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CORTRAK 2 Revalidation

6421A 8-15

Content• Positioning and setting up the Monitor Unit

• Preparing the patient

• Positioning the Smart Receiver Unit (SRU)

• Inserting the Transmitting Stylet

• Re-insertion of the Transmitting Stylet

• Troubleshooting tips

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Positioning And Setting Up The Monitor Unit• Position the Monitor Unit ensuring that you have an easy view of the

screen at all times and that the Monitor Unit is at least 60cm from the Smart Receiver Unit.

• Turn the CORTRAK 2 Monitor Unit on by holding down the ON/OFF button and log-in to your operator account using the touch screen. This will be a test account: your own log in and password will be set up when you are ready to perform your first clinical placement.

• Follow the screen menu to open the placement history or perform a new placement.

• If you are performing a new placement, you will need to enter your patient’s first and last name, hospital identification number and press NEXT.

• The placement screen will then present you with two real time displays – an anterior display and a depth cross-sectional display (Figure 1).

• During the placement procedure, the operator is presented with real-time 3-dimensional views of the Transmitting Stylet tip location and deployment path. The system provides a means for the operator to toggle both the major and minor displays such that a combination of the Anterior View and either Depth Cross-Section or Lateral View display simultaneously, thereby providing a complete presentation of the procedural data in all 3 dimensions.

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Preparing The PatientIf the patient can communicate, it is important to agree upon a ‘stop signal’ that they can give if they wish to pause or stop the procedure, should they feel any discomfort or pain.

• This need only be a simple action, such as raising their hand. It can also help to calm the patient because they gain some control over the procedure

• Explain the equipment and procedure to the patient; you may want to give them a copy of the CORTRAK 2 Patient Information Booklet prior to the procedure if appropriate

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Preparing The PatientPatient positionAssist the patient into a semi-upright position in the bed or chair. Support the patients’ head with pillows so that it is not tilted backwards or forwards.

Insertion procedureOnce you have prepared the equipment and the patient, NG feeding tube insertion can begin.

Preparing the Transmitting Stylet• Ensure that the Transmitting Stylet is seated firmly in the tube and the ports are closed

• Connect the Transmitting Stylet connector to the Monitor Unit and to the Interconnect cable (attached to the Monitor Unit)

• Check that the CORTRAK 2 Monitor Unit is close enough to the patient so that the length of the Transmitting Stylet will allow for full tube placement, but at least 60cm or more away from the Smart Receiver Unit (SRU) when positioned on the patient.

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Positioning The ReceiverWhen using CORTRAK 2 system it is very important to observe the position of the SRU on the patient

• The SRU picks up the signal transmitted from the Transmitting Stylet tip and displays the relative tip locator on the CORTRAK 2 Monitor Unit

• The underside of the SRU has three feet

– The front foot of the Smart Receiver Unit sits on the patients Xiphoid process, the anatomical landmark for the oesophageal/gastric junction

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Positioning The Receiver• The SRU does not need to make contact with the patient’s skin and has a range of

approximately 30cm

• It is important that the SRU be reasonably level and centred along the mid-sagittal line of the patient in order to accurately represent the feeding tube tip path during placement

– If needed you may use the levelling device (a wedge-like device) included with the CORTRAK 2 to make the SRU level, or use the SRU stabiliser (a weighted belt that sits across the Smart Receiver Unit) to help hold the SRU in place

– When the SRU is connected to the Monitor, the system will automatically perform a self test verifying the integrity of the SRU. An indicator light located on the SRU button displays the results of this self test. If the SRU is not connected or a fault is detected in the SRU, the operator will be notified by an error message on the screen and the indicator light of the SRU will illuminate red

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Positioning The Receiver

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TOP TIP: It is essential that the SRU is placed correctly at the Xiphoid process and does not move during placement

TOP TIP: Movement of the SRU during placement will cause the displayed image to the Transmitting Stylet tip position to change.

