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CNSC Exam 2021 > Chapter 12: Enteral Access Devices > Flashcards

Chapter 12: Enteral Access Devices Flashcards

1
Q

Gastric feeding

A

Generally reserved for patients with normal gastric emptying and low risk of gastric aspiration

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2
Q

Small bowel feeding

A

Preferred in the presence of gastric outlet obstruction, gastroparesis, severely increased risk of aspiration, and pancreatitis

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3
Q

Gastrojejunal tube systems

A

Allow for simultaneous gastric decompression, and small bowel feedings. May be indicated for gastric outlet obstruction, severe GERD, gastroparesis, and early (postoperative) feeding

The use of small bowel feeding to reduce the risk of aspiration PNA is controversial, although recent data and meta-analysis suggest this feeding approach may be of benefit.

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4
Q

(T/F) Most NG or nasoenteric tubes are constructed of polyurethane.

A

TRUE

It allows for a relatively larger inner tube diameter for a given outer diameter size

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5
Q

(T/F) Most PEG tubes are constructed out of silicone.

A

TRUE

Silicone has inherent material longevity and comfort.

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6
Q

(T/F) You can use Foley catheters or red rubber catheters for enteral feeding.

A

FALSE

That is no longer possible due to the 2017 mandate to have ENfit connectors

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7
Q

(T/F) All feeding tubes sizes are reported by the tube’s internal diameter measurement.

A

FALSE

Measured by the EXTERNAL diameter measurement.

Flow through the tubes and susceptibility to clogging depends on the tube’s inner diameter. The inner diameter may vary depending on the specific material used to construct the tube.

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8
Q

What is generally true about the diameter size with polyurethane and silicone tubes?

A

Polyurethane tubes with the same outer diameter as a silicone tube will have a larger internal diameter that may be less likely to clog.

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9
Q

What are stylets or guidewires?

A

They are provided with most nasoenteric feeding tubes to provide tube structure and/or guidance while passing these relatively floppy tubes.

Designed to be shorter than the length of the tube and to have a flexible distal tip to avoid perforation of the GI wall.

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10
Q

When are water-activated lubricants used?

A

Used to coat the tube’s internal lumen to allow easier removal of the stylets or guidewires after the feeding tube is in place.

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11
Q

What is the difference between a 1-port and a Y-port?

A

1 port for feeding

Y-port has one port for feeding and the other for medication and/or irrigation.

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12
Q

(T/F) Dual ports allow for concomitant feeding and medication administration and/or irrigation.

A

TRUE

However, to prevent clogging, medications should be administered through the tube only after the TFs are HELD and the feeding tube is flushed with water.

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13
Q

What is the Global Enteral Device Supplier Association?

A

A non-profit trade association formed to introduce the new international standards for enteral feeding connectors that are designed to increase patient safety and optimal delivery of EN by reducing the risk of tubing misconnections. ENfit connectors.

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14
Q

(T/F) Weighted tube tips facilitate the transpyloric passage when placing a feeding tube.

A

FALSE

Research does not demonstrate a clear advantage with the use of either weighted or unweighted tips.

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15
Q

When and why are solid internal bolsters used?

A

More common in initial percutaneous enterostomy tube placement

Have greater longevity

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16
Q

When and why are balloon-type internal bolsters used?

A

Inserted more commonly with radiologic and surgical tube placement; used as replacement devices in office settings because of their ease in placement.

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17
Q

How much volume will a balloon-type internal bolster be filled with, if placed in the small bowel? And why?

A

Not typically more than 3-4 mL, so it will not obstruct the lumen.

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18
Q

How long do balloon-type internal bolsters last?

A

4 - 6 months.

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19
Q

What bolster type (balloon-type or solid) is preferred for a direct jejunal tube placement? And why?

A

Non-balloon-type is preferred; to avoid occluding the narrower jejunal lumen.

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20
Q

What is a solid internal bolster constrained with a dissolvable capsule? When is it used? What is the benefit?

A

It is placed in the same manner as a balloon-type; used for laparoscopic initial gastric or direct jejunal tube placement, and as replacements.

