Jejunal Enteral Feeding Tubes - Guidelines for the Management of Patients with

Publication: 16/06/2014  --
Last review: 30/09/2020  
Next review: 30/09/2023  
Clinical Guideline
CURRENT 
ID: 3870 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guidelines for the Management of Adult Patients with Jejunal Enteral Feeding Tubes

Summary

These guidelines have been produced to support staff in the correct management of adults with a current jejunal tube.
Jejunal tubes can be used for:

  • Artificial nutrition
  • Artificial hydration
  • Administration of appropriate medicines

Jejunal feeding is a method of nutrition support used to feed patients in whom gastric feeding is not possible, not tolerated or contraindicated. These guidelines are based on evidence where it is available and expert opinion where it is not, with the aim of reducing clinical patient risk
.
Table of contents

Aims

  • To improve the management of jejunal feeding and ensure it is safe, effective and comfortable for the patient.
  • To provide support for standardised practice and support the care plans for enteral feeding via the nasojejunal or jejunostomy routes in adults.

These guidelines must be used in conjunction with enteral feeding plans and the current LTHT Enteral feeding policy

Indications and Precautions

Jejunal feeding may be indicated for patients:

  • with gastric stasis and subsequent aspiration risk
  • following major gastrointestinal or hepato-biliary surgery  
  • where the clinical condition of the patient increases the likelihood of gastric stasis  
  • when gastric feeding has failed 

Jejunal feeding may be contraindicated in patients who have non functioning gastrointestinal tract, ileus, proximal small bowel stoma or fistula distal to the position of the jejunal tube. Further specific contraindications are highlighted in Appendix 1.

Precautions:
Stop feed / medication delivery immediately if there is:

  • prolonged or severe pain after jejunostomy insertion
  • pain on feeding
  • fresh bleeding
  • external leakage of feed/bowel contents
  • tube displacement

Obtain senior advice urgently and consider CT scan, contrast study or surgical review.

Principles of practice

Professionals should adhere to The Code of Professional Conduct (NMC, 2018)
A good standard of hygiene is necessary to prevent the patient developing an infection.
Nurses should refer to the Leeds Teaching Hospitals NHS Trust Standard Infection Prevention and Control Precautions available at
detail.aspx?ID=671

Consent for placement of a jejunal feeding tube should be sought under guidance from the Leeds Teaching Hospitals Trust most recent recommendations and as appropriate for the chosen method of placement.

Back to top

Types of Jejunal Tubes

The nasojejunal and jejunostomy routes



Fig 1: The nasojejunal route of feeding



Fig 2: The jejunostomy route of feeding
Types of tube

Back to top

Nasojejunal (NJ) tubes

These are available in a number of sizes and by several manufacturers. The tubes currently used within the LTHT are demonstrated below. Tube selection is made according to the most appropriate method of placement.

See also Appendix 2 for further details of tube identification.

Corflo nasoenteric tube (Merck) (8Fr or 10Fr 120cm or 132cm)

This tube is placed under radiological guidance to ensure correct placement.

Freka Endolumina Nasojejunal tube (8Fr up to 270cm)


This tube is placed via an endoscopy to ensure correct placement.
Wilson-Cook Nasojejunal tube (Cook Medical) (8Fr or 10Fr up to 240cm tube)

This tube is placed via an endoscopy to ensure correct placement.

Please note for all types of nasojejunal tubes:
Aspiration of nasojejunal tubes is not a viable method to identify ongoing tube position. Aspirate may be difficult to obtain and when it is measured the pH is likely to be variable. An acidic pH is only useful when feeding into the acid environment of the stomach. As the jejunum is more alkaline a pH level will provide no guidance as to whether or not it is safe to feed. Please see ‘Confirming Tube position’ section for further information.

Flushing
Nasojejunal tubes commonly block/clog due to their length, fine-bore and typically longer periods of feeding. This can be prevented by incorporating regular water flushes into the feeding regimen. Dietitians are encouraged to prescribe 4 hourly 60ml (or a much as can be tolerated) water flushes via the nasojejunal tube. To avoid a patient being disturbed during an overnight feed, flushes should be given before sleeping and immediately upon waking.

Back to top

Jejunostomy tubes

There are a number of jejunostomy tubes available at LTHT. The most common are placed surgically via a laparotomy or laparoscopy, they are demonstrated below.

