Nasogastric Tube Placement and Verification in Children

13 Pages·2014·0.2 MB·English

Crit Care Nurse Papers in Press. Published on April 15, 2014 as Manuscript ccn2014606
Nasogastric Tube Placement and Verification
in Children: Review of the Current Literature
Sharon Y. Irving, RN, PhD, CRNP
Beth Lyman, RN, MSN, CNSC
LaDonna Northington, RN, DNS
Jacqueline A. Bartlett, RN, PhD
Carol Kemper, RN, PhD, CPHQ
NOVEL Project Work Group
Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is common practice and
largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct
initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications
for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially
lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying
placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside
placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli
for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Soci-
ety for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology
development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric
populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children
through an overview of the current state of the science. It is important for all health care professionals to be knowledgeable
about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and
ongoing verification of tube location. (Critical Care Nurse. Published online April 15, 2014.)
I
n 2012, a safety alert was distributed by the Child Health Patient alert.1In addition, the alert specifies
Safety Organization to recommend immediate discontinuation of children who are considered at high
the auscultation method for the assessment and verification of risk for misplaced or dislodged gas-
nasogastric tube placement.1A study cited in the alert reported that 1.3% tric enteral tubes: neonates, children
to 2.4% of nasogastric tubes in more than 2000 insertions were located with neurological impairment, chil-
outside the gastrointestinal tract. Moreover, more than 20% of the mis- dren in an obtunded neurological state,
placed nasogastric tubes led to pulmonary complications.1,2This alert and children who are encephalopathic,
acknowledges an abdominal radiograph as the current gold standard have a decreased gag reflex, or are
when other nonradiographic methods for validation of tube location sedated or critically ill. For these chil-
are not confirmatory. In lieu of or when abdominal radiography is not dren, the alert included a recommen-
readily available, accurate measurement of enteral tube insertion length, dation for abdominal radiography as
gastric pH testing, and visual observation of gastric aspirate are accept- the best practice for verifying location
able nonradiologic methods for assessing tube placement listed in the of a gastric enteral tube.1
Although placement of a nasogas-
Critical Care Nurse and Nutrition in Clinical Practicehave arranged to publish this article simultane-
tric tube is a common procedure, it is
ously in their publications. Minor differences in style may appear in each publication but the article is
substantially the same in each journal. not without risk of significant harm
©2014 American Society for Parenteral and Enteral Nutrition and American Association of Critical-
or death. In addition to this alert, the
Care Nurses doi: http://dx.doi.org/10.4037/ccn2014606
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American Association of Critical-Care of The New Opportunities for Veri- placement for both the inpatient and
Nurses issued a practice alert3and fication of Enteral Tube Location outpatient pediatric populations.”
the American Society for Parenteral (NOVEL) Project sponsored by In an effort to present the scope
and Enteral Nutrition (A.S.P.E.N.) A.S.P.E.N. NOVEL is an interorgani- of the challenge for bedside place-
implemented practice recommenda- zational, multiprofessional under- ment of a nasogastric tube accurately,
tions4to address the risks and poten- taking with representatives from the the authors felt it important to pres-
tial complications associated with American Association of Critical-Care entan overview of the current liter-
misplaced nasogastric tubes. Place- Nurses; the Society of Pediatric ature addressing this issue. Therefore,
ment of a gastric EAD potentially Nurses; the North American Society the purpose of this article is to review
poses risks to patient safety, and device for Pediatric Gastroenterology, the current state of the science for
dislodgement poses similar risks. Hepatology, and Nutrition; the Child verification of bedside placement
These phenomena are not predictable. Health Patient Safety Organization; of nasogastric tubes and ongoing
Because of the threat to patient safety, and the American Association for assessment of tube location in chil-
placement of a nasogastric tube Medical Instrumentation. This issue dren. Although the term nasogas-
should be treated with the same of nasogastric tube placement and tric tube is well-recognized and
respect as placement and manage- ongoing location verification crosses often used, the more comprehensive
ment of a central venous access device the continuum of care. Recognizing and inclusive term is nasogastric
or an indwelling urinary catheter. this, the goal of the NOVEL project enteral access device (NG-EAD),
All health care professionals should is to work toward effective, practical the preferred terminology of
avoid complacency with nasogastric solutions to the challenge of safe ini- A.S.P.E.N.4This term will be used
tube placement and ongoing location tial placement of nasogastric tubes throughout the remainder of this
verification and be vigilant for possi- and ongoing verification of correct article.
ble complications. placement. Its mission is “to identify
This practice alert along with and promote best practices for [naso- Background
long-standing challenges surround- gastrictube] placement and to explore In many hospitalized children
ing bedside placement (also called the potential of technology develop- and pediatric patients receiving
blind placement) of nasogastric tubes ment that will allow for accurate home care, NG-EADs are used to
was the stimulus for the conception determination of [nasogastric] tube facilitate nutrient intake and med-
ication administration.5-8Halloran
et al9estimated that more than 1
Authors
million NG-EADs are placed annu-
Sharon Y. Irving is a pediatric critical care nurse practitioner at The Children’s Hospital of
Philadelphia and an assistant professor at the University of Pennsylvania, School of Nursing, ally in adults. However, the number
Philadelphia, Pennsylvania. She is the AACN liaison for the New Opportunities for Verifica-
of NG-EADs placed and used in
tion of Enteral Tube Location (NOVEL) project sponsored by the American Society of Parenteral
and Enteral Nutrition (A.S.P.E.N.). children and the frequency of
Beth Lyman is a senior program coordinator for the nutrition support team at Children’s placement errors is not known.
