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Wie wird die Lage von Magensonden kontrolliert?
Abstract
Das Legen von Magensonden erfolgt auf vielen Intensivstationen ärztlich delegiert durch Pflegefachpersonen. Diese benötigen aktuelles Wissen über die Eignung von Methoden zur Lagekontrolle. Im vorliegenden Beitrag werden eine systematische Literaturübersicht sowie eine Fragebogenerhebung auf Intensivstationen im Kölner Umland dargestellt. Die Ergebnisse der Befragung geben erstmals Hinweise über eingesetzte Methoden zur Lagekontrolle durch Pflegefachpersonen in Deutschland.
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Nasogastric feeding tube insertion is a common but invasive procedure most often blindly placed by nurses in acute and chronic care settings. Although usually not harmful, serious and fatal complications with misplacement still occur and variation in practice still exists. These tubes can be used for drainage or administration of fluids, drugs and/or enteral feeding. During blind insertion, it is important to achieve correct tip position of the tube ideally reaching the body of the stomach. If the insertion length is too short, the tip and/or distal side-openings at the end of the tube can be located in the esophagus increasing the risk of aspiration (pneumonia). Conversely, when the insertion length is too long, the tube might kink in the stomach, curl upwards into the esophagus or enter the duodenum. Studies have demonstrated that the most frequently used technique to determine insertion length (the nose-earlobe-xiphoid method) is too short a distance; new safer methods should be used and further more robust evidence is needed. After blind placement, verifying correct gastric tip positioning is of major importance to avoid serious and sometimes lethal complications.
Objective:
to analyze in the scientific literature the evidence on nasogastric/nasoenteric tube related adverse events in adult patients.
Method:
integrative literature review through the search of publications in journals indexed in PubMed/MEDLINE, CINAHL, LILACS, EMBASE and Scopus, and hand searching, was undertaken up to April 2017.
Results:
the sample consisted of 69 primary studies, mainly in English and published in the USA and UK. They were divided in two main categories and subcategories: the first category refers to Mechanical Adverse Events (respiratory complications; esophageal or pharyngeal complications; tube obstruction; intestinal perforation; intracranial perforation and unplanned tube removal) and the second alludes to Others (pressure injury related to fixation and misconnections). Death was reported in 16 articles.
Conclusion:
nasogastric/nasoenteric tube related adverse events are relatively common and the majority involved respiratory harm that resulted in increased hospitalization and/or death. The results may contribute to healthcare professionals, especially nurses, to develop an evidence-based guideline for insertion and correct positioning of bedside enteral tubes in adult patients.
Background
Insertion of a tube via the nasal passage is a common procedure which has been practiced for many years. There are various ways to assess the position of the nasogastric tube (NGT).
Objectives
The objective of this study was to discuss the advantages and limitations of each method of NGT placement confirmation, to identify gaps in literature, and provide suggestions for future research.
Methods
A search was performed with Pubmed, CINAHL, and Embase. The following keywords were used: “nasogastric,” “tube,” “placement,” “insertion,” and “measurement.” The results were narrowed down to those with full text available, published in the English language, those published within the last 10 years, and those studies done in the adult population. The reference lists of those articles were also referred to and relevant articles were retrieved. A final 26 relevant articles were included in this review, including six that were published more than 10 years ago but still relevant in this review.
Results
A method to confirm NGT placement that is accurate, affordable, does not require gastric aspirates, and is able to be used not only upon insertion but also at regular intervals is lacking.
Conclusions
This article provides a summary of the different methods of NGT placement confirmation and discusses their advantages and limitations. Gaps in literature and suggestions for future research were also deliberated.
Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.
In the medical intensive care unit at the University of Virginia Health System, capnography is used to detect end-tidal carbon dioxide to protect patients from inadvertent airway cannulation during placement of gastric tubes.
To compare the method in which capnography is used with a method in which a colorimetric carbon dioxide detector is used and to determine what variables affect accurate placement of gastric tubes.
A prospective convenience sample of 195 gastric tube insertions was studied in 130 adult patients in a medical intensive care unit. Standard insertions of gastric tubes (done with capnography) were simultaneously monitored by using a disposable colorimetric device, with a color change indicating the presence of carbon dioxide.