Other tubes which may be used include percutaneous jejunostomies (which may have a balloon retention device) or low profile jejunostomies such as a “button” device.

Freka (9Fr Fresenius Kabi)

This tube is inserted surgically and is secured by sutures on the external triangular fixation device. The sutures need to stay in situ to allow the tube to stay in place therefore if the sutures fall out they will need to be replaced quickly by a competent practitioner. Sutures should not be removed until the tube is intended to be removed. This tube is used for short term jejunal feeding. In cases where sutures are causing peristomal skin damage or discomfort, then a secure dressing may be considered.

MIC Jejunostomy (14Fr Vygon)

This tube is inserted surgically and is secured in place with two wings within a tunnelled small bowel. A dacron cuff helps retain the tube in place. This tube is used for longer term jejunal feeding. There is a short term external suture which tacks the tube in place. This can be removed by staff or community nurses 7-10 days post insertion, as the dacron cuff should be secured by this time.

Monarch Capsule tube (12fr and 14 fr)

This tube is inserted surgically and is secured with an internal disc bumper. The tube is for longer term jejunal feeding. A short term external suture tacks the tube in place. This can be removed by staff or community nurses 7-10 days post insertion. Monarch tubes require replacement every 18 months and this can be done by traction removal and replacement at the bedside. Monarch jejunostomy tubes must be changed in the hospital setting by the enteral Feeding Nurses.

Balloon Retention tubes

If a water filled balloon tube is used for jejunal feeding, the water in the balloon should be checked fortnightly to prevent it from accidentally dislodging. Please contact the Enteral Feeding Nurse or Dietitian about how much water should be used and follow these steps:

  1. Gently move the external fixator away and take note of the cm marking at the abdominal wall
  2. Gently push the tube 1cm into the jejunum to prevent displacement
  3. Using a 10ml normal luer slip syringe, remove the water from the balloon port.
  4. Using a prefilled luer slip syringe of sterile water, insert the recommended volume into balloon port. This may be between 2.5 and 5 mls, depending on the patient.
  5. Pull the tube back so that you can feel the resistance of the balloon against the abdominal wall, ensuring that it is back to its’ original cm marking.
  6. Reposition external fixator
  7. Flush the tube with 30mls sterile water

If there is any pain, resistance or leakage on flushing contact the patients’ medical team before continuing to use the tube.
Balloon jejunostomy tubes are changed every 12 weeks and can be changed either in the hospital setting by the Enteral feeding nurses or in the patients home by the Fresenius Kabi nurses for those living within the Leeds catchment area.

Back to top

Other nasojejunal and jejunostomy tubes

There are several other manufacturers who make nasojejunal and jejunostomy feeding tubes. It is therefore possible that a patient may be admitted to a unit or ward with a feeding tube other than those available in LTHT. If this situation occurs it is recommended that a member of the multidisciplinary team establish the following:

  • The tube manufacturer
  • The tube type
  • The tube size and length
  • The number of lumens and their individual function (e.g. balloon port, gastric port, jejunal port)
  • When the tube was placed
  • Where the tube was placed
  • Whether extension kits or connectors are required before enteral feeding can be commenced
  • Advice may need to be sought from the manufacturer as well as the relevant department/Trust where the tube was inserted. It is important to obtain as much relevant information as possible to facilitate safe enteral feeding.

Information obtained will need to be documented in the patients care plan so that it is available to all multidisciplinary staff involved in patient care.

Dressings
If the jejunostomy tube has resulted in a surgical wound due to a laparotomy/mini -laparotomy, or if the site is leaking then treat and dress as per current wound management protocol and assess daily.
If the stoma site is clean and dry, leave uncovered but monitor daily as per care plan.

Back to top

Nasogastric tubes

It is sometimes possible that a nasogastric tube may be used for nasojejunal feeding in patients who have had previous surgery, for example partial or total gastrectomy or oesophagectomy, or other conditions whereby the jejunum sits higher in the thoracic cavity and can be accessed via a shorter tube length.

