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Repair of double-lumen tube with simple and inexpensive materials
TIPS & TECHNIQUES
Repair of Double-Lumen Tube With Simple and Inexpensive Materials Gonzalo Martin-Pen˜a, MD, PhD, Marı´a Dura´n-Martinez, MD, Jesu´s M. Culebras, MD, PhD, Lope Gomez-Molero, MD, and Julian Ruiz-Galiana, MD, PhD From the Department of Medicine, Division of Clinical Nutrition, Mo´stoles General Hospital, Madrid; and the Hospital de Leo´n, Leo´n, Spain INTRODUCTION Double-lumen nasoenteral tubes allow enteral nutrition to be administered in the duodenum or jejunum simultaneously with gastric aspiration. The double function of these tubes enables early enteral feeding of patients undergoing abdominal surgery without the need for an enterostomy and the administration of nutrition through the intestine when gastroparesis, duodenal obstruction, or pancreatitis is present.1–3 We describe how a rupture of the external portion of one of these tubes can be repaired.
CLINICAL CASE A 55-y-old patient with hemorrhagic necrotic pancreatitis and pseudocyst that was complicated by sepsis required treatment with multiple antibiotics and parenteral nutrition for 4 mo. On day 122 of hospitalization, a Stay-put double-lumen tube (Novartis Nutrition, Munich, Germany) was fluoroscopically placed with the distal tip beyond the ligament of Treitz. Tube placement was difficult, necessitating the insertion of a metal guidewire to help advance the tube to the desired position. When we attempted to remove the metal guide, however, it could not be advanced toward the outlet hole because it hit the angle formed by the bifurcation of the proximal and distal lumens. Thus, we had to cut off the tube to withdraw the metal guide wire. Because sectioning the tube precluded gastric aspiration with simultaneous administration of enteral nutrition, we performed a simple repair procedure.
tracheal adapter tube, a 4.5-cm long 6 French metal needle with a Luer-type connection, and an intravenous infusion system with a distal rubber portion. The repair procedure is illustrated in Figure 1. First, the tip of the double-lumen tube was wrapped with one layer of adhesive tape. On top of the adhesive tape, successive layers of waxed paraffin paper were wrapped around the tube until the tube was thick enough to form a hermetic seal with the T tube. Periodically, the layers of waxed paraffin paper were heated slightly with a flame to facilitate the formation of a solid block with the tube. Next the bevel of the needle and its cutting edge were cut off with an emery stone. The enteral nutrition distal route was washed thoroughly with saline solution and the entire length of the needle was inserted into the tube. If necessary, a small amount of soap, oil, or glycerine can be used to facilitate the insertion of the needle.
The external aspiration tube with the waxed paraffin paper and the needle inserted in the feeding tube are then passed through the T Dual Axis Swivel adapter and the aspiration tube firmly pressed and secured to the Swivel adapter with adhesive tape. Again waxed paraffin paper is used to wrap the union of both tubes in order to protect and secure it. This last layer of paraffin paper must also be reheated. The needle connected to the distal tube was passed through the opposite side of the T tube, in which there is a rubber plug that can be adapted to different diameters. If the needle diameter is not sufficient for hermetic closure, adaptation can be improved by using a small rubber tube such as those used in some intravenous drop systems. This rubber tube should be placed around the needle. The aspiration system or gastric drainage bag can then be connected to the free arm of the tube when necessary.
MATERIALS AND METHODS The materials for repair included a transparent T PEEP-Keep Dual Axis Swivel adapter (Sims Portex Inc., Keene, NH, USA) endo-
Correspondence to: Gonzalo Martin-Pen˜a, MD, Servicio de Medicina Interna, Hospital de Mo´stoles, C/Rio Jucar s/n, 28936 Mo´stoles Madrid, Spain. E-mail: [email protected]
FIG. 1. Insertion of the external aspiration tube, wrapped in paraffin paper, into the T Dual Axis Swivel adapter (upper drawing). External aspiration tube and T Dual Axis Swivel adapter once assembled (lower drawing).
Nutrition 16:83– 84, 2000 ©Elsevier Science Inc., 2000. Printed in the United States. All rights reserved.
0899-9007/00/$20.00 PII S0899-9007(99)00257-9
84
DISCUSSION In this report, we explained how to repair the proximal tip of a double-lumen tube. We had to section the tube because we could not easily remove the guidewire from the proximal end of the lumen used to administer enteral nutrition; other situations (e.g., luminal obstruction, ruptures, and problems with adapting to nutrition systems) may require a similar procedure. Although the first course of action in such situations should be to
DOUBLE-LUMEN TUBE REPAIR change the tube, on some occasions this may be very difficult. This problem was easily solved with devices commonly used in hospitals, allowing enteral nutrition to continue to be administered into the small bowel simultaneously with gastric suctioning. The tube functioned correctly for 40 d except for an occasional obstruction of the feeding lumen, which was resolved by flushing this lumen with pancreatic enzymes and a carbonated cola beverage. The tube was removed when it was no longer needed.
