Ch 12: Enteral Access Devices Flashcards
Factors in determining the most appropriate enteral access device
- Underlying disease
- Gastric and small bowel function
- Short- and long-term goals
- Anticipated length of therapy
- Risk factors related to the method of tube placement
- Ethical considerations
Should involve the patient and/or family in decision-making process
Main factors in determining nasal tube vs. percutaneous enterostomy:
- Estimated duration of EN therapy
- Desire for an enteral feeding trial to assess for TF tolerance before an invasive procedure
Duration for short term feeding tubes
<4-6 weeks
Duration for long term feeding tubes
> 4-6 weeks
Short term (<4-6 weeks) recommend what type of tube(s)? How are they placed?
- NG/OG tubes placed at bedside
- Placement may be done blindly, with the aid of an electromagnetic tracking device (CORPAK), endoscopically, or fluoroscopically in interventional radiology
Long term (>4-6 weeks) recommend what type of tube(s)? How are they placed?
Recommend percutaneous enterostomy tubes placed in the stomach or small bowel using endoscopic, fluoroscopic, laparoscopic, and open laparotomy techniques
What needs to be considered prior to placement of long term feeding tubes?
Must assess:
* Condition of the external abdominal wall
* Ability to correct coagulopathies
* Patient tolerance to anesthesia
What should also be evaluated (re: abdomen) prior to long term feeding tube placement?
- Previous surgical scars in the abdominal wall
- Existing surgical wounds and fistulas
- The presence of or future requirements for ostomies
- Percutaneous or intra-abdominal infusion devices
- Ascites
- PD catheters
All must be part of the decision making process
The decision to place a feeding tube is based on:
- gastric motility
- gastric aspiration risk
- alterations in GI anatomy (i.e. postsurgical)
- coexisting medical conditions
Gastric feeding
Reserved for pts with normal gastric emptying and a low risk of gastric aspiration
* Now seen as a first line approach in the ICU setting
Small bowel feeding:
Preferred for pts in the presence of gastric outlet obstruction, gastroparesis, severely increased risk of aspiration, and pancreatitis
Gastrojejunal tubes:
Allow for simultaneous gastric decompression and small bowel feedings
* May be indicated for gastric outlet obstruction, severe GERD, gastroparesis, and early post-op feeding
Why is it encouraged, whenever possible, to feed into the stomach?
- This is the most physiologically normal for the body
- Ensures adequate mixing of nutrients with gastric acid
- Allows flexibility of schedules
- Safest regarding formula contamination 2/2 to no formula hang time
- Allows for blenderized diets
- Most cost-effective
physical characteristics
Key criteria for choosing a brand of feeding tube:
patient comfort and tube performance
physical characteristics
Most NG/NI tubes are made of
Polyurethane
It allows for a relatively larger inner tube diameter for a given outer diameter size
physical characteristics
Most percutaneous tubes are made of
Silicone
Because of its material longevity and comfort
physical characteristics
Why are rubber tubes (used in foley catheters and red rubber surgical jejunostomy tubes) inferior?
Because they degrade rapidly and lack internal (red rubber) or external (Foley catheter) retaining devices
All tube sizes are based on
the external diameter measurement
Flow and susceptibility to clogging depend on
the inner diameter
What is the difference between polyurethane and silicone tubes re: diameter and clogging?
In general, polyurethane tubes with the same outer diameter as a silicone tube will have a larger internal diameter that may be less likely to clog
Stylets or guidewires are provided with nasal tubes to
provide structure as they are relatively floppy (and are removed after tube is placed)
Stylets/guidewires are designed to have _ _ _ to avoid perforation of the GI wall
a flexible distal tip
To prevent clogging in Y-configuration nasoenteric feeding tubes, medications should be
administered through the tube after feedings are held and the feeding tube is flushed with water
Difference between weighted and unweighted tube tubes
There is not a clear advantage to the use of weighted or unweighted feeding tube tips
* Weighted thought to facilitate transpyloric passage
Percutaneous enterostomy feedings tubes
Internal retention bolsters are constructed of either
solid material (silicone or polyurethane) or silicone balloons
Solid internal bolsters are more common with
initial placement because they have greater longevity
Balloon-type internal bolsters are inserted more commonly with
Radiologic and surgical tube placement
* Are used as replacement devices in the office setting because of their ease of placement
General facts:
Balloon type internal bolsters
- If placed in the small bowel, balloon is filled with 3-4 mL so it will not obstruct the lumen
- Life span of 4-6 months
- If possible, do not use balloons for direct jejunal placement to avoid occluding the narrower jejunal lumen
- If the internal bolster of a PEG tube is a balloon, an additional 3rd port is present for balloon inflation/deflation
Low profile tube are
Skin-level devices used as initial placement, or for replacement devices for G-tubes, GJ-tubes, J-tubes
Why would low profile tubes be preferred?
