A Minimally Invasive, Visualized Method for Nasojejunal Tube Placement

Summary

This study introduces a bedside visualized method to improve nasojejunal tube placement in intensive care unit patients, enhancing efficiency and reducing patient discomfort.

Abstract

Malnutrition is a common issue in critically ill patients, often stemming from illness, injury, or surgery. Prolonged fasting leads to intestinal issues, emphasizing the importance of early enteral nutrition, specifically through jejunal nutrition. While enteral nutrition is crucial, complications with current techniques exist. Nasojejunal (NJ) tubes are commonly used, with placement methods categorized as surgical or non-surgical. Non-surgical methods, including endoscopic guidance, have varying success rates, with endoscopic-assisted placement being the most successful but requiring specialized expertise and logistics.

This study introduces a bedside, visualized method for NJ tube placement to enhance success rates and reduce patient discomfort in the intensive care unit (ICU). In this study involving 19 ICU patients, the method achieved an initial success rate of 94.74% with an average insertion time of 11.2 ± 6.4 min. This visualized method demonstrates efficiency and reduces the need for additional imaging, and the introduction of a miniaturized endoscope shows promise, enabling successful intubation at the bedside and minimizing patient discomfort. Adjustments to the guidewire lens and catheter are necessary but pose opportunities for future refinements.

Introduction

Malnutrition frequently manifests as a common complication in critically ill patients, rendering them incapable of consuming or digesting food normally, primarily as a consequence of illness, injury, or surgical interventions^1,2,3,4. Between 30% and 60% of hospitalized patients continue to experience malnutrition⁵. As a result, the provision of early enteral nutrition support is deemed crucial⁶. The implementation of early jejunal nutrition serves not only to uphold the integrity of gastrointestinal function and safeguard the intestinal mucosal barrier but also contributes to enhanced immunity and a reduction in complications^7,8. There exists a consensus asserting the necessity of supplemental nutrition support, with evidence indicating its capacity to enhance outcomes for patients^9,10. In such situations, nutrition can be administered through a tube inserted into either the stomach or the small bowel, known as enteral nutrition (EN). Research into the effectiveness of enteral access devices and placement techniques has become more crucial.

Inserting nasogastric (NG) tubes blindly at the bedside is generally successful. Tube feeding can commence once a radiograph confirms the NG tube tip is correctly positioned within the stomach¹¹. However, during critical illness, gastric emptying can be delayed, leading to increased gastric residual volumes (GRVs) during EN delivery¹². High GRVs pose a risk of aspiration, prompting healthcare providers to halt EN administration¹². As a solution, the nasojejunal (NJ) tube is a commonly employed method for delivering nutrition to critically ill patients. Currently, there exist numerous methods for the placement of NJ tubes, primarily classified as surgical or non-surgical approaches. There are several non-surgical methods for placing a nasojejunal (NJ) tube, including blind insertion, X-ray fluoroscopy with electromagnetic tracing (e.g., Cortrak, ENvue), ultrasound-guided placement, and endoscopic guidance^13,14,15,16.

Blind bedside NJ tube placement has been extensively studied, but the success rate of this procedure varies widely, ranging from 17% to 83% in patients^17,18. In the absence of guided tube placement, it becomes challenging to know when the NJ tube has successfully passed through the pylorus. Additionally, there is a risk of the catheter mistakenly entering the airway, especially in critical patients who are unconscious. Among the non-surgical methods, endoscopic-assisted tube placement emerges as the most successful, with a success rate ranging from 73.3% to 97.6%^14,19,20. Usually, the endoscopic placement of an NJ tube typically necessitates the expertise of a gastroenterologist in an endoscopy room. Additionally, the relatively large diameter of the digestive endoscope can induce significant discomfort for the patient, often mandating the use of general anesthesia.

Furthermore, transferring patients to the gastrointestinal endoscopy room poses a significant logistical challenge, particularly for critically ill patients in the intensive care unit (ICU). These patients frequently exhibit unstable vital signs, including shock and severe respiratory failure. Critically ill patients are at high risk and likely to experience adverse events while being transported²¹. Various methods for placing NJ tubes using direct endoscopic visualization have been discussed. These methods have reported success rates ranging from 80% to 90% in small studies^22,23,24. However, these procedures are often time-consuming, technically challenging, and require a steep learning curve.

Therefore, at our institution, we employ a miniature visualization device to insert the NJ tube in patients at the bedside. This ensures that the tube's tip traverses the pylorus and avoids accidental entry into the airway, all under continuous visual monitoring. Our goal with this method is to offer healthcare professionals, especially those in the ICU, a new approach to enhance the success rate of NJ tube placement in critically ill patients, ultimately minimizing patient discomfort.

Protocol

This study was approved by the Clinical Research Ethics Committee of the People's Hospital of Anji County. All procedures were carried out in accordance with institutionally approved protocols and with the informed consent of the patients. 1. Patient selection and preparation Choose patients based on the following inclusion and exclusion criteria. Set the inclusion criteria as patients with acute gastrointestinal dysfunction; those undergoing mechan…

Representative Results

Clinical outcomes In this study, a total of 19 critically ill patients in the ICU underwent NJ tube placement under visualization guidance. Among the study subjects, there were 12 males (63.16%) and 7 females (36.84%), with an average age of 64.47 ± 13.43 years. Diagnoses included severe pneumonia (n = 6, 31.58%), sepsis (n = 1, 5.26%), successful cardiac arrest resuscitation (n = 1, 5.26%), acute pancreatitis (n = 1, 5.26%), acute exacerbation of chronic obstructive pulmonary disease (n = 3, …

Discussion

We utilized a small visualization tool to insert NJ tubes at the patient's bedside. By employing visualization methods and adjusting patient positioning, we achieved a 94.47% success rate for the initial tube placement. The average time for inserting the tube was just 11.21 ± 6.44 min (Table 2). One patient initially failed intubation but was successfully intubated after receiving a 10 mg intramuscular injection of metoclopramide 20 min before their second attempt (Table 2).

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Materials

Disposable nasogastrointestinal tube	JiangSu Jianzhiyuan Medical Instrument Technology Co., Ltd.	W-4.7-1400mm	The outer diameter of the guide tube is 4.7 mm.
Lidocaine Hydrochloride Gel	Manufacturers are not limited		For local anaesthesia
Medical Endoscopy Image Processor	JiangSu Jianzhiyuan Medical Instrument Technology Co., Ltd.	HD1080	The diameter of the guide wire lens is 2 mm.
Metoclopramide Dihydrochloride Injection	Manufacturers are not limited		Promote gastric motility
SPSS 20.0 software	International Business Machines Corporation		Statistical analysis
Sterile liquid paraffin oil	Manufacturers are not limited		For catheter lubrication