[chikusachin]

hi!
i work in a paediatric Intensive care setting. We are trying to develop a guideline for my unit for bedside placement of NJ tubes and testing the tube position.
is anyone aware of any exisitng policies or research into this or a method that is being used in your specific units/wards.

If so, could i please have a look at it with a view to develop our own? Grateful for any information. Thanks

[suzanne4]

They need to be checked for placement with an x-ray. No other way to do it.

[janfrn]

A number of years ago our unit did a study on blind placement of nasojejeunal tubes at the bedside and as a result developed our procedure. I'm on vacation right now but I should be able to track down the resulting paper when I get back. Meanwhile, I can tell you how we do it...

The patient gets 0.1 mg/kg metoclopramide IV prior to beginning. The tube is measured and marked as for nasogastric placement, then marked again at the midaxillary line of the right costal margin. The patient is placed right sidelying, over as far as you can support them. A syringe (10 ml for infants, 20 ml for toddlers and up) is attached to the stylet and the med port closed. The tip is lubricated well and the insertion is identical as for nasogastric placement to the point of auscultating for the whoosh/gurgle, and aspirating stomach contents. After that point, the tube is advanced a couple of centimeters at a time using a slight corkscrewing motion and air is instilled with each advancement. (This takes two hands and some dexterity. You may need a second pair of hands to help keep the child positioned and to keep them from flying off the bed!) When the second mark is at the naris, placement is checked by auscultating for the whoosh/gurgle over the midaxillary line at the right costal margin. Attempts to aspirate should be met with a vacuum, ie the plunger should snap back when released. The brisker the snap the more likely that placement is correct... but can indicate that the tube is kinked or has coiled in the stomach. Also the tube will not usually slip back out if it has passed the pyloric sphincter. Once you are convinced the tube is where you want it, it is secured in place with Op-Site or Tegaderm and the stylet left in situ. An abdominal x-ray is obtained; if the tube clearly crosses the midline on x-ray, you're good to go. To remove the stylet, instill 2-3 ml sterile water through the stylet and withdraw the wire. Don't try to pull it out without the water... it won't come. I once had a patient who repeatedly dislodged her NJ tube and the doc said to put it in "a little farther" so if she pulled it out a bit it would still be in the small bowel. We all had a good laugh at the x-ray... the tube crossed the midline three times, and everyone was teasing me about checking her diaper!

[Redneckmedic63]

Originally Posted by janfrn

A number of years ago our unit did a study on blind placement of nasojejeunal tubes at the bedside and as a result developed our procedure. I'm on vacation right now but I should be able to track down the resulting paper when I get back. Meanwhile, I can tell you how we do it...

The patient gets 0.1 mg/kg metoclopramide IV prior to beginning. The tube is measured and marked as for nasogastric placement, then marked again at the midaxillary line of the right costal margin. The patient is placed right sidelying, over as far as you can support them. A syringe (10 ml for infants, 20 ml for toddlers and up) is attached to the stylet and the med port closed. The tip is lubricated well and the insertion is identical as for nasogastric placement to the point of auscultating for the whoosh/gurgle, and aspirating stomach contents. After that point, the tube is advanced a couple of centimeters at a time using a slight corkscrewing motion and air is instilled with each advancement. (This takes two hands and some dexterity. You may need a second pair of hands to help keep the child postioned and to keep them from flying off the bed!) When the second mark is at the naris, placement is checked by auscultating for the whoosh/gurgle over the midaxilary line at the right costal margin. Attempts to aspirate should be met with a vacuum, ie the plunger should snap back when released. The brisker the snap the more likely that placement is correct... but can indicate that the tube is kinked or has coiled in the stomach. Also the tube will not usually slip back out if it has passed the pyloric sphincter. Once you are convinced the tube is where you want it, it is secured in place with Op-Site or Tegaderm and the stylet left in situ. An abdominal x-ray is obtained; if the tube clearly crosses the midline on x-ray, you're good to go. To remove the stylet, instill 2-3 ml sterile water through the stylet and withdraw the wire. Don't try to pull it out without the water... it won't come. I once had a patient who repeatedly dislodged her NJ tube and the doc said to put it in "a little farther" so if she pulled it out a bit it would still be in the small bowel. We all had a good laugh at the x-ray... the tube crossed the midline three times, and everyone was teasing me about checking her diaper!

