Naso Jejunal Tubes Insertion And Management

Clinical Guideline

NASO-JEJUNAL TUBES INSERTION AND MANAGEMENT

SETTING FOR STAFF PATIENTS

Bristol Royal Hospital for Children and Neonatal Intensive Care Unit All clinical staff (exception PICU staff) Paediatric inpatients (exception PICU patients)

Contents

Indications For Use Type Of Tube Insertion Procedure Documentation Ongoing Confirmation Of Tube Position On The Ward Administering Feeds And Flushes Administering Medications Reducing The Risk Of Aspiration And Strangulation Oral Hygiene Discharging A Patient Home With An Naso-jejunal Tube Accountability Troubleshooting Appendix 1: Naso-jejunal Tube Procedure Sticker Appendix 2: Flowchart For The Placement Of A Naso-Jejunal Tube In Children Appendix 3: Flowchart For Monitoring Naso-Jejunal Tube Feeding In Children References

INDICATIONS FOR USE

Naso-jejunal (NJ) tubes are indicated if it is not safe or effective to feed via the stomach due to:

- Congenital gastrointestinal abnormalities - Gastric dysmotility / High risk of aspiration - Severe vomiting causing faltering growth - Anti-cancer treatment-induced nausea / mucositis - Patients with a gastro-oesophageal disconnection may require an NJ tube for drainage

The tube is passed through the stomach and pylorus, through the duodenum into the jejunum

TYPE OF TUBE

Refer to Enteral Feeding Equipment Management SOP

Extra length must be measured for the tube to be long enough to reach the proximal jejunum

A wider tube is preferable to minimise risk of tube blockage:

0 ? 5 years old: 8fr and at least 85cm long term nasogastric tube (non-weighted) 6 years and over: 8fr - 10fr and at least 120cm long term nasogastric tube (non-weighted) A nasojejunal non-weighted Corflo tube is available in size 8fr, 140cm for older children

Version 1 ? 05 2015 - Review 05 2017

Extended until Jan 2024

Author(s) Zoe Hull, Specialist Dietitian, Jackie Porter, Gastro Nurse

Page 1 of 10

INSERTION PROCEDURE (with the exception of PICU ? see local guidance)

A decision to insert an NJ tube must be made in daytime working hours by the Medical Team

If fluids and/or nutrients are to be administered, the Nurse must refer to the Dietitian

An appointment in Radiology must be confirmed before passing the tube. The tube will be fluoroscopically guided into the proximal jejunum and position checked by abdominal x-ray

Blind placement of an NJ tube into the small bowel is not performed on the ward at the bedside

A Nurse must pass the tube at the bedside into the stomach in line with the Nasogastric / Orogastric Tube Clinical Guideline

Additional length of tubing must then be inserted after removal of the guidewire to allow the tube a chance to migrate through the stomach prior to attending Radiology for confirmation and manipulation of tube tip placement. Refer to Appendix 2 for how far to advance the tube:

WARD-BASED NASO-JEJUNAL TUBE INSERTION CHILDREN'S NURSING PATHWAY

If there is any resistance felt during insertion, do not attempt to insert any further

NJ tubes cannot be passed in the community. The child will need to be admitted if the tube is accidentally removed at home or requires changing for radiological placement

DOCUMENTATION

The Medical Team must document the rationale for an NJ tube in the medical notes, including discussions held with Parents/Carers and the multi-disciplinary team

The Nurse must record date and time of passing the tube, including tube make, width, length on a Naso-jejunal Procedure Sticker: Appendix 1 and stick in the medical notes

The Radiologist will record the external length the NJ tube is passed to (from nostril to feeding port) on the Naso-jejunal Procedure Sticker Appendix 1 once the procedure is complete and mark this length at the nostril with permanent pen (aids safe checking of the NJ tube position)

The Nurse must record make, width and length of NJ tube, and marked external insertion length in the Core Care Plan Booklet and Naso-jejunal Tube Teaching Pack

ONGOING CONFIRMATION OF TUBE POSITION ON THE WARD

NJ tubes can fully or partially dislodge and migrate into the stomach. This is rare once NJ tube position has been confirmed in the proximal jejunum by radiology

