The purpose of this video is to provide general information and education about the care of
a critically ill child.
It is in no way a substitute for the independent decision-making and judgment by a qualified
health care professional.
The information contained in this video should not be used to make a diagnosis, or to overrule
the advice of a qualified health care provider, nor should it be used to provide advice for
emergency medical treatment.
Post-pyloric Tube Placement by Susan Hamilton.
Please note that in this video, we will be following the guidelines used at Boston Children's
Hospital.
Some of this information may need to be modified based on the equipment, guidelines, and practices
in place in your institution.
Introduction.
I'm Susan Hamilton.
I'm a Clinical Nurse Specialist at Children's Hospital Boston.
I'm going to demonstrate for you today how to place a feeding tube in a child so that
they may get nutrition if they're unable to take their nutrition orally.
I'm going to place this patients tube post-pylorically.
Post-pyloric placement needs to be done under controlled situation and only by trained personnel.
You would make policies in your institution and use the resources that you have for placing
a tube into the post-pyloric position.
Indications.
The major indication for performing this procedure is to provide enteral feeding or deliver medications
to a child who will not tolerate oral or gastric feeding, secondary to known or suspected risk
for aspiration, the use of non invasive ventilation, or severe gastric dysmotility.
Contraindications.
The first contraindication that would prompt health care providers to refrain from this
procedure is the presence of any nasal, facial, or basilar skull fractures.
Another contraindication would be any clinical disorders of the esophagus, stomach, or small
intestine, including esophageal atresia, severe esophageal or small intestinal stricture,
and esophageal or gastric perforation.
Please exercise caution when performing this procedure in patients receiving anticoagulant
therapy or that have a bleeding disorder or thrombocytopenia with a platelet count less
than 50,000.
Equipment.
You will need the following equipment to perform the procedure-- styletted feeding tube, syringe,
lubricant, tape, stethoscope, sharps container, clear adhesive dressing.
Procedure.
The first thing that we want to do in order to place a tube is to actually make the measurements.
I'm going to use this styletted feeding tube.
If I was only going to the stomach, I would start with my measurement of nose to ear and
ear to xiphoid, and that measurement would be for a stomach placement.
These tubes actually have markings on them with numbers.
But if you're going to be putting this tube in for long-term, a piece of tape or a marking
with a marker that's indelible would be the best thing to do.
So I'm going to put a mark right there.
That will be a "1" for stomach placement.
The next measurement would be to take the tube and measure from the mid-xiphoid to the
mid-axillary line.
That would help to get the tube across the pylorus and into the first part of the duodenum.
I'm going to put a second marking there.
And then, depending on the size of the child, you want to add a few more centimeters onto
the length of the tube, to allow the tube to move forward closer to the jejunum.
Once the tube is all set, you'll prepare your patient for tube placement.
You'll lubricate your tube and get ready for insertion.
Point of Clarification.
To approximate the jejunal, or third, marking from the duodenal, or second, marking, add
the following centimeters-- five to seven centimeters for a newborn; seven to ten centimeters
for one to four years; ten centimeters for greater than four years.
Flush the tube with water through the stylet port prior to inserting it into the patient.
This will activate the internal powdered lubricant, making removal of the stylet easier.
I'm now ready to place the tube.
I'm going to get the patient into a position of comfort.
For a post pyloric feeding tube placement, it is actually helpful to place the patient
down on the right side to facilitate gravity movement of the tube past the stomach through
the pyloric sphincter.
I'm going to lubricate the tube, and I'm going to attach a syringe to the end of the tube,
because I'm going to use air to help move the tube once I get past the stomach marking.
The first marking I'm going to go to is the stomach marking.
At that point, I'm going to stop, confirm placement, and try to obtain a pH aspirate.
Once the patient is ready, I'm going ahead and start to place the tube.
If the patient starts to have coughing at this point, that they can't stop and they
appear distressed, immediately pull out the tube and allow the patient to recover.
Excessive coughing can be a sign that the tube is actually heading into the lung instead
of the stomach.
I'm going to ensure that the patient's not coughing or having any respiratory distress.
At the stomach marking, I'm going to stop and have a listen for air.
To advance the tube past the stomach, a bolus of air is used to try to open the pyloric
sphincter and move the tube along.