The following instructions will guide you through the insertion procedure for CORTRAK 2 NG tubes

1 Determine if the patient’s preferred nostril for insertion. Ask the patient to sniff with one nostril closed, and then repeat with the other nostril if possible. This will help to identify any obstructions that could prevent or make intubation more difficult

2 Dip the tube in water to activate the lubricant on the outside of the tube

3 Insert the tube into the selected nostril. Aim the tip parallel to the nasal septum and superior surface of the hard palate and allow the tube to seek its own passage towards the nasopharynx following the natural anatomy of the nose. Ask the patient to start swallowing and sipping water unless contraindicated. If nil by mouth, dry swallowing may also assist with the passage of the tube

4 Continue to insert the feeding tube for 5-10cm before activating the SRU. To activate press the button on the SRU or press START on the CORTRAK 2 monitor screen This will bring the Transmitting Stylet into range of the SRU and produce a representation of the Transmitting Stylet’s location on the screen. Indicated by a green dot (Figures 1 and 2)

The CORTRAK 2 NG tip is more than 30 cm away from the foot of the SRU, continue to slowly advance the tube until the green dot appears on the screen

Figure 1: Energizing the Transmitting Stylet

Energizing Transmitting Stylet message

Figure 2: Transmitting

Stylet out of range

Out of range message

TOP TIP: If display shows the tube coming in from the side and moving up before coming down near the midline, this may indicate the patient’s head being forward or turned to the side (it is safe to continue if no resistance)

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Nasogastric tube placement

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5 Advance the tube down the oesophagus. The display will show a representation of the relative position of the Transmitting Stylet tip and the path it has taken (Figure 1). Note that the yellow line is a history of where the tip of the tube has been

Figure 1: Progression of the feeding tube down the oesophagus

TOP TIP: Each increment on the display represents approximately 5 cm

6 Ensure the tube does not enter the right bronchus (Figure 2(a) or the left bronchus (Figure 2(b). If this occurs, retract the tube until the tip is above the origin of the oesophagus and adjust the placement until a straight line is shown along the vertical axis (assuming typical anatomy). The CORTRAK 2 system erases the tracing when retracting the feeding tube.

Figure 2. Misplacement of the feeding tube into a) the right bronchus b) the left bronchus

Inserting The Transmitting Stylet

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7 Continue to advance the feeding tube down the oesophagus until it reaches the stomach. When the SRU is properly positioned at the Xiphoid process, the horizontal axis of the anterior view represents the base of the diaphragm in patients with normal anatomy (Figure 1)

Figure 1. Stomach placement starts with a left-sided deviation just above the central horizontal line

TOP TIP: Use the increment markings on the display to check the progress of the trace to make sure it is heading in the right direction

8 For a correct NG placement, the trace journey will progress straight down the vertical with no deviations above the horizontal midline, the green dot and yellow trace should be in the bottom left quadrant (Figure 2)

Figure 2. Endpoint for NG placement

TOP TIP: Always ask yourself, are both the journey AND the final position correct?

TOP TIP: The left quadrant of the screen is displayed as seen from the patient’s perspective. So, the bottom left quadrant will be on your right.

Inserting The Transmitting Stylet

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9 To end the placement, press END on the monitor screen or press the SRU button. The green dot will turn red to show that the placement has ended and has been saved on the CORTRAK 2 system

10 Confirm tube position per institution protocol (i.e. CORTRAK 2 placement image, X-ray and or pH etc.)

11 Secure the tube at the patient’s nose with the Coverlet dressing (provided) or the CORGRIP retention device.

12 Flush the tube through the side port with 10 ml of water, to activate the internal lubricant allowing easy removal of the Transmitting Stylet

13 Remove the Transmitting Stylet (do not discard) and close the access ports of the feeding tube

14 Disconnect the Transmitting Stylet from the interconnect cable (ensure the interconnect cable remains attached to the CORTRAK 2 Monitor Unit)

15 Log out of the CORTRAK 2 system

16 If desired, rinse the Transmitting Stylet in warm water or 70% isopropryl alcohol and retain it in the storage bag provided, or similar aerated container and label with the patient’s ID sticker for later use.

17 Record centimetre marking at patient’s nostril in the patient’s notes.

18 Press print on the CORTRAK 2 screen and place the printed image in the patient’s notes. The placement will automatically be saved and can be uploaded onto a USB device for viewing on a PC with the CORVIEW software.