REFERENCES 1. Moore EE, Jones TN. Benefits of immediate jejunostomy feeding after major abdominal trauma. A prospective, randomized study. J Trauma 1986;26:874 2. Naked A, Piessevaux H, Marot J-C, et al. Is early enteral nutrition in acute pancreatitis dangerous? About 20 patients fed by an endoscopically placed nasogastrojejunal tube. Pancreas 1998;17:187 3. Kalfarentzos F, Kehagias J, Mead N, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 1997;84:1665
Repair of Double-Lumen Tube With Simple and Inexpensive Materials Gonzalo Martin-Pen˜a, MD, PhD, Marı´a Dura´n-Martinez, MD, Jesu´s M. Culebras, MD, PhD, Lope Gomez-Molero, MD, and Julian Ruiz-Galiana, MD, PhD From the Department of Medicine, Division of Clinical Nutrition, Mo´stoles General Hospital, Madrid; and the Hospital de Leo´n, Leo´n, Spain INTRODUCTION Double-lumen nasoenteral tubes allow enteral nutrition to be administered in the duodenum or jejunum simultaneously with gastric aspiration. The double function of these tubes enables early enteral feeding of patients undergoing abdominal surgery without the need for an enterostomy and the administration of nutrition through the intestine when gastroparesis, duodenal obstruction, or pancreatitis is present.1–3 We describe how a rupture of the external portion of one of these tubes can be repaired.
CLINICAL CASE A 55-y-old patient with hemorrhagic necrotic pancreatitis and pseudocyst that was complicated by sepsis required treatment with multiple antibiotics and parenteral nutrition for 4 mo. On day 122 of hospitalization, a Stay-put double-lumen tube (Novartis Nutrition, Munich, Germany) was fluoroscopically placed with the distal tip beyond the ligament of Treitz. Tube placement was difficult, necessitating the insertion of a metal guidewire to help advance the tube to the desired position. When we attempted to remove the metal guide, however, it could not be advanced toward the outlet hole because it hit the angle formed by the bifurcation of the proximal and distal lumens. Thus, we had to cut off the tube to withdraw the metal guide wire. Because sectioning the tube precluded gastric aspiration with simultaneous administration of enteral nutrition, we performed a simple repair procedure.
tracheal adapter tube, a 4.5-cm long 6 French metal needle with a Luer-type connection, and an intravenous infusion system with a distal rubber portion. The repair procedure is illustrated in Figure 1. First, the tip of the double-lumen tube was wrapped with one layer of adhesive tape. On top of the adhesive tape, successive layers of waxed paraffin paper were wrapped around the tube until the tube was thick enough to form a hermetic seal with the T tube. Periodically, the layers of waxed paraffin paper were heated slightly with a flame to facilitate the formation of a solid block with the tube. Next the bevel of the needle and its cutting edge were cut off with an emery stone. The enteral nutrition distal route was washed thoroughly with saline solution and the entire length of the needle was inserted into the tube. If necessary, a small amount of soap, oil, or glycerine can be used to facilitate the insertion of the needle.
The external aspiration tube with the waxed paraffin paper and the needle inserted in the feeding tube are then passed through the T Dual Axis Swivel adapter and the aspiration tube firmly pressed and secured to the Swivel adapter with adhesive tape. Again waxed paraffin paper is used to wrap the union of both tubes in order to protect and secure it. This last layer of paraffin paper must also be reheated. The needle connected to the distal tube was passed through the opposite side of the T tube, in which there is a rubber plug that can be adapted to different diameters. If the needle diameter is not sufficient for hermetic closure, adaptation can be improved by using a small rubber tube such as those used in some intravenous drop systems. This rubber tube should be placed around the needle. The aspiration system or gastric drainage bag can then be connected to the free arm of the tube when necessary.
MATERIALS AND METHODS The materials for repair included a transparent T PEEP-Keep Dual Axis Swivel adapter (Sims Portex Inc., Keene, NH, USA) endo-
Correspondence to: Gonzalo Martin-Pen˜a, MD, Servicio de Medicina Interna, Hospital de Mo´stoles, C/Rio Jucar s/n, 28936 Mo´stoles Madrid, Spain. E-mail: [email protected]
FIG. 1. Insertion of the external aspiration tube, wrapped in paraffin paper, into the T Dual Axis Swivel adapter (upper drawing). External aspiration tube and T Dual Axis Swivel adapter once assembled (lower drawing).
Nutrition 16:83– 84, 2000 ©Elsevier Science Inc., 2000. Printed in the United States. All rights reserved.
0899-9007/00/$20.00 PII S0899-9007(99)00257-9
84
DISCUSSION In this report, we explained how to repair the proximal tip of a double-lumen tube. We had to section the tube because we could not easily remove the guidewire from the proximal end of the lumen used to administer enteral nutrition; other situations (e.g., luminal obstruction, ruptures, and problems with adapting to nutrition systems) may require a similar procedure. Although the first course of action in such situations should be to
DOUBLE-LUMEN TUBE REPAIR change the tube, on some occasions this may be very difficult. This problem was easily solved with devices commonly used in hospitals, allowing enteral nutrition to continue to be administered into the small bowel simultaneously with gastric suctioning. The tube functioned correctly for 40 d except for an occasional obstruction of the feeding lumen, which was resolved by flushing this lumen with pancreatic enzymes and a carbonated cola beverage. The tube was removed when it was no longer needed.
REFERENCES 1. Moore EE, Jones TN. Benefits of immediate jejunostomy feeding after major abdominal trauma. A prospective, randomized study. J Trauma 1986;26:874 2. Naked A, Piessevaux H, Marot J-C, et al. Is early enteral nutrition in acute pancreatitis dangerous? About 20 patients fed by an endoscopically placed nasogastrojejunal tube. Pancreas 1998;17:187 3. Kalfarentzos F, Kehagias J, Mead N, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 1997;84:1665