Ileus is a common problem we face in the intensive care unit (ICU), and in pursuit of safer enteral nutrition, we are routinely placing small bore feeding tubes (SBFT) past the gastric pylorus. This is especially important in patients with severe GERD, gastrointestinal dysmotility, recurrent emesis, and those at high risk for aspiration.
Intuitively, it makes sense – placing a post-pyloric SBFT should confer a decreased risk for aspiration. It also minimizes gastric distention which could otherwise compromise respiratory function; however, the data shows no statistically significant difference in the rate of aspiration/vomiting events in gastric vs post-pyloric feeds. Of note, the latter is associated with a decreased risk of pneumonia.
The primary disadvantage of post-pyloric feeding is actually placing the SBFT. Here’s how I try to optimize my chance for success:
- Administer erythromycin or metoclopramide – both are promotility agents which will “push” contents distally.
- Place the patient in the right lateral decubitus position.
- Measure the small bore feeding tube (SBFT) from the nose tip, down to the stomach, and across the midline several centimeters (approximating the location of the pylorus).
- Advance the SBFT into the stomach (usually around 40 centimeters).
- Insufflate the stomach with ~300 cc of air. This straightens out the rugae and makes the stomach more bowl shaped.
- Continue advancing 3-5 centimeters at a time with ~10 cc bursts of air injected into the SBFT.
- Usually around the 70-80 cm mark, you hope you’re well within the duodenum.
- Get the abdominal x-ray and cross your fingers!
Ideally, the SBFT will be positioned in the distal duodenum or jejunum. You should see the tube enter the stomach, cross midline, and potentially loop around (there are four parts to the duodenum). A tube placed distally will be less likely to get dislodged in the event of excessive coughing.