Cortrak feeding tube placement: accuracy of the ‘GI flexure system’ versus manufacturer guidance
Electromagnetic (EM) guided enteral tube placement may reduce lung misplacement to almost zero in expert centres, but more than 60 undetected misplacements had occurred by 2016 resulting in major morbidity or death. Aim: Determine the accuracy of manufacturer guidance in trace interpretation against what is referred to as the ‘GI flexure system’. Methods: The authors prospectively observed the accuracy of the ‘GI flexure system’ of trace interpretation against manufacturer guidance in primary nasointestinal (NI) tube placements. Findings: Contrary to manufacturer guidance, 33% of traces deviated >5 cm from the sagittal midline and 26.5% were oesophageal when entering the lower left quadrant, incorrectly indicating lung and gastric placement, respectively. Conversely, the GI flexure system identified ≥99.4% of GI traces when they reached the gastric body flexure; 100% at the superior duodenal flexure. All lung misplacements were identified by the absence of GI flexures. Conclusion: Current manufacturer guidance should be updated to the GI flexure system of interpretation.
The rate of complications caused by undetected lung misplacement of feeding tubes is relatively small (estimated at 0.01%) (Jones, 2020) when compared with the relatively common major complications caused by lung misplacement that is detected (0.5%) (Krenitsky, 2011). Based on the number of tubes used, an estimated 4000 complications due to identified lung misplacement can be expected annually in the UK (Krenitsky, 2011). Guided tube placement has the potential to almost eliminate these complications by pre-empting deep lung placement of the tube. One method, Cortrak, facilitates this by tracing the path of an electromagnet at the tip of the tube guide-wire, warning in real-time of potential deviation into the lung.
Unfortunately, up to the end of February 2016 there were 54 adverse events reported on the Manufacturer and User Facility Device Experience (MAUDE) database in the USA; 98% were lung misplacements, undetected by Cortrak operators, commonly resulting in pneumothorax (77%), pneumonitis (21%) and death (17%) (Bourgault et al, 2017). In a parallel report of MAUDE events, 17 of 25 events resulted in pneumothorax, despite only six being fed (Metheny and Meert, 2017). These data show that, unless misplacement is detected before the tube has advanced deeply into the lung, pneumothorax, pneumonitis and death are possible. Failure to detect lung misplacement has been reported to be as high as 2.1% with Cortrak (Bryant et al, 2015), similar to the 1.4% seen in blind placement (Krenitsky, 2011), and was thought to be due to inadequate training.
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