Insertion variables included tube type (60% Salem sump tubes, 40% soft-bore feeding tubes), route of insertion (71% oral, 29% nasal), mechanical ventilation (81%), and decreased mental status (72%). Carbon dioxide was successfully detected with the colorimetric indicator (within seconds) in all insertions in which carbon dioxide was detected by capnography. When carbon dioxide was detected (27% of insertions), the tubes were withdrawn and reinserted. Carbon dioxide detection during tube placement was significantly associated with nasal insertions (P = .03) and spontaneously breathing/nonintubated status (P = .01) but not with mental status or tube type.
A colorimetric device is as accurate as capnography for detecting carbon dioxide during placement of gastric tubes.
Zusammenfassung: Hintergrund: Die Anlage und Überprüfung der korrekten Lage blind applizierter Magensonden wird in der klinischen Praxis häufig durch Pflegefachpersonen durchgeführt. Internationale Leitlinien empfehlen zur Lagebestimmung eine radiologische Überprüfung als Methode der Wahl oder wenn die pH-Wert-Messung nicht möglich ist. Für Deutschland liegen weder evidenzbasierte Empfehlungen noch aktuelle Kenntnisse vor. Fragestellung: Welche Methoden setzen Pflegefachpersonen auf deutschen Intensivstationen zur Überprüfung der korrekten Lage von blind applizierten Magensonden ein und wie wird die Zuverlässigkeit verschiedener Methoden eingeschätzt? Methoden: Multizentrisches Fragebogensurvey. Eingeschlossen wurden Überwachungs- und Intensivstationen einer Gelegenheitsstichprobe aus Krankenhäusern in und um Köln. Pro teilnehmende Station wurde eine Pflegefachperson eingeschlossen. Die Auswertung erfolgte vornehmlich deskriptiv. Ergebnisse: In 22 Krankenhäusern haben 38 Stationen ihre Teilnahme zugesagt und 32 (84%) an der Befragung teilgenommen. Die Auskultation am Oberbauch bei gleichzeitiger Luftinsufflation sowie die Aspiration von Magensekret sind wesentliche Methoden zur Lagebestimmung von Magensonden. Als zuverlässige Methoden werden die Auskultation, die Aspiration von Magensekret sowie die radiologische Kontrolle eingeschätzt. Schlussfolgerungen: Die Ergebnisse entsprechen hinsichtlich der Nutzung der Auskultationsmethode nicht internationalen Empfehlungen und belegen die Notwendigkeit evidenzbasierter Best-Practice-Empfehlungen und Schulungen. Es besteht Forschungsbedarf hinsichtlich praktikabler und valider bettseitiger Methoden.
The insertion of a gastric tube in the operating room (OR) or in an intensive care unit (ICU) is a routine procedure. Although the tube is often inserted by nursing staff, the indications and selection of the procedure for position control remain the physician’s responsibility. For immediate position control, the injection of air through the inserted tube with simultaneous auscultation of the epigastrium is probably the most simple and common clinical method. A typical “bubbling” is often regarded as a sufficiently reliable sign of correct gastric tube position. This procedure can be described as a routine standard both in the OR and the ICU; however, numerous examples from clinical practice and quality reviews show gastric tube mispositioning in esophageal, bronchial, pulmonary or even pleural positions in individual cases. Since auscultation findings are misinterpreted as tracheal, bronchial, or pleural secretions, mispositioning may remain undetected. In addition, adequate documentation of the procedure is lacking. In the worst case, hyperosmolar tube feeding occurs via the malpositioned tube into the lungs or pleural space causing subsequent severe pneumonia or pleuritis, which is often fatal for the patient outcome. In contrast to many other similar procedures in intensive care medicine, such as the installation of central venous catheters or endotracheal intubation, to our knowledge there is no uniform standard for forensic verification of the correct position after gastric tube positioning. The present work provides an overview of existing practices and the scientific background for confirmation of gastric tube positioning without ionizing radiation.
Insertion and postinsertion care of enteral nasogastric feeding tubes are common procedures in the United States, with more than 1.2 million temporary nasogastric feeding tubes inserted annually. Although there are some evidence-based practice guidelines and recommendations for care of these tubes, variation in practice still exists. Additional research is needed to determine the best methodology for insertion and confirmation of nasogastric feeding tubes. Routine competency and training on feeding tube insertion, enteral nutrition, and postinsertion care is crucial to prevent patient safety events. Variable results have been reported with different technologies; however, radiographic confirmation remains the criterion standard. It is important that health care institutions develop standardized procedures for insertion and confirmation on the basis of evidence-based practices to minimize risks and complications from temporary nasogastric feeding tubes.
