Comparison of the effects of different types of nasointestinal tube placement techniques for ICU patients: A Bayesian network meta-analysis

Comparison of the effects of different types of nasointestinal tube placement techniques for ICU patients: A Bayesian network meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of the effects of different types of nasointestinal tube placement techniques for ICU patients: A Bayesian network meta-analysis Peiyi Li, Jia Peng, Mengyu He, Liqin Wang, Xu Lu, Xi Liu, Shuang Wu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8626067/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Apr, 2026 Read the published version in BMC Anesthesiology → Version 1 posted 12 You are reading this latest preprint version Abstract Objective To systematically evaluate the comparative effectiveness and safety of different nasoenteric tube (NET) placement techniques in Intensive Care Unit (ICU) patients through a Bayesian network meta-analysis (NMA). Methods In accordance with PRISMA-NMA guidelines, we conducted a systematic review of randomized controlled trials (RCTs) from major English and Chinese databases, including PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CBM, CNKI, Wanfang, and VIP. The analysis of data was performed within a Bayesian framework utilizing the 'BUGSnet' package in R. Efficacy rankings were established according to the surface under the cumulative ranking curve (SUCRA) values. The assessed outcomes were placement success rate, procedure time, complication incidence rate, and direct healthcare costs. Results This NMA evaluated 19 RCTs involving 1,554 ICU patients. The investigation revealed that all instrument-assisted methods surpassed the Blind placement regarding placement success rates. Of the five assessed techniques, Fluoroscopic guiding had the highest ranking for optimizing placement success and reducing complication incidence rate. Furthermore, Electromagnetic and Endoscopic placement were the most time-efficient solutions, markedly decreasing procedural duration relative to the Blind method. Although there were no statistically significant differences in direct healthcare costs, SUCRA rankings suggested a potential cost-benefit advantage for Fluoroscopic guiding. Conclusions This NMA shows that instrument-guided methods are better than Blind placement for NET placement in ICU patients. Fluoroscopic guidance provides the best success rates and safety, although electromagnetic guidance exhibits greater efficiency in minimizing process duration. Clinical medical professionals should prioritize instrument-assisted methods to improve patient safety and procedural efficacy. Additionally, they have to select the placement method according to resource availability and particular clinical requirements. network meta-analysis nasointestinal tube placement intensive care units magnetic navigation endoscope fluoroscopy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 1. Background Critically ill patients in the Intensive Care Unit (ICU) require nutritional support to maintain metabolic stability and improve clinical outcomes[ 1 ]. Enteral nutrition (EN) is the preferred method because to its proven advantages in minimizing infection complications and its greater cost-effectiveness relative to parenteral nutrition[ 2 ].However, many ICU patients cannot tolerate oral feeding and require via nasoenteric tube (NET) for nutrition due to poor gastrointestinal motility, swallowing difficulty, or significant aspiration risk [ 3 ]. NET is better than a nasogastric tube (NGT) because it lowers the risk of aspiration by preventing gastric reflux and avoids problems caused by delayed stomach emptying. This is especially important for patients who need long-term mechanical ventilation[ 4 , 5 ]. Consequently, extremely crucial to put NET in an appropriate place to make sure that ICU patients get enough nutrition, minimize the risk of complications, and contribute to their get recuperating. However, placement NET in ICU is challenging due to patient-related difficulties like decreased awareness and mechanical breathing, as well as procedural hurdles such accidental misplacement into the respiratory system[ 4 ]. At present, various techniques are presently employed for the placement of NETs in the ICU, including blind insertion, fluoroscopic guidance, electromagnetic guidance, ultrasound guidance, and endoscopic assistance. Nevertheless, the existing approaches exhibit inconsistent efficacy, as each approach has distinct benefits and limitations. Blind insertion is widely used due to its simplicity and cost-effectiveness, but it has a high failure rate and risk of pulmonary misplacement[ 6 , 7 ]. Fluoroscopic-guided NET placement, once the gold standard for complex cases, is limited by the inherent risk of ionizing radiation exposure to patients and staff[ 8 , 9 ]. To overcome the limitations of traditional methods, several new bedside-compatible technologies have emerged in recent years. Such as Electromagnetic-guided systems provide real-time catheter visualization, which ensures high placement accuracy [ 10 ]. Meanwhile, it has been reported that ultrasound-guided technology has been applied to patients in ICU, and the success rate of catheterization is about 80%[ 11 ]. The endoscopic-assisted technique boasts a high success rate due to the utilization of a slender, flexible tube equipped with a camera, allowing for direct visualization during tube placement[ 12 ]. Despite their high reliability, these technologies are underutilized because to their substantial resource requirements, the necessity for specialized equipment and trained personnel, and their limited availability in various ICUs. The current evidence regarding NET placement is constrained by a predominance of single-center, small-sample randomized controlled trials (RCTs). Most of these studies compare individual novel techniques against conventional methods, thereby lacking robust direct comparisons across multiple techniques. Although some traditional pairwise meta-analyses have been conducted, they are limited to direct comparisons between only two technologies and often rely on a small number of head-to-head trials[ 3 , 10 , 13 ]. As a result, the current evidence is inconclusive concerning the optimal and clinically acceptable method for NET placement in ICU patients. Therefore, a systematic and comprehensive evaluation is urgently needed to integrate direct and indirect evidence, establish consensus recommendations, and support evidence-based decision-making in NET placement practice. Network meta-analysis (NMA) expands traditional pairwise meta-analysis by concurrently comparing several treatments or technologies through the synthesis of both direct and indirect evidence[ 14 , 15 ]. Accordingly, this study intends to synthesize existing evidence by conducting a NMA that compares several NET insertion techniques in ICU environments. Key outcomes will include placement success, insertion time, insertion-related complications incidence rate and direct healthcare costs. By systematically ranking and analyzing these treatments, we aim to provide medical staffs with evidence-based guidelines for selecting the most effective placement technique. 2. Methods This NMA was carried out in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines for systematic reviews [ 16 , 17 ]. The protocol for the study has been submitted to the PROSPERO for registration. ( CRD420251239614 ). 2.1 PICOS criteria P articipants were ICU patients who required NET placement for enteral nutrition. I ntervention encompassed the use of specific NET insertion techniques, including fluoroscopic guidance, electromagnetic guidance, ultrasound guidance, and endoscopic assistance. C ontrol was another NET insertion technique or the traditional blind insertion method. O utcome measures were classified into primary and secondary outcomes. Primary outcome is the placement success. Secondary outcomes included insertion time, insertion-related complications incidence rate and direct healthcare costs. S tudy type was RCT published domestically and internationally, disregarding allocation concealment or blinding status. All studies possessed complete clinical information, and there were no language limitations. 2.2 Data sources and searches We conducted a search on Pubmed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Wanfang database, and Chinese Scientific Journal Database (VIP database) to identify appropriate articles for eligible studies published until October 20, 2025. The search included keywords such as "nasointestinal tube" "Intensive Care Units" and "insertion". Search terms used a combination of medical subject headings (MeSH) and free-text terms. Key MeSH terms were as follows: ‘Intensive Care Units’, ‘Intubation, Gastrointestinal’. The search terms and search algorithm for PubMed are available in the supplement ( Supplementary Part A ). 2.3 Inclusion and exclusion criteria We identified relevant studies with complete texts based on the specified PICOS selection criteria. 2.3.1 Population We recruited patients who required short-term enteral treatment as assessed by the attending ICU physicians. And we excluded patients with preexisting nasopharyngeal anomalies that precluded nasal intubation, those with ileus or mechanical bowel blockage, and instances where informed consent could not be obtained from the patient or their authorized legal representative. 2.3.2 Interventions and comparisons In this NMA, interventions were categorized into five distinct nodes based on the primary guidance modality used during insertion. To ensure conceptual homogeneity and verify the transitivity assumption of the network, we focused strictly on device-dependent methods. Consequently, studies investigating solely pharmacological interventions (e.g., prokinetics such as erythromycin or metoclopramide) or manual facilitation maneuvers (e.g., air insufflation, corkscrew technique) in the absence of specific guidance devices were excluded. The final categorization comprised the following nodes: (1) Blind placement, (2) Fluoroscopic guidance, (3) Electromagnetic guidance, (4) Ultrasound guidance, and (5) Endoscopic guidance. 2.3.3 Outcomes The primary outcomes were the success rate of the procedure, defined as the proportion of successful tube placements in the intended location as determined. The secondary outcomes encompassed included insertion time, insertion-related complications incidence rate and direct healthcare costs. 2.3.4 Research design Only RCTs were selected for inclusion. Review, protocols, editorials, meta-analysis, conference abstracts, other secondary sources, letters to the editor, and animal experiment research were excluded. 2.4 Data selection and extraction 2.4.1 Selection of studies All studies were imported into Noteexpress 4.0 software for removal of duplication. Two researchers (LPY and PJ) independently evaluated all titles and abstracts obtained from the searches and examined the full texts of the remaining articles for eligibility. Discrepancies between the two researchers will be addressed through consultation and arbitration by other members of the review team (WS and HMY). 