EasE of UsE• Self-advancingtechnologyminimiseshands-ontimeforclinicians.

• Requiresnoadditionaldevicesorcostlycapitalequipmenttofacilitateplacement.

• Uniquedesignhelpspreventkinkingandmigrationintothestomach.

Cost-EffECtivE• Eliminatesneedforexpensiveplacementprocedures(i.e.,surgery,fluoroscopy,endoscopy).

• Requiresonlyonex-raytoconfirmfinalplacementinthejejunum.

improvEd NUtritioN admiNistratioN • Bedsideplacementallowsenteralfeedingtobestartedsoonerthanothermethods.

• Small-bowelfeedingresultsinhigherintakeofcaloriesandproteinforquickerachievement ofpatients’nutritionalgoals.1

patiENt safEty• Eliminatesriskstopatientsduringtransporttooperatingroomorradiologyfortubeplacement.

Why You Switched to the Tiger 2™ Self-Advancing Nasal Jejunal Feeding Tube

Why You Switched

Product Features

Product Features

Distance markingsevery10cmfrom40-100cmprovidevisualconfirmationoftubeposition.(Tubeisradiopaquetoenhancex-rayvisualisation.)

14 Fr diameteroptimizesdeliveryofmedicationsandthicker,fiber-containingformulas.

Five large sideports helppreventthetubefromclogging.

Blunt, closed tipisatraumatictointernalstructuresandtissue.

Polyurethane material issoft,pliantand“memoryfree,”whichpreventskinkingandallowstubetotravelsmoothlythroughthegastrointestinaltractwithoutdamaginginternalstructures.

Universal adapterallowsconnectiontoavarietyofenteralfeedingsystems.

Cilia-like flapshelpfeedingtubeself-advance,aidinreducingtheriskofdislodgementandeliminatetheneedtorepositionthepatient.

Indications/Contraindications

Indications:Tiger 2 is intended to provide short-term enteral access for delivery of nutrition and/or medications to the small bowel.

Contraindications:• Oesophagealorgastricvarices

• Internationalnormalisedratio>1.3(attimeofinsertion and/or expected at time of removal)

• Anticoagulatedpatients(anticoagulatedattimeofinsertionand/orexpectedtobeanticoagulatedattimeofremoval)

• Pathologiccoagulopathies

• Historyofbleedingdisorders

• Small-orlarge-bowelobstruction

• Ischemicbowel

• Peritonitis

• Oesophagealstrictureorobstruction

• Gastricobstruction

• Recentnasal,oral,oesophagealorgastricsurgeryortrauma

• Deviatedseptum

• Inabilitytopassthefeedingtubethroughthenares

• Uncooperativepatient

Indications/ Contraindications

Insertion Checklist

The following items may be helpful during the Tiger 2 insertion process. Refertohospitalprotocolforthespecificmixofitemsrecommendedbyyourinstitution.

● Torque cable

● Stethoscope

● Water-soluble lubricant

● Lidocaine gel

● Non-Luerlockirrigationsyringe,60mLorlarger

● Towel

● Gloves

● Sterilewater

● 4 x 4 inch gauze

● Skinprep

● Prokineticagent(asrecommendedbyyourhospital)

● pHpaperinhalfstripsorCO2 detector

● Emesis basin

● HypoallergenictapeorNGstriptosecuretube

Insertion Checklist

Precautions

• Tiger2shouldonlybeusedbyorunderthesupervisionofpersonneltrained in standard gastric tube placement procedure.

• Proceedveryslowlywhenremovingthetubethroughthenoseormouth.

• ThefeedingadapterismanufacturedfromPVC(polyvinylchloride),which containsDEHP. The catheter itself does not contain DEHP.

• Thetubeisnotintendedforusebeyond30days.

• Thetorquecable(suppliedseparately)shouldbeusedonlytofacilitate placement of the Tiger 2 through the nose or mouth and into the stomach. Thetubeshouldbeadvancedonly50-70cmintothestomach.

• DonotinsertthetorquecableintoaTiger2thatisalreadyinsitu.Doingso may cause damage to internal tissues/structures.

Precautions

Instructions for Use (Abbreviated)*

1. Visuallyinspectthetubetocheckforkinks,bendsorbreaks that would inhibit proper working condition.

2.Applylubricanttothedistaltip.

3.Advance50-70cmofthefeedingtubenasallyororallyintothe stomach(dependingonpatient’sanatomicalmeasurements).Use insufflation and auscultation to confirm placement in the stomach.

4.Leavetubeinplaceat50-70cmfor30minutesto1hour.

