Kimberly-Clark MIC‑KEY Bedienungsanleitung Seite 3

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Description
The Kimberly-Clark* MIC-KEY* Transgastric-Jejunal
feeding tube (Fig 1) provides for simultaneous gastric
decompression / drainage and delivery of enteral nutrition
into the distal duodenum or proximal jejunum.
Indications For Use
The Kimberly-Clark* MIC-KEY* Transgastric-Jejunal feeding
tube is indicated for use in patients who cannot absorb
adequate nutrition through the stomach, who have intestinal
motility problems, gastric outlet obstruction, severe
gastroesophageal reflux, are at risk of aspiration, or in those
who have had previous esophagectomy or gastrectomy.
Contraindications
Contraindications for placement of a transgastric-jejunal
feeding tube include, but are not limited to ascites, colonic
interposition, portal hypertension, peritonitis and morbid
obesity.
Complications
The following complications may be associated with any
transgastric-jejunal feeding tube:
• Skin Breakdown • Infection
• Hypergranulation Tissue • Stomach or Duodenal Ulcers
• Intraperitoneal Leakage • Pressure Necrosis
NoTE: Verify package integrity. Do not use if package is
damaged or sterile barrier compromised.
Placement
The Kimberly-Clark* MIC-KEY* Transgastric-Jejunal feeding
tube may be placed percutaneously under fluoroscopic or
endoscopic guidance or as a replacement to an existing
device using an established stoma tract.
CAUTIoN: A gAsTRoPExY MUsT BE PERFoRMED To AFFIx
ThE sToMACh To ThE ANTERIoR ABDoMINAL wALL,
ThE FEEDINg TUBE INsERTIoN sITE IDENTIFIED, sToMA
TRACT DILATED AND MEAsURED PRIoR To INITIAL TUBE
INsERTIoN To ENsURE PATIENT sAFETY AND CoMFoRT.
ThE LENgTh oF ThE TUBE shoULD BE sUFFICIENT To BE
PLACED 10‑15 CM BEYoND ThE LIgAMENT oF TREITz.
CAUTIoN: Do NoT UsE ThE RETENTIoN BALLooN oF ThE
FEEDINg TUBE As A gAsTRoPExY DEvICE. ThE BALLooN
MAY BURsT AND FAIL To ATTACh ThE sToMACh To ThE
ANTERIoR ABDoMINAL wALL.
Tube Preparation
1. Select the appropriate size MIC-KEY* Transgastric-
Jejunal feeding tube, remove from the package and
inspect for damage.
2. Using the 6 ml Luer slip syringe contained in the kit,
inflate the balloon with 5 ml sterile or distilled water
through the balloon port. (Fig 1A)
3. Remove the syringe and verify balloon integrity by
gently squeezing the balloon to check for leaks. Visually
inspect the balloon to verify symmetry. Symmetry may
be achieved by gently rolling the balloon between the
fingers. Reinsert the syringe and remove all the water
from the balloon.
4. Using a 6 ml Luer slip syringe, flush water through
both the gastric and jejunal ports (Fig 1A & B) to verify
patency.
5. Lubricate the distal end of the tube with water-soluble
lubricant. Do Not Use Mineral Oil Or Petroleum Jelly.
6. Generously lubricate the jejunal lumen with water-soluble
lubricant. Do Not Use Mineral Oil Or Petroleum Jelly.
7. Insert the introducer cannula (Fig 5) into the Jejunal port
until the hub is in contact with the Jejunal feeding port
and the introducer cannula is clearly visible inside the
tube. The introducer cannula opens the one-way valve
and protects it from damage by the guidewire.
suggested Radiologic Placement Procedure
1. Place the patient in the supine position.
2. Prep and sedate the patient according to clinical
protocol.
3. Insure that the left lobe of the liver is not over the fundus
or the body of the stomach.
4. Identify the medial edge of the liver by CT scan or
ultrasound.
5. Glucagon 0.5 to 1.0 mg IV may be administered to
diminish gastric peristalsis.
CAUTIoN: CoNsULT gLUCAgoN INsTRUCTIoNs
FoR UsE FoR RATE oF Iv INJECTIoN AND
RECoMMENDATIoNs FoR UsE wITh INsULIN
DEPENDENT PATIENTs.
6. Insufflate the stomach with air using a nasogastric
catheter, usually 500 to 1,000 ml or until adequate
distention is achieved. It is often necessary to continue
air insufflation during the procedure, especially at the
time of needle puncture and tract dilation, to keep the
stomach distended so as to oppose the gastric wall
against the anterior abdominal wall.
7. Choose a catheter insertion site in the left sub-costal
region, preferably over the lateral aspect or lateral to the
rectus abdominis muscle (N.B. the superior epigastric
artery courses along the medial aspect of the rectus)
and directly over the body of the stomach toward the
greater curvature. Using fluoroscopy, choose a location
that allows as direct a vertical needle path as possible.
Obtain a cross table lateral view prior to placement
of gastrostomy when interposed colon or small bowel
anterior to the stomach is suspected.
NoTE: PO/NG contrast may be administered the night
prior or an enema administered prior to placement to
opacify the transverse colon.
8. Prep and drape according to facility protocol.
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 fluoroscopic 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 fluoroscopic visualization to verify correct needle
placement. Additionally, to aid in verification, a water
filled syringe may be attached to the needle hub and air
aspirated from the gastric lumen.
NoTE: Contrast may be injected upon return of air to
visualize gastric folds and confirm position.
5. Advance a guidewire, up to .038", through the needle and
coil in the fundus of the stomach. Confirm position.
6. Remove the introducer needle, leaving the guidewire in
place and dispose of according to facility protocol.
7. Advance a .038" compatible flexible catheter over the
guidewire and using fluoroscopic guidance, manipulate
the guidewire into the antrum of the stomach.
8. Advance the guidewire and flexible catheter until the
catheter tip is at the pylorus.
9. Negotiate through the pylorus and advance the
guidewire and catheter into the duodenum and 10-15 cm
beyond the Ligament of Treitz.
10. Remove the catheter and leave the guidewire in place.
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 Kimberly-Clark*
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
NoTE: A peel-away sheath may be used to facilitate
advancement of the tube through the stoma tract.
1. Select the appropriate MIC-KEY* Transgastric-Jejunal
feeding tube and prepare according to the directions in
the Tube Preparation section listed above.
2. Advance the distal end of the tube over the guidewire
until the proximal end of the guidewire exits the
introducer cannula.
NoTE: Direct visualization and manipulation of the
introducer and guidewire may be required to pass the
guidewire through the end of the introducer.
3. Hold the introducer hub and jejunal feeding port while
advancing the tube over the guidewire and into the
stomach.
4. Rotate the Kimberly-Clark* MIC-KEY* Transgastric-
Jejunal feeding tube while advancing to facilitate
passage of the tube through the pylorus and into the
jejunum.
5. Advance the tube until the tip of the tube is 10-15 cm
beyond the Ligament of Treitz and the balloon is in the
stomach.
6. Ensure the external bolster is flush with the skin.
7. Using a Luer slip syringe, inflate the balloon.
• Inflate the balloon with 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.
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