Department of Nutrition and Dietetics, Level 6, Gate 10, Brunel Building, Southmead Hospital Bristol, BS10 5NB, United Kingdom.
Intensive Crit Care Nurs. 2019 Dec;55:102766. doi: 10.1016/j.iccn.2019.102766. Epub 2019 Nov 6.
Determine why Cortrak-guided, undetected tube misplacement may occur in relation to the system of trace interpretation used.
From 2010 to 2017 we obtained seven of the eight Cortrak traces from the United Kingdom where misplacement was undetected and the patient received feed. Seven suffered serious harm. Each misplacement was interpreted by three systems: screen position, manufacturer guidance and gastrointestinal (GI) flexures.
National and local records.
Ability to identify misplacement.
Traces that were later identified as misplacements, could not be differentiated from GI position when they wholly or partially: a) overlapped with the GI screen area plotted from historical records (57-71%) or b) met both manufacturer guidance criteria or were confused with receiver misplacement or unusual anatomy and reached the lower left quadrant (14-71%). Conversely, all lung misplacements were identified as unsafe using the GI flexure system. All three systems failed to detect the intra-peritoneal trace. Traces were inconsistently stored by healthcare centres.
Trace file storage should be mandated by and accessible to relevant health authorisation bodies to improve safety research. Screen position alone and manufacturer guidance fail to consistently differentiate the shape of safe from unsafe traces. GI flexure interpretation appears safer but requires testing in larger studies.
确定为什么在使用跟踪解释系统时，Cortrak 引导的未检测到的管错位会发生。
在 2010 年至 2017 年期间，我们从英国获得了七个 Cortrak 轨迹中的八个，其中七个轨迹未被检测到且患者接受了喂养。七个轨迹都遭受了严重的伤害。每个管错位都由三个系统进行解释：屏幕位置、制造商指南和胃肠道（GI）弯曲。
国家和地方记录。
识别错位的能力。
后来被确定为错位的轨迹，当它们全部或部分：a）与从历史记录中绘制的 GI 屏幕区域重叠（57-71%）或 b）符合制造商指南标准或与接收器错位或异常解剖混淆并到达左下象限（14-71%）时，无法与 GI 位置区分开来。相反，所有肺部错位都可以使用 GI 弯曲系统识别为不安全。所有三个系统都未能检测到腹腔内轨迹。医疗中心的轨迹存储不一致。
应通过相关卫生授权机构授权并提供轨迹文件存储，以提高安全性研究。单独的屏幕位置和制造商指南无法始终区分安全和不安全轨迹的形状。GI 弯曲解释似乎更安全，但需要在更大的研究中进行测试。
