AACN News—November 2007—Practice

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Vol. 24, No. 11, NOVEMBER 2007


Practice Resource Network


Q:

For many years, blue dye was our standard for checking for aspiration of stomach contents in patients who were being fed via enteral feeding tube. Is there an alternative liquid that can be used for this purpose? If not, what method do you recommend?

A:

As you have indicated, it is not appropriate to use FD&C Blue #1 for verification of aspiration in patients who are being fed via enteral feeding tube even though it had been a practice for over 30 years. As a result of toxicity issues related to Blue #1, the Food and Drug Administration issued the following Public Health Advisory: REPORTS OF BLUE DISCOLORATION AND DEATH IN PATIENTS RECEIVING ENTERAL FEEDINGS TINTED WITH THE DYE, FD&C BLUE NO. 1.1 Below are some excerpts that will provide the findings associated with the recommendation that the FDA incorporated in this advisory..
“The Food and Drug Administration (FDA) would like you to be aware of several reports of toxicity, including death, temporally associated with the use of FD&C Blue No. 1 (Blue 1) in enteral feeding solutions. In these reports, Blue 1 was intended to help in the detection and/or monitoring of pulmonary aspiration in patients being fed by an enteral feeding tube. Reported episodes were manifested by blue discoloration of the skin, urine, feces, or serum and some were associated with serious complications such as refractory hypotension, metabolic acidosis and death. Case reports indicate that seriously ill patients, particularly those with a likely increase in gut permeability (e.g., patients with sepsis), may be at greater risk for these complications. Because these events were reported voluntarily from a population of unknown size, it is not possible to establish the incidence of these episodes.
At this time, the FDA believes practitioners should be aware of the following points:

• Use of Blue 1-tinted enteral feedings for detecting aspiration has been associated with several serious adverse events, including death, although a direct causal relationship has not been definitely established.
• The safety of Blue 1-tinted enteral feedings for detecting aspiration has not been documented.
• Based on the reports received to date, patients at risk for increased intestinal permeability, which includes those with sepsis, burns, trauma, shock, surgical interventions, renal failure, celiac sprue, or inflammatory bowel disease, appear to be at increased risk of absorbing Blue 1 from tinted enteral feedings.
• In addition to the possibility of systemic toxicity, Blue 1-tinted enteral feedings may interfere with diagnostic stool examinations, such as the hemoccult test.
• Other blue dyes, such as methylene blue and FD&C Blue No. 2, may have similar if not greater toxicity potential than Blue 1 and would not be appropriate replacements.”
The AACN Practice Alert (PA)12 titled “Blue Dye in Enteral Feeding” also provides background information and references as to why blue dye should not be used for detection of aspiration.

“Research and case reports of aspiration have shown that dye in enteral feedings is not visually detectable in situations similar to aspiration pneumonia.2-5 A recent consensus statement on methods for identifying aspiration in critically ill patients recommended that dye be eliminated from enteral feeding since it lacks sensitivity for identifying aspiration of gastric contents.6

• The addition of dye to enteral feeding has been associated with several adverse events, including gastric bacterial colonization and diarrhea, systemic dye absorption, and death.7-10 The FDA recently issued a Public Heath Advisory based on reports of toxicity and death associated with dye in enteral feeding, although a direct causal relationship has not yet been definitively confirmed. 9 The majority of reported cases of toxicity and/or death occurred in patients with sepsis.
• Use of glucose testing of tracheal aspirates,2,11 once proposed as a method for identification of gastric aspiration, is no longer recommended as a viable strategy.”
Why is it important to monitor for aspiration of enteral feedings? The reason is clearly stated in the article from the Distinguished Research Lecture presentation at the AACN National Teaching Institute, May 22, 2006.13 Dr. Norma Metheny summarizes this in the abstract of the article:
“The most dreaded complication of tube feedings is tracheobronchial aspiration of gastric contents. Strong evidence indicates that most critically ill tube-fed patients receiving mechanical ventilation aspirate gastric contents at least once during their early days of tube feeding. Those who aspirate frequently are about 4 times more likely to have pneumonia develop than are those who aspirate infrequently.”
Therefore, since it is a standard to not use FD&C blue #1, FD&C blue #2, methylene blue or glucose testing of tracheal secretions for checking for aspiration of enteral formula, what is the best practice to check for aspiration as well as preventing its occurrence?
These questions are answered in the AACN Practice Alert12 titled “Verification of Feeding Tube Placement,” the “AACN Procedure Manual for Critical Care”14 and the AACN Protocols for Practice, “Care of Mechanically Ventilated Patients.”15 The key points are as follows:
• Always verify proper position of a blindly placed enteral feeding tube by abdominal X-ray upon initial placement and anytime there is a question about proper position.
• Use bedside techniques routinely to ensure the feeding tube remains in the proper position. Helpful techniques are measuring pH and observing the appearance of fluid that is withdrawn from the feeding tube. DO NOT rely on auscultation as it is unreliable in determining proper tube placement.
• Elevate the head of the bed 30-45 degrees, unless contraindicated.
• Monitor gastric residual and tolerance of feeding; every 6 hours initially for continuous feedings.
The Practice Alert defines the appearance of fluids withdrawn from the feeding tube based on location of the feeding tube and notes the pH you would expect to see depending on the location of the feeding tube. For instance, a pH of 6.0 or greater would indicate that the feeding tube was located in the tracheobronchial tree or the pleural space. Thus, checking pH and assessing color of secretions obtained when suctioning patients may be the best indicator we have at this time to evaluate aspiration. Dr. Norma Metheny has done work on using other methods, and a literature search could be performed using CINAHL, which is available to members on the AACN Web site, www.aacn.org.

