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This is a report of an in vitro study evaluating clotting ability of some formulas with intact protein and hydrolyzed protein sources in a series of buffers ranging from a pH of 1 thru 10. The following 10 products were tested: Ensure Plus, Ensure, Enrich, Osmolite, Pulmocare, Citrotein, Resource, Vivonex TEN, Vital, and Hepatic Acid II. Protein (10 and 20 g/liter) was added to Citrotein and Ensure Plus. All formulas were tested at full and some at half strength. Clotting occurred only in premixed intact protein formulas (Pulmocare, Ensure Plus, Osmolite, Enrich, Ensure) and in Resource. No clotting was observed for Citrotein (intact protein formula in powder form), Vital, Vivonex TEN, and Hepatic Aid II. Adding protein did not cause or increase clotting. In summary, clotting of some liquid formula diet appears to be an important factor causing possible gastric feeding tube occlusion. The following measures may help in preventing this problem: flushing before and after aspirating for gastric residuals to eliminate acid precipitation of formula in the feeding tube, advance the nasogastric feeding tube into the duodenum if possible, and avoid mixing these products with liquid medications having a pH value of 5.0 or less.

We report here our clinical experiences of "fine bore" nasogastric feeding tubes. Data have been collated over a 7-year period (1978-1985). A total of 403 patients were intubated on 809 occasions. In the first retrospective study, the clinical use of 491 unweighted tubes was compared with that of fifty 3.5-g weighted tubes. No advantage was found in the use of the weighted tubes. In the second prospective controlled clinical trial, these results were confirmed. Forty-six patients were intubated on 76 occasions with an 85-cm open-ended, unweighted nasogastric feeding tube (Prima, Portex UK), and 57 patients were intubated on 79 occasions with a 91-cm 3.0-g weighted tube (Entriflex, Biosearch, Raritan, NJ). Mean duration of placement was similar in each case, and 62% of both types of tubes were inadvertently removed. Without exception, all the tubes remained in the stomach throughout. Disappointed with the similar and overall performance of both types of tubes, we initiated a design program which resulted in the development of two new nasogastric tubes, one weighted and one unweighted. The tubes were manufactured with polyurethane, rather than polyvinylchloride (PVC), which permitted an increase in diameter of the internal lumen which, in turn, was coated with water-activated lubricant to ease removal of the introducer wire. A specially modeled outflow port was incorporated into the tips of both tubes. The performance of the two new polyurethane nasogastric feeding tubes was assessed under controlled trial conditions; as a reference, a widely used PVC unweighted open-ended tube was used.(ABSTRACT TRUNCATED AT 250 WORDS)

A performance evaluation of a new polyurethane nasogastric feeding tube and stainless steel stylette (Nutriflex, No 8 French) was conducted at University Hospital. Thirty-eight tubes were successfully placed in 18 patients. Tubes remained in place less than 1-29 days and feedings were administered for a total of 196 patient days. Enteral formulas commonly available were administered via continuous drip. The tube use was surveyed for ease of insertion primarily; however, patency and comfort to the patient were felt to be positive with the use of this tube. With slight modifications the new feeding tube is a welcome addition to the expanding technology associated with enteral feedings.

Background Nasogastric tube position should be checked every day by either aspirate pH or chest radiography to prevent fatal misplaced feeding into the lungs. Many patients do not have acidic gastric aspirates and require daily chest radiographs. We developed and validated a lipase test that was compatible with non-acidic gastric aspirates. Methods We conducted evaluations of diagnostic test accuracy at a teaching hospital in development and validation stages. Development: We collected gastric and lung aspirates from 34 consecutive patients. We measured pH and human gastric lipase activity in the laboratory. These data helped us develop the lipase test. Ingenza Ltd (Roslin, Scotland) created tributyrin-coated pH test paper, which human gastric lipase converted into butyric acid, thus correcting false negatives. Validation: We tested nasogastric feeding tube aspirates from 36 consecutive patients with pH and lipase tests, using chest radiography or trial by use as the reference standard. Results Development: We demonstrated human gastric lipase activity in the non-acidic stomach aspirates. Validation: The accuracy of the lipase test (sensitivity 97.2%, specificity 100%) was significantly better than pH (sensitivity 65.7%, specificity 100%, p Conclusions When nasogastric tube stomach aspirates were not acidic and pH was falsely negative, the lipase test showed a true positive and was significantly more accurate.

