The feasibility of electromagnetic sensing aided post pyloric feeding tube placement (CORTRAK) in patients with thrombocytopenia with or without anticoagulation on the intensive care unit

Abstract

Background The successful initiation of enteral nutrition is frequently hampered by various complications occurring in patients treated in the intensive care unit (ICU). Successful placement of a nasojejunal tube by CORTRAK enteral access system (CEAS) has been reported to be a simple bedside tool for placing the postpyloric (PP) feeding tube. Methods We evaluated the efficacy and side effects using CEAS to establish EN in patients with critical illness, thrombocytopenia, and/or anticoagulation. Results Fifty‐six mechanically ventilated patients were analyzed. Twenty‐four of them underwent prior hematopoietic stem cell transplantation (SCT). Sixteen patients received extracorporeal membrane oxygenation treatment because of acute respiratory distress syndrome. The median platelet count at PP placement was 26 g/L (range, 4–106 g/L); 16 patients received therapeutic anticoagulation (activated partial thromboplastin time, 50–70 s). CEAS‐assisted placement of a PP nasojejunal tube was performed successfully in all patients. The most frequent adverse event was epistaxis in 27 patients (48.2%), which was mostly mild (Common Terminology Criteria for Adverse Events grade 1, n = 21 [77.8%], and grade 2, n = 6). A significant association between a low platelet count and bleeding complications was observed (P < 0.001). Conclusion Performed by an experienced operator, CEAS is a simple, rapidly available, and effective bedside tool for safely placing PP feeding tubes for EN in patients with thrombocytopenia, even when showing an otherwise‐caused coagulopathy in the ICU. Higher‐grade bleeding complications were not observed despite their obvious correlation to thrombocytopenia. A prospective study is in preparation.

Enteric Access: GI Perspective

“…Air insufflation has also been used to flatten the gastric folds. Using IV prokinetics (to increase peristalsis), supine patient's position (removes gastric folding), and massaging the right upper quadrant in an inward and upward direction (to move the tube tip over the duodenal flexure) have also been described to help placement of NJ tube Gerritsen et al 36 Stecher et al 37 DeLegge 19 Electromagnetic (EM)-guided placement of NJ tubes has been found to be a simple, safe, and less costly alternative to radiologic and endoscopic techniques. Additionally, no fasting is required before the procedure.…”

“…36 EM-guided placement of NJ tube is feasible and safe in patients with thrombocytopenia. 37 Even though this technique was approved by the U.S. Food and Drug Administration for confirmation of appropriate position of the NJ tube, it was associated with severe complications and even death due to clinicians' failure to recognize lung placement 19…”

“…36 EM-guided placement of NJ tube is feasible and safe in patients with thrombocytopenia. 37 Even though this technique was approved by the U.S. Food and Drug Administration for confirmation of appropriate position of the NJ tube, it was associated with severe complications and even death due to clinicians' failure to recognize lung placement 19 Lord et al 38 The combination of metoclopramide and unweighted feeding tube achieved postpyloric position in 84, 86, and 92% at 4 h, 1 d, and 2 d, respectively, in ICU patients without a need for additional intervention Joubert et al 39 Puiggròs et al 40 In patients with acute pancreatitis, the combination of metoclopramide and a self-propelling NJ tube (with distal pigtail) was associated with successful migration of the feeding tube to the ligament of Treitz in 61% of patients. The success rate correlated with the severity of AP.…”