Transcript Document

Gastrostomy Tubes:
A Primer
Tamara Simon, M.D.
Assisted by Kim Washington, CPNP
Special Care Clinic
July 2004, August 2005
Purpose
• Allow for enteral feedings for children with:
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swallowing dysfunction
severe gastroesophageal reflux
esophageal atresia
esophageal burns or strictures
craniofacial abnormalities
chronic malabsorption
failure to thrive
Procedure
• Placed using endoscopic technique
– Done by GI or pediatric surgery
– Placed with percutaneous endoscopic technique:
• Stomach and anterior abdominal wall punctured
• Feeding catheter is inserted
• Gastrocutaneous fistula forms around gastrostomy tube held in
placed by internal and external bumper guards
• Sutures, if placed, hold the tube in the stoma
• Placed in conjunction with Nissen
– Requires pH probe +/- upper GI series
– Done by pediatric surgery
Procedure (continued)
• Gastrocutaneous fistula matures between 24 weeks and up to 3 months after creation
• Replacement with low profile button after
stoma matures
– Balloon tip (MIC-Key)
– Mushroom tip (Bard)
– Collapsible wing tip
MIC-Key Balloon-tip
Gastrostomy Button
Pros:
No venting needed
Easier to change
Cons:
More mobile portion
between button and
balloon
Develops leaks
Bard mushroom tip
Gastrostomy Button with Obdurator
Pros:
Sturdier construction
Used in PEG placement
due to size
Cons:
Venting apparatus needed
Difficult to change
Requires training
Complications
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Wound infection
Hemorrhage
Mucosal injury
Gastrostomy tube dysfunction:
– Obstruction of tube
– Dislodgement of tube
– Cracking or fracture of tube
Complications (continued)
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Leakage around wall
Granulation tissue formation
Migration of tube
Fistula formation
Wound infection
• Seen in 20% of patients
• Purulent, bloody, cellulitic skin; yellow-brown
discharge without signs of infection is normal
• Avoid occlusive dressings because moisture
accumulates and predisposes to infection
• Usually superficial and can be treated easily
– Clean with region with antiseptic
– Apply topical antibiotics
• Cellulitis may be occasionally be present
– Systemic antibiotics are required
– Vigilance for necrotizing fasciitis
Hemorrhage
• Usually small amount of self-limited
bleeding at the time of placement
• Bleeding remote from the time of placement
may indicate ulcers or erosion of the gastric
mucosa
Mucosal injury
• Range from erosions of gastric mucosa
(gastritis) to perforation of stomach
• Can occur in gastric wall opposite the
gastrostomy tube
Gastrostomy tube dysfunction:
Obstruction of tube
• Most common cause of tube malfunction (14%)
• Caused most often by formulas coagulating in
acidic pH
– Avoid mixing medication with formula (some meds are
acidic)
– Crushed pills, especially sustained release, commonly
cause obstruction
– Proteinaceous material implicated
• Can be prevented by flushing before and after
feeds and medication administration
Gastrostomy tube dysfunction:
Obstruction of tube
• Attempt to flush gently with 5 ml warm water with 5 ml
syringe, instill and pull back up to 5 times
• Try smaller syringe to create increased pressure
• If successful, flush tube again to ensure patency
• If unsuccessful, try solution of pancreatic enzymes (crush
Viokase 8 tablet and 325 mg sodium bicarbonate tablet into
fine powder, mix with 5 ml warm water, instill in 10 ml
syringe, wait 5 minutes
• Attempt to flush with 5 ml or smaller syringes
• Can repeat above for 30 minutes
Gastrostomy tube dysfunction:
Obstruction of tube
• Other solutions- carbonated liquids, meat tenderizer, and/or
milking the tube
• Then notify GI/surgery that feeding tube cannot be cleared
Gastrostomy tube dysfunction:
Dislodgement of tube
(immature fistula)
• Immature fistula : < 4 wks post-surgical
placement, < 12 weeks post-percutaneous
placement
– Stoma relies on the apposition of skin and
gastric mucosa
– Gastric layer closes faster than skin
– Almost anything can be used to keep stoma
patent
– The stomach is not sterile
Gastrostomy tube dysfunction:
Dislodgement of tube
(immature fistula)
– Gently place small Foley
– However, complications could include detachment
of stomach from abdominal wall, development of
false tract, peritonitis, pneumoperitoneum, and/or
air embolism
– If any resistance felt, consult surgery or GI
immediately
– If necessary, nasogastric tube can be inserted and
stoma permitted to close
Gastrostomy tube dysfunction:
Dislodgement of tube (cont)
• Mature fistula
– Attempt to replace same size and type of tube
or button
– If size not known, measuring device can be
used (consult G tube nurse); use taped Foley
catheter left in place if nurse not immediately
available
Gastrostomy tube dysfunction:
Dislodgement of tube (cont)
– Original tube or Foley catheter can be inserted
to maintain patency until device obtained
• stoma closes in 24-48 hours
• If fistula has almost closed, consult
surgery/GI and nasogastric tube can be
inserted
– Place successively larger tubes (Foleys) every
30 minutes to dilate
– Do not dilate with hemostat!