Confirming tube position

Back to top

Nasojejunal tube position (endoscopic and radiological NJ tubes)

  • Initial insertion technique varies, but usually no additional x-ray confirmation is required (but please check report)
  • The external length of NJ tubes needs to be recorded upon insertion to identify if the tube becomes displaced.
  • This needs to be checked prior to administration of water, medications or feed via the tube or if there is any evidence or concern of displacement.
  • The external length is measured from the part of the tube exiting the nostril to the tip of the feeding port. The length should be recorded in centimetres. This is demonstrated in the picture (although the tube may look different).
  • Clinical judgement and expertise should be used in combination with observation to assess ongoing tube position.
  • Aspiration of nasojejunal tubes is not a viable method to identify ongoing tube position. Aspirate may be difficult to obtain and when it is measured the pH is likely to be variable. An acidic pH is only useful when feeding into the acid environment of the stomach. As the jejunum is more alkaline a pH level will provide no guidance as to whether or not it is safe to feed.
  • External measurements should be recorded on the patients ‘Care of adults with nasojejunal (NJ) feeding tubes’ feeding care plan. These should be carried out:
    • Before each feed or drug administration
    • Following vomiting/endotracheal suction/coughing spasms
    • At least once every 12 hours during continuous feeds
    • Following evidence of tube displacement
  • If there is any doubt over the ongoing position of the nasojejunal tube then x-ray or contrast study is required to ensure that the tube has not moved from the small bowel.

Back to top

Jejunostomy Feeding tube position

  • Surgically placed jejunostomy tubes are usually secured by sutures or dacron cuff at the time of placement. Feeding can commence at the direction of the surgeon. Tube position can be rechecked using a contrast medium if required. This should be checked if there are any signs of:
    • External displacement of tube
    • Bleeding
    • Leakage around the tube site of any bowel or feed content
    • Prolonged or severe pain on feeding

In the event of these occurring:

  •  
    • Stop feed / medication delivery immediately
    • Obtain senior advice urgently and consider CT scan, contrast study or surgical review.

Back to top

Ongoing feeding jejunostomy tube position issues

  • The external length of the jejunostomy tube at exit from the stoma should not alter as position should be secured via an internal dacron cuff or external sutures.
  • If the tube appears to be displaced, the sutures are inadvertently cut (Freka), or the cuff of the tube is visualised (MIC Vygon), STOP FEEDING, fix the tube in place with tape and call the Enteral Feeding Nurses or medical team for further advice. It may be necessary to request a tubogram to confirm position.

Back to top

Blockage of any type of jejunal feeding tube

  • Tube blockage may be indicated by difficulty in flushing the tube or when connectors or syringes are pushed out of place as the tube is flushed.
  • Prevention of tube blockage is the best management.

Tubes commonly block due to:

  •  
    • inadequate frequency or volume of flushes
    • inadequate flushing between medications
    • inappropriately crushed medications flushed via tube
    • medications mixed together rather than given separately

Back to top

Management of tube blockage

If the tube is blocked, try one or more of the following to help unblock the tube:

  • Flush with warm (not hot) sterile or cooled boiled water
  • Use a pull-push syringe technique to attempt aspiration of the blockage from the tube

If unsuccessful try a pancreatic enzyme e.g. Creon® 10,000 units, although please note it is not licensed for this use.
Pancreatic enzymes such as Creon® are enteric coated and need to be dissolved in sodium bicarbonate and water (This needs to be prescribed).
Recipe - use 1 Creon® 10,000 unit capsule and 10ml sodium bicarbonate liquid 0.8mmol/ml or 500mg sodium bicarbonate dissolved in 10ml water.
Method
Remove residual liquid from feeding tube
Instil enzyme solution, replace cap and leave for 15 minutes
Irrigate the jejunal tube with water and repeat procedure if tube fails to clear.

  • If all of the above fail please refer to radiology where the tube may need to be replaced or if possible unblocked.  

High risk actions to avoid when a tube is blocked

  • Do not flush with any drink such as cola, pineapple juice or alcohol 
  • Do not insert a guidewire or any other type of material into the tube to try to unblock it 
  • Do not use force to unblock the tube 
  • Do not use a small syringe which can increase pressure within the tube and cause tube perforation 

Back to top

Accidental removal of tube

  • Accidental removal of any jejunal feeding tube requires medical or surgical review, and a plan for ongoing nutrition support. Replacement if indicated should be made by a competent practitioner via the most suitable method.
  • For community patients this may mean admission to hospital via the surgical registrar on call or via an assessment area depending upon the individual’s ability to maintain adequate nutrition and hydration without their jejunal feeding tube.
  • If it is possible to maintain the tract via a tube (e.g. enteral feeding tube, Foley Catheter) this should be attempted providing there is no resistance. An urgent referral to radiology should be made to allow radiologically-guided replacement and the temporary tube should not be used under any circumstances.

