Feeding Tube Insertion and Placement Confirmation Using Electromagnetic Guidance: A Team Review

Role of registered dietitians in nasoenteric feeding tube placement

Provision of enteral nutrition (EN) in hospitalized patients is an integral part of clinical care. For various reasons, including but not limited to delayed enteral access placement and EN initiation, it is becoming more prevalent for registered dietitians (RDs) to place feeding tubes in various clinical settings. Although numerous RDs have expanded their practice by learning this skill, many remain hesitant about adding feeding tube placement to their scope of responsibilities. Feeding tube placement is within RDs' scope of practice. The recently updated Accreditation Council for Education in Nutrition and Dietetics (ACEND) standards is requiring dietetic interns to learn the process and assist in placing feeding tubes. This will help promote the inclusion of this practice and open doors for future advancement in the scope of practice for RDs. This review will provide an overview of feeding tube placement methods, evidence-based techniques, training, competencies, and barriers to accepting this practice in dietetics.

Small-bore feeding tubes placed with an electromagnetic imaging device leads to cost avoidance and decreased time to initiation of enteral nutrition

BACKGROUND

The Cortrak Enteral Access System (CEAS) was previously approved by the United States Food and Drug Administration (FDA) to be used in lieu of radiographic confirmation imaging for feeding tubes placed by trained clinicians. Following an institutional protocol change in 2016, our registered dietitians had the option to forgo radiographic confirmation imaging for tubes placed using the CEAS. Our research aimed to determine the difference in the number of radiographic confirmation images for feeding tubes placed using the CEAS between preprotocol and postprotocol environments and the associated cost avoidance after the institutional policy change.

METHODS

We retrospectively reviewed data from 506 tube placements (n = 253 per protocol environment) in adult patients with diverse diagnoses admitted to various in-patient care units.

RESULTS

There was a significant reduction in the mean number of radiographic images per tube placement (preprotocol = 1.10 [95% CI, 1.05-1.15]; postprotocol = 0.36 [95% CI, 0.30-0.41]; P < 0.001), leading to a cost avoidance of $67,282.80 for the 253 tube placements and a potential cost avoidance of $279,236 over the 5-year postprotocol environment. Additionally, the mean time to initiation of enteral nutrition was significantly reduced by 2.65 h in the postprotocol environment (P < 0.001).

CONCLUSION

Our findings suggest that using the CEAS can reduce the number of radiographic images, provide cost avoidance, and improve nutrition outcomes. However, updated 2022 FDA regulatory changes to the use of the CEAS for tube confirmation lead to an uncertain future for this practice because of safety concerns.

Nasogastric tube insertion length measurement and tip verification in adults: a narrative review

Nasogastric feeding tube insertion is a common but invasive procedure most often blindly placed by nurses in acute and chronic care settings. Although usually not harmful, serious and fatal complications with misplacement still occur and variation in practice still exists. These tubes can be used for drainage or administration of fluids, drugs and/or enteral feeding. During blind insertion, it is important to achieve correct tip position of the tube ideally reaching the body of the stomach. If the insertion length is too short, the tip and/or distal side-openings at the end of the tube can be located in the esophagus increasing the risk of aspiration (pneumonia). Conversely, when the insertion length is too long, the tube might kink in the stomach, curl upwards into the esophagus or enter the duodenum. Studies have demonstrated that the most frequently used technique to determine insertion length (the nose-earlobe-xiphoid method) is too short a distance; new safer methods should be used and further more robust evidence is needed. After blind placement, verifying correct gastric tip positioning is of major importance to avoid serious and sometimes lethal complications.