Gastrostomy tube dysfunction:
Cracking or fracture of tube
– Remove original
• Balloon-tip (MIC-Key) - remove after
deflating balloon
• Mushroom or collapsible-wing tip (Bard)gentle traction or, if necessary, cut tip at
external surface of wall and push into
stomach for later excretion or removal by
endoscopy
Gastrostomy tube dysfunction:
Replacement of tube
– Balloon tip (MIC-Key)
• Clean site and select proper replacement
• Test new button by inflating and deflating
balloon with water or saline- 360° inflation
• Lubricate tube with water soluble jelly
• Gently insert in stoma perpendicular to
abdominal wall- 3 cm beyond balloon
• Reinflate balloon with water or saline (3-5
ml for infants, 5-7 ml for children)
Gastrostomy tube dysfunction:
Replacement of tube
• Test placement
• Apply gentle traction pulling balloon against
gastric mucosa
• Button should lie flat against abdomen
Gastrostomy tube dysfunction:
replacement of tube
– Mushroom and collapsible-wing tips
• Insert obdurator into open sides of tip to distend
tip before placing in stoma
• With tip distended, tube is inserted into stoma
perpendicular to abdominal wall with steady
pressure until flush with abdominal wall
• Once fully inserted, obdurator is removed
• Test placement
• Button should lie flat against abdomen
Confirming gastric placement
• Check pH of aspirate (<5)
• Check color of aspirate
• If no aspirate obtained, inject 5 ml air and aspirate
again
• Also reposition patient
• Transpyloric placement (for NG)
– Bilious, high pH
– Withdraw tube 3-5 cm and recheck
• Pulmonary placement bilious, high pH
– Respiratory distress, serosanguinous aspirate, pH 5-6
– Remove immediately
Leakage around wall
• Occurs in 10% of patients
• Looks like formula
• May be caused by:
– clogged tube
– deterioration of tube- check balloon
– stoma that is enlarged due to external traction
on the tube
• May be treated with :
– Sorbsan around the site if the stoma is too big
– Stoma adhesive powder and Maalox/Aquaphor
solution can be used for leakage alone
Granulation tissue
• May accumulate on abdominal wall
• Bleeds easily, causes discharge, irritation, and
discomfort
• Clean secretions or crusts from site
• Apply water soluble jelly to normal tissue in 5 cm
circle surrounding granulation
• Silver nitrate stick can be used to cauterize tissue
once daily for 7-10 days (up to 3 weeks) until
granuloma is gone
Granulation tissue
• Recurrences are frequent
• Check for prolapse (pinker, regular color) which
does not respond to silver nitrate – i.e. doesn’t turn
gray
• Apply Kenalog cream tid for 2 weeks (wait 1 hour
if after silver nitrate)
Migration of Tube
• Can migrate down the intestinal tract or up
the esophagus
• Downward migration can cause obstruction
or even perforation
• Upward migration can cause aspiration
Further Questions
• Questioning potential complications?
• Get a radiologic dye study +/- abdominal
radiographs, upper GI series, or endoscopy
• Consult G tube nurse
• Consult Kim Washington if Special Care
Clinic patient
• Consult gastroenterologist or surgeon who
originally placed G tube
References
• Teoh DL. Tricks of the Trade: Assessment
of High-Tech Gear in Special Needs
Children. Clinical Pediatric Emergency
Medicine. 3(1), March 2002.
• Washington, K. G Tube Care handout.
• Joffe, M. Troubleshooting Lines, Tubes, and
Catheters. Pediatric Hospitalist Meeting,
Denver, July 2005.