2.4.2 Data extraction and management Using a pre-prepared data structure extraction sheet, the same two researchers (LPY and PJ) independently read and extracted the data from each trial. The extracted data encompassed study characteristics, baseline participant characteristics, placement method types, and outcomes. The two researchers addressed any discrepancies in data extraction through the participation of a third researcher (WS). 2.5 Risk of bias assessment and quality of evidence Two separate researchers (LPY and PJ) evaluated the included studies' methodological quality using the Cochrane risk-of-bias tool for randomized crossover trials at the study level (RoB2) [ 18 ]. The tool evaluates the presence of selection bias by examining six aspects: selection bias resulting from the randomization process, performance bias resulting from variations from planned interventions, detection bias resulting from missing outcome data, attrition bias resulting from the measuring of the outcome; and overall biases. Following the guidelines laid out in the Cochrane Handbook, the potential for bias was rated as either low, high, or as yet unknown. 2.6 Statistical analysis All data were double-entered into the database to ensure accuracy. Effectiveness comparisons were analyzed using Bayesian contrast-based multilevel NMA models [ 19 ] and Markov Chain Monte Carlo (MCMC) simulation, which calculated stable distribution probabilities and the area under the posterior distribution curve [ 19 , 20 ]. The NMA was carried out in R utilizing the 'BUGSnet' package. To establish more conservative confidence intervals for pooled point estimates, we initially employed the random-effects model to address the variability in clinical presentation and methods among studies. Subsequently, we compared the deviance information criteria (DIC) values to assess the appropriateness of the consistency versus inconsistency model[ 21 ]. To validate the reasonableness of the transitivity assumption, we ran a consistency test by graphically comparing results from the consistency model and the inconsistency model ( Supplementary Part B ). Additionally, we utilized the Potential Scale Reduction Factor (PSRF) and trace plots in evaluating the model's convergence[ 22 ]. The combined results for binary outcomes were odds ratios (ORs) with 95% credible intervals (CIs). To facilitate pooled analyses, medians with ranges or interquartile ranges (IQR) were changed to mean ± standard deviation (SD). ORs for categorical outcomes and mean differences (MDs) for continuous variables with 95% CIs were used to examine effect sizes. Statistical significance was evaluated by 95% CIs without the null line. This study provided network geometry diagrams to show the direct comparative relationships for each goal outcome. Various visual representations of the results were created, including forest plots, league table heatmaps, cumulative ranking (SUCRA) values, and rank probability plots. 3. Results 3.1 Literature Search Results An aggregate of 4,915 records was found through a search of databases. After the removal of 1,657 duplicates, the remaining 3,258 records underwent title and abstract screening. We subsequently retrieved 132 full-text research articles for detailed eligibility assessment. Finally, 19 RCTs (comprising 1,554 patients) involving five NET placement techniques were included. The process of study selection is depicted in Fig. 1 . 3.2 Included study characteristics A total of 19 RCTs published between 2000 and 2024, involving 1554 participants, were included in this NMA. The sample size ranged from 17 to 82. No significant differences in demographic factors were observed at the baseline (P > 0.05). All studies were two-arm studies. The geometry of the entire network included the following arms: Blind (11 studies), Fluoroscopic (4 studies), Electromagnetic (8 studies), Ultrasound (5 studies), Endoscopic (10 studies). Comprehensive details of the listed studies are included in Table 1 . Table 1 Characteristics of included studies. Study Study population Sample size Types of placement method Age(years) Outcomes Li. 2024 [ 23 ] traumatic brain injury patients I:48 C:48 I: Endoscopic C: Ultrasound I:66.25 ± 7.80 C:67.56 ± 8.43 ①② Ma.2024 [ 24 ] neurocritical care patients I:43 C:42 I: Electromagnetic C: Ultrasound I:51.81 ± 13.56 C:57.17 ± 12.23 ①②③ Zhang.2023 [ 25 ] critically ill patients I:54 C:54 I: Endoscopic C: Blind I:65.35 ± 17.33 C:64.94 ± 18.80 ①②③ Shang. 2017 [ 26 ] traumatic brain injury patients I:33 C:32 I: Ultrasound C: Blind I:37.4 ± 15.5 C:36.2 ± 14.6 ①③ Shen. 2012 [ 27 ] critically ill patients I:22 C:21 I: Fluoroscopic C: Endoscopic I:50.1 ± 10.3 C:49.1 ± 12.2 ①③ Wang. 2024 [ 28 ] neurocritical care patients I:34 C:34 I: Endoscopic C: Blind I:54.62 ± 17.65 C:54.59 ± 17.33 ①②③④ Cao. 2024 [ 29 ] critically ill patients I:35 C:35 I: Ultrasound C: Blind I:63. 3 ± 8. 1 C:63. 3 ± 8. 1 ①③ Wei. 2024 [ 30 ] critically ill patients I:40 C:40 I: Electromagnetic C: Blind I:57.50 ± 13.59 C:60.83 ± 13.43 ①②③ Hou.2024 [ 31 ] critically ill neurosurgical patients I:30 C:30 I: Electromagnetic C: Blind I:50.07 ± 15.61 C:53.53 ± 11.76 ①②③ Gao.2018 [ 32 ] critically Ill patients I:81 C:80 I: Electromagnetic C: Endoscopic I:51.5 ± 18.3 C:52.3 ± 18.2 ①②③④ Wang. 2024 [ 11 ] critically Ill patients I:50 C:50 I: Ultrasound C: Blind I:67.78 ± 15.50 C:65.32 ± 16.50 ①② Holzinger. 2011[ 33 ] critically ill patients I:44 C:22 I: Electromagnetic C: Endoscopic I:55 ± 18 C:55 ± 15 ①②③ Jha.2020 [ 34 ] critically ill children I:28 C:24 I: Electromagnetic C: Blind I:1.45 ± 3.35 C:9.55 ± 3.76 ①②③ Foote.2004 [ 35 ] critically ill patients I:26 C:17 I: Endoscopic C: Fluoroscopic I:59.0 ± 4.1 C:58.1 ± 5.6 ①②③ Chen.2022 [ 36 ] critically ill patients I:61 C:61 I: Endoscopic C: Blind I:66.98 ± 15.73 C:66.18 ± 13.06 ①②③④ Kline.2011 [ 37 ] critically ill children I:22 C:26 I: Electromagnetic C: Blind I:2.1 ± 4.2 C:1.9 ± 3.0 ① Fang.2005 [ 38 ] critically ill patients I:50 C:50 I: Endoscopic C: Fluoroscopic I:52 ± 20.75 C:55 ± 19.25 ①② Huerta.2000[ 39 ] critically ill patients I:17 C:15 I: Fluoroscopic C: Blind I:45 ± 6 C:56 ± 5 ①③④ Kappelle. 2018[ 40 ] critically ill patients I:82 C:73 I: Electromagnetic C: Endoscopic I:57.9 ± 16.8 C:56.6 ± 14.3 ①②③④ Note: ①the placement success;②insertion time;③insertion-related complications incidence rate;④direct healthcare costs. 3.3 Risk of bias The NMA's RCTs demonstrated a reasonable and relatively low risk of bias. Virtually all of the studies included adhered to the principle of randomization. With the 19 papers analyzed, 12 trials (63.2%) exhibited a high risk of bias, 5 trials (26.3%) shown a medium risk, and 3 trials (10.5%) presented a low risk of bias (Fig. 2 ). 3.4Analyses of outcomes The comprehensive NMA graphs representing different NET placement methods are presented in Fig. 3 , based on how the NET insertion techniques affected the placement success, insertion time, insertion-related complications incidence rate and direct healthcare costs. In these graphs, each node represents each insertion technique. Enlarging the nodes indicates more participants included in every study, and a thicker line connecting two nodes means a greater number of articles. 3.4.1 Primary outcome: placement success rate The network graph illustrates all available comparisons of placement success rate from the included trials (Fig. 3 ). The NMA model analyzed 5 placement methods: Blind, Fluoroscopic, Electromagnetic, Ultrasound, Endoscopic. All 4 types of techniques showed positive effects in increasing placement success rate compared to Blind, with ORs ranging from 14.84 (95% CI = 4.27 to 39.75) for Fluoroscopic to 5.91 (95% CI = 2.68 to 11.54) for Ultrasound. However, there was no significant difference among the other 4 insertion techniques in placement success rate. The comparative effectiveness of various NET placement techniques regarding placement success rate is presented via SUCRA plot and league heat table ( Fig. 40 ). The SUCRA research revealed that Fluoroscopic had the highest likelihood of efficacy (85.90%), followed by Endoscopic (73.01%), Electromagnetic (54.21%), Ultrasound (36.86%) and Blind (0%). 3.4.2 Procedure time The network graph illustrating insertion procedure time displayed all available comparisons from the included trials (Fig. 3 ). In terms of procedure time 14 studies reported outcomes involving 5 different methods. Overall, the results indicated that only Electromagnetic and Endoscopic placement methods effectively reduced the procedure time compare with Blind. Specifically, Electromagnetic placement (MD = -19.86, 95%CI = -30.55 to -9.14), Endoscopic placement (MD = -19.70, 95%CI = -30.37 to -9.06). Meanwhile, Fluoroscopic and Ultrasound demonstrated a negligible effect. The comparative effectiveness of various techniques in reducing procedure time was illustrated using an SUCRA plot and league heat table (Fig. 5 ). The SUCRA analysis indicated that Electromagnetic had the highest likelihood of being the most effective placement technique (79.51%), followed by Endoscopic (79.15%), Fluoroscopic (63.84%), Blind (19.00%), and Ultrasound (8.51%). 3.4.3 Complication incidence rate The network graph depicting complication incidence rate displayed comparisons from the included trials (Fig. 3 ). 14 studies examined the impact of different type of NET placement techniques on Complications, 5 placement methods (Blind, Fluoroscopic, Electromagnetic, Ultrasound, Endoscopic). The league table heatmap (Fig. 6 ) displays a detailed matrix of pairwise comparisons derived from NMA. Our research demonstrated statistically significant differences (P < 0.05) between Fluoroscopic and other approaches in mitigating complication incidence rates, with odds ratios ranging from 4.46 (95% CI = 0.61 to 16.20) for Electromagnetic to 20.93 (95% CI = 3.05 to 73.82) for Blind. A league heat table and SUCRA plot were used to compare the effectiveness of various insertion techniques in reducing the incidence of complications (). According to the SUCRA analysis, the most safety insertion type was Fluoroscopic (97.28%), followed by Electromagnetic (73.69%), Endoscopic (43.03%), Ultrasound (33.49%), and Blind (2.51%). 3.4.4 Direct healthcare costs Five studies evaluating direct healthcare costs included four insertion methods: Blind, Fluoroscopic, Electromagnetic, Endoscopic. The network configuration is depicted in Fig. 3 . The league table heatmap (Fig. 7 ) reveals no statistically significant differences between any type of NET placement techniques regarding direct healthcare costs. The efficacy hierarchy established through SUCRA analysis identified Fluoroscopic as the most probable optimal methods (76.92%), followed by followed by followed by Electromagnetic (66.07%), Blind (52.05%), Endoscopic (4.99%). 4. Discussion This NMA thoroughly analyzed the efficacy of several different NET placement techniques for ICU patients, using the special features of NMA to conduct both direct and indirect comparisons among various insertion methods. Utilizing the four established results of interest (placement success rate, procedure time, complication incidence rate, and direct healthcare costs), we developed separate network frameworks and performed Bayesian NMA, subsequently ranking the efficacy of all included methods based on the results of the analysis. 