Routine transpyloric placement of feeding tubes reduces aspiration in intensive care unit patients. Spontaneous passage eliminates the need for radiologic or endoscopic intervention. It is unclear whether the addition of a weight to the end of the tube or the use of the prokinetic agent metoclopramide in the conventional dose (10 mg) improves spontaneous transpyloric placement. In a randomized, prospective trial, 39 intensive care unit patients (age > 2 years) had a total of 50 nasoenteral tubes placed after intravenous metoclopramide (20 mg in adults, 0.2 mg/kg in children). The tubes were 8 French in diameter with either a weighted end or an unweighted bullet tip. Tip position was confirmed radiographically within 4 hours after blinded placement and at 1 and 2 days if spontaneous passage had not occurred. At 4 hours, 36% of the weighted tubes and 84% of the unweighted tubes (p < .002) had passed through the pylorus. At 1 day, 48% of the weighted tubes and 86% of the unweighted tubes (p < .007) had achieved transpyloric position. At 2 days, 56% and 92% of the weighted and unweighted tubes, respectively, had passed through the pylorus (p < .009, chi 2). The occurrence of transpyloric passage and the rapidity at which it occurred was significantly greater for the unweighted tube during all time periods. A poststudy trial was conducted to evaluate the effect of the normal dose of metoclopramide (10 mg in adults and 0.1 mg/kg in children) and the transpyloric passage of the unweighted feeding tube. Twenty-five patients received 10 mg of metoclopramide before the insertion of the unweighted tube.(ABSTRACT TRUNCATED AT 250 WORDS)
A term male infant was born to a healthy 24-year-old mother with antenatally diagnosed liver-up, left congenital diaphragmatic hernia (CDH) and gastroschisis. The infant was stabilised in the neonatal intensive care unit and then underwent primary repair of the CDH via left subcostal incision and silo placement for the gastroschisis. Serial silo reductions were started postoperatively and umbilical flap closure for the gastroschisis was performed on day of life 6. The patient was weaned from respiratory support, started on enteral feeds, and discharged home at 1 month of age. He was weaned from supplemental nasogastric feeds by 6 weeks of age and is currently well and thriving at 11 months of age.
Introduction: Gastrostomy tube (G-tube)-related problems, including dislodgements, are a frequent cause for emergency department (ED) visits in pediatric patients. We aimed to reduce G-tube-related ED visits at our children's hospital. Methods: An interprofessional team was formed including a family advisor, nurse practitioners, discharge coordinators, a pediatric surgeon, surgical residents, nurses, and quality improvement coaches. A number of interventions were put into place intended to improve caregiver preparation for G-tube placement, improved communication during the hospitalization, and postoperative interventions, including a new family education pathway and mechanical barriers to prevent tube dislodgment. Results: Overall, tube dislodgment accounted for 64% of G-tube-related ED visits: 14% in tubes less than 3 months from insertion and 86% in tubes older than 3 months. Our rate of ED visits for G-tube dislodgement had an initial baseline of nine visits per month. In the 3 years after the intervention, ED visits decreased from a median of 9.5 per month to 8 per month. Discussion: An interprofessional team implemented a quality improvement project that reduced G-tube-related ED visits in pediatric patients. Further efforts are needed to better understand the contributing drivers of G-tube-related ED visits and ways to minimize these events. Grant monies have been obtained from URMC Quality Institute and Vermont Oxford Network NICU Follow Thru Health Equity to continue our family-led quality improvement efforts.
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