Enteral Access Devices Flashcards
Factors that should be considered when determining the type of 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 placement
Ethical considerations
Is a patient with head and neck cancer a candidate to receive an enteral feeding device? If so, what type of enteral feeding tube should be used?
Scenario: 72 y/o M w/ metastatic squamous cell carcinoma of tongue. Scheduled for 6 week course of chemo and radiation. Wt 80 kg, lost 11 kg in 3 months (14% wt loss). Labs WNL.
Could benefit from an enteral feeding tube to address both his existing malnutrition as well as likely further decreases in oral intake related to mucositis, nausea, and vomiting from chemoradiation. Expected duration of therapy is at least 6 weeks. Percutaneous gastrostomy tube (G-tube) is appropriate
What is the “introducer” method of G-tube placement?
Used by interventional radiologists, surgeons, or endoscopists to minimize the risk of tumor implantation during G-tube placement in a head/neck cancer patient. The stomach is insufflated and anchored to the anterior abdominal wall with T-fasteners, and the G-tube is introduced percutaneously. In this manner, the tube is not pulled through the region with active cancer and risk for tumor seeding is decreased
What type of long-term tube (stomach or small bowel) should patients receive if they have the preexisting condition of GERD? Does the answer change if the patient is in the ICU?
Whenever possible, patients should be fed into the stomach as it is the most physiologically normal for the body, ensuring appropriate mixing of nutrients with gastric acid. Feeding into the stomach also allows for schedule flexibility, is the safest with regard to formula contamination secondary to no formula hang time, allows for blenderized diets, and is the most cost-effective. IF the patient does not tolerate gastric feeding or has an aspiration event, the feeding can be diverted to the small intestine
All feeding tube sizes are reported by the tube’s internal or external diameter measurement?
External
The flow through the enteral tube and susceptibility to clogging depend on a tube’s inner or outer diameter?
Inner
Polyurethane tubes with the same outer diameter as a silicone tube will have a smaller or larger internal diameter?
Larger
Differences in characteristics of polyurethane vs silicone tubing
Silicone tubes are more comfortable and less stiff than polyurethane
Wall width is thinner in polyurethane and they are more resistance to fungal degradation
Nasoenteric feeding tube port comparisons and options?
Have either 1 port for feeding or 2 in a “Y” configuration: one for feeding and the other for medication and/or irrigation
Factors that determine which type of feeding tube tip to use?
There is no specific data to favor one design over another (weighted vs unweighted; side vs end feeding holes; number of distal feeding delivery holes)
The choice is determined by the preference of the individual clinician, institutional availability, and mode of placement
What are the two options for an internal retention bolster for percutaneous tubes?
Solid material (silicone or polyurethane) or silicone balloons
What type of internal retention bolster is more commonly used with initial percutaneous enterostomy tube placement and why?
Solid internal bolster. They have greater longevity
Why would a silicone balloon internal bolster be used?
Ease in placement
Define some characteristics of the use of a silicone balloon internal bolster?
Ease of placement. Inserted more frequently with radiologic and surgical tube placement, and used as replacement devices in the office setting. If placed in the small bowel, the balloon is typically filled with a volume of 3-4 ml so as not to obstruct the lumen. Typically only have a lifespan of 4-6 months. Use of a nonballoon tube is preferred for direct jejunal tube placement to avoid occluding the narrower jejunal lumen.
Describe the characteristics of an enteral feeding tube with a solid internal bolster constrained in a dissolvable capsule that can be placed in the same manner as a balloon tube
May be used for laparoscopic initial gastric or direct jejunal tube placement, as well as for replacement tubes. It combines the longevity of a solid internal bolster with the ease of placement of a balloon-type internal bolster tube
Why would a percutaneous enterostomy feeding tube have multiple ports?
Separate ports are included for feeding and medication and/or irrigation. Balloon-type internal bolsters also have a third port for balloon inflation or deflation
Difference in placement of a gastrojejunal vs jejunal feeding tube?
Percutaneous gastrojejunal feeding tubes are inserted into the stomach with a smaller-bore extension tube that passes through the pylorus into the jejunum. Some are specifically designed with separate gastric and jejunal lumens and have ports that allow for both jejunal feeding and gastric decompression. Direct percutaneous jejunostomy tubes are placed directly into the jejunum without passage through the stomach
What are low-profile tubes?
Skin-level devices that are used as initial placement or, more commonly, for replacement devices for gastrostomies, gastrojejunostomies, and jejunostomies. Excellent option for patients who are concerned about the cosmetic appearance of a feeding tube. Can also be more comfortable for patients who are active, sleep in the prone position, or need only intermittent therapy. Patient will need adequate manual dexterity or caregiver assistance to attach a feeding connector to a skin-level device
When is nasogastric or nasoenteric tube placement contraindicated?
When patient has an obstructing head, neck, and esophageal pathology or injury that prevents safe insertion
Which prokinetic had the highest success rate when passing a feeding tube post-pyloric?
IV erythromycin
What are the available methods to place long-term enterostomy tubes?
Endoscopic, fluoroscopic, or surgical
When should preprocedural testing of coagulation parameters and platelets be done before long-term feeding tube placement?
If there is concern for abnormal coagulation due to anticoagulant medication< medical history of excessive bleeding, or recent antibiotic use
Is placement of a percutaneous feeding tube considered a high- or low-bleeding risk procedure?
High-bleeding risk
Name specific and relative contraindications for endoscopic gastrostomy tube placement?
Specific: obstruction of the GI tract proximal to the stomach and the inability to transilluminate the abdominal wall for identification of a safe abdominal access site
Relative: ascites, coagulopathy, gastric varices, active head and neck cancers, morbid obesity, and neoplastic, infiltrative, or inflammatory disease of the gastric or abdominal wall
Describe the Ponsky (pull) method of PEG tube insertion?
Air is insufflated into the stomach via endoscope. The optimal site for PEG tube placement is determined through simultaneous endoscopic transillumination of the abdominal wall and endoscopically visualized finger indentation at the site. A small incision is made at this site and a needle/trocar is inserted through the abdominal wall and into the stomach. A guidewire is passed through the endoscope; then, the guidewire, snare, and endoscope are withdrawn through the mouth. A G-tube is affixed to the guidewire and pulled through the esophagus into the stomach and out the abdominal wall. The G-tube is held in place by a solid, mushroom-type internal retention device and an external bumper
Name advantages of PEG placement?
Performance at bedside, lack of radiation, and ability to perform diagnostic and therapeutic endoscopic procedures simultaneously
