Access Devices

Question 1

Gastric feeding

Answer 1

Generally reserved for patients with normal gastric emptying and low risk of gastric aspiration

Question 2

Small bowel feeding

Answer 2

Preferred in the presence of gastric outlet obstruction, gastroparesis, severely increased risk of aspiration, and pancreatitis

Question 3

Gastrojejunal tube systems

Answer 3

Allow for simultaneous gastric decompression, and small bowel feedings. May be indicated for gastric outlet obstruction, severe GERD, gastroparesis, and early (postoperative) feeding

The use of small bowel feeding to reduce the risk of aspiration PNA is controversial, although recent data and meta-analysis suggest this feeding approach may be of benefit.

Question 4

(T/F) Most NG or nasoenteric tubes are constructed of polyurethane.

Answer 4

TRUE

It allows for a relatively larger inner tube diameter for a given outer diameter size

Question 5

(T/F) Most PEG tubes are constructed out of silicone.

Answer 5

TRUE

Silicone has inherent material longevity and comfort.

Question 6

(T/F) You can use Foley catheters or red rubber catheters for enteral feeding.

Answer 6

FALSE

That is no longer possible due to the 2017 mandate to have ENfit connectors

Question 7

(T/F) All feeding tubes sizes are reported by the tube’s internal diameter measurement.

Answer 7

FALSE

Measured by the EXTERNAL diameter measurement.

Flow through the tubes and susceptibility to clogging depends on the tube’s inner diameter. The inner diameter may vary depending on the specific material used to construct the tube.

Question 8

What is generally true about the diameter size with polyurethane and silicone tubes?

Answer 8

Polyurethane tubes with the same outer diameter as a silicone tube will have a larger internal diameter that may be less likely to clog.

Question 9

What are stylets or guidewires?

Answer 9

They are provided with most nasoenteric feeding tubes to provide tube structure and/or guidance while passing these relatively floppy tubes.

Designed to be shorter than the length of the tube and to have a flexible distal tip to avoid perforation of the GI wall.

Question 10

When are water-activated lubricants used?

Answer 10

Used to coat the tube’s internal lumen to allow easier removal of the stylets or guidewires after the feeding tube is in place.

Question 11

What is the difference between a 1-port and a Y-port?

Answer 11

1 port for feeding

Y-port has one port for feeding and the other for medication and/or irrigation.

Question 12

(T/F) Dual ports allow for concomitant feeding and medication administration and/or irrigation.

Answer 12

TRUE

However, to prevent clogging, medications should be administered through the tube only after the TFs are HELD and the feeding tube is flushed with water.

Question 13

What is the Global Enteral Device Supplier Association?

Answer 13

A non-profit trade association formed to introduce the new international standards for enteral feeding connectors that are designed to increase patient safety and optimal delivery of EN by reducing the risk of tubing misconnections. ENfit connectors.

Question 14

(T/F) Weighted tube tips facilitate the transpyloric passage when placing a feeding tube.

Answer 14

FALSE

Research does not demonstrate a clear advantage with the use of either weighted or unweighted tips.

Question 15

When and why are solid internal bolsters used?

Answer 15

More common in initial percutaneous enterostomy tube placement

Have greater longevity

Question 16

When and why are balloon-type internal bolsters used?

Answer 16

Inserted more commonly with radiologic and surgical tube placement; used as replacement devices in office settings because of their ease in placement.

Question 17

How much volume will a balloon-type internal bolster be filled with, if placed in the small bowel? And why?

Answer 17

Not typically more than 3-4 mL, so it will not obstruct the lumen.

Question 18

How long do balloon-type internal bolsters last?

Answer 18

4 - 6 months.

Question 19

What bolster type (balloon-type or solid) is preferred for a direct jejunal tube placement? And why?

Answer 19

Non-balloon-type is preferred; to avoid occluding the narrower jejunal lumen.

Question 20

What is a solid internal bolster constrained with a dissolvable capsule? When is it used? What is the benefit?

Answer 20

It is placed in the same manner as a balloon-type; used for laparoscopic initial gastric or direct jejunal tube placement, and as replacements.

The benefit is that it combines the longevity of a solid internal bolster with the ease of placement of a balloon-type bolster

Question 21

(T/F) Internal balloon-type bolsters have 3 ports.

Answer 21

TRUE.

1 for feeding; medications/irrigation; balloon inflation/deflation

Question 22

What is the gold standard for confirmation of feeding tube placement?

Answer 22

Plain abdominal or chest radiography

Question 23

(T/F) Feeding tubes should not be used for feeding until confirmation of proper position.

Answer 23

TRUE

Question 24

What are added to bedside techniques and may increase success rates of feeding tube placement?

Answer 24

Prokinetics (erythromycin or metoclopramide).

IV Erythromycin (in doses of 200-500 mg) had the highest success rate.

Question 25

What are two devices that have been developed to assist with nasoenteric tube placements?

Answer 25

Bedside magnet, and electromagnetic imaging system (success rates have been documented as greater than 90%).

Question 26

What is the reported bedside success rate for nasoenteric tubes? What is the success rate for endoscopic and fluoroscopic placement?

Answer 26

56 - 92% for bedside

Greater than 90% for endo- and fluoro-

Question 27

(T/F) The American Society of Gastrointestinal Endoscopy guidelines consider placement of a percutaneous feeding tube to be a high-bleeding-risk procedure.

Answer 27

TRUE

Routine pre-procedural testing of coagulation parameters and platelets is no longer recommended for patients undergoing enterostomy tube placement. But these should be considered if there is a concern.

Question 28

How long should:

• Thienopyridines
• Warfarin
• Aspirin

be held for, in relation to a PEG placement? If these cannot be held, what is recommended?

Answer 28

1. Thienopyridines: should be held for 5-7 days BEFORE
   - If holding is not possible: Sometimes EPINEPHRINE will be added to the lidocaine for local anesthesia, and clinicians will make sure the bolsters are firm (not tight) for 3-4 before loosening them.
   2. Warfarin: should be held 5 days BEFORE; High-risk patients should be bridged with short-acting heparin and the new direct-acting oral anticoagulants should be held for at least 48 hours BEFORE the procedure, and restarted up to 48 hours AFTERWARDS.
   3. Aspirin regimens should be continued in patients with high thromboembolic risk.

Question 29

What medication is administered when enterostomy tubes are placed?

Answer 29

Prophylactic antibiotics; are shown to decrease peristomal infection rates when using endoscopic methods for initial placement

Question 30

Explain the Ponsky pull technique for PEG placement.

Answer 30

Most common; Endoscopy is fed through the mouth into the stomach. The placement for the feeding tube is determined through simultaneous endoscopic transillumination of the abdominal wall. A small incision is made at that site and a needle is inserted into the stomach. A guidewire is inserted within the needle and caught on the endoscopy snare. The guidewire is fed up to exit the mouth. The feeding tube is attached to the guidewire, then pulled from the placement site down into the mouth, esophagus, into the stomach and through the abdominal wall, until it is in place. The internal bolster holds it in place, and an external bolster is placed on the outside.

Question 31

What are the advantages of a PEG placement?

Answer 31

• Performance at bedside
• Lack of radiation
• Ability to perform diagnostic and therapeutic endoscopic procedures simultaneously.

Question 32

What are the contraindications for endoscopic PEG placement?

Answer 32

Specific:

• Obstruction of GI tract proximal to the stomach
• Inability to transilluminate the abdominal wall for ID of safe abdominal access

Relative:

• Ascites
• Coagulopathy
• Gastric varices
• Active head and neck cancers
• Morbid obesity
• Neoplastic, infiltrative, or inflammatory disease of the gastric or abdominal wall

Question 33

What are the advantages of fluoroscopic gastrostomy placement?

Answer 33

• Lack of need for conscious sedation in some patients
• Ability to perform in patients with severe stenosis/trauma of the upper GI tract
• Potentially decreased risk of tumor seeding from upper aerodigestive tract cancers

Question 34

When is surgical placement of feeding tubes used? (3)

Answer 34

AKA Laparoscopic or open (laparotomy) method: is performed in the operating room under general anesthesia.

• When patients are undergoing another abdominal operation
• When endoscopic and radiologic attempts fail
• And/or in the presence of an aerodigestive tract obstruction or facial trauma

Question 35

What is the Stamm technique?

Answer 35

the most commonly used surgical placement of an open G-tube

Question 36

In what situations is a percutaneous endoscopic gastrojejunostomy (PEJ) indicated?

Answer 36

• Impaired gastric motility
• Pancreatitis
• s/p pancreatic surgery
• Anytime enteral feeding into the small bowel with simultaneous stomach decompression is required.

Question 37

Explain how a PEG-J is placed.

Answer 37

Most commonly, a guidewire is placed through the existing gastrostomy, grasped endoscopically and carried into the jejunum. The endoscope is then withdrawn, leaving the guidewire in place. The jejunal extension tube is threaded over the guidewire into the small bowel.

Some methods include use of reclosable clips.

Question 38

When is fluoroscopic feeding tube placement appropriate?

Answer 38

When endoscopy cannot be performed!

Question 39

How is a direct jejunostomy tube placed?

Answer 39

Various fluoroscopic ways

Question 40

How is direct percutaneous jejunostomy placed?

