Eur Surg (2011) 43/1: 24–29
© Springer-Verlag 2011
ACA Acta Chirurgica Austriaca
Printed in Austria
Gut access in critically ill and injured patients: Where
have we gone thus far?
N. Kulvatunyou, B. Joseph, A. Tang, T. O’Keeffe, J. L. Wynne, R. S. Friese, R. Latifi, P. Rhee
Division of Trauma, Critical Care and Emergency Surgery, Department of Surgery, The University of Arizona,
Tucson, AZ, USA
Received December 3, 2010; accepted December 15, 2010
Zugänge zur enteralen Ernährung beim kritisch
Kranken und Schwerverletzten: Wo stehen
Zusammenfassung. Grundlagen: Erna ¨hrung beim kri-
tisch Kranken und Schwerverletzten ist essentiell und
kann parenteral oder enteral erfolgen. Jede Methode hat
ihre Vor-und Nachteile. Hier untersuchen wir den ente-
ralen Zugang, vor allem die Zugangswege.
Methodik: U¨bersicht der Literatur.
Ergebnisse: Folgende Zugangswege fu ¨r enterale Er-
na ¨hrungssonden stehen uns zur Verfu ¨gung: orogastrisch,
nasogastrisch, nasojejunal. Die beliebtere Methode ist
die permanente endoskopische Gastrostomie (PEG),
aus o ¨konomischen und sicherheitstechnischen U¨berle-
gungen. Alternativ finden sich die offene Gastrostomie,
laparoskopische oder laparoskopisch assistierte Gastro-
stomie und Jejunostomie.
Schlussfolgerungen: Wann immer ein enteraler Zu-
gang mo ¨glich ist, sollte einer enteralen Erna ¨hrung der
Vorzug gegeben werden, ob pra ¨- oder post-pylorisch ist
derzeit nicht eindeutig zu beantworten. PEG ist sicher
und o ¨konomisch sinnvoll.
Schlu ¨sselwo ¨rter: Erna ¨hrungssonde, perkutane endosko-
pische Gastrostomie (PEG), Nasojejunalsonde.
Summary. Background: Nutritional support in critically
ill and injured patients is crucial. It can be provided via
parenteral or enteral access, each of which has advan-
tages and disadvantages. In this article, we review enteral
support, particularly gut access.
Methods: We conducted a literature review.
Results: A number of techniques enable access to
the gastrointestinal tract in critically ill and injured pa-
tients. A temporary orogastric (OG), nasogastric (NG), or
nasojejunal (NJ) feeding tube can be placed. But the
endoscopic gastrostomy (PEG), which has economic as
well as safety benefits. Other techniques include open
operative gastrostomy, laparoscopic or laparoscopic-as-
sisted gastrostomy, and jejunostomy.
Conclusions: Nutritional support should be provid-
ed enterally, via gut access whenever possible. The issue
of pre- versus post-pyloric access remains controversial.
PEG is safe and economical for long-term access.
Keywords: Feeding tube, percutaneous endoscopic gas-
trostomy, nasogastric tube, nasojejunostomy.
Anyone who practices intensive care medicine would
agree that providing daily nutritional support to criti-
cally ill and injured patients is not only necessary but
also vital. The Society of Critical Care Medicine and the
American Society for Parenteral and Enteral Nutrition
have recently updated guidelines for providing and as-
sessing nutritional support in critically ill adults . In
this literature review, we focus on the issue of enteral
nutrition (EN), particularly gut access. We also incorpo-
rate our own perspective, drawing on our combined
multiple years of experience of intensive care medicine
practice, mostly in a trauma center’s surgical intensive
care unit (ICU) .
According to the current consensus and to common-
sense logic, “if gut is available, use it” [3, 4]. But the
studies comparing the complications and benefits of EN
and parenteral nutrition (PN) do not necessarily yield
straightforward conclusions, given design weaknesses
Correspondence: Narong Kulvatunyou, MD, FACS, Assistant Profes-
sor, Division of Trauma, Critical Care and Emergency Surgery,
Department of Surgery, University of Arizona Health Science Center,
1501 N. Campbell Ave., Room 5325, PO Box 245603, Tucson, AZ
Eur Surg 1/2011
© Springer-VerlagGut access in critically ill and injured patients
published studies have suggested that PN can lead to
increased infectious complications, and that early EN
support is a must in order to prevent infectious com-
to 36 hours after the onset of critical illness or after
injury) EN is now universal. We have evenly applied
early EN to our trauma patient population, even to the
unique subgroup of “open abdomen” patients .
Plurad et al. and Rhee et al. [11, 12] recently demon-
strated a trend of decreased PN use, over time, in their
contemporary trauma ICU.
