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Placement of Small Bowel Feeding Tube Using Cortrak Enteral Access System (Adult & Pediatric) (2.25)

Placement of Small Bowel Feeding Tube Using Cortrak Enteral Access System (Adult & Pediatric) (2.25) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Gastrointestinal

2.25

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
April 29, 2016


Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 2.25AP

Original
Revision

Page
1
of 8

Title: Placement of Small Bowel Feeding
Tube Using Cortrak® Enteral Access
System (Adult & Pediatric)

I. PURPOSE

To establish a clear and consistent standard of care for the safe placement of feeding
tubes in adult and select pediatric patients using the Cortrak® Enteral Access System.

II. POLICY

ξ Cortrak® Enteral Access System may only be used by members of the Feeding
Tube Team at the Clinical Science Center (CSC) and by Care Team Leaders
at The American Center (TAC).

ξ When there is a contraindication for a nurse-placed tube, the provider is
notified.

ξ The Feeding Tube Team will place enteral feeding tubes on pediatric patients
that are at least 15 years of age and more than 100 pounds. For other pediatric
patients, the Feeding Tube Team nurse can be consulted on an individual basis
for appropriateness of tube placement.

III. EQUIPMENT

A. Cortrak® Enteral Access System
B. Cortrak® feeding tube with transmitting stylet (43 or 55 inches depending on
patient size)
C. Stethoscope
D. 60 mL syringe
E. Lubricant
F. Nasogastric/feeding tube stabilization device or nasal bridle

IV. PREPARATION FOR PROCEDURE

A. Consult process
1. Reference the consult list for the Feeding Tube Team in the Patient’s
Clinical Record. Feeding tube team consult must be ordered by a
provider.
2. Tube placement is triaged with acute burn patients given priority.
The Feeding Tube Nurse will schedule time for tube placement with
the patient’s nurse.


Page 2 of 8

B. Order review
1. Review order panel “Feeding Tube Bedside Placement-Adult”

C. Determination of Feeding Tube Placement:
1. The Feeding Tube Nurse will review the patient’s medical history.
2. If the following absolute contraindications to a nurse-placed feeding
tube are identified, the provider will need to consult with GI
Radiology regarding placement:

a. Facial fractures
b.Anterior or basilar skull fractures, including sphenoid sinus
c. Recent ENT surgery
d.LVAD Heart Mate II
e. Brain Stimulator
f. Previous mal-position of feeding tube with Cortrak®
g.Aberrant right subclavian artery
h. Hiatal hernia
i. TPA administered with in last 24 hours
j. Esophagectomy
k. Platelet level <30uL
l. INR >2.5
m. Gastric or small bowel obstructions
n. Esophageal or gastric cancer
o.Esophageal varices or strictures. Consideration given if banding
of varices occurred greater than 48 hours with no additional
bleeding.
p. Zenker’s diverticulum

3. Special Considerations:
a. Feeding tube team will discuss with ordering provider the
benefits versus the risks of feed tube placement in select cases
noted below in 3.b. If decision is made to go ahead with tube
placement, the ordering provider will document such in the
patient’s clinical record and the feeding tube team will proceed
with tube placement.
b. In select cases a decision by the Feeding Tube Team and the
provider may be for the provider to pass the tube to the gastric
area and then the Feeding Tube nurse will advance the tube
with the Cortrak® to the desired location.

i. Altered GI anatomy
ii. Unable to review patient history
iii. Instability of patient condition
iv. Platelet level 30-50 uL
4. Review flowsheets/notes for patient’s current status to determine if
the patient is stable for tube placement.
a. Vital signs
b. Respiratory status to include: pulse oximetry readings,
respiratory rate and use of non-rebreather mask or

Page 3 of 8

BIPAP/CPAP
c. Additional studies planned for the patient such as:
i. Swallow study
ii. Planned extubation within the next 12-24 hours
iii. Any procedures scheduled that should be performed prior
to tube placement, such as bronchoscopy, endoscopic
retrograde cholangiopancreatography (ERCP),
esophagogastroduodenoscopy (EGD), or transesophageal
echocardiogram (TEE)
iv. Surgery
v. Line placement: intrajugular, arterial line or Swan Ganz
D. Pediatric patient feeding tube recommendations
1. Assess age and size for appropriate placement
a. Determine if Child Life or sedation is needed to help support the
patient.
b.Follow the same parameters as the adult population.