Excellent choice for patient concerned about cosmetic appearance of feeding tube
* May be more comfortable in active patients, use in intermittent therapy, or those who sleep prone
* Will require manual dexterity or caregiver assistance
Nasoenteric feeding tube placement is contraindicated if the pt has
- An obstructing head, neck, and esophageal pathology
- Injury that prevents safe insertion
What is the gold standard for confirmation of tube placement?
Plain abdominal or chest radiography
Recent studies suggest radiologic confirmation…
…may not be required when electromagnetic imaging technology is used by an experienced tube team
Other methods to confirm tube placement include:
Auscultation, pH set up, and capnography
are unreliable and still require radiologic confirmation
Which type of feeding tube is the easiest to insert?
NG tubes
Try to convert larger, stiffer tubes to
small-bore feeding tubes (6-12 Fr)
The most reliable method for measuring the length of the tube necessary for gastric placement is
“NEMU” (direct distance from nose to earlobe to mid-umbilicus)
* Many clinicians still use “NEX” (nose, earlobe, xiphoid)
Nasoenteric tubes can be placed at
Bedside, endoscopically, or fluoroscopically
* Prokinetics (erythromycin, metoclopramide) are often added to bedside techniques and may increase success rates
* IV erythromycin (200-500mg) had the highest success rates
Percutaneous Enterostomy Tubes can be placed by
endoscopic, fluoroscopic, or surgical methods
Compared to surgical methods, endoscopic or fluoroscopic techniques to place a Percutaneous Enterostomy Tube is associated with:
Less morbidity and cost
Routine pre-procedural testing of coags and platelets is
No longer recommended for pts undergoing enterostomy tube placement
* These tests should be considered if there is concern for abnormal coagulation due to anticoagulation medication, hx of excessive bleeding, or recent antibiotic use
The American Society of Gastrointestinal Endoscopy guidelines consider PEG tube placement
a high bleeding risk procedure
Meds and hold times prior to PEG placement:
Thienopyridines (antiplatelet meds; ex: clopidogrel) should be held for
5-7 days before PEG placement
Meds and hold times prior to PEG placement:
Aspirin regimens should be continued in pts with
high thromboembolic risk
Meds and hold times prior to PEG placement:
Warfarin should be held
5 days before PEG placement
High-risk patients should be bridged with short acting heparin
Meds and hold times prior to PEG placement:
New, direct-acting PO anticoagulants should be held for at least _ _ _ prior to high-risk procedures and restarted up to _ _ _ after procedure
48 hours prior to high-risk procedures and restarted up to 48 hours after procedure
Contraindications for endoscopic placement of PEG tube include:
- Obstruction of the GI tract proximal to the stomach
- Inability to transilluminate the abdominal wall for identification of a safe abdominal access site
- Ascites
- Coagulopathy
- Gastric varices
- Active head and neck cancers
- Morbid obesity
- Neoplastic, infiltrative, or inflammatory disease of the gastric or abdominal wall
Most common method of PEG insertion is the
Ponsky (pull) technique
Laparoscopic or open laparoscopic procedure is done in the
OR under general anesthesia
G-tube is held in place by a
solid, mushroom-type internal retention device and external bumper
Advantages of a PEG placement:
- Performance at bedside
- Lack of radiation
- Ability to perform diagnostic and therapeutic endoscopic procedures simultaneously
Advantages of a fluoroscopic g-tube placement includes:
- Lack of need for conscious sedation in some patients
- Ability to perform in patients with severe stenosis/trauma of the UGI tract
- Potentially decreased risk of tumor seeding from upper aerodigestive tract cancers
What technique is most commonly used for surgical placement of an open G-tube?
The Stamm technique
When should G-J tubes be considered?
