Enteral Access Devices: Types, Function, Care, and Challenges

Transcription

1 Invited Review Enteral Access Devices: Types, Function, Care, and Challenges Nutrition in Clinical Practice Volume 33 Number 1 February C 2018 American Society for Parenteral and Enteral Nutrition DOI: /ncp wileyonlinelibrary.com Linda M. Lord, NP, CNSC, ACNP-BC Abstract Enteral access feeding devices are placed in patients who have a functional and accessible gastrointestinal (GI) tract but are not able to consume or absorb enough nutrients to sustain adequate nutrition and hydration. For many individuals, enteral nutrition support is a lifesaving modality to prevent or treat a depleted nutrient state that can lead to tissue breakdown, compromised immune function, and poor wound healing. Psychological well-being is also affected with malnutrition and dehydration, triggering feelings of apathy, depression, fatigue, and loss of morale, negatively impacting a patient s ability for self-care. 1 A variety of existing devices can be placed through the nares, mouth, stomach or small intestine to provide liquid nutrition, fluids, and medications directly to the GI tract. If indicated, some of the larger-bore devices may be used for gastric decompression and drainage. These enteral access devices need to be cared for properly to avert patient discomfort, mechanical device related complications, and interruptions in the delivery of needed nutrients, hydration, and medications. Clinicians who seek knowledge about enteral access devices and actively participate in the selection and care of these devices will be an invaluable resource to any healthcare team. This article will review the types, care, proper positioning, and replacement schedules of the various enteral access devices, along with the prevention and troubleshooting of potential problems. (Nutr Clin Pract. 2018;33:16 38) Keywords enteral access; enteral nutrition; feeding tube; gastrostomy Introduction Enteral access feeding devices are placed in patients who have a functional and accessible gastrointestinal (GI) tract but are not able to consume or absorb enough nutrients to sustain adequate nutrition and hydration. The provision of nutrition through these devices can be a lifesaving modality to prevent or treat the dangers of a depleted nutrient state: tissue breakdown, compromised immune function, and poor wound healing. 1-4 Enteral nutrition (EN) support can also promote psychological well-being because malnutrition and dehydration have been shown to produce feelings of apathy, depression, fatigue, and loss of morale, negatively impacting a patient s ability for self-care. 5 A variety of existing devices can be positioned through the nares, mouth, stomach, or small intestine to provide liquid nutrition, fluids, and medications directly to the GI tract. Enteral access feeding devices may be used short term to provide nutrients for optimal functioning through periods of illness, trauma, or arduous medical therapies. Longterm enteral access feeding devices can provide nutrients through extended periods of medical need and lifelong, if indicated. Gastrostomy tubes and gastric ports of duallumen tubes may also be used for gastric decompression and drainage to avert nausea and vomiting that can ensue with gastroparesis, chemotherapy agents, gastric outlet or intestinal obstructions, or other conditions. Enteral access devices need to be cared for properly to prevent patient discomfort, mechanical device related complications and interruptions in the delivery of needed nutrients, hydration, and medications. Clinicians who seek knowledge about enteral access devices and actively participate in the selection and care of these devices will be an invaluable resource to any healthcare team. This article will review the types, care, proper positioning, and replacement schedules of the various enteral access devices, along with the prevention and troubleshooting of potential problems. From the University of Rochester Medical Center, Rochester, New York, USA. Financial disclosure: None declared. Conflicts of interest: None declared. Received for publication July 3, 2016; accepted for publication August 6, Corresponding Author: Linda M. Lord, NP, CNSC, ACNP-BC, University of Rochester Medical Center, Rochester, NY 14642, USA. linda_lord@urmc.rochester.edu