It's a feel situation, that you will feel a give in the tube once you've gotten it past
the stomach.
So at the same time, you want to advance the tube and push the bolus of air to blow open
the sphincter.
The tube should begin to move easily if you've actually gotten past the stomach.
You can stop at that spot.
And if you still have free give, you can continue to move, with the bolus of air, the tube to
the final marking, at the number three.
Once you've gotten the tube to the desired position, you want to do two more things to
help confirm placement.
I'm actually going to have Kate help hold the tube here, so that I don't lose the tube
while I'm doing this.
So Kate holds that secure.
Two ways that you want to check.
The first one is to get a positive snap.
A snap test is when the tube gets into the small bowel, because the lumen of the bowel
is smaller, you will, if you instill air, you should not be able to get air back.
So what I will do is take about five mLs of air and inject it into the bowel.
And when I pull back, I should not be able to get any air, and the syringe will pull
right back and suck the air, any air, right back in.
That would be a positive snap.
I also want to listen for high-pitched gurgling sounds over the right upper quadrant of the
abdomen.
I'm first going to listen over the stomach and then at the right upper quadrant of the
abdomen.
And then I want to listen at the esophagus for the absence of air.
In small babies, you may still hear sounds in the stomach because of the overall size
of the abdomen.
It may be referred sounds.
I'm just going to use about five mLs of air again, and I'm going to listen over the stomach.
And I should hear faint gurgling.
I'm going to use five more mLs and I'm going to listen in the right upper quadrant.
And I'm looking for high-pitched gurgling or crackling type noises.
Then I want to listen one more time over the esophagus, to be sure that there are no sounds,
which would be a sign that the tube has gone back into the stomach and back into the esophagus.
I hear no sounds over the esophagus, and I have a positive snap and high-pitched crackles.
So I feel confident this tube is in place.
But I will confirm it with an x-ray.
At this point, I want to go ahead and take the stylet out.
The stylet has been pre-lubricated, so it should come right out.
You have that tight?
Yes.
I'm going to pull that out.
And at that point, you want to put this in a sharps container, in case of contamination.
I'm going to get that tube secured.
And I'm going to go ahead and get an x-ray.
Once the tube placement has been confirmed and you're ready to start feedings, there's
a few things that you need to do for care and maintenance of this tube.
Because of the small diameter of the tube and potentially thick formula or other type
of feed, you want to make sure that you prophylactically flush this tube at least every eight hours
with 5 to 10 mLs of water.
If the patient is receiving medications through this tube, a flush should be given after every
med.
So if you have to give three meds, you should give the med and then a flush, and then start
with the next med and give a flush.
If there's any resistance to flushing, you want to use about a 10 mL size syringe, and
try to just flush with water or with normal saline, and try to pull back.
Never put the stylet back in once it's been taken out, due to the risk of perforation
of the bowel.
You also want to confirm that the marking is where it should be and where it was.
So in your documentation, you should document what number or put the magic marker mark on
there.
And always confirm that it's still in place before you start feedings.
And if you're using a small bowel tube, you never want to give feeds in a bolus fashion.
You always want to give these feeds continuously, because a large bolus would not be tolerated
in the small bowel.
Complications.
The complications that you may observe include inadvertent placement into the lungs, nasal,
gastric, or small intestinal bleeding from mucosal irritation or injury, feeding-related
diarrhea, or gastric, esophageal, or small bowel perforation.
Please note that you may or may not observe any of these complications during or following
this procedure.
I encourage you to monitor your patient closely for signs or symptoms of complications and
to be prepared to manage them, which includes having the necessary equipment available to
treat the complications, should any arise.
Assessment and Monitoring.
First of all, it is important to monitor the patient's vital signs, including oxygen saturation.
You will also want to observe for significant and/or unresolving coughing.
Finally, you will want to assess the patient's comfort during the procedure.
Documentation.
Following post-pyloric tube placement, you should document the following information
in the patient's medical record-- the indication for the procedure, the time and date of the
procedure, the depth of tube insertion, a confirmation of post-pyloric placement-- which
includes the presence or absence of a snap and the presence of the tube in the small
intestine on abdominal x-ray-- the vital signs before, during, and after the procedure.
You will also want to document the patient's comfort with the procedure and any adverse
outcomes.
This concludes our video.
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