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Clinical Costs of Feeding Tube Placement

Jose Eduardo de Aguilar-Nascimento, MD, PhD^* and Kenneth A. Kudsk, MD

From the ^* Department of Surgery, Federal University of Mato Grosso, Cuiaba, Brazil; and the Veterans Administration Surgical Services, William S. Middleton Memorial Veterans Hospital Madison and the Department of Surgery, The University of Wisconsin–Madison, Madison, Wisconsin

Correspondence: Kenneth A Kudsk, MD, H4/736 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-7375. Electronic mail may be sent to kudsk{at}surgery.wisc.edu.

Background: Although small-bore tube placement is common, insertion can lead to serious complications. We investigated the use of radiographs, fluoroscopy, feeding tubes, and complications associated with blind feeding-tube placement. Methods: The electronic and paper records of adult patients receiving a small-bore feeding tube in 2005 were retrospectively reviewed for the following variables: demographics, desired location (gastric or postpyloric), number of radiographs, number of tubes per individual, time interval between medical prescription, tube placement and delivery of the diet, complications, transport for fluoroscopy, and hospital location of placement (intensive care unit vs floor). Results: We identified 1822 tubes placed into 729 patients (male: 449, 61.6%; female: 280, 38.4%; median age: 59 years old, range 18–98). All tubes were placed by nurses unless fluoroscopically placed in radiology or placed after head and neck surgery in the operating room. An average of 2.5 (range 1–20) tubes was used per patient. A total of 2696 radiographs were obtained for an average of 3.7 (range 0–32) films per patient and 1.5 (range 0–11) per feeding tube. Successful placement was higher for intragastric (93.3%) than for postpyloric position (60.4%; p < .001). Fluoroscopy was needed in 18.6% of the patients, mostly for postpyloric insertion (p < .001). Respiratory tree misplacement occurred in 23 (3.2%) patients; 9 (1.2%) had a pneumothorax and 4 (0.5%) died. Patients with a malpositioned feeding tube underwent more tube insertions (6.8 ± 5.4; range 2–20) than patients without complications (2.2 ± 1.8; range 1–18; p < .001). Conclusions: The incidence of airway misplacement of feeding tubes (3.2%) at a major tertiary referral university hospital was alarming. Mandatory radiographs may eliminate the risk of respiratory administration of feedings but not misplacements. The associated costs of radiographs, unsuccessful placements, fluoroscopy, and complications are significant. A solution to this problem will require focused attention and development of specific protocols, possibly using new technologies.

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