4.1 Principal finding This systematic review and NMA examined 19 RCTs encompassing 1,554 ICU patients. The analysis indicates that all insertion methods are superior to Blind placement in terms of success rates. Fluoroscopic guidance emerged as the optimal modality for maximizing placement success and minimizing complications. Compared to the Blind method, the Electromagnetic and Endoscopic procedures greatly shortened the procedural duration. Moreover, the SUCRA ranking suggests that Fluoroscopic guidance may be a better value, but there was no statistically significant difference in direct healthcare costs. These results point to a substantial shift in clinical practice toward instrument-assisted techniques. 4.2 Comparison with existing literature Previous conventional meta-analyses have underscored the advantages of instrument-assisted insertion techniques for patients, aligning with our results [ 3 , 9 , 10 , 13 , 41 ]. Nevertheless, these studies were confined to direct pairwise comparisons, lacking the establishment of a comprehensive hierarchy among all available modalities. This study builds on previous findings by using an NMA approach, which combines direct and indirect evidence to rank safety and efficacy. For the past few decades, Fluoroscopic technology has been the "gold standard" and "final arbiter" for testing the accuracy of new placement technologies like Ultrasound and Electromagnetic[ 40 , 42 ]. This NMA confirms that Fluoroscopic placement is the most preferred method because it has the highest rates of both placement success (SUCRA 85.90%) and complication prevention (SUCRA 97.28%). Fluoroscopy is better because it can show the whole insertion pathway in real time and with movement, which makes it easier to find your way through the pylorus and the ligament of Treitz[ 3 , 9 ]. Additionally, safety is the most important thing to think about when placing a NET. Our results indicate that Fluoroscopic technology serves as the paramount barrier against iatrogenic complications. Fluoroscopy, on the other hand, lets you see the guidewire's path before you move it forward. This lets you find and fix any mistakes in real time. Fluoroscopy necessitates merely a hydrophilic guidewire, in contrast to the endoscopic technique, which requires a cumbersome instrument, resulting in a markedly reduced occurrence of dyspnea and abdominal discomfort[ 3 ]. Nonetheless, the studies included did not consider the safety of radiation exposure. The most important ethical and safety issue with using X-rays is the risk of radiation exposure [ 43 ]. For ICU patients requiring long-term enteral nutrition and potentially facing multiple tube replacements or positional adjustments, the cumulative radiation dose constitutes a medical concern that necessitates attention. Fluoroscopic is the best at effectiveness, but Electromagnetic and Endoscopic techniques represent a critical advancement in procedural efficiency (SUCRA 79.51% and 79.15%, respectively). Electromagnetic navigation uses weak electromagnetic sensing technology to measure the head position of the built-in magnetic guidewire catheter in real time, and plots its movement path into a trajectory line, which is presented in two and three dimensional forms on the screen[ 44 ]. Electromagnetic guidance reduces the duration by getting rid of the logistical delays that come with moving patients to the radiology suite. This makes it a great bedside option for ICU patients who are not stable. The field of endoscopic technology is also always changing, and recent improvements have made NET placement much more efficient. Research demonstrates that ultrathin transnasal endoscopy considerably reduces procedure duration compared to conventional endoscopy, thus enabling successful bedside insertion for critically ill patients[ 36 ]. In addition to placement, this technology enables simultaneous diagnostic upper gastrointestinal endoscopy to detect suspicious lesions, a diagnostic capability exclusive to the endoscopic method[ 45 ]. Nevertheless, our results show poor performance of Ultrasound-guided placement, particularly regarding procedure time, where it ranked even lower than the Blind technique. In recent years, critical care ultrasound technology has attracted clinical attention. It has the benefits of being easy to use, efficient, and radiation-free, and it can be done at the bedside[ 13 , 46 , 47 ]. However, it is hampered by significant physical limitations. Ultrasonography is more effective at penetrating solid structures, like organs, or liquids, but it has limitations when it comes to interacting with gas, which is often found in the digestive tract[ 48 ]. The visualization of the pylorus and duodenum is frequently obscured by bowel gas artifacts and depth attenuation, particularly in obese patients[ 49 ]. Additionally, Ultrasound requires the identification of a specific acoustic window, which can be time-consuming and technically challenging. Those suggest that Ultrasound is a promising non-invasive method, which makes it less effective than other methods. In terms of economic outcomes, Fluoroscopic placement emerged as the most cost-effective method. Although Fluoroscopy incurs initial radiology fees, its high one-time likely reduces the total cost of care by minimizing repeated insertion attempts and treating of expensive complications. Conversely, Endoscopic placement was the least cost-effective method, probably because endoscopic equipment, sterilization, and specialized staff are all extremely costly[ 40 , 50 ]. However, most of studies concentrated on the procedure costs associated with short-term hospital stays, overlooking long-term comparisons, including readmission due to catheter dysfunction or costs related to malnutrition[ 51 ]. Furthermore, only five studies in our meta-analysis reported data on direct healthcare costs, these economic findings must be interpreted with caution. Consequently, the existing evidence is inadequate to ascertain a conclusive determination regarding the economic superiority of any singular method. Additional high-quality studies concentrating on cost-utility analysis are critically required to corroborate these findings. 4.3 Strengths and Limitations To our knowledge, it is the first NMA to comprehensively rank these five NET placement techniques, moving beyond simple pairwise comparisons to provide a global hierarchy of efficacy and safety. Only RCT were included in our NMA, ensuring rigorous design and thus providing eligible quality evidence. However, there are a number of limitations that need to be recognized. First, the sample sizes in some of the studies that were included were relatively small. These small-sample trials may not have enough statistical power, which could affect the accuracy of our network estimates. Second, only five studies had information about direct healthcare costs. This lack of economic data makes our cost-effectiveness conclusions less reliable and less applicable to other situations. 5. Conclusions This NMA provides comprehensive evidence on the effectiveness of various NET insertion techniques for ICU patients, highlighting that all instrument-assisted placement types are significantly better to Blind control. Fluoroscopic guidance offers the highest success and safety. Additionally, Electromagnetic have shown the best efficacy in shortening procedure time. Clinicians should prioritize instrumental guidance to enhance patient safety and operational efficiency, tailoring the choice of method to available resources and specific patient needs. Declarations Ethics approval and consent to participate Not applicable. Clinical trial number Not applicable Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details 1 Intensive Care Unit, Respiratory and Critical Care Medicine Department, Changsha Central Hospital, No. 161, Shaoshan South Road, Changesha, Hunan 410000, China. Funding Project supported by the Natural Science Foundation of Hunan, China (2708) and Key Scientific Research Project of Changsha Central Hospital, China (YNKT202515). Author Contribution LPY, Q L designed research; LPY, PJ, HMY, WLQ, LX, LX, WS conducted research; LPY, PJ, HMY, WS analyzed data; LPY wrote the first draft of manuscript; LPY, WS had primary responsibility for final content. Every author read and reached consensus on the final version of the manuscript. Every author made a contribution to the study's conception or design, as well as to the data collection, analysis, and interpretation. The work was either drafted or critically revised by all authors, and the final version that was submitted for publication received their final approval. Each author pledges to take responsibility for every facet of the work, guaranteed accuracy and integrity. Acknowledgements Not applicable Data Availability All pertinent data have been included in the manuscript. 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Bedside electromagnetic-guided placement of nasoenteral feeding tubes among critically Ill patients: A single-centre randomized controlled trial. J Crit Care. 2018;48:216–21. Holzinger U, Brunner R, Miehsler W, Herkner H, Kitzberger R, Fuhrmann V, Metnitz PG, Kamolz LP, Madl C. Jejunal tube placement in critically ill patients: A prospective, randomized trial comparing the endoscopic technique with the electromagnetically visualized method. Crit Care Med. 2011;39(1):73–7. Jha P, Rupp L, Bonilla L, Gelfond J, Shah JN, Meyer AD. Electromagnetic Versus Blind Guidance of a Postpyloric Feeding Tube in Critically Ill Children. Pediatrics. 2020;146(4):e20193773. Foote JA, Kemmeter PR, Prichard PA, Baker RS, Paauw JD, Gawel JC, Davis AT. A randomized trial of endoscopic and fluoroscopic placement of postpyloric feeding tubes in critically ill patients. JPEN J Parenter Enter Nutr. 2004;28(3):154–7. Chen Y, Tian X, Liu C, Zhang L, Xv Y, Xv S. Application of visual placement of a nasojejunal indwelling feeding tube in intensive care unit patients receiving mechanical ventilation. Front Med (Lausanne). 2022;9:1022815. Kline AM, Sorce L, Sullivan C, Weishaar J, Steinhorn DM. Use of a noninvasive electromagnetic device to place transpyloric feeding tubes in critically ill children. Am J Crit Care. 2011;20(6):453–9. quiz 460. Fang JC, Hilden K, Holubkov R, DiSario JA. Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients. Gastrointest Endosc. 2005;62(5):661–6. Huerta G, Puri VK. Nasoenteric feeding tubes in critically ill patients (fluoroscopy versus blind). Nutrition. 2000;16(4):264–7. Kappelle WFW, Walter D, Stadhouders PH, Jebbink HJA, Vleggaar FP, van der Schaar PJ, Kappelle JW, van der Tweel I, Van den Broek MFM, Wessels FJ, Siersema PD, Monkelbaan JF. Electromagnetic-guided placement of nasoduodenal feeding tubes versus endoscopic placement: a randomized, multicenter trial. Gastrointest Endosc. 2018;87(1):110–8. Mancini FC, de Moura DTH, Funari MP, Ribeiro IB, Neto FLP, Mendieta PJO, McCarty TR, Bernardo WM, Nahas SC, de Moura EGH. Use of an electromagnetic-guided device to assist with post-pyloric placement of a nasoenteral feeding tube: A systematic review and meta-analysis. Endosc Int Open. 2022;10(8):E1118–26. Re R, Lassola S, De Rosa S. Placement and Verification of the Nasogastric Tube: An In-depth Analysis of Ultrasonographic Technique. Dimens Crit Care Nurs. 2025;44(5):239–45. Hiles P, Gilligan P, Damilakis J, Briers E, Candela-Juan C, Faj D, Foley S, Frija G, Granata C, de Gala LH, Pauwels H, Sans Merce R, Simantirakis M, Vano G. European consensus on patient contact shielding. Insights Imaging. 