Add to Collection. Added to Collection. This alert is the latest in a series of advisories issued by AACN to standardize practice and update nurses and other healthcare providers on new clinical advances and trends. Based on the most current evidence, the expected practice during the insertion procedure is to use a combination of two or more of the following bedside methods to predict tube location:. These results can be used to determine when it is time to use radiography to confirm tube location and may be able to reduce the number of confirming radiographs to one.
This article reviews complications associated with small-bore feeding tube insertion and potential methods to promote safe gastric or postpyloric placement. Usually cm is sufficient. Advance Tube into Small Bowel Smal advancing tube with a twisting, corkscrew-like motion in 10cm increments. In adults, stomach volume can be anywhere from to ml 5. Correct placement of a blindly inserted small-bore or large-bore tube should be confirmed with a radiograph that Cdw private purchase the entire course of the tube prior to its initial use for feedings or medication administration. These findings do not support eliminating radiographs to confirm correct Insertion small bore feeding tube placement following use of an electromagnetic tube placement device. Added Indertion Collection. St Louis, MO : Saunders ; : — Image 10 above : The tip of this tube is curling upward from the point where the duodenum is expected Detection of inadvertent airway intubation during gastric tube insertion: capnography versus a colorimetric carbon dioxide detector.
Porn for men. Objectives
Providing patients with adequate nutrition is a prime responsibility of the bedside nurse.
- Background Clinicians are unsure if radiography is needed to confirm correct positioning of feeding tubes inserted with assistance from an electromagnetic system.
- Filed under Critical Care Medicine.
- Although often considered an innocuous procedure, bedside placement of a feeding tube can cause serious and even fatal complications.
- Ensure that patient and health care provider safety standards are met during this procedure including:.
Background Clinicians are unsure if radiography is needed to confirm correct positioning of feeding tubes inserted with assistance from an electromagnetic system.
Objectives To compare radiographic reports of feeding tube placement with images generated by an electromagnetic feeding tube placement device. Methods The medical records of consecutive patients who had feeding tubes inserted with assistance from an electromagnetic feeding tube placement device were reviewed retrospectively.
Radiographic reports of tube site were compared with images generated by the device. Results Radiographic evidence of tube sites was available in cases: tubes were located in portions of the gastrointestinal tract.
Ninety of the tubes were situated in the optimal site distal duodenum or jejunum radiographically. Images generated by the electromagnetic device were available in cases; of these, 52 tubes appeared to end in the expected left lower quadrant. Tubes shown on radiographs to be in other sites also occasionally appeared to end in the left lower quadrant. Nurses using the device did not recognize 4 of the tubes 2. No consistent pattern of quadrant distribution was found for tubes positioned in the stomach or proximal duodenum.
Conclusions Images generated by the electromagnetic tube placement device provided inconsistent results regarding tube location. A small percentage of seriously malpositioned tubes were not detected by using the electromagnetic device. These findings do not support eliminating radiographs to confirm correct tube placement following use of an electromagnetic tube placement device.
A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:. To read this article and take the CE test online, visit www. It is estimated that more than 1 million styleted feeding tubes are placed in the United States annually. Reliable final placement of enteric feeding tubes is inherently important in the prevention of avoidable morbidity and mortality.
The ability of operators of an electromagnetic enteral access device to detect unintended misplacement of feeding tubes is uncertain. Additional information is needed to help clinicians decide if a confirming radiograph is needed to assess tube position when such a device is used.
To compare images generated by an electromagnetic tube placement device with radiographic reports of tube location for agreement. To describe the number of times that CEAS-assisted tube insertions result in inadvertent placement of tubes in the respiratory tract. To describe the number of cases of pneumothoraces following CEAS placement of feeding tubes. To review the educational experiences about use of the electromagnetic tube placement device provided to nurses at the data collection site between January 1, , and December 31, Following approval from the appropriate institutional review boards, medical records at a single-center, bed, nonprofit community hospital where nurses place approximately enteric tubes annually were retrospectively reviewed.
The study population consisted of a convenience sample of the first hospitalized patients to undergo enteric tube placements with the electromagnetic Cortrak 2 Enteral Access System CEAS in Patients with blindly placed enteric tubes were excluded from the study. Variables included in the medical record review were as follows: radiographic reports of tube site, radiographic images, images generated from the electromagnetic tracking device, centimeter marks on the enteric tubing recorded at the end of the placement procedure, number of placement attempts per episode, and educational experience of placement personnel.
Abdominal radiographs were required for all placements of small-bowel feeding tubes. All radiographs were interpreted by a radiologist, independent of information generated by the CEAS.