Noninvasive (temporary) gut access
Types of tubes
Numerous studies have compared nasogastric (NG) and
nasojejunal (NJ) feeding tubes [13–25]. But, again,
drawing firm conclusions is quite difficult because of
small sample sizes, inconsistent and heterogeneous
patient populations, and the lack of a scientific basis
for associated complications (such as gastroesophageal
reflux and pneumonia). In intubated patients with facial
injuries OG tube is an acceptable method of providing
nutrition support, until more permanent solution is
obtained. For any enteral access, the goals are ease of
tube placement; cost-efficiency; timely fulfillment of
calorie requirements; and minimal procedure-related
complications. In terms of fulfilling calorie require-
ments sooner, some studies [13–18] favor the NJ tube,
while others [19, 20] favor the NG tube. But overall, the
associated complications of aspiration, pneumonia, “of
aspiration pneumonia” and death do not appear to
significantly differ [13–24]. Two main caveats apply:
First, in general, NG placement is much easier, and NJ
placement is more difficult and takes longer. However,
placement time certainly depends more on the specific
institution’s capability, the technique used, and the
available resources. The overall success-failure rate of
placement is operator-dependent. Moreover, the re-
ported delay in NJ placement [19, 20] probably does
not translate into any clinical significance. By the same
token, while NG placement may be easier, the time to
reach the calorie goal can be affected by gastric empty-
ing status, which most studies do not elaborate on.
Hence, interpreting the overall outcome can be chal-
lenging. Second, the usual clinical endpoints of interest
are the rate of aspiration and the possibly associated
complication of pneumonia. Heyland et al. , using a
radioisotope, demonstrated that the incidence of gas-
troesophageal regurgitation and microaspiration is
higher with NG tubes. But no one has been able to
demonstrate a temporal relationship between aspirati-
on and aspiration pneumonia. Most studies use venti-
lator-associated pneumonia (VAP) as an outcome, but
diagnosing VAP in the ICU is difficult; in addition,
several independent variables are not controlled for in
most studies. One of us has personally witnessed a
temporal relationship between aspiration, aspiration
pneumonitis, hypoxia, and death, in both NG and NJ
We therefore agree with the general wisdom [24, 26] that
vigilant clinical assessment is most important. NG feed-
ing is certainly simple and economical. The head of the
NG patient’s bed should always be elevated, to minimize
the incidence of reflux and aspiration. A daily (or even
more frequent) assessment for possible feeding intoler-
ance and for any delay in gastric emptying should be
performed; any problems should prompt a switch to NJ
placement. Once the NJ tube has been placed, the clini-
cian must continually make sure that it is fully advanced,
that it stays advanced, and that it has not fallen back into
the stomach. Assessment of gastric residual volume
should be carfully monitored.
NJ placement techniques
In most cases, NJ tubes are placed by a blind technique,
with the assistance of the patient’s positioning and
prokinetic medications . The goal standard has been
fluoroscopic or endoscopically guided placement, with
a nearly reported 100% success rate. But fluoroscopic or
endoscopically guided placement is time-consuming
and, in most institutions, not always practical. Several
new techniques are now available, including transnasal
endoscopic placement [28, 29], a self-propelled Tiger
Tube (Cook Medical Inc., Bloomington, IN) , and the
Cortrak system (Viasys Medsystems, Wheeling, IL) .
At our institution, we use the Cortrak system; most of
our ICU nurses are fully trained and skilled in NJ place-
ment, and we have not noticed any significant delay
vigilant, making sure that the tube does not remain too
proximal in the duodenum (which often leads to gas-
troduodenal reflux or to tube dislodgement back into
Most reported complications are related to the tube itself
[32, 33]. Reported tube malpositions in the right main-
stem bronchus [AS MEANT?] have resulted in pneumo-
thorax and hypoxia. Several case reports have noted tube
malpositions in the intracranial space [AS MEANT?]
through the cribriform plate, resulting in craniofacial
trauma. Incomplete advancement, or dislodgement, of
NG tubes has injured the esophagus. Metheny et al. 
advocated routine X-ray confirmation of all tube place-
ments, pointing out that auscultation (particularly with
NG placement) is not always reliable.
The NG tube is often associated with an increase in
gastric residual volume, which predisposes to aspiration
and respiratory compromise . In our ICU, where the
incidence of tube-feeding-related diarrhea. That in-
creased incidence is not cited very often in studies com-
paring NG and NJ feeding. We do not know whether the
or whether it is dependent on the formula and its
Gut access in critically ill and injured patients
A known, albeit uncommon, complication is tube-
feeding-related nonocclusive bowel necrosis (NOBN).