Mercy Hospital in Kansas City, Missouri, and is the chair of the NOVEL project sponsored The initial placement and ongoing
by A.S.P.E.N.
verification of an NG-EAD is com-
LaDonna Northington is director of the traditional undergraduate program at the University
mon practice for pediatric nurses
of Mississippi, School of Nursing, in Jackson, and a member of the Society of Pediatric Nursing.
and other care providers.6,10These
Jacqueline A. Bartlett is director of evidence-based practice at Children’s Mercy Hospital in
Kansas City, Missouri. devices are most often placed at the
bedside without radiographic assis-
Carol Kemper is vice president of quality and safety at Children’s Mercy Hospital in Kansas
City, Missouri and a steering committee member for the Children Health Patient Safety tance, and such placement has the
Organization/Children’s Hospital Association.
potential for serious complications.
Corresponding author: Sharon Y. Irving, RN, PhD, FCCM, CRNP,The Children’s Hospital of Philadelphia, University of Studies2,10-12have demonstrated
Pennsylvania, School of Nursing, Claire M. Fagin Hall, 418 Curie Blvd, Rm 427, Philadelphia, PA 19104 (e-mail:
[email protected]). that errors in NG-EAD placement
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses,101 Columbia, are not uncommon. Sorokin and
Aliso Viejo, CA 92656. Phone, [phone] or [phone] (ext 532); fax, [phone]; e-mail,
[email protected]. Gottlieb2reported a 1.3% to 2.4%
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incidence of misplacement of an radiograph may be low, repeated outside the inpatient acute care
EAD in 2000 NG-EAD insertions exposures for multiple placement setting, orogastric EADs can also
into adults. Of the misplaced devices, verifications may, over time, result be used for the same purpose as
28% resulted in pulmonary complica- in high cumulative radiation doses. NG-EADs; they may, however, have
tions, with 2 of these misplacements Both cohort and case-control studies an increased risk of displacement
culminating in death.2In a retrospec- have associated increased radiation because of the greater oral stimula-
tive study with children, Ellett et al13 doses with various types of cancer tion.14In this article, we specifically
demonstrated by radiographic docu- including childhood leukemia.17,18 refer to NG-EAD placement for
mentation a prevalence of 21% for Moreover, obtaining abdominal simplicity, with the inherent under-
misplaced or dislodged nasogastric, radiographs for home care patients standing that orogastric EADs carry
orogastric, and transpyloric EADs. and those in ambulatory and long- similar risks to patient safety.9
In a follow-up prospective study, term care centers is not practical.10 The placement and use of an
Ellett and Beckstrand14used abdomi- The desire to provide enteral NG-EAD presents 2 issues of con-
nal radiography to evaluate device nutrition and deliver medications cern that have important implica-
placement and reported a prevalence by the most physiological route with tions for patient safety: (1) the
between 22% and 44% in NG-EAD minimal risk to the patient prompts achievement of correct initial NG-
placement error in children in their the bedside placement and use of an EAD placement and (2) ongoing
institution, beyond the range found EAD. Placement of such a device is verification for correct NG-EAD
in adult studies. appropriate for those patients with location. Despite the routine nature
Although alternative methods a functional and intact gastrointesti- of their use, errors in NG-EAD
exist, abdominal radiographic imaging nal tract with adequate length and placement and difficulties with
is the “‘gold standard” for verifying absorptive ability3,4whom the clinical ongoing location verification con-
NG-EAD placement.4,6,7,10,15However, team has determined cannot or should tinue to exist and are reported with
even with radiographs, there may be not feed by mouth, and in whom varying frequency, making it diffi-
variation in the interpretation of the use of the EAD is temporary.19,20 cult to quantify the incidence of
device location. This variation is due Techniques for inserting a gastric placement errors and failures in
to a lack of consensus on identification EAD and equipment vary across ongoing maintenance of correct
of specific anatomic landmarks used institutions. The task of verifying location.2,22Variability in defining
to verify the NG-EAD position within tube position and ensuring ongoing misplacement (device placement
the gastric cavity.15In addition, the lack correct location lies largely with the anywhere other than its intended
of a relevant clinical history explain- nurse but is the responsibility of the location) and inconsistency in report-
ing the need for a radiograph along entire team caring for the patient. ingdevice dislodgement (movement
with omission of a specific request Constructed of polyurethane or from original intended location)
for device and device tip locationin silicone, the diameter of NG-EADs following initial insertion add to
the radiology requisition can influence runs from 3.5F to 16F and the length the complexity of this issue.9,10
the radiology report.15,16Despite this, runs from 15 to 170 cm.21These tubes
radiographic determination is the may be designed with a removable Methods
standard by which all other methods stylet, weighted tip, magnet, or Systematic searches of PubMed,
