Evaluation of a technique for blind placement of post-pyloric feeding tubes in intensive care: application in patients with gastric ileus

Abstract

Objective

To evaluate a blind ‘active’ technique for the bedside placement of post-pyloric enteral feeding tubes in a critically ill population with proven gastric ileus.

Design and setting

An open study to evaluate the success rate and duration of the technique in cardiothoracic and general intensive care units of a tertiary referral hospital.

Patients

20 consecutive, ventilated patients requiring enteral nutrition, where feeding had failed via the gastric route.

Interventions

Previously described insertion technique—the Corpak 10-10-10 protocol—for post-pyloric enteral feeding tube placement, modified after 20 min if placement had not been achieved, by insufflation of air into the stomach to promote pyloric opening.

Measurements and results

A standard protocol and a set method to identify final tube position were used in each case. In 90% (18/20) of cases tubes were placed on the first attempt, with an additional tube being successfully placed on the second attempt. The median time for tube placement was 18 min (range 3–55 min). In 20% (4/20) insufflation of air was required to aid trans-pyloric passage.

Conclusions

The previously described technique, modified by insufflation of air into the stomach in prolonged attempts to achieve trans-pyloric passage, proved to be an effective and cost efficient method to place post-pyloric enteral feeding tubes. This technique, even in the presence of gastric ileus, could be incorporated by all critical care facilities, without the need for any additional equipment or costs. This approach avoids the costs of additional equipment, time-delays and necessity to transfer the patient from the ICU for the more traditional techniques of endoscopy and radiographic screening.

Appendix

The Corpak 10-10-10 protocol for blind insertion of nasojejunal feeding tubes at the bedside.

• 1. Unless clinically contraindicated, 10 mg metoclopramide is given by slow intravenous injection (if not given in the preceding 4 h). Allow 10 min after the metoclopramide before commencing tube placement.

• 2. Lubricate the end of the fine bore feeding tube with aqueous gel.

• 3. Measure the tube from the patient's nose, via the ear, down to the xiphoid process.

• 4. Ideally place the patient in a semi-supine position at 30°.

• 5. Advance the tube via the nostril, aiming the tip parallel to the nasal septum and superior surface of hard palate, into the nasopharynx, until the previously measured length (approx. 40 cm) is reached.

• 6. Confirm placement in the stomach.

• 7. Flush the tube with 1 ml 0.9% saline to lubricate the wire within the tube.

• 8. Advance the tube further by continued gentle pushing, pulling back if any resistance is felt, until a further 15 cm of tube has been advanced. Check tube passage.

• 9. To do this the guide wire should be pulled back a little way (no more than 5 cm). If resistance is met when pulling back the guide wire then the tube is likely to be coiled in the stomach. This resistance can be characterized with the feeling that the guide wire is ‘popping’ when it is pulled back.

• 10. If the tube is coiled, pull it back slowly 5 cm at a time until the wire can be manipulated freely.

• 11. Continue to advance the tube again slowly but again check at 70, 75, 80, 85, 90 and 95 cm to ensure that the tube has not become coiled. Follow steps 9 and 10.

• 12. Once the 95-cm point has been reached without the tube becoming coiled, the tube can be advanced slowly to 105 cm to ensure successful placement in the jejunum.

• 13. If the procedure has been underway for more than 20 min, 200 ml air should be insufflated into the stomach via the NG tube. Further attempts to pass the tube should be made for 20 min.

• 14. Final tube placement confirmation:

  • If on aspiration there is a high volume of air (> 20 ml) it is likely that the tube remains in either the oesophagus or the upper portion of the stomach.

  • If on aspiration 20 ml or more of secretions is obtained, the tube is most likely to be in the stomach. These secretions usually have a pH < 5.0.

  • If no more than 5–10 ml bright yellow secretions is obtained, the tube is likely to be in the small bowel. Secretions from the small bowel should be pH 6–7.

  • If no secretions are obtained, bolus 10 ml air down the tube. If on attempted aspiration resistance is met, the tube can be judged to be in the small bowel.

  • Flush the tube with 10 ml 0.9% saline. If less than 5 ml can be aspirated easily, the tube is likely to be in the small bowel.

• 15. Remove the guide wire. If the wire has maintained its smooth appearance, the tube can be judged to be in the small bowel. Secure the tube to the side of the patient's head.

• 16. Request confirmation of placement by upper abdominal radiography. The tube is radio-opaque even with the guidewire removed. The tube is seen to cross the midline from patient's left to right, and then to cross again from right to left if placement into the jejunum has been successful.

• 17. Once placement has been confirmed, restart feeding via the NG route. Leave the NG tube in situ and aspirate it 4 hly to identify reflux of feed, back into the stomach.