bedside placement of nasojejunal tubes

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!

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...