Safety of blind versus guided feeding tube placement: Misplacement and pneumothorax risk

Most intensive care unit patients require a feeding tube, but misplacement risk is high due to the presence of artificial airways and because unconsciousness reduces clinical warnings. Predominantly, tubes are placed 'blindly', where position is not known throughout placement. The result is that 1.6% enter the lung, 0.5% cause pneumothorax and potentially 5% are left in the oesophagus. Guided placement, by identifying tube position in real time, may prevent these problems, but undetected misplacements still occur. We review the safety of guided methods of confirming tube position, including rates of pneumothorax, in the context of current unguided methods. During blind tube placement, tube position can only be tracked intermittently. Excepting X-ray and ultra-sound, most methods of checking position are simple. Conversely, guided tube placement can track tube position from the nose to small intestine (IRIS®), or oesophagus to jejunum (Cortrak™, ENvue®). However, this requires expertise. Overall, guided placement is associated with lower rates of pneumothorax. Unfortunately, for Cortrak, low-use centres have higher rates of undetected misplacement compared with blind placement whereas Cortrak use in high-use centres had lower risk compared with blind placement and low use centres. Because guided placement requires high-level expertise manufacturer training packages have been developed but currently appear insufficient. Specifically, Cortrak's package is less accurate in determining tube position compared to the 'gastrointestinal flexure' system. Validation of an evidence-based guide for IRIS placement is underway. Recommendations are made regarding the training of new operators, including minimum numbers of placements required to achieve expertise.

The Evolving Use of Magnets in Surgery: Biomedical Considerations and a Review of Their Current Applications

The novel use of magnetic force to optimize modern surgical techniques originated in the 1970s. Since then, magnets have been utilized as an adjunct or alternative to a wide array of existing surgical procedures, ranging from gastrointestinal to vascular surgery. As the use of magnets in surgery continues to grow, the body of knowledge on magnetic surgical devices from preclinical development to clinical implementation has expanded significantly; however, the current magnetic surgical devices can be organized based on their core function: serving as a guidance system, creating a new connection, recreating a physiologic function, or utilization of an internal–external paired magnet system. The purpose of this article is to discuss the biomedical considerations during magnetic device development and review the current surgical applications of magnetic devices.

Intrapulmonary Feeding Tube Placements While Using an Electromagnetic Placement Device: A Review (2019-2021)

BACKGROUND

Intrapulmonary placements of feeding tubes inserted with use of an electromagnetic placement device (EMPD) continue to occur.

OBJECTIVE

To describe circumstances and outcomes associated with intrapulmonary feeding tube placements during use of an EMPD.

METHODS

A retrospective review of reports to the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database of intrapulmonary feeding tube placements during use of an EMPD from 2019 through 2021. Complications, outcomes, operator training, interference from anatomical variations and medical devices, and the use and accuracy of radiographs in identifying pulmonary placements were recorded.

RESULTS

Sixty-two cases of intrapulmonary tube placement were identified; 10 were associated with a fatal outcome. Pneumothorax occurred in 35 cases and feedings were delivered into the lung in 11 cases. User error was cited in 6 cases and was implicit in most others. Little information was provided about operator training. Four intrapulmonary placements were associated with anatomical variations and 1 with a left ventricular assist device. Radiographic follow-up was described in 28 cases and correctly identified 23 of the intrapulmonary placements.

CONCLUSIONS

User error was a significant factor, which highlights the need for empirical data to clarify the amount of training needed to safely credential EMPD operators. Clearer information is needed about anatomical variations that may contraindicate use of an EMPD, as well as medical devices that may interfere with an EMPD. Use of follow-up radiographs, interpreted by qualified personnel, is supported to increase the probability of identifying intrapulmonary tube placements.

Application of visual placement of a nasojejunal indwelling feeding tube in intensive care unit patients receiving mechanical ventilation

Background

Compared with nasogastric nutrition, nasojejunal nutrition may prevent some complications of critically ill patients by maintaining better nutritional status, and blind placement of nasojejunal dwelling feeding tubes is widely used. However, the visual placement seems to be safer and more effective than the blind placement, and is still seldom reported.

Objective

We tried to develop visual placement of a nasojejunal feeding tube in intensive care unit patients.

Methods

A total of 122 patients receiving mechanical ventilation were admitted to the Department of Critical Care Medicine of the Fifth Affiliated Hospital of Wenzhou Medical University and received the placement of nasojejunal feeding tubes. These patients were randomly and evenly assigned into two groups, one group receiving visual placement of nasojejunal dwelling feeding tubes and another group receiving blind placement. Actual tube placement was confirmed by X-ray. The primary outcome included the success rates of first placement of feeding tubes. The secondary outcome included the time of tube placement, complications, the total cost, heart rates and respiratory rates.

