avanos MIC-KEY Mode D'emploi page 4

Measuring the Stoma Length
Caution: Selection of the correct size MIC-KEY* Feeding Tube is critical
for the safety and comfort of the patient. Measure the length of the patient's
stoma with the Stoma Measuring Device. The shaft length of the MIC-KEY*
Feeding Tube selected should be the same as the length of the stoma. An
inappropriately sized MIC-KEY* Feeding Tube can cause necrosis, buried bumper
syndrome and/or hypergranulation tissue.
1. Moisten the tip of the Stoma Measuring Device with water soluble lubricant.
Do not use mineral oil. Do not use petroleum jelly.
2. Advance the Stoma Measuring Device over the guidewire, through the
stoma and into the stomach. DO NOT USE FORCE.
3. Fill the Luer slip syringe with 5ml of water and attach to the balloon port.
Depress the syringe plunger and inflate the balloon.
4. Gently pull the device toward the abdomen until the balloon rests against
the inside of the stomach wall.
5. Slide the plastic disc down to the abdomen and record the measurement
above the disc.
6. Add 4–5 mm to the recorded measurement to ensure the proper stoma
length and fit in any position. Record the measurement.
7. Using a Luer slip syringe, remove the water in the balloon.
8. Remove the stoma measuring device.
9. Document the date, lot number and measured centimeter shaft length.
Tube Placement
Note: A peel-away sheath may be used to facilitate advancement of the tube
through the stoma tract.
1. Select the appropriate MIC-KEY* Jejunal Feeding Tube and prepare
according to the directions in the Tube Preparation section listed above.
2. Advance the distal end of the tube over the guidewire until the proximal end
of the guidewire exits the introducer cannula.
Note: Direct visualization and manipulation of the introducer and guidewire
may be required to pass the guidewire through the end of the introducer.
3. Hold the introducer hub and jejunal feeding port while advancing the tube
over the guidewire and into the stomach.
4. Rotate the AVANOS* MIC-KEY* Jejunal Feeding Tube while advancing to
facilitate passage of the tube through the pylorus and into the jejunum.
5. Advance the tube until the tip of the tube is 10–15 cm beyond the Ligament
of Treitz and the balloon is in the stomach.
6. Ensure the external bolster is flush with the skin.
7. Using a Luer slip syringe, inflate the balloon.
• Inflate the balloon with 5 ml of sterile or distilled water.
Caution: Do not exceed 10 ml total balloon volume.
Do not use air. Do not inject contrast into the balloon.
8. Remove the guidewire through the introducer cannula while holding the
cannula in position. Remove the introducer cannula.
Verify Tube Position
1. Verify proper tube placement radiographically to avoid potential
complication (e.g. bowel irritation or perforation) and ensure the tube is not
looped within the stomach or small bowel.
Note: The tube is radiopaque and can be used to radiographically confirm
position. Do not inject contrast into the balloon.
2. Flush the lumen to verify patency.
3. Check for moisture around the stoma. If there are signs of gastric leakage,
check the tube position and external bolster placement. Add fluid as need in
1–2 ml increments.
Caution: Do not exceed total balloon volume indicated above.
4. Check to assure that the external bolster is not placed too tightly against the
skin and rests 2–3 mm above the abdomen.
5. Document the date, the type, the size and lot number of the tube, the
fill volume of the balloon, skin condition and patient tolerance to the
procedure. Start feeding and medication administration per physician
orders and after confirmation of proper tube placement and patency.
Radiologic Placement Through An Established Gas-
trostomy Tract
1. Under fluoroscopic guidance, insert a floppy-tipped guidewire, up to .038",
through the indwelling gastrostomy tube.
2. Remove the gastrostomy tube over the guidewire.
3. Direct the guidewire through the stoma and coil in the stomach.
4. Advance a .038" guidewire compatible flexible catheter over the guidewire
until the catheter tip is at the pylorus.
5. Negotiate the pylorus and advance the guidewire into the duodenum. If the
catheter is difficult to advance through the pylorus, reduce the length of the
catheter coiled in the stomach. A rotational motion on the flexible catheter
may allow easier passage over the guidewire.
6. Advance the guidewire and catheter to a point 10–15 cm beyond the
Ligament of Treitz.
