DHT

Video Guide: https://www.youtube.com/watch?v=qUh5AJ5uIZo

 

Indications

  • Enteral feeding if unable to swallow; passing meds
  • DHT deliver meds and fluids, NGT provide suction to decompress (can also deliver meds/fluids); nurses place NGT, residents (and ICU nurses) place DHT

 

Relative Contraindications

  • Esophageal varices or strictures (most hepatologists say this is not a contra-indication)
  • Other altered gastric anatomy that may prevent passage. (i.e. gastric bypass, esophageal hernias, tumors or other possible obstructions).

 

Absolute Contraindications for blind approach

  • Facial (increased risk of intracranial placement), pharyngeal or esophageal trauma

 

Procedure considerations

  • Silicone-based, flexible tubing, less than 12fr in size, can be left in place for longer periods of time. NGTs are PVC-based, more rigid, and larger allowing gastric decompression
  • Prior to placement, fully fasten the stylet in the fully-hubbed position to reduce bending and folding over of the weighted tip while advancing
  • Make sure DHT and bridle sizes correlate

 

Group consensus and recommendations

  • Anesthetic use with lidocaine gel (order Lidocaine uro-jet) and nasal swab; reduces pt discomfort, reduces gag reflex, and assists with clearance of the nasal passages
  • Have the patient sit upright with the head tilted toward the chest to encourage posterior oropharynx positioning of the DHT while advancing.
  • If pt can participate safely, have the patient swallow before advancement; pt can suck on straw to utilize pharyngeal muscles to position DHT into esophagus
  • Excessive coughing, difficulty phonating, or resistance may indicate trachea placement. Withdraw tube and re-attempt. Consider Duoneb to reduce bronchospasms
  • 3 failed attempts should be made at the bedside before sending for fluoro-guidance
  • When post-pyloric placement is requested, 1 attempt at post-pyloric placement with the blind approach at the bedside is acceptable before referring to fluoroscopic guidance

 

Placement Tips & Tricks

  • Insufflation of air and auscultation of bowel sounds over the gastric area can be reassuring of correct placement of DHT prior to bridling and leaving the bedside.  Always obtain KUB for radiological confirmation of placement. Leaving the stylet in for confirmation can make it easier to see on KUB and can allows re-advancement 
  • Place bridle and dog-bone tape while at the bedside to reduce dislodgement
  • When placing bridle, keep alignment markers (as clearly marked on both probes) together so magnetic tips will align once past the nasal septum
  • When placing the bridle, remove the green stylet housed within the white probe before retracting back and removing the white probe

 

Post-pyloric placement

  • Consider in patients with high pulmonary aspiration risk and severe esophageal reflux/esophagitis, recurrent emesis, impaired gastric motility, and pancreatitis
  • Post-pyloric placement has been shown up to 90% successful with intermittent insufflation of 10-20cc of air ~every 10cm of advancement after 55cm to promote pylorus opening. IV Reglan or Erythromycin may also help

 

Post-procedural considerations

  • ALWAYS confirm the position radiographically before medications are given!
  • Most mispositioned/coiled tubes have to be removed and re-attempted, but it is ok to advance or withdraw if Stylet is still in place. However, once removed, a stylet should not be re-introduced to a mispositioned/coiled tube due to risk of GI perforation
  • Listen to the patient, repeat imaging (Plain film or CT) if concern for any perforation, and notify appropriate surgical service.
  • In case of cranial placement, don’t remove, consult NSGY
  • De-clogging: Clog Zapper Kit (can type this into Epic directly); Coca cola