2 Lord 17 Figure 1. Feeding tube in stomach. C Nestlé Health Science, reprinted with permission. Figure 2. Feeding tube in small bowel. C Nestlé Health Science, reprinted with permission. Nasally Placed Feeding Tubes: Types, Indications, and Key Components Nasally placed feeding tubes are short-term enteral access devices with distal tips positioned in the stomach (Figure 1) or small intestine (Figure 2). They are commonly used in the inpatient setting for temporary EN support, up to about 4 6 weeks, because they can be placed at the bedside by appropriately trained clinicians and are easily removed when no longer necessary. They are generally available in French (Fr), which describes their outer diameter. Some practitioners use larger-bore Fr nasogastric tubes manufactured for gastric decompression and drainage as a vehicle for tube feeding administration. These tubes may not clog as readily as smaller tubes, and gastric residual volumes (GRVs) may be easier to obtain. However, clinicians need to check their state public health laws because using larger-bores tubes for feeding may be prohibited unless medically necessary, as in the case of New York State. 6 These larger-bore, stiffer tubes are not ideal as feeding tubes because they are uncomfortable and may increase the risk for sinusitis and pressure ulcers. Placement of a tube into the stomach is the initial option unless small-bowel tube position is needed for anatomical reasons (gastrectomy, gastric outlet obstruction) or to provide nutrients beyond a proximal fistula, obstruction, or bowel leak. Clinicians may also prefer smallbowel feeding tube placement for those patients who are at high aspiration risk. This includes patients with decreased level of consciousness, diminished cough or gag reflex, impaired lower esophageal sphincter, neurologic deficits, severe gastroesophageal reflux disease, severe gastroparesis, elevated GRVs, and emesis. Dual-lumen tubes can provide simultaneous gastric decompression and drainage, along with small-bowel tube feeding. Patients who have had recent nasal surgery, nasal fractures, or severe trauma to the midface should not have a feeding tube placed nasally. Additional patients considered high risk for nasally placed feeding tubes are those with significant coagulation abnormalities, severe esophageal varices or stricture, or alkaline ingestion, and those who have undergone recent esophageal banding. 7 UpperGIor head and neck cancers may preclude feeding tube placement through the esophagus. Enteral tubes can also be placed orally for short-term gastric access in intubated and sedated patients, such as those with altered nasal anatomy or nasal trauma, sinusitis, or facial fractures, but otherwise oral gastric tubes are not advised because of patient discomfort. 8 Most tubes are approximately 36 inches, long enough for small-bowel passage, but lengths are available up to inches for tall adults and further small-bowel advancement beyond the ligament of Treitz. Small-bore feeding tubes tend to be of a soft material, polyurethane or silicone, so many contain a temporary metal stylet or guidewire within the lumen to stiffen the tube for ease of insertion (Figures 3 and 4). The stylet is subsequently removed after proper tube position is confirmed and should not be reinserted unless the manufacturer has deemed it safe per its specific guidelines. Stylet reinsertion risks include tube perforation or exit through the outflow port potentially perforating the esophagus or GI tract. Some manufacturers may allow reinsertion of the stylet into their particular feeding tube, to assist in positioning it into the small bowel or repositioning if it has moved out of a desired location. This ability can minimize radiograph exposure and patient discomfort. The clinician should check the integrity of the stylet, follow the manufacturer s instructions carefully, and only reinsert the stylet that was originally provided with the feeding tube. The tip of feeding tubes may contain a weighted material, like tungsten (Figure 5), but nonweighted tips are also available (Figure 6). It is thought that the weight may help maintain tube position in the

3 18 Nutrition in Clinical Practice 33(1) Figure 3. Weighted feeding tube with stylet. Figure 5. Weighted feeding tube tip. Figure 4. Unweighted feeding tube with stylet. GI tract; however, studies have not confirmed this. Nonweighted tip feeding tubes tend to be easier to insert through the nares and have been shown to pass more readily into the small bowel, compared with weighted tip feeding tubes, after administration of intravenous (IV) metoclopramide 9 and an equally high rate of small-bowel passage after IV erythromycin. 10 In addition to single lumen feeding tubes, there are dual-lumen tubes where the outlet holes of one lumen are positioned in the stomach and the alternate lumen continues to the small intestine. With dual-lumen tubes, the gastric lumen is often used for either decompression and drainage of the stomach or medication administration. The small-bowel lumen, often referred to as the jejunal lumen, is typically used for tube feeding delivery. Alternatively, a larger-bore nasogastric tube can be placed in 1 nares temporarily for gastric decompression and drainage, and a Figure 6. Unweight feeding tube tip.