See Appendix 3: Flowchart for Monitoring Naso-jejunal Tube Feeding in Children

Prior to each use, 4 hourly during continuous feeding (12 hourly once target rate has been maintained for 24 hours) and if there are concerns over displacement, confirm tube position:

A) Check the marked external insertion length at the nostril has not changed i.e. tube has not moved significantly in or out of the nose, and ensure the tube is securely taped

If the external marked length has not changed and the patient is tolerating feeds without cause for concern, feed as directed by the Dietitian

Version 1 ? 05 2015 - Review 05 2017

Extended until Jan 2024

Author(s) Zoe Hull, Specialist Dietitian, Jackie Porter, Gastro Nurse

Page 2 of 10

 If the marked external length has moved or disappeared or the risk of NJ tube displacement is high (patient retching/vomiting feed, aspiration, abdominal distension) the tube tip may be malpositioned. Do not use the NJ tube ? follow the advice below:

If the patient has been receiving continuous feeds and/or medications, stop using the tube and wait at least one hour for intestinal contents to empty (pH level of gastric aspirate may be elevated by acid-suppressant medications and enteral feeds)

Instil 2 ? 10ml of air into the NJ tube; if unable to aspirate the air back, the NJ tube is likely still in the jejunum. If a large volume of air (> 15ml) is aspirated, tube may be coiled in the stomach

Attempt to gently aspirate fluid from the NJ tube and check colour and pH (aspirate is very difficult to obtain from the jejunum, so only a small amount, if any, will be obtained)

If only a small volume (< 15ml) `light/dark golden yellow' aspirate is obtained, the tube is likely to still be in the jejunum. The pH will test 6 ? 8 (alkaline)

If a large volume (> 15ml) of `grass green' clear or `cloudy white with residual formula' aspirate is obtained, the tube tip is likely to be in the stomach. The pH should test 5.5 (be aware of acid suppressant drugs which may elevate gastric pH above this level)

If there is still doubt over the correct position of the NJ tube in the jejunum, contact the Medical Team to request an abdominal x-ray to confirm position before using the tube

NOTE: Routine aspiration of jejunal tubes is not advised (risk of tube collapse)

ADMINISTERING FEEDS AND FLUSHES

Aseptic Technique and Aseptic Non Touch Technique Policy must be employed before and after handling a jejunal tube and disposable gloves worn (due to bypassing stomach defences)

Adhere to Enteral Feeding Infection Control Guideline

Before each use of the NJ tube, confirm tube position using methods A) B) and C) above

Follow instructions on the Dietitian's Yellow Feed Plan. If the Dietitian is unable to assess the patient, use the Jejunal Out of Hours Feeding Regimen (authorised by a Consultant)

Bolus feeds must not be given into the jejunum (dumping syndrome/discomfort can occur)

Continuous naso-jejunal feeding will take place for up to 24 hours in the day and/or night. See Enteral Feeding Guidelines (Paediatric) `how to administer continuous feeds'

Thickened feeds must not be given into the jejunum (e.g. Thixo-D, Nutilis, Gaviscon)

Flush with 5 ? 10ml sterile water (adjust to child's age / size) or amount advised by Dietitian, before and after feeding (exception NICU ? no water flushes given due to fluid overload risk)

Use a new 60ml enteral syringe (10 ? 20ml small infants) to flush before and after feeding

Flush every 4 - 6 hours if the tube is not in routine use and during continuous feeding to minimise blockages (exception NICU ? no water flushes)

Administer all flushes with a `push pause' technique to help minimise blockages. Slow flushing into the jejunum is advised to minimise discomfort. Never use vigorous pressure

Version 1 ? 05 2015 - Review 05 2017

Extended until Jan 2024

Author(s) Zoe Hull, Specialist Dietitian, Jackie Porter, Gastro Nurse

Page 3 of 10

ADMINISTERING MEDICATIONS

Refer to Enteral Feeding Guidelines (Paediatric) `how to administer medications'

Do not give medications via an NJ tube where possible. Check first with a Pharmacist, as some medications are not effective unless given into the stomach and may increase risk of blockages

Flush with sterile water before and after each medication with a new 60ml (10 ? 20ml small infants) enteral syringe for each episode (exception NICU ? no water flushes)

Medications may be administered in smaller size syringes if the dose is very small