References:
1. FDA Public Health Advisory, REPORTS OF BLUE DISCOLORATION AND DEATH IN PATIENTS RECEIVING ENTERAL FEEDINGS TINTED WITH THE DYE, FD&C BLUE NO. 1; September 29, 2003.
2. Potts R, Zaroukian M, Guerrero P, Baker C. Comparison of blue dye visualization and glucose oxidase test strip methods for detecting pulmonary aspiration of enteral feedings in intubated adults. Chest. 1993;103:117-121.
3. Thompson-Henry S, Braddock B. The modified Evan’s blue dye procedure fails to detect aspiration in the tracheostomized patients: Five case reports. Dysphagia. 1995;10:172-174.
4. Metheny N, Dahms T, Stewart B, et al. Efficacy of dye-stained enteral formula in detecting pulmonary aspiration in intubated adults. Chest. 2002;122:276-281.
5. McClave S, Lukan J, Stefater J, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Critical Care Medicine. 2005;33(2):324-330.
6. McClave S, DeMeo M, DeLegge M, et al. North American Summit on Aspiration in Critically Ill Patients: Consensus statement. JPEN. 2002;26:S80-85.
7. File T, Tan J, Thomson R, et al. An outbreak of pseudomonas aeruginosa ventilator-associated respiratory infection and the significance of gastric colonization preceding nosocomial pneumonia. Infect Control Hosp Epidemiol. 1995;16:417-418.
8. Maloney J, Halbower A, Fouty R, et al. Systemic absorption of food dye in patients with sepsis (letter). N Engl J Med. 2000;343:1047-1048.
9. Bell R, Fishman S. Eosinophilia from food dye added to enteral feedings (letter). N Engl J Med. 1990;322:1822.
10. Acheson D. FDA Public Health Advisory: Reports of blue discoloration and death in patients receiving enteral feedings tinted with the dye, FD&C Blue No. 1. FDA Web site. Accessed September, 29, 2003, http://www.cfsan.fda.gov/~dms/col-ltr2.html.
11. Metheny N, St.John R, Clouse R. Measurement of glucose in tracheobronchial secretions to detect aspiration of enteral feedings. Heart and Lung. 1998;27:285-292.
12. Practice Alerts are available at www.aacn.org > Clinical Practice> Practice Alerts.
13. Metheny N. Preventing Respiratory Complication of Tube Feeding: Evidence-Based Practice. AJCC 2006;15(4):360-369.
14. AACN Procedure Manual for Critical Care (5th ed). Lynn-McHale Wiegand D, Carlson K (Eds). Elsevier Saunders; 2005: 1142-1149, 1162-1166.
15. AACN Protocols for Practice: Care of Mechanically Ventilated Patients (2nd Ed.). Burns S (Ed) Jones and Bartlett; 2007:193-252.

Nominations Open for 2009 Distinguished Research Lecture Award


Dec. 1, 2007 is the deadline to nominate a colleague for the 2009 AACN Distinguished Research Lecture (DRL) Award. The criteria for the award include: nationally recognized nurse researcher, numerous publications in relation to the specified area of research, presentations in area of research and clinical expertise, and mentoring novice researchers in research relevant to acute and critical care nursing. The recipient is viewed as a consultant in his or her area of expertise and has made significant contributions to acute and critical care research.