Answer 40

Either endoscopic or fluoroscopic guidance; more difficult than placing a percutaneous gastrostomy.

Question 41

When can enterostomy tubes be safely removed or replaced?

Answer 41

After the stoma tract has matured. Maturation occurs 1-2 weeks after initial placement, but clinicians prefer to wait 4-6 weeks prior to removal to ensure it is mature.

Question 42

What could happen if an enterostomy is removed before the stoma tract is mature?

Answer 42

Stomach or small bowel falling away from the abdominal wall, allowing bowel contents to leak into the peritoneum

Question 43

What is the type of liquid and how much should be used for balloon-type bolsters for gastric tubes? Small bowel tubes?

Answer 43

Sterile water, 5-20 mL for gastric tubes & 3-4 mL for small bowel tubes.

Question 44

How do you properly clean the stoma site?

Answer 44

Mild soap and water, thoroughly rinse and dry area

Question 45

(T/F) The use of antibiotic ointments and hydrogen peroxide at the tube site is recommended for cleanliness.

Answer 45

FALSE. Dressings can be applied if there is drainage from the stoma site, but avoid excessive tension which can promote infection and buried bumper syndrome.

Question 46

(T/F) Whether medications is in a pill or liquid form, each medication should be given separately with a water flush, before and after each medication administration.

Answer 46

TRUE.

Liquid form medications may contain higher amounts of sorbitol/sugar, have a higher osmolarity, and/or a higher viscosity, and may be more expensive than a tablet form.

Giving a crushed and diluted medication could be more preferable; however; crushed pills can be more likely to clog a small-bore tube than medication in a liquid form.

Question 47

What is the overall success rate for procedure-rated complications for placing NG tubes?

Answer 47

~10%; epistaxis, aspiration, and circulatory or respiratory compromise

~2-4%; misplacement of NG tube into bronchopulmonary tree

Question 48

What is the gold standard for ensuring correct feeding tube placement?

Answer 48

RADIOGRAPHY

Question 49

What are postprocedural complications for NG tubes?

Answer 49

• Inadvertent tube dislodgement (~25-41% of cases)
• Tube malfunction (~11-20% of the time)
• Tube occlusion (~20-45% of the time)
• Intestinal ischemia

Question 50

What method significantly reduces NG tube dislodgement?

Answer 50

Nasal bridle; decreases from 36% to 10%

Question 51

What results in buried bumper syndrome? What are the risk factors?

Answer 51

From growth of the gastric mucosa over the internal bumper.

Risk factors: excessive tension between the internal and external bumpers, poor wound healing, and significant weight gain

Question 52

What are some methods that can be used for patients prone to pulling tubes?

Answer 52

• Use of abdominal binder
• Mittens over the patient’s hands
• Decreasing the external tube length to 6 to 8 cm
• Switching to a low-profile device

Question 53

**Where does ASPEN recommend feeding first?

Answer 53

**Stomach as a first choice.

Note, that recent data and meta-analysis suggest that jejunal feeding may be associated with decreased risk of aspiration PNA.

Question 54

Factors that should be considered when determining the type of enteral access device?

Answer 54

Underlying disease
Gastric and small bowel function
Short- and long-term goals
Anticipated length of therapy
Risk factors related to the method of placement
Ethical considerations

Question 55

Is a patient with head and neck cancer a candidate to receive an enteral feeding device? If so, what type of enteral feeding tube should be used?
Scenario: 72 y/o M w/ metastatic squamous cell carcinoma of tongue. Scheduled for 6 week course of chemo and radiation. Wt 80 kg, lost 11 kg in 3 months (14% wt loss). Labs WNL.

Answer 55

Could benefit from an enteral feeding tube to address both his existing malnutrition as well as likely further decreases in oral intake related to mucositis, nausea, and vomiting from chemoradiation. Expected duration of therapy is at least 6 weeks. Percutaneous gastrostomy tube (G-tube) is appropriate

Question 56

What is the “introducer” method of G-tube placement?

Answer 56

Used by interventional radiologists, surgeons, or endoscopists to minimize the risk of tumor implantation during G-tube placement in a head/neck cancer patient. The stomach is insufflated and anchored to the anterior abdominal wall with T-fasteners, and the G-tube is introduced percutaneously. In this manner, the tube is not pulled through the region with active cancer and risk for tumor seeding is decreased

Question 57

What type of long-term tube (stomach or small bowel) should patients receive if they have the preexisting condition of GERD? Does the answer change if the patient is in the ICU?

Answer 57

Whenever possible, patients should be fed into the stomach as it is the most physiologically normal for the body, ensuring appropriate mixing of nutrients with gastric acid. Feeding into the stomach also allows for schedule flexibility, is the safest with regard to formula contamination secondary to no formula hang time, allows for blenderized diets, and is the most cost-effective. IF the patient does not tolerate gastric feeding or has an aspiration event, the feeding can be diverted to the small intestine

Question 58

All feeding tube sizes are reported by the tube’s internal or external diameter measurement?

Answer 58

External

Question 59

The flow through the enteral tube and susceptibility to clogging depend on a tube’s inner or outer diameter?

Answer 59

Inner

Question 60

Polyurethane tubes with the same outer diameter as a silicone tube will have a smaller or larger internal diameter?

Answer 60

Larger

Question 61

Differences in characteristics of polyurethane vs silicone tubing

Answer 61

Silicone tubes are more comfortable and less stiff than polyurethane
Wall width is thinner in polyurethane and they are more resistance to fungal degradation

Question 62

Nasoenteric feeding tube port comparisons and options?

Answer 62

Have either 1 port for feeding or 2 in a “Y” configuration: one for feeding and the other for medication and/or irrigation

Question 63

Factors that determine which type of feeding tube tip to use?

Answer 63

There is no specific data to favor one design over another (weighted vs unweighted; side vs end feeding holes; number of distal feeding delivery holes)
The choice is determined by the preference of the individual clinician, institutional availability, and mode of placement

Question 64

What are the two options for an internal retention bolster for percutaneous tubes?

Answer 64

Solid material (silicone or polyurethane) or silicone balloons

Question 65

What type of internal retention bolster is more commonly used with initial percutaneous enterostomy tube placement and why?

Answer 65

Solid internal bolster. They have greater longevity

Question 66

Why would a silicone balloon internal bolster be used?

Answer 66

Ease in placement

Question 67

Define some characteristics of the use of a silicone balloon internal bolster?

Answer 67

Ease of placement. Inserted more frequently with radiologic and surgical tube placement, and used as replacement devices in the office setting. If placed in the small bowel, the balloon is typically filled with a volume of 3-4 ml so as not to obstruct the lumen. Typically only have a lifespan of 4-6 months. Use of a nonballoon tube is preferred for direct jejunal tube placement to avoid occluding the narrower jejunal lumen.

Question 68

Describe the characteristics of an enteral feeding tube with a solid internal bolster constrained in a dissolvable capsule that can be placed in the same manner as a balloon tube

Answer 68

May be used for laparoscopic initial gastric or direct jejunal tube placement, as well as for replacement tubes. It combines the longevity of a solid internal bolster with the ease of placement of a balloon-type internal bolster tube

Question 69

Why would a percutaneous enterostomy feeding tube have multiple ports?

Answer 69

Separate ports are included for feeding and medication and/or irrigation. Balloon-type internal bolsters also have a third port for balloon inflation or deflation

Question 70

Difference in placement of a gastrojejunal vs jejunal feeding tube?

Answer 70

Percutaneous gastrojejunal feeding tubes are inserted into the stomach with a smaller-bore extension tube that passes through the pylorus into the jejunum. Some are specifically designed with separate gastric and jejunal lumens and have ports that allow for both jejunal feeding and gastric decompression. Direct percutaneous jejunostomy tubes are placed directly into the jejunum without passage through the stomach

Question 71

What are low-profile tubes?

Answer 71

Skin-level devices that are used as initial placement or, more commonly, for replacement devices for gastrostomies, gastrojejunostomies, and jejunostomies. Excellent option for patients who are concerned about the cosmetic appearance of a feeding tube. Can also be more comfortable for patients who are active, sleep in the prone position, or need only intermittent therapy. Patient will need adequate manual dexterity or caregiver assistance to attach a feeding connector to a skin-level device

Question 72

When is nasogastric or nasoenteric tube placement contraindicated?

Answer 72

When patient has an obstructing head, neck, and esophageal pathology or injury that prevents safe insertion

Question 73

Which prokinetic had the highest success rate when passing a feeding tube post-pyloric?

Answer 73

IV erythromycin

Question 74

What are the available methods to place long-term enterostomy tubes?

Answer 74

Endoscopic, fluoroscopic, or surgical

Question 75

When should preprocedural testing of coagulation parameters and platelets be done before long-term feeding tube placement?

Answer 75

If there is concern for abnormal coagulation due to anticoagulant medication< medical history of excessive bleeding, or recent antibiotic use

Question 76

Is placement of a percutaneous feeding tube considered a high- or low-bleeding risk procedure?

Answer 76

High-bleeding risk

Question 77

Name specific and relative contraindications for endoscopic gastrostomy tube placement?

