Nursing Manager Rainbow Babies and Children's Hospital, United States
Abstract:
Introduction: Enteral caloric intake is essential for optimal outcome for infants with congenital heart disease, in both the pre- and post-operative periods. Some of these infants require post-pyloric feeding due to various etiologies of feeding intolerance. In some situations, blind placement of post-pyloric feeding tubes is technically unsuccessful at the bedside. While sonographic assisted placement is gaining traction, not all pediatric critical care units have this technology. Thus, when blind placement of a post-pyloric feeding tube is unsuccessful, placement under fluoroscopic guidance, generally by a pediatric radiologist, may be required. Unfortunately, aligning personnel comfortable with this procedure in small, complex infants in combination with access to fluoroscopy resources can be logistically challenging and time consuming. Such hurdles often delay providing adequate enteral calories to infants within the cardiac critical care environment.
Objective: We developed a comprehensive, interdisciplinary protocol for post-pyloric feeding tube placement by cardiac critical care nurse practitioners under fluoroscopic guidance in the pediatric cardiac catheterization lab.
Methods: In conjunction with the Sections of Interventional Cardiology and Pediatric Radiology, a formal assessment of benefits and risks was undertaken in the development of a comprehensive post-pyloric feeding tube placement protocol. The initial attempt at post-pyloric tube placement occurs at the patient’s bedside by a nurse or nurse practitioner trained in the procedure. The protocol allows for three attempts including the use of beside enteral contrast administration and promotility medications. If success has not been achieved after approximately 12 hours, the patient is brought to the pediatric cardiac catheterization lab (during standard lab hours) for placement with fluoroscopic guidance by a cardiac critical care nurse practitioner. A trained radiologic technologist from the catheterization lab team manages the fluoroscopy using standard safety protocols. Placement is confirmed real-time by the nurse practitioner as well as by a pediatric radiologist via a still image.
Results: Early in this process, six post-pyloric enteral feeding tubes have been placed with fluoroscopic assistance under this protocol with the tip at or beyond the second portion of the duodenum, each on the first attempt and without adverse event. Data collection for this quality improvement project is ongoing and includes total time from decision to place a post-pyloric feeding tube to successful completion, success rate, total fluoroscopy time, and occurrence of any complications.
Conclusions: Post-pyloric feeding tube placement using a team approach by pediatric cardiac critical care nurse practitioners and radiologic technologists under fluoroscopic guidance in the cardiac catheterization lab is a promising approach to shortening time to enteral feeding in pediatric cardiac patients who are intolerant of gastric feeding. Additional data are needed before a more definitive statement can be made.