V. PROCEDURE

A. Acknowledge the consult order.
B. Identify patient and contact the patient’s nurse to schedule tube placement.
C. Assess the patient.
1. Determine the patient’s current hemodynamic and respiratory status;
for example, assess the patient’s ability to tolerate interrupted
respiratory support such as non-rebreather, oxygen mask, or
CPAP/BIPAP during procedure. Take into consideration
oxygenation level, work of breathing, vital signs and/or ICP
readings.
2. If the patient is combative or unable to follow directions, consider
delaying the procedure until the patient is cooperative or when
sedation can be provided. Sedation will be administered by a second
clinician based on UWHC Hospital Administrative Policies 8.38,
UWHC Adult Sedation or 8.56, Pediatric Sedation.
3. If the patient is intubated and sedated, assess the patient’s current
hemodynamic status, to include vital signs, oxygenation level,
neurological status and ICP readings. If needed, request another
nurse to be present during insertion to monitor the patient.
4. If RN/feeding tube team deems patient unstable for placement,
discuss with provider the next steps and document in the patient
clinical record.
5. If the patient is stable, educate the patient and family about the
feeding tube insertion process.
D. Preparation
1. Perform hand hygiene according to UWHC Hospital Administrative
Policy 13.08, Hand Hygiene.
2. To start the placement program, turn on the Cortrak monitor. Follow
the screen menu for step-by-step instructions.
3. Cortrak® set-up is based on the manufacturer’s recommendations.
a. Smart Receiver Unit (SRU) placement:

Page 4 of 8

i. Palpate the lower sternum and follow it to the xypho-
sternal junctions.
ii. Place the top of the SRU positioned at the xypho-sternal
junction. The RU must be centered along the patient’s
midline and be level. Use rolled cloth to level the SRU.
iii. The stabilizer or tape can be used to secure the SRU in
place.
b. Connect the transmitter stylet to the interconnect cable by lining
up the arrows.
c. Activate internal tube lubricant by flushing with 8 mL sterile
saline and 10 mL of air.
d. Test the tube to ensure all connections are sufficient and to
ensure the tip is readable on the monitor.
e. Measure the length of the tube to be inserted. This information is
useful in determining if the tube has advanced to the gastric area.
Place the tube at the tip of the nose, extend the tube to the
earlobe, then to the xyphoid process.
E. Tube insertion
1. Insert the feeding tube to approximately 20 cm or the back of the
throat.
a. Direct the feeding tube posterior, bevel down and aiming tip
parallel to the nasal septum and superior surfaces of the hard
palate.
b. Advance the tube slowly to the nasopharynx, allowing the tip to
find its own passage.
2. Press START on either the SRU button or the monitor screen of the
Cortrak® device to allow for visualization of the advancement of the
tube tip position. As the feeding tube with stylet is inserted slowly
into the patient, the relative position of the tube tip will appear on the
monitor.
3. Advance the tip of the tube across the greater curvature of the
stomach. Once tube tip has been advanced to the gastric position,
insert air bolus to confirm placement.
a. Observe the monitor as the tube crosses the mid-line into the
duodenum. Some manipulation of the proximal end of the tube
may be needed to encourage the passage across the midline. An
air bolus can be used to assist crossing the midline through the
pylorus.
b. If the tube does not advance, intravenous metoclopramide may
be needed to support passage of the tube into the post pyloric
region. A provider order will need to be obtained if not included
in the initial order set. Lowering the head of the bed may also
assist with tube advancement. Assure it is okay to lower the head
of bed.
4. The tip passing the midline axis on the Cortrak® monitor suggests
passage into the duodenum, generally around 75 cm. There will be
negative pressure at this time when a syringe is pulled back. An
increase in depth, as indicated in the “Depth Cross Section View” of
the Cortrak® placement screen, is an indication of duodenal

