Program Goals: We implemented in a low to middle income country(LMIC) hospital reliable inexpensive bedside placement of transpyloric nasoenteric(TP) tubes for enteral nutrition as a quality improvement for pediatric patients unable to tolerate safely nasogastric tube feedings. We taught indications for enteral feedings, level of access, and technique for bedside placement of TP tubes using syringe air insufflation, auscultation and measurement, and techniques for non-radiographic confirmation of transpyloric placement. This was followed by hands-on bedside training of physicians who would later promote the technique among peers. We report a 12 month sample of our experience of implementation over a 7 year span at a large children’s hospital in Guatemala. Methods: Didactic presentation was followed by demonstration on a qualifying patient of our technique of non-radiographic transpyloric placement of silastic naso-enteric feeding tubes, guiding providers at the bedside, beginning with the Intensive Care Unit staff. After teaching a cohort of physicians (especially residents and unit directors), a supply line was established for sustained use of the technology. The trained providers were encouraged to improve their skills to teach and promote the technology among their peers and trainees beyond the ICU. Over the next 3 years, annual visits were made to reinforce training of the technique and to encourage its implementation. A survey for recording outcomes was administered by senior residents. Evaluation: Over a 12 month recording period during the third year after introduction: 73 tubes were placed in PICU, NICU/Newborn Nursery, and Children’s, Nutrition, and Oncology Wards. Diagnoses included marasmus and pancreatitis, as well as patients who were post-operation. The majority of placements were done by 21 2nd- and 3rd-year resident physicians and by 4 attendings, but by no nurses. The mean duration for procedure attempts was 5 minutes. Success of placement was 80% in neonates, and 95% in older children. 45% succeeded on the 1st attempt, most succeeded by the second attempt, and one required 4 attempts. Placing TP tubes was easier on sedated ICU patients and in patients with encephalopathy. No complications were reported. Discussion: Our data support the efficacy of an easily learned and validated technique for bedside placement of TP tubes in critically-ill as well as non-sedated pediatric patients limiting the use of radiography and replacing the unsustainable and physiologically less favorable option of parenteral nutrition in a resource-limited hospital. This procedure has become a standard option throughout the hospital sustained over 7 years. A trained cohort of physicians in LMIC settings can independently promote and sustain this technique of bedside placement of transpyloric nasoenteral feeding tubes reliably and safely, providing safe and effective nutrition support to patients intolerant of other options.
Bedside transpyloric enteral nutrition in a LMIC Children’s Hospital.
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Karem A. Perez, laura chicas, Maryjo Grant, rodolfo Espinoza, William Jackson; Bedside transpyloric enteral nutrition in a LMIC Children’s Hospital.. Pediatrics July 2020; 146 (1_MeetingAbstract): 296–297. 10.1542/peds.146.1MA4.296
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