Answer 77

Specific: obstruction of the GI tract proximal to the stomach and the inability to transilluminate the abdominal wall for identification of a safe abdominal access site
Relative: ascites, coagulopathy, gastric varices, active head and neck cancers, morbid obesity, and neoplastic, infiltrative, or inflammatory disease of the gastric or abdominal wall

Question 78

Describe the Ponsky (pull) method of PEG tube insertion?

Answer 78

Air is insufflated into the stomach via endoscope. The optimal site for PEG tube placement is determined through simultaneous endoscopic transillumination of the abdominal wall and endoscopically visualized finger indentation at the site. A small incision is made at this site and a needle/trocar is inserted through the abdominal wall and into the stomach. A guidewire is passed through the endoscope; then, the guidewire, snare, and endoscope are withdrawn through the mouth. A G-tube is affixed to the guidewire and pulled through the esophagus into the stomach and out the abdominal wall. The G-tube is held in place by a solid, mushroom-type internal retention device and an external bumper

Question 79

Name advantages of PEG placement?

Answer 79

Performance at bedside, lack of radiation, and ability to perform diagnostic and therapeutic endoscopic procedures simultaneously

Question 80

Describe the first of 2 fluoroscopic methods of percutaneous G-tube placement (the more common method)

Answer 80

A NG tube is placed to insufflate the stomach, a safe window is identified under fluoroscopy, and 1 to 4 T-fasteners are used to perform a gastropexy to secure the stomach wall to the abdominal wall. A needle is used to obtain gastric access, the guidewire is advanced through the needle, and the tract is dilated sequentially until there is a large enough hole for the tube to go through. Lastly, the G-tube is placed through the tract using a peel-away sheath.

Question 81

Describe the second of 2 fluoroscopic methods of percutaneous G-tube placement (the less common method)

Answer 81

Uses a slightly curved 18-gauge needle or vascular sheath; it is advanced into the stomach and pointed toward the gastroesophageal junction after gastric insufflation. The guidewire is then advanced with or without the help of an angiographic catheter into the esophagus and oropharynx and out of the mouth. A G-tube is then threaded over the wire, advanced until it emerges from the abdominal wall, and then pulled into the desired position.

Question 82

What are advantages of fluoroscopic gastrostomy placement?

Answer 82

Lack of need for conscious sedation in some patients, ability to perform in patients with severe stenosis/trauma of the upper GI tract, and potentially decreased risk of tumor seeding from upper aerodigestive tract cancers

Question 83

When would surgical placement of a feeding tube take place?

Answer 83

Used when patients are undergoing another abdominal operation, when endoscopic and radiologic attempts fail, and/or in the presence of an aerodigestive tract obstruction or facial trauma

Question 84

When would direct laparoscopic gastric tube placement occur?

Answer 84

When endoscopic or radiologic placement fails or is not available

Question 85

Describe the laparoscopic technique of placing a feeding tube?

Answer 85

Accesses the peritoneal cavity by way of small ports that enter through the abdominal wall. A pneumoperitoneum is created through a port inserted just below the umbilicus through which a camera is passed. The stomach is accessed an manipulated through a second port entering the LLQ and a third port entering through the RUQ. T-fasteners or laparoscopic sutures are placed to affix the stomach to the abdominal wall. The procedure then proceeds in a manner similar to fluoroscopic gastrostomy, with a hollow needle advanced percutaneously into the stomach lumen followed by wire, dilators, peel-away sheath, and finally the G-tube

Question 86

Describe the Stamm technique of surgical placement of an open G-tube?

Answer 86

Requires a small laparotomy in the upper midline of the abdomen. The G-tube is brought into the stomach through a small stab wound in the upper abdominal wall. A small incision is made into the stomach through which the feeding tube enters and around which purse-string sutures are placed to secure the stomach around the G-tube. The stomach is then sutured to the anterior abdominal wall. This tube may be held in place with an inflated balloon or sutured to the abdominal wall to prevent tube migration

Question 87

What is a risk with gastrojejunal tubes?

Answer 87

The jejunal tube piece might migrate back into the stomach

Question 88

Describe the process of fluoroscopic gastrojejunal tube placement?

Answer 88

Initial steps similar to fluoroscopic gastrostomy placement. To facilitate placement of the gastrojejunostomy, puncture of the stomach is performed in the direction of the pylorus. A guidewire is advanced through the stomach to the ligament of Treitz, and the jejunal extension tube is advanced over the wire into the jejunum. Fluoroscopic technique can be used when patient cannot undergo endoscopy

Question 89

Why are endoscopic jejunostomy tubes more stable than fluoroscopic tubes?

Answer 89

The endoscopic tubes have solid, mushroom-type internal bolsters and larger tube diameters (18-20 Fr vs 10-14 Fr)

Question 90

When does maturation of the enterostomy stoma tract usually occur?

Answer 90

1-2 weeks after initial placement, but many clinicians prefer to wait 4-6 weeks prior to removal to ensure the stoma tract is mature

Question 91

Size and length of nasogastric tubes?

Answer 91

8-16 Fr, 38-91 cm

Question 92

Size and length of nasoenteric tubes?

Answer 92

8-12 Fr, 91-240 cm

Question 93

Size of gastrostomy tubes?

Answer 93

12-30 Fr

Question 94

Size of gastrojejunal tubes?

Answer 94

6-14 Fr

Question 95

Size and length of jejunal extension through existing gastrostomy?

Answer 95

8-12 Fr, 15-95 cm

Question 96

Size of dual lumen (gastric and jejunal) tubes?

Answer 96

16-30 Fr

Question 97

Size and length of single lumen (jejunal only) tubes?

Answer 97

12-24 Fr, 15-58 cm

Question 98

Size and length of low-profile gastrostomy (replacement) tubes?

Answer 98

12-24 Fr, 0.8-6.5 cm

Question 99

Size and length of low-profile gastrojejunostomy tubes?

Answer 99

14-22 Fr, 15-45 cm

Question 100

What are potential complications of removing G-tubes before stoma tract maturation?

Answer 100

May result in the stomach or small bowel falling away from the abdominal wall, allowing bowel contents to leak into the peritoneum

Question 101

Describe the traction method of removing a percutaneous feeding tube with a solid internal bolster?

Answer 101

Patient is placed in the supine position with knees bent to relax the abdominal muscles. The exposed gastric tubing is firmly grasped and pulled forcefully

Question 102

Usual causes of clogged feeding tubes?

Answer 102

Suboptimal flushing
Not flushing prior to and after each medication
Accumulation of pill fragments
Frequent residual checks
Administration of high-protein or high-fiber formulas

Question 103

Prophylactic methods to help prevent clogging?

Answer 103

Compliance with intermittent flushing protocols
Using water as the flush fluid of choice
Prophylactic use of pancreatic enzymes to prevent tube occlusion

Question 104

Nasal tube complications during the insertion period?

Answer 104

Epistaxis, aspiration, circulatory or respiratory compromise - occurrence of 10%
Initial misplacement of nasoenteric tube into the bronchopulmonary tree - occurrence of 2-4%

Question 105

Postprocedural complications of nasal feeding tubes?

Answer 105

Inadvertent tube dislodgement (25-41% of cases)
Tube malfunction (breaking, cracking, or kinking - occurs 11-20% of the time)
Sinusitis (12% occurrence)
Tube occlusion (20-45% occurrence)
Tube feeding aspiration
Intestinal ischemia

Question 106

The incidence of accidental tube dislodgement decreases from 36% to 10% when what is used?

Answer 106

When magnet-based system was used to place a nasal bridle

Question 107

Risk factors for nasal tube occlusion?

Answer 107

Increasing tube length
Decreasing tube caliber
Inadequate water flushing
Frequent medication delivery
Use of the tube to measure residual volumes

Question 108

Name the major post-procedure complications of enterostomy tube placement and their reported frequency

Answer 108

Aspiration (0.3-1%)
Hemorrhage (0-2.5%)
Peritonitis/necrotizing fasciitis (0.5-1.3%)
Death (0-2.1%)

Question 109

Name the minor post-procedure complications of enterostomy tube placement and their reported frequency

Answer 109

Peristomal infection (5.4-30%)
Peristomal leakage (1-2%)
Buried bumper syndrome (0.3-2.4%)
Inadvertent removal (1.6-4.4%)
Fistulous tracts (0.3-6.7%)

Question 110

Procedural complications of percutaneous enterostomy tubes?

Answer 110

Intraprocedural aspiration
Hemorrhage
Perforation of the GI lumen
Prolonged ileus

Question 111

Risk factors for leakage around the gastrostomy site?

Answer 111

Infection
Excessive cleaning with irritant solutions (hydrogen peroxide, povidone-iodine)
Excessive tension and side torsion on the external portion of the feeding tube

Question 112

How do you address leakage around the gastrostomy site?

Answer 112

Prompt treatment of infection
Good ostomy skin care
Loosening of the outer bumper
Stabilizing the G-tube to prevent torsion on the tube

Question 113

What should you do if a G-tube is accidentally removed and a standard tube is not promptly available?

Answer 113

A suitably sized Foley or red rubber catheter can be used to keep the tract open until a standard replacement tube can be placed

Question 114

Ways you can reduce the chance of a patient accidentally pulling their G-tube (if prone to pulling tubes)?

Answer 114

Use of an abdominal binder
Placing mittens on patient’s hands
Cutting down the external tube length to 6-8 cm
Switching to a low-profile device

Question 115

Along with the same complications present for G-tubes, what are additional complications for GJ- and J-tubes?