Thus far, 40 cases have been reported [34–44] in the
English-language literature. Most of those cases devel-
oped postoperatively after major abdominal operations
and after FJ tube placement [34, 38–40, 42, 44]. The
remaining cases were in trauma or burn patients. Marvin
5-year period, for a reported 0.3% incidence. After 8 years
NOBN – in an 18-year-old woman with severe traumatic
brain injury, 10 days after her admission (Fig. 1). The
clinical manifestation in this patient was very insidious
(as commonly reported in the literature), with nonspecif-
ic signs and symptoms of feeding intolerance. Her diag-
nosis was confirmed by a pneumointestinalis on the
abdominal computed tomography (CT) scan (Fig. 2). The
pathophysiology of NOBN is still not well defined;
several theories have been suggested, including, to name
bowel distention, and hyperosmolarity of the tube
feed. Treatment remains early diagnosis and surgical
Invasive (permanent) gut access
Most ICU patients who have a prolonged recovery or who
are ventilator-dependent are offered more permanent
access for invasive feeding, for the sake of their comfort
(similar to the timing and thought process for tracheos-
access in ICU patients have not been extensively studied
and are not necessarily the same as the general indica-
tions [45–47]. Moreover, in our ICU, where a number of
patients typically have severe head trauma, most will
require prolonged feeding access long into their rehabili-
tative recovery phase. Permanent feeding access is more
secure and reliable; not incidentally, it often assists with
the ease of placement into a rehabilitation facility.
Percutaneous endoscopic gastrostomy (PEG)
The traditional operating room surgical open gastro-
stomy (SOG)  has now given way to the less invasive,
more economical, and much more steadfast efficiency of
bedside PEG . Several comparison studies between
SOG and PEG have been performed [50–53], but none
applied to ICU patients. Dwyer et al.  demonstrated
the cost benefit of bedside PEG in surgical/trauma ICU
patients, as well as its safety benefit in relation to SOG.
The safety benefit has also been demonstrated by other
studies [55, 56].
The most common PEG technique is the “pull” tech-
nique, first described by Gauderer et al. . It was first
performed in a pediatric population, but is now per-
formed in patients of all ages and in various care settings
[45–47]. In addition, a variation of a “push” technique is
available; it can be performed using endoscopic [57–60]
or fluoroscopic [57, 61–63] guidance, with or without
gastropexy. The “pull” and “push” techniques have
equivalent outcomes and efficacy. Several “push” tech-
nique studies [58–60] have suggested a possible lower
Fig. 1: Intraoperative finding of tube-feeding-related transmural bowel
necrosis of the proximal jejunum
Fig. 2: Computed tomography scan of the abdomen demonstrating
a pneumointestinalis (arrows)
© Springer-Verlag Gut access in critically ill and injured patients
infection rate, because the tube is not dragged through
the contaminated oral and gastrointestinal tract; howev-
er, the sample sizes were small, so definitive conclusions
are not possible.
PEG is generally considered very safe, with very low
procedure-related complications and with almost no
associated mortality . Any associated mortality is
always associated with the underlying disease . The
reported overall complication rate [46–56] can be as low
as 0%  or as high as 16% , but interpreting those
results is difficult because of thevariation in sample sizes,
in patient populations, and in definitions of complica-
tions. Schulenberg et al.  reported PEG-related com-
plications that required surgical intervention, over a
3-year period: of more than 1200 PEGs, the complication
rate was just 2.1%.
The most common recognized complication of PEG
is peristomal site infection ; the ranges from 0 to 47%
[50–56, 66–71]. Again, interpreting results can be difficult
because of the variation in patient populations, in pro-
phylactic antibiotic use, and in sample sizes. Several
randomized controlled trials of prophylactic antibiotic
use [66–71] after PEG have suggested a lower infection
complication rate, but all of those trials were marred by
the lack of sample size calculation. Most were in non-ICU
Infection rates after PEG in trauma patients popu-
lations have been reported by Dwyer et al.  as 1%
(n¼95); by Carrillo et al.  as 0% (n¼54); and by
Lockett et al.  as 5.4% (n¼11). The overall incidence
appeared to be small. Uncommon complications have
also been recognized, such as tube dislodgement ,
including a “buried bumper syndrome” ; tube
leakage internally and externally ; pneumoperito-
neum [73, 74]; and inadvertent injury to other internal
Laparoscopic tube placement
Viable technique that has replaced SOG is less invasive
laparoscopic approach [75, 76]. In patients undergoing
laparotomy and who will need long tern gut access for
nutrition support SOG or FJ should be done at the time of
the operation. And yet PEG can even be performed safely
despite a prior laparotomy . Because it is more inva-
sive than PEG and is associated with the complications of
the underlying surgical procedures [50, 53], laparoscopic
assisted gastrostomy has a higher complication rate than
In summary, the current standard for nutritional support
of critically ill and injured patients is enteral (gut) access.
The issue of pre- versus post-pyloric access remains
controversial, with still-uncertain clinical implications.
Clinicians must be aware of tube-related malpositions,
even though such complications are uncommon. The
unusual presentation of NOBN also requires vigilance.
PEG offers the most efficient, economical, and secure
permanent feeding access.
Conflict of interest
The authors declare that there is no conflict of interest.
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