Gastric versus post-pyloric feeding: a systematic review
Postpyloric feeding is an important and promising alternative to parenteral nutrition. The indications for this kind of feeding are increasing and include a variety of clinical conditions, such as gastroparesis, acute pancreatitis, gastric outlet stenosis, hyperemesis (including gravida), recurrent aspiration, tracheoesophageal fistula and stenosis in mainaman.co by: postpyloric feeding. The provision of nutrients directly to the duodenum or jejunum via a small-bore catheter advanced through the nose, nasopharynx, esophagus, and stomach into the small bowel. It can be used to manage conditions such as acute pancreatitis, gastric outlet obstruction, or gastroparesis. See also: feeding.
Ileus is a common problem we face in the intensive care unit ICUand in pursuit of safer enteral nutrition, we are routinely placing small bore feeding tubes SBFT past the gastric pylorus. This is especially important in patients with severe GERD, gastrointestinal dysmotility, recurrent emesis, and those at high risk for aspiration.
Intuitively, it makes sense — placing a post-pyloric SBFT should confer a decreased how to read bike tube size for aspiration. Of note, the latter is associated with a decreased risk of pneumonia.
The primary disadvantage of post-pyloric feeding is actually placing the SBFT. Ideally, the SBFT will be positioned in the distal duodenum or jejunum. You should see the tube enter the stomach, cross midline, and potentially loop around there are four parts to the duodenum. A tube placed distally will be less likely to get dislodged in the event of excessive coughing.
Your email address will not be published. Post-pyloric feeding tube crosses midline Intuitively, it makes sense — placing a post-pyloric SBFT should confer a decreased risk for aspiration. Place the patient in the right lateral decubitus position. Measure the small bore feeding tube SBFT from the nose tip, down to the stomach, and across the midline several centimeters what is post- pyloric feeding the location of the pylorus.
Advance the SBFT into the stomach usually around 40 centimeters. This straightens out the rugae and makes the stomach more bowl shaped. Get the abdominal x-ray and cross your fingers! Rishi October 8, 0 1 minute read. Related Articles.
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Aug 04, · Nutrition is supplied in a special liquid form, which is delivered through a tube placed in the mouth or nose of the person and extended into the stomach (gastric), or the tube may be advanced more distally to reach the small bowel (duodenum or jejunum), in which case it is called a post-pyloric feeding tube. We wanted to learn about the safety and potential benefits associated . Background: Our objective was to evaluate the impact of gastric versus post-pyloric feeding on the incidence of pneumonia, caloric intake, intensive care unit (ICU) length of stay (LOS), and mortality in critically ill and injured ICU patients. Method: Data sources were Medline, Embase, Healthstar, citation review of relevant primary and review articles, personal files, and contact with expert Cited by: Oct 31, · Gastric versus post-pyloric feeding: a systematic review. Crit Care ; 7:R Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F. Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults.
Jejunal feeding is the method of feeding directly into the small bowel. The feeding tube is passed into the stomach, through the pylorus and into the jejunum. This type of feeding is also known as post-pyloric or trans-pyloric feeding. Jejunal feeding is indicated in patients who have a functioning gastro-intestinal tract, but who have an absent gag reflex, gastric dysmotility or persistent vomiting resulting in faltering growth.
Jejunal feeding may be initiated in any age group of patient, although the duration of feeding can be limited or difficult due to the following factors:. Jejunal feeds are most appropriate for patients with gastric outlet obstruction, gastroparesis, pancreatitis and in those with known reflux and aspiration of gastric contents where gastric feeding has failed. Ensure referral to a dietitian is made prior to placement of jejunal tube. Nasojejunal tubes may be placed with the assistance of endoscopy or fluoroscopy.
Confirmation of correct position of a newly inserted tube is mandatory before feedings or medications are administered. Six French 6FR enteral tubes are not recommended as they block easily. For longer term feeding a surgical jejunostomy PEJ tube or a gastrostomy-jejunostomy G-J tube is usually a more successful route for delivering nutrition support.
This requires a longer tube and has the potential for displacement compared to a tube with direct access to the jejunum. Studies in children and adults have shown that feeding via a jejunostomy vs gastrojejunostomy require less manipulations and hospital admissions each year. The pH level of the NJT should not be tested. The tip of the jejunal tube has potential to migrate back into the stomach.
The tube marking at the nostril should be recorded after insertion. This should be checked prior to administrating any liquid, feed or medication via the tube to confirm correct position.
If a patient is experiencing clinical symptoms such as retching, vomiting, excessive coughing- this may indicate the tube may have migrated to the stomach. Do not aspirate the NJT as this can cause collapse and recoil of the tube. The PEJ or G-J tube must not be rotated as there is a risk of displacing the jejunal tube by coiling it up in the stomach. As an alternative, the tube should be moved very gently in and out of the tract approximately one centimetre.
Jejunal feeding tubes need regular flushing to maintain patency and it is recommended that sterile water is always used. The jejunal feeding tube should be flushed:. Flushing will be more effective with a push-pause technique. The lowest volume necessary to clear the tube is recommended for neonatal and paediatric patients.