2021;12(1):194. Powers J, Luebbehusen M, Aguirre L, Cluff J, David MA, Holly V, Linford L, Park N, Brunelle R. Improved Safety and Efficacy of Small-Bore Feeding Tube Confirmation Using an Electromagnetic Placement Device. Nutr Clin Pract. 2018;33(2):268–73. Long C, Yu Y, Cui B, Jagessar SAR, Zhang J, Ji G, Huang G, Zhang F. A novel quick transendoscopic enteral tubing in mid-gut: technique and training with video. BMC Gastroenterol. 2018;18(1):37. Liu Z, Guo J, Ren W, Tang S, Huang Y, Huang L, Sun S, Lin L. Evaluation of ultrasound-guided Freka-Trelumina enteral nutrition tube placement in the treatment of acute pancreatitis. BMC Gastroenterol. 2020;20(1):21. Wu N, Shen H. Safety and effectiveness of dual guidance with video-laryngoscopy and ultrasound in jejunal tube placement in patients undergoing invasive mechanical ventilation. Ann Palliat Med. 2021;10(3):3128–34. Ferraboli SF, Beghetto MG. Bedside ultrasonography for the confirmation of nasogastric tube placement: agreement between nurse and physician. Rev Gaucha Enferm. 2022;43(spe):e20220211. Li G, Pan Y, Zhou J, Tong Z, Ke L, Li W. Enteral nutrition tube placement assisted by ultrasonography in patients with severe acute pancreatitis: A novel method for quality improvement. Med (Baltim). 2017;96(45):e8482. Galaski A, Peng WW, Ellis M, Darling P, Common A, Tucker E. Gastrostomy tube placement by radiological versus endoscopic methods in an acute care setting: a retrospective review of frequency, indications, complications and outcomes. Can J Gastroenterol. 2009;23(2):109–14. Ribeiro FA, Sodré da Costa LS, Pedroso AC, de Paula Nogueira PB, Brandi S, Toledo DO, Laselva CR, Malheiro DT, Silva JM Jr. Evaluating multifaceted strategies to prevent nasoenteral tube complications and achieve significant cost savings in critically ill patients: the ENHANCE-CRIT trial. BMJ Open Qual. 2025;14(1):e003177. Additional Declarations No competing interests reported. Supplementary Files Supplementary.docx Cite Share Download PDF Status: Published Journal Publication published 14 Apr, 2026 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Revision requested 12 Feb, 2026 Reviews received at journal 12 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers agreed at journal 07 Feb, 2026 Reviewers agreed at journal 04 Feb, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers invited by journal 21 Jan, 2026 Editor invited by journal 20 Jan, 2026 Editor assigned by journal 19 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 17 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8626067","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578831616,"identity":"72b5b348-2c61-4716-bb5c-5af19e995b64","order_by":0,"name":"Peiyi Li","email":"","orcid":"","institution":"Changsha Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peiyi","middleName":"","lastName":"Li","suffix":""},{"id":578831617,"identity":"ce674527-4480-4d0d-a8f5-3e18e8e2ab16","order_by":1,"name":"Jia Peng","email":"","orcid":"","institution":"Changsha Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jia","middleName":"","lastName":"Peng","suffix":""},{"id":578831618,"identity":"6939f32d-aed6-415e-affa-7179188ccc65","order_by":2,"name":"Mengyu He","email":"","orcid":"","institution":"Changsha Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mengyu","middleName":"","lastName":"He","suffix":""},{"id":578831619,"identity":"048496da-f355-475d-b31e-497bdc75af9c","order_by":3,"name":"Liqin Wang","email":"","orcid":"","institution":"Changsha Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Liqin","middleName":"","lastName":"Wang","suffix":""},{"id":578831620,"identity":"1d1c30e5-e904-4889-9650-695d3475da2a","order_by":4,"name":"Xu Lu","email":"","orcid":"","institution":"Changsha Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Lu","suffix":""},{"id":578831621,"identity":"6be27123-4d78-4e35-8809-0571ed1bf945","order_by":5,"name":"Xi Liu","email":"","orcid":"","institution":"Changsha Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xi","middleName":"","lastName":"Liu","suffix":""},{"id":578831622,"identity":"eac10958-648a-4af8-bcb8-0f546c10ba10","order_by":6,"name":"Shuang Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBACfmbmww8+VNjI8bM3EKlFsp0tzXDGmTRjyZ4DRGoxOM9jIM3bdjhxw40EYm1p5jEw4DmTlthw8/HGGww1NtEEtfAzsxU8kKiwMW6cnVZswXAsLbeBsC3MGwwMzqTJNkvnmEkwNhwmrMXgMIOBRGLbYcY2yTNEa2ExkDjYdlixR4KHSC2SzcBAbgAGsgQP0C8JxPiFn//w4cd/gFFpf/zwxhsfamwIa0FxpEQCKcohWkjVMQpGwSgYBSMDAAAWNkG5hH8ZZgAAAABJRU5ErkJggg==","orcid":"","institution":"Changsha Central Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shuang","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2026-01-17 12:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8626067/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8626067/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12871-026-03828-6","type":"published","date":"2026-04-14T15:57:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101207928,"identity":"db2b4001-af4e-4246-b7e6-8d0993292f93","added_by":"auto","created_at":"2026-01-27 10:07:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":172192,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of systematic review\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8626067/v1/bb5667d12ff299ad9b4f3957.png"},{"id":101207985,"identity":"9925f4b0-c724-4b85-8847-27592ff71e27","added_by":"auto","created_at":"2026-01-27 10:08:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":131195,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of the methodological quality of included studies\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8626067/v1/3fd7593671865235e93ac498.png"},{"id":101207896,"identity":"bca73676-f9f7-41d7-9c9b-cacf4cf0eb06","added_by":"auto","created_at":"2026-01-27 10:07:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":116727,"visible":true,"origin":"","legend":"\u003cp\u003eA NMA graph for placement success rate. B NMA graph for procedure time. C NMA graph for complication incidence rate. D NMA graph for direct healthcare costs.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8626067/v1/e41ab5fd0dcf49cf8d53c337.png"},{"id":101207937,"identity":"7c817c78-8762-4528-84d2-ff49f9849912","added_by":"auto","created_at":"2026-01-27 10:07:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":127810,"visible":true,"origin":"","legend":"\u003cp\u003eA League heat table for placement success rate network. B SUCRA values for placement success rate network. The symbol ** in the figure indicates significant differences between the placement methods (P \u0026lt; 0.05).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8626067/v1/c7aff1a20f49f0febdd1ad6b.png"},{"id":101208990,"identity":"1fbda000-0032-44f3-94ef-6896c570b611","added_by":"auto","created_at":"2026-01-27 10:12:31","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":133777,"visible":true,"origin":"","legend":"\u003cp\u003eA League heat table for procedure time network. B SUCRA values for procedure time network. The symbol ** in the figure indicates significant differences between the methods (P \u0026lt; 0.05).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8626067/v1/934ccd29a28a58b2726453b7.png"},{"id":101207895,"identity":"9c2bad5e-03ac-4482-8316-f835b8bec6d6","added_by":"auto","created_at":"2026-01-27 10:07:44","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":121925,"visible":true,"origin":"","legend":"\u003cp\u003eA League heat table for complication incidence rate network. B SUCRA values for complication incidence rate network. The symbol ** in the figure indicates significant differences between the insertion techniques (P \u0026lt; 0.05).\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8626067/v1/0f14043fa21e465d159d4840.png"},{"id":101208949,"identity":"01598956-3d7c-499f-9377-5cac78063c6e","added_by":"auto","created_at":"2026-01-27 10:12:17","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":102099,"visible":true,"origin":"","legend":"\u003cp\u003eA League heat table for Direct healthcare costs network. B SUCRA values for Direct healthcare costs network. The symbol ** in the figure indicates significant differences between the insertion techniques (P \u0026lt; 0.05).\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-8626067/v1/3a245e99fd0d2d98c6002f62.png"},{"id":107350701,"identity":"fd8ee80d-13e9-46e7-b9bf-0643b1d61055","added_by":"auto","created_at":"2026-04-20 16:00:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1294301,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8626067/v1/517abb4f-acdc-4220-9141-6f01860dc86b.pdf"},{"id":101210140,"identity":"622ea942-e5a4-49b2-96d1-f9e95e625153","added_by":"auto","created_at":"2026-01-27 10:20:04","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":1904255,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary.docx","url":"https://assets-eu.researchsquare.com/files/rs-8626067/v1/382c1486f3d2b03b154f908b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of the effects of different types of nasointestinal tube placement techniques for ICU patients: A Bayesian network meta-analysis","fulltext":[{"header":"1. Background","content":"\u003cp\u003eCritically ill patients in the Intensive Care Unit (ICU) require nutritional support to maintain metabolic stability and improve clinical outcomes[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Enteral nutrition (EN) is the preferred method because to its proven advantages in minimizing infection complications and its greater cost-effectiveness relative to parenteral nutrition[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].However, many ICU patients cannot tolerate oral feeding and require via nasoenteric tube (NET) for nutrition due to poor gastrointestinal motility, swallowing difficulty, or significant aspiration risk [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. NET is better than a nasogastric tube (NGT) because it lowers the risk of aspiration by preventing gastric reflux and avoids problems caused by delayed stomach emptying. This is especially important for patients who need long-term mechanical ventilation[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Consequently, extremely crucial to put NET in an appropriate place to make sure that ICU patients get enough nutrition, minimize the risk of complications, and contribute to their get recuperating. However, placement NET in ICU is challenging due to patient-related difficulties like decreased awareness and mechanical breathing, as well as procedural hurdles such accidental misplacement into the respiratory system[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt present, various techniques are presently employed for the placement of NETs in the ICU, including blind insertion, fluoroscopic guidance, electromagnetic guidance, ultrasound guidance, and endoscopic assistance. Nevertheless, the existing approaches exhibit inconsistent efficacy, as each approach has distinct benefits and limitations. Blind insertion is widely used due to its simplicity and cost-effectiveness, but it has a high failure rate and risk of pulmonary misplacement[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Fluoroscopic-guided NET placement, once the gold standard for complex cases, is limited by the inherent risk of ionizing radiation exposure to patients and staff[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. To overcome the limitations of traditional methods, several new bedside-compatible technologies have emerged in recent years. Such as Electromagnetic-guided systems provide real-time catheter visualization, which ensures high placement accuracy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Meanwhile, it has been reported that ultrasound-guided technology has been applied to patients in ICU, and the success rate of catheterization is about 80%[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The endoscopic-assisted technique boasts a high success rate due to the utilization of a slender, flexible tube equipped with a camera, allowing for direct visualization during tube placement[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite their high reliability, these technologies are underutilized because to their substantial resource requirements, the necessity for specialized equipment and trained personnel, and their limited availability in various ICUs.