Reviewed and revised 28 June 2014
- Tiger tube
- Self advancing nasojejunal tube
- short-term enteric feeding into the jejunum (<30 days)
- enteric administration of medications
- Uncooperative patient
- Esophageal or gastric varices
- Bleeding diathesis
— INR (international normalized ratio) > 1.3 (at time of insertion and/or expected at time of removal)
— anticoagulated patients (anticoagulated at time of insertion and/or expected to be anticoagulated at time of removal)
— bleeding disorders
- Obstruction to passage:
— deviated septum or inability pass the feeding tube through the nares
— esophageal stricture or obstruction, gastric obstruction, small or large bowel obstruction(s)
- Recent nasal, oral, esophageal, or gastric surgery or trauma
- Ischemic bowel
- 14 Fr
- made of soft, compliant polyurethane
- has multiple ports
- Alternating cilia-like flaps along the Tiger 2 help to advance it into the distal portions of the small bowel via peristalsis
- Centimeter markings every 10 cm from 40-100 cm provide visual confirmation of tube position
METHOD OF INSERTION AND REMOVAL
- Visually inspect for to kinks, bends or breaks
- Apply lubricant to distal tip
- Advance the lubricated feeding tube through the nose or mouth 50-70 cm into the stomach
— this distance is dependent on the patient’s anatomical measurement
- The use of insufflation and auscultation will confirm that the catheter is in the stomach
— IF uncertain, obtain a CXR
- The feeding tube should be left in place for 30 minutes to 1 hour to allow the patient’s peristalsis to advance the catheter
- Manually advance the feeding tube 10 cm every 30 minutes to 1 hour until the 100 cm mark is reached
— If peristalsis is very weak, the feeding tube can be advanced 10 cm every two hours
— If the patient’s stomach is anatomically unusual, advance the tube in 5 cm increments
- Pharmacologic agents may be used to increase peristalsis (e.g. metoclopramide 10 mgIV and/ or erythromycin 250mg IV)
- At the 100 cm mark, an abdominal X-ray should be taken to confirm position in the small intestine
— Consider injecting 20 mL gastrografin through the Tiger tube to improve visualisation of the tip
- Secure the feeding tube in place using hypoallergenic tape.
- removal slowly with gentle traction
- self-advancing placement reduces the risk of perforation or misplacement that is seen with weighted-tipped feeding tubes and avoids endoscopy or fluoroscopy procedures
- early postpyloric placement allows nutritional goals to be met sooner
- Optional Torque Cable can be used to add body/stiffness to facilitate gastric placement – remove before advancing the Tiger tube beyond the pylorus
- Failure to pass through pylorus
- Clogged or leaking feeding tube
- Premature displacement of the tube
- kinking of the tube
- Aspiration and tracheal placement
- Nasal irritation
- Sore throat
- Bowel erosion and/or intestinal perforation
References and links
- Deane Adam M, Rupinder D, Day Andrew G, Ridley Emma J, Davies Andrew R, Heyland Daren K. Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis. Crit Care. 2013 Jun 21;17(3):R125. PMC4056800.
FOAM and web resources
- Cook Medical — Tiger 2™ Self-Advancing Nasal Jejunal Feeding Tube
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.