Suggested volumes are:. Without the stomach acting as a reservoir, feed given as a bolus directly into the jejunum can cause abdominal pain, diarrhoea and dumping syndrome.
This results from rapid delivery of hyperosmolar feed into the jejunum. Therefore, feeds delivered into the jejunum should always be given slowly by continuous infusion.
Within the paediatric population, there is little data to suggest what rates can be safely tolerated. The dietitian should be referred to provide recommendations regarding an appropriate feeding regimen.
Through feeding directly into the jejunum, feed enters the intestine distal to the site of release of pancreatic enzymes and bile. If malabsorption occurs, a trial period of hydrolysed protein feed is recommended. Thickened feeds are not recommended and can contribute to tube blockage. Clinicians should evaluate:. For example, antacids act locally in the stomach and are not suitable for post-pyloric administration. Bioavailability may increase with intra-jejunal delivery of some drugs, namely opioids, tricyclics, beta blockers or nitrates.
Medication in liquid form is strongly encouraged where available. In general, medication should not be added to the enteral formula, both to reduce the risk of contamination for closed systems and to avoid drug-nutrient incompatibilities. Diarrhoea, cramping and abdominal distension may occur after administration of hyperosmolar products through the feeding tube.
Nutrient intake is reduced There is little evidence to support how frequently jejunal feeding tubes should be changed. Commonly, tubes are changed when they become blocked or dislodged.
It is the responsibility of the managing medical team to arrange tube changes within the appropriate time frames. Please ensure the dietitian is referred at least 48 hours prior to discharge. Feeding pump: a pump is required for jejunal feeding, and is preferred for gastric feeding in critically ill patients. Equipment provision:.
For patients fed via a jejunal tube, required fasting times should be discussed with their anesthetist and may be adjusted at the discretion of their anesthetist. Tube blockage is a common issue with patients receiving jejunal feeding that is both time and resource intensive to address. There is no data to show that carbonated cola beverages are more effective than water as a flush solution, and research has proven the superiority of water over cranberry juice to maintain tube patency.
The complete evidence table can be viewed here. The development of this nursing guideline was coordinated by Elise Alexander, Dietitian and approved by the Nursing Clinical Effectiveness Committee. First published November The Royal Children's Hospital Melbourne. Jejunal Feeding Guideline. Jejunal Feeding Guideline Introduction Aim Definition of terms Assessment Management Special considerations Companion documents Evidence table References Introduction Jejunal feeding is the method of feeding directly into the small bowel.
Dumping Syndrome — rapid gastric emptying where food moves through the small bowel too quickly, resulting in a number of symptoms such as nausea, diarrhoea and abdominal cramps. Percutaneous Endoscopic Jejunostomy PEJ - a feeding tube which is inserted through the abdominal wall into the stomach and then extends into the jejunum. Gastrostomy-Jejunostomy G-J — a feeding tube which is inserted through the abdominal wall, containing two entry points ports - a gastric port which opens into the stomach, and jejunal port which opens into the jejunum.
Assessment Patient group Jejunal feeding may be initiated in any age group of patient, although the duration of feeding can be limited or difficult due to the following factors: The tubes are difficult to place There is an increased risk of gastro-intestinal infection as the tube bypasses the natural microbiological defenses of the stomach, therefore sterile or pasteurized feeds must be used and an aseptic non-touch technique adhered to when manipulating the feeding set The tube can easily become blocked so requires frequent flushing Longer periods of feeding result in reduced mobility of the patient The type of feed given may require review Radiological exposure and expertise is often required Jejunal feeds are most appropriate for patients with gastric outlet obstruction, gastroparesis, pancreatitis and in those with known reflux and aspiration of gastric contents where gastric feeding has failed.
Tube management Do not aspirate the NJT as this can cause collapse and recoil of the tube. The jejunal feeding tube should be flushed: Prior to each feeding session After each feeding session Prior to administration of medicines After administration of medicines 4 hourly if the tube is not in use 4 hourly when on continuous feeds at each bottle change Flushing will be more effective with a push-pause technique.
Feed Type Through feeding directly into the jejunum, feed enters the intestine distal to the site of release of pancreatic enzymes and bile. Pureed food should not be put down the tube for any reason.
Clinicians should evaluate: Tube type and diameter Location of the distal end of the feeding tube relative to the site of drug absorption Effects of food on drug absorption 11 For example, antacids act locally in the stomach and are not suitable for post-pyloric administration.
Frequency of Change There is little evidence to support how frequently jejunal feeding tubes should be changed. Jejunal Tube Blockages Tube blockage is a common issue with patients receiving jejunal feeding that is both time and resource intensive to address. References Ferrie S. Nutrition Support Interest group. Enteral nutrition manual for adults in health care facilities. Boullata J I. Journal of Parenteral and Enteral Nutrition.
Volume 41 Number 1. Pre-Pyloric versus post-pyloric feeding. Clinical Nutrition 24, Enteral Feeding in patients with major burn injury: the use of nasojejunal feeding after the failure of nasogastric feeding. Bankhead R. Mehta N. Volume The Annals of Pharmacotherapy, ;