\u003c/p\u003e \u003cp\u003eThe current evidence regarding NET placement is constrained by a predominance of single-center, small-sample randomized controlled trials (RCTs). Most of these studies compare individual novel techniques against conventional methods, thereby lacking robust direct comparisons across multiple techniques. Although some traditional pairwise meta-analyses have been conducted, they are limited to direct comparisons between only two technologies and often rely on a small number of head-to-head trials[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As a result, the current evidence is inconclusive concerning the optimal and clinically acceptable method for NET placement in ICU patients. Therefore, a systematic and comprehensive evaluation is urgently needed to integrate direct and indirect evidence, establish consensus recommendations, and support evidence-based decision-making in NET placement practice.\u003c/p\u003e \u003cp\u003eNetwork meta-analysis (NMA) expands traditional pairwise meta-analysis by concurrently comparing several treatments or technologies through the synthesis of both direct and indirect evidence[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Accordingly, this study intends to synthesize existing evidence by conducting a NMA that compares several NET insertion techniques in ICU environments. Key outcomes will include placement success, insertion time, insertion-related complications incidence rate and direct healthcare costs. By systematically ranking and analyzing these treatments, we aim to provide medical staffs with evidence-based guidelines for selecting the most effective placement technique.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis NMA was carried out in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines for systematic reviews [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The protocol for the study has been submitted to the PROSPERO for registration. (\u003cb\u003eCRD420251239614\u003c/b\u003e).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 PICOS criteria\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eP\u003c/b\u003earticipants were ICU patients who required NET placement for enteral nutrition.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eI\u003c/b\u003entervention encompassed the use of specific NET insertion techniques, including fluoroscopic guidance, electromagnetic guidance, ultrasound guidance, and endoscopic assistance.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eC\u003c/b\u003eontrol was another NET insertion technique or the traditional blind insertion method.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eO\u003c/b\u003eutcome measures were classified into primary and secondary outcomes. Primary outcome is the placement success. Secondary outcomes included insertion time, insertion-related complications incidence rate and direct healthcare costs.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eS\u003c/b\u003etudy type was RCT published domestically and internationally, disregarding allocation concealment or blinding status. All studies possessed complete clinical information, and there were no language limitations.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data sources and searches\u003c/h2\u003e \u003cp\u003eWe conducted a search on Pubmed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Wanfang database, and Chinese Scientific Journal Database (VIP database) to identify appropriate articles for eligible studies published until October 20, 2025. The search included keywords such as \"nasointestinal tube\" \"Intensive Care Units\" and \"insertion\". Search terms used a combination of medical subject headings (MeSH) and free-text terms. Key MeSH terms were as follows: \u0026lsquo;Intensive Care Units\u0026rsquo;, \u0026lsquo;Intubation, Gastrointestinal\u0026rsquo;. The search terms and search algorithm for PubMed are available in the supplement (\u003cb\u003eSupplementary Part A\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Inclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eWe identified relevant studies with complete texts based on the specified PICOS selection criteria.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Population\u003c/h2\u003e \u003cp\u003eWe recruited patients who required short-term enteral treatment as assessed by the attending ICU physicians. And we excluded patients with preexisting nasopharyngeal anomalies that precluded nasal intubation, those with ileus or mechanical bowel blockage, and instances where informed consent could not be obtained from the patient or their authorized legal representative.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Interventions and comparisons\u003c/h2\u003e \u003cp\u003eIn this NMA, interventions were categorized into five distinct nodes based on the primary guidance modality used during insertion. To ensure conceptual homogeneity and verify the transitivity assumption of the network, we focused strictly on device-dependent methods. Consequently, studies investigating solely pharmacological interventions (e.g., prokinetics such as erythromycin or metoclopramide) or manual facilitation maneuvers (e.g., air insufflation, corkscrew technique) in the absence of specific guidance devices were excluded. The final categorization comprised the following nodes: (1) Blind placement, (2) Fluoroscopic guidance, (3) Electromagnetic guidance, (4) Ultrasound guidance, and (5) Endoscopic guidance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.3 Outcomes\u003c/h2\u003e \u003cp\u003eThe primary outcomes were the success rate of the procedure, defined as the proportion of successful tube placements in the intended location as determined. The secondary outcomes encompassed included insertion time, insertion-related complications incidence rate and direct healthcare costs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.3.4 Research design\u003c/h2\u003e \u003cp\u003eOnly RCTs were selected for inclusion. Review, protocols, editorials, meta-analysis, conference abstracts, other secondary sources, letters to the editor, and animal experiment research were excluded.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data selection and extraction\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1 Selection of studies\u003c/h2\u003e \u003cp\u003eAll studies were imported into Noteexpress 4.0 software for removal of duplication. Two researchers (LPY and PJ) independently evaluated all titles and abstracts obtained from the searches and examined the full texts of the remaining articles for eligibility. Discrepancies between the two researchers will be addressed through consultation and arbitration by other members of the review team (WS and HMY).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2 Data extraction and management\u003c/h2\u003e \u003cp\u003eUsing a pre-prepared data structure extraction sheet, the same two researchers (LPY and PJ) independently read and extracted the data from each trial. The extracted data encompassed study characteristics, baseline participant characteristics, placement method types, and outcomes. The two researchers addressed any discrepancies in data extraction through the participation of a third researcher (WS).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Risk of bias assessment and quality of evidence\u003c/h2\u003e \u003cp\u003eTwo separate researchers (LPY and PJ) evaluated the included studies' methodological quality using the Cochrane risk-of-bias tool for randomized crossover trials at the study level (RoB2) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The tool evaluates the presence of selection bias by examining six aspects: selection bias resulting from the randomization process, performance bias resulting from variations from planned interventions, detection bias resulting from missing outcome data, attrition bias resulting from the measuring of the outcome; and overall biases. Following the guidelines laid out in the Cochrane Handbook, the potential for bias was rated as either low, high, or as yet unknown.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical analysis\u003c/h2\u003e \u003cp\u003eAll data were double-entered into the database to ensure accuracy. Effectiveness comparisons were analyzed using Bayesian contrast-based multilevel NMA models [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and Markov Chain Monte Carlo (MCMC) simulation, which calculated stable distribution probabilities and the area under the posterior distribution curve [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The NMA was carried out in R utilizing the 'BUGSnet' package.\u003c/p\u003e \u003cp\u003eTo establish more conservative confidence intervals for pooled point estimates, we initially employed the random-effects model to address the variability in clinical presentation and methods among studies. Subsequently, we compared the deviance information criteria (DIC) values to assess the appropriateness of the consistency versus inconsistency model[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. To validate the reasonableness of the transitivity assumption, we ran a consistency test by graphically comparing results from the consistency model and the inconsistency model (\u003cb\u003eSupplementary Part B\u003c/b\u003e). Additionally, we utilized the Potential Scale Reduction Factor (PSRF) and trace plots in evaluating the model's convergence[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe combined results for binary outcomes were odds ratios (ORs) with 95% credible intervals (CIs). To facilitate pooled analyses, medians with ranges or interquartile ranges (IQR) were changed to mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). ORs for categorical outcomes and mean differences (MDs) for continuous variables with 95% CIs were used to examine effect sizes. Statistical significance was evaluated by 95% CIs without the null line. This study provided network geometry diagrams to show the direct comparative relationships for each goal outcome. Various visual representations of the results were created, including forest plots, league table heatmaps, cumulative ranking (SUCRA) values, and rank probability plots.