of verifying NG-EAD location are radiopaque indicators to assist with Scopus, and the Cumulative Index
measured. An abdominal or chest placement.22The number of institu- to Nursing and Allied Health Litera-
radiograph that includes an abdomi- tions that routinely provide gastric ture (CINAHL) databases were con-
nal view is considered the most reli- EADs with a stylet for insertion has ducted to identify peer-reviewed,
able method to document the course not been reported; however, anecdotal English language, human subject
of the EAD and its tip location at the information is that most tubes used research studies published from
time the radiograph is obtained.10 in children require a stylet because January 2004 to May 2013, examin-
Although the radiation exposure of the small size and pliability of the ing the measurement, placement,
associated with a single abdominal tube. Although less frequently used and verification of NG-EADs in the
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pediatric population. Search phrases Overview of the Literature capacity.24-26It is associated with
used were gastric tube, nasogastric tube, Misplacement and abdominal pain and distension,
feeding tube,and nasogastric intubation. Dislodgement hypoglycemia, and diarrhea. The
The term enteral access devicewas not A misplaced or dislodged NG- accelerated bypass of the stomach
used in the search because that term EAD puts the patient at risk for a along with the increased osmotic
produced articles related to percuta- variety of complications. In a retro- load into the proximal small intes-
neous and endoscopic devices, which spective investigation, Quandt and tine results in fluid shifts out of the
were not the topic of interest. These colleagues8reported that NG-EAD intravascular space into the intes-
terms were then meshed with terms misplacement occurred in 59% of tinal lumen. This causes distension
that included complications, place- the 381 radiographs reviewed from of the small intestine, leading to
ment, misplacement, or displacement 173 neonates. Although single-center hypoglycemia and hypovolemia.24,27
and filtered to the specifications reporting is useful, the overall num- Dumping syndrome is a complex,
described. Although NG-EADs have ber of NG-EADs placed and used in multiphasic condition, a full descrip-
been used for decades, the authors US facilities specifically in children tion and explanation of which is
chose the defined interval years, Jan- and the overall incidence of misplace- beyond the scope of this article. It
uary 2004 to May 2013, to identify mentor dislodgement are unknown. is, however, an important potential
the most current published literature A tube misplaced into the esoph- complication of a distally misplaced
related to NG-EAD placement and agus increases the risk of aspiration NG-EAD.
ongoing verification of tube location. owing to the proximity of the trachea. Initial NG-EAD misplacement
Duplicate articles were removed. Misplacement or dislodgement of the can occur because of a patient’s size
Eight studies conducted solely NG-EAD into the trachea or lungs and may be related to the require-
within pediatrics during the specified risks tracheal or pulmonary perfora- ment for a smaller tube, proximity
time interval were found (see Table). tion and pneumothorax. Instilling of the trachea to the esophagus,
Of the 8 studies found, 7 were con- enteral formula and/or medications depressed or dysfunctional cough
ducted in hospitalized children and into the pulmonary bed results in reflex, and the experience of the
1 in a pediatric emergency depart- aspiration with potential for chemi- nurse, other health care provider, or
ment. Only 1 of these studies was a cal pneumonitis and pneumonia.10,23 caregiver placing the tube.7,10,26Chil-
randomized controlled trial; the oth- An EAD misplaced into the trachea dren, as compared with adults, are at
ers were observational studies. One or lungs is a potentially devastating increased risk for NG-EAD displace-
adult study reported data from a and life-threatening complication. ment because of their age (younger
pediatric subset. The remaining arti- There are situations in which children are at higher risk), increased
cles referenced are studies carried out feeding into the proximal portion of activity, and nonpurposeful move-
in adults, review articles, case reports, the patient’s intestine (the duodenum ments of limbs or the head and
editorials, or commentaries that or jejunum) is intended, in which neck.10,14In addition, a change in or
added to the definition and clarity case an EAD is placed specifically for an altered level of consciousness,
of the topic of interest. Primary adult- that purpose. However, a misplaced vomiting, dysfunctional swallowing,
based studies were referenced if they tube distal to the gastric cavity may and the type and size of the NG-EAD
were frequently cited and where we increase the risk for dumping syn- used put the patient at risk for device
deemed necessary to support the drome if enteral feeding intended misplacement or dislodgement.10,26,28
overall purpose of this review. Finally, to be gastric is delivered in bolus Malpositioning of the tube can pre-
articles that included neonates were amounts into the duodenum or cipitate an adverse event and result
included, with the exception of stud- jejunum. Dumping syndrome can in untoward outcomes for patients.