Answer 115

GJ-tube: frequent (up to 70%) malfunction, migration, and/or occlusion of the smaller jejunal extension tube
J-tube: jejunal volvulus and/or small bowel perforation

Question 116

True or false: jejunal feedings are confidently associated with lower aspiration risk

Answer 116

False, not definitive and needs more research. Expert opinion is to feed more distal with jejunal feeding to reduce risk of aspiration. Recent data and meta-analysis suggest that jejunal feeding may be associated with decreased risk of aspiration

Question 117

Describe oral hygiene and skin care recommendations for feeding tubes?

Answer 117

All patients require appropriate oral hygiene regardless of tube type or insertion technique. Important for preventing aspiration pneumonia in ventilator-dependent patients or those with a depressed LOC.
Nasal tube: benefit from skin care to nasal area to address prolonged exposure to tape and adhesive products; repositioning nasal tube and avoiding pressure to nares is important to prevent pressure necrosis
Percutaneous: use mild soap and water to cleanse stoma site. Rinse and thoroughly dry area. Avoid routine use of antibiotic ointments of hydrogen peroxide. Dressing may be applied to stoma site if there is drainage, but should not be placed with excessive tension (can promote infection and buried bumper syndrome)

Question 118

What is the complication in a patient with percutaneous gastrostomy tube (G-tube) who develops abdominal pain after tube exchange?
Scenario: Patient has a 24 Fr gastric balloon decompression tube that was initially placed several years ago and is regularly changed by patient at home. Patient uneventfully changed gastric tube the day before presenting to ED with severe abdominal pain. Awoke in the middle of the night with gastric leakage and intense pain around feeding tube. Unable to aspirate any gastric fluid from the feeding tube or move the tube within the tract. Skin very reddened and ulcerated from leakage of gastric fluid.

Answer 118

If patient develops abdominal pain after percutaneous feeding tube replacement, the concern is that the tube was potentially placed within the stoma tract instead of correctly into the gastric lumen or perforated into the peritoneal space. Most often occurs when there has been difficulty with tube replacement, but it can also occur when replacement is reported to go smoothly. When malpositioned tube is suspected, the tube position should be evaluated fluoroscopically or endoscopically. Treatment depends on how severe the problem is and if there has been contamination of enteral feeds into the peritoneal cavity. If significant peritoneal contamination has not occurred, the malpositioned tube can be removed and another tube placed using the same tract. If more significant disruption of the tract occurs, patient can be supported with nasoenteric feeding tube while the stoma tract closes and any infection is treated. If significant leakage has occurred and abdominal sepsis develops, patient is supported with IV fluids and antibiotics along with surgical consultation

Question 119

Define diameter.

Answer 119

Can refer to the internal or external diameter and is measured in millimeters

Question 120

Define french size.

Answer 120

A measure of the outer diameter (1 mm = 3 Fr)

Question 121

Define gauge.

Answer 121

A unit of measure that is inversely proportional to the catheter’s outer diameter

Question 122

What are the CDC guidelines for peripheral access?

Answer 122

Recommend close monitoring; with the peripheral IV line removed no more frequently than every 72 to 96 hours, unless clinically indicated.

Question 123

What is purpose of cuffs?

Answer 123

Cuffs attached to CVCs are designed to serve as subcutaneous anchors and mechanical barriers.

Question 124

What is the most commonly used line for the acute care setting, for short duration?

Answer 124

Nontunneled, noncuffed CVADs; they have a dwell time of 5 to 7 days.

Question 125

Define CVAD

Answer 125

Central Venous Access Devices

Question 126

Define PICC.

Answer 126

Peripherally Inserted Central Catheter A catheter inserted via a peripheral vein with the tip in the SVC (superior vena cava); classified as nontunneled

Question 127

What are the 3 categories of CVADs?

Answer 127

1. Nontunneled
2. Tunneled
3. Implanted

Question 128

(TRUE/FALSE)

Stabilization devices are necessary to maintain PICC placement and avoid malposition.

Answer 128

TRUE

Question 129

Describe tunneled central venous catheters, including their advantages.

Answer 129

Silicone elastomer catheter was inserted by subclavian venipuncture, with the distal tip placed in the midatrium; last for months to years

Advantages:

• Ease of self-care by the patient
• Placement on the chest wall so they are covered by clothing
• Decreased risk of dislodgement
• Ability to reapir the external lumen in the event of catheter breakage

Question 130

Describe TIVADs

Answer 130

Totally Implanted Venous Access Devices (TIVADs)

Consist of silicone or polyurethane catheter attached to a portal reservoir made of stainless steel, polysufone or titanium with a self-sealing silicon elastomer septum

Can be implanted into the subcutaneous pocket in the upper chest, upper arm, or forearm.

Question 131

What are the patient factors to consider when choosing an appropriate catheter?

Answer 131

• Safe
• Meets the patient’s needs
• Cost-effective
• Type of medication/solution to be delivered
• Overall therapeutic regimen
• Anticipated duration of therapy
• Patient’s lifestyle
• Potential impact of the device on the patient’s body image
• Their activity level

Question 132

How often should CVADs and mid-line catheters be assessed? For peripheral catheters?

Answer 132

Daily

At least Q 4 hours

Question 133

What are the appropriate antiseptic agents for cleaning a catheter exit site?

Answer 133

• CHG (chlorheidine gluconate)
• 70% alcohol
• 10% povidone-iodine

Question 134

What are the appropriate drying times for catheter sites?

Answer 134

• Alcohol/CHG: must dry at least 30 seconds
• Iopophors: at least 1.5 to 2 minutes

Agents must be fully dried before dressing is applied.

Question 135

(TRUE/FALSE)

Routine use of antibiotic ointments at the catheter insertion site is recommended.

Answer 135

FALSE

Not recommended because they may change the bacterial flora and contribute to the emergence of resistant bacteria or fungi

Question 136

Define hub.

Answer 136

The end of the VAD that connects to the medication tubing or caps.

Question 137

Define CRBSIs.

Answer 137

Catheter-related Bloodstream Infection

Includes: Elevated WBC (greater than 10,500/mcL), fever, chills, N/V, hypotension, tachycardia

Question 138

(TRUE/FALSE)

VADs should be assessed for blood return prior to each infusion and flushed with NS after each infusion to clear all infused medications or solutions.

Answer 138

TRUE

These steps help ensure catheter patency by reducing the risk of incompatible medications causing preciptations, and decreasing the risk of intraluminal occlusion by the reflux of blood into or remaining in the catheter.

Question 139

Define a locking VAD.

Answer 139

The instillation of a limited amount of antimicrobial or antiseptic solution with sufficient volume to fill the internal priming volume of the catheter, following routine catheter flush.

Solutions include:

• Ethanol
• Taurolidine
• Citrate
• 26% sodium chloride
• EDTA

Question 140

(TRUE/FALSE)

CDC guidelines recommend that the practice should be limited to patients with long-term catheters who have a history of multiple CRBSIs, and a systematic review of the clinical trials supported by this recommendation.

Answer 140

TRUE

Question 141

Define CLABSI.

Answer 141

Central Line-Associated Bloodstream Infection; Clinical term used for diagnosis and tx of BSI

A labatory-confirmed BSI in which the central line or umbilical catheter was in place for more than 2 calendar days on the date of the event, with day of device placement being Day 1, AND the line was also in place on the date of event or the day before.

Question 142

Describe the “Central Line Bundle.”

Answer 142

Proposed set of evidence-based practices,, which has been designed to reduce the incidence of infections associated with central lines.

1. Hand Hygiene
2. Maximal barrier precautions
3. CHG skin antisepsis
4. Optimal catheter site selection
5. Daily review of line necessity, with the prompt removal of unnecessary lines

Question 143

(TRUE/FALSE)

In reference to the “Central Line Bundle,” failure to complete any aspect of the bundle is regarded as noncompliance with the entire protocol.

Answer 143

TRUE

Question 144

How is catheter patency defined?

Answer 144

With 2 criteria: the ability to infuse without resistance and the ability to aspirate blood without resistance. When either of these criteria is not met, the catheter is occluded.

Question 145

Define venous thrombosis.

Answer 145

Refers to a thrombus in the vessel that may partially or totally occlude the vessel.

Question 146

What is Alteplase?

Answer 146

A tissue plasminogen activator, approved thrombolytic agent for CVAD occlusions.

2 mg in a 2-mL volume is injected into the catheter and allowed to dwell for 30 minutes to 4 hours, then aspiration of the solution is attempted. Repeat if necessary.

Question 147

(TRUE/FALSE)

In patients with catheter-associated mural or venous thrombosis, catheter removal is recommended as the first treatment.

Answer 147

FALSE, it is NOT recommended.

Question 148

What are the leading causes of intraluminal occlusions?

Answer 148

1. Drug-heparin interactions
2. PN formulations
3. Lipid residue

Question 149

(TRUE/FALSE)

The use of a 0.9% NS flush between all IV medications, infusions, and heparin is the key to prevention.

