J Clin Nurs. 2001 Jul;10(4):482-90. Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Ramirez-Perez C.Department of Health Sciences, University of Jaen, Spain. pancorbo@ujaen.es

Enteral nutrition through a nasogastric tube is a technique often used with hospitalized patients when they present problems with oral nutrition. Patients receiving enteral nutrition show several kinds of complications such as diarrhoea, vomiting, constipation, lung aspiration, tube dislodgement, tube clogging, hyperglycaemia and electrolytic alterations. We present a prospective and observational study carried out in an Internal Medicine Unit with 64 patients who were fed by a nasogastric tube. From the results it can be seen that older people represented a majority (the average age was 76.2 years), and difficulty in swallowing was the main reason for beginning enteral nutrition. The complications which appeared were: tube dislodgement (48.5%); electrolytic alterations (45.5%); hyperglycaemia (34.5%); diarrhoea (32.8%); constipation (29.7%); vomiting (20.4%); tube clogging (12.5%); and lung aspiration (3.1%). We discuss the possible relationship between the different factors associated with the enteral nutrition procedure and the occurrence of these complications. Finally, some nursing interventions are suggested, such as: checking the gastric residue periodically; attempting to place the tube in the duodenum in unconscious patients; and the use of protective mittens in disturbed patients.

Am Fam Physician. 2002 Apr 15;65(8):1605-10, 1515. Related Articles, Links Feeding tubes in patients with severe dementia.Li I. Family Medicine Department, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA. kostali@mindspring.com

Patients with advanced dementia are among the most challenging patients to care for because they are often bedridden and dependent in all activities of daily living. Difficulty with eating is especially prominent and distresses family members and health care professionals. Health care professionals commonly rely on feeding tubes to supply nutrition to these severely demented patients. However, various studies have not shown use of feeding tubes to be effective in preventing malnutrition. Furthermore, they have not been demonstrated to prevent the occurrence or increase the healing of pressure sores, prevent aspiration pneumonia, provide comfort, improve functional status, or extend life. High complication rates, increased use of restraints, and other adverse effects further increase the burden of feeding tubes in severely demented patients. Feeding tubes should be avoided in many situations in which they are currently used. The preferable alternative to tube feeding is hand feeding. Though it may not be effective in preventing malnutrition and dehydration, hand feeding allows the maintenance of patient comfort and intimate patient care.

Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: Results of a randomized controlled trial.

Objective: To determine the extent to which postpyloric feeding reduces gastroesophageal regurgitation and pulmonary microaspiration in critically ill patients. Design: Randomized trial. Setting: A medical/surgical intensive care unit at a tertiary care hospital. Participants: Intensive care unit patients were expected to remain ventilated >72 hrs. We excluded patients with esophageal, gastric, or small bowel surgery in the last week and patients with overt or clinically significant gastrointestinal bleeding. We studied 33 patients; 42.4% were female, mean age (sd) was 59.2 ( 16.8) yrs, and mean Acute Physiology and Chronic Health Evaluation II score was 22.5 (7.8). Interventions: Patients were randomized to gastric or postpyloric enteral feeds. Technetium 99-sulphur colloid was added to the feeds for 6 hrs of each of the first 3 days on study. Measurements and Results : We sampled the oropharynx and trachea hourly for the 6 hrs per day that patients received radioisotope-labeled enteral feeds, and the level of radioactivity in these specimens was measured. We defined an episode of gastroesophageal regurgitation and microaspiration as an increase in radioactivity >100 counts per minute/g. Patients fed into the stomach had more episodes of gastroesophageal regurgitation (39.8% vs. 24.9%, p = .04) and trended toward more microaspiration (7.5% vs. 3.9%, p = .22) compared with patients fed beyond the pylorus. When the logarithmic mean of the radioactivity count was compared across groups, there was a trend toward an increase in gastroesophageal regurgitation (3.7 vs. 2.9 counts/g, p = .22) and a trend toward increased microaspiration (1.9 vs. 1.4 counts/g, p = .09) in patients fed into the stomach. Patients who had gastroesophageal regurgitation were much more likely to aspirate than patients who did not have gastroesophageal regurgitation (odds ratio: 3.2; 95% confidence interval: 1.36, 7.77). Conclusions: Feeding beyond the pylorus is associated with a significant reduction in gastroesophageal regurgitation and a trend toward less microaspiration.

Excerpts from "Dysphagia" by Nam-Jong Paik, MD, PhD update for E-medicine.com August 19, 2004

Enteral feeding methods: In some patients (eg, patients with impaired level of consciousness, massive aspiration, silent aspiration, esophageal obstruction, recurrent respiratory infections), enteral feeding may be necessary to bypass the oral cavity and pharynx. In general, enteral feeding is indicated in any patient who is unable to achieve adequate alimentation and hydration by mouth.

Nasoenteric tube remains a commonly used method for enteral feeding. In patients who have a short-term life expectancy, nasoenteric feeding is a more appropriate route for enteral nutrition.

Percutaneous endoscopic gastrostomy (PEG) has several advantages over surgical gastrostomy, including reduced procedure time, cost, recovery time, and no need for general anesthesia. Relative contraindications for PEG are aspiration pneumonia due to gastroesophageal reflux, significant ascites, and morbid obesity. Prospective randomized trials have shown increased compliance, convenience, and continuity of feeding with PEG tubes compared to nasogastric (NG) tubes.

Oroesophageal tube feeding was introduced first in 1988 by Campbell-Taylor et al. This method can be used by patients who refuse nasogastric or gastrostomy tubes. The patient is taught to insert the 14 French urethral tube into the mouth past the side of the tongue and to push very slowly until the catheter end reaches the lips. Food supplements and liquid are administered by means of a 500 mL syringe at a rate of approximately 50 mL/min.

Surgical placement of a gastrostomy tube requires a laparotomy under general or local anesthesia. This procedure is more expensive and has a greater morbidity than PEG. Surgery rarely is indicated in patients with oral or pharyngeal dysphagia, but it can be effective in selected patients.

Adaptive equipment for patients who have difficulty with the motor or perceptual components of feeding compensates for decreased upper extremity functions of limited grasp, incoordination, decreased ROM, and hemiparesis. Rocker knives, swivel utensils, built-up handles on utensils, scoop dishes, nonskid mats, and large-handled cups are examples.

Cricopharyngeal myotomy (CPM) is a procedure designed to decrease the pharyngoesophageal sphincter (PES) pressure by incising the main muscular component of PES; however, no means of determining precisely the underlying PES dysfunction exists yet. For this reason, no rational guidelines have been compiled for recommending CPM. Much less certain is the advisability of performing a CPM in patients with neurogenic dysphagia, such as patients with stroke. The fact that neurogenic causes of dysphagia usually involve lack of coordination of the swallow, rather than any intrinsic or extrinsic muscle dysfunction, probably explains this consideration. Recently, botulinum toxin injection into PES has been introduced in replacement of CPM.

Surgery for chronic aspiration: