SECTION A: CURRENT STATE – EVIDENCE – RECOMMENDATION (To be completed by author of IFI)

• Topic:

Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique

1.Current State: Policy (Existing policy? If so, applicable content)

• N/A

2.Current State: Practice (Brief statement of current state)

At present in our critical care units, Nasogastric and Nasojejunostomy tube insertion is done blindly and confirm through several ways such as residual volume aspiration, pH testing and Chest xray.

• Evidence: (References and bulleted statement from evidence, in lieu of Evidence Review Tool which is currently in development)

Cortrak^® (Viasys Healthcare, UK) is an electromagnetic sensing device that tracks and displays the path of feeding tubes during the placement procedure. The implementation of this method may assist the bedside placement of feeding tubes and may help the continued improvement in our nutritional practices in line with clinical governance requirements

All patients requiring either nasogastric (NG) or nasojejunal (NJ) tubes for enteral nutrition were included. A Corflo NG or NJ tube with a Cortrak^® stylet was inserted and its position monitored using the Cortrak^® sensor. NG tube position was also confirmed using the auscultation technique, aspiration and chest X-ray. Postpyloric (NJ) tube position was confirmed using abdomen X-ray. Data relating to the difference in time taken for tube insertion and confirmation using Cortrak^® and X-ray was recorded.

Twenty patients, male:female 12:8, age 65 (IQR 56–73) years were recruited. NG tubes were inserted in ten patients, while the remaining had NJ tubes. Cortrak^® confirmed the position of NG and NJ tubes in all twenty patients. Time taken for NG tube insertion (median 0.48 (IQR 0.34–1.09) min) was significantly less than that for NJ tubes (median 6.16 (IQR 3.55–9.03) min; P=0.001). X-ray confirmed tube tip positions in all twenty patients, but the time taken for getting the X-rays done and reviewed resulted in a delay of median 50 (IQR 45–65) min. Auscultation test was positive in all NG tube placements. Fluid aspiration was successful in five and three out of ten of NG and NJ placements respectively.

Reference- M. M. Rao,R. Kallam,I. Flindall,M. Gatt andJ. MacfieUse of Cortrak® – an electromagnetic sensing device in placement of enteral feeding tubes | Proceedings of the Nutrition Society | Cambridge Core Published online by Cambridge University Press: 30 June 2021

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.

Reference Annette M. Bourgault, PhD, RN, CNL; Jan Powers, PhD, RN, CCNS, CCRN, NE-BC; Lillian Aguirre, DNP, APRN, CCNS, CCRN Am J Crit Care (2020) 29 (1): 22–32. Pneumothoraces Prevented With Use of Electromagnetic Device to Place Feeding Tubes Pneumothoraces Prevented With Use of Electromagnetic Device to Place Feeding Tubes | American Journal of Critical Care | American Association of Critical-Care Nurses (aacnjournals.org)

The purpose of this study was to evaluate the safety and efficacy of using Electromagnetic Placement Device (EMPD )verification, instead of routine abdominal radiographic confirmation, for small-bore feeding tube placement.

Variables evaluated were adverse events, utilization of radiographs for confirmation, and success rate of feeding tube placement in the ordered location. Two time frames were reviewed. In a 1-year period, 3754 small-bore feeding tubes were placed using EMPD, with zero adverse events noted. Radiographic confirmation was utilized in 0%-29.2% of the EMPD placed tubes. Successful placement of feeding tubes using EMPD ranged from 94%-99.6%. During a 5-year period, 7081 EMPD feeding tubes were evaluated. One adverse event, pneumothorax, occurred during the placement of these 7081 tubes, for a rate of 0.014%.

Reference Jan Powers ¹, Michael Luebbehusen ², Lillian Aguirre ³, Julia Cluff ⁴, Mary Ann David ⁵, Vince Holly ⁶, Lorraine Linford ⁴, Nancy Park ⁷, Rocco BrunelleImproved Safety and Efficacy of Small-Bore Feeding Tube Confirmation Using an Electromagnetic Placement Device Improved Safety and Efficacy of Small-Bore Feeding Tube Confirmation Using an Electromagnetic Placement Device – PubMed (nih.gov)

4.Evidence-Based Conclusion:

No adverse events occurred with the implementation of bedside feeding tube placement using an Electromagnetic tube placement device (ETPD). In addition, Small Bowel Feeding Tube placement with an ETPD by designated ICU Resident Doctor/RN teams resulted in lower x-ray costs and more timely initiation of enteral feedings compared with blind placement.

Feeding tube placement confirmation is safe and efficacious via EMPD providing an effective method of feeding tube placement with a success rate >94% into the desired location. EMPD is an accurate verification method of distal tip location, eliminating the need for routine abdominal radiographic confirmation.

Cortrak^® demonstrates 100% accuracy in confirming pre and post-pyloric tube placements and can be used for confirmation of tube tip position.

5.Recommendation:

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.