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Recommendations Summary

CI: Gastric vs. Small Bowel Feeding Tube Placement 2012

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CI: Feeding Tube Placement

    If a critically ill adult patient is mechanically ventilated and requires enteral nutrition (EN), the Registered Dietitian (RD) should recommend small bowel feeding tube placement. The largest research studies with ventilator-associated pneumonia (VAP) as a primary outcome, suggest that small bowel EN vs. gastric EN reduces VAP. However, other benefits (ensuring adequacy of nutrient delivery, and reducing costs of medical care, days on mechanical ventilation,  and mortality) have not been demonstrated. 
     

    Rating: Fair
    Conditional

    • Risks/Harms of Implementing This Recommendation

      • If there is a delay due to small bowel placement:
        • Underfeeding may result 
        • Benefits of early initiation of EN may be lost
      • Repeated confirmation X-rays increase radiation exposure.

       

    • Conditions of Application

      • The placement of feeding tubes in the small bowel position requires skilled practitioners (hospitals vary in who places tubes from medical or nursing to dietetics personnel) and/or protocols  
      • Some but not all protocols use fluoroscopy to aid in tube placement, while others use promotility agents or magnets and radiographic confirmation of tube tip position
      • There may be specific disease states or conditions that may warrant small bowel tube placement (e.g., fistulas, pancreatitis, gastroparesis), however they were not evaluated at this phase of the analysis.

    • Potential Costs Associated with Application

      The impact of feeding tube placement on cost of medical care has not been adequately evaluated.

    • Recommendation Narrative

      A total of 14 studies were included in the evidence analysis for this recommendation:

      • Nine positive quality randomized controlled trials (RCTs) (Acosta-Escribano et al, 2010; Boivin et al, 2001; Davies et al, 2002; Hsu et al, 2009; Kearns et al, 2000; Kortbeek et al, 1999; Montecalvo et al, 1992; Montejo et al, 2002; and White et al, 2009)
      • Two positive quality meta-analyses (Heyland et al, 2003; and Marik and Zaloga, 2003) 
      • One neutral quality RCT (Esparza and Boivin, 2001)
      • One neutral quality non-randomized trial (Metheny et al, 2010)
      • One positive quality consensus statement (McClave et al, 2002).

      Impact of Enteral Feeding Tube Tip Site in the Gastric vs. Small Bowel Position on Mortality

      • Nine studies provide evidence that small bowel feeding is unlikely to reduce mortality in adult critically ill patients. To date, adequately powered studies have not been conducted to demonstrate a significant difference in mortality when comparing gastric vs. small bowel feeding tube position in critically ill patients.
      • There was no difference in mortality rate attributable to gastric vs. small bowel feeding
      • Mortality was not a primary outcome in most studies
      • Evidence is based on the following studies: Boivin et al, 2001; Davies et al, 2002; Esparza and Boivin, 2001; Heyland et al, 2003; Hsu et al, 2009; Kearns et al, 2000; Kortbeek et al, 1999; Marik and Zaloga, 2003; and White et al, 2009.

      Impact of Enteral Feeding Tube Tip Site in the Gastric vs. Small Bowel Position on Infectious Complications (Aspiration Pneumonia)

      • Twelve studies provide evidence that clinical trials with the largest number of subjects having pneumonia as a primary outcome suggest that post-pyloric EN reduces aspiration pneumonia in critically ill adult patients  
      • Evidence is based on the following studies: Acosta-Escribano et al, 2010; Davies et al, 2002; Esparza and Boivin, 2001; Heyland et al, 2003; Hsu et al, 2009; Kearns et al, 2000; Kortbeek et al, 1999; Marik and Zaloga, 2003; Metheny et al, 2010; Montecalvo et al, 1992; Montejo et al, 2002; and White et al, 2009.

      Impact of Enteral Feeding Tube Tip Site in the Gastric vs. Small Bowel Position on Length of Stay (LOS)

      • Eight studies provide evidence that intensive care unit (ICU) or hospital LOS in adult critically ill patients do not differ when the feeding tube tip is placed in gastric vs. small bowel position. However, adequately powered studies have not been conducted
      • In none was ICU or hospital LOS a primary outcome  
      • Evidence is based on the following studies: Acosta-Escribano et al, 2010; Boivin et al, 2001; Hsu et al, 2009; Kearns et al, 2000; Kortbeek et al, 1999; Marik and Zaloga, 2003; Metheny et al, 2010; and White et al, 2009.

      Impact of Enteral Feeding Tube Tip Site in the Gastric vs. Small Bowel Position on Days on Mechanical Ventilation

      • Six studies provide evidence that days on mechanical ventilation in adult critically ill patients do not differ when the EN feeding tube tip is placed in gastric vs. small bowel position. However, adequately powered studies have not been conducted.
      • In none was days on mechanical ventilation a primary outcome
      • Evidence is based on the following studies: Acosta-Escribano et al, 2010; Boivin et al, 2001; Hsu et al, 2009; Kortbeek et al, 1999; Metheny et al, 2010; and White et al, 2009.

      Impact of Enteral Feeding Tube Tip Site in the Gastric vs. Small Bowel Position on Cost of Medical Care

      • No studies evaluating the impact of feeding tube tip placement on the cost of medical care in critically ill patients were located.

      Impact of Enteral Feeding Tube Tip Site in the Gastric vs. Small Bowel Position on Adequacy of Nutrient Delivery

      • Eleven studies provide evidence that it is unclear whether site of enteral feeding tube tip in the gastric vs. small bowel position impacts adequacy of nutrient delivery in adult critically ill patients.
      • Evidence is based on the following studies: Acosta-Escribano et al, 2010; Boivin et al, 2001; Davies et al, 2002; Esparza and Boivin, 2001; Kearns et al, 2000; Kortbeek et al, 1999; Marik and Zaloga, 2003; Metheny et al, 2010; Montecalvo et al, 1992; Montejo et al, 2002; and White et al, 2009.

    • Recommendation Strength Rationale

      • Subjects were primarily middle-aged and elderly
      • Grade II evidence is available for the conclusion statements regarding impact of the site of enteral feeding tube tip in the gastric vs. small bowel position in critically ill adults on:
        • Adequacy of nutrient delivery
        • Infectious complications (aspiration pneumonia) 
      • Grade III evidence is available for the conclusion statements regarding impact of the sie of enteral feeding tube tip in the gastric vs. small bowel position in critically ill adults on:
        • Mortality
        • LOS
        • Days on mechanical ventilation
      • Grade V evidence is available for the conclusion statement regarding the effect of the site of enteral feeding tube tip in the gastric vs. small bowel position impact cost of medical care in critically ill adult.

       

    • Minority Opinions

      None.