Department of Nutrition & Dietetics, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, United Kingdom.
Department of Nutrition & Dietetics, Royal Brompton and Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, SW3 6NP, United Kingdom.
Intensive Crit Care Nurs. 2023 Jun;76:103387. doi: 10.1016/j.iccn.2023.103387. Epub 2023 Jan 17.
Most intensive care unit patients require a feeding tube, but misplacement risk is high due to the presence of artificial airways and because unconsciousness reduces clinical warnings. Predominantly, tubes are placed 'blindly', where position is not known throughout placement. The result is that 1.6% enter the lung, 0.5% cause pneumothorax and potentially 5% are left in the oesophagus. Guided placement, by identifying tube position in real time, may prevent these problems, but undetected misplacements still occur. We review the safety of guided methods of confirming tube position, including rates of pneumothorax, in the context of current unguided methods. During blind tube placement, tube position can only be tracked intermittently. Excepting X-ray and ultra-sound, most methods of checking position are simple. Conversely, guided tube placement can track tube position from the nose to small intestine (IRIS®), or oesophagus to jejunum (Cortrak™, ENvue®). However, this requires expertise. Overall, guided placement is associated with lower rates of pneumothorax. Unfortunately, for Cortrak, low-use centres have higher rates of undetected misplacement compared with blind placement whereas Cortrak use in high-use centres had lower risk compared with blind placement and low use centres. Because guided placement requires high-level expertise manufacturer training packages have been developed but currently appear insufficient. Specifically, Cortrak's package is less accurate in determining tube position compared to the 'gastrointestinal flexure' system. Validation of an evidence-based guide for IRIS placement is underway. Recommendations are made regarding the training of new operators, including minimum numbers of placements required to achieve expertise.
大多数重症监护病房的患者都需要放置饲管，但由于存在人工气道，且意识不清会减少临床警示，因此存在较高的置管位置不当风险。饲管主要是“盲目”放置的，在放置过程中无法全程确认位置。结果是，有 1.6%的饲管进入肺部，0.5%导致气胸，潜在的 5%留在食管中。实时确认管位置的引导式置管方法可能会预防这些问题，但仍会发生未被发现的置管位置不当。我们回顾了引导式确认管位置方法的安全性，包括气胸发生率，并结合了目前非引导式方法的情况。在盲目置管期间，只能间歇性地跟踪管位置。除 X 射线和超声外，大多数检查位置的方法都很简单。相反，引导式置管可以从鼻子到小肠（IRIS®）或食管到空肠（Cortrak™，ENvue®）跟踪管位置。但这需要专业知识。总体而言，引导式置管与较低的气胸发生率相关。不幸的是，对于 Cortrak 来说，与盲目置管相比，低使用率中心的未被发现的置管位置不当发生率更高，而 Cortrak 在高使用率中心的使用与盲目置管和低使用率中心相比风险更低。由于引导式置管需要高水平的专业知识，因此制造商已经开发了培训包，但目前看来这些培训包还不够完善。具体来说，与“胃肠道弯曲”系统相比，Cortrak 套件在确定管位置方面的准确性较低。正在对 IRIS 置管的基于证据的指南进行验证。针对新操作人员的培训提出了建议，包括达到专业水平所需的最低放置数量。
