Placement Care of Dobhoff

[chenoaspirit, ASN, RN]

I had a patient with dobhoff, receiving tube feeds. Her lungs were progressively filling up with fluid. Her sats were gradually dropping. So I turned off the dobhoff and IV fluids, called the doc. She assessed the patient and asked me why I turned off the tubefeeds. I told her I did so in case the dobhoff had displaced/migrated into lung. She acted like I was an idiot. I was taught to do so in school and thats how I've always cared for any dobhoff. I've had them to dislodge and it isn't pretty. I was also taught to tape the wire on the wall in the patient's room just in case its needed. Well, the doc finally agreed to a chest xray, which showed the dobhoff below the diaphragm so I turned the TF's back on. But I wasnt comfortable turning it on until placement was verified. Also, is it feasible to check placement like you do a NG tube.....injecting air into it and auscultating via stethoscope? I've never been able to hear the gurgling with a dobhoff. Any suggestions, please. And also, would you have also been concerned about placement? I've never had a doc to question it before. Thanks.

[registerednutrn, BSN, RN]

I am pretty sure the only way to verify placement of a dobbhoff is by x-ray since it actually goes into the duodenum. I was also taught that you should keep the guide wire handy since it may be need to replace the tube. Sound to me like you did the right thing and is what I would have done

[RazorbackRN, BSN, RN]

Was it supposed to be gastric or transpyloric (TP)?

Typically, we use Dobhoffs only when we're feeding TP. If it was supposed to be TP, then a quick way to check placement is with a "snap". You can put a 10cc syringe on the end of the tube and when you pull back on it, the plunger should snap back down. Of course, this is not a 100% reliable method, but it is a pretty good way to check until xray.

You can also stick the end of the tube (cap open) in a glass of water. If you see air bubbles upon expiration, you can bet it may be in a lung. Again, just a quick check until xray.

You can also auscultate, but it is heard more midline to the right, rather than in the stomach ( if it is trans-pyloric).

By the way, you totally did the right thing by turning off the feeds until you knew what was causing the resp. issues.

[kmoonshine, RN]

Yeah, you did the right thing. Just imagine if it been in her lungs! The conversation from the doc would've been different then: "Why DIDN'T you turn the feeding off, since her sats were dropping and you noticed fluid filling her lungs throughout the shift!?!"

Better safe than sorry - GOOD JOB.

[chenoaspirit, ASN, RN]

Thanks for your replies! The entire conversation with the doc made me question myself. I thought I was right, but still wondered.

[NurseCard, ADN]

wow, interesting timing of this thread... I also have a patient who recently received a dobhoff, know little to nothing ABOUT dobhoff's, and we also had respiratory issues just early yesterday morning, so that patient also stopped getting her fluid.

In fact I didn't even know that the dobhoff is supposed to go into the duodenum, not just the stomach. The nurse that I gave report to this morning asked me why a KUB has not been done to confirm placement... only a chest X ray. I basically had to tell her I did not know but that the lung specialist who had the tube placed said that based on the X rays that had been done, the tube could be used.

I feel like an idiot.

[Daytonite, BSN, RN]

there is information on dobhoff tubes on this webpage:

• http://www.icufaqs.org/ngtubes.doc - n/g tubes for beginners

[AuntieRN]

I also always thought the only way to check placement with a dobhoff was a kub but my hospitals policy is to check placement with air bolus like an NGT. This makes no sense to me...we had one a few weeks ago...checked it twice with a kub and the pt pulled it out during the night. When they replaced it the nursing supv told them they did not need an xray....check placement like NGT and use it. I was very uncomfortable with this and tried to find policy on it. We couldnt find anything specific to the dobhoff so my clinical director decided we just needed to verify placement as if it was an NGT. So thats what was done.

I too would have shut off the feedings until placement could have been verified for certain. Why chance it....

[NeosynephRN]

With our dobhoffs when we place it initially it has to be verified by an KUB....then we verify placement q4 hours the same way we do with an NGT except you want to listen on the lower right side...I would have done the exact same thing you did by shuting off the feed...I mean even if that tube was in the right place, it still sounds like she was aspirating..we are lucky on our floor we can order the KUBs as needed for dobhoffs. We are also the only people in house who can place them...well endo can but they are not there when I work.

They recently changed the policy about the guide wires..we now throw them away...because apparently you increase the chance of perferation if you try to re advance that wire..I have not read any lit on this...just was the reasoning we got. Good Job!!

[glasgow3]

AuntieRN said:

I also always thought the only way to check placement with a dobhoff was a kub but my hospitals policy is to check placement with air bolus like an NGT. This makes no sense to me...we had one a few weeks ago...checked it twice with a kub and the pt pulled it out during the night. When they replaced it the nursing supv told them they did not need an xray....check placement like NGT and use it. I was very uncomfortable with this and tried to find policy on it. We couldnt find anything specific to the dobhoff so my clinical director decided we just needed to verify placement as if it was an NGT. So thats what was done.

You should check an initial feeding tube placement with a KUB. Once confirmed the tube should be marked so you can see if it moved. Only after initial placement is confirmed with x-ray are other methods acceptable to (re)confirm (ie for periodic routine placement confirmation).

Personally, if I had a marked tube and used one or more periodic confirmation techniques after an initial KUB I probably would not have turned off the feeding all things being equal----on the other hand so what if you DID happen to shut it off unnecessarily? Big deal! Unless you did it so frequently that the patient wasn't getting their calories what was the harm? None that I can see, and your hunch could have been correct.

The NGT business is a non-issue------if it's to be used for feedings or meds, then its placement should be confirmed/maintained exactly the same way!!

If memory serves the AACN is quite clear on this; I would regard initial KUB confirmation as a standard of care. I think your hospital's policy should be revised ASAP.