7. Remove the catheter and leave the guidewire in place.
8. Measure the stoma length with the AVANOS* Stoma Measuring Device.
Tube Placement
1. Select the appropriate size MIC-KEY* Jejunal Feeding Tube and prepare
according to the directions in the Tube Preparation section above.
4
2. Advance the distal end of the tube over the guidewire and into the stomach.
3. Rotate the AVANOS* MIC-KEY* Jejunal Feeding Tube while advancing to
facilitate passage of the tube through the pylorus and into the jejunum.
4. Advance the tube until the tip of the tube is 10–15 cm beyond the Ligament
of Treitz and the balloon is in the stomach.
5. Using a Luer slip syringe, inflate the balloon.
• Inflate the balloon with 5 ml of sterile or distilled water.
Caution: Do not exceed 10 ml total balloon volume. Do not use air. Do
not inject contrast into the balloon.
6. Remove the guidewire through the introducer cannula while holding the
cannula in position.
7. Remove the introducer cannula.
8. Verify proper tube placement according to Verify Tube Position section
above.
Suggested Endoscopic Placement Procedure
1. Perform routine Esophagogastroduodenoscopy (EGD). Once the procedure
is complete and no abnormalities are identified that could pose a
contraindication to placement of the tube, place the patient in the supine
position and insufflate the stomach with air.
2. Transilluminate through the anterior abdominal wall to select a gastrostomy
site that is free of major vessels, viscera and scar tissue. The site is usually
one third the distance from the umbilicus to the left costal margin at the
midclavicular line.
3. Depress the intended insertion site with a finger. The endoscopist should
clearly see the resulting depression on the anterior surface of the gastric
wall.
4. Prep and drape the skin at the selected insertion site.
Gastropexy Placement
Caution: It is recommended to perform a three point gastropexy in a
triangle configuration to ensure attachment of the gastric wall to the anterior
abdominal wall.
1. Place a skin mark at the tube insertion site. Define the gastropexy pattern
by placing three skin marks equidistant from the tube insertion site and in a
triangle configuration.
Warning: Allow adequate distance between the insertion
site and gastropexy placement to prevent interference of the
T-Fastener and inflated balloon.
2. Localize the puncture sites with 1% lidocaine and administer local
anesthesia to the skin and peritoneum.
3. Place the first T-Fastener and confirm Intragastric position. Repeat the
procedure until all three T-Fasteners are inserted at the corners of the
triangle.
4. Secure the stomach to the anterior abdominal wall and complete the
procedure.
Create the Stoma Tract
1. Create the stoma tract with the stomach still insufflated and in apposition
to the abdominal wall. Identify the puncture site at the center of the
gastropexy pattern. With endoscopic guidance confirm that the site overlies
the distal body of the stomach below the costal margin and above the
transverse colon.
Caution: Avoid the epigastric artery that courses at the junction of the
medial two-thirds and lateral one-third of the rectus muscle.
Warning: Take care not to advance the puncture needle too
deeply in order to avoid puncturing the posterior gastric wall,
pancreas, left kidney, aorta or spleen.
2. Anesthetize the puncture site with local injection of 1% lidocaine down to
the peritoneal surface.
3. Insert a .038" compatible introducer needle at the center of the gastropexy
pattern into the gastric lumen directed toward the pylorus.
Note: The best angle of insertion is a 45 degree angle to the surface of
the skin.
4. Use endoscopic visualization to verify correct needle placement.
5. Advance a guidewire, up to .038", through the needle into the stomach.
Using endoscopic visualization, grasp the guidewire with atraumatic forceps.
6. Remove the introducer needle, leaving the guidewire in place and dispose of
according to facility protocol.
Dilation
1. Use a #11 scalpel blade to create a small skin incision that extends alongside
the guidewire, downward through the subcutaneous tissue and fascia of the
abdominal musculature. After the incision is made, dispose of according to
facility protocol.
2. Advance a dilator over the guidewire and dilate the stoma tract to the
desired size.
3. Remove the dilator over the guidewire, leaving the guidewire in place.
4. Measure the stoma length with the AVANOS* Stoma Measuring Device.
Measuring the Stoma Length
Caution: Selection of the correct size MIC-KEY* Feeding Tube is critical
for the safety and comfort of the patient. Measure the length of the patient's
stoma with the Stoma Measuring Device. The shaft length of the MIC-KEY*
Feeding Tube selected should be the same as the length of the stoma. An
inappropriately sized MIC-KEY* Feeding Tube can cause necrosis, buried bumper
syndrome and/or hypergranulation tissue.