Answer 149

TRUE

Question 150

Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention sets ____ that create specialized vascular access teams

Answer 150

guidelines

Question 151

what is the goal of an effective infection control program

Answer 151

eliminate CRBSI from all patient care areas

Question 152

The major blood vessel that receives blood from the external jugular veins

Answer 152

Superior Vena Cava

Question 153

what blood flow can the SVC can handle up to ____mL per min

Answer 153

2000mL

Question 154

the preferred vessel or central access and infusion of PN solutions

Answer 154

SVC

Question 155

maximum osmolarity peripheral veins

Answer 155

900mOsm/L

Question 156

diameter of a catheter is the ____ or ____ diameter measured in mm

Answer 156

internal or external diameter

Question 157

French size measures the _____ diameter of a catheter

Answer 157

outer

Question 158

the gauge is a unit of measure that is ______ proportional to catheters of the outer diameter

Answer 158

inversely

Question 159

____ lumen catheters allow for simultaneous infusion of multiple solutions or incompatible drugs’

Answer 159

multi-lumen

Question 160

____ are attached to central venous catheters that act as subcutaneous anchors or mechanical barriers

Answer 160

cuffs

Question 161

a ____ venous access device is a pressure sensitive, 3-2ay slit valve that prevents retrograde blood flow and eliminates the need for daily heparinized flushes

Answer 161

Groshong

Question 162

moth IV catheters are made of _____

Answer 162

polyurethane

Question 163

silicone IV catheters have an increased of _____ ____ formation

Answer 163

fibrin sleeve

Question 164

catheter access is defined by the position of the

Answer 164

distal catheter tip

Question 165

peripheral vein preservation should be considered when placing IV access. make sure solutions are these 3 things

Answer 165

non-irrtiant
non-vesicant
non-hyperosmolar

Question 166

if a patient is fluid restricted, this type of access should not be used as they won’t be able to meet their nutrient needs

Answer 166

PPN

Question 167

the most commonly used VAD are ____lines

Answer 167

peripheral

Question 168

sings of thrombophlebitis

Answer 168

pain, erythema, tenderness

Question 169

how often should peripheral IVs be changed

Answer 169

when clinically indicated

Question 170

CDC guidelines suggest that close monitoring of _______ access and remove the IV line no more frequently than every ____ to ____ hours unless clinically indicated

Answer 170

peripheral, 72-96 hours

Question 171

Midline catheters are 8-10 cm long and lower the rates of

Answer 171

phlebitis, lower infection

Question 172

midline catheters are indicated for ___ to ___ weeks

Answer 172

2-6 weeks

Question 173

midline catheters don’t need to be

Answer 173

frequently changed

Question 174

non tunneled catheters are most often used in this setting

Answer 174

acute health care

Question 175

non tunneled catheters are only indicated for ______ ___ use

Answer 175

short term

Question 176

this is the method of placing non tunneled catheters by accessing the vein with a small needle, placing a guidewire and removing the needle

Answer 176

Seldinger approach

Question 177

what is the dwell time of a non tunneled catheter

Answer 177

5-7 days

Question 178

tunneled catheters are a ____ term catheter proven to be safe of therapy up to months/years

Answer 178

long term

Question 179

advantages of a tunneled catheter

Answer 179

ease of self care of the patient, placed on the chest wall so it is covered by clothing, decreased risk of dislodgment

Question 180

Totally Implanted Venous Access Devices are also called

Answer 180

subcutaneous Ports

Question 181

This type of catheter is made up of a silicone or polyurethane catheter attached to a portal reservoir made of stainless steel, polysuflane or titanium

Answer 181

port

Question 182

a port catheter can be accessed up to _____ to ____ times

Answer 182

1,000-2,000 times

Question 183

port catheter’s have the _____ infection rates

Answer 183

lowest

Question 184

picking an access device for a patient should take into consideration

Answer 184

safety, meets the patient’s needs, depends on medication needed, duration of therapy, impact on body image, impact on patient’s lifestyle and activity level

Question 185

the ideal goal of home PN therapy is

Answer 185

to restore the patient to their prior level of function

Question 186

the ____ the number of lumens the _____the chance or infection

Answer 186

lower, lower

Question 187

what are contraindications to placing central venous access devices (CVADs)

Answer 187

change in Tx plan with sudden clinical deterioration
new/unexplained fever
absolute neutropenia <1,000 WBC per mL
platelet counts <50,000 plates within 2 hrs of placing

Question 188

what is the MOST important thing to prevent infection/complications with IV placement

Answer 188

use of maximal barrier protections

Question 189

maximal barrier protections include

Answer 189

cap, mask, disposable gown, gloves, large drape

Question 190

immediate complications of catheter placement include

Answer 190

pneumothorax, air embolism, arrhythmia bleeding, cardiac tamponade

Question 191

signs of pneumothorax

Answer 191

dyspnea, cough, hypoxia, chest pain with tachycardia

Question 192

onset of chest pain, dyspnea, tachycardia, nausea, hypotension or enlarged neck veins can indicate this IV insertion complication

Answer 192

arrhythmia

Question 193

_____ should be the only ones to use ultrasound guidance when placing IV’s

Answer 193

well trained clinicians

Question 194

what is mandatory to do before using a IV after insertion

Answer 194

confirm the tip placement BEFORE use

Question 195

what is the desired tip placement in the SVC

Answer 195

the distal 1/3 of the SVC or cavoartiral junction

Question 196

what is the gold standard way to check IV placement

Answer 196

Chest Xray

Question 197

this type of method uses P waves to provide real time tip confirmation as the catheter approaches the right atrium

Answer 197

Electrocardiography Guided CVAD

Question 198

CVAD’s should be monitored every ___ hours in acute care

Answer 198

4 hours

Question 199

the goal of catheter care is

Answer 199

to maintain vascular access and reduce the risk of complication

Question 200

what can be used to clean a CVAD

Answer 200

chlorhexidine, 70% alcohol, or iodine

Question 201

what is the MOST effective CVAD cleaning agent

Answer 201

Chlorhexidine

Question 202

is routine use of antibiotic ointment on catheter insertion site recommended

Answer 202

NOOOOOOO

Question 203

this part of the catheter that is the end of the VAD that connects to the medication tubing or caps

Answer 203

hub

Question 204

what ensures catheter patency

Answer 204

assess blood return

Question 205

what is a chemical agent that is not readily available in the U.S. shown to help prevent CRBSI’s

Answer 205

Taurolidine

Question 206

what is the most common non-infectious complication with VADs

Answer 206

catheter occlusion

Question 207

elevated WBC count >10,500 mc/L, fever, chills, malaise, nausea, vomiting, hypotension, tachycardia, headache, erythema, purulent exudate at insertion site and fever may indicate a

Answer 207

Catheter Related Bloodstream Infection

Question 208

CLABSI stands for

Answer 208

Central Line Associated Blood Stream Infection

Question 209

erythema or induration within 2 cm of the catheter exit site in the absence of concomitant BSI without concomitant purulence is indicative of

Answer 209

exit site infection

Question 210

tenderness, erythema or site induration > 2cm of catheter site along the subcutaneous tract of a tunneled catheter in the absence of concomitant BSI

Answer 210

tunnel infection

Question 211

purulent fluid in the subcutaneous pocket of a totally implanted IV catheter that might or might not be associated with spontaneous rupture and drainage or necrosis of the overlaying skin in the absence of a BSI

Answer 211

pocket infection

Question 212

bacteremia or fungemia in a patient with IV catheter with at least 1 positive blood culture obtained from a peripheral vein is called

Answer 212

a blood stream infection

Question 213

fever, chills and hypotension could indcate

Answer 213

a BSI

Question 214

contamination of the IV catheter can come from these places

Answer 214

endogenous skin flora at insertion site
contamination of the hub by hands/devices
hematogenous seeding form a distant infection
contamination of the infusate

Question 215

the most common cause of intraluminal contamination of long term VAD’s come from

Answer 215

the hub of the IV catheter

Question 216

when a biofilm develops on an IV what should be done

Answer 216

remove the CVAD and start systemic antibiotics

Question 217

what is used to prevent the development of biofilm

Answer 217

antimicrobial catheter locks

Question 218

what is the primary cause of contamination that causes blood stream infections

Answer 218

hand contamination

Question 219

this was designed to reduce the incidence of infections associated with central lines by the institute of healthcare improvement which consists of 5 components including proper hand hygiene, maximal barrier precautions, CHG skin antiseptics, daily review of line necessity, optimal cath site selection and prompt removal of unnecessary lines

Answer 219

Central Line Bundle

Question 220

when a CRBSI is suspected what should be provided and how long should it dwell

Answer 220

70% ethanol cath lock solution 2mL for 6 hours

Question 221

when is appropriate to remove a CVC in the setting of infection

Answer 221

if it is a fungal infection or staff aureus

Question 222

_____ is an antiseptic that provides bactericidal activity to a broad range of bacteria and is less likely to promote bacterial resistance

Answer 222

70% ethanol lock solution

Question 223

an air embolism is a ____ condition and often fatal

Answer 223

rare

Question 224

sudden chest pain, dyspnea, headache and confusion and sometimes death are symptoms of

Answer 224

air embolism

Question 225

if a patient is suspected to have an air embolism of the VAD what should be done

Answer 225

clamp the catheter and place the patient immediately in Trendelenburg with left lateral decubitus position

Question 226

occlu sion of catheter lumens should be maintained at all times when not in use to prevent

