adequate nutrition is of vital importance in the critically ill patients to decrease the mortality and morbidity in the intensive care unit ( icu ) . patients expected to stay in icu for more than 3 days without adequate oral intake should be started on nutrition supplement preferably through enteral route . however , it is not tolerated in a subset of patients as indicated by high residual volume . small - bowel feeding was started in such patients to avoid parenteral feeding and its associated complications using a predesigned tube , tiger 2 tube . the ease of insertion , success rate of placement , and the duration in indicated cases were retrospectively analyzed . a retrospective observational study was carried out over a 3-year period from 2012 to 2015 in a 13-bedded adult icu of a tertiary care hospital with mixed patient population . all patients expected to stay in the icu for more than 1 week and eligible for enteral nutrition were included . patients who had adequate oral intake or were planned for parenteral nutrition were excluded from the study . enteral feeds were started in these patients after adequate stabilization with gastric feeding tubes using standardized feeding formulas according to the feeding protocol in the unit [ figure 1 ] . the aim was to achieve 80% of target calories ( 2025 kcal / kg / day ) over the next 72 h. gastric residual volume ( grv ) was checked at 4 h interval . metoclopramide 10 mg intravenous tid was started as prokinetic if grv was more than 200 ml . small - bowel feeding was started in cases where the grv continued to be high despite using two doses of prokinetic agent and when the target calories were not achieved . 12f and 14f tubes made of silicone and 150 cm in length were introduced after adequate lubrication nasally or orally . the tiger tube has claw - like extension which helps in forward propulsion of the tube with peristalsis , helps anchorage , and prevents retrograde migration . prerequisites : ( i ) enteral feeding possible , ( ii ) resuscitation completed , ( iii ) feeding tube inserted and position confirmed with x - ray , ( iv ) calculate the desired calories , ( v ) achieve 80% of target at 72 h the tube was inserted up to 5055 cm into the stomach . its position was confirmed by pushing air using syringe and auscultation over the epigastrium . x - ray was taken only if there was doubt about the position of tube . the tube was gradually pushed by 10 cm / h by the attending nurse till 100 cm . tip of the tube crossing the midline over the vertebral column at lumbar region indicated its presence in the small bowel . subsequently , the feeding was started as per the protocol to achieve the desired calories . image of abdominal x - rays showing successful placement of small - bowel feeding tubes abdominal x - ray showing postpyloric feeding tube in patient with high residual gastric volume abdominal x - ray showing postpyloric feeding tube in case of ileus abdominal x - ray in post laparotomy patient with postpyloric feeding tube the success rate of insertion , ease of placement of the tube , time taken for insertion , confirmation of the tube 's position , and the time taken to start feeding were noted . if the tube was not in the desired position , it was withdrawn back to 55 cm and the procedure repeated once again . on failing at the second attempt , procedure was abandoned and endoscopic insertion was planned at the earliest . feeding tube was inserted in the first attempt in 18 patients with exception of one which required second attempt . endoscopic placement was successfully attempted in 4 of 6 patients where manual placement had failed . cases were small - bowel tube insertion failed total time taken from start for insertion to the final planned level ranged from 4 to 9 h. the duration required to confirm tube position by abdominal x - ray was also noted . the time taken for initiation of feeding ranged from 8 to 13 h with an average of 11 h. no immediate postprocedure complication was noted . target feeds could not be achieved in three patients , in two due to raised intra - abdominal pressure , and in one due to nonosmotic diarrhea . the rate of successful insertion was 78% and the ability to achieve desired feeding target was in 60% of these cases [ table 2 ] . adequate caloric intake in the critically ill patients has shown to decrease icu mortality and morbidity . inability to achieve the target calories by 7 days warrants supplementation with parenteral feeds partially or completely . feeds can be introduced in the stomach , duodenum , or jejunum to provide nutritional benefits . postpyloric feeds reduce the risk of nosocomial pneumonia , aspiration , and vomiting significantly as shown recently by a meta - analysis . gastric feeding is the preferred mode in our unit due to the ease of insertion of the tubes . the number of patients in our study is small as postpyloric feeding was considered only after adequate trial of gastric feeds . small - bowel feeding is required in a subset of icu patients who develop gastroparesis with high grv due to underlying condition - burns , pancreatitis , postoperative patients , and neuroendocrine dysfunction or the effect of medications . postpyloric feeding tubes are smaller in size ( 812f ) and tend to get blocked or displaced . successful insertion has facilitated at the bedside using stylet , positioning the patient in right lateral position , using prokinetics , and insertion under fluoroscopy or by endoscopy . the role of prokinetic to facilitate placement of postpyloric tubes is debatable . since the use of metoclopramide as a prokinetics is a part of our feeding protocol , all patients with high grv received at least two doses of this medications before small - bowel feeding tubes were considered . although a grv up to 500 ml can be acceptable without the fear of aspiration according to clinical studies , we accepted grv of 200 ml to interrupt the feeding as our unit has a nurse - driven protocol . endoscopic insertion is considered the gold standard for insertion of postpyloric feeding tubes with high success rate in expert hands . insertion under fluoroscopy requires shifting the critically ill patients out of the icu to remote areas and involves manpower and patient safety issues . both these methods use nonclawed , smaller sized tubes . in our method , no additional manpower or resources are required and avoids unnecessary delays . only one x - ray was taken in most of the cases except one where insertion was successful in first attempt . one of the major causes of delay in initiating feeds was the time required to obtain the confirmatory x - ray which depends on availability of radiographer . the success rate in various studies using different methods and tubes varies from 62% to 95% . perhaps early initiation of small - bowel feeds would have improved the success rate in these cases . attempt to establish enteral feeding should be made in critically ill patients with a functional gut . bedside placement of small - bowel feeding tube facilitates enteral feeding in patients with failed gastric feeding , thus reducing the need for parenteral nutrition and its associated complications . a larger study would be required to show significance of its advantages over endoscopic insertion at the bedside . the tiger 2 tube was used solely as it was procured by the hospital stores . the tiger 2 tube was used solely as it was procured by the hospital stores . the tiger 2 tube was used solely as it was procured by the hospital stores .
enteral nutrition is the preferred mode of nutrition in critically ill patients whenever feasible as it has a number of advantages over parenteral feeding . 
 both gastric and small - bowel feeding can effectively deliver calories . in patients with gastroparesis , small - bowel feeding can help avoid parenteral feeding . 
 we carried out a retrospective observational study to assess the ability to insert the tiger 2 tube into the small bowel at the bedside in 25 patients who failed to tolerate gastric feeds . 
 the time taken , rate of successful insertion , and ability to feed these patients using a standardized feeding protocol were noted . success rate of insertion was 78% and feeding could be established . 
 this method reduced the delays and risks associated with transportation and dependence on other specialties .