- Used for impaired gastric motility
- Pancreatitis or pancreatic surgery
- Anytime enteral feeds into the small bowel with simultaneous gastric decompression is required
What are the advantages/disadvantages of G-J tubes?
- Advantage: the patient benefits from gastric decompression while receiving enteral feeds into the SB
- Disadvantage: risk of jejunal tube migrating back to the stomach on a regular basis
Surgical J-tubes more common because
endoscopic and radiologic methods are complex
Endoscopic J-tubes are more stable than fluoroscopic tubes because
The endoscopic tubes have a solid, mushroom-type internal bolster and larger tube diameter (18-20 Fr vs 10-14 Fr)
Enterostomy tubes can be replaced or removed after the stoma tract has matured
- 1-2 weeks after initial placement
- Clinicians prefer to wait 4-6 weeks
Longer waiting time period for removal is beneficial for the
- immunosuppressed
- pts on steroids
- obese
- or when poor wound healing is suspected
Removal before maturation may result in
The stomach or small bowel falling away from the abdominal wall, allowing bowel contents to leak into the peritoneum
How are tubes with a solid internal bolster vs balloon bolster removed?
- Tubes with a solid internal bolster are forcefully pulled out and may be painful (mild sedation may be required)
- Tubes with an inflated balloon are deflated and the tube is gently removed (no sedation required)
Replacement tubes are held in place with
An inflated internal balloon or a solid silicone internal retention bolster
* Generally 5-20ml sterile water inflates a gastric balloon and 3-4 ml for a small bowel tube
If there is any concern for misplacement, the tube position should be assessed with
fluoroscopic or endoscopic imaging
If pt develops abd pain after percutaneous feeding tube replacement, the concern is that:
the tube was potentially placed within the stoma tract instead of into gastric lumen, or perforated into the peritoneal space
If more significant disruption of the tract occurs and a new tube can’t be placed at existing site, the pt can be supported through NI feeds while stoma tract closes and infection is treated.
Necrotizing fasciitis has been reported in severe cases of untreated, uncontrolled infection.
Oral hygiene important for preventing
aspiration pneumonia in vent dependent pts or those with a depressed level of consciousness
Patients with nasal tubes benefit from skincare to nasal area to address
- Prolonged exposure to tape and adhesives
- Repositioning the nasal tube and avoiding pressure to the nares is important to prevent pressure necrosis
How should you clean the stoma site for percutaneous tubes?
Use mild soap and water
Routine use or antibiotic cream or hydrogen peroxide at the tube site is
not recommended
Dressings can be applied if there is drainage from the stoma site, however they should not be
placed with excessive tension which can promote infection and buried bumper syndrome
Causes of clogs:
- Suboptimal flushing
- Not flushing prior to and after each medication administration
- Accumulation of pill fragments
- Frequent checking of GRV’s
- High protein or fiber formulas
Liquid vs crushed meds & feeding tubes
Liquid meds may be costlier, but crushed pills are more likely to clog a small-bore feeding tube
Confirmation of NG tube placement:
Radiography is gold standard for ensuring correct placement and should be performed prior to feeding tube use
Post-procedural complications s/p NG tube insertion:
- Inadvertent tube dislodgement, tube malfunction, sinusitis, tube occlusion, TF aspiration, intestinal ischemia
- Dislodgment occurs in 25-41% of cases
- Nasal bridle decreases tube dislodgement dramatically
What should you do when a feeding tube becomes clogged?
- When feeding tube becomes clogged, simple flushing with water can relieve obstruction in 1/3 of patients
- If water flushes fail, pancreatic enzymes can reopen 50% of the occluded tubes
Buried Bumper Syndrome
Results from the growth of the gastric mucosa over the internal bumper
Risk factors for buried bumper syndrome:
- Excessive tension between the internal and external bumpers
- Poor wound healing
- Significant weight gain
If peritonitis is suspected:
Infuse water-soluble contrast with fluoroscopic or computed tomography imaging
What is the most common complication of G-tube placement
Peristomal infection
Gastrojejunal and Jejunal Tubes + aspiration risk
- No clear evidence that jejunal tubes markedly decrease risk of aspiration however recent data and meta-analysis suggest jejunal feeding may be associated with decreased risk of aspiration pneumonia
- ASPEN recommends feeding into the stomach as a first choice