5.Thereafter,manuallyadvancethetube10cmevery30minutes to1houruntilthe100cmmarkisreached.

6.Atthe100cmmark,takeanabdominalx-raytoconfirmposition in the small intestine.

7. Securethefeedingtubeusinghypoallergenictape.

*RefertotheTiger2IFUforcompleteinstructionsforuse.

Instructions for Use

Important Information

Torque CableAtorquecable(suppliedseparately)willprovideadditionalsupportinsideTiger2foradvancementindifficultcases.Itshouldbeusedonlytofacilitateplacement50-70cm intothestomach.Donotinsertthetorquecableintoatubethatisalreadyinsitu,as doing so may cause damage to internal tissues/structures.

Prokinetic AgentsProkineticagentsmaybeusedtoincreaseperistalsisinaccordancewith institutional protocol.

Placement Time Finalplacementinthesmallintestineusuallyoccurswithin3-4hours;however,itmaytake12-24hoursinthecaseofdecreasedperistalsis.Iffinalplacementisnotachievedwithin24hours,alternativemethodsofprovidingnutritionalsupportmayneedtobeconsidered.

FlushingA.S.P.E.Nrecommendsflushingfeedingtubeswith30mLofwaterevery4hoursduringcontinuousfeedingorbeforeandafterintermittentfeedingsinadultpatients.Sterilewater should be used for immunocompromised or critically ill patients.2Refertoyourhospital protocol for more information on flushing. The inner diameter of the Tiger 2 is3.3mm.RemembertocompareTiger2measurementswithyourexistingfeedingtubein case an adjusted flush volume is warranted.

Removal WhenremovingTiger2,proceedcautiouslyinaslow,controlledmanner.Thetubeismade from a soft and pliant polyurethane material to reduce the likelihood of tissue or structural damage during placement and removal.

Important Information

Tiger 2 Guarantee Program

IfyourTiger2feedingtubekinks,clogs,doesnotadvance,migratesbackintothestomachorispulledoutbythepatientwithin30daysofplacement,CookMedicalwillprovideanewtubefreeofcharge.

ContactyourlocalCookrepresentativeformoreinformation.

Guarantee Program

Appendix 1: A.S.P.E.N. Guidelines for Selection of Feeding Route3

Standard 9: Selection of RouteTherouteselectedtoprovidespecializednutritionsupport(SNS)shallbeappropriatetothepatient’smedicalcondition.

9.1Enteralnutrition(EN)shouldbeusedinpreferencetoparenteralnutrition(PN)tothegreatestextentpossible.

9.2PNshouldbeusedwhenthegastrointestinaltractisnotfunctionalorcannotbeaccessed,orthepatient’s nutrientneedsaregreaterthanthosethatcanbemetthroughthegastrointestinaltract.

9.3TherouteofSNSadministrationshouldbeperiodicallyreassessedforadequacyandappropriateness.

Appendices

Appendix 2: Feeding Anatomy

MouthBreaks down food particles through chewing and release of saliva.

Large IntestineAbsorbssomewater,ionsandvitamins;processes waste material into feces.

PharynxSwallowsfood.

StomachStoresandchurnsfood;secretesenzymesandacidstoaidindigestion;killsmostofthe germs found in food.

Small IntestineCompletesmostofthechemicaldigestion process and is also the location where the majority of nutrient absorption occurs.

PancreasReleasespancreaticjuices,orenzymes,thathelpdigestfoodinthesmallintestine;hormones regulate blood glucose.

LiverProducesbile,whichaidsin digestion;processesand regulates substances entering the bloodstream from digested food.

EsophagusTransports food to the stomach.

Gall BladderStoresandconcentratesbile.

RectumStoresandejectsfeces.

Appendix 3: A.S.P.E.N. Nutrition Support Algorithm4

References

1.HsuCW,SunSF,LinSL,etal.Duodenalversusgastricfeedinginmedicalintensivecareunitpatients: aprospective,randomized,clinicalstudy.Crit Care Med.2009:37(6);1866-1872.

2.BankheadR,BoullataJ,BrantleyS,etal.Enteralnutritionpracticerecommendations.JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.

3.RussellMK,AndrewsMR,BrewerCK,etal.Standardsforspecializednutritionsupport:adulthospitalizedpatients. Nutr Clin Pract. 2002.;17(6):384-391.

4.ReprintedfromJ Parenter Enteral Nutr17(suppl4),A.S.P.E.N.Board:guidelinesfortheuseofparenteralandenteral nutritioninadultandpediatricpatients,7SA,copyright©1993,withpermissionfromSAGEPublications.

©COOK2012 CC-BOUSM-T2IFB-EN-201201