The benefit is that it combines the longevity of a solid internal bolster with the ease of placement of a balloon-type bolster

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21
Q

(T/F) Internal balloon-type bolsters have 3 ports.

A

TRUE.

1 for feeding; medications/irrigation; balloon inflation/deflation

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22
Q

What is the gold standard for confirmation of feeding tube placement?

A

Plain abdominal or chest radiography

23
Q

(T/F) Feeding tubes should not be used for feeding until confirmation of proper position.

A

TRUE

24
Q

What are added to bedside techniques and may increase success rates of feeding tube placement?

A

Prokinetics (erythromycin or metoclopramide).

IV Erythromycin (in doses of 200-500 mg) had the highest success rate.

25
Q

What are two devices that have been developed to assist with nasoenteric tube placements?

A

Bedside magnet, and electromagnetic imaging system (success rates have been documented as greater than 90%).

26
Q

What is the reported bedside success rate for nasoenteric tubes? What is the success rate for endoscopic and fluoroscopic placement?

A

56 - 92% for bedside

Greater than 90% for endo- and fluoro-

27
Q

(T/F) The American Society of Gastrointestinal Endoscopy guidelines consider placement of a percutaneous feeding tube to be a high-bleeding-risk procedure.

A

TRUE

Routine pre-procedural testing of coagulation parameters and platelets is no longer recommended for patients undergoing enterostomy tube placement. But these should be considered if there is a concern.

28
Q

How long should:

  • Thienopyridines
  • Warfarin
  • Aspirin

be held for, in relation to a PEG placement? If these cannot be held, what is recommended?

A
  1. Thienopyridines: should be held for 5-7 days BEFORE
    - If holding is not possible: Sometimes EPINEPHRINE will be added to the lidocaine for local anesthesia, and clinicians will make sure the bolsters are firm (not tight) for 3-4 before loosening them.
    1. Warfarin: should be held 5 days BEFORE; High-risk patients should be bridged with short-acting heparin and the new direct-acting oral anticoagulants should be held for at least 48 hours BEFORE the procedure, and restarted up to 48 hours AFTERWARDS.
    2. Aspirin regimens should be continued in patients with high thromboembolic risk.
29
Q

What medication is administered when enterostomy tubes are placed?

A

Prophylactic antibiotics; are shown to decrease peristomal infection rates when using endoscopic methods for initial placement

30
Q

Explain the Ponsky pull technique for PEG placement.

A

Most common; Endoscopy is fed through the mouth into the stomach. The placement for the feeding tube is determined through simultaneous endoscopic transillumination of the abdominal wall. A small incision is made at that site and a needle is inserted into the stomach. A guidewire is inserted within the needle and caught on the endoscopy snare. The guidewire is fed up to exit the mouth. The feeding tube is attached to the guidewire, then pulled from the placement site down into the mouth, esophagus, into the stomach and through the abdominal wall, until it is in place. The internal bolster holds it in place, and an external bolster is placed on the outside.

31
Q

What are the advantages of a PEG placement?

A
  • Performance at bedside
  • Lack of radiation
  • Ability to perform diagnostic and therapeutic endoscopic procedures simultaneously.
32
Q

What are the contraindications for endoscopic PEG placement?

A

Specific:

  • Obstruction of GI tract proximal to the stomach
  • Inability to transilluminate the abdominal wall for ID of safe abdominal access

Relative:

  • Ascites
  • Coagulopathy
  • Gastric varices
  • Active head and neck cancers
  • Morbid obesity
  • Neoplastic, infiltrative, or inflammatory disease of the gastric or abdominal wall
33
Q

What are the advantages of fluoroscopic gastrostomy placement?

A
  • Lack of need for conscious sedation in some patients
  • Ability to perform in patients with severe stenosis/trauma of the upper GI tract
  • Potentially decreased risk of tumor seeding from upper aerodigestive tract cancers
34
Q

When is surgical placement of feeding tubes used? (3)

A

AKA Laparoscopic or open (laparotomy) method: is performed in the operating room under general anesthesia.