Answer 226

air embolism

Question 227

a blood clot that breaks off from another thrombus in the body that travels to the lungs occluding pulmonary blood vessels is called

Answer 227

pulmonary embolism

Question 228

if a patient is suspected to have a pulmonary embolism what should be done

Answer 228

diagnose with a CT scan or ventilation perfusion scan and then use anticoagulation therapy

Question 229

what is the most common non infectious catheter related complication

Answer 229

catheter occlusion

Question 230

the ability to infuse into an IV without resistance and ability to aspirate blood without resistance is called

Answer 230

catheter patency

Question 231

if an IV does NOT have the ability to infuse without resistance and blood cannot be aspirated without resistance this indicates

Answer 231

an occlusion

Question 232

when a vessel wall injury occurs with catheter it leads to this type of occlusion

Answer 232

thrombotic

Question 233

A bundle of platelets and blood cells composed of fibrin developed after a vessel wall injury is known as a

Answer 233

venous thrombi

Question 234

this coagulation factor becomes cross linked and interwoven with platelets/leukocytes is known as

Answer 234

fibrin

Question 235

what catheter to vein ratio prevents a DVT

Answer 235

1:3

Question 236

risk factors for developing a thrombosis

Answer 236

catheter tip position, catheter material, type of infusate, length of catheter duration, multiple insertion attempts, previous CVC insertion

Question 237

other signs of catheter occlusion

Answer 237

neck vein distention, edema, tingling or pain, tight feeling in the throat

Question 238

inadequate flushing or blood reflux in the IV resulting in sluggish catheter Fx/occlusion is caused by

Answer 238

intraluminal clotting

Question 239

if there is evidence of intraluminal clotting what is the treatmet

Answer 239

flush 2x the volume with 5-10mL of normal saline

Question 240

a covering formed over the distal tip of the catheter is known as the

Answer 240

fibrin sheath

Question 241

how can you tell if there is intraluminal clotting

Answer 241

when you flush the IV with saline following blood aspiration is inadequate

Question 242

a sheath formed over the distal tip of a catheter is called

Answer 242

a fibrin sheath

Question 243

when you are unable to aspirated blood from a catheter but it is still working there may be a

Answer 243

fibrin sheath

Question 244

what is the best way to treat a fibrin sheath

Answer 244

thombolytic agent (atepelase)

Question 245

a thrombus within the vessel that may partially or totally occlude a vessel if called a

Answer 245

venous thrombosis

Question 246

this type of thrombosis may initially present as a venous obstruction

Answer 246

mural thrombus

Question 247

Ateplase should dwell for

Answer 247

30 mins to 4 hours

Question 248

this is a tissue plasminogen activator/thrombolytic agent used to get rid of IV thrombi

Answer 248

Ateplase

Question 249

is catheter removal the first line of action

Answer 249

NOOOOO

Question 250

other non occlusive causes of poor IV blood flow

Answer 250

kinks, sutures, clamps

Question 251

an intermittent mechanical obstruction related to postural changes caused by catheter compression between the clavicle and 1st rib is called

Answer 251

catheter pinch off syndrome

Question 252

what is the first line of therapy when catheter pinchoff syndrome is detected

Answer 252

remove the IV line

Question 253

per the CDC, assess a peripheral IV every ____ to ____ hours an only remove if ____

Answer 253

72-96 hours, only if there is an issues

Question 254

in order to provide TPN, the catheter tip needs to end where

Answer 254

the distal 3rd end of the SVC or RAJ

Question 255

never advance any external portion of a catheter that has been in contact with the ______ into the insertion site

Answer 255

the skin

Question 256

Trans lumbar or transhepatic central lines emptying into the _____ vena cava

Answer 256

inferior

Question 257

which central line placements provide the highest risk of infection

Answer 257

femoral/inguinal

Question 258

how is pinch off syndrome identified

Answer 258

when a patient puts their arm down at their side, the tip of the cath is pinched off but when they lift up their arm, the sensation is releived

Question 259

the development of purulence/pus within 2 cm of an IV line is called

Answer 259

exit site infection

Question 260

the development of erythema, tenderness and purulence greater than 2 cm of an IV site is called

Answer 260

Tunnel infection

Question 261

the development of erythema over the port, purulent drainage, cellulitis or necrosis is called

Answer 261

pocket infection

Question 262

What should IV’s be properly flushed with

Answer 262

10mL NaCl 0.9%

Question 263

What method of flushing a catheter prevents a thrombotic occlusion

Answer 263

push, pause method where you give 10 short 1mL pushes interrupted by a brief pause to remove solids

Question 264

an IV line should be _______ before and after hooking up and taking off TPN

Answer 264

flushed

Question 265

this type of thrombotic occlusion occurs inside the lumen of the IV where you are unable to infuse or aspirate such as a calcium precipitate

Answer 265

intraluminal thrombus

Question 266

this type of thrombotic occlusion fully occludes the tip and lumen, looking like a sock over the tip of the IV line

Answer 266

fibrin sheath

Question 267

this type of thrombotic occlusion develops a partial occlusion with a tail over the tip identified when you flush saline and try to draw blood but you cannot flush it through or aspirate blood (no draw back)

Answer 267

Fibrin Tail

Question 268

this type of thrombotic occlusion occludes around the lumen causing obstruction identified by sweeping at the arm, hard infusation caused from vessel wall injury where fibrin binds to the catheter surface

Answer 268

mural thrombus

Question 269

what is used to dissolve acidic precipitates with a pH <6

Answer 269

HCL (0.1) N

Question 270

what is used to dissolve lipid precipitates in an IV

Answer 270

ehtanol

Question 271

what is used to dissolve alkaline drug precipitates with a pH >7

Answer 271

Sodium Bicarb

Question 272

CRBSI stands for

Answer 272

Catheter Related Blood Stream Infection

Question 273

what is the most common cause of a hospital acquired inefection

Answer 273

CRBSI

Question 274

Ethyl Alcohol Lock Therapy kills ____ and ____ and decreases the adherence of bacteria to prevent CRBSIs

Answer 274

bacteria and fungi

Question 275

this type of locking solution decreases the adherence of bacteria to avoid CRBSis

Answer 275

ethyl alcohol lock

Question 276

this type of locking solution is not used in the US but is a broad spectrum anti-septic that prevents the growth of bacteria and fungi and does not cause antibiotic resistance

Answer 276

Taurolidine

Question 277

Taurolidine is a great locking solution because it will not cause

Answer 277

antibiotic resistance

Question 278

the HUB of a catheter can be wiped with _____ before use

Answer 278

alcohol wipe

Question 279

the best way to prevent infection is to use ________________ with anti septic technique prior to and during insertion of catheters

Answer 279

maximum barrier protection

Question 280

the best anti septic for IV lines is

Answer 280

2% aqueous chlorhexidine

Question 281

the lower the number of lumens the _____ the risk for infection

Answer 281

lesser

Question 282

avoid ______ to prevent catheter infection as it can increase fungal colonization and cause antibiotic resistance and has not been shown to decrease the rates of CRBSI’s

Answer 282

antibiotic ointment

Question 283

a ______ central line has either a single or double lumen, is small in diameter and used in the geriatric or pediatric population

Answer 283

Broviac

Question 284

a _______catheter can provide up to 3 lumens

Answer 284

Hickman

Question 285

a ____ catheter comes in lumens that are equal in size

Answer 285

leonard

Question 286

when checking PICC Placement, an EKG is used to assess _____ waves when the tip reaches the CAJ

Answer 286

P waves

Question 287

when the P wave is at ____amplitude, the PICC Is at the correct location

Answer 287

maximum amplitude

Question 288

a _____ cuff is attached to a catheter to help secure the IV lime via fibrous tissue ingrowth and creates a barrier to decrease the risk of infection by limiting migration of bacteria

Answer 288

surecuff

Question 289

a _____ cuff contains antimicrobials that infuse over time

Answer 289

vitacuff

Question 290

this type of IV access is surgically placed into the subcutaneous pocket in the anterior chest or arm as a peripheral vascular access system (PAS) ends in the inferior vena cava and has double lumen ports where you can infuse 2 compatible solutions as the 2 lumens are separated

Answer 290

implanted port (PAS)

Question 291

the benefits of a port

Answer 291

long term use, minimal alteration in body image, lower infectious rate, can be used anywhere from 1 ,000- 2,000 times and is either single or double lumen

Question 292

this type of IV access is surgically placed into the chest wall ending in the SVC

Answer 292

Port a Cath

Question 293

this type of IV access has a valve on the side that only needs to be flushed with normal saline Q 90 days to maintain. It is usually used in patients who get intermittent chemo

Answer 293

Groshong Port

Question 294

If a Groshong port is being used currently does it need to be flushed? how often

Answer 294

yes every week

Question 295

what is the major cause of morbidity in home PN patients

Answer 295

septicemia

Question 296

a very common complication of home PN nutrition is

Answer 296

catheter related infection

Question 297

what is the most common cause of re hospitalization for HPN

Answer 297

Catheter Related Blood Stream Infections

Question 298

Which venous access devices (VADs) are used for home PN include these 2 lines (when PN needed for >4 weeks)

Answer 298

Implantable Port/Tunneled Catheters

Hickman or Broviac

Question 299

a patient undergoing radiation and chemo for cancer in the region of the mediastinum is getting TPN and reports wt loss, and pain/swelling in her neck/right arm. The likely cause of this is