Radiographic reports included the following tube sites: esophagus, gastroesophageal juncture, stomach, gastroduodenal juncture duodenal bulb , duodenum first or second part, duodenum third or fourth part, jejunum ligament of Treitz , right lung, and left lung. Images from the CEAS were reviewed independently by the 2 nurse members of the research team to determine where the tube tips were positioned in relation to the vertical and horizontal reference lines provided on the anterior view, default placement screen, accounts mode of the CEAS.
Possible positions included above the horizontal axis to the left of the vertical axis, below the horizontal axis to the left of the vertical axis, above the horizontal axis to the right of the vertical axis, and below the horizontal axis to the right of the vertical axis.
The centimeter mark indicating the length of tube inserted into the patient was recorded in the medical record by the registered nurse who inserted the feeding tube at the time of placement. These markings were recorded to determine the extent to which they compare with radiographic evidence of the tube site.
Using information published by Gatt and MacFie, 6 centimeter marks are associated with anatomic tube position. For example, esophageal placement was associated with the to cm mark, gastric placement was associated with the to cm mark, and distal small-bowel placement was associated with the cm mark. Data on the number of insertion attempts number of Cortrak tracing events per placement episode were also retrieved from the medical records. If multiple attempts were made to place the enteric tube, only the last tracing was included in the sample.
All of the tubes were placed by registered nurses employed at the study site. All placement nurses received training in using the CEAS. It was not possible to track the amount of training given to each nurse in past years. However, a review was conducted of recorded educational programs provided by the hospital on use of the electromagnetic feeding tube placement device during the data collection period January through December 31, The quadrant in which each feeding tube tip ended on the CEAS image was recorded for each of the radiographically identified feeding tube sites.
Descriptive statistics frequencies, percentages, means and standard deviations were used to report the findings. Other statistical comparisons were not possible because of the relatively small numbers in some of the anatomic tube placement sites.
Two hundred patients were reviewed in the study; The mean age of the patients was All patients represented cases that met criteria for small-bowel nutrition as evaluated by a physician. Although cases were initially examined, 12 cases had missing radiographic reports and 11 had missing CEAS images; in addition, 1 of the cases failed to meet the inclusion criteria and was deleted from the sample.
A sample of cases with radiographic data remained. Table 1 shows the placement locations of the tip of the feeding tube within the gastrointestinal tract and respiratory tract. The extent to which feeding tubes were placed into acceptable locations also was described. Of the tubes with radiographic reports, only had recorded images generated by the CEAS. Table 2 shows the CEAS image quadrants in which the feeding tube tips were located when the confirmatory radiographs were obtained to determine the final position of the feeding tube.
When compared with confirmatory radiographs of tubes situated at the optimal site distal duodenum or jejunum , the electromagnetically generated images indicated that only 52 tubes ended in the expected left lower quadrant.
Four of the tubes with radiographic reports 2. A tube placed in the lung would be expected to be situated in an upper quadrant on the CEAS image above the diaphragm ; however, 2 of the tubes placed in the right lung were shown in CEAS images to end in the left lower quadrant Table 2. Table 3 lists the various tube insertion lengths as indicated by centimeter marks on the tubes. Although mean insertion lengths were greater for tubes positioned in the small bowel than for tubes placed in the upper portions of the gastrointestinal tract, there was considerable overlap in the centimeter markings according to the various tube sites.
The number of attempts made by the nurses who used the CEAS to place tubes varied from 1 to 30 per episode mean, 5. Description of the training provided to the specific registered nurses who placed the feeding tubes with the CEAS was not entirely available. All nurses who placed feeding tubes did have documentation of some degree of initial training using the CEAS; however, no documented evidence of standardized training or competency was found.
During the data collection period January 1, through December 31, , didactic training classes for using the CEAS ranged from 30 minutes to 2 hours long, and clinical training varied from 0 to 10 supervised placements. Nurses were able to place Additionally, the nurses did not detect 4.
The 4 most serious incidents involved placements into the lung 2 of which resulted in pneumothoraces , which resulted in an incidence of pulmonary placement and pneumothorax similar to the rate observed when feeding tubes are placed blindly.
Fortunately, none of the enteric tubes placed in the lung during the study were used to provide nutrition to the patients. Failure to detect malpositioned tubes when using an electromagnetic enteral access device can lead to serious complications. Altered mental status, preexisting endotracheal tube, and critical illness place patients at higher risk for malposition.
Use of the centimeter mark to determine location of enteric tubes was an unpredictable measure of correct anatomic position Table 3. Overlap and variability between the various sites in the gastrointestinal tract and in the lung were considerable Table 3. Findings from this review generate serious uncertainty about the reliability of centimeter marks for predicting tube tip location accurately.
