Where are the stripes?

Labs and Lytes 013

Author: Priya Rao
Reviewer: Chris Nickson

An ICU nurse asks you to review a recently performed radiograph:

PR fig 2

Q1. What does the radiograph show?

  • adequately positioned endotracheal tube
  • central line with tip in the SVC
  • bilateral intercostal catheters
  • gastric tube
  • jejunal tube
  • externally applied ECG monitoring

Q2. What is a Tiger™ tube?

The Cook Medical Tiger™ 2 Self Advancing Nasal Jejunal tube is the most commonly used jejunal tube in The Alfred ICU. It may be used to allow enteric feeding in patients who cannot tolerate gastric feeding.

It has these features:

  • 14 Fr
  • made of soft, compliant polyurethrane
  • has multiple ports
  • Alternating cilia-like flaps along the Tiger™ 2 help to advance it into the distal portions of the small bowel via peristalsis
  • Centimeter markings every 10 cm from 40-100 cm provide visual confirmation of tube position

Click here to see a photo of the Tiger™ 2.

A meta-analysis suggests that the use of small intestinal feeding, compared with gastric feeding, may improve nutritional intake and reduce the incidence of ICU-acquired pneumonia in ICU patients (Deane et al, 2013). There was no improvement in a number of other outcomes such as ICU length of stay or mortality.

Q3. How is a Tiger™ tube inserted?

Insertion is performed by a Senior Registrar or Consultant at The Alfred ICU. It involves the following steps:

  •  Visually inspect for kinks, bends or breaks
  • Apply lubricant to distal tip
  • Advance the lubricated feeding tube through the nose or mouth 50-70 cm into the stomach
    — this distance is dependent on the patient’s anatomical measurement
  • The use of insufflation and auscultation will confirm that the catheter is in the stomach
    — IF uncertain, obtain a CXR
  • The feeding tube should be left in place for 30 minutes to 1 hour to allow the patient’s peristalsis to advance the catheter
  • Manually advance the feeding tube 10 cm every 30 minutes to 1 hour until the 100 cm mark is reached
    — If peristalsis is very weak, the feeding tube can be advanced 10 cm every two hours
    — If the patient’s stomach is anatomically unusual, advance the tube in 5 cm increments
  • Pharmacologic agents may be used to increase peristalsis (e.g. metoclopramide 10 mgIV and/ or erythromycin 250mg IV)
  • At the 100 cm mark, an abdominal X-ray should be taken to confirm position in the small intestine
    — Consider injecting 20 mL gastrograffin through the Tiger tube to improve visualisation of the tip
  • Secure the feeding tube in place using hypoallergenic tape.

There is also an optional Torque Cable that can be used to add body/stiffness to facilitate gastric placement. It must be removed before advancing the Tiger™ 2 beyond the pylorus.

Removal of the Tiger™ 2 should be performed in a slow steady fashion.

Q4. What are the possible complications associated with insertion and use?

Insertion

  • Failure to pass through pylorus (contra-indicated if nasal obstruction or bowel obstruction)
  • Bleeding (contra-indicated if varices, bleeding diathesis or local ENT or GIT trauma/ surgery)
  • Aspiration and tracheal placement
  • Kinking of the tube
  • Discomfort and nasopharyngeal trauma
  • Potential for intra-cranial passage if base-of-skull fracture

Use

  • Nasal irritation
  • Sinusitis
  • Sore throat
  • Pressure sores if incorrectly secured
  • Bowel erosion and/or intestinal perforation (contra-indicated if peritonitis or ischaemic bowel)
  • Clogged or leaking feeding tube
  • Premature displacement of the tube

References and Links

  • LITFL CCC — Tiger Tube
  • Deane AM, Rupinder D, Day AG, Ridley EJ, Davies AR, Heyland DK. Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis. Crit Care. 2013 Jun 21;17(3):R125. [Epub ahead of print] PubMed PMID: 23799928; PubMed Central PMCID: PMC4056800.

One comment on “Where are the stripes?
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