4 Lord 19 separate small-bore feeding tube positioned in the alternate nares for small-bowel tube feed administration. Nasally Placed Feeding Tubes: Placement Nasally placed gastric and small-bowel feeding tubes are typically inserted at the bedside either blindly or with the aid of a manufactured device to enhance patient safety. For blind tube placements, radiographic film should be obtained to determine tube tip location before the instillation of feedings or medications. If inserted blindly, predicted length of tubing required to reach the stomach is predetermined for each patient. Clinicians commonly follow the nose-earxiphoid method, where the measurement starts at the tip of the nose to an earlobe to the bottom of the xiphoid process. The accuracy method of this was tested, along with other variables, in adult patients undergoing esophageal motility procedures. 11 The ideal feeding tube tip position for gastric placement was identified as being between 3 and 10 cm past the distal lower esophageal sphincter. The nose-ear-xiphoid method was found to be accurate 72.4% of the time. In this investigation, a more accurate method to achieve ideal gastric placement was described as a 3-variable model using gender, weight, and a nose-to-umbilicus measurement while the patient s head is lying flat on the bed. The accuracy rate of having the tube positioned 3 10 cm into the stomach rose to 85.3%. The tubes outside this intended position were placed too proximal in half of the cases and too distal in the other half. This regression model uses nomograms, one for male and one for female, where a line is drawn from the nose to umbilicus measurement located on the left column to the body weight measurement located on the right column, and the predicted gastric tube insertion distance is determined at the cross-sectional point. One of the most hazardous risks of feeding tube insertion is inadvertent tube placement into the bronchial tree. It has been reported that between 1% and 2% of blind feeding tube placements result in passage into the bronchi, and some of these will cause pulmonary injury and even death. 12 Pulmonary intubation of a feeding tube can lead to pneumothorax, pneumonia, and empyema Feeding tubes also have the potential of perforating the esophagus, 16 and intracranial placement has been reported Risk factors for inadvertent bronchopulmonary intubation of feeding tubes include altered mental status, sedation, presence of a tracheostomy or endotracheal tube, absence of the cough reflex, difficulty with tube placement, and anatomic abnormalities. 12 If the tube is placed blindly, it should be withdrawn immediately if there are any signs of respiratory distress, like dyspnea, choking, or coughing, or if the patient is unable to talk. If the patient is alert, sips of water taken while the tube is inserted and advanced will help guide it in appropriately through the esophagus. Figure 7. Grassy green feeding tube aspirate. Once the predetermined length has been inserted, aspiration of fluid from the tube should be used initially to help determine tube tip location, reducing the number of radiographic films needed to verify placement. A 30- to 60-mL syringe is used to instill 30 ml of air to clear the tube and then aspirate fluid. 21 This can be attempted twice and if unsuccessful, reposition the patient and try again. 22 The aspirate volume, color, and ph measurement (a drop of aspirate can be placed on a colorimetric ph strip) can be assessed. If the aspirate is cloudy and grassy green (Figure 7), clear and colorless, tan or off-white, or bloody or brown, and has an acidic ph of 5.5, gastric placement is highly likely especially if it is a large volume Smallbowel aspirates tend to be smaller volumes and are brownish green or light to dark golden yellow (bile colored). 22 Pleural fluid is typically watery, pale yellow, or straw colored, and tracheobronchial secretions are usually tan or off-white fluid of mucous consistency, and either can be tainted with streaks of blood. A ph value >6 can be associated with gastric, small-bowel or respiratory placement, so this higher value is not reliable for determining tube tip location. The use of gastric acid suppressants and continuous drip tube feedings can increase the gastric ph levels Abdominal auscultation over the epigastrium by stethoscope while instilling air through the tube does not let the clinician know the location of the tube tip. 25,30,31 The inability to instill air, however, may identify a kinked tube. Esophageal placement may be suspect if the air is burped back by the patient, but hearing the air bubble by auscultation does not determine esophageal, gastric, small-bowel, or bronchopulmonary placement. If the tube is inserted blindly, it is highly recommended that a radiographic film be obtained that identifies the entire route of the tube to the distal tip, before instilling tube feedings or medications. 32 Inadvertent bronchial placement needs to be ruled out, but additionally the tube tip could be positioned near the gastroesophageal junction or in the esophagus if insufficient length is inserted or the tube could loop back from the stomach upwards placing the patient is at high risk for aspiration of the infused fluids. The tube tip

