Symposium 7 E t n l era N t u iti r on f sa er practi ti ce

Transcription

1 Symposium 7 Enteral Nutrition safer practice

2 Confirming the position of nasogastric feeding tubes: what does the future hold? L C l i i Lynne Colagiovanni Consultant Nurse Nutrition Support University Hospital Birmingham

3 Aims - 1 Briefly review methods used pre NPSA alert Briefly discuss current recommendations: * ph * Xray Review new/developing methods: * capnography * Cortrak Outline future possibilities

4 Aims - 2 Gastric vs respiratory placement In adult patients Across all care settings Newly inserted tubes & during ongoing use Assess new methods in terms of: Reliability Practicality Training issues Cost effectiveness

5 Pre NPASA Auscultation No evidence this is effective for ruling out respiratory placement Multiple reports of its ineffectiveness (Metheny & Meert (2004) Alerts stating this practice should be abandoned (NPASA 2006 AACCN 2006) Recent survey of 44 USA nurses found 86% still using this method. (Wenzel et al 2006)

6 Pre NPASA litmus paper Not specific Only tells if fluid is acidic or not Respiratory/pleural secretions can be slightly acidic False positives have been reported

7 NPASA recommendation - ph ph H5 or below taken to indicate gastric position Metheny et al (1998) 1200 fasting patients 18% gastric aspirates = ph % gastric aspirates = ph >7 100% respiratory aspirates = ph> 6

8 NPSA recommendations Xray Not for routine use Identify locally groups of high risk patients Risk assessment about when to use Need fully radio-opaque tubes

9 ph testing & X ray - problems ph Htestingti X ray Can t get aspirate Needs competent Aspirate often > 5.0 person to review Need to stop feed to Delays feeding check ph X ray exposure Colour differentials Out of hours issues difficult on some ph No use in community sticks settings Not helpful during ongoing care

10 New/alternative methods 2 step X ray protocol Tube is initially advanced blindly to 30cm X ray is done at this point to confirm tube not placed in bronchus If OK proceed with insertion X ray again at end (Roubinov o & Ravich 1989) Used routinely in USA i th ld t d d f f l t f is the gold standard for safe placement of nasoenteric feeding tubes (Roberts et al 2006)

11 New/alternative methods - Capnography Based on premise that t feeding tube inadvertently positioned in the respiratory tract will reveal a characteristic exhaled carbon dioxide waveform. Tube is inserted to level of the mid oesophagus (30cm) & connected to end tidal carbon dioxide monitoring equipment If carbon dioxide is detected, respiratory placement is suspected, if not tubes is assumed to be in oesophagus and is then advanced into stomach.

12 Capnography Burns et al (2001) Kindrupp et al (2001) 20 tubes on ITU patients 13 large bore ITU patients 7fi fine bore Fine bore all in procedure with oesophagus & confirmed by absence of carbon dioxide Large bore 3 in respiratory tract all showed carbon dioxide All correctly placed tubes X rayed to confirm they were in stomach and not oesophagus 100 tube placements in Used 2 step X ray capnography at step 1 11 tubes identified as being in tracheo- bronchial tree all confirmed by X ray.

13 Capnometry Colourmetric carbon dioxide indicator Attaches to end of tube Colour change if carbon dioxide present Uses 2 step technique, substituting Co 2 nfirm Now at step 1

14 Capnography Burns et al (2006) Elperm et al (2007) 195 tube insertions in tube placements in 69 ITU patients ITU patients Compared Con 2 firm Now all tubes > 14 fg with capnograph p capnometry incorrectly 60% large bore & 40% identified 16% of gastric fine bore placements as being in 27% were in tracheo tracheo-bronchial tree bronchial tree? reason for false 100% agreement positives between Co 2 nfirmnow and capnograph

15 Capnography Reliability * small studies/mainly ITU * Mainly large bore tubes * not accurate if fluid in tubes *?h holes in tube block with debris *? affect of carbonated a drinks * not 100% reliable Practicality * no if using capnograph * yes if using colourmetric detector * still need X ray to confirm position in stomach * not useful in ongoing management

16 Training i issues Cost effectiveness * Many with * More expensive than capnograph ph * Few with colourmetric * Cheaper than X ray indicator * Main problem is who trains especially in community * maintaining competency

17 Cortrak An electromagnetic tube placement device (ETPD) Shows the relative location of tube tip during placement Tip of tube stylet has electromagnetic transmitter Receiver unit sits on patients xyphoid process & acquires signal from stylet as it moves through patient Track of tube is shown on computer monitor

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21 Ackerman et al (2004) Phang et al (2006) 25 ITU patients 25 ITU patients 4 had lung placement 100% reliable in identified by Cortrak indicating tube Non placed into lung placement and not identified by Cortrak 100% reliable in avoiding lung placement

22 Lei et al (2007) 57 tube insertions in 52 ITU patients Cortrak 100% reliable in confirming tube position Gastric aspiration successful in 40% 14% had ph > X rays could have been avoided Saving of 2,300

23 Cortrak Reliability Small studies in ITU patients t Only in abstract form Appears to be 100% reliable in ruling out inadvertent lung placement Practicality Bulky & heavy to carry around Would need more than one if to be used routinely? how could be used in community Patient positioning Can uses to confirm position during ongoing use

24 Training issues Big consideration Need training and competencies Who s going to do it? How will competency be maintained? Cost effectiveness Expensive at first look Tubes 50 Machine 5500 Savings on X ray

25 Other suggestions ph in combination with concentrations of pepsin p and trypsin (Metheny 1997) ph in combination with bilirubin (Metheny et al 2000) Hot of the press! an electrochemical process and nanotechnology Prof Linda Sheilds Hull University

26 Summary Cortrak the most reliable Training, practicality and cost issues More studies needed in other patient groups More oework on ate alternativesat es

27 What price patient safety?