1. Moisten the tip of the Stoma Measuring Device with water soluble lubricant.
Do not use mineral oil. Do not use petroleum jelly.
2. Advance the Stoma Measuring Device over the guidewire, through the
stoma and into the stomach. DO NOT USE FORCE.
3. Fill the Luer slip syringe with 5ml of water and attach to the balloon port.
Depress the syringe plunger and inflate the balloon.
4. Gently pull the device toward the abdomen until the balloon rests against
the inside of the stomach wall.
5. Slide the plastic disc down to the abdomen and record the measurement
above the disc.
6. Add 4–5 mm to the recorded measurement to ensure the proper stoma
length and fit in any position. Record the measurement.
7. Using a Luer slip syringe, remove the water in the balloon.
8. Remove the stoma measuring device.
9. Document the date, lot number and measured centimeter shaft length.
Tube Placement
1. Select the appropriate sized MIC-KEY* Jejunal Feeding Tube and prepare
according to the directions in the Tube Preparation section listed above.
2. Advance the distal end of the tube over the guidewire until the proximal end
of the guidewire exits the introducer cannula.
Note: Direct visualization and manipulation of the introducer and guidewire
may be required to pass the guidewire through the end of the introducer.
3. Hold the introducer hub and jejunal port while advancing the tube over the
guidewire and into the stomach.
4. Using endoscopic guidance, grasp the tip of the tube with atraumatic
forceps.
5. Advance the AVANOS* MIC-KEY* Jejunal Feeding Tube through the pylorus
and upper duodenum. Continue to advance the tube using the forceps
until the tip is positioned 10–15 cm beyond the Ligament of Treitz and the
balloon is in the stomach.
6. Release the tube and withdraw the endoscope and forceps in tandem,
leaving the tube in place.
7. Ensure that the external bolster is flush with the skin.
8. Using a Luer slip syringe, inflate the balloon.
• Inflate the balloon with 5 ml of sterile or distilled water.
Caution: Do not exceed the 10 ml total balloon volume.
Do not use air. Do not inject contrast into the balloon.
9. Remove the guidewire through the introducer cannula while holding the
cannula in place.
10. Remove the cannula.
Verify Tube Position
1. Verify proper tube placement radiographically to avoid potential
complication (e.g. bowel irritation or perforation) and ensure that the tube
is not looped within the stomach or small bowel.
Note: The tube is radiopaque and can be used to radiographically confirm
position. Do not inject contrast into the balloon.
2. Flush the gastric and jejunal lumens to verify patency.
3. Check for moisture around the stoma. If there are signs of gastric leakage,
check the tube position and the external bolster placement. Add fluid as
needed in 1–2 ml increments.
Caution: Do not exceed total balloon volume indicated above.
4. Check to assure that the external bolster is not placed too tightly against the
skin and rest 2–3 mm above the abdomen.
5. Document the date, the type, the size, and lot number of the tube, the
fill volume of the balloon, skin condition and patient tolerance to the
procedure. Start feeding and medication administration per physician
orders and after confirmation of proper tube placement and patency.
Endoscopic Placement Through An Existing
Gastrostomy Tract
1. Following established protocol, perform routine
Esophagogastroduodenoscopy (EGD). Once the procedure is complete
and no abnormalities are identified that could pose a contraindication
to placement of the tube, place the patient in the supine position and
insufflate the stomach with air.
2. Manipulate the endoscope until the indwelling gastrostomy tube is in the
visual field.
3. Insert a floppy-tip guidewire through the indwelling gastrostomy tube and
remove the tube.
4. Measure the stoma length with the AVANOS* Stoma Measuring Device.
Tube Placement
1. Select the appropriate sized MIC-KEY* Jejunal Feeding Tube and prepare
according to the directions in the Tube Preparation section above.
2. Hold the introducer cannula and jejunal hub while advancing the
AVANOS* MIC-KEY* Jejunal Feeding Tube over the guidewire and
into the stomach.
3. Refer to step 2 in the Tube Placement section above and complete the
procedure according to the steps listed.
4. Verify proper placement according to the directions in the Verify Tube
Position section listed above.