Quality nutrition is vital for critically ill pediatric patients to heal and boost their recovery. Since many of these patients cannot eat on their own, effective delivery of liquid food is especially important. Administering nutritional support through the digestive tract rather than intravenously is more suitable in critically ill children who are intolerant of nasogastric feeding or have a high risk of pulmonary aspiration. However, medical caregivers historically have had difficulty accomplishing it at the bedside – until now.
Garrett Kitt, a pediatric intensive care unit (PICU) nurse at Children’s Hospital Central California, recently won the annual American Academy of Pediatrics (AAP) Section on Critical Care “Best Abstract for Nursing Award” for his work on this subject. Under the guidance of Dr. Bob Dimand, former chief of pediatrics at Children’s, Kitt collaborated with Dr. Cathy Xu, a third-year pediatric resident at the UC San Francisco-Fresno program at Children’s, to demonstrate that not only can a feeding tube be placed successfully in the small intestine in critically ill pediatric patients at the bedside, but also a nurse can do it consistently and safely.
“Starting enteral (tube) feeding early on results in better care, including decreasing the patient’s length of stay, number of ventilator days, risk of aspiration pneumonia and inflammation,” said Kitt, who is the second medical caregiver at Children’s to receive an AAP award in the past two years. “So the more we can do this successfully, the better it is for the patient.”
Inserting transpyloric feeding tubes, which bypass the stomach to reach the small intestine, typically requires multiple attempts as well as additional time-consuming and costly methods, including fluorescent or endoscopic guidance. As a result, many medical facilities across the country turn to radiologists, attending physicians and nurse practitioners to complete the task. However, Children’s PICU nurses have been performing this procedure effectively with no patient complications for years – without the need for physician involvement, or fluorescent or endoscopic guidance.
To validate Children’s approach, Kitt and Dr. Xu, along with help from other PICU nurses and doctors at Children’s, worked together on the research study. Of the 81 bedside transpyloric feeding tube placements randomly selected from September 2009 to September 2010, the PICU nurses achieved a 100 percent success rate. About 75 percent of the selected patients – most of who were mechanically ventilated and sedated – only required one attempt to place the feeding tube successfully. Each placement was confirmed by abdominal X-ray. If the first placement failed, a second placement achieved a 90 percent success rate and was usually performed within 20 minutes of the first.
“People would say that nurses can’t do this, that it can’t be done,” said Dr. Dimand, who has a special interest in enteral and parenteral (intravenous) nutrition and is the former professor and chair, department of pediatrics, at the UC San Francisco-Fresno program at Children’s. “Garrett and the team proved that they can, and in doing so, provide optimum care for the patients.”
Transpyloric feeding is especially effective in critically ill patients, who often have impaired stomach emptying due to their severe illness and decreased gastric motility from the use of narcotics and other medications.
The PICU nurses accomplished their excellent results by combining an air insufflation technique with the Hospital’s standard protocol for placing feeding tubes. After inserting the transpyloric feeding tube via the mouth, 3 to 5 ml of air was used when it reached the passage at the lower end of the stomach known as the pylorus so that the tube could pass more easily into the small intestine.
“The support that we received for this project from the Hospital and resident program was incredible,” said Dr. Xu. “Research is so important, and this shows that we can do anything if we put our minds to it, we can make it happen.”
The abstract authored by Dr. Xu, Kitt and Dr. Dimand on successful transpyloric placement by nursing staff at the bedside in PICU patients was published in the September issue of “Pediatric Critical Care Medicine.”
In 2009, Dr. Aaron Reitman, a pediatric resident at the UC San Francisco-Fresno program at Children’s, won the annual AAP “Best Abstract for Physician in Training Award.” Dr. Reitman’s research focused on procalcitonin as a biomarker for bacteremia in pediatric patients with a fever and abnormally low white blood cell count.