ies that were specific to premature be described as the accelerated trans- Such an event can cause significant
infants, owing to known differences in portof a large amount of hyperos- psychological distress for the family,
anatomy and physiology in premature molar fluid (enteral formula) into the health care provider who placed
infants that may influence NG-EAD the duodenum or proximal intes- the tube, and those persons caring
placement and mode(s) of verification. tine, overwhelming its absorptive for the patient after the event.29,30
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Verification Methods of histamine receptor antagonists did not significantly affect testing of
2
Although methods for assessing and proton pump inhibitor medica- gastric pH as a determinant of NG-
correct NG-EAD location at the bed- tions confounds the usefulness of EAD placement.32Overall, this
side are available, each has its limita- assessing pH to verify NG-EAD study demonstrated a rate of 21%
tions. Current nonradiologic methods placement.10,28,33-35In addition, contin- for misplaced NG-EADs in their
used to verify NG-EAD location uous infusion of enteral formula, study population.
include air auscultation; visual which many children require, further In another pediatric study (n=56),
inspection of aspirated gastric secre- complicates pH testing. The range Westhus34investigated the pH, aspi-
tions; gastric secretion pH, bilirubin, of pH for gastric secretions is 1 to 4, rate color, and pepsin and trypsin
and/or enzyme testing; tube-end in contrast to the pH of many com- concentrations in gastric and small-
water submersion; capnography; mercially prepared formulas, which bowel aspirates. This researcher
electromagnetic tracer; age-related, is 6.6. This produces an alkalizing concluded that a pH of 6 or less and
height-based measurements; and effect, confounding the accuracy of clear, tan, or green coloration of the
ultrasound. Discussion of each of gastric pH measurement as a method aspirate was indicative of gastric
these methods follows. to verify NG-EAD placement. In addi- placement. These data are based on
tion, sterile water, which has a pH of results of aspirate testing with 87%
Auscultation Insufflated air aus- 5.5 to 7, may produce spurious results gastric placement and 13% duode-
cultation over the epigastrium or the if used to flush an NG-EAD before nal placement.34In this study,34a
left upper quadrant of the abdomen use. Last, small-bore feeding tubes pH of 6 or less was obtained from
to assess NG-EAD placement has often collapse when negative pres- the gastric aspirate in 23 of 49 par-
been common practice to verify cor- sure is applied to aspirate gastric ticipants (47%) who were receiving
rect placement. However, air insuffla- contents, making it difficult, if not acid-blocking medications.
tion with auscultation is problematic impossible, to obtain aspirate for Another prospective pediatric
in that sounds emitted from the intro- visualization and inspection or pH, study investigating the usefulness
ductionof air through the NG-EAD bilirubin, or enzyme testing.7 of pH as a method to verify NG-EAD
can be transmitted to the epigastrium In a 2005 prospective study (n=72) location was conducted by Gilbert-
regardlessof placement of the device by Ellett et al,32a pH upper limit of 5 son and colleagues,35who confirmed
in the lung, esophagus, or stom- was used to correctly predict proper gastric placement with a pH of 5.5
ach.4,6,10,11,25,31-34Because of the potential placement in 62% of NG-EADs shown or less in 93% of the 4330 specimens
for duplicity of sounds from sur- by radiography to be properly placed from 645 patients tested. However,
rounding orifices, auscultation as a in the stomach. Using the same pH the investigators also reported a
means of verifying NG-EAD place- upper limit of 5, 54% of the NG-EADs coiled tube in the esophagus that
ment is discouraged in the literature were improperly placed outside of the produced a pH of 5.5; thus, it was
and is no longer supported by clini- stomach. These researchers reported determined that a pH of 5.5 or less
cal practice organizations.3,4,6,22,33 a sensitivity of 54% and specificity was not acceptable as definitive of
of 69% for NG-EAD placement when gastric placement.35Instead, these
Aspiration of Gastric Secretions the pH limit was expanded to 5.15 data suggest that a cutoff pH of 5
Aspiration of gastric secretions is for their study sample.32The study or less, which produced 90% confir-
used for visualization and inspection, sample was further stratified, com- mation of gastric placement, is rec-
pH testing, and/or testing for biliru- paring participants who received ommended.35
bin content or gastric enzyme concen- histamine receptor antagonists In a study conducted in an urban
2
tration. Each of these methods can against participants not receiving emergency department with pedi-
be challenging because of the contin- these medications. They reported atric patients, Stock and colleagues36
uum of pH between gastric and 60% sensitivity and 88% specificity reported that gastric pH testing was