5 20 Nutrition in Clinical Practice 33(1) may also end up in another unintended position, such as duodenal placement of an intended gastric tube. Some techniques to reduce the risk for pulmonary placement include listening for air exchange at the end of the tube after 25 cm tube length has been inserted, 22 carbon dioxide calorimetry, and tube placement check by radiograph. 37 Fluoroscopic and endoscopic guidance for feeding tube placement have been utilized, and placement is verified during tube placement. 12,38,39 There are also ongoing efforts by industry to promote the safe and proper placement of feeding tubes. There are manufactured small = bore feeding tubes that contain realtime imaging techniques such as electromagnetic tracking, where a signal is transmitted and tracked by a receiver that is placed on a patient s chest and a graphic display is visualized on a monitor during tube advancement or the integration of a tube with a 3-mm camera where the anatomy is visualized along the tube s course and displayed on a monitor. 44 With the advent of these technologies for safe feeding tube passage, blind feeding tube placement in patients at high risk for inadvertent bronchopulmonary intubation should be avoided. 12 If small-bowel placement is desired, the tube tip ideally should be eased past the pylorus, through the 12 inches of duodenum, curved beyond the ligament of Treitz and into the jejunum to minimize retrograde reflux of the tube feeding formula and lower the risk for tube migration back into the stomach. Prokinetic agents, like metoclopramide and erythromycin, can facilitate this progression and have shown the most benefit if administered before the insertion of nonweighted tip feeding tubes. 9,10 One retrospective analysis of critically ill, mechanically ventilated patients showed that aspiration was significantly lower in the small bowel compared with placement in the stomach, and aspiration decreased significantly the farther the feeding tube was into the small bowel. 48 Aspiration was 11.6% lower just past the pylorus, 13.2% lower in the second/third portions of the duodenum, and 18% lower in the fourth portion of the small bowel and beyond. This analysis also reported that pneumonia occurred significantly less often when the feeding was positioned at the second portion of the duodenum or beyond. Nasally Placed Feeding Tubes: Securement Once the tube tip is properly positioned in the stomach or small intestine, it must be immediately secured to the nose or cheek with tape, adhesive strips, a transparent physiologic dressing, or securement device per the institution s protocol. It is beneficial to provide some slack and attach a more distal portion of tube to the cheek with some type of adhesive as an added securement. These tubes may cause distress in confused patients who may then attempt to dislodge them. Nasal bridles have been used in patients who may Figure 8. Nasal bridle. Image courtesy of Applied Medical Technology, Inc. Figure 9. Incremental markings. pull at their tubes or who have facial wounds or burns preventing adhesive securement of their tubes 49 (Figure 8). A recent meta-analysis has shown them to be superior to adhesive tape for tube securement and prevention of tube dislodgement. 50 Nasal bridles are also less invasive compared with the suturing of feeding tubes to the nose. Tubes can potentially slip through any type of securement, so it is imperative that there be some method to detect tube migration inward or outward. The tube can be marked with indelible ink where it enters the nose or mouth, or if the tube has incremental markings (Figure 9), the marking at the mouth or nose can be recorded. The length of visible tubing could also be measured, recorded, and compared with future position checks (Figure 10). One of these methods should be chosen and utilized so that any tube movement can be dealt with promptly.

