avanos MIC Mode D'emploi page 4

10. Advance a .038" compatible flexible catheter over the guidewire and using fluoroscopic
guidance, manipulate the guidewire into the antrum of the stomach.
11. Advance the guidewire and flexible catheter until the catheter tip is at the pylorus.
12. Negotiate through the pylorus and advance the guidewire and catheter into the duodenum
and 10–15 cm beyond the Ligament of Treitz.
13. Remove the catheter, leaving the guidewire in place, and dispose of according to facility
protocol.
Create the Stoma Tract under Endoscopic Visualization
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.
Warning: 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.
14. Anesthetize the puncture site with local injection of 1% lidocaine down to the peritoneal
surface.
15. Insert a .038" compatible introducer needle at the center of the gastropexy pattern into the
gastric lumen directed toward the pylorus.
Note: For J tube placement, the best angle of insertion is a 45 degree angle to the surface of
the skin.
16. Use endoscopic visualization to verify correct needle placement.
17. Advance a guidewire, up to .038", through the needle and into the stomach. Confirm position.
18. Use endoscopic visualization to grasp the guidewire with atraumatic forceps.
19. 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 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 the scalpel according to facility protocol.
2. Advance a dilator over the guidewire and dilate the stoma tract at least four French sizes
larger than the enteral feeding tube being placed.
3. Remove the dilator over the guidewire, leaving the guidewire in place.
Note: After dilation, a peel-away sheath may be used to facilitate advancement of the tube
through the stoma tract.
Surgical Tube Placement
1. Advance the MIC* J Feeding Tube until the balloon is in the stomach.
2. Palpate the tube through the duodenum. When satisfied with the placement, check the
position. The tip should lie 10–15 cm past the Ligament of Treitz.
Using a male Luer syringe, inflate the balloon.
• Inflate the LV balloon with 2–3 ml of sterile or distilled water.
• Inflate the standard balloon with 7–10 ml of sterile or distilled water.
Caution: Do not exceed 5 ml total balloon volume inside the LV balloon and 20 ml
total balloon volume in the Standard balloon. Do not use air. Do not inject contrast into the
balloon.
3. Tie the purse string sutures around the tube.
4. Gently pull the tube up and away from the abdomen until the balloon contacts the inner
stomach wall.
5. Use the purse string sutures to attach the stomach to the peritoneum. Take care to avoid
puncture of the balloon.
6. Clean the residual fluid or lubricant from the tube and stoma.
7. Gently slide the external retention bolster to approximately 2–3 mm above the skin. Do not
suture the bolster to the skin.
Tube Placement under Fluoroscopic (Radiologic) Visualization
1. Advance the distal end of the tube over the guidewire, through the stoma tract and into the
stomach.
2. Rotate the MIC* J Feeding Tube while advancing to facilitate passage of the tube through the
pylorus and in the jejunum.
3. 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.
Using a male Luer syringe, inflate the balloon.
• Inflate the LV balloon with 2–3 ml of sterile or distilled water.
• Inflate the standard balloon with 7–10 ml of sterile or distilled water.
Caution: Do not exceed 5 ml total balloon volume inside the LV balloon and 20 ml total
balloon volume inside the Standard balloon. Do not use air. Do not inject contrast into the
balloon.
4. Gently pull the tube up and away from the abdomen until the balloon contacts the inner
stomach wall.
5. Clean the residual fluid or lubricant from the tube and stoma.
6. Gently slide the external retention bolster to approximately 2–3 mm above the skin. Do not
suture the bolster to the skin.
7. Remove the guidewire.
Tube Placement under Endoscopic Visualization
1. Advance the distal end of the tube over the guidewire, through the stoma tract and into the
stomach.
2. Grasp the suture loop or the tip of the tube with atraumatic forceps.
3. Advance the MIC* J 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.
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4. Release the tube and withdraw the endoscope and forceps in tandem, leaving the tube in
place.
Using a male Luer syringe, inflate the balloon.
• Inflate the LV balloon with 2–3 ml of sterile or distilled water.
• Inflate the standard balloon with 7–10 ml of sterile or distilled water.
Caution: Do not exceed 5 ml total balloon volume inside the LV balloon and 20 ml total
balloon volume inside the Standard balloon. Do not use air. Do not inject contrast into the
balloon.