intestinal sites and the difficulty in using an upper limit pH of 5.9. It reliable in a group of predominately
obtaining aspirate from some small- was concluded from these data that healthy children. The gastric pH
bore tubes.10,11,34,35The widespread use the use of acid-inhibiting medication was 4 or less in 86.8% of the 393
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Table
Summary of articles related to methods of verifying feeding tube placement in pediatric and neonatal patients
Reference, year Study design Population, setting, N Study objective
Westhus,342004 Prospective cohort Children (birth-168 months), Identify pH, aspirate color, pepsin and trypsin
NICU or PICU, N=56 concentrations as determinates for differentiating
gastric versus intestinal tube placement
Ellett et al,322005 Prospective cohort Children (3 days-88 months) Test the effectiveness of carbon dioxide, pH, and
with gastric tube placed, bilirubin levels to determine the internal position of
hospitalized, N=72 the nasogastric tube
Beckstrand et al,412007 Prospective cohort Children (2 weeks-231 Assess effectiveness of nasogastric tube insertion
months), suite for diag- methods (height-specific equations, NEX, NAR, NU,
nostic endoscopy and NMU, NEM)
manometry, N=498
Stock et al,362008 Prospective cohort Children (<18 years), Determine if gastric aspirates can be obtained after
emergency department nasogastric tube placement to determine pH; deter-
mine pH of children with and without gastroenteri-
tis and if gastric pH is affected
Quandt et al,82009 Retrospective cohort Neonates (25-42 weeks Radiologic feeding tube evaluation
gestational age), NICU,
N=173 (381 radiographs)
Gilbertson et al,352011 Prospective cohort Children (4-62 months), Determine pH cutoff for confirming nasogastric tube
hospitalized patients, placement; compare range of pH values between
inclusive of ICU and gastric and endotracheal aspirate; obtain evidence
cardiac patients, N=645 for National Patient Safety Agency consensus
(4330 gastric aspirate statement
samples)
Powers et al,402011 Prospective cohorta Children (12 days-204 Assess accuracy of electromagnetic placement device
months), multicenter, for gastric placement of a small-bore feeding tube
hospitalized children, total by comparing with an abdominal radiograph
of 206 patients (194 for
analysis), 18 children
Ellett et al,202012 Randomized control trial Children (1 month-204 To compare error rates of 3 methods (ARHB, NEX,
months), hospital, N=103 and NEMU) used to predict correct nasogastric
tube insertion
Abbreviations: ARHB, age-related, height based; NAR, nose around ear-10th rib; NEM, nose-ear-mid-xiphoid; NEMU, nose-ear-mid-xiphoid-umbilicus; NEX, nose-ear-
xiphoid; NICU, neonatal intensive care unit; NMU, nose-mid-xiphoid-umbilicus; NU, nose-umbilicus; PICU, pediatric intensive care unit; PPV, positive predictive value.
aResearchers in this study broke out data for the pediatric subset population, these data are reported within this table.
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Results Comments
pH <6 in 78% of nasogastric tubes placed in stomach, resulting in a PPV of 94.4% The authors attempted to increase the specificity and
Participants taking acid inhibitors had significantly higher (P=.006) mean pH = 4.97 sensitivity of the tests by combining the tests.
(SD, 0.48) than did those not taking acid inhibitors (mean pH, 3.27; SD, 0.36) The combination of pH and color assessment resulted
Gastric aspirate color was indicative of gastric contents in 84% (41/49) of aspirates in a specificity of 100%, a sensitivity of 70%, and a
obtained PPV of 100%.
Aspirate color was consistent with intestinal contents in 71% (5/7) of intestinal tubes Author acknowledged that laboratory enzyme markers
Trypsin and pepsin were significant discriminators (P<.001 and P=.03, respec- are not readily available for bedside use.
tively) between gastric and intestinal aspirates
Correct placement in 79.2% (57/72) validated by radiograph All patients were assessed with the gold standard
pH parameter set at <5 detected gastric placement in 61.8% (34/55); PPV, 85% (abdominal radiograph).
Patients taking acid inhibitor medications with a pH set at 5.9, PPV of 92% (60% Two different measures (pH paper, pH meter) were
sensitivity, 89% specificity for gastric placement) used for pH measurements based on the amount of
Bilirubin testing set at >5 mg/dL failed to detect tubes placed in duodenum gastric aspirate obtained.
No tubes placed into trachea
Carbon dioxide levels were 0-2 mm Hg, well below the adult established cutoff of
<15 mm Hg
Regression modeling indicated that height-specific equations were superior to other Of the participants, 396 had oral manometry only,
methods of inserting nasogastric tubes with the nasal-oral distance for the equations being
NEM was the only morphological distance method that approached the height- based on the estimated age-stratified 95th percentile
specific equations of a subset of the population (n=34) in which oral
and nasal manometry was used.
Aspirates with pH ≤4 were obtained in 86.8% (341/393) of participants Radiograph to confirm tube placement was not used
Median pH in all participants was 2 in all participants.
