7. Use reliable infusion pumps that control rate and detect

obstruction.

8. Limit infusion of hypertonic solutions and do not

deliver bolus feedings beyond the pylorus.

9. Consider the effect of continuous feedings on medication absorption.

282 Section VII ■ Tube Replacement

E

D

C

A B

Fig. 40.3. Radiographic examples of misplaced feeding

tubes. A: Tube coiled in the oropharynx and upper esophagus,

simulating an esophageal atresia. B: Tube into the left mainstem bronchus. C: Tube coiled in the lower esophagus.

D: Tube doubled on itself in the stomach with its distal end in

the esophagus (arrow). E: Tube the esophagus. A rush may be

heard on auscultation over the stomach when air is injected

through a tube lying in this position, making an unreliable

verification of gastric location.

Chapter 40 ■ Gastric and Transpyloric Tubes 283

F. Special Circumstances

1. See Oral or Nasal Gastric Tubes (F).

G. Technique

1. Follow steps 1 through 4 above under Oral or Nasal

Gastric Tubes (G).

2. Measure distance from glabella to heels or from the tip

of the nose to the ear to the xiphoid to the right lateral

costal margin (19). Mark point with tape on transpyloric tube.

3. Turn patient onto right side and elevate the head of the

bed 30 to 45 degrees.

4. Pass transpyloric tube to predetermined depth.

5. After approximately 10 minutes with infant remaining

on right side, gently aspirate through transpyloric tube.

Tube may be in position within duodenum if aspirate is

a. Without air

b. Bilious (gold or yellow in color)

c. pH >6, although this method alone is not reliable

(4,19)

6. Verify placement with radiograph. The tip of the tube

should be just beyond the second portion of duodenum

(4,19) (Fig. 40.5).

7. Avoid pushing to advance tube after initial placement.

If tube is not in far enough, retape to give external slack

and to allow peristalsis to carry tip to new position.

8. After verifying correct positioning, close transpyloric

tube or start continuous infusion.

9. Document patient response, observing any physiologic

changes and verifying tube placement. Note the location of the tube at the nares and document it on the

chart. Check this location before each use.

10. Transpyloric tubes may also be placed with fluoroscopic guidance.

Fig. 40.4. Chest radiograph showing esophageal perforation by

an orogastric tube.

A

B

Fig. 40.5. A: Abdominal radiograph showing appropriate position

of transpyloric tube. B: Radiographic demonstration of a transpyloric

feeding tube that has passed the ligament of Treitz, well below the

appropriate level, increasing the risk of perforation or nutritional

dumping.