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2 devices that unclog feeding tubes


 

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Originally posted January 2005

2 devices that unclog feeding tubes

By Rose-Marie Smith, RN and Sheila A. Myers, RN, BSN

ROSE-MARIE SMITH and SHEILA MYERS are nurses in nutritional support services at Palmetto Health Richland in Columbia, SC. The authors have no financial relationships to disclose.

When a patient's enteral feeding tube becomes clogged, both the feeding and your schedule come to an abrupt halt. Clogged tubes can be time-consuming to unclog and expensive to replace. They interrupt the patient's supply of nutrients and cause him discomfort, and they're discouraging to everyone involved.

Tube occlusion is a common and frustrating problem among patients receiving enteral nutrition. These nurses share two methods they found work best for unclogging feeding tubes.

When a patient's enteral feeding tube becomes clogged, both the feeding and your schedule come to an abrupt halt. Clogged tubes can be time-consuming to unclog and expensive to replace. They interrupt the patient's supply of nutrients and cause him discomfort, and they're discouraging to everyone involved.

Many nursing policies recommend flushing feeding tubes with 20 - 30 ml of water every four to six hours, and before and after administering medications or checking gastric residuals.1 Even with these policies, the rate of feeding tube occlusion is approximately 12.5%.2

Tube occlusion was a major concern at our hospital, a 649-bed regional community teaching medical center and Level 1 trauma facility. In addition to caring for our admitted patients with tubes, the Nutritional Support Services (NSS) nurses see outpatients from home, clinics, and senior-care and extended-care facilities.

To minimize the impact of tube occlusion at our hospital, the NSS nurses began to research ways to unclog feeding tubes. This article describes the two methods we found that work the best and the process we went through to find and evaluate them.

A common problem at our facility

Most of our patients who require enteral nutrition are initially fed through small-bore feeding tubes (SBFT) inserted nasally or orally and advanced to the ligament of Treitz at the junction of the duodenum and the jejunum. Others are fed through gastrostomy or jejunostomy tubes placed by physicians in the OR, radiology department, or GI laboratory. Occasionally, patients are fed through large-bore (16 F) nasogastric or orogastric tubes.

Small-bore tubes are more prone to clogging than large-bore tubes, and we soon realized that clogging of these tubes was a major cause of feeding downtime. A patient with an occluded tube could miss several hours of feeding before the tube was unclogged or replaced—a situation that could lead to nutritional deficiencies if it were to recur. A clogged tube could also delay the administration of medication. This concerned us, as did our patients' discomfort and the expense incurred by having to replace tubes that could not be unclogged.

Our policy was to first try to clear the clogged tube by instilling water, but this didn't always work. To save patients the discomfort and time of having a new tube inserted, we wanted to determine if any other methods of clearing the tube might be more effective.

We began our research by reviewing the literature and found an abundance of information about SBFT placement techniques, routine care, and complications. We located a number of articles on maintaining tube patency, but very little information on restoring it.

After reviewing the literature, we identified several common causes of tube occlusion. Tubes were likely to clog when formula bags were allowed to run dry, the tube was not adequately or routinely flushed, or medications were administered improperly through the tube.3,4 Improper medication administration includes not fully crushing a drug, giving two or more drugs simultaneously, giving a drug and formula together, and giving a drug without flushing before and after its administration.3,4

We determined that these practices were contributing to tube occlusions at our facility. With this in mind, we provided short inservices on preventing occlusions. (The box on page 41 lists recommendations for maintaining feeding tube patency.) However, a reliable method of restoring patency once a tube became clogged was still needed.

Testing to see what works

We tried several unclogging methods that were described in the literature, including passing tiny brushes on wires—from Bard (Billerica, MA; 800-367-2273)—into the tubes. This sometimes worked on gastrostomy tubes, but often, the device compressed the clogged matter, making unclogging even more difficult.

