Bedside Placement and Care of a Nasojejunal Tube

Introduction

The aim of this document is to provide a short summary guideline for the bedside placement of a Nasojejunal tube (NJ tube). A routine nasogastric tube (NG tube) is not needed but in special circumstances both an NG tube and an NJ tube maybe required.

Scope & Purpose

This guideline is for use by all Registered Nursing staff (band 4 and up) and medical staff that provide care for children with differing physical, psychological, social and emotional needs who require a NJ tube. The aim of this guideline is guide staff in the placement of an NJ tube on the ward. It outlines the clinical standards required for safe and competent care when placing and feeding a child via an NJ tube​.

Definitions

Nasogastric Tube (NG tube)
A narrow bore tube passed into the stomach via the nose. It is used for short / medium / long term nutritional support; also for aspiration of stomach contents – e.g. for decompression of intestinal obstruction

Naso/oro jejunal tube (NJ tube)
A narrow bore long term tube passed into the small bowel (jejunum) via the nose. It is used for short / medium / long term nutritional support. For the purposes of this guideline naso/ oro jejunal tubes will be referred to as NJ tube, although it is recognised in some circumstances an orogastric tube will be required.

NEX measurement
Nose; Ear; Xiphisternum measurement – this is how to measure the length of an NG tube.

pH indicator strip
An indicator strip that shows level of acidity

Gastric decompression
The removal of pressure caused by gas or fluid from the stomach.

Turbulent Flush
Using a push stop, push stop technique on the syringe rather than a slow steady push

Bedside Placement of a Nasojejunal Tube

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Placement of a feeding tube into the small bowel

The decision to place the tube in the duodenum (the first section of the small bowel) or the jejunum (the second section of the small bowel) depends on the clinical condition of the child. It must be document in the child’s health records.
Jejunal feeding may be initiated in any age group of patients following discussion with the wider multi-disciplinary team.

Considerations for jejunal feeding are:

• Severe gastro oesophageal reflux

• Delayed gastric emptying

• Persistent vomiting

• Trauma e.g. traumatic brain injury (TBI)

• Malignancy

Contraindications for jejunal feeding are:

• Bowel obstruction

• Oesophageal atresia/stenosis

• Significant upper GI bleeding

• Necrotising enterocolitis (conservative management)

• Ischaemic bowel

Consideration for orojejunal rather than naso-jejunal tube:

• Basal skull fracture

• Maxillo facial abnormalities

• Nasopharyngeal abnormalities

Please consider the following points before initiating jejunal feeding

If you are considering a referral to the paediatric gastroenterology team; please discuss the placement of an NJ tube with the gastroenterology team first.

Consideration and documentation of the following is imperative before placing an NJ tube:
Indication for placing an NJ tube?

• Growth (height and weight)

• Continuous gastric feeding with breaks should be tried. A regimen of 10 hours of continuous feeding followed by a 2 hours break and repeat.

• Fully understand the risks and benefits associated with NJ tubes; including the risk of recurrent displacement.

• Full and frank discussion with multi-disciplinary team

• Plan for tube replacement post discharge

• Patient follow-up and exit strategy

Recurrent replacement of an NJ tube is an invasive procedure

• Displacement is more likely in:

  • ​younger children

  • children with neurological movement disorders

  • those with recurring vomiting (particularly retching) as they will vomit out the tube

• NJ tubes can be placed on ward following this guideline

• If NJ placement is unsuccessful on the ward (following 2 attempts) discussion with radiology is required for fluoroscopic placement.

Considerations for Patient Discharge

Appendix B - Equipment Required for Jejunal Tube Placement

• Naso-jejunal tube (6 – 8 Fr long term tube with a guidewire) – Consider the child’s age, nasal cavity size and other relevant anatomical considerations when deciding on size of tube

• Plastic apron and gloves – mouth and eye protection should be available

• Hand gel

• Tape (or nasal tube fixation device)

• Tape measure

• Syringe

• Water for lubrication

• Sterile water in hospital

• pH indicator strip (check expiry date)

• Vomit bowl and Tissues

• Oxygen and suction (check both are working)

• Prepared medication or feed

• A drink with a straw or a dummy for a child to suck on (if appropriate)

• Drainage bag if to have an NG on drainage as well

Appendix C - Aspiration of a Nasojejunal Tube

This should only be attempted by those trained to do so if there are concerns that the NJ tube has displaced based on clinical judgement.

• Gently push 5ml of air into the tube, briefly remove the syringe, reattach and then attempt to draw back. If a vacuum is present, this is an indicator that the tip of the tube is within the intestine.

• If air can be drawn back up the tube, this is a strong indicator that the end of the tube is in the stomach.

• The smallest size syringe that must be used to aspirate the tube is a 10ml.

• A vacuum should be felt when aspirating an NJ tube, this is normal for a Jejunal aspirate.

• Fluids pass through the jejunum and do not accumulate within it, as in the stomach, obtaining an aspirate can be a timely process and may not be possible, thus if the other indicators are acceptable, an aspirate is not required.

• Pulling against a vacuum is the only way to achieve an aspirate from the jejunum, but excessive pressure on the tube can contribute to its displacement from the intestine.

• If an aspirate is obtained, test pH (if below 5 most likely gastric content)

• A record must be maintained showing the length of the NJ tube at the nostril, as from initial placement, which was confirmed by screening fluoroscopy or x-ray. This must be recorded daily whilst in hospital.

• Of Note

  • Prior to feed/medication/water being administered, the length of the tube should be checked and documented (see appendix F).

  • As the numbers wear off the NJ tube once it has been in place for a while, the tube should be marked with a black line at the nostril, to indicate correct placement length.

Appendix D - Measuring for a Nasojejunal Tube

It important to determine the length of NJ TUBE required to reach the jejunum prior to insertion. This should be done in two measurements A and B:

• Distance A: This is the NEX measurement (nose, ear, xiphisternum) as per a nasogastric tube

• Distance B: The length of tube required to place an NJ tube in the small bowel. See pictures below for the different age groups. Oral jejunal tubes should be measured from the mouth and not the nose for all age groups. The measurements are obtained as follows:

Both lengths should be clearly documented in the patient notes.
​Distance B (is measured according to age)

Appendix E - X-Ray Interpretation

The NJ tube tip should been seen to go through the pylorus and around the c-shaped duodenum. The tip should ideally lie either in the midline (over a vertebral body) or to the left of the patients midline in the jejunum (picture 1).

• If NJ tube is too far in e.g. seen to curl in small bowel loops gently withdraw as necessary. You can measure the exact distance to withdraw on the X-ray.

• If NJ tube is through the pylorus but lies short, then loosen the securing tapes and advance further as necessary. Re-X-ray to confirm final position before feeding is commenced.

• If there is any uncertainty about the position of an NJ tube, please discuss with a radiologist before the tube is removed.

• If NJ tube is coiled in the stomach, without going through the pylorus discuss with radiology before attempting a second placement.

• If the NJ tube has taken an unusual path within the bowel discuss with the radiologist before removal of the tube (picture 2).

Picture 1 - Correct Placement

Picture 2

Appendix F - Potential Complication of Jejunal Tube Placement

Appendix G - Nasojejunal Tube Position Check Pathway (Inpatient)

Appendix H - Nasojejunal Tube Teaching for Parents and Carers

References

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17. Everitt L, Dick K, Pridgeon J, et al (2016) G30 Paediatric Jejunal feeding is resource intensive; report of 5 year practice in Wessex Archives of Disease in Childhood 101:A21- A22. (http://dx.doi.org/10.1136/archdischild-2016-310863.29)