Answer 299

a catheter related complication

Question 300

large ____ in PPN must be provided to meet energy needs/protein compared to TPN and therefor not desirable when ___ restricted

Answer 300

fluid, fluid

Question 301

when considering PPN suspected use should be for > ___ days

Answer 301

5

Question 302

to avoid phlebitis, PPN lines are usually rotated every ___ hours

Answer 302

48-72 hours

Question 303

contraindications to PPN are

Answer 303

significant malnutrition, severe metabolic stress, marked electrolyte needs, high doses of potassium, fluid restriction, needed for nutrition for >2 weeks and renal/liver compromise

Question 304

the CDC recommends chlorhexidine/silver sulfadiazine or rifampin imprgenanted CVS if catheter is to remain in place > ___ days

Answer 304

5

Question 305

enterococci can come from endogenous flora or ______

Answer 305

hands of health care workers

Question 306

can candida (yeast) cause sepsis

Answer 306

yes

Question 307

the gold standard for the treatment of a diagnosis of CRBSI is catheter removal, however in patients that require _______, catheter salvage is more desired than removal

Answer 307

long term IV therapy

Question 308

Central Venous Catheter blood cultures that become positive over ____ hours sooner than peripheral cultures are considered predictive for CRBSI

Answer 308

2 hours

Question 309

how can catheter salvage be obtained during suspicion of CRBSI

Answer 309

70% ethanol lock solution and systemic abx therapy

Question 310

_______ing catheters are both considered a treatment and prevention for recurrent CRBSi’s

Answer 310

locking

Question 311

when the tip of a catheter migrates into the heart chambers ____ can result in cardiac tamponade

Answer 311

pericardium puncture

Question 312

____ injury can occur up to months after central line insertion where the patient has paralysis of the diaphragm leading to respiratory distress, decreased air flow to the lungs and decreased respiratory rate

Answer 312

phrenic nerve injury

Question 313

symptoms of adverse reaction to lipide injectable emulsions

Answer 313

allergic egg reaction, cyanosis, flushing, sweating, nausea, vomiting, headache

Question 314

azotemia in PN can result from

Answer 314

excessive protein/amino acid administration

Question 315

Name 2 large central veins?

Answer 315

Inferior vena cava (IVC)
Superior vena cava (SVC)

Question 316

Which is the main vessel for venous return from the upper trunk emptying into the right atrium?

Answer 316

Superior vena cava (SVC)

Question 317

What is the preferred vessel for PN solutions via central access and its estimated blood flow per minute?

Answer 317

SVC
2000 ml/min

Question 318

What does diameter refer to with catheter measurements?

Answer 318

Can refer to the internal or external diameter and is measured in millimeters. Depending on the catheter material, the internal diameter may vary between catheters with the same external diameter

Question 319

What is French size?

Answer 319

A measure of the outer diameter (1 mm = 3 Fr.)

Question 320

What is gauge measurement of catheters?

Answer 320

A unit of measure that is inversely proportional to the catheter’s outer diameter

Question 321

What is a benefit of a multilumen CVC?

Answer 321

Provides for simultaneous infusion of multiple solutions or incompatible drugs

Question 322

What is a CVC cuff?

Answer 322

Designed to serve as a subcutaneous anchor and mechanical barrier

Question 323

What is a Dacron cuff?

Answer 323

Most often attached to tunneled catheters. Positioned in the subcutaneous tissue and serve to anchor the catheter by facilitating fibrous ingrowth

Question 324

What is a collagen cuff?

Answer 324

Impregnated with silver ions, the gradual release of the silver ions exerts short-term antimicrobial activity

Question 325

What is a Groshong catheter?

Answer 325

A venous access device with a pressure sensitive 3-way slit valve on the tunneled catheter which eliminates the need for daily heparinized flushes and catheter clamping before disconnecting at the catheter hub

Question 326

What substance are catheters most often made of?

Answer 326

Polyurethane or silicone

Question 327

What is a negative effect of using PVC catheters?

Answer 327

Have been associated with an increase in thrombus formation and phlebitis compared with other polymeric catheters

Question 328

Describe some characteristics of polyurethane catheters?

Answer 328

Smooth surface which demonstrates resistance to hydrolytic enzymes. Greater tensile strength than silicone and lower degrees of microbial colonization

Question 329

Describe characteristics of silicone catheters?

Answer 329

Excellent elasticity and softness, cause less damage to the vessel intima. Low inflammatory-provoking potential in the tissues, surface is less attractive for adherence of microbial populations when compared with other biomaterials. Tends to be chemically inert to blood with reduced plasma adherence

Question 330

What is a common complication of silicone catheters?

Answer 330

Fibrin sleeve formation

Question 331

Where are peripheral catheters inserted and where do they terminate?

Answer 331

Enter and terminate in peripheral veins in the hand and lower arm

Question 332

Where is the tip located in central catheters?

Answer 332

Distal CVC, IVC, or right atrium

Question 333

List advantages of peripheral catheters

Answer 333

Least expensive
Least risk for catheter-related infections
Does not require a special placement room
Clinicians easily trained in placement

Question 334

What type of PN is not appropriate for peripheral use?

Answer 334

PN that has a final concentration >10% dextrose or other additives that result in an osmolarity >900 mOsm/L

Question 335

What is the leading complication associated with peripheral access?

Answer 335

Peripheral venous thrombophlebitis

Question 336

What are the hallmark signs of infusion phlebitis?

Answer 336

Pain, erythema, tenderness, palpable cord

Question 337

Where does the catheter tip reside in midline catheters?

Answer 337

Basilic or cephalic vein, with the tip at or before the axilla, distal to the shoulder

Question 338

What is an advantage of a midline catheter?

Answer 338

Lower phlebitis rates than standard, short peripheral catheters and lower rates of infection than CVADs

Question 339

What type of IV therapy is a midline peripheral catheter appropriate for?

Answer 339

Peripheral compatible solutions where treatment is considered for 2-6 weeks

Question 340

What are the most common sites of venipuncture for central access?

Answer 340

Cephalic, basilic, subclavian, jugular, and femoral veins

Question 341

Which vein is preferred for SVC access for patients with CKD who might require dialysis?

Answer 341

Right internal jugular vein

Question 342

Which catheter is ideal for all situations?

Answer 342

None, catheter choice is guided by the advantages and disadvantages with various optoins

Question 343

A venous site where the catheter-to-vein ratio is equal to or less than what % should be selected to minimize the risk of venous thrombosis when placing a PICC?

Answer 343

45%

Question 344

Where can PICC line placement occur?

Answer 344

At patient’s home, at the bedside, or IR

Question 345

List some advantages of a PICC line?

Answer 345

Safer insertion in the arm
Cost-effectiveness
Convenience of placement by vascular access teams

Question 346

What complications may PICC lines lead to?

Answer 346

Luminal occlusions
Malpositioning and dislodgement
Infection at PICC insertion site
Superficial thrombophlebitis at insertion site

Question 347

True or false: PICCs are not appropriate for infusion of irritants and vesicants such as PN and chemo for any length of duration

Answer 347

False. They are appropriate

Question 348

What is the theory behind catheter tunneling decreasing the risk of catheter infection?

Answer 348

It separates the exit and venipuncture sites

Question 349

What is the length of time that tunneled catheters have been demonstrated to be safe and effective for?

Answer 349

Long-term therapies ranging from months to years

Question 350

Name some advantages to tunneled CVCs

Answer 350

Ease of self care by the patient
Placement on the chest wall so they are covered by clothing
Decreased risk of dislodgement
Ability to repair the external lumen in the event of catheter breakage

Question 351

What sites can be used when repeated catheterizations to common vein sites affect the likelihood of the vein’s preservation?

Answer 351

Translumbar, transhepatic, and transcollateral

Question 352

Describe the characteristics of TIVADs

Answer 352

A silicone or polyurethane catheter attached to a portal reservoir made of stainless steel, polysulfone, or titanium with a self-sealing silicone elastomer septum

Question 353

Where can TIVADs be implanted?

Answer 353

A subcutaneous pocket in the upper chest, upper arm, or forearm

Question 354

How many times can TIVAD ports be accessed?

Answer 354

1000-2000 times

Question 355

What is the goal of device selection for VAD?

Answer 355

To choose a device that is safe, meets the patient’s access needs, and is cost-effective

Question 356

What factors play a role in the decision making process for choosing a VAD?

Answer 356

Type of medication or solution to be delivered
Overall therapeutic regimen
Anticipated duration of therapy
Patient’s lifestyle
Potential impact of the device on the patient’s body image and his/her activity level

Question 357

What other factors need to be considered when choosing a VAD for patients in the home setting?

Answer 357

Cognitive ability and willingness to perform necessary tasks

Question 358

What 3 factors were associated with the failure of placement of a CVC in the subclavian vein?

Answer 358

Prior surgery or radiation in the region
BMI >30 or <20
Previous catheterization

Question 359

Why did the MAGIC expert panel rate insertion of devices (PICC, midline catheters) into the arm veins as inappropriate for patients with renal disease?

Answer 359

The need to preserve peripheral and central veins for possible hemodialysis or creation of arteriovenous fistulae and grafts

Question 360

Where does the MAGIC expert panel recommend venous access for 5 days or fewer in renal disease patients?

Answer 360

Peripheral IV in the dorsum of the hand (avoiding the forearm veins) for peripheral-compatible infusates

Question 361

What type of VAD does the MAGIC panel recommend when central access is needed for renal disease patients?

Answer 361

A tunneled, 4-Fr single-lumen or 5-Fr double-lumen inserted into the jugular vein and tunneled into the distal SVC

Question 362

Why should clinicians choose a CVAD with the least number of lumens or ports appropriate for the patient?

Answer 362

Unnecessary lumens require more manipulation and access of the catheter, thereby increasing the risk for CVAD-related infection and complications

Question 363

What are immediate complications of CVAD insertion?

Answer 363

Pneumothorax (most common)
Air embolism
Arterial puncture
Arrhythmia
Bleeding

Question 364

How does the venous cutdown CVAD insertion approach virtually eliminate the risk of a pneumothorax?

Answer 364

Venous cutdown is performed using the cephalic, external jugular, or internal jugular vein. The vein is dissected and a venotomy allows the clinician to directly visualize the vessel while inserting the catheter

Question 365

How has the use of ultrasound guidance improved placement of CVADs?

Answer 365

Increasing successful placement rates, reducing number of needle punctures, lowering the incidence of needle-stick complications

Question 366

How often should CVADs and midline catheters be assessed?

Answer 366

Daily

Question 367

How often should short peripheral catheters be assessed?

Answer 367

Every 4 hours

Question 368

What should be used to cleanse the catheter exit site?

Answer 368

Antiseptic agent: chlorohexidine gluconate (CHG), 70% alcohol, or 10% povidone-iodine

Question 369

CDC guidelines recommend skin should be prepped with what before catheter placement?

Answer 369

> 0.5% CHG preparation containing alcohol

Question 370

Which antiseptic agent was found to be significantly more effective than the other 2 in decreasing both local infection and catheter-related sepsis: 2% aqueous chlorohexidine, 70% alcohol, or 10% povidone-iodine?

Answer 370

2% aqueous chlorohexidine

Question 371

Why is the routine use of antibiotic ointments at the catheter insertion site not recommended?

Answer 371

They may change normal bacterial flora and contribute to the emergence of resistant bacteria or fungi

Question 372

Describe the recommended process for hub disinfection by the Infusion Nurses Society

Answer 372

Perform a vigorous scrub for manual disinfection of the needless connector prior to each VAD access and allow to air dry. Length of contact time for scrubbing and drying depends on the design of the needless connector and the properties of the disinfecting agent

Question 373

How often should VADs be assessed for blood return?

Answer 373

Prior to each infusion and flushed with normal saline after each infusion to clear all infused medication or solutions

Question 374

How does assessing the VAD for blood return prior to each infusion and flushing with normal saline after each infusion help ensure catheter patency?

Answer 374

Clears of all infused medication or solutions
Reduces the risk of incompatible medications causing precipitation
Decreases the risk of intraluminal occlusion by the reflux of blood into or remaining in the catheter

Question 375

What does it mean to lock a VAD?

Answer 375

The instillation of a limited amount of antimicrobial or antiseptic solution, with sufficient volume to fill the internal priming volume of the catheter, following routine catheter flush

Question 376

Why is it recommended to aspirate all antimicrobial locking solutions from the CVAD at the end of the locking period?

Answer 376

Flushing the locking solution into the patient’s bloodstream could increase the development of antibiotic resistance

Question 377

The CDC recommends the prophylactic use of antimicrobial locks to prevent CRBSI should be limited to what kind of patients?

Answer 377

Patients with long-term catheters who have a history of multiple CRBSIs

Question 378

What is the purpose of effective catheter stabilization?

Answer 378

Helps prevent subtle movement of the catheter tip against the wall of the blood vessel, which can create irritation and promote thrombus formation

Question 379

What is the most common noninfectious complication observed with the long-term use of VADs?

Answer 379

Catheter occlusion

Question 380

What is the difference between CRBSI (catheter-related bloodstream infection) and CLABSI (central line-associated bloodstream infection)?

Answer 380

CRBSI is a clinical term used for diagnosis and treatment of a bloodstream infection. CLABSI is a surveillance term used by the CDC to determine a causal relationship between the catheter and bloodstream infection

Question 381

What are the signs and symptoms of CRBSI?

Answer 381

Elevated WBC count, fever, chills, malaise, nausea, vomiting, hypotension, tachycardia, headache, backache

Question 382

What are the 4 recognized sources from which CVC-related infections can originate?

Answer 382

Endogenous skin flora at the insertion site
Contamination of the catheter hub by hands or devices
Hematogenous seeding from a distant infection source
Contamination of infusate

Question 383

What are the 2 primary portals for contamination of CVCs that have been identified?

Answer 383

The skin insertion site and the hub

Question 384

What is the most frequent cause of intraluminal contamination in the long-term use of VADs?

Answer 384

Hub contamination

Question 385

What is the predominant pathogen associated with infections from biomedical devices?

Answer 385

Gram-positive, coagulase-negative staphylococci

Question 386

What increases the difficulty of successfully treating a catheter-related infection without removing the catheter?

Answer 386

The presence of a biofilm

Question 387

What is the usual treatment for other infections such as sepsis and UTIs that can be caused by bacterial cells from the biofilm sloughing off and traveling in the bloodstream?

Answer 387

Removal of the CVAD and initiation of systemic antibiotic therapy

Question 388

What is the primary means of nosocomial acquisition of bloodstream infections?

Answer 388

Hand contamination

Question 389

Aside from hand contamination, what is another mean of nosocomial acquisition of bloodstream infections?

Answer 389

Microbial aerosols produced during periods of rhinorrhea

Question 390

What factors are associated with the emergence of VRE (vancomycin-resistant enterococci)?

Answer 390

Previous antibiotic therapy involving third generation cephalosporins and vancomycin use
GI colonization with VRE
Severity of the underlying disease
Prolonged hospital stay
Use of indwelling VADs

Question 391

What microbial pathogen occurs in approximately 60% of CVC infections?

Answer 391

Coagulase-negative staphylococci

Question 392

Recurrent gram-negative infections of central lines have been observed in what kind of PN patients?

Answer 392

Patients with short bowel syndrome receiving PN

Question 393

What are the 5 components of the Central Line Bundle?

Answer 393

Hand hygiene
Maximal barrier precautions
CHG skin antisepsis
Optimal catheter site selection
Daily review of line necessity and prompt removal of unnecessary lines

Question 394

When should maximal barrier precautions be used?

Answer 394

During the insertion of CVCs, PICCs, or guidewire exchange

Question 395

What should be done in the event of a CRBSI diagnosis in a patient that requires long-term IV therapy?

Answer 395

Catheter salvage using both a 70% ethanol lock as well as systemic antibiotic therapy

Question 396

Removal of a catheter is recommended for what type of infections?

Answer 396

Fungal infections and S. aureus

Question 397

Should the CVAD be used for blood sampling when PN is administered?

Answer 397

No, to reduce the risk of CRBSI

Question 398

List noninfectious complications of CVADs

Answer 398

Air embolism
Pulmonary embolism
Catheter migration
Cardiac tamponade
Nerve injury

Question 399

What should be done if air embolism is suspected?

Answer 399

Catheter lumens should be clamped and the patient immediately placed in Trendelenburg with a left lateral decubitus position

Question 400

What are risk factors for development of pulmonary embolism with CVADs?

Answer 400

Diagnosis of cancer
Immobility for long periods of time
Recent surgery or trauma
DVT
Other thrombus elsewhere in the body

Question 401

What are the 2 criteria that define catheter patency?

Answer 401

The ability to infuse without resistance
Ability to aspirate blood without resistance

Question 402

What are the 3 key factors that result in the development of vessel thrombus?

Answer 402

Vessel wall damage
Blood flow changes
A systemic alteration in coagulation

Question 403

What is the recommended catheter to vein ratio recommended by the MAGIC expert panel to reduce the risk for catheter-related DVT?

Answer 403

1:3 catheter-to-vein ratio

Question 404

What are risk factors for thrombus formation?

Answer 404

Catheter tip position, catheter material, type of infusate, length of catheter duration

Question 405

What is the recommended volume of flush solution?

Answer 405

At least twice the volume of the catheter (eg 5-10 ml normal saline)

Question 406

What is an approved thrombolytic agent for CVAD occlusions?

Answer 406

Alteplase

Question 407

What are the leading causes of intraluminal occlusions?

Answer 407

Drug-heparin interactions
PN formulations with inappropriate calcium-to-phosphate ratios
Lipid residue

Question 408

What is the key to preventing nonthrombotic occlusion?

Answer 408

The use of a 0.9% normal saline flush between all IV medications, infusions, and heparin

Question 409

What is catheter pinch-off syndrome?

Answer 409

An intermittent mechanical obstruction related to postural changes caused by catheter compression between the clavicle and the first rib

Question 410

What are the appropriate disinfecting agents for hub disinfection?

Answer 410

70% isopropyl alcohol
Iodophors
>0.5% chlorohexidine in alcohol solution

Question 411

What are the 3 categories of CVADs?

Answer 411

Nontunneled
Tunneled
Implanted