Back to top

Replacement of tubes

MRSA Screening
Where it is intended to insert a jejunostomy tube, the patient must have a current MRSA screen (including anterior nares, groin, axilla and if practicable any other site that is likely to be colonised). A current screen is one that has been taken within the three months prior to the procedure.

Patients whose MRSA screen is negative do not require MRSA decolonisation

Patients whose MRSA screen is positive must be decolonised, with decolonisation timed to finish on the day before the procedure, according to the principles for MRSA decolonisation in patients undergoing a surgical procedure. Further information can be gained from the LTHT MRSA guideline:
detail.aspx?ID=684
In the event that jejunostomy placement is delayed, decolonisation should only be repeated if there is a delay of 14 days or more.
Please ensure swab results are checked to determine if there is any resistance to mupirocin or neomycin to ensure correct decolonisation therapy is given.

Replacement of NJ tubes should be undertaken via the most appropriate method.

Back to top

Documentation

Documentation should be made in the medical/ surgical and nursing notes and should include:

  • date of insertion
  • type and size of tube
  • the external length of tube at exit from nose (NJ) or stoma site (feeding jejunostomy) to tip/end of the tube, not including the cap
  • method of tube insertion (endoscopic or radiological)

Documentation should be made in the patients nasojejunal or jejunostomy feeding care plan.

Appendices

Back to top

Appendix 1 - Contraindications and potential adverse effects of jejunal feeding

Contraindications for nasojejunal feeding

The following include absolute and relative contraindications to the use of a nasojejunal tube but are not limited to:

Absolute

  • Anticoagulated patients at time of insertion and/or expected to be anticoagulated at the time of removal
  • Pathological coagulopathies
  • Small or large bowel obstruction
  • Ischaemic bowel
  • Peritonitis
  • Base of skull fracture

Relative

  • Oesophageal varices
  • Gastric varices
  • INR > 1.3 at the time of insertion and/or expected time of removal
  • History of bleeding disorders
  • Oesophageal stricture or obstruction
  • Recent nasal, oral, oesophageal or gastric surgery or trauma
  • Nasal polyps
  • Deviated septum
  • Inability to pass the feeding tube through the nares
  • Uncooperative patient

Back to top

Potential adverse effects of nasojejunal feeding

These adverse effects can occur with placement and use of a nasojejunal feeding tube. They include, but are not limited to:

  • Bleeding
  • Clogged or leaking feeding tube
  • Sinusitis
  • Premature displacement of the tube
  • Aspiration
  • Nasal irritation
  • Sore throat
  • Other adverse effects may occur related to the individual’s condition, medical or surgical history. Please consider these risks when placing or using the nasojejunal tube.

Back to top

Contraindications to surgical jejunostomy feeding

The following include absolute and relative contraindications to the use of a surgical jejunostomy tube, but are not limited to:

Absolute

  • Ileus
  • Peritonitis
  • Acute abdomen
  • Sepsis
  • Ascites
  • Blood clotting disorders
  • Severe general wound healing disorders

Relative

  • Peritoneal carcinoma
  • Immune suppression

Back to top

Potential adverse effects of jejunostomy feeding

These adverse effects can occur with placement and use of a jejunostomy feeding tube. They include, but are not limited to:

  • Bleeding
  • Leakage, pain, swelling, redness or irritation at insertion site
  • Tube displacement
  • Blocked tube
  • Other adverse effects may occur related to the individual’s condition, medical or surgical history. Please consider these risks when placing or using the jejunostomy tube.

Back to top

Appendix 2 - Tube Identification Guide

Nasojejunal Tube Guide
This is a guide which provides some further information. Please also refer to manufacturer information.