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Literature Search Results\u003c/h2\u003e \u003cp\u003eAn aggregate of 4,915 records was found through a search of databases. After the removal of 1,657 duplicates, the remaining 3,258 records underwent title and abstract screening. We subsequently retrieved 132 full-text research articles for detailed eligibility assessment. Finally, 19 RCTs (comprising 1,554 patients) involving five NET placement techniques were included. The process of study selection is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Included study characteristics\u003c/h2\u003e \u003cp\u003eA total of 19 RCTs published between 2000 and 2024, involving 1554 participants, were included in this NMA. The sample size ranged from 17 to 82. No significant differences in demographic factors were observed at the baseline (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). All studies were two-arm studies. The geometry of the entire network included the following arms: Blind (11 studies), Fluoroscopic (4 studies), Electromagnetic (8 studies), Ultrasound (5 studies), Endoscopic (10 studies). Comprehensive details of the listed studies are included in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of included studies.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTypes of placement method\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi. 2024\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003etraumatic brain injury patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:48\u003c/p\u003e \u003cp\u003eC:48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Endoscopic \u003c/p\u003e \u003cp\u003eC: Ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:66.25\u0026thinsp;\u0026plusmn;\u0026thinsp;7.80\u003c/p\u003e \u003cp\u003eC:67.56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMa.2024\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eneurocritical care patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:43\u003c/p\u003e \u003cp\u003eC:42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Electromagnetic\u003c/p\u003e \u003cp\u003eC: Ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:51.81\u0026thinsp;\u0026plusmn;\u0026thinsp;13.56\u003c/p\u003e \u003cp\u003eC:57.17\u0026thinsp;\u0026plusmn;\u0026thinsp;12.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZhang.2023\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:54\u003c/p\u003e \u003cp\u003eC:54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Endoscopic \u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:65.35\u0026thinsp;\u0026plusmn;\u0026thinsp;17.33\u003c/p\u003e \u003cp\u003eC:64.94\u0026thinsp;\u0026plusmn;\u0026thinsp;18.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShang. 2017\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003etraumatic brain injury patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:33\u003c/p\u003e \u003cp\u003eC:32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Ultrasound\u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5\u003c/p\u003e \u003cp\u003eC:36.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShen. 2012\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:22\u003c/p\u003e \u003cp\u003eC:21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Fluoroscopic\u003c/p\u003e \u003cp\u003eC: Endoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:50.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/p\u003e \u003cp\u003eC:49.1\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWang. 2024\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eneurocritical care patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:34\u003c/p\u003e \u003cp\u003eC:34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Endoscopic \u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:54.62\u0026thinsp;\u0026plusmn;\u0026thinsp;17.65\u003c/p\u003e \u003cp\u003eC:54.59\u0026thinsp;\u0026plusmn;\u0026thinsp;17.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③④\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCao. 2024\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:35\u003c/p\u003e \u003cp\u003eC:35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Ultrasound\u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:63. 3\u0026thinsp;\u0026plusmn;\u0026thinsp;8. 1\u003c/p\u003e \u003cp\u003eC:63. 3\u0026thinsp;\u0026plusmn;\u0026thinsp;8. 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWei. 2024\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:40\u003c/p\u003e \u003cp\u003eC:40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Electromagnetic \u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:57.50\u0026thinsp;\u0026plusmn;\u0026thinsp;13.59\u003c/p\u003e \u003cp\u003eC:60.83\u0026thinsp;\u0026plusmn;\u0026thinsp;13.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHou.2024\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill neurosurgical patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:30\u003c/p\u003e \u003cp\u003eC:30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Electromagnetic \u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:50.07\u0026thinsp;\u0026plusmn;\u0026thinsp;15.61\u003c/p\u003e \u003cp\u003eC:53.53\u0026thinsp;\u0026plusmn;\u0026thinsp;11.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGao.2018\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically Ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:81\u003c/p\u003e \u003cp\u003eC:80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Electromagnetic\u003c/p\u003e \u003cp\u003eC: Endoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:51.5\u0026thinsp;\u0026plusmn;\u0026thinsp;18.3\u003c/p\u003e \u003cp\u003eC:52.3\u0026thinsp;\u0026plusmn;\u0026thinsp;18.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③④\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWang. 2024\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically Ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:50\u003c/p\u003e \u003cp\u003eC:50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Ultrasound\u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:67.78\u0026thinsp;\u0026plusmn;\u0026thinsp;15.50\u003c/p\u003e \u003cp\u003eC:65.32\u0026thinsp;\u0026plusmn;\u0026thinsp;16.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHolzinger. 2011[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:44\u003c/p\u003e \u003cp\u003eC:22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Electromagnetic\u003c/p\u003e \u003cp\u003eC: Endoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:55\u0026thinsp;\u0026plusmn;\u0026thinsp;18\u003c/p\u003e \u003cp\u003eC:55\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJha.2020\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:28\u003c/p\u003e \u003cp\u003eC:24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Electromagnetic \u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;3.35\u003c/p\u003e \u003cp\u003eC:9.55\u0026thinsp;\u0026plusmn;\u0026thinsp;3.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFoote.2004\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:26\u003c/p\u003e \u003cp\u003eC:17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Endoscopic\u003c/p\u003e \u003cp\u003eC: Fluoroscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:59.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003cp\u003eC:58.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChen.2022\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:61\u003c/p\u003e \u003cp\u003eC:61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Endoscopic \u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:66.98\u0026thinsp;\u0026plusmn;\u0026thinsp;15.73\u003c/p\u003e \u003cp\u003eC:66.18\u0026thinsp;\u0026plusmn;\u0026thinsp;13.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③④\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKline.2011\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:22\u003c/p\u003e \u003cp\u003eC:26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Electromagnetic\u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003cp\u003eC:1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFang.2005\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:50\u003c/p\u003e \u003cp\u003eC:50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Endoscopic\u003c/p\u003e \u003cp\u003eC: Fluoroscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:52\u0026thinsp;\u0026plusmn;\u0026thinsp;20.75\u003c/p\u003e \u003cp\u003eC:55\u0026thinsp;\u0026plusmn;\u0026thinsp;19.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHuerta.2000[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:17\u003c/p\u003e \u003cp\u003eC:15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Fluoroscopic\u003c/p\u003e \u003cp\u003eC: Blind\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:45\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e \u003cp\u003eC:56\u0026thinsp;\u0026plusmn;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①③④\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKappelle.\u003c/p\u003e \u003cp\u003e2018[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecritically ill patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI:82\u003c/p\u003e \u003cp\u003eC:73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI: Electromagnetic\u003c/p\u003e \u003cp\u003eC: Endoscopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI:57.9\u0026thinsp;\u0026plusmn;\u0026thinsp;16.8\u003c/p\u003e \u003cp\u003eC:56.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e①②③④\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: ①the placement success;②insertion time;③insertion-related complications incidence rate;④direct healthcare costs.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Risk of bias\u003c/h2\u003e \u003cp\u003eThe NMA's RCTs demonstrated a reasonable and relatively low risk of bias. Virtually all of the studies included adhered to the principle of randomization. With the 19 papers analyzed, 12 trials (63.2%) exhibited a high risk of bias, 5 trials (26.3%) shown a medium risk, and 3 trials (10.5%) presented a low risk of bias (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.4Analyses of outcomes\u003c/h2\u003e \u003cp\u003eThe comprehensive NMA graphs representing different NET placement methods are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, based on how the NET insertion techniques affected the placement success, insertion time, insertion-related complications incidence rate and direct healthcare costs. In these graphs, each node represents each insertion technique. Enlarging the nodes indicates more participants included in every study, and a thicker line connecting two nodes means a greater number of articles.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Primary outcome: placement success rate\u003c/h2\u003e \u003cp\u003eThe network graph illustrates all available comparisons of placement success rate from the included trials (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The NMA model analyzed 5 placement methods: Blind, Fluoroscopic, Electromagnetic, Ultrasound, Endoscopic. All 4 types of techniques showed positive effects in increasing placement success rate compared to Blind, with ORs ranging from 14.84 (95% CI\u0026thinsp;=\u0026thinsp;4.27 to 39.75) for Fluoroscopic to 5.91 (95% CI\u0026thinsp;=\u0026thinsp;2.68 to 11.54) for Ultrasound. However, there was no significant difference among the other 4 insertion techniques in placement success rate. The comparative effectiveness of various NET placement techniques regarding placement success rate is presented via SUCRA plot and league heat table (\u003cb\u003eFig.