Nasojejunal (duodenal)
• Blind
• Endoscopically
• During open surgery
• Electromagnetic-guidance
• (Cortrak®)
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• Bedside EM-guided placement of naso-enteral
feeding tubes appears to be as safe and effective
as fluoroscopic or endoscopic placement.
• Placed by nurses
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2015
2016
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Case reports of misplacement (FDA)
• Right lung (n = 13)
• Left lung (n = 6)
• Unspecified lung (n = 4)
• Bronchus (n = 2)
• A pneumothorax occurred in 17 of the 25
misplacements
• Feedings were administered in 6 cases33
2017
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• 2006-2016: 54 adverse events
• Lung placement: 98% (LL 46%)
• Pneumonitis: 21%
• Death in of 17% lung placements
• 89% of clinicians failed to detect
malpositioned insertion tracings reviewed
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2017
EXPERIENCE-COMPETENCY!!
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Long Time EN Acces
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ESPEN HEN-guidelines
• A PEG should be preferred over a surgical
gastrostomy mainly due a lower complication
rate, cost-effectiveness and operating time.
Grade of recommendation B
• If a PEG if not suitable a percutaneous
laparosocpic assisted gastrostomy
(PLAG) may be a safe alternative.
Grade of recommendation 0
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• N = 735 (11 RCT)
• PEG: less intervention failure
• No other significant differences in
important outcomes
• But scarce detailed patient characteristics
in studies (underlying disease, placement
technique,….)
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2015
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2018
GASTROSTOMY VS
NASOGASTRIC
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QOL (NG vs PEG)
• Inconvenience,
• Discomfort
• Altered body image
• Social activities
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• Pro
• Weight loss ▼
• Therapy
interruptions ▼
• Dehydration ▼
• Hospitalisation ▼
• QoL▲
• Contra• Procedural
complications
• QoL▼• Body image
• Social isolation
• Longer dependency
of TF
• Swallowing
motivation ▼
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2011
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2003-2010
22 serious incidents:
- 11 patients died
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Incidents reported
• 9 cases of leakage of feed into the peritoneal cavity
and/or peritonitis
• 2 of colonic puncture
• 1 related to haemorrhage
• 1 involving both haemorrhage and colonic puncture;
• 1 septic shock secondary to aspiration
• 1 of leakage of feed into thoracic cavity
• 1 of surgical emphysema
• 6 of unclear mechanism
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2017
2007
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PEG/PEG-J • Aftercare/complications
• ESPEN HEN guidelines 2019
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- Stoma care
- Burried Bumper
- Leakage
- Hypergrannulation
- Infection
- Inadvertent removal
- …..
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Overgranulation
• Prolonged stimulation of fibrous tissue
and new blood vessels (angiogenesis)
• Excess friction/movement a/o moisture
• Infection
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• Pain and bleeding
• Treatment: silver nitrate application
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Treatment
• Dermal corticosteroid cream, ointment
• (With antibiotics)
• (Antimicrobial) aliginate,foam (+ silver)
dressing to keep modest pressure on the skin
around the stoma and minimize movement.
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• Hypergranulation = oedematous tissue
• N = 8 (paediatric patients)
• Daily 1/3 of 5 ml teaspoon salt ‘sprinkled’ over
the tissue
• Treatment period: 3 days-2 months
• Positive result in all patients but 5/8 recurrence
but successfully repeated treatment afterwards
• 1 skin erosion: salt irrigated 10 minutes after
application
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2013
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Buried bumper
• Tube blockage
• Pain with flushing
• Persisting leakage
• Chronic site infection
• Possible evolution to an abscess and
fisitulisation
• Even erodation onto the abdominal wall
• Sometimes rotation possible:
• Gastro mucosa ‘pocket’ round the bumper
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Burried bumper
• Serious but preventable complication
• Normally a long-term complication
• Aftercare!
• Release external bumper
• Clean PEG-site
• Advance PEG into abdomen minimum 2-3 cm
but ideally 5 to even 10 cm (at least once a
week!)
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Treatment
• Needle-knife
• Laparoscopy
• Laparatomy
• Jejunal extension through the PEG (if PEG
facilitates that) leaving tip in the stomach
• If too high risk: leave it insitu and new PEG
beside the existing one
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TO CLOSE
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