In 85.2% (335/393), pH was the only confirmatory method of tube location Tube location assumed because no respiratory symp-
Radiography for tube placement performed in 18 of 52 participants (34.6%), of toms were noted.
these 3 tubes (1.7%) were misplaced into the distal esophagus Author recommends radiograph if no aspirate is
obtained and/or the gastric pH is >4.
Feeding tube correctly placed in 41% (124/303) of the population NEX method used to measure tube insertion length.
Of the 179 incorrect placements, 61.4% (110/179) were along stomach greater Correct nasogastric tube placement was defined as
curvature or in pyloric sphincter the tube’s tip or orifices being in body of stomach.
The odds of a feeding tube being displaced into lower part of esophagus is 2.74 Per protocol results were reported as the researchers
times higher in intubated neonates than in nonintubated neonates were not able to visualize the tip of the nasogastric
No tubes were placed into trachea tube and/or the stomach in 78 radiographs; there-
fore, these results were excluded from the analysis.
27% of participants were receiving antacid medication and had a higher pH (mean, Inconsistent assessment of nasogastric tube place-
4.2 vs 3.4) ment based on consent obtained for study participa-
More participants <1 year old had increased mean pH than those >1 year old (4.0 tion.
vs 3.3) With consent, if pH >4, radiograph obtained for place-
Mean pH = 8.3 (95% CI, 6.0-9.5) in patients with endotracheal tubes ment verification.
No difference in aspirate color between gastric aspirate and endotracheal aspirate Without consent, if pH >4, nasogastric tube place-
When gastric aspirate could not be obtained, radiograph was used, 8 misplaced ment was then verified by evidence-based tech-
tubes were identified niques (although most [73%] of these techniques
Recommend pH value <5 for 90% confirmation rate; 77% if antacid medications used were not recorded).
Median time for nasogastric tube placement was 20 minutes All children were enrolled from same site.
In the tubes placed with placement device, correct placement confirmed 99.4% of Small pediatric sample size
the time by first radiograph No inadvertent airway tube placement
Inadvertent airway placement avoided in 4/18 (22%) participants No raw data presented related to radiographic confir-
mation of nasogastric tube placement following use
of device (eg, what was the outcome of the remain-
ing 13% at first abdominal radiograph?)
Device was used only by a trained experienced nurse,
who was well versed in its use.
Method of tube placement: 36 tubes placed by ARHB, 35 by NEMU, and 32 by NEX Correct nasogastric tube placement was defined as
Accuracy of placement using each method: NEMU, 97.1%; ARHB, 88.9%; NEX, 59.4% tubes placed in the stomach, pylorus, or duodenum.
Accuracy of nasogastric tube placement differed (P< .001) among the 3 methods All patients received the gold standard (abdominal
NEMU and ARHB more accurate than NEX (P< .001). radiograph reviewed by a pediatric radiologist) fol-
No significant difference between ARHB and NEMU methods lowing initial tube placement to verify placement.
Using NEX rather than ARHB or NEMU increased risk of tube misplacement x5
Acid-inhibiting medications did not substantially change results
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participants in the study, which cor- confirmatory method to verify NG- placement in adults. It is recom-
related with correct gastric NG-EAD EAD placement.32,34,35 mended, however, that capnogra-
placement.36For the 52 participants phy be combined with other bedside
with pH greater than 4, only 18 had Submergence Submerging the methods for NG-EAD verification,
an abdominal radiograph obtained open end of the NG-EAD in water as it is not useful for discerning dif-
to confirm NG-EAD placement; the and observing for bubbles synchro- ferences in esophageal, gastric, or
auscultation method was used in 7 nous with expiratory respiration is a intestinal placement.11,24,38
participants, 11 participants had bedside verification technique some-
feedings aspirated, and no informa- times used in adults.37The submer- Electromagnetic Device The
tion on how NG-EAD location was gence method may be helpful to real-time electromagnetic tracer
verified was provided for the remain- determine tracheal placement if uses specialized EADs and an exter-
ing 16 participants.36Results of that rhythmic bubbling is observed; how- nal receiver to assist with tube posi-
study suggested that pH testing of ever, the absence of bubbling does tion and placement. Powers and
gastric aspirate is a reliable method not ensure gastric location. There- colleagues40demonstrated 100%
of verifying NG-EAD location in chil- fore, submergence is not considered success in NG-EAD placement using
dren in an emergency department an efficient, reliable method of veri- an electromagnetic device in the 18
setting. However, the researchers rec- fying NG-EAD location.37,38In addi- children included in their investiga-
ommended a radiograph to confirm tion, the tube submersion method tion. The immediate detection and
location when no aspirate is obtained may increase the risk for aspiration correction of airway placement in
or the pH of the gastric aspirate is with the patient’s inspiration and is this study prevented any inadver-
greater than 4.36 therefore not recommended. tent airway intubations, and no
Bilirubin testing is best used to complications were reported.40
determine placement of an EAD Capnography The use of colori- Additionally, although children
beyond the gastric cavity, as bilirubin metric capnography to detect were a small subset (9.2%) of the
is excreted through the common bile expired carbon dioxide during place- larger study, these researchers sug-
duct into the duodenum.7,34It has been ment of an EAD has shown promise gested that proper use of an electro-
suggested that combining bilirubin in adults with a high sensitivity (88%- magnetic device may eliminate or
testing with pH testing may provide a 100%) and specificity (95%-100%) for significantly reduce the need for
more accurate differentiation between lung misplacement.24,39Ellett et al32(N radiographic confirmation of NG-
respiratory, gastric, and postpyloric = 72) demonstrated 98.6% accuracy EAD placement.40A limitation of
placement of an NG-EAD.7Ellett et al32 for NG-EAD placement using this method is the diameter of the
found very little bilirubin in the gas- capnography with a valueof 0 mm EAD—8F is currently the smallest
tric aspirate of children. In addition Hg at tube insertion. These tube that can be traced by using
to bilirubin concentration, Westhus34 researchers reported that all EADs this device. An 8F EAD is not uni-
also examined the presence and con- were outside the respiratory tract, formly used in children because of
centration of trypsin and pepsin as a although not all were in the stom- the large tube size.