\u0026nbsp;40\u003c/b\u003e). The SUCRA research revealed that Fluoroscopic had the highest likelihood of efficacy (85.90%), followed by Endoscopic (73.01%), Electromagnetic (54.21%), Ultrasound (36.86%) and Blind (0%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Procedure time\u003c/h2\u003e \u003cp\u003eThe network graph illustrating insertion procedure time displayed all available comparisons from the included trials (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In terms of procedure time 14 studies reported outcomes involving 5 different methods. Overall, the results indicated that only Electromagnetic and Endoscopic placement methods effectively reduced the procedure time compare with Blind. Specifically, Electromagnetic placement (MD = -19.86, 95%CI = -30.55 to -9.14), Endoscopic placement (MD = -19.70, 95%CI = -30.37 to -9.06). Meanwhile, Fluoroscopic and Ultrasound demonstrated a negligible effect. The comparative effectiveness of various techniques in reducing procedure time was illustrated using an SUCRA plot and league heat table (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The SUCRA analysis indicated that Electromagnetic had the highest likelihood of being the most effective placement technique (79.51%), followed by Endoscopic (79.15%), Fluoroscopic (63.84%), Blind (19.00%), and Ultrasound (8.51%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e3.4.3 Complication incidence rate\u003c/h2\u003e \u003cp\u003eThe network graph depicting complication incidence rate displayed comparisons from the included trials (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). 14 studies examined the impact of different type of NET placement techniques on Complications, 5 placement methods (Blind, Fluoroscopic, Electromagnetic, Ultrasound, Endoscopic). The league table heatmap (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) displays a detailed matrix of pairwise comparisons derived from NMA. Our research demonstrated statistically significant differences (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) between Fluoroscopic and other approaches in mitigating complication incidence rates, with odds ratios ranging from 4.46 (95% CI\u0026thinsp;=\u0026thinsp;0.61 to 16.20) for Electromagnetic to 20.93 (95% CI\u0026thinsp;=\u0026thinsp;3.05 to 73.82) for Blind. A league heat table and SUCRA plot were used to compare the effectiveness of various insertion techniques in reducing the incidence of complications (). According to the SUCRA analysis, the most safety insertion type was Fluoroscopic (97.28%), followed by Electromagnetic (73.69%), Endoscopic (43.03%), Ultrasound (33.49%), and Blind (2.51%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e3.4.4 Direct healthcare costs\u003c/h2\u003e \u003cp\u003eFive studies evaluating direct healthcare costs included four insertion methods: Blind, Fluoroscopic, Electromagnetic, Endoscopic. The network configuration is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The league table heatmap (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e) reveals no statistically significant differences between any type of NET placement techniques regarding direct healthcare costs. The efficacy hierarchy established through SUCRA analysis identified Fluoroscopic as the most probable optimal methods (76.92%), followed by followed by followed by Electromagnetic (66.07%), Blind (52.05%), Endoscopic (4.99%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis NMA thoroughly analyzed the efficacy of several different NET placement techniques for ICU patients, using the special features of NMA to conduct both direct and indirect comparisons among various insertion methods. Utilizing the four established results of interest (placement success rate, procedure time, complication incidence rate, and direct healthcare costs), we developed separate network frameworks and performed Bayesian NMA, subsequently ranking the efficacy of all included methods based on the results of the analysis.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Principal finding\u003c/h2\u003e \u003cp\u003eThis systematic review and NMA examined 19 RCTs encompassing 1,554 ICU patients. The analysis indicates that all insertion methods are superior to Blind placement in terms of success rates. Fluoroscopic guidance emerged as the optimal modality for maximizing placement success and minimizing complications. Compared to the Blind method, the Electromagnetic and Endoscopic procedures greatly shortened the procedural duration. Moreover, the SUCRA ranking suggests that Fluoroscopic guidance may be a better value, but there was no statistically significant difference in direct healthcare costs. These results point to a substantial shift in clinical practice toward instrument-assisted techniques.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Comparison with existing literature\u003c/h2\u003e \u003cp\u003ePrevious conventional meta-analyses have underscored the advantages of instrument-assisted insertion techniques for patients, aligning with our results [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Nevertheless, these studies were confined to direct pairwise comparisons, lacking the establishment of a comprehensive hierarchy among all available modalities. This study builds on previous findings by using an NMA approach, which combines direct and indirect evidence to rank safety and efficacy.\u003c/p\u003e \u003cp\u003eFor the past few decades, Fluoroscopic technology has been the \"gold standard\" and \"final arbiter\" for testing the accuracy of new placement technologies like Ultrasound and Electromagnetic[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. This NMA confirms that Fluoroscopic placement is the most preferred method because it has the highest rates of both placement success (SUCRA 85.90%) and complication prevention (SUCRA 97.28%). Fluoroscopy is better because it can show the whole insertion pathway in real time and with movement, which makes it easier to find your way through the pylorus and the ligament of Treitz[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Additionally, safety is the most important thing to think about when placing a NET. Our results indicate that Fluoroscopic technology serves as the paramount barrier against iatrogenic complications. Fluoroscopy, on the other hand, lets you see the guidewire's path before you move it forward. This lets you find and fix any mistakes in real time. Fluoroscopy necessitates merely a hydrophilic guidewire, in contrast to the endoscopic technique, which requires a cumbersome instrument, resulting in a markedly reduced occurrence of dyspnea and abdominal discomfort[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Nonetheless, the studies included did not consider the safety of radiation exposure. The most important ethical and safety issue with using X-rays is the risk of radiation exposure [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. For ICU patients requiring long-term enteral nutrition and potentially facing multiple tube replacements or positional adjustments, the cumulative radiation dose constitutes a medical concern that necessitates attention.\u003c/p\u003e \u003cp\u003eFluoroscopic is the best at effectiveness, but Electromagnetic and Endoscopic techniques represent a critical advancement in procedural efficiency (SUCRA 79.51% and 79.15%, respectively). Electromagnetic navigation uses weak electromagnetic sensing technology to measure the head position of the built-in magnetic guidewire catheter in real time, and plots its movement path into a trajectory line, which is presented in two and three dimensional forms on the screen[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Electromagnetic guidance reduces the duration by getting rid of the logistical delays that come with moving patients to the radiology suite. This makes it a great bedside option for ICU patients who are not stable. The field of endoscopic technology is also always changing, and recent improvements have made NET placement much more efficient. Research demonstrates that ultrathin transnasal endoscopy considerably reduces procedure duration compared to conventional endoscopy, thus enabling successful bedside insertion for critically ill patients[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In addition to placement, this technology enables simultaneous diagnostic upper gastrointestinal endoscopy to detect suspicious lesions, a diagnostic capability exclusive to the endoscopic method[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, our results show poor performance of Ultrasound-guided placement, particularly regarding procedure time, where it ranked even lower than the Blind technique. In recent years, critical care ultrasound technology has attracted clinical attention. It has the benefits of being easy to use, efficient, and radiation-free, and it can be done at the bedside[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. However, it is hampered by significant physical limitations. Ultrasonography is more effective at penetrating solid structures, like organs, or liquids, but it has limitations when it comes to interacting with gas, which is often found in the digestive tract[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The visualization of the pylorus and duodenum is frequently obscured by bowel gas artifacts and depth attenuation, particularly in obese patients[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Additionally, Ultrasound requires the identification of a specific acoustic window, which can be time-consuming and technically challenging. Those suggest that Ultrasound is a promising non-invasive method, which makes it less effective than other methods.\u003c/p\u003e \u003cp\u003eIn terms of economic outcomes, Fluoroscopic placement emerged as the most cost-effective method. Although Fluoroscopy incurs initial radiology fees, its high one-time likely reduces the total cost of care by minimizing repeated insertion attempts and treating of expensive complications. Conversely, Endoscopic placement was the least cost-effective method, probably because endoscopic equipment, sterilization, and specialized staff are all extremely costly[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. However, most of studies concentrated on the procedure costs associated with short-term hospital stays, overlooking long-term comparisons, including readmission due to catheter dysfunction or costs related to malnutrition[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Furthermore, only five studies in our meta-analysis reported data on direct healthcare costs, these economic findings must be interpreted with caution. Consequently, the existing evidence is inadequate to ascertain a conclusive determination regarding the economic superiority of any singular method. Additional high-quality studies concentrating on cost-utility analysis are critically required to corroborate these findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Strengths and Limitations\u003c/h2\u003e \u003cp\u003eTo our knowledge, it is the first NMA to comprehensively rank these five NET placement techniques, moving beyond simple pairwise comparisons to provide a global hierarchy of efficacy and safety. Only RCT were included in our NMA, ensuring rigorous design and thus providing eligible quality evidence.