We also tried a product called the DeClogger, from Bionix (Toledo, OH; 800-551-7096). It is a long, threaded, flexible screw-like device that you insert into a clogged tube until it reaches the clog; then you twist it and pull it out, bringing the clogged material with it. This device worked for gastrostomy tubes, but it was too short to use on other tubes.

We read studies in which various substances, including carbonated cola, cranberry juice, meat tenderizer, water, and enzymes such as pancrelipase (Viokase, Cotazym, others), papain, and chymotrypsin, were instilled in an attempt to clear clogged tubes. The results were mixed, with no clear consensus. One study found that papain and chymotrypsin worked better than cola or cranberry juice.5 Another found that cola and water were both superior to cranberry juice.6 Some researchers reported that acidic liquids, such as colas and cranberry juice, may contribute to clogging by denaturing proteins in the enteral formulas, and therefore recommended using only water.3,7

Since opinions varied on which solution worked best, we conducted our own tests using various colas and juices. These liquids were effective in clearing some tubes, at least initially; however, they did seem to increase the chances that a tube would clog again.

We read about tubes being flushed with small syringes containing meat tenderizer, but we did not try this method. We were worried that using a syringe smaller than 30 cc would deliver too much pressure and rupture the tube. (Our hospital policy calls for a 60 cc syringe for flushing feeding tubes.) We were also concerned that the meat tenderizer would exceed some patients' recommended daily allowance of sodium.

Regardless of which solution we tried, a basic problem in restoring patency was getting the solution to the site of the occlusion. When using a syringe for instillation, much of the solution appeared to adhere to the side of the feeding tube. We tried threading IV catheters into the tubes and then passing the solution of choice through the catheter, but the cost of the catheters and the time invested was prohibitive, and the technique was rarely successful.

Our diligence pays off

During our research, we came across a short article that described the InTRO-ReDUCER, a product made by Health Improvement Associates (Freeland, MI; 800-526-6364). The device is a 53-inch (132.5 cm), 4 F, polyvinyl chloride hollow catheter with a blunt cut on one end and a female Luer-Lok on the other (click here to see images of the InTRO-ReDUCER). The catheter is inserted into a feeding tube and a solution is instilled through it. This allows the solution to be delivered directly to the site of the occlusion.

We received samples of the InTRO-ReDUCER and tested them. After finding that this device was often effective, we incorporated it into our protocol as follows:

If a feeding tube clogs, the patient's staff nurse explains the procedure to the patient, puts on gloves, and attempts to flush and aspirate the tube with a 60 cc syringe filled with 30 ml of tepid tap water, regardless of the size of the patient's feeding tube. If the tube flushes, feeding is resumed. Sometimes turning the patient will reposition the tube with the GI tract, thus relieving a kink and restoring patency. If patency can't be restored by either flushing or repositioning, the nurse then notifies the NSS nurses, and we use the InTRO-ReDUCER.

To prevent the InTRO-ReDUCER's catheter from being accidentally inserted all the way through the feeding tube into the patient's GI tract, we measure and mark the catheter to match the length of the patient's tube. We then prepare an unclogging solution consisting of 8 oz hot water, 21/43 oz castile soap, and 11/42 teaspoonful meat tenderizer. Through trial and error, we had determined that this combination was the smallest amount of soap and meat tenderizer we could use that would still effectively clear clogs. (When using the InTRO-ReDUCER, only a minute amount of the unclogging solution enters the patient's GI tract, so neither the sodium in the meat tenderizer nor the soap is a concern.) The manufacturer recommends using hot water, but suggests that other agents, such as baking soda, dishwashing liquid, or enzymes, may be added as needed.8

We prime the device with the unclogging solution using a 10 cc Luer-Lok syringe, and place a towel and emesis basin under the entrance to the feeding tube. We insert the InTRO-ReDUCER into the feeding tube and begin flushing the tube as we advance the device; this produces a small, steady stream of solution that hits the clogged matter, breaks it up, and washes it back out of the tube into the basin. The clogged substance often looks like thin spaghetti.