The mean number of placement attempts reported in this review was 5 range, 1— A placement attempt was defined as each time the placement procedure was reinitiated and retraced by using the CEAS device during a placement episode.
With a mean of 5 attempts per placement procedure, one could surmise that the training may not have been adequate. The level of training established in this study was thought to be far less than reported in a large study by Koopmann et al, 1 in which the CEAS device used by a dedicated team was effective in eliminating cases of pneumothorax associated with tube placements, or in the study by Rivera et al, 10 where 1 designated nurse placed feeding tubes with the use of the CEAS device, resulting in greater accuracy in distal small-bowel placement.
The major strength of this study was that it evaluated the ability of nurses in a community hospital setting to use the CEAS device to place feeding tubes for 1 year. The retrospective review of medical records used in the study is recognized as a limitation by design. Another important limitation of the study was the lack of specific information about the training, competencies, and experience levels of all the nurses who inserted tubes with assistance from the CEAS.
More importantly, they did not detect 4 of the tubes that entered the lung, or 4 tubes that were positioned in the esophagus or gastroesophageal juncture. The study setting was thought to be fairly representative of hospitals across the nation that do not employ a dedicated nurse or teams to place enteric feeding tubes. Training and competency were also thought to be similar to those in hospitals without a designated placement nurse or teams.
The images generated by the electromagnetic feeding tube placement device provided inconsistent results regarding tube location. This finding, combined with a varied clinical skill mix, could very well increase risk of an adverse event. These results do not support eliminating obtaining radiographs to confirm correct tube placement following use of an electromagnetic tube placement device.
In addition, this study uncovered an opportunity for improvement at the study site. A process review at the institution was initiated that included clinical retraining, updating of institutional policies, and a standardization of process according to national standards. Future research is planned to replicate, readdress, review, and expand on these study results. This was a Capstone Project performed as a partial requirement for completion of a doctorate in nursing practice degree from Saint Louis University School of Nursing, St Louis, Missouri.
Visit www. For more about feeding tube placement, visit the Critical Care Nurse Web site, www. User Name Password Sign In. Jean Phang is a quality assurance nurse at Baptist Hospital of Miami.
Kevin Abrams is medical director of the radiology department at Baptist Hospital of Miami. Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives: Identify the potential complications of feeding tube placement.
Explain the results of the study. Discuss the implications to practice as a result of this study. Previous Section Next Section.
Sample and Setting Following approval from the appropriate institutional review boards, medical records at a single-center, bed, nonprofit community hospital where nurses place approximately enteric tubes annually were retrospectively reviewed.
All of the tubes were placed by registered nurses employed at the study site. J Oral Maxillofac Surg. In Wiegand DL , ed. X-ray confirmation is required. Br J Nurs.
Insertion small bore feeding tube. Expected Practice
Add to Collection. Added to Collection. This alert is the latest in a series of advisories issued by AACN to standardize practice and update nurses and other healthcare providers on new clinical advances and trends. Based on the most current evidence, the expected practice during the insertion procedure is to use a combination of two or more of the following bedside methods to predict tube location:.
These results can be used to determine when it is time to use radiography to confirm tube location and may be able to reduce the number of confirming radiographs to one. Nurses should not use the auscultatory air bolus or water bubbling method holding tube under water to determine tube location. Correct placement of a blindly inserted small-bore or large-bore tube should be confirmed with a radiograph that visualizes the entire course of the tube prior to its initial use for feedings or medication administration.
This recommendation also applies to a tube inserted with assistance from an electronic tube placement ETP device and gastric decompression tubes that are later used for other purposes.
Supported by authoritative evidence, each AACN Practice Alert seeks to ensure excellence in practice along with promotion of a safe and humane work environment. Topics address both nursing and interprofessional activities of importance to patients in acute and critical care environments. Some alerts include additional resources for staff education and performance-improvement activities.
Additional alerts address aspiration, noninvasive blood pressure monitoring, dysrhythmia monitoring, pulmonary artery pressure monitoring, ST segment monitoring, family presence during CPR and invasive procedures and prevention of catheter-associated urinary tract infections. AACN represents the interests of more than half a million acute and critical care nurses and includes more than chapters worldwide.
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Newsroom Feeding Tube Placement. Add to Collection Added to Collection. Feeding tubes require initial and ongoing verification to minimize complications. Based on the most current evidence, the expected practice during the insertion procedure is to use a combination of two or more of the following bedside methods to predict tube location: Observe for signs of respiratory distress Use capnography if available Measure pH of aspirate from tube if pH strips are available Observe visual characteristics of aspirate from the tube These results can be used to determine when it is time to use radiography to confirm tube location and may be able to reduce the number of confirming radiographs to one.
After feedings are started, tube location should be checked at four-hour intervals.