Results

The primary outcome showed that the success rates of first placement were 96.70% (59 cases/61 cases) in the visual placement group, and two cases failed due to pyloric stenosis and gastroparesis. The success rates were 83.6% (51 cases/61 cases) in the blind placement group and 10 cases failed due to either wrong placement or retrograde tube migration. The success rates in the visual placement group were higher than that in the blind placement group (P = 0.015). The secondary outcome showed that the time of tube placement in the visual placement group was shorter than that in the blind placement group (P < 0.0001). The cost of tube placement in the visual placement group was higher than that in the blind placement group (P < 0.0001). The statistical differences in complications, heart and respiratory rates were insignificant between the two groups (P > 0.05).

Conclusion

Compared with the blind placement, the visual placement shortened the time of nasojejunal tube placement and increased success rates of first placement. The visual placement was more efficient, easy to operate, safe, and has potential clinical applications.

Integrated real-time imaging system, 'IRIS', Kangaroo feeding tube: a guide to placement and image interpretation

Background

Lung complications occur in 0.5% of the millions of blind tube placements. This represents a major health burden. Use of a Kangaroo feeding tubes with an ‘integrated real-time imaging system’ (‘IRIS’ tube) may pre-empt such complications. We aimed to produce a preliminary operator guide to IRIS tube placement and interpretation of position.

Methods

In a single centre, IRIS tubes were prospectively placed in intensive care unit patients. Characteristics of tube placement and visualised anatomy were recorded in each organ to produce a guide.

Results

Of 45 patients having one tube placement, 3 were aborted due to refusal (n=1) or inability to enter the oesophagus (n=2). Of 43 tubes placed beyond 30 cm, 12 (28%) initially entered the respiratory tract but all were withdrawn before reaching the main carina. We identified anatomical markers for the nasal or oral cavity (97.8%), respiratory tract (100%), oesophagus (97.6%), stomach (100%) and intestine (100%). Organ differentiation was possible in 100%: trachea-oesophagus, oesophagus-stomach and stomach-intestine. Gastric tube position was confirmed by aspiration of fluid with a pH <4.0 and/ or X-ray. Trauma was avoided in 13.6% by identifying that the tube remained in the nasal lumen in the presence of a base of skull fracture (n=3) and in the stomach in the presence of recently bleeding polyps or mucosa (n=3). A systematic guide was produced from records of tube placement and interpretation of anatomical images.

Conclusion

By permitting real-time confirmation of tube position, direct vision may reduce risk of lung complications. The preliminary operator guide requires validation in larger studies.

The feasibility of electromagnetic sensing aided post pyloric feeding tube placement (CORTRAK) in patients with thrombocytopenia with or without anticoagulation on the intensive care unit

BACKGROUND

The successful initiation of enteral nutrition is frequently hampered by various complications occurring in patients treated in the intensive care unit (ICU). Successful placement of a nasojejunal tube by CORTRAK enteral access system (CEAS) has been reported to be a simple bedside tool for placing the postpyloric (PP) feeding tube.

METHODS

We evaluated the efficacy and side effects using CEAS to establish EN in patients with critical illness, thrombocytopenia, and/or anticoagulation.

RESULTS

Fifty-six mechanically ventilated patients were analyzed. Twenty-four of them underwent prior hematopoietic stem cell transplantation (SCT). Sixteen patients received extracorporeal membrane oxygenation treatment because of acute respiratory distress syndrome. The median platelet count at PP placement was 26 g/L (range, 4-106 g/L); 16 patients received therapeutic anticoagulation (activated partial thromboplastin time, 50-70 s). CEAS-assisted placement of a PP nasojejunal tube was performed successfully in all patients. The most frequent adverse event was epistaxis in 27 patients (48.2%), which was mostly mild (Common Terminology Criteria for Adverse Events grade 1, n = 21 [77.8%], and grade 2, n = 6). A significant association between a low platelet count and bleeding complications was observed (P < 0.001).