We do almost exactly the same, although don't routinely use the Reglan. You may not always hear the "woosh" over the midaxillary area, especially in the little ones, but the syringe snapping back is a good sign. Well written!

[kleern]

This is how we do it in our PICU and Peds unit. Xray is a must before feeding is started.

[EricEnfermero]

Are NJ tubes still standard practice in PICU? Over the last couple of years, our NICU has almost completely gotten away from NJ/ND tubes. It has been months since I inserted one. Just curious...

[*ac*]

At my hosp they are placed in Interventional Radiology.

[janfrn]

Originally Posted by EricEnfermero

Are NJ tubes still standard practice in PICU? Over the last couple of years, our NICU has almost completely gotten away from NJ/ND tubes. It has been months since I inserted one. Just curious...

They will always be standard practice in our unit. Along with nursing our patients sitting up... and so stoned they can't cough. (We're probably Canada's largest purchasers of methadone ) We're very proactive about early enteral feeds (sometimes Day 1 post-op CV surgery if the kid's not on a lot of pressors) and since many of pur patients are intubated for weeks to months, this reduces our risk of aspiration dramatically.

I popped one into an 11 day old on Tuesday that was probably the easiest one I've ever done. Took less than two minutes from the naris to the jejunum. But I've also had some not-so-easy ones, like the older baby with heterotaxy. She wasn't my patient but I was the only certified nurse on that day. Her nurse was very new to the PICU and didn't know the significance of the organs being backwards, so she didn't think to tell me that the baby needed to be on her LEFT side. Poor baby, I had to give up after four attempts and three AXRs... that I didn't look at myself because the resident "was on it". She didn't think I needed to know the stomach curved to the left!

Anotehr stand out experience was a few weeks ago. Patient was a teenager with significant developmental delay and a hyperpactive gag. He was in the unit for aspiration pneumonia, an ileus that precipitated the emesis that led to the aspiration (of PEG... ewww!) and has a history of reflux, so we really didn't want to feed him NG. His dad refused to leave the room out of fear that something else horrible would happen to his son, and I was perhaps a little too confident of my skills. Because of the gag, I could only advance the tube about 3 inches at a time, then wait several minutes while he coughed, gagged and turned red. But the tube passed easily enough until I got almost to the final mark. Then I'd get resistance, back the tube out a few inches and try again. On the third try, suddenly the tube fillled with blood. I yanked it and watched in horror as he coughed, coughed again, coughed a third time and his ETT filled with blood. The coughing and gagging with an oral ETT in place had eroded a vessel in his throat and even though he had a cuffed tube, his coughing allowed the bleeding to leak down into his trachea. He recovered rapidly from this event, but the die was cast. Despite his extremely high risk of aspiration we fed him NG for two days before we got him extubated. He's completely recovered and home now. Thank heaven.

[WarEagle4Life]

Our unit is also fairly aggressive with feeding our ventilated kiddos. Generally when we intubate, we go ahead and drop an ND or NJ while the child is still paralyzed from RSI. The procedure is exactly as Jan described. As long as the child is not on pressors, we start tube feeds via the NJ/ND. We place NG/OG strictly to decompress the stomach.

I had one patient who defied even the interventional radiologist. For over an hour, this MD tried and tried to pass the tube under fluoro. If it didn't kink or coil in spot, it kinked and coiled in another. He finally got to the stomach. Multiple attempts were made to advance the tube, but got only just a bit past the pylorus - no midline cross anywhere.

Most nurses on our unit are over-achievers. We tend to cross midline several times.