Tube

Method of placement

Detail

Corflo Nasojejunal Tube
(Merck)

 

radiology

  • Polyurethane tube
  • French size 8Fr
  • 140cm length
  • Radiopaque
  • Secure to face with appropriate dressing/ tape.
  • Replace dressing as required.
  • External length recorded on insertion by radiology (in cm)
  • Maintain adequate hygiene/infection control due to the increased risk of infection as there is no acid barrier protection within the small bowel.
  • ENFIT feeding ports

Wilson-Cook (Cook Medical)

 

Endoscopy

  • Product contains DEHP (di 2-ethylhexyl phthalate)
  • Not intended for use over 30 days
  • Size 8 Fr
  • Secure to face with appropriate dressing/ tape.
  • Replace dressing as required.
  • Maintain adequate hygiene/infection control due to the increased risk of infection as there is no acid barrier protection within the small bowel.
  • ENFIT feeding ports.
  • External length of tube recorded by endoscopist on insertion (in cm)

Back to top

Feeding Jejunostomy Guide

Tube

Method of placement

Detail

Freka jejunostomy

 

Surgical

 

 

 

 

 

 

  • Held in place externally with a triangular fixation device which is secured with sutures. The sutures must remain in situ for the life if tube. 
  • French Size - 9 
  • Polyurethane tube 
  • White luer lock adaptor. 
  • Clamp on tube. 
  • Removable at bedside (no internal retention device). 
  • A transparent dressing may be applied. Please do not use keyhole dressings as these may increase the chance of sutures being pulled. 

Vygon *MIC* Jejunostomy

Surgical

  • Held in place internally with a Dacron cuff
  • 14 Fr size
  • Silicone material
  • Luer lock or bolus adaptor
  • No clamp on tube
  • Surgically removed.

Corflo Transgastric Jejunostomy Tube


Endoscopic placement via a Corflo PEG tube

  • PEG held in place with internal bumper and jejunal inner tube secured at feeding port
  • Jejunal tube inserted through internal lumen of PEG tube
  • Dual ports for gastric and jejunal access
  • Available for use in 16fr and 20fr PEGs, jejunal inner tube 6fr and 8fr

Freka Transgastric Jejunostomy Tube


Endoscopic placement via a Freka PEG tube

  • PEG held in place with internal bumper and jejunal inner tube secured at feeding port
  • Jejunal tube inserted through internal lumen of PEG tube
  • Dual ports for gastric and jejunal access
  • Available for use in 15fr PEG. Jejunal inner tube 9fr

EnteralUK G-Jet Transgastric Jejunostomy Tube


Radiological /Endoscopic placement via existing gastrostomy

  • Held in place with water filled balloon
  • Low profile /button device
  • Dual ports for gastric and jejunal access
  • Requires extension sets to access ports
  • Available in 14fr and 16fr and in 15cm, 22cm, 30cm and 45cm jejunal lengths
  • Usually requires replacement within 12 months

Vygon Transgastric Jejunostomy Tube


Radiological /Endoscopic placement via existing gastrostomy

  • Held in place with water filled balloon
  • External fixator to anchor tube to abdomen
  • Dual ports for gastric and jejunal access
  • Available in 16fr, 18fr and 22fr and in 15cm, 22cm, 30cm and 45cm jejunal lengths
  • Usually requires replacement within 12 months

Provenance

Record: 3870
Objective:

The objectives of this guideline are to provide adequate information and support to ensure safe use of jejunal feeding tubes. This will allow:

  • Maintenance of nutrition and hydration
  • Safe administration of appropriate medicines
  • Risk reduction of potential complications e.g. tube displacement, tube blockage and accidental removal.
Clinical condition:

Adults requiring feeding or hydration via the jejunal route

Target patient group: Adults requiring jejunal enteral feeding
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

The Leeds Teaching Hospitals NHS Trust Enteral Feeding Policy 2020

The Leeds Teaching Hospitals NHS Trust Enteral Feeding Infection Control Policy. Available at:
detail.aspx?ID=679

Guidelines for the management of problems with a gastrostomy feeding tube. Leeds Healthcare. Available at:
detail.aspx?id=779

MRSA guideline
detail.aspx?ID=684

Fresenius-Kabi Ltd
Cestrian Court
Eastgate Way
Manor Park
Runcorn Cheshire
WA7 1NT
www.fresenius-kabi.co.uk

Merck Serono Ltd
Feltham
UK
www.merckge.co.uk

Cook Medical
http://www.cookmedical.com/esc/familyListingAction.do?family=Enteral

Kimberly-Clark Ltd
1 Tower View
Kings Hill
West Malling
ME19 4HA
http://www.kchealthcare.com/productpromosite/mickey/www/Index.asp?action=Main

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.