CONCLUSION

Performed by an experienced operator, CEAS is a simple, rapidly available, and effective bedside tool for safely placing PP feeding tubes for EN in patients with thrombocytopenia, even when showing an otherwise-caused coagulopathy in the ICU. Higher-grade bleeding complications were not observed despite their obvious correlation to thrombocytopenia. A prospective study is in preparation.

Comparison of electromagnetic guided imagery to standard confirmatory methods for ascertaining nasogastric tube placement in children

PURPOSE

Evaluate the accuracy of an electromagnetic device (EMD) guided nasogastric tube (NGT) placement compared with standard confirmation methods. A secondary aim was to determine if EMD guided NGT placement would avert potential pulmonary misplacements of the tube.

DESIGN AND METHODS

Pediatric Intensive Care Unit (PICU) patients were enrolled if they had an NGT order during the study period of April 2014 through December 2016. Patients were included if they were one through 18 years of age. An EMD trained nurse inserted the NGT using EMD guidance. An insertion questionnaire, confirming if the nurse determined the NGT to be gastric per EMD, was completed immediately after NGT placement and before confirmation via either pH testing or radiographic imaging.

RESULTS

Forty-five patients were enrolled in the study. Nurses reported, based on EMD, that 86.7% (n = 39) of placements were gastric. Overall agreement between EMD guided tube placement and pH testing was 58% (n = 26). The marginal distribution was significantly different between the two methods (p = .0029). When compared to radiographic confirmation, sensitivity of the pH method was 32% (95% confidence interval [CI]: 17%-51%) compared with 85% (95% CI 69%-95%) for the EMD method.

CONCLUSIONS

EMD guidance was superior to pH testing when compared with radiographic confirmation of nasogastric tube placement in children.

PRACTICE IMPLICATIONS

EMD guided NGT placement is a potentially viable method for confirming nasogastric tube placement in children when done by appropriately trained clinicians. More research on EMD guided NGT placement in children is needed before any practice recommendation can be made.

Tube placement using 'IRIS': A pilot assessment of its utility and safety

INTRODUCTION

Most critically ill patients have a feeding tube placed blindly, but 0.5% result in a major lung complication because misplacement is only detected at the end of procedure. Real-time guided tube placement may pre-empt such complications. This clinical effectiveness study examined the ability to visualise anatomy using Kangaroo™ feeding tubes with IRIS technology ('IRIS' tube).

METHODS

In a single centre, gastric or intestinal integrated real-time imaging system (IRIS) tubes were prospectively placed in critically ill patients noting the anatomical visualisation.

RESULTS

Of 15 placements, 13 were successful gastric placements and used for feeding but one gastric and one intestinal placement failed because of signal loss and inability to find the pylorus, respectively; both tubes were removed. Air insufflation and fluid aspiration were possible with all tubes. Respiratory misplacement was clearly differentiated, prior to reaching the main carina, from gastrointestinal (GI) anatomical markers, permitting removal before causing trauma. Furthermore, non-traumatic placement was visualised in high-risk cases including during advancement through a nostril with a base of skull fracture and into a stomach with a recently haemorrhaging gastric polyp. Individually assessed, direct vision may offer greater safety. X-ray or pH of aspirated fluid confirmed the position of GI tube placements. One adverse event occurred during placement, reversible bradycardia, in a patient previously having bradycardia. Vision was intermittently obscured by bile, mucus or impaction with mucosa.

CONCLUSION

'IRIS' tubes offer real-time guidance regarding anatomical position. Larger studies are needed to establish the best techniques of deploying this equipment and over-coming the difficulties observed.

Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

National Survey of Feeding Tube Verification Practices: An Urgent Call for Auscultation Deimplementation

BACKGROUND

Harm events such as pneumothoraces and pneumonia continue to be associated with feeding tube insertion. Most bedside verification methods are not accurate to discriminate pulmonary from gastrointestinal system. Evidence-based clinical practice guidelines do not support auscultation of feeding tubes in adults, yet auscultation is the most common method used.

