Cortrak tube placement part 2: guidance to avoid misplacement is inadequate.

Electromagnetic (EM)-guided tube placement has been successfully used to pre-empt lung misplacement, but undetected misplacements continue to occur. The authors conducted an audit to investigate whether official Cortrak or local guidance enabled differentiation of gastrointestinal (GI) from lung traces. X-ray, pH or an EM trace beyond the gastric body were used to independently confirm gastric position. The authors undertook 596 nasointestinal (NI) tube placements, of which 361 were primary GI placements and 41 lung misplacements. Official guidance that in GI traces a midline deviation is absent cannot differentiate GI from lung traces because deviation is common in both. However, when comparing a trace in the same patient, midline deviation during lung misplacement always occurred >18 cm above the horizontal line compared with only 33% of the subsequent GI deviation (p<0.0001). Official guidance could lead to aborted GI placements or undetected lung placements. EM-guided placement must have an expert-led understanding of the 3D trace pattern, artefact correction and appraised practical experience differentiating GI from lung placement. The authors invite Halyard Health to update guidance in view of these findings.

Cortrak tube placement part 1: confirming by quadrant may be unsafe.

Gastric confirmation by pH is only achievable in approximately 50% of placements and X-rays are expensive and may be misinterpreted. Bedside electromagnetic (EM) guidance offers real-time confirmation. The authors determined the accuracy of guidance in predicting gastric body position from the EM trace using official Cortrak guidance (the EM trace reaches the bottom left quadrant of the anterior screen) compared with local guidance (detailed anterior-depth description of the GI flexures). X-ray, pH or an EM trace beyond the gastric body were used to independently confirm gastric position. Of 496 EM traces, 49% of tubes were in the oesophagus on entry to the lower left quadrant whereas 12% had already reached the gastric body in the upper left quadrant. Overall, predicting position by quadrant was 70% accurate whereas differentiating the pre-gastro-oesophageal junction (pre-GOJ) from the gastric body flexure was 100% accurate. Confirming gastric position by the anterior trace quadrant appears to be unsafe whereas expert differentiation of the pre-GOJ and gastric body flexures was reliable. The authors invite Corpak Medsystems (now owned by Halyard Health) to update its guidance in view of these findings.

Stroke: ineffective tube securement reduces nutrition and drug treatment.

Stroke patients with dysphagia often depend on nutrition, hydration and medication via nasogastric (NG) feeding tubes. Securing tubes using tape is associated with repeated tube loss. In this study, the authors determined cause and effect by auditing tube placement methods, delays incurred, duration and costs. Of 202 NG tube placements in 75 patients, 67 placements occurred in 17 patients over a full course of enteral nutrition (EN) and 40 of these placements were tracked. Tubes were secured by tape in 100%, mittens 31% and special observation 5.4%. However, over an EN course, inadvertent tube loss occurred in 82% of patients and was associated with age (p=0.049) and mitten use (p<0.001): 64% of tubes were lost due to patients and 9% slipped. Average 'tube life' was 2 days, less than 25% of the EN episode (p<0.001). While tube placement occurred within 2.55 hours of request, X-ray confirmation led to a delay in feed and drugs of 8-9 hours per tube placement and loss of 18.8% of feeding time per EN episode. Delays exceeded the 1-hour and 4-hour limits for antibiotics and other medicines in 20% and 80%, respectively. In the 17 tracked patients, it was estimated that 55% of the £5979 direct costs could be saved by nasal bridle use. In conclusion, most tubes studied were lost to inadvertent tube removal, leading to clinically significant delays to nutrition, hydration and drug treatments; this may impair recovery. Reducing tube loss is likely to reduce patient distress, treatment cost and enhance recovery.