method to determine NG-EAD place- ach. The tip of 13 of the EADs were
ment. Although these enzymes were in the esophagus and in 2 cases, the Tube Measurement Methods
significant discriminators for gastric tip was beyond the pyloric sphinc- The use of age-related, height-based
versus intestinal placement, West- ter.32In a recent meta-analysis,398 (ARHB) measurement has emerged
hus34acknowledges that bedside adult studies were reviewed to evalu- as a potential method for determin-
enzyme testing of trypsin and pepsin ate the effectiveness of capnography ing initial placement length of a gas-
may not be practical. Despite the as a method to verify NG-EAD tric EAD. Use of charts derivedfrom
accuracy of pH and enzyme testing, if placement. The results of this review prediction equations based on the
NG-EAD placement or location is demonstrated that capnography is child’s stature to determine inser-
uncertain, an abdominal radiograph an effective method for differentiat- tion length of an EAD holds prom-
is warranted, as it is accepted as the ing respiratory and gastric tube ise. Further investigation is
e8 CriticalCareNurse
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necessary to establish the utility and and the device tip difficult.42,43Using sary to guide the development of
accuracy of this technique.41 the specified search criteria and limi- technological solutions to address
Ellett et al20demonstrated differ- tations set for this article, we found this issue.
ences in 3 commonly used methods no studies evaluating the use of
for measuring tube length for correct ultrasound for NG-EAD location Establishing Procedures and
gastric cavity placement in children. and position verification in children, Protocols
Of the 3 methods studied, the nose- the population of interest. Provider education to promote con-
ear-mid-umbilicus (NEMU) and the sistency in practice is an essential
ARHB method were superior to the Discussion component of NG-EAD placement
commonly used nose-ear-xiphoid Current publications validate sig- and ongoing verification of the
(NEX) method for determining the nificant challenges surrounding the device’s location. The practice of
NG-EAD length to be inserted.20In placement and ongoing verification obtaining an abdominal radiograph
this study (N=103), Ellett et al20 of NG-EADs in children. This diffi- to confirm location of the device
demonstrated high accuracy of the cult problem requires attention. The and its tip is generally driven by
NEMU (97%) and the ARHB (89%) potential devastation that can occur individual institution protocol.
methods for correct EAD placement with tube misplacement and unde- Device misplacement often occurs
when compared with the reference tected dislodgement is significant. during bedside insertion and may go
standard of radiographic evaluation. Even 1 misplaced or dislodged EAD undetectedfor a prolonged period
In contrast, the NEX method demon- can affect the patient, the patient’s while waitingfor the radiograph to
strated 59% accuracy when compared family, and the person placing the be obtained and interpreted.
with radiographic evaluation.20Based device. To minimize the use of radi- Provider education for observation
on the findings and recommendations ographic imaging, it is imperative of patients and assessment for overt
from this study, and recommenda- to develop additional reliable and signs of NG-EAD misplacement are
tions of the Child Health Patient Safety practical methods for bedside assess- necessary to thwart complications
Organization, the NEX method to mentof NG-EAD placement and associated with bedside NG-EAD
determine NG-EAD insertion length ongoing verification of device loca- placement.
is no longer recommended for use tion in children. In a survey of nurses in an adult
in children.1,21The combination of a Bedside placement of an NG-EAD intensive care unit (ICU), Metheny
proper method of measurement for is considered an innocuous proce- et al45exposed a lack of consistency
NG-EAD placement and use of age- dure, yet it carries risk of serious among this group of specialized
specific equations may be a superior and potentially lethal complications. nurses regarding insertion and con-
approach to determining length of The current methods used for bed- firmation of NG-EAD placement.