OBJECTIVES

Our survey assessed national feeding tube verification practices used by critical care nurses, including progress in auscultation method deimplementation, and stylet reinsertion and cleansing practices.

METHODS

A national survey of 408 critical care nurses was performed.

RESULTS

The majority performed auscultation (311 of 408 [76%]) to verify feeding tube placement. In the final multivariable model, nursing education, facility type, observation of colleagues performing auscultation, and awareness of an institutional policy were associated with auscultation of feeding tubes. Thirty-five percent used enteral access devices to verify initial feeding tube placement. Stylet cleansing methods were variable; 38% of reinserted stylets were not cleansed.

DISCUSSION

Minimal progress has been made in deimplementation of auscultation in the past 7 years despite passive knowledge dissemination in research articles, clinical practice guidelines, and procedure manuals. Although pH measure is used as a first-line feeding tube verification method in the United Kingdom, it is rarely used in the United States. Clinical practice guidelines should be updated to incorporate new research on enteral access systems.

CONCLUSIONS

Tradition-based practices such as auscultation and certain stylet cleansing methods should be deimplemented. A focused interdisciplinary, multifaceted program is needed to deimplement auscultation practice for adult feeding tubes.

Efficacy and safety of a modified method for blind bedside placement of post-pyloric feeding tube: a prospective preliminary clinical trial

Objective

To compare the efficacy and safety of a new modified method of bedside post-pyloric feeding tube catheterization with the Corpak protocol versus electromagnetic-guided catheterization.

Materials and Methods

We conducted a single-center, single-blinded, prospective clinical trial. Sixty-three patients were treated with a non-gravity type gastrointestinal feeding tube using different procedures: modified bedside post-pyloric feeding tube placement (M group), the conventional Corpak protocol (C group), and standard electromagnetic-guided tube placement (EM group).

Results

The success rate in the M group, C group, and EM group was 82.9% (34/41), 70.7% (29/41), and 88.2% (15/17), respectively, with significant differences among the groups. The time required to pass the pylorus was significantly shorter in the M group (26.9 minutes) than in the C group (31.9 minutes) and EM group (42.1 minutes). The proportion of pylorus-passing operations completed within 30 minutes was significantly higher in the M group than in the C group and EM group. No severe complications occurred.

Conclusion

This modified method of bedside post-pyloric feeding tube catheterization significantly shortened the time required to pass the pylorus with no severe adverse reactions. This method is effective and safe for enteral nutrition catheterization of patients with dysphagia and a high risk of aspiration pneumonia.

Electromagnetic-guided versus endoscopic placement of post-pyloric feeding tubes: a systematic review and meta-analysis of randomised controlled trials

Background

Current evidence supporting the utility of electromagnetic (EM)-guided method as the preferred technique for post-pyloric feeding tube placement is limited. We conducted a meta-analysis to compare the performance of EM-guided versus endoscopic placement.

Methods

We searched several databases for all randomised controlled trials evaluating the EM-guided vs. endoscopic placement of post-pyloric feeding tubes up to 28 July 2020. Primary outcome was procedure success rate. Secondary outcomes included reinsertion rate, number of attempts, placement-related complications, tube-related complications, insertion time, total procedure time, patient discomfort, recommendation scores, length of hospital stay, mortality, and total costs.

Results

Four trials involving 536 patients were qualified for the final analysis. There was no difference between the two groups in procedure success rate (RR 0.97; 95% CI 0.91–1.03), reinsertion rate (RR 0.84; 95% CI 0.59–1.20), number of attempts (WMD − 0.23; 95% CI − 0.99–0.53), placement-related complications (RR 0.78; 95% CI 0.41–1.49), tube-related complications (RR 1.08; 95% CI 0.82–1.44), total procedure time (WMD − 18.09 min; 95% CI − 38.66–2.47), length of hospital stay (WMD 1.57 days; 95% CI − 0.33–3.47), ICU mortality (RR 0.80; 95% CI 0.50–1.29), in-hospital mortality (RR 0.87; 95% CI 0.59–1.28), and total costs (SMD − 1.80; 95% CI − 3.96–0.36). The EM group was associated with longer insertion time (WMD 4.3 min; 95% CI 0.2–8.39), higher patient discomfort level (WMD 1.28; 95% CI 0.46–2.1), and higher recommendation scores (WMD 1.67; 95% CI 0.24–3.10).