Es wird uber einen Fall berichtet, in dem einem bewustlosen Patienten eine nasal gelegte tiefgekuhlte Magensonde durch die intakte Schadelbasis nach intrakraniell und transzerebral vorgeschoben wurde. Wegen dieser seltenen, aber auch sehr schwerwiegenden Komplikation wird auf die besondere Bedeutung der Kontrolle des regelrechten Sitzes der Magensonde hingewiesen. In a comatose patient the attempt of positioning a nasogastric feeding tube previously stored in a refrigerator led to penetration of the intact skull base in intracranial and transcerebral direction. Because of this rare but extremely serious complication special attention is drawn to the great importance of controlling the proper positioning of gastric tubes.

Essential to the management of the head and neck cancer patient is carefully monitored nutritional support. Traditionally, enteral alimentation, using the nasogastric feeding tube, has been the mainstay of treatment. Tube feedings should provide ample amounts of essential nutrients, minerals, vitamins, and adequate calories and protein. Knowledge of the tube feedings available and problems associated with their administration helps to avoid the pitfalls which limit their effectiveness. The inadequacies of enteral alimentation preclude its use in selected circumstances of severe nutritional depletion. Parenteral hyperalimentation, as a primary or adjuvant mode of therapy, may be capable of rapidly reversing deficits, improving postoperative morbidity and increasing tolerance to radiation and chemotherapy. Postoperative deglutition abnormalities may prolong the nutritional problems of head and neck cancer patients as well.

To the Editor:— The method of nasogastric tube feeding described by Davis and Hoffman ( 209 :685, 1969) has also been described by Casper, Darby, and Picard ( Geriatrics 15 : 172, 1960). This should probably be brought to the authors' attention, since their article is published under the deck "TECHNICAL ADVANCES."

A long-term nasogastric feeding tube, made from modified Penrose tubing, is soft and flexible and it collapses completely when empty. Use of this tubing in patients unable to swallow voluntarily causes less nasal and throat irritation. It also allows the cardioesophageal sphincter to remain competent, thus minimizing esophagitis and tracheal aspiration from gastric reflux.

To the Editor:— About 20 years ago, at the annual meeting of the Washington State Medical Society, I described a cellophane tubing sold by the Visking Company, the diameter of which approximated that of the common Levin tube. This tube was filled with melted butter as an obturator, chilled, and passed before the butter could melt. The result was a pliable nonirritating tube which permitted feeding without the problems of the Levin tube. The Penrose tube described seems unduly complex, and I think our "butter tube" has definite advantages. It has been used in the Northwest by many men and found extremely valuable. I have kept it in place as long as four months.

To the Editor.— A variety of complications has been reported in the course of gastrointestinal intubations. 1,2 An additional mishap is described which occurred after a plastic nasogastric feeding tube had remained in the stomach too long and had become rigid. A routine replacement of a size 16 plastic nasogastric tube was attempted in a decerebrate accident victim. The tube had been in place for an unknown period of time, presumably many weeks. When marked resistance to the removal was encountered, x-ray films were taken while a contrast medium was injected into the tube. This maneuver revealed the tube to be patent and positioned along the greater curvature of the stomach. The entire outline was normal down to what appeared to be the distal tip. No reason was evident why the tube could not be pulled out. After prolonged manipulation and some trauma, the tube was finally recovered. The cause

To the Editor:— Dr. Picard's nasogastric tube design is indeed similar to ours. However, in comatose patients we found aspiration of the small mercury bag to be a problem when passing the soft Penrose tube soley by gravity. To correct this, the Penrose tubing was modified to allow a conventional Levin tube to serve as a passing guide.

To the Editor:— This is not new. I used it during my surgical residency at the Pondville Cancer Hospital in Walpole, Mass, in 1958. One patient was fed with the tube for six months without detrimental effect. The tube is illustrated in brief within "Is the Oral Cavity Neglected?" ( J Maine Med Assoc 52 :361, 1961).