5. Gently pull the tube up and away from the abdomen until the balloon contacts the inner
stomach wall.
6. Clean the residual fluid or lubricant from the tube and stoma.
7. Gently slide the external retention bolster to approximately 2–3 mm above the skin. Do not
suture the bolster to the skin.
8. Remove the guidewire.
Verify Tube Position and Patency
1. Verify proper tube placement radiologically to avoid potential complication (e.g. bowel
irritation or perforation) and ensure the tube is not looped within the stomach or small
bowel.
2. Flush the jejunal lumen with water to verify patency.
3. Check for moisture around the stoma. If there are signs of gastric leakage, check the tube
position and placement of the external retention bolster. Add sterile or distilled water as
needed in 1–2 ml increments. Do not exceed balloon capacity as indicated previously.
4. Check to ensure that the external retention bolster is not placed too tightly against the
skin and rests 2–3 mm above the abdomen for initial placement and 1–2 mm above the
abdomen for a replacement tube.
5. Begin feeding only after confirmation of proper patency, placement and according to
physician instructions.
Replacement Procedure Through an Established
Gastrostomy Tract
1. Cleanse the skin around the stoma site and allow the area to air dry.
2. Select the appropriate size MIC* J Feeding Tube and prepare according to the instructions in
the Tube Preparation section above.
3. If using endoscopic visualization, 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. Manipulate the endoscope until the indwelling gastrostomy
tube is in the visual field.
4. Under either fluoroscopic guidance or endoscopic guidance, insert a floppy-tipped guidewire,
up to .038", through the indwelling gastrostomy tube.
5. Remove the gastrostomy tube over the guidewire.
6. Place the MIC* J Feeding Tube according to the Tube Placement section above.
Caution: For a replacement feeding tube, gently slide the external retention bolster to
approximately 1–2 mm above the skin. Do not suture the bolster to the skin.
7. Verify tube position and patency using the Verify Tube Position and Patency section above.
Tube Patency Guidelines
Proper tube flushing is the best way to avoid clogging and maintain tube patency. The following
are guidelines to avoid clogging and maintain tube patency.
• Flush the feeding tube with water every 4–6 hours during continuous feeding, anytime the
feeding is interrupted, or at least every 8 hours if the tube is not being used.
• Flush the feeding tube before and after medication administration and between medications.
This will prevent the medication from interacting with formula and potentially causing the
tube to clog.
• Use liquid medication when possible and consult the pharmacist to determine if it is safe to
crush solid medication and to mix with water. If safe, pulverize the solid medication into a
fine powder form and dissolve the powder in warm water before administering through the
feeding tube. Never crush enteric-coated medication or mix medication with formula.
• Avoid using acidic fluids such as cranberry juice and cola beverages to flush feeding tubes
as the acidic quality when combined with formula proteins may actually contribute to tube
clogging.
General Flushing Guidelines
Flush the feeding tube with water using an ENFit® syringe every 4–6 hours during continuous
feeding, anytime the feeding is interrupted, at least every 8 hours if the tube is not being used,
or per clinician's instructions. Flush the feeding tube before, after, and in between medication
administration. Avoid using acidic irrigants such as cranberry juice and cola beverages to flush
feeding tubes.
• Use a 30 to 60 ml ENFit® syringe. Do not use smaller size syringes as this can increase pressure
on the tube and potentially rupture smaller tubes.
• Use room temperature water for tube flushing. Sterile water may be appropriate where the
quality of municipal water supplies is of concern. The amount of water will depend on the
patient's needs, clinical condition, and type of tube, but the average volume ranges from 10
to 50 ml for adults, and 3 to 10 ml for infants. Hydration status also influences the volume
used for flushing feeding tubes. In many cases, increasing the flushing volume can avoid the
need for supplemental intravenous fluid. However, individuals with renal failure and other
fluid restrictions should receive the minimum flushing volume necessary to maintain patency.
• Do not use excessive force to flush the tube. Excessive force can perforate the tube and can
cause injury to the gastrointestinal tract.
• Document the time and amount of water used in the patient's record. This will enable all
caregivers to monitor the patient's needs more accurately.