\u003c/p\u003e \u003cp\u003eHowever, there are a number of limitations that need to be recognized. First, the sample sizes in some of the studies that were included were relatively small. These small-sample trials may not have enough statistical power, which could affect the accuracy of our network estimates. Second, only five studies had information about direct healthcare costs. This lack of economic data makes our cost-effectiveness conclusions less reliable and less applicable to other situations.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis NMA provides comprehensive evidence on the effectiveness of various NET insertion techniques for ICU patients, highlighting that all instrument-assisted placement types are significantly better to Blind control. Fluoroscopic guidance offers the highest success and safety. Additionally, Electromagnetic have shown the best efficacy in shortening procedure time. Clinicians should prioritize instrumental guidance to enhance patient safety and operational efficiency, tailoring the choice of method to available resources and specific patient needs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAuthor details\u003c/h2\u003e \u003cp\u003e \u003csup\u003e1\u003c/sup\u003e Intensive Care Unit, Respiratory and Critical Care Medicine Department, Changsha Central Hospital, No. 161, Shaoshan South Road, Changesha, Hunan 410000, China.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eProject supported by the Natural Science Foundation of Hunan, China (2708) and Key Scientific Research Project of Changsha Central Hospital, China (YNKT202515).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLPY, Q L designed research; LPY, PJ, HMY, WLQ, LX, LX, WS conducted research; LPY, PJ, HMY, WS analyzed data; LPY wrote the first draft of manuscript; LPY, WS had primary responsibility for final content. Every author read and reached consensus on the final version of the manuscript. Every author made a contribution to the study's conception or design, as well as to the data collection, analysis, and interpretation. The work was either drafted or critically revised by all authors, and the final version that was submitted for publication received their final approval. Each author pledges to take responsibility for every facet of the work, guaranteed accuracy and integrity.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll pertinent data have been included in the manuscript. The dataset underpinning the conclusions of this paper is obtainable from the authors upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang WN, Wang CY, Hsu CY, Fu PK. 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Electromagnetic Versus Blind Guidance of a Postpyloric Feeding Tube in Critically Ill Children. Pediatrics. 2020;146(4):e20193773.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoote JA, Kemmeter PR, Prichard PA, Baker RS, Paauw JD, Gawel JC, Davis AT. A randomized trial of endoscopic and fluoroscopic placement of postpyloric feeding tubes in critically ill patients. JPEN J Parenter Enter Nutr. 2004;28(3):154\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Y, Tian X, Liu C, Zhang L, Xv Y, Xv S. Application of visual placement of a nasojejunal indwelling feeding tube in intensive care unit patients receiving mechanical ventilation. Front Med (Lausanne). 2022;9:1022815.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKline AM, Sorce L, Sullivan C, Weishaar J, Steinhorn DM. Use of a noninvasive electromagnetic device to place transpyloric feeding tubes in critically ill children. Am J Crit Care. 2011;20(6):453\u0026ndash;9. quiz 460.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFang JC, Hilden K, Holubkov R, DiSario JA. Transnasal endoscopy vs. fluoroscopy for the placement of nasoenteric feeding tubes in critically ill patients. Gastrointest Endosc. 2005;62(5):661\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuerta G, Puri VK. Nasoenteric feeding tubes in critically ill patients (fluoroscopy versus blind). Nutrition. 2000;16(4):264\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKappelle WFW, Walter D, Stadhouders PH, Jebbink HJA, Vleggaar FP, van der Schaar PJ, Kappelle JW, van der Tweel I, Van den Broek MFM, Wessels FJ, Siersema PD, Monkelbaan JF. Electromagnetic-guided placement of nasoduodenal feeding tubes versus endoscopic placement: a randomized, multicenter trial. Gastrointest Endosc. 2018;87(1):110\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMancini FC, de Moura DTH, Funari MP, Ribeiro IB, Neto FLP, Mendieta PJO, McCarty TR, Bernardo WM, Nahas SC, de Moura EGH. Use of an electromagnetic-guided device to assist with post-pyloric placement of a nasoenteral feeding tube: A systematic review and meta-analysis. Endosc Int Open. 2022;10(8):E1118\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRe R, Lassola S, De Rosa S. Placement and Verification of the Nasogastric Tube: An In-depth Analysis of Ultrasonographic Technique. Dimens Crit Care Nurs. 2025;44(5):239\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiles P, Gilligan P, Damilakis J, Briers E, Candela-Juan C, Faj D, Foley S, Frija G, Granata C, de Gala LH, Pauwels H, Sans Merce R, Simantirakis M, Vano G. European consensus on patient contact shielding. 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Safety and effectiveness of dual guidance with video-laryngoscopy and ultrasound in jejunal tube placement in patients undergoing invasive mechanical ventilation. Ann Palliat Med. 2021;10(3):3128\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerraboli SF, Beghetto MG. Bedside ultrasonography for the confirmation of nasogastric tube placement: agreement between nurse and physician. Rev Gaucha Enferm. 2022;43(spe):e20220211.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi G, Pan Y, Zhou J, Tong Z, Ke L, Li W. Enteral nutrition tube placement assisted by ultrasonography in patients with severe acute pancreatitis: A novel method for quality improvement. Med (Baltim). 2017;96(45):e8482.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalaski A, Peng WW, Ellis M, Darling P, Common A, Tucker E. Gastrostomy tube placement by radiological versus endoscopic methods in an acute care setting: a retrospective review of frequency, indications, complications and outcomes. Can J Gastroenterol. 2009;23(2):109\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRibeiro FA, Sodr\u0026eacute; da Costa LS, Pedroso AC, de Paula Nogueira PB, Brandi S, Toledo DO, Laselva CR, Malheiro DT, Silva JM Jr. Evaluating multifaceted strategies to prevent nasoenteral tube complications and achieve significant cost savings in critically ill patients: the ENHANCE-CRIT trial. BMJ Open Qual. 2025;14(1):e003177.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"network meta-analysis, nasointestinal tube placement, intensive care units, magnetic navigation, endoscope, fluoroscopy","lastPublishedDoi":"10.21203/rs.3.rs-8626067/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8626067/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo systematically evaluate the comparative effectiveness and safety of different nasoenteric tube (NET) placement techniques in Intensive Care Unit (ICU) patients through a Bayesian network meta-analysis (NMA).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e In accordance with PRISMA-NMA guidelines, we conducted a systematic review of randomized controlled trials (RCTs) from major English and Chinese databases, including PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CBM, CNKI, Wanfang, and VIP. The analysis of data was performed within a Bayesian framework utilizing the 'BUGSnet' package in R. Efficacy rankings were established according to the surface under the cumulative ranking curve (SUCRA) values. The assessed outcomes were placement success rate, procedure time, complication incidence rate, and direct healthcare costs.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThis NMA evaluated 19 RCTs involving 1,554 ICU patients. The investigation revealed that all instrument-assisted methods surpassed the Blind placement regarding placement success rates. Of the five assessed techniques, Fluoroscopic guiding had the highest ranking for optimizing placement success and reducing complication incidence rate. Furthermore, Electromagnetic and Endoscopic placement were the most time-efficient solutions, markedly decreasing procedural duration relative to the Blind method. Although there were no statistically significant differences in direct healthcare costs, SUCRA rankings suggested a potential cost-benefit advantage for Fluoroscopic guiding.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis NMA shows that instrument-guided methods are better than Blind placement for NET placement in ICU patients. Fluoroscopic guidance provides the best success rates and safety, although electromagnetic guidance exhibits greater efficiency in minimizing process duration. Clinical medical professionals should prioritize instrument-assisted methods to improve patient safety and procedural efficacy. Additionally, they have to select the placement method according to resource availability and particular clinical requirements.\u003c/p\u003e","manuscriptTitle":"Comparison of the effects of different types of nasointestinal tube placement techniques for ICU patients: A Bayesian network meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-24 00:38:24","doi":"10.21203/rs.3.rs-8626067/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-12T10:52:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T07:49:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T18:03:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155920689486869020196548449764035068248","date":"2026-02-09T16:49:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243349415628204618763427897970846405377","date":"2026-02-07T06:44:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288035143834405435982665031480627220232","date":"2026-02-04T08:38:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328503009298123984017817260236433568680","date":"2026-01-22T11:37:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T13:54:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-20T13:01:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-19T10:06:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T10:02:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2026-01-17T12:35:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f40daafa-85b0-46bf-ade5-c67d6a617185","owner":[],"postedDate":"January 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:00:10+00:00","versionOfRecord":{"articleIdentity":"rs-8626067","link":"https://doi.org/10.1186/s12871-026-03828-6","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2026-04-14 15:57:02","publishedOnDateReadable":"April 14th, 2026"},"versionCreatedAt":"2026-01-24 00:38:24","video":"","vorDoi":"10.1186/s12871-026-03828-6","vorDoiUrl":"https://doi.org/10.1186/s12871-026-03828-6","workflowStages":[]},"version":"v1","identity":"rs-8626067","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8626067","identity":"rs-8626067","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}