  • When patients are undergoing another abdominal operation
  • When endoscopic and radiologic attempts fail
  • And/or in the presence of an aerodigestive tract obstruction or facial trauma
35
Q

What is the Stamm technique?

A

the most commonly used surgical placement of an open G-tube

36
Q

In what situations is a percutaneous endoscopic gastrojejunostomy (PEJ) indicated?

A
  • Impaired gastric motility
  • Pancreatitis
  • s/p pancreatic surgery
  • Anytime enteral feeding into the small bowel with simultaneous stomach decompression is required.
37
Q

Explain how a PEG-J is placed.

A

Most commonly, a guidewire is placed through the existing gastrostomy, grasped endoscopically and carried into the jejunum. The endoscope is then withdrawn, leaving the guidewire in place. The jejunal extension tube is threaded over the guidewire into the small bowel.

Some methods include use of reclosable clips.

38
Q

When is fluoroscopic feeding tube placement appropriate?

A

When endoscopy cannot be performed!

39
Q

How is a direct jejunostomy tube placed?

A

Various fluoroscopic ways

40
Q

How is direct percutaneous jejunostomy placed?

A

Either endoscopic or fluoroscopic guidance; more difficult than placing a percutaneous gastrostomy.

41
Q

When can enterostomy tubes be safely removed or replaced?

A

After the stoma tract has matured. Maturation occurs 1-2 weeks after initial placement, but clinicians prefer to wait 4-6 weeks prior to removal to ensure it is mature.

42
Q

What could happen if an enterostomy is removed before the stoma tract is mature?

A

Stomach or small bowel falling away from the abdominal wall, allowing bowel contents to leak into the peritoneum

43
Q

What is the type of liquid and how much should be used for balloon-type bolsters for gastric tubes? Small bowel tubes?

A

Sterile water, 5-20 mL for gastric tubes & 3-4 mL for small bowel tubes.

44
Q

How do you properly clean the stoma site?

A

Mild soap and water, thoroughly rinse and dry area

45
Q

(T/F) The use of antibiotic ointments and hydrogen peroxide at the tube site is recommended for cleanliness.

A

FALSE. Dressings can be applied if there is drainage from the stoma site, but avoid excessive tension which can promote infection and buried bumper syndrome.

46
Q

(T/F) Whether medications is in a pill or liquid form, each medication should be given separately with a water flush, before and after each medication administration.

A

TRUE.

Liquid form medications may contain higher amounts of sorbitol/sugar, have a higher osmolarity, and/or a higher viscosity, and may be more expensive than a tablet form.

Giving a crushed and diluted medication could be more preferable; however; crushed pills can be more likely to clog a small-bore tube than medication in a liquid form.

47
Q

What is the overall success rate for procedure-rated complications for placing NG tubes?

A

~10%; epistaxis, aspiration, and circulatory or respiratory compromise

~2-4%; misplacement of NG tube into bronchopulmonary tree

48
Q

What is the gold standard for ensuring correct feeding tube placement?

A

RADIOGRAPHY

49
Q

What are postprocedural complications for NG tubes?

A
  • Inadvertent tube dislodgement (~25-41% of cases)
  • Tube malfunction (~11-20% of the time)
  • Tube occlusion (~20-45% of the time)
  • Intestinal ischemia
50
Q

What method significantly reduces NG tube dislodgement?

A

Nasal bridle; decreases from 36% to 10%

51
Q

What results in buried bumper syndrome? What are the risk factors?

A

From growth of the gastric mucosa over the internal bumper.

Risk factors: excessive tension between the internal and external bumpers, poor wound healing, and significant weight gain

52
Q

What are some methods that can be used for patients prone to pulling tubes?

A
  • Use of abdominal binder
  • Mittens over the patient’s hands
  • Decreasing the external tube length to 6 to 8 cm
  • Switching to a low-profile device
53
Q

**Where does ASPEN recommend feeding first?

A

**Stomach as a first choice.

Note, that recent data and meta-analysis suggest that jejunal feeding may be associated with decreased risk of aspiration PNA.

CNSC Exam 2021 (50 decks)

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