TOP TIP: To get the most accurate result always make sure that the SRU is in the correct position and does not move during the placement procedure

Inserting The Stylet

• Feeding tubes that have been initially inserted correctly can move out of the desired location at a later stage. It is important to check the placement of the tube each time feeding is initiated or the tube is accessed for medication administration or flushing. This can be achieved by re-inserting the Transmitting Stylet into the feeding tube. In addition to checking the centimetre markings printed on the feeding tube as noted in the placement procedure section.

Patient Safety:• Before re-passing the Transmitting Stylet, it is important to check the integrity of the

Transmitting Stylet and that it is still functional. Never use a Transmitting Stylet other than the one originally provided with the patient’s feeding tube.

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TOP TIP: The Transmitting Stylet must be handled with care at all times and discarded if the transmitting wire is broken. Wear gloves to check the Transmitting Stylet as handling the

Transmitting Stylet with your bare hands may interfere with the transmission.

Re-Insertion of the Transmitting Stylet

1. Set up the CORTRAK 2 Monitor Unit and SRU, as per the initial insertion protocol

2. Connect the feeding tube Transmitting Stylet to the CORTRAK 2 interconnect cable. Check the integrity of the Transmitting Stylet with gloved hands

3. Lubricate the original Transmitting Stylet with water-soluble lubricant

4. Pinch the tube at the patient’s nostril, insert and advance the Transmitting Stylet until the tip can be felt at the nostril.

5. Press START either on the CORTRAK 2 monitor or the SRU

6. Slowly advance the Transmitting Stylet into the feeding tube, watching the CORTRAK 2 display for indication of tube position. If lung placement is suspected, immediately withdraw the feeding tube AND Transmitting Stylet as one and reinsert as above.

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TOP TIP: Advance the Transmitting Stylet slowly, if there is any resistance,

stop the procedure and remove the feeding tube and the Transmitting Stylet as one

Re-Insertion of the Transmitting Stylet

Stylet Reinsertion7. If no indication of lung placement is noted, continue to advance the Transmitting Stylet

until it reaches the straight arm port of the feeding tube. You may need to advance or retract the tube to achieve the correct positioning

8. Confirm correct placement as described above. For a correct NG placement in patients with typical anatomy, the track should end in the bottom left quadrant with the journey trace above the horizontal midline showing no deviation.

9. End the placement on the CORTRAK 2 screen or SRU if you are happy with the journey and the end position on the CORTRAK 2 screen

10. Print the CORTRAK 2 image and place it in the patient’s notes

11. Rinse the Transmitting Stylet in warm water or 70% isopropyl alcohol and retain in the storage bag provided, or a similar aerated container and label with patient ID.

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Troubleshooting TipsRecognising any technical problems that may occur during NG insertion with the CORTRAK 2 system will help you to take appropriate action. Some of the most common problems encountered are listed here:

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Out of range If an out of range notice appears on the CORTRAK 2 screen, this indicates the Transmitting Stylet tip is working, but is out of range of the SRU (approximately 30cm)

Stylet failure The CORTRAK 2 system will detect most failures of the Transmitting Stylet and display a ‘Transmission not Detected’ notification to indicate a fault with the Transmitting Stylet. To address this problem reconnect and/or reactivate the Transmitting Stylet. If this fails, the Transmitting Stylet may need to be replaced.

Smart Receiver Unit failure

The ‘Smart Receiver Unit Not Found’ notification indicates a fault in the connection between the Monitor Unit and the Smart Receiver Unit. If this occurs, check the connection and try again or end the placement and confirm the tube in accordance with alterative institution policy. This notification may indicate a fault within the SRU which may need to be replaced.

Monitor Unit error during placement

If a Monitor Unit error occurs during a procedure, the CORTRAK 2 Monitor Unit will report this to you with an on screen message. It will then commence a protective automatic shutdown, to avoid any potentially harmful situations.

Erroneous screen images

If you see that the track of the tube has emerged from the side of the screen and moves towards the centre, this may indicate that the receiver is detecting external interference. This may be caused by other equipment in the vicinity an implanted medical device or possibly that the Monitor Unit is too close to the receiver, so ensure that there is at least a 60cm gap between the device and the unit. If tracing is not providing meaningful information or the pathway is not as expected, discontinue use and place feeding tube via alternate local protocol.