large vs small bore feeding tube on inititation of gastric feeding

[DJ]

i work in an ICU that advances feeding tubes routinely to the small
bowel under fluro. It does happen a few times per month that we
can't get the feeding tube into the small bowel: physically the tube
wouldn't pass the pylorus, radiologist unavailable, too many feeding
tube insertions in one day etc.

we of course then start gastric feeds. Is there any good literature
or guidance on starting gastric feeds in the critically ill
population. Should you start with a large bore tube and if stable
over 48-72 hours switch to a small, soft feeding tube? I know there
is literature indicating higher incidence of aspiration with large
bore tube insitu, but the risk of a small bore tube is inacurrate
residules as the tube collapses.

And also my delima is if we've started gastric and all is going well
do I need to really have that tube advanced? Following the CPGs
patients should be fed into small bowel, but really if gastric was
initiated for logistic reasons and its well tolerated, I feel that I
learn towards the concept of "why fix it if its not broken!" Or
should I persist on getting the tube advanced to small bowel. I often
feel it might not be an economical use of time or resources if the
advancement of the tube isn't indicated by any gastric intolerances at
that point.

Advice please!
DJ

[DJ]

[Shyam]

We are a unit which routinely practise gastric feeds for our icu
patients.
As far I as know, the literature suggests that use of gastric feeds,
if well tolerated,
is as good as small bowel feeds. If you have the necessary logistic
support ,then
you can go for small bowel feeds.
If the gastris feeds are not tolerated well then you can insert the
feeding tube
into the small bowel . Also consider the routine use of prokinetic
agents.

[DJ]

I understand that bit about gastric vs small bowel. But when you are
starting gastric is there any guidelines about a large bore vs small
bore NG tube?

[dk...@queensu.ca]

hi

i would like to make the following points in this discussion.

there is a signal that distal small bowel feeding reduces regurg/aspiration and clinical pneumonia (data summarized on our website) but admittedly there are considerable logistical difficulties in achieving small bowel access which lead us to recommend it in high risk patients only (those kind of patients who are lying flat on their backs, sedated, paralyzed, etc.).  If you have a COPD'er who is sitting up and on the ventilator, intragastric feeds would probably be fine and low risk.  The problem with the 'if it ain't broken, don't fix it" philosophy is that intragastric feeds causing microaspiration, you won't see the problem! you will only discover when you patient develops pneumonia and then it is too late.  I would rather try and prevent VAP by aggressive use of small bowel feeds. that's why we are experiementing with different bedside tubes, like the TIger tube by COok, to figure out a safe and efficacious way of achiving small bowel access.

 

There are no RCTs or large bore vs small bore tubes examining clinically important endpoints so we are left with opinion based medicine.  We usually, for pragmatic reasons, start EN early with whatever tube is in place. this is usually a large bore tube in the stomach (hopefully thru the mouth, not the nose). the advantage to the large bore is that it allows for more accurate assessments of residual volumes. The disadvantage is that it may cause greater regurgitation.  Typically, we switch from a large bore tube thru the mouth to a small bore tube thru the nose when the patient is getting better and is established on their feeds.

 

my two bits...

best,

Daren Heyland

[Melinda Heidebrecht]

We don't have guidelines but I would like to know from several others as
to what type of NG feeding tubes are routinely being used in ICU and
other areas. We routinely use a 14 Fr gastric levine tube and find it
very irritating to some people. Thanks, MH

>>> jen...@rogers.com 4/11/2008 9:31 AM >>>