6 Lord 21 Figure 10. Tape measure. Nasally Placed Feeding Tubes: Site Care and Replacement Skin checks around the nose, or mouth if placed orally, should be performed routinely and skin should be inspected whenever the tape or securement device is replaced. The tube should be positioned so that it is not pulling on the nares or mouth as this may lead to pressure injury or ulceration. The tape or securement device should be examined to be sure that it is adequately holding the tube in position and should be changed as per the institution s policy. Nasally placed feeding tubes should be replaced routinely following manufacturers recommendations, monthly is generally an accepted guideline. Stomal Feeding Tubes: Types, Indications, and Key Components Longer-term devices are placed when patients require enteral access for >4 6 weeks. These are tubes placed directly into the stomach or small intestine surgically, laparoscopically, endoscopically, or radiographically; they are referred to as stomal or percutaneous tubes. 38 Gastrostomy (G) tubes, jejunostomy (J) tubes, and gastrojejunostomy (G/J) tubes fall under this category. The term percutaneous endoscopic gastrostomy (PEG) is sometimes used as a generic term for G tube, but they are one type of G tube: the type that is inserted endoscopically and typically contains an internal plastic dome-shaped funnel. If a patient requires longer-term enteral access and is already scheduled for surgery or a laparoscopic, a radiographic, or an endoscopic procedure, then placing the enteral access device at the same time should be considered. Before placement, the abdominal wall needs to be inspected for suitable condition (note surgical scars, ostomies, fistulae, drainage tubes, or open wounds), the patient needs to be assessed for the ability to undergo anesthesia, and coagulopathies need to be corrected. Some G tubes can be placed using IV conscious sedation with local anesthesia administered in the abdomen where the tube is to be inserted. The indications for gastric and small-bowel access are similar to those for nasally inserted feeding tubes. In addition, stomal feeding tubes may be used for nutrition and hydration in palliative care and dementia but warrant careful individual assessment before the institution of this therapy. 51 Patients who are terminally ill may not experience hunger and thirst, and an enteral access device with forced nutrition may promote abdominal discomfort and fullness, nausea, emesis, fluid retention, and increased risk for aspiration and pneumonia. Advanced dementia is also considered a terminal disease. Hand feeding should be considered initially because it provides social stimulation, direct human touch, and nurturing. Swallowing studies should be obtained and dysphagia diets utilized whenever possible. G Tubes G tubes are positioned in a gastric stoma for the delivery of liquid feeding formulas, fluid, and liquid medications into the stomach. They can also be used for gastric decompression and drainage. In general, G tubes are less likely to clog compared with nasally placed feeding tubes because they have larger diameters and are shorter in length. 52 Gtubesthataresecuredtotheabdominalwall under clothing are typically more acceptable to patients than nasally placed tubes that are visible on the face and produce the sensation of a foreign body in the pharynx. G tubes are manufactured of either a polyurethane or silicone material. Although silicone material is softer and more comfortable than polyurethane, the internal diameters are narrower due to thicker walls, and one prospective investigation showed increased material deterioration (dilatation and bubbling) and tube obstruction associated with fungal colonization in silicone tubes compared with polyurethane tubes. 53 G tubes are identified: by the French size (12 30 Fr); by the internal retention device: balloon (inflatable internal balloon) or nonballoon (plastic dome or mushroom-shaped funnel); or as standard (visible tube exiting abdomen) or lowprofile (skin level tube flush with abdomen; stoma length also needs to be identified). Standard G tubes. Manufactured standard G tubes have a plastic external retention device (referred to as a bolster, disc, bumper, phalange, or anchor) that is movable along the

7 22 Nutrition in Clinical Practice 33(1) Figure 11. External retention device. Figure 12. Gastrostomy tube in situ. C Nestlé Health Science, reprinted with permission tube and fitted snug to the skin to prevent inward migration of the tube (Figure 11). The proper position of this external retention device is a dime s width from skin. It can be either circular, star-, or rod-shaped depending on the brand. The grip of this device varies depending on the brand. For those with a looser grip or if the grip loosens over time, a zip tie can be applied on or just above the movable external retention device to secure it in position, being careful not to tighten it so much that the tube lumen or balloon port (if present) obstructs. Foley catheters with an inflatable balloon and Malecot winged nonballoon catheters are not recommended as G tubes because they do not contain a movable external retention device and, therefore, require sutures or some alternate tube attachment device to prevent inward migration of the tube. They will not connect to enteral bags or syringes with the new ENFit design (see later Enteral Connections section). Standard G tubes also contain an internal retention device to prevent tube migration outward and potential dislodgment (Figure 12). This internal retention device is either an inflatable balloon (balloon G tubes) or nonballoon plastic dome or mushroom-shaped funnel (nonballoon G tubes). It is the tension between the internal and external retention devices that prevents tube migration inward or outward. Balloon G tubes are easier to remove and replace, but they require more frequent replacements compared with nonballoon G tubes. The balloon G tube contains an internal balloon that is filled with water (Figures 13 and 14). It can easily be identified because it contains a balloon port where the water can be instilled or withdrawn from the internal balloon. Sterile or distilled water is recommended because the minerals in saline or tap water may precipitate Figure 13. Balloon gastrostomy tube. Figure 14. Balloon gastrostomy tube: internal balloon.

