Introduction: Critical Congenital heart disease (CCHD) can have a significant impact on the gastrointestinal system. Many neonatal and infant cardiac patients struggle to tolerate gastric feeds due to reflux, slow gastric motility, and increased heart failure. After reviewing current hospital protocols and equipment, many limitations were found including 1) nurses were not trained to place transpyloric tubes (TPTs) thus limiting availability of procedure completion, 2) exposure to increased radiation due to placement under fluoroscopy, and 3) the equipment does not currently meet the needs of neonatal and infant cardiac patients. Utilizing an already published technique of placing transpyloric feeding tubes, a Pediatric Cardiothoracic Intensive Care Unit (CTICU) sought to initiate a nurse driven process for placing TPTs at the bedside. 

Methods: Hospitalized neonates and infants with CCHD were included in this study over a 14-month period. The educational protocol included the CTICU nurse manager, who served as the lead person responsible for the training and competency of other nurses. Training included an initial simulation lab and a skills checkoff list was created and utilized during the training. Following that, each nurse had to complete 2 successful TPT placements under supervision before proceeding unsupervised.  Given the low frequency of TPTs needed, to ensure ongoing competency, each nurse had to renew their competency level annually at a simulation lab skills fair.

Results: Three nurses were qualified during this period. Twenty-five patients were included, ages 2 weeks to 18 months, and mean weight 4 kg (2.9-6). All patients received a 6Fr transpyloric feeding tube. All tubes were placed blindly (without fluoroscopy) with a stylet at the bedside in the CTICU and all patients received prokinetic agents 1 hour prior to initiation of the procedure. A post procedure abdominal x-ray was routinely obtained to confirm proper positioning. All of the 25 tubes (100%) were successfully placed past the pylorus and past the first part of the duodenum. Twenty-four (96%) were placed on first attempt and one on the second attempt. Procedure duration was recorded to be less than 4 minutes for all 1st attempts and 9 minutes on the 2nd attempt. 

Conclusion: Following a strict training protocol, a nurse driven process for inserting TPT can be safely implemented. The short procedure duration time ensures timely initiation and escalation of feeds in these critical patients. Additionally, there was no need for any additional medical and potentially expensive equipment and more importantly, there was no need for fluoroscopy; therefore, minimizing radiation. The CTICU now has the ability to place TPTs any day of the week.