REDUCING THE RISK OF ASPIRATION / STRANGULATION

Position the infant/child on their back or right side with their feet at the foot of the cot/bed

Elevate the head of the cot / bed by 30 ? 45 degrees, or sit the patient upright during feeding and for one hour after feeding has finished

Keep tubing away from the infant/child's head by positioning the NJ tube over the ear and threading down the back of the baby-gro or pyjamas

Place the enteral feeding pump at the top of the cot/bed and thread tubing through bars

Patients having a continuous feed must be nursed in an easily observable ward bed. Babies should be nursed on an apnoea monitor (saturation monitoring if a monitor is unavailable)

If there are signs of retching, vomiting, or coughing spasms, stop feeding immediately. The tube may need to be removed if this continues

If the patient settles down, confirm tube position before use in case the tube has dislodged

ORAL HYGIENE

If the patient is not able to take any oral fluids, give mouth care every 2 ? 4 hours to help prevent their mouth getting very dry and brush their teeth as usual

ACCOUNTABILITY

Registered practitioners identified individually at the Ward Manager's discretion, that have attended training and have been assessed as competent, may undertake insertion of tubes as far as the stomach only, test for correct placement, and administer feeds, but not medications

Student nurses that have attended Trust training, and have been assessed as competent, may under DIRECT supervision of a registered Nurse undertake insertion of tubes as far as the stomach only, test for correct placement, and administer feeds, but not medications

Overall responsibility and accountability lies with the registered Nurse to confirm placement of the tube in the stomach by observing documentation, before taking the child to Radiology

Version 1 ? 05 2015 - Review 05 2017

Extended until Jan 2024

Author(s) Zoe Hull, Specialist Dietitian, Jackie Porter, Gastro Nurse

Page 4 of 10

DISCHARGING THE PATIENT HOME WITH AN NJ TUBE

Naso-jejunal tubes cannot be passed at home. Before discharge, the Medical Team must arrange a plan for admission for emergency placement if the tube comes out with Parents/Carers. The plan must be recorded in the medical notes, including the maximum time (ideally not over 12 hours) the child can remain without an NJ tube in situ, and whether they are able to have a nasogastric tube placed in the meantime

IV support may be required until Radiology is able to place the tube. For urgent NJ tube replacement, contact the Radiologist on call

If the NJ tube is accidentally removed at home, parents must bring the child to the Children's Emergency Department (CED). CED staff will refer to the emergency plan documented in the medical notes by the Medical Team

The Medical Team must also arrange a date and place with Parents/Carers, the ward and Radiology for the child to be admitted for a planned tube change before discharge

A plan for review and consideration of long-term nutrition support methods should be documented by the Medical Team in the patient's notes and discussed with Parents/Carers

CED staff need the correct size and length of NJ tube to pass before child attends Radiology. The Dietitian will inform CED when a child is discharged home with an NJT and take a spare tube of correct size and length to CED for that child. A list of community patients with NJ tubes will be updated by the Dietitians (via CED secretary) and emergency stock of these tubes for named children will be maintained in theatres and CED

Parents / Carers must be educated in safe care of a child with an NJ tube using the Nasojejunal Tube Teaching Pack and signed off as competent prior to discharge by Nursing Staff

The `Competency summary sheet' in the Nurse section of the pack is filed in the medical notes

Adhere to Discharging a Patient Home with a Naso-jejunal Tube in the teaching pack

If patient is on continuous overnight feeds, the Dietitian must liaise with the local home enteral feeding team and confirm if this can be supported at home. If this will not be possible, the Dietitian must agree a day feeding regimen with the Consultant

If overnight feeding can be supported, a `Risk Assessment for Overnight Feeding' (see Naso-jejunal Tube Teaching Pack) must be completed by a Nurse before discharge

For patients living in the Bristol area (under Home Management Services)

- Parents/Carers must be taught to flush the NJ tube with a 60ml syringe at least one week before discharge (community policy)

- Parents/Carers must be informed that cooled boiled water may be advised at home and also that they may be given reusable syringes at home (depending on local policy)

Version 1 ? 05 2015 - Review 05 2017

Extended until Jan 2024

Author(s) Zoe Hull, Specialist Dietitian, Jackie Porter, Gastro Nurse

Page 5 of 10

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