8 Lord 23 Figure 15. Nonballoon gastrostomy tube. Figure 17. Low profile balloon gastrostomy tube. type usually contains a clamp on the tubing to prevent the backflow of gastric fluids when uncapping tube. The balloon G tube does not contain a clamp because it could damage the internal tubule that carries the water between the balloon port and the internal balloon. If a clamp is not present, the tubing needs to be pinched when uncapping the tube. Figure 16. Nonballoon gastrostomy tube: internal. and cause blockage of the balloon port. Balloon G tubes are placed transabdominally as an initial G tube or a replacement G tube and require replacement every 3 4 months to prevent balloon fatigue and rupture. If it is placed as the initial device, a gastropexy technique is used with temporary T-fasteners or dissolvable sutures that hold the stomach to the abdomen until it affixes to the abdominal wall. 54 Nonballoon G tubes contain an internal funnel, referred to a bolster, disc, bumper, mushroom, or dome (Figures 15 and 16). They may stay in place for 6 12 months. These tubes are usually placed transorally down the esophagus and through the stomach. Tubes placed endoscopically, referred to as PEG tubes, are nonballoon G tubes. 55 Most manufactured G tubes have incremental markings on the tube that indicate the distance from the stomach wall and signify the length of the stomal tract. The nonballoon Low profile G tubes. There are also low profile or skin-level G tubes, commonly referred to as button G tubes, where the visible portion of the tube is rod shaped with a cap closure and is premeasured to be flush to the abdomen. The stomal tract length needs to be measured (in cm) for the appropriate low profile tube shaft length to be placed. There are manufactured stomal measuring devices, but the clinician can also look at the incremental markings on the existing G tube to determine the stomal tract length. Low profile G tubes are identified by both a Fr size and shaft length (in cm). Currently, they are available in shaft lengths from 0.8 to 6.0 cm. The internal retention device may be a water balloon requiring replacement every 3 4 months (Figure 17) or a nonballoon mushroom-shaped dome (Figures 18 and 19) requiring replacement every 6 12 months. Low profile G tubes contain an antireflux valve to prevent leakage of gastric contents when uncapping the device. A separate extension tubing is plugged into low profile G tubes for infusions and then removed when the infusion is complete (Figures 20 and 21). Compared with the standard G tubes (Figure 22), low profile G tubes are less visible and lighter, have fewer

9 24 Nutrition in Clinical Practice 33(1) Figure 20. Extension tube for low profile balloon gastrostomy tube. Figure 18. Low profile nonballoon gastrostomy tube. Figure 21. Extension tube low profile non-balloon gastrostomy tube. Figure 19. Low profile nonballoon gastrostomy tube. Image courtesy of Applied Medical Technology, Inc. restrictions on mobility, do not require tape to secure excess tubing to skin, and are less likely to dislodge by getting caught on something (Figure 23). Another advantage to the low profile G tube is the antireflux valve so if the cap should open, there would not be the gastric fluid leakage that could occur if the standard G tube cap became loose and inadvertently opened. Low profile G tubes are well established in the pediatric population, but they can provide all these same benefits for adults, who may also appreciate this option. Figure 22. Standard gastrostomy tube. Courtesy Halyard Health.

