Competency in Post-pyloric Tube Placement, by Susan Hamilton and Julia Perkins
Introduction.
I'm going to place this patient’s 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 medication
to a child who will not tolerate oral or gastric feeding, secondary to known or suspected risk
of aspiration, the use of non-invasive ventilation,
depressed gag, severe GERD, gastric feeding intolerance,
and bronchospasm.
Contraindications.
Absolute contraindications that would prompt healthcare
providers to refrain from this procedure include
active GI bleeding and nasal, facial, or basilar skull fractures.
Exercise caution in performing this procedure in patients
patients receiving anticoagulant therapy and in patients that have a bleeding
disorder or thrombocytopenia with platelet counts of less than 50,000.
Exclusion criteria requiring further consideration includes
neonates less than 32 weeks post menstrual age and/or less than 1.5kg,
patients at high risk for gut ischemia or
radiographic evidence of necrotizing enterocolitis,
patients who are status post major anoxic injury with renal and liver dysfunction,
intestinal obstruction, suspected intestinal graft versus host disease,
a history of esophageal atresia, and patients with a history of
multiple previous failed attemps of placement on the floor.
Equipment.
You will need the following equipment to perform the procedure-- styletted feeding tube, syringe,
lubricant, tape, stethoscope, sharps container,
clear adhesive dressing, a marker, hydrocolloid dressing,
and sterile water.
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 the 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 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 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.
To approximate the jejunal, or third marking from the duodenal, or second marking, add
the following centimeters-- five to seven centimeters for a newborns,
seven to ten centimeters
for one to four years of age,
and ten centimeters for greater than four years.
If the patient has sensitive skin, consider placing duoderm
on the cheek prior to tube placement.
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.
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.
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.
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 first marking I’m going to place the patient down on the right side
to facilitate gravity movement of the tube past the stomach through
the pyloric sphincter.
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 kind of 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.
And 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.
Clinical pearl.
If the snap test is not positive, gently pull the tube back to the first, or gastric,
mark and repeat the steps until a positive snap is elicited.
You have up to three attempts to elicit a positive snap.
Once you have a positive snap, proceed to the next step.
Note that after the snap test, you should auscultate in the right upper quadrant
for high pitched crackles, and auscultate over the distal esophagus for
absence of sounds. In order to hear any high pitched or gurgling sounds, you
will need to push 2-5ml of air simultaneously
into both locations. I'm just going to use about five mLs of air,
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.
Never put the stylet back in once it's been taken out, due to the risk of perforation
of the bowel.
I'm going to get that tube secured.
And I'm going to go ahead and get an x-ray.
Point of Clarification.
Secure the tube to the patient’s face with dressing and tape,
Label the tube as post-pyloric, and obtain an abdominal x-ray to confirm proper
post-pyloric placement of the tube.
Consider maintain the patient in the right side-lying position for 30 minutes as
tolerated before getting an x-ray to facilitate peristalsis of the tube
into the jejunum.
Do not use the tube until the placement is confirmed by abdominal x-ray and
the provider has confirmed it is ok to use.