Pflegerisches Know-how auf der Intensivstation und in der Anästhesie
Mit dem „Larsen“ haben Sie das Standard-Lehrbuch in der Hand, das Sie durch die Fachweiterbildung und in der Praxis begleitet!
Alle Inhalte systematisch aufbereitet, verständlich und nachvollziehbar erklärt, mit zahlreichen Abbildungen und Tabellen ergänzt. Zahlreiche Tipps für den Umgang mit dem Patienten, aktuelle Literatur für Wissbegierige und ein übersichtliches Glossar machen das Werk besonders praxistauglich.
Aus dem Inhalt
• Grundlagen und Verfahren in der Anästhesie und Anästhesiepflege
• Postoperative Versorgung
• Grundlagen der Intensivmedizin und Intensivpflege
• Lunge, Atmung, Beatmung, Weaning
• Herz-Kreislauf-Funktion und ihre Störungen
• Niere, Wasser-Elektrolyt- und Säure-Basen-Haushalt
• Spezielle Intensivmedizin in den verschiedenen Fachgebieten
Die 10. Auflage, nun unter interprofessioneller Herausgeberschaft. Komplett aktualisiert und um folgende Themen erweitert: Anästhesie in der Gynäkologie und bei geriatrischen Patienten, innerklinische Reanimation, spezielle Intensivpflege, Intensivbehandlung der Covid-19-Krankheit.
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Ein Muss für alle Pflegekräfte auf Intensivstation oder in der Anästhesie, Fachweiterbildungsteilnehmer und Lehrkräfte. Auch für Ärzte zum Lernen und Lehren ein bewährtes Nachschlagewerk!
Die Herausgeber
Prof. Dr. Reinhard Larsen, ehemaliger Direktor der Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie am Universitätsklinikum des Saarlandes sowie Autor zahlreicher Bücher im Bereich der Anästhesie und Intensivmedizin
Prof. Dr. Tobias Fink, D.E.S.A., M.H.B.A., ständiger Vertreter des Klinikdirektors der Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie sowie stellvertretender ärztlicher Leiter der Fachweiterbildung Intensivpflege und Anästhesie am Universitätsklinikum des Saarlandes, Homburg
Tilmann Müller-Wolff, B.Sc., M.A., Akademieleiter der Regionalen Kliniken Holding, Ludwigsburg; Fachkrankenpfleger für Intensivpflege und Anästhesie, Pflege- und Gesundheitswissenschaftler, Mitherausgeber der DIVI-Zeitschrift und Autor zahlreicher Fachpublikationen im Bereich Intensivpflege und Anästhesie
Background:
Harm events such as pneumothoraces and pneumonia continue to be associated with feeding tube insertion. Most bedside verification methods are not accurate to discriminate pulmonary from gastrointestinal system. Evidence-based clinical practice guidelines do not support auscultation of feeding tubes in adults, yet auscultation is the most common method used.
Objectives:
Our survey assessed national feeding tube verification practices used by critical care nurses, including progress in auscultation method deimplementation, and stylet reinsertion and cleansing practices.
Methods:
A national survey of 408 critical care nurses was performed.
Results:
The majority performed auscultation (311 of 408 [76%]) to verify feeding tube placement. In the final multivariable model, nursing education, facility type, observation of colleagues performing auscultation, and awareness of an institutional policy were associated with auscultation of feeding tubes. Thirty-five percent used enteral access devices to verify initial feeding tube placement. Stylet cleansing methods were variable; 38% of reinserted stylets were not cleansed.
Discussion:
Minimal progress has been made in deimplementation of auscultation in the past 7 years despite passive knowledge dissemination in research articles, clinical practice guidelines, and procedure manuals. Although pH measure is used as a first-line feeding tube verification method in the United Kingdom, it is rarely used in the United States. Clinical practice guidelines should be updated to incorporate new research on enteral access systems.
Conclusions:
Tradition-based practices such as auscultation and certain stylet cleansing methods should be deimplemented. A focused interdisciplinary, multifaceted program is needed to deimplement auscultation practice for adult feeding tubes.