Conclusions

No significant difference was found between the two groups in efficacy, safety, and costs. Further studies are needed to confirm our findings.

Systematic review registration

PROSPERO (CRD42020172427)

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-020-00506-8.

Cortrak feeding tube placement: accuracy of the 'GI flexure system' versus manufacturer guidance

Electromagnetic (EM) guided enteral tube placement may reduce lung misplacement to almost zero in expert centres, but more than 60 undetected misplacements had occurred by 2016 resulting in major morbidity or death.

AIM

Determine the accuracy of manufacturer guidance in trace interpretation against what is referred to as the 'GI flexure system'.

METHODS

The authors prospectively observed the accuracy of the 'GI flexure system' of trace interpretation against manufacturer guidance in primary nasointestinal (NI) tube placements.

FINDINGS

Contrary to manufacturer guidance, 33% of traces deviated >5 cm from the sagittal midline and 26.5% were oesophageal when entering the lower left quadrant, incorrectly indicating lung and gastric placement, respectively. Conversely, the GI flexure system identified ≥99.4% of GI traces when they reached the gastric body flexure; 100% at the superior duodenal flexure. All lung misplacements were identified by the absence of GI flexures.

CONCLUSION

Current manufacturer guidance should be updated to the GI flexure system of interpretation.

Migration of Feeding Tubes Assessed by Using an Electromagnetic Device: A Cohort Study

BACKGROUND

Bedside methods to verify placement of a feeding tube are not accurate for detecting placement within the gastrointestinal tract, increasing risk of pulmonary aspiration. Current guidelines recommend verifying placement every 4 hours, yet the rationale for this recommendation is unknown.

OBJECTIVE

To assess spontaneous migration of small-bore feeding tubes in critically ill adults.

METHODS

A prospective, repeated-measures cohort study was performed in 2 intensive care units. An electromagnetic placement device was used to assess distal feeding tube location every 24 hours for 7 days. Tube migration between zones-esophageal, gastric, and postpyloric- was considered clinically significant.

RESULTS

Feeding tubes were analyzed in 20 patients. Interrater agreement was substantial for round 2 of a blinded analysis of insertion tracings (g = 0.78); 100% agreement was achieved after unblinding. Among 62 outcomes (migration assessments), 4 feeding tubes migrated 8 times (3 forward and 5 retrograde). All migrations occurred in the postpyloric zone and none were clinically significant. Within 24 hours of insertion, 50% of feeding tubes had migrated forward. Repeated-measures analysis showed a greater likelihood of migration in patients with an endotracheal tube (relative risk, 3.46 [95% CI, 1.14-10.53]; P = .03).

CONCLUSIONS

No tubes migrated retrograde into the stomach or esophagus, challenging the practice of verifying placement every 4 hours. Verification every 24 hours may be adequate if migration is not suspected. Also, lack of visible anatomical structures on insertion tracings from an electromagnetic placement device make subtle changes in postpyloric placement difficult to identify accurately.

Malposition of a nasogastric feeding tube into the right pleural space of a poststroke patient

Nasogastric feeding tube plays an important role in administering enteral feeding and drug delivery for poststroke patients with consciousness disorders or poststroke dysphagia. Nevertheless, placement of nasogastric tubes is not without any risk of potential harm. Inadvertent malposition into the trachea or the distal tracheobronchial tree could induce severe pulmonary complications. As for poststroke patients with long-term dysphoria, such tubes have to be replaced periodically to prevent the overdue service of the tubes. Therefore, the risk of feeding tube misplacement into pulmonary system for these patients is increased. Here, we present a case of a 79-year-old poststroke patient with hydropneumothorax induced by malposition of nasogastric tube into the right pleura after routine replacement, accompanied by acute anterior wall myocardial infarction.

