This study introduces a bedside visualized method to improve nasojejunal tube placement in intensive care unit patients, enhancing efficiency and reducing patient discomfort.
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.
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 interventions1,2,3,4. 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 complications7,8. There exists a consensus asserting the necessity of supplemental nutrition support, with evidence indicating its capacity to enhance outcomes for patients9,10. 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 guidance13,14,15,16.
Blind bedside NJ tube placement has been extensively studied, but the success rate of this procedure varies widely, ranging from 17% to 83% in patients17,18. 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 studies22,23,24. 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.
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).
…The authors have nothing to disclose.
The study was supported by various colleagues from the hospital's Department of Critical Care Medicine and Department of Orthopedics. This research received external funding from the Zhejiang Province Medical and Health Science and Technology Program (2019RC170) and the General scientific research project of the Zhejiang Provincial Department of Education (Y201941857).
Disposable nasogastrointestinal tube | JiangSu Jianzhiyuan Medical Instrument Technology Co., Ltd. | W![]() |
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 |
.