NG-EAD insertion. Measurement of side placement have success rates Survey results indicated that nurses
proper device length may be the first from 80% to 85%.44The need exists did not place styletted devices as
step in decreasing the potential for for a focused, collaborative approach often as physicians did, but when a
error when inserting NG-EADs. to develop a reliable, user-friendly stylet was used, a radiograph was
method to safely insert and continu- obtained to confirm placement
Ultrasonography Reports of ally verify correct NG-EAD placement 92.3% of the time compared with
investigations into the use of ultra- in children. The NOVEL project seeks radiographic confirmation 57.5%
sound to determine NG-EAD place- to address this need. Project goals of the time when a nonstyletted
ment, particularly in adults, are include (1) further defining the chal- device was placed.45Nurses reported
emerging. These studies acknowl- lenges surrounding NG-EAD place- using a combination of air insuffla-
edge ultrasound to be a simple, non- ment, (2) identifying potential tion and auscultation, appearance
invasive, radiation-free method for solutions to those challenges, (3) of aspirate, and observation for res-
verifying location of an NG-EAD; defining the necessary components piratory distress as primary means
however, gas interposition can ren- of provider education, and (4) iden- of confirming NG-EAD placement,
der identification of the NG-EAD tifying specific requirements neces- with only 11.4% of nurses surveyed
CriticalCareNurse e9
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reporting that they check pH to ver- to establish its usefulness in NG- It may be that development of
ify location.45The study findings sug- EAD placement and ongoing loca- best practice guidelines for NG-EAD
gest that bedside nurses are unaware tion verification. The application of placement and ongoing location ver-
of current evidence and recommen- such technology could decrease ification by a multiprofessional, col-
dations of professional organizations health care costs related to NG-EADs, laborative team is warranted. Best
related to NG-EAD placement. Addi- reduce the incidence of misplaced and practice guidelines based on the
tionally, results of this study suggest displaced devices, and decrease the available knowledge and evidence of
marked inconsistency among ICU associated morbidity and mortality. current methods are necessary to
nurses on the technique used for NG- With a focus on patient safety, the decrease variability in practice for
EAD placement. Although these data ideal technology to verify insertion EAD placement, management of
are from nurses in an adult ICU, the and maintenance of NG-EADs should patients, and ongoing verification of
study findings are concerning in that incorporate the following features device location. These guidelines
it is often the bedside nurse who edu- and advantages: would serve not only to establish
cates the patient’s family on NG-EAD • Placement accuracy across a wide best practice, but they would also
placement and ongoing verification. range of feeding tube sizes (5F- establish a platform to educate
Technology that will minimize or 10F) commonly used in children health care providers, patients, and
eliminate the need for frequent radi- • Allow ongoing verification of patients’ family members who need
ographs is needed to assist providers the location of the device and its to manage these devices outside of
to accurately place and verify the tip with accuracy the acute care environment. It will
location of an NG-EAD and its tip. It • Incorporate simple, user- be difficult to develop such guide-
is likely that more than 1 technology friendly, portable technology lines for children until the actual
or method may be needed to address • Have a reasonable cost with number of NG-EADs placed in chil-
this issue in children. The target pop- durability for sustainable use dren is known. Additionally, the
ulations—neonatal, pediatric inpa- • Provide electromagnetic com- methods used for NG-EAD place-
tients and pediatric outpatients, those patibility (eg, with pacemakers, ment verification and ongoing man-
cared for at home or those children subcutaneous medication agement of device location vary in
living in a long-term care facility— pumps) the inpatient and the outpatient
have unique and distinct challenges • Not require any change in the environments.
regarding NG-EAD placement and pliability and flexibility of the To better describe the incidence
ongoing location verification. Each of EAD of NG-EAD errors, it is necessary to
these populations will most likely develop universal terminology with
require different approaches to NG- Future Direction and operational definitions for misplace-
EAD placement and ongoing verifica- Long-Term Focus ment,dislodgement, and/or dis-
tion of the location of the device and Understanding the scope of the placement that transcends both
its tip. Should placement, mainte- problem of placing NG-EADs and children and adults. These terms
nance, and ongoing verification of an verifying their location, developing currently appear to be used inter-
NG-EAD become hazardous, risking potential solutions, and actualizing changeably in published reports,
the patient’s health, consideration of their use is multifaceted. New tech- making it difficult to fully understand
alternative methods for delivery of nology to improve the accuracy and the extent of this clinical problem.
nutrition and medications is necessary. efficiency of placement and ongoing Universal terminology is primary to
The ideal technology will provide location verification is ideal; however, understanding and defining the issue
equal, if not more accurate, NG-EAD its development and market realiza- and would be an important first step
placement when compared with the tion may be some years away. This to move the practice of placement
reference standard—radiologic imag- fact should not, however, minimize and management of NG-EADs for-
ing. The specificity and sensitivity of the current need to address the chal- ward. Work is currently underway
any new technology must be assessed lenges surrounding placement and to address these and other compo-
with various populations of patients use of NG-EADs. nents of this complex issue in children.
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