Oral and nasal enteral tube placement errors and complications in a pediatric intensive care unit*

Abstract

Patients in the pediatric intensive care unit may have characteristics that place them at an increased risk for misplacement of oral or nasal enteral tubes into the respiratory tract. Placement of enteral tubes into the respiratory tract may cause serious morbidity and possibly mortality. Checking the placement of enteral tubes with traditional methods does not prevent misplacement in the respiratory tree, and new techniques should be considered.

Examining the Evidence to Guide Practice: Challenging Practice Habits

“…The nurse should feel confident with the result of the verification methods that the tip of the tube is in the stomach. Numerous case reports of tubes verified as being in correct place by auscultation, later found to be malpositioned 97,100,101,115 Cutoff values for capnography not established Colorimetric device may detect respiratory placement 120 but does not allow distinction between esophageal, gastric, and intestinal placement Conflicting evidence that the cutoff of 5 mg/dL allows distinction between gastric and intestinal placement 89,124,125 No bedside test Values highly variable during first year of life [126][127][128] Conflicting evidence regarding predictive value 124,129 No bedside test Values <50 μg/mL may be associated with gastric placement, but values ≥50 μg/mL may not be associated with intestinal placement 129 No bedside test pH values ≤5 good predictor of gastric placement 89,124 ; however, values >5.0 are not as helpful at identifying tubes that are not in the stomach 89 Does not allow distinction between respiratory and intestinal placement Most useful if used in conjunction with aspirate color 102,105,129,130 Subjective May not allow distinction between respiratory, esophageal, and gastric placement Most useful if used in conjunction with pH 102,105,129,130 limitations associated with various methods of verifying tube placement. Radiography remains the only single method by which feeding tube placement can be reliably determined.…”

“…In infants and children, reported error rates with auscultation range from 3.4% to 50%. 109,110 Additionally, numerous case reports in children describe instances of malpositioned tubes in the esophagus or respiratory tract that went undetected by auscultation, leading to aspiration, 115 pneumothorax, 100 pulmonary hemorrhage, 100 pulmonary perforation, 97 esophageal perforation, and death. 97,100 A significant problem with auscultation is that sounds can be transmitted to the epigastric area, regardless of the location of the tube tip; this concern is even more exaggerated in infants and young children because of their smaller torsos.…”

“…94,95 Reported complications of malpositioned feeding tubes in infants and children include pneumothorax, 96 hydropneumothorax, 97 esophageal perforation, 98,99 urinary bladder perforation, 99 and death. 100,101 Ensuring safe and effective feeding via nasogastric tubes requires the nurse to initially insert the tube to the correct place and periodically confirm that the tube remains in the intended location. Even if a nasogastric tube is positioned correctly upon insertion and secured, the distal tip can migrate forward or backward from its original position.…”

Electrocardiographic Guidance for the Placement of Gastric Feeding Tubes: A Pediatric Case Series

“…The inadvertent placement of a gastric tube in the trachea contributes most substantially to the morbidities associated with tube misplacement, including instillation of food into the trachea, tracheal perforation, pneumothorax, and pulmonary hemorrhage. [18][19][20][21] Factors associated with errors in enteral tube placement in children include younger age, decreased level of consciousness, abdominal distention, presence of emesis, and the use of the orogastric route. 1 The EA di waveforms can immediately notify the clinician that the tube is not in the esophagus/stomach and may be in the trachea.…”

Nasogastric Tube Placement and Verification in Children: Review of the Current Literature

“…10,11,34,35 The widespread use of histamine 2 receptor antagonists and proton pump inhibitor medications confounds the usefulness of assessing pH to verify NG-EAD placement. 10,28,[33][34][35] In addition, continuous infusion of enteral formula, which many children require, further complicates pH testing. The range of pH for gastric secretions is 1 to 4, in contrast to the pH of many commercially prepared formulas, which is 6.6.…”