Enteral feeding and medication administration if unable to swallow
DHT vs. NGT: DHT deliver meds and fluids, NGT provide suction to decompress (can also deliver meds/fluids); nurses place NGT, residents (and ICU nurses) place DHT
Relative contraindications
Esophageal varices or strictures (most hepatologists say this is not a contra-indication, but discuss if recent bleed or recent banding)
Other altered gastric anatomy that may prevent passage (e.g. gastric bypass, esophageal hernias, tumors or other possible obstructions)
SBO or ileus (use NGT instead for suction)
Hx of major epistaxis
Absolute contraindications for blind approach
Facial trauma, basilar skull fracture, pharyngeal or esophageal trauma
Consent
Common risks: malposition (lung PTX or PNA; pyriform sinus; coiling anywhere along tract), perforation anywhere along the tract, aspiration, nasal ulceration, esophagitis, gastritis, bleeding, vagal response, discomfort
Verbal Consent is adequate; no form on Medex.
Supplies
DHT kit (make sure it isn’t the CORTRACK kit; long yellow sensor wire)
Bridle
Straw and cup of water (if use to use from aspiration perspective)
Lidocaine jelly
Scissors (suture removal kit)
10ml syringe (if planning air insufflation)
Also consider:
Box of tissues
Emesis bag
Plastic bin to carry supplies to bedside
Pre-procedural considerations
Bleeding risk guidelines: Plts > 10k, no specific INR guidelines
Make sure DHT and bridle sizes correlate
Determine whether a patient needs DHT or NG
For patient comfort preferred sizes for DHT is 8F or 10F (if at risk for occlusion, or planning to discharge home with tube), NG is 14F
Measure expected advancement depth by measuring distance from tip of nose, around ear, and to xiphoid process - Prior to placement, fasten the stylet in the fully-hubbed position to reduce bending and folding over of the weighted tip while advancing
Apply anesthetic with lidocaine gel (order Lidocaine uro-jet) and nasal swab to reduce pt discomfort, reduce gag reflex, and assist with clearance of the nasal passages
Consider fluoro-guided placement after 3 failed bedside attempts
Post-pyloric placement
Consider in pts with high pulmonary aspiration risk, severe esophageal reflux/esophagitis, recurrent emesis, impaired gastric mobility, and pancreatitis
Refer for fluoro-guided post-pyloric advancement after 1 failed bedside attempt
Procedural considerations
Have the pt sit upright with their head tilted toward the chest
Tip: advance horizontally (nose tip to ear lobe), not angled up
If pt can participate safely, have the pt swallow in conjunction with advancement.
Excessive coughing, difficulty phonating, or resistance may indicate tracheal placement. Withdraw tube and re-attempt. Consider Duonebs to reduce bronchospasms
Post-pyloric placement has been shown to be up to 90% successful with intermittent insufflation of 10-20cc of air ~every 10cm of advancement after 55cm to promote pylorus opening. IV Reglan or erythromycin may also help
When placing bridle (recommend AFTER xray confirmation), keep alignment markers (marked on both probes) together so magnetic tips will align once past the nasal septum
When placing the bridle, remove the green stylet housed within the white probe before retracting back and removing the white probe
Post-procedural considerations
ALWAYS confirm position with KUB before medications are given
Insufflation of air and auscultation of bowel sounds over the gastric area can be reassuring of correct placement of DHT prior to taping/bridling and leaving the bedside
Most mispositioned/coiled tubes have to be removed and re-attempted, but it is ok to advance or withdraw if the stylet is still in place. However, once removed, a stylet should not be re-introduced to a mispositioned/coiled tube due to risk of GI perforation
In case of cranial placement, don’t remove, consult Neurosurgery
De-clogging: Clog Zapper Kit (can type this into Epic directly); Coca cola