Page 5 of 8

placement. The tube traversing back across the midline indicates
placement of the feeding tube into the small bowel.
5. When the desired tube tip position has been achieved, press STOP
either on the SRU or the monitor.
6. Considerations during feeding tube placement
a. Change in the patient’s status during insertion procedure
i. If there is a decrease in oxygenation, blood pressure or
signs of patient de-compensation, stop or pause the
procedure. Dependent on each situation, the tube may need
to be withdrawn and provider notified of the patient’s
present status and need to delay the procedure. Collaborate
with the team to come back later or recommend placement
in GI Radiology.
ii. Write consult note of findings and any follow-up.
b. With an alert and oriented patient or alert and intubated patient,
coughing may indicate intrabronchial migration of the feeding
tube.
i. Have the patient swallow can aid in progression of the tube
into the stomach.
ii. If intrabronchial migration is suspected, stop, pull back the
tube to the nasal pharynx, and allow the patient to recover
before re-attempting insertion. If a second attempt yields
the same result, stop and remove the tube.
iii. Document your findings and follow-up with the ordering
provider and patient’s nurse.
c. Tracing noted on Cortrak® monitor tracking to the right or left
intra-bronchial area after 30 to 35 cm are inserted (second or
third hash mark on screen).
i. Stop procedure. Completely withdraw the tube to the nasal
pharynx or completely remove the tube. If the tube is not
pulled back far enough, it may still be in the trachea.
ii. Attempt a second insertion slowly and monitor the course
of the tube. If a second attempt tracks the same direction to
the right or left intra-bronchial passage, remove the tube.
Inform the patient’s provider and primary nurse for a
follow-up.
ξ Recommend GI Radiology.
ξ Write a consult note regarding two attempts and
resultant tracking to the intra-bronchi including
who was notified and the follow-up plan.
d. If resistance is encountered during insertion within the first three
hash marks on the screen, or if the monitor is not clearly picked
up the tube tracking, stop the procedure. This may indicate the
tube is tracking into the intra-bronchial tree or deeper into the
lung, potentially causing harm (pneumothorax).
i. Stop the procedure and follow directions as in section V, E,
6, c, ii, above.
ii. Contact the provider to determine if an x-ray is needed.
e. Unable to pass through the nasal passage