As long as both solution and clogged matter are returning, we continue to slowly advance—and to occasionally withdraw—the unclogging device while we flush. When there is no longer a return of solution and clogged matter, we assume that the clog has been cleared and remove the InTRO-ReDUCER. We then flush the tube with 30 ml of water, and resume the tube feeding.

If, while using the InTRO-ReDUCER, the solution comes back clear, without any dried formula or particles, or the feeding tube bows or curves as we attempt to advance the device, we suspect that the tube is kinked. We stop the procedure and obtain a portable abdominal X-ray to check tube placement.

If the X-ray shows a kink, we attempt to reposition the tube. If we're unable to remove the kink, the tube must be replaced.

Once the kink is resolved, we use the InTRO-ReDUCER to unclog the rest of the tube, if necessary, or we flush the tube with water and resume the feeding. If the tube kinks a second time, we replace it.

Help for challenging clogs

When a tube is occluded by medications or has been clogged for a long time, we found that the InTRO-ReDUCER didn't always restore patency. For these cases, we began using the Clog Zapper, (click here to see image of Clog Zapper) by Viasys Medsystems (Wheeling, IL; 800-323-6305). The system includes a 10 cc syringe filled with a premixed unclogging powder, a 6 cc syringe, two 4 × 4 pads, and a 12-inch (31 cm) applicator that looks like a short InTRO-ReDUCER. The powder consists of maltodextrin, cellulase, alpha-amylose, potassium sorbate, papain, ascorbic acid, disodium phosphate, sodium lauryl sulfate, disodium EDTA, and citric acid.9

Before we use the Clog Zapper, we check to see if the patient is allergic to any of the ingredients. Unless we're working with a pediatric patient or a patient with a short gastrostomy tube, we rarely have to measure the applicator because it's only 31 cm long, which means there's almost no risk of accidentally inserting the applicator into the patient's GI tract. We fill the 10 cc powder-containing syringe with enough water (7.1 ml) to make 10 ml. We replace the cap and shake the syringe until the powder dissolves. After priming the applicator and inserting it into the tube, we instill 2 - 4 ml of solution. Next, we remove and rinse the applicator, close the tube, and leave the solution in the tube for about an hour.

Although the manufacturer supplies a 6 cc syringe for flushing the tube after the hour has passed, we do not use it. Instead, we attempt to flush the tube with 30 ml of water in a 60 cc syringe, as outlined by our facility's policy. If it flushes, we resume feeding; if it does not flush, we repeat the procedure. There is enough product for two or three attempts, if necessary. Any remaining solution must be refrigerated and used within 24 hours.9 If a tube still cannot be cleared with the Clog Zapper, we obtain an order to replace the feeding tube.

Documenting is essential

When we first started using the InTRO-ReDUCER and the Clog Zapper, a physician's order was required for each usage. Having to wait for an order meant the patient often went without feeding for a long time. We changed our policy after the first year so that we no longer need a physician's order; a nursing protocol is now in place. Also, to help prevent tubes from clogging, we now encourage nurses to alert the NSS nurses as soon as a tube becomes sluggish, and not to wait until it becomes completely clogged. Doing so has led to the percentage of feeding tubes that clog at our facility to drop from 13% in 2001 to 8% in 2003.

NSS nurses document enteral feeding tube problems in the patient's chart, beginning with the time the team was notified. We verify that the nurse's attempt to flush the tube with water was unsuccessful, then we document our actions, noting the procedure time and results. When applicable, we document the results of the abdominal X-ray and any efforts to remove kinks.

Since instituting these simple procedures, we have been able to successfully clear approximately 85% of clogged feeding tubes. We have reduced feeding delays and kept the cost of replacing feeding tubes to a minimum—only three tubes had to be replaced in 2003, compared to 10 in 2001. Although no method works 100% of the time, we've been pleased with the success we've achieved with the InTRO-ReDUCER and Clog Zapper. By restoring patency at the bedside, we're able to maintain our patients' comfort while ensuring that they continue to receive adequate nutrition.