The purpose of this review was to (1) identify areas of agreement and disagreement in guidelines/recommendations to distinguish between gastric and pulmonary placement of nasogastric tube and (2) summarize factors that affect choices made by clinicians regarding which method(s) to use in specific situations. Systematic searches were conducted in the PubMed, Scopus, and CINAHL Plus databases using a combination of keywords and data-specific subject headings. Searches were limited to guidelines/recommendations from national level specialty groups and governmental sources published in the English language between January 1, 2015 and September 20, 2018. Fourteen guidelines that described methods to distinguish between gastric and pulmonary placement of nasogastric tubes were identified from a variety of geographic locations. Tube placement testing methods included in the review were: radiography, respiratory distress, aspirate appearance, aspirate pH, auscultation, carbon dioxide detection and enteral access devices. All fourteen guidelines agreed that radiography is the most accurate testing method. Of the nonradiographic methods, pH testing was most favored; least favored was auscultation.
Objectives:
This present study was designed to determine the efficacy of the colorimetric capnometry method used to verify the correct placement of the nasogastric tube.
Methods:
The present study comprised forty patients who had a nasogastric tube inserted and were being monitored in the adult intensive care unit. After the insertion of the nasogastric tube, 40 colorimetric capnometry and 40 auscultation measurements were performed. Auscultation and colorimetric capnometry results were compared with tube placement results confirmed radiologically.
Results:
In the confirmation of the placement of the nasogastric tube, the consistency was 97.5% (p<0.05) between the colorimetric capnometry method and the radiological method, and 82.5% (p>0.05) between the auscultatory method and the radiological method. The oesophageal placement of the nasogastric tube was detected with the colorimetric capnometry method, but the gastric and duodenal insertions were not determined. While the sensitivity and specificity of the colorimetric capnometry method in determining the correct placement of the nasogastric tube were 1.00 and 0.667 respectively, those of the auscultatory method were 0.89 and 0.0 respectively.
Conclusion:
As a result, for the confirmation of the NGT placement, the colorimetric capnometry method is considered more reliable than the auscultatory method and is compatible with the radiological method. However, the colorimetric capnometry method is inadequate to distinguish between the gastric or duodenal insertion.
Bolus nasogastric tube feeding is common. Unsafe practices such as failure to confirm tube placement can result in death. It is vital to ensure that nurses are adopting safe practices.
To evaluate nurses' practices on bolus nasogastric feeding relating to verification of tube placement, management of gastric residual volume, and response to complications during feeding.
Cross-sectional, self-administered survey using clinical scenarios.
All nurses who worked in the general wards in a tertiary hospital in August 2008.
We developed six clinical scenarios to describe common clinical situations in nurses' daily practices. Participants were instructed to choose the responses that best reflected their practices, and to return the completed questionnaires to the study member present.
The survey participation rate was 99.5% (1203 nurses). Seventy-six percent would choose two or more methods to verify placement when they were in doubt. Percentage of hydrogen (pH) testing was the most common first method of checking tube placement. The second and third self-reported methods were auscultation and the bubble test. Few chose radiography to confirm tube placement. When the aspirate was pH 7, and in the presence of positive auscultation, most participants would take further steps to confirm placement. There were variations in the nurses' responses on managing the gastric residual volume, with 78.1% indicating that they would return the aspirate. Most nurses lacked the knowledge to effectively manage patients' distress during tube feeding.
The findings showed that the majority of participants reported that they would exercise due caution by taking additional measures to check tube placement when in doubt. The practice gaps identified in the study highlighted a need to realign our care to best practices. Following the study, we revised the institution's guideline, reinforced specific safety precautions on nasogastric feeding, and incorporated clinical scenarios in our training.
The accidental placement of feeding tubes into the airway is a rare but serious complication of blind feeding tube placement in pediatrics. A method using a colorimetric carbon dioxide detector has been tested as a means of decreasing the risk of inadvertent airway placement of gastric tubes in adults, but to date, a similar study has not been accomplished in pediatric patients. This study sought to evaluate the efficacy of a procedure using the colorimetric device during blind gastric tube placement in children. The results demonstrated that the study procedure using the device is effective in detecting inadvertent tube placement into the lung in the pediatric population.
AACN. Initial and Ongoing Verification of Feeding Tube Placement in Adults (applies to blind insertions and placements with an electromagnetic device).