Inserting guidewires (2003)

We were very concerned that part of the procedure described in the article, “Bedside Placement of Small-Bowel Feeding Tubes in the Intensive Care Unit” (February 2003:16–24), involves removing the stylet, flexing it to an angle, and reinserting the stylet to complete the placement, because this is not an accepted technique. In researching the question, we can find no support for reinserting the stylet after removal other than the research referenced. In fact, the standard procedure is for the stylet to remain in place until tube confirmation can be achieved radiographically. In our opinion, the first red flag should have been the fact that the researchers acknowledge that the technique is contrary to the manufacturer’s recommendations. In addition, numerous other sources note that removal of the stylet (or guidewire) should not occur until confirmation of tube placement. In addition, the only research we could locate that supported the researchers’ method was published in AACN Clinical Issues. We have included a list of references, both electronic and from a MEDLINE search, that directly contradict this technique as well as the one piece of research in support of removing a feeding tube stylet before placement confirmation. As professionals, we must ensure that the implementation of research techniques does not endanger our patients; our fear is that publishing research that supports procedures that are not proven safe will endorse the use of said procedures and consequently endanger patients.We would like to address several concerns identified by these readers. The term “evidence-based practice” refers to using the strongest or best evidence available to guide clinical practice as opposed to “blind” reliance on traditional practices taught years ago. Sources of knowledge in nursing come from several areas; the best source is randomized, prospective research trials. Other sources are trial and error, logical reasoning, and expert opinion, which we have employed in this case. Tradition, or “standard practice,” is unfortunately the basis for a lot of nursing practice, and traditions often interfere with the ability to perceive alternative practices. The purpose of research is to question tradition and present new or alternative methods of practice. Sometimes, the best evidence, that is, randomized, prospective trials, is not available, and the best available evidence is expert opinion. The practice of never replacing a guidewire in a feeding tube, because of possibly puncturing the tube, was accepted as truth and not questioned until recently. When we were developing our current protocol based on the Zaloga technique, we also had concerns regarding this practice. However, we found no good evidence in the literature to support the prohibition against guidewire reinsertion.To our knowledge, there are no published reports of undesirable outcomes resulting from replacement of feeding tube guidewires while the tube is in the patient. On the other hand, we believe there is sufficient evidence supporting this practice. This is a standard component of many procedures, including endoscopic placement of percutaneous endoscopic gastrostomy tubes, fluoroscopic placement of small-bowel feeding tubes, placement of central catheters, and cardiac catheterizations. In all these procedures, guidewires are commonly removed and reinserted without complications. This technique is described by Zaloga and others in several publications.1–3In the last 4 years at our institution alone, we have placed more than 1000 tubes using this technique, with no punctures of feeding tubes or other complications. We asked Dr Zaloga, a well-known and respected expert in the area of nutrition support in critical care, to comment on this practice. In conversations with Dr Zaloga (February 2003), he stated that he and his colleagues have placed more than 3000 tubes using his technique without punctures. This totals more than 4000 tubes placed with no punctures of feeding tubes, and we accept this as the strongest evidence available in support of the practice.According to Dr Zaloga, no evidence indicates that replacing a guidewire is harmful. In fact, it is routinely done for vascular catheters as well as feeding tubes. Thus, evidence-based medicine would indicate that it is a safe procedure. In fact, most of the publications in the literature are studies of tube placements in which the procedure includes replacement of the guidewire. In Dr Zaloga’s publications on bedside small-bowel feeding tube placement, the authors recommend reinserting the guidewire. They believe that it is a safe procedure when done by trained individuals. This is not to say there is no potential for abuse; there may be instances of injury caused by untrained individuals inserting guidewires into tubes. There are probably more instances of injury done by placing nasogastric tubes into patients without the guidance of fluoroscopy, yet we do not recommend fluoroscopy for all nasogastric placements.The manufacturer does not support the practice of reinsertion of the guidewire while it is in the patient. This recommendation is based on the manufacturer’s belief rather than scientific evidence. Manufacturers often put this type of information on their packaging to avoid any possible liability and these recommendations tend to cover every remote possibility and variation in practice that could occur. There are similar warnings found on many various types of catheters used in critical care areas where wires are routinely reinserted.In our literature review, we could not find any evidence against reinsertion of feeding tube guidewires. The wire in the Corpak tube is flexible and has a blunted tip; we do not advocate this technique with other types of feeding tubes that may have stiffer wires. A key provision is that this technique should be practiced only by trained providers. There is no evidence that reinsertion of the wire punctures tubes in the hands of trained professionals. Evidence suggests just the opposite, that this is a safe practice when carried out by trained individuals, who will not force the wire if resistance is met. Our position is that this technique of tube placement including removal and reinsertion of the guide-wire is a safe procedure in the hands of trained individuals; however, in untrained hands, even a safe procedure can be dangerous.