REFERENCES

1. Fish, J. "Tube feeding in the ICU: Overcoming the obstacles." 2002. www.rosslearningcenter.com/library/ Tube%20Feeding%20in%20the%20ICU_RX.pdf (14 Oct. 2004).

2. Pancorbo-Hidalgo, P. L., Garcia-Fernandez, F. P., & Ramirez-Perez, C. (2001). Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. J Clin Nurs, 10(4), 482.

3. Guenter, P. "Administering medications via feeding tubes: What consultant pharmacists need to know." 1999. http://www.ascp.com/public/pubs/tcp/1999/ jan/tubes.shtml (14 Oct. 2004).(14 Oct. 2004).

4. Barnadas, G. (2003). Navigating home care: Enteral nutrition—Part one. Pract Gastroenterol, 27(10), 13.

5. Nicholson, L. J. (1987). Declogging small-bore feeding tubes. JPEN J Parenter Enteral Nutr, 11(6), 594.

6. Metheny, N., Eisenberg, P., & McSweeney, M. (1988). Effect of feeding tube properties and three irrigants on clogging rates. Nurs Res, 37(3), 165.

7. Beckwith, M. C., Feddema, S. S., et al. (2004). A guide to drug therapy in patients with enteral feeding tubes: Dosage form selection and administration methods. Hosp Pharm, 39(3), 225.

8. Health Improvement Associates, Inc. InTRO-ReDUCER feeding tube clearing and cleaning device. Freeland, MI: Author.

9. Viasys Medsystems. Clog Zapper enteral feeding tube unclogging system. Wheeling, IL: Author.


Using the InTRO-ReDUCER


A close-up of the Clog Zapper


The best approach? Prevention

One of the most effective ways of keeping a feeding tube patent is to flush it periodically with 20 - 30 ml of water using a 30 - 60 cc syringe. Check your facility's protocol to determine how often you should do this; typically, it's called for before and after administering medication or formula through the tube and every four to six hours.

Below are additional recommendations for making feeding tube occlusions less likely:

  • Use the appropriate-sized feeding tube. While smaller tubes are generally more comfortable than larger ones, tubes smaller than 8 or 10 F clog more easily. The tube should be wide enough to maximize formula flow.
  • Whenever possible, select a less calorically dense formula. Generally, calorically dense formulas are thicker and more likely to occlude the tube.
  • Use a feeding pump with an automatic water flush feature.
  • Don't add medications to formula. This isn't a reliable way to administer drugs, and can cause formula to thicken. (According to a report in the journal Hospital Pharmacy, about 15% of enteral feeding tube occlusions are caused by medication.)
  • Before giving a drug through the tube, stop the formula infusion, flush the tube with 30 ml of water, give the medication, and flush the tube again. If you're administering more than one drug, give each one separately, and flush with 5 ml of water between the two.
  • If a drug must be crushed, make sure it's crushed finely and dispersed well in water. Use liquid forms of drugs whenever possible. Don't crush enteric-coated, sustained-release, or time-release tablets or capsules. If you're unsure whether a drug may be crushed, check with the pharmacist.
  • Sources:

    1. Guenter, P. "Administering medications via feeding tubes: What consultant pharmacists need to know." 1999. http://www.ascp.com/public/pubs/tcp/1999/ jan/tubes.shtml (14 Oct. 2004).

    2. Fish, J. "Tube feeding in the ICU: Overcoming the obstacles."2002 .http://www.rosslearningcenter.com/library/ Tube%20Feeding%20in%20the%20ICU_RX.pdf (14 Oct. 2004).

    3. Barnadas, G. (2003). Navigating home care: Enteral nutrition-part one. Pract Gastroenterol, 27(10), 13.

    4. Beckwith, M. C., Feddema, S. S., et al. (2004). A guide to drug therapy in patients with enteral feeding tubes: Dosage form selection and administration methods. Hosp Pharm, 39(3), 225.


 

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