The recipient of the 2009 DRL award will present the Distinguished Research Lecture at NTI 2009 in New Orleans and will prepare an abstract and a paper for publication in the American Journal of Critical Care. The recipient receives an honorarium of $1,000 and an additional $1,000 toward NTI expenses. The recipient is also acknowledged on the AACN Web site and in numerous AACN publications. For nomination information, go to www.aacn.org > Research > Awards & Recognition > Distinguished Research Lecture. If you have specific questions, e-mail research@aacn.org.

Half-day Regional CE Programs on Cardiovascular Disease Risk Reduction Scheduled

The Preventive Cardiovascular Nurses Association continues its series of regional programs on cardiovascular disease (CVD) risk reduction. Advanced practice nurses and other clinical nurses specializing in cardiovascular disease management and prevention are invited to attend free of charge.
The three-contact hour continuing education programs examine current guidelines in the prevention and treatment of dyslipidemia, hypertension and diabetes. The practice guidelines, based on national guidelines from the American Heart Association, JNC 7, ATP III and the American Diabetes Association, provide interventions and treatment goals proven to reduce risk in individuals with known or increased risk for CVD. Participants will learn how to use the guidelines in their practice and to improve outcomes for CVD prevention.
Following is the program schedule for the remainder of the year.
Nov. 10, 2007 Cleveland, Ohio and Miami, Fla.
Nov. 17, 2007 Spokane, Wash. and Tampa, Fla.
Dec. 1, 2007 Sacramento, Calif.
Preregistration is required at www.pcna.net/members/chapevent_register/guidelines.

New Continuing Education Programs Available

Two new CE programs, initially presented at NTI 2007, have been added to AACN’s Online Free CE Center. The first, “Hyponatremia: Diagnosis and Management in the Critical Care Setting,” is sponsored by the Academy for Healthcare Education and supported by an educational grant from Astellas Pharma US, Inc. The second, “The Acute and Critical Care Nurses’ Role in Assessing Venous Thromboembolism and Heparin-induced Thrombocytopenia,” is sponsored by the Center for Medical Knowledge and supported by an educational grant from GlaxoSmithKline.
To access the programs, log on to the AACN Web site (www.aacn.org) and click on Continuing Education.

Jan. 1 Is the Deadline to Apply for These AACN Nursing Research Grants

Unless otherwise specified, all research grant proposals must meet the following criteria: 1) Relevant to acute and/or critical care nursing practice, 2) Addresses one or more of AACN’s research priorities, and 3) principal investigator is a current AACN member and remains a member throughout the life of the grant funding.
Jan. 1, 2008 is the deadline to apply for the following research grants.

Small Grants
AACN Clinical Inquiry Grant
Five awards up to $500 each are available for projects that directly benefit patients and/or families. Interdisciplinary projects are especially invited. The principal investigator must be currently employed in a clinical setting and directly involved in patient care.

AACN End-of-Life/Palliative Care Small Projects Grant
One award up to $500 is available for a project that focuses on patients of all ages, patient education, staff development, CQI projects, outcomes evaluation projects or small clinical research studies. A broad range of topics may be addressed including bereavement, communication issues, caregiver needs, symptom management, advance directives and life support withdrawal.

AACN Evidence-Based Clinical Practice Grant
Three awards up to $1,000 each for projects focusing on research utilization studies, CQI projects or outcome evaluation studies. Collaborative projects are encouraged and may involve interdisciplinary teams, multiple nursing units, home health, sub-acute and transitional care, other institutions and community agencies.

Large Grants
AACN Mentorship Grant
One award up to $10,000 to provide research support for a novice researcher, with limited or no research experience, who will act as the principal investigator for the study. The study must be directed by a mentor with strong research experience in the area of proposed investigation. The mentor can be an AACN member; however, it is not a requirement for funding. The mentor may not be a mentor on an AACN Mentorship Grant in two consecutive years.

AACN Critical Care Grant
One award up to $15,000 for a study relative to acute and critical care nursing and focused on one or more of AACN’s research priorities.

To find out more about AACN’s research priorities and research grant opportunities, visit the Research area of the AACN Web site, www.aacn.org > Research > Grants or e-mail research@aacn.org.
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