Cortrak feeding tube placement: interpretation agreement of the ‘GI flexure’ system versus X-ray

Background:

Blind (unguided) feeding tube placement results in 0.5% of patients suffering major complications mainly due to lung misplacement detected prior to feeding. Electromagnet-guided (Cortrak) tube placement could pre-empt such complications but undetected misplacements still occur due to incorrect trace interpretation. By identifying gastrointestinal (GI) flexures from the trace, ‘the GI flexure system’, it has been proposed that tube position can be interpreted.

Aims:

To audit agreement between standards of interpreting tube position: the Cortrak ‘GI flexure’ system versus X-ray.

Methods:

In 185 primary nasointestinal tube placements tube position determined by Cortrak trace interpretation (GI flexure) was retrospectively compared with radiological position in a blinded study.

Findings:

Radiological and Cortrak interpretation agreed in 92.2–98.3% of placements at different GI flexures. Discrepancy mainly occurred because some radiological images were unclear or did not cover all anatomical points.

Conclusion:

The GI flexure method of Cortrak interpretation appears safe but would necessitate prospective radiological investigation to definitively test equivalence.

Pneumothoraces Prevented With Use of Electromagnetic Device to Place Feeding Tubes

BACKGROUND

A US Food and Drug Administration safety letter warned about the risk for pneumothoraces during feeding tube insertion despite the use of electromagnetic placement devices that provide real-time visualization of feeding tube position.

OBJECTIVES

To systematically assess pulmonary placement and pneumothoraces in CORTRAK-assisted feeding tube insertions.

METHODS

CINAHL, MEDLINE, and Cochrane databases were searched for studies of CORTRAK-assisted feeding tube insertion. Thirty-two studies documenting pulmonary placement and/or complications of feeding tube insertion were found.

RESULTS

Operators recognized pulmonary placement on insertion tracings during 202 CORTRAK-assisted feeding tube insertion procedures, resulting in the immediate withdrawal of 199 feeding tubes. One pneumothorax was identified later by radiography. Seven pulmonary placements were not recognized by CORTRAK operators at the time of feeding tube insertion, resulting in 2 pneumothoraces. The incidence of pneumothorax for CORTRAK-assisted feeding tube insertions was 0.02% (3 of 17039). Of the feeding tubes inserted into the pulmonary system - either found during or after the procedure -1.4% (3 of 209) resulted in pneumothoraces (as opposed to the 19% to 28% incidence of pneumothorax for blind feeding tube insertions. Operators recognizing pulmonary placement on CORTRAK insertion tracings may have prevented 97% (202 of 209) of feeding tubes from being inserted farther into the respiratory tract.

CONCLUSIONS

Feeding tube insertion with an electromagnetic placement device is advantageous over blind feeding tube insertion because the operator can recognize pulmonary placement early and withdraw the feeding tube, thus decreasing the risk of pulmonary complications.

Undetected Cortrak tube misplacements in the United Kingdom 2010-17: An audit of trace interpretation

OBJECTIVES

Determine why Cortrak-guided, undetected tube misplacement may occur in relation to the system of trace interpretation used.

METHODOLOGY

From 2010 to 2017 we obtained seven of the eight Cortrak traces from the United Kingdom where misplacement was undetected and the patient received feed. Seven suffered serious harm. Each misplacement was interpreted by three systems: screen position, manufacturer guidance and gastrointestinal (GI) flexures.

SETTING

National and local records.

MAIN OUTCOME MEASURES

Ability to identify misplacement.

RESULTS

Traces that were later identified as misplacements, could not be differentiated from GI position when they wholly or partially: a) overlapped with the GI screen area plotted from historical records (57-71%) or b) met both manufacturer guidance criteria or were confused with receiver misplacement or unusual anatomy and reached the lower left quadrant (14-71%). Conversely, all lung misplacements were identified as unsafe using the GI flexure system. All three systems failed to detect the intra-peritoneal trace. Traces were inconsistently stored by healthcare centres.

CONCLUSION

Trace file storage should be mandated by and accessible to relevant health authorisation bodies to improve safety research. Screen position alone and manufacturer guidance fail to consistently differentiate the shape of safe from unsafe traces. GI flexure interpretation appears safer but requires testing in larger studies.