Page 6 of 8

i. Reposition the patient’s head and re-attempt
ii. Remove the tube and attempt insertion in the other nostril
iii. If bleeding is noted, do not force the tube. Remove and
notify the provider.
f. Unable to pass post pylorus
i. Use metoclopramide if appropriate.
ii. Reposition the patient on right side and use an air bolus.
iii. Lower the head of bed if the patient is able to tolerate.
iv. Slowly turn the tube counter clockwise.
g. After 30 minutes of attempting to pass the post-pyloric region,
stop the procedure. Remove the wire, label, and save in a plastic
bag in the patient’s room. Secure tube and inform the patient’s
nurse and/or provider you believe the tip is at the pylorus and
that the tube will need time to migrate post-pylorically.
i. Release abdominal x-ray after one (1) hour.
ii. Assess abdominal x-ray results; if not positioned post-
pylorically, request abdominal x-ray repeat in AM or re-
evaluate the patient later and if appropriate, attempt to
advance the tube.
iii. Keep the patient on active consult list until resolved or if
placement is not successful after two attempts. Contact the
ordering provider and recommend GI Radiology.
F. Post procedure
1. Remove guide wire from the tube and check tip of wire for
intactness. Place guide wire in a plastic bag with a patient label for
future use. Leave at bedside.
2. Securement of the feeding tube
a. Bridle securement if appropriate (refer to UWHC Nursing
Patient Care Policy 2.24, Nasal Bridles: Use, Maintenance and
Removal).
b. For patients without bridles, secure the feeding tube with
nasogastric/feeding tube stabilization device. Do not secure
tightly to avoid causing a nasal pressure ulcer.
3. Release the abdominal x-ray (KUB) order to determine tip
placement.
4. Documentation in Patient’s Clinical Record
a. Complete documentation note with SMART TEXT to include
consult and procedure note.
b. Doc flowsheet – On I & O drains flowsheet, add LDA and ENT,
then follow prompts.
c. Placement confirmed and tip location is left blank until final
abdominal x-ray is read and completed by the unit.
d. Complete documentation note with SMART TEXT to include
the number of attempts, problems encountered, patient’s
tolerance to the procedure and notification of provider and
patient’s nurse regarding any problems or concerns.
5. Communicate with patient’s nurse or team nurse before leaving the
patient’s unit that the feeding tube cannot be used until confirmation
of tip placement by abdominal (KUB) x-ray.

Page 7 of 8


VI. FEEDING TUBE PLACEMENT TEAM INFORMATION
A. For UW Hospital (CSC):
1. Pager Number: 7777
2. Hours of service: 8:00am –6:00pm
3. Availability: 7 days a week
B. For The American Center
1. Contact the Care Team Leader on the Overnight Care Unit

VII. UWHC CROSS REFERENCES

A. Hospital Administrative Policy 7.62, Small-bore Nasoenteric (Dobhoff) Tube
Placement in Adult Patients
B. Hospital Administrative Policy 8.38, UWHC Adult Sedation
C. Hospital Administrative Policy 8.56, Pediatric Sedation
D. Hospital Administrative Policy 13.08, Hand Hygiene
E. Nursing Patient Care Policy 2.20, Care and Maintenance of Enteral Tubes
(Adult & Pediatric)
F. Nursing Patient Care Policy 2.24AP, Nasal Bridles: Use, Maintenance and
Removal (Adult & Pediatric)

VIII. REFERENCES

A. Lee, A., Eve, R., Bennett, M. (2006). Evaluation of a technique for blind
placement of post-pyloric feeding tubes in intensive care: application in
patients with gastric ileus. Intensive Care Medicine, 32, 553-556.
B. MedSystems (2012). Cortrak enteral access system: operator’s guide.
Wheeling, IL: MEDSYSTEMS.
C. Rollins, C. M. (2013). Blind bedside placement of postpyloric feeding tubes by
registered dieticians. Nutrition in Clinical Practice, June.
D. Gray, R., Tynam,C., & et al. (2007). Bedside electromagnetic-guided feeding
tube placement: an improvement over traditional placement technique.
Nutrition in Clinical Practice, 22(4), 436-444.
E. Koopmann, M., Kudsk, K., Szotkowski, M., & Rees, S. (2011). A team-based
protocol and electromagnetic technology eliminate feeding tube placement
complications. Annals of Surgery, Feb, 297-302.
F. Rivera, R. J., Campana, J., Seidner, D., & Hamilton, C. (2009). Small bowel
feeding tube placement using an electromagnetic tube placement device:
accuracy of tip placement. Journal of Parenteral and Enteral Nutrition, 33(2),
225.
G. Roberts, S., Echeverria, P., & Gabriel, S. (2007). Devices and techniques for
bedside enteral feeding tube placement. Nutrition in Clinical Practice, 22, 412-
420.

IX. REVIEWED BY

Nurse Manager, Feeding Tube Team
UWHC Feeding Tube Team
Director, Professional Services UW Health at The American Center

Page 8 of 8

Nursing Patient Care Policy and Procedure Committee, April 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer