4
5. Negotiate the pylorus and advance the guidewire into the duodenum. If the
catheter is difficult to advance through the pylorus, reduce the length of the
catheter coiled in the stomach. A rotational motion on the flexible catheter
may allow easier passage over the guidewire.
6. Advance the guidewire and catheter to a point 10–15 cm beyond the
Ligament of Treitz.
7. Remove the catheter and leave the guidewire in place.
8. Measure the stoma length with the HALYARD* Stoma Measuring Device.
Tube Placement
1. Select the appropriate size MIC-KEY* Gastric-Jejunal Feeding Tube and
prepare according to the directions in the Tube Preparation section above.
2. Advance the distal end of the tube over the guidewire and into the stomach.
3. Rotate the HALYARD* MIC-KEY* Gastric-Jejunal Feeding Tube while
advancing to facilitate passage of the tube through the pylorus and into the
jejunum.
4. Advance the tube until the tip of the tube is 10–15 cm beyond the Ligament
of Treitz and the balloon is in the stomach.
5. Using a Luer slip syringe, inflate the balloon.
• Inflate the balloon with 3–5 ml of sterile or distilled water for pediatric
sized tubes (REF numbers ending in -15, -22 or -30)
Caution:
Do not exceed 5 ml total balloon volume. Do not use air. Do
not inject contrast into the balloon.
• Inflate the balloon with 7–10 ml of sterile or distilled water for adult sized
tubes (REF numbers ending in -45).
Caution:
Do not exceed 10 ml total balloon volume. Do not use air. Do
not inject contrast into the balloon.
6. Remove the guidewire through the introducer cannula while holding the
cannula in position.
7. Remove the introducer cannula.
8. Verify proper tube placement according to Verify Tube Position section
above.
Suggested Endoscopic Placement Procedure
1. Perform routine Esophagogastroduodenoscopy (EGD). Once the procedure
is complete and no abnormalities are identified that could pose a
contraindication to placement of the tube, place the patient in the supine
position and insufflate the stomach with air.
2. Transilluminate through the anterior abdominal wall to select a gastrostomy
site that is free of major vessels, viscera and scar tissue. The site is usually
one third the distance from the umbilicus to the left costal margin at the
midclavicular line.
3. Depress the intended insertion site with a finger. The endoscopist should
clearly see the resulting depression on the anterior surface of the gastric
wall.
4. Prep and drape the skin at the selected insertion site.
Gastropexy Placement
Caution:
It is recommended to perform a three point gastropexy in a
triangle configuration to ensure attachment of the gastric wall to the anterior
abdominal wall.
1. Place a skin mark at the tube insertion site. Define the gastropexy pattern
by placing three skin marks equidistant from the tube insertion site and in a
triangle configuration.
Warning: Allow adequate distance between the insertion
site and gastropexy placement to prevent interference of the
T-Fastener and inflated balloon.
2. Localize the puncture sites with 1% lidocaine and administer local
anesthesia to the skin and peritoneum.
3. Place the first T-Fastener and confirm Intragastric position. Repeat the
procedure until all three T-Fasteners are inserted at the corners of the
triangle.
4. Secure the stomach to the anterior abdominal wall and complete the
procedure.
Create the Stoma Tract
1. Create the stoma tract with the stomach still insufflated and in apposition
to the abdominal wall. Identify the puncture site at the center of the
gastropexy pattern. With endoscopic guidance confirm that the site overlies
the distal body of the stomach below the costal margin and above the
transverse colon.
Caution:
Avoid the epigastric artery that courses at the junction of the
medial two-thirds and lateral one-third of the rectus muscle.
Warning: Take care not to advance the puncture needle too
deeply in order to avoid puncturing the posterior gastric wall,
pancreas, left kidney, aorta or spleen.
2. Anesthetize the puncture site with local injection of 1% lidocaine down to
the peritoneal surface.
3. Insert a .038” compatible introducer needle at the center of the gastropexy
pattern into the gastric lumen directed toward the pylorus.
Note:
The best angle of insertion is a 45 degree angle to the surface of the
skin.
4. Use endoscopic visualization to verify correct needle placement.
5. Advance a guidewire, up to .038”, through the needle into the stomach.
Using endoscopic visualization, grasp the guidewire with atraumatic
forceps.
6. Remove the introducer needle, leaving the guidewire in place and dispose
of according to facility protocol.
Dilation
1. Use a #11 scalpel blade to create a small skin incision that extends alongside
the guidewire, downward through the subcutaneous tissue and fascia of the
abdominal musculature. After the incision is made, dispose of according to
facility protocol.
2. Advance a dilator over the guidewire and dilate the stoma tract to the
desired size.
3. Remove the dilator over the guidewire, leaving the guidewire in place.
4. Measure the stoma length with the HALYARD* Stoma Measuring Device.
Measuring the Stoma Length
Caution:
Selection of the correct size MIC-KEY* is critical for the safety
and comfort of the patient. Measure the length of the patient’s stoma with the
Stoma Measuring Device. The shaft length of the MIC-KEY* selected should be
the same as the length of the stoma. An inappropriately sized MIC-KEY* can
cause necrosis, buried bumper syndrome and/or hypergranulation tissue.
1. Moisten the tip of the Stoma Measuring Device with water soluble lubricant.
Do not us mineral oil. Do not use petroleum jelly.
2. Advance the Stoma Measuring Device over the guidewire, through the
stoma and into the stomach. DO NOT USE FORCE.
3. Fill the Luer slip syringe with 5ml of water and attach to the balloon port.
Depress the syringe plunger and inflate the balloon.
4. Gently pull the device toward the abdomen until the balloon rests against
the inside of the stomach wall.
5. Slide the plastic disc down to the abdomen and record the measurement
above the disc.
6. Add 4–5 mm to the recorded measurement to ensure the proper stoma
length and fit in any position. Record the measurement.
7. Using a Luer slip syringe, remove the water in the balloon.
8. Remove the stoma measuring device.
9. Document the date, lot number and measured centimeter shaft length.
Tube Placement
1. Select the appropriate sized MIC-KEY* Gastric-Jejunal Feeding Tube and
prepare according to the directions in the Tube Preparation section listed
above.
2. Advance the distal end of the tube over the guidewire until the proximal
end of the guidewire exits the introducer cannula.
Note:
Direct visualization and manipulation of the introducer and guidewire
may be required to pass the guidewire through the end of the introducer.
3. Hold the introducer hub and jejunal port while advancing the tube over the
guidewire and into the stomach.
4. Using endoscopic guidance, grasp the suture loop or the tip of the tube with
atraumatic forceps.
5. Advance the HALYARD* MIC-KEY* Gastric-Jejunal Feeding Tube through
the pylorus and upper duodenum. Continue to advance the tube using the
forceps until the tip is positioned 10–15 cm beyond the Ligament of Treitz
and the balloon is in the stomach.
6. Release the tube and withdraw the endoscope and forceps in tandem,
leaving the tube in place.
7. Ensure that the external bolster is flush with the skin.
8. Using a Luer slip syringe, inflate the balloon.
• Inflate the balloon with 3–5 ml of sterile or distilled water for pediatric
sized tubes (REF numbers ending in -15, -22 or -30).
Caution:
Do not exceed 5 ml total balloon volume. Do not use air. Do
not inject contrast into the balloon.
• Inflate the balloon with 7–10 ml of sterile or distilled water for adult sized
tubes (REF numbers ending in -45).
Caution:
Do not exceed the 10 ml total balloon volume. Do not use air.
Do not inject contrast into the balloon.
9. Remove the guidewire through the introducer cannula while holding the
cannula in place.
10. Remove the cannula.
Verify Tube Position
1. Verify proper tube placement radiographically to avoid potential
complication (e.g., bowel irritation or perforation) and ensure that the tube
is not looped within the stomach or small bowel.
Note:
The jejunal portion of the tube contains tungsten which is radiopaque
and can be used to radiographically confirm position. Do not inject contrast
into the balloon.
2. Flush the gastric and jejunal lumens to verify patency.
3. Check for moisture around the stoma. If there are signs of gastric leakage,
check the tube position and the external bolster placement. Add fluid as
needed in 1–2 ml increments.
Caution:
Do not exceed total balloon volume indicated above.
4. Check to assure that the external bolster is not placed too tightly against the
skin and rest 2–3mm above the abdomen.
5. Document the date, the type, the size, and lot number of the tube, the
fill volume of the balloon, skin condition and patient tolerance to the
procedure. Start feeding and medication administration per physician
orders and after confirmation of proper tube placement and patency.
Endoscopic Placement Through An Existing Gastros-
tomy Tract
1. Following established protocol, perform routine
Esophagogastroduodenoscopy (EGD). Once the procedure is complete
and no abnormalities are identified that could pose a contraindication
to placement of the tube, place the patient in the supine position and
insufflate the stomach with air.
2. Manipulate the endoscope until the indwelling gastrostomy tube is in the
visual field.
3. Insert a floppy-tip guidewire through the indwelling gastrostomy tube and
remove the tube.
4. Measure the stoma length with the HALYARD* Stoma Measuring Device.
Tube Placement
1. Select the appropriate sized MIC-KEY* Gastric-Jejunal Feeding Tube and
prepare according to the directions in the Tube Preparation section above.
2. Hold the introducer cannula and jejunal hub while advancing the HALYARD*
MIC-KEY* Gastric-Jejunal Feeding Tube over the guidewire and into the
stomach.
3. Refer to step 2 in the Tube Placement section above and complete the
procedure according to the steps listed.
4. Verify proper placement according to the directions in the Verify Tube
Position section listed above.
Extension Set Assembly For Jejunal Feeding
1. Open the feeding port cover
(Fig 1-C)
located at the top of the MIC-KEY*
Gastric-Jejunal Feeding Tube.
2. Insert the MIC-KEY* extension set
(Fig 2)
into the port labeled “Jejunal” by
aligning the lock and key connector. Align the black orientation marking on
the set with the corresponding black orientation line on the jejunal feeding
port.
3. Lock the set into the jejunal feeding port by pushing in and rotating the
connector clockwise until a slight resistance is felt (approximately 1/4 turn)
Do not rotate the connector past the stop point.
4. Remove the extension set by rotating the connector counter clockwise until
the black line on the set aligns with the black line on the jejunal feeding
port.
5. Remove the set and cap the gastric and jejunal ports with the attached port
cover.
Caution:
Never connect the jejunal port to suction. Do not measure
residuals from the jejunal port.
Extension Set Assembly For Gastric
Decompression
1. Open the feeding port cover located at the top of the MIC-KEY* Gastric-
Jejunal Feeding Tube.
2. Insert the MIC-KEY* Bolus Extension set
(Fig 3)
into the port labeled
“Gastric” by aligning the lock and key connector. Align the black orientation
marking on the set with the corresponding black orientation line on the
gastric port.
3. Lock the set into the gastric decompression port by pushing in and rotating
the connector clockwise until a slight resistance is felt (approximately 1/4
turn).
Note:
Do not rotate the connector past the stop point.
4. Remove the extension set by rotating the connector counter-clockwise until
the black line on the set aligns with the black line on the gastric port.
5. Remove the set and cap the gastric and jejunal ports with the attached port
cover.
Caution:
Do not use continuous or high intermittent suctions. High
pressure could collapse the tube or injure the stomach tissue and cause
bleeding.
Medication Administration
Use liquid medication when possible and consult the pharmacist to determine
if it is safe to crush solid medication and mix with water. If safe, pulverize the
solid medication into a fine powder form and dissolve the powder in water
before administering through the feeding tube. Never crush enteric coated
medication or mix medication with formula.
Using a catheter tip syringe flush the tube with the prescribed amount of water.
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, before and after every
intermittent feeding, or at least every 8 hours if the tube is not being used.
