Patients tolerate nasal tubes better than oral tubes, but the nasal route is associated with more frequent bleeding during insertion, erosion of the nares, and sinusitis. Nasal intubation is relatively contraindicated in patients with a fractured base of skull because of the risk of intracranial penetration. Nasogastric feeding usually starts using a 12- to 14-FG tube to allow aspiration of gastric contents to check feed absorption and administration of viscous elixirs or crushed tablets. If the nasogastric aspirates are large (i.e. more than 200-300 ml), transpyloric tube placement should be considered. Many different fine-bore enteral feeding tubes (less than 12 FG and usually 8 FG) are available. The designs vary, but all require a wire stylet or guidewire to facilitate insertion. Most have a weighted tip, although this probably does not assist transpyloric placement. Less than 50 per cent of fine-bore tubes pass through the pylorus spontaneously within 24 h of insertion, and the proportion appears to be much less in patients needing intensive care. Prokinetic drugs such as cisapride (10 mg every 6 h), metoclopramide (10-20 mg intravenously every 6 h), or erythromycin (100-200 mg intravenously) are used to assist transpyloric placement. Fine-bore tubes can also be guided through the pylorus, using fluoroscopy or endoscopy, so that the tip lies in the duodenum or jejunum. Naso- or orogastric tubes are misplaced in 0.3 to 4 per cent of blind insertions, with the most serious complications following accidental tracheal intubation. Risks can be reduced by inserting the fine-bore tube through a larger esophageal introducer. The position of the tip of a feeding tube must always be confirmed by radiography before feeding starts.

Some centers favor creation of a feeding jejunostomy when critically ill patients undergo laparotomy. This allows early enteral nutrition in most patients, but complications are common compared with nasojejunal intubation. They include leaks, peritonitis, wound infection, and bowel obstruction.

The use and timing of percutaneous endoscopic gastrostomy varies between different intensive care units. The principle indication is for long-term enteral nutrition in patients with impaired consciousness or dysphagia. The tube is less likely to be accidentally removed or become blocked, medication can be given through the tube more easily, and the sinus and middle-ear problems associated with nasogastric intubation are avoided. Overall complication rates from percutaneous endoscopic gastrostomy are as high as 25 per cent. They include wound infection, leaks, and peritonitis. It is suggested that feeding by percutaneous endoscopic gastrostomy reduces the risk of pulmonary aspiration and chest infection, but this has not been confirmed.

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