NASO/ORO-JEJUNAL TUBE INSERTION - Weebly

[Pages:3]Techniques

MCH NICU

NASO/ORO-JEJUNAL TUBE INSERTION

Indications

Naso- or oro-jejunal (or duodenal) tubes are also known as transpyloric tubes and are used in patients with an inability to tolerate gastric feeds for various reasons.

Contraindications

Upper GI mechanical obstruction (e.g. esophageal/duodenal atresia or stenosis) Significant upper GI bleeding Esophageal varices Active necrotizing enterocolitis (NEC) Avoid insertion by nurse in cases where:

- baby weighs less than 2.4 kg, - has had recent upper GI or mouth/nose surgery, - previous fundoplication, suspected NEC, - significant cardiorespiratory instability, - known short gut, - severe coagulopathy or is on anticoagulation therapy.

Materials

The appropriate transpyloric tubes can be found in the tall grey cupboard in the cooling room in the second drawer from the top.

Transpyloric polyurethane feeding tube (see table below for guide to choosing size) Gastric feeding tube (6Fr or 8Fr) 60 mL syringe 10 mL syringe Sterile water Adhesive tape for securement Water-soluble lubricant (e.g. Muko) Permanent marker

Note: This procedure requires the insertion of two tubes

Gestational age

44 weeks CGA

> 44 weeks CGA

Weight

2.4 kg ? 3 kg > 3 kg

2.4 kg ? 3 kg 3.1 - 5 kg > 5 kg

Size

5 Fr 6 Fr

5 Fr 6 Fr 8 Fr

Weighted tip

No

Guidewire

No (May be used by radiology only)

NJ/OJ tube insertion

Extract from MCH Protocol - Blind Bedside Nasal or Oral Transpyloric Feeding Tube Insertion, Monitoring, and Maintenance in Neonatal and Pediatric Patients Updated Jan 2019

Page | 1 of 3

Techniques

Key points

Transpyloric feeding tubes can be inserted nasally or orally. Orally inserted tubes are preferred in cases of:

- Posterior pharyngeal injuries - Maxillo-facial injury involving nares or palate - Patients requiring non-invasive ventilator support (e.g. bCPAP) - Obstruction of nasal passages (e.g. choanal atresia)

Nasally inserted tubes are preferred in cases of: - Infants in oro-motor exploration stage of development

Procedure

1. Measure length of insertion of transpyloric tube (see table below)

44 weeks CGA

? Measure from the crown of the head to the mid-calf with leg fully extended ? Mark this point on the tube with permanent marker

MCH NICU

> 44 weeks CGA

? Measure from the nose to the earlobe, then from the earlobe to the mid-umbilicus. Finally, measure to the lateral costal margin (see picture below).

? Mark this point on the tube with permanent marker

Earlobe

Nare

Lateral costal margin

Umbilicus

2. Insert the NG/OG as per protocol and secure it. 3. Insert the transpyloric tube to the same length as the NG/OG and close both ports of the transpyloric tube. 4. Insufflate the stomach with 10 ml/kg of air via the NG/OG. 5. Place the patient on their right side with the head of the bed elevated to a 45-degree angle and proceed to push the

transpyloric tube until the length indicated by the permanent marker. You may encounter some light resistance. This indicates that you have reached the pyloric sphincter. You should keep pushing and may use and spiral or corkscrew method to push past the pyloric sphincter. NOTE: If you encounter strong resistance, stop pushing, remove the tubes and consult the medical team. 6. Secure transpyloric tube when the marking is at the patient's lip or nose. 7. Perform the `air test': Close the NG/OG and attempt to remove the air pushed into stomach via the transpyloric tube;

If you can remove air, you are most likely in the stomach. Decompress the stomach via the NG/OG and advise the medical team.

If you cannot remove air, you may be in the small bowel. Decompress the stomach via the NG/OG and confirm placement with an X-ray. DO NOT administer any fluid via the transpyloric tube until placement is confirmed by the medical team.

NJ/OJ tube insertion

Extract from MCH Protocol - Blind Bedside Nasal or Oral Transpyloric Feeding Tube Insertion, Monitoring, and Maintenance in Neonatal and Pediatric Patients Updated Jan 2019

Page | 2 of 3

Techniques

MCH NICU

8. Document the intervention and patient's tolerance.

WARNING: Transpyloric feeding tubes should NEVER be used for bolus feeds. Bolus feeds via these tubes are associated with a significant risk of dumping syndrome with subsequent hypoglycemia,

dehydration, and electrolyte instability. Transpyloric tubes should be used for continuous feeds alone.

Maintenance and monitoring

Frequency Intervention

After medication administration

? Flush tube with 1-10 mL of sterile water to ensure medication is completely administered and any residue is flushed through the tube (volume of flush depends on size and tolerance of patient).

? Note if any resistance to flushing is felt (refer to Troubleshooting section below) ? NOTE: Only liquid and very finely crushed medications dissolved in water should be administered by

transpyloric tube. Large granules of medication will cause these tubes to block (refer to Troubleshooting section below).

Q 12 hours

? Assess and document tolerance of feeds. ? Assess and document position using measurement on tube ? Flush tube with 1-10 mL of sterile water (volume of flush depends on size and tolerance of patient).

NOTE: not necessary if already flushed for medication administration at least twice per 24 hours.

Q 28 days

? Change tube following procedure described above ? NOTE: This does not apply to tubes inserted in the Operating Room by General Surgery, nor to tubes

placed by radiology

Troubleshooting

Problem

Resistance to flushing

Displaced tube

Solution

? Begin by attempting to flush tube with warm water. ? Use 10 mL syringe or larger and turbulent flushing technique. ? DO NOT INSTILL COKE OR FRUIT JUICE ? discuss further steps with MD (digestive enzymes may be

considered)

? Do not feed patient (stop feed) ? Inform treating team ? X-ray (AP and lateral) should be ordered to determine exact placement ? Remove tube as ordered by treating team

NJ/OJ tube insertion

Extract from MCH Protocol - Blind Bedside Nasal or Oral Transpyloric Feeding Tube Insertion, Monitoring, and Maintenance in Neonatal and Pediatric Patients Updated Jan 2019

Page | 3 of 3

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