10 Lord 25 Figure 23. Low-profile gastrostomy tube. Courtesy Halyard Health Patient and caregiver preference should be considered when offering a low profile tube because, in some cases, they may prefer not to deal with the extension tubing attachment and are content with the standard G tube. Some medical facilities are not properly trained to attach the extension tubing. Also, in obese individuals, the gastric stoma tract length may be longer than the commercially available low profile tube shaft lengths. Janeway Gastrostomy A Janeway gastrostomy is a surgical procedure where a tunnel is created within the stomach that is brought out through the abdomen to form a permanent stoma. 56 A catheter or feeding tube is inserted into the stoma, approximately 6 inches, to administer infusions and medications into the stomach. The catheter or tube is removed when not being used to allow the stoma to close and prevent leakage between feedings. A Janeway gastrostomy is useful for patients who may pull at and dislodge their tubes. G/J and J Tubes Jejunal ports of G/J tubes and J tubes are positioned in the small bowel for the delivery of liquid feeding formulas, fluid, and possibly liquid medications for the same indications as outlined for nasally placed small-bowel feeding tubes. Jejunal ports of G/J tubes and J tubes are more likely to clog compared with G tubes due to their longer length and smaller diameter. Patient and caregiver education should highlight techniques for preventing and treating tube clogging because G/J tubes and newly placed J tubes require fluoroscopy or endoscopy for replacement. Figure 24. Standard transgastric balloon G/J tube. Courtesy Halyard Health G/J and J tubes are identified: by the Fr size: G/J tubes (14 24 Fr), J tubes (5 16 Fr); by the internal gastric retention device, if present: balloon (inflatable internal balloon) or nonballoon (plastic dome or mushroom shaped funnel); as standard (visible tube exiting abdomen) or low profile (skin-level tube flush with abdomen; stoma length also needs to be identified); or by length, if G/J tube (15 95 cm). Transgastric G/J tubes. Transgastric implies that the tube enters and is guided through the stomach for ultimate entry into the small bowel. One option for small-bowel access is to thread a jejunal catheter through an existing G tube. In this scenario, the gastric port of the G tube is blocked to gain access into the small bowel. There are also manufactured transgastric G/J tubes that contain 2 separate lumens for gastric and small-bowel access or transgastric J tubes that contain 1 lumen only for small-bowel access. These are available as balloon (Figure 24) or nonballoon and as standard (Figure 24) or low profile (Figure 25) tubes as described earlier. When small-bowel access is needed via a gastric stoma, postinsertion tube placement is verified radiographically, endoscopically, or surgically to ensure appropriate position of the tube tip. Transgastric small-bowel tubes may malposition back to the stomach, so obtaining residual checks for volume, color, and ph value through the gastric port (if available) and jejunal port may give the clinician some information on tube tip location. J tubes. Instead of accessing the small bowel by the transgastric route, a tube could be placed directly through a surgically created jejunal stoma to avert gastric malposition, thereby lowering the risk for aspirated tube feeding formula

11 26 Nutrition in Clinical Practice 33(1) Figure 25. Low profile transgastric Balloon J tube. Figure 26. J tube. and fluids. In addition, direct J tubes can potentially be replaced in a home or clinic setting, without radiographic guidance, once the stoma tract has matured. The Witzel jejunostomy is a surgically created serosal tunnel into the small bowel, and the J tube is inserted into it. The tube should be at least 6 inches into the tunnel to prevent backflow and site leakage of the formula, fluid, or medications. There are commercially available J tubes that have a Dacron cuff that is embedded within the skin layers (Figure 26); some contain a small internal water balloon to prevent tube displacement (3 7 ml), and others require securement with either sutures or some type of external anchoring device. A needle catheter jejunostomy involves inserting a needle obliquely through the small bowel; then a Seldinger technique is used to insert a very small-bore feeding tube (5 Fr) into the small bowel. 57 The commonly used urethral red rubber catheter, as a jejunal feeding tube, will not connect to enteral bags or syringes with the new upcoming ENFit design (see later Enteral Connections section). Stomal Feeding Tubes: Securement Strategiescanbeemployedforpatientswhotendtopull at their stomal tubes, such as tucking the tube away under clothing or applying an abdominal binder, which is a wide elastic wrapped around the abdomen and secured with Velcro. Care must taken that a binder is not too tight, causing pressure or trauma to the tube site. For stomal tubes that do not contain an external retention device, tube securement can be achieved with manufactured tube attachment devices that are secured to the abdomen with adhesive, Steri-Strips, tape, or sutures. Stomal Feeding Tubes: Site Care Newly placed stomal tubes have a split gauze dressing inserted either underneath or above the external (bolster, disc, bumper, phalange, anchor) that can be removed after 24 hours. Afterward, the site can be left open to air, or a new split-gauze dressing can be applied daily and as needed for excessive site drainage. If the gauze is placed underneath the external retention device, be sure it is not causing excessive tension to the site. Some patients like the padding a gauze provides around the site or under the external (bolster, disc, bumper, phalange, anchor). The site should be washed gently with soap, followed by a water rinse and patted dry, including underneath the external (bolster, disc, bumper, phalange, anchor). Harsh agents such as hydrogen peroxide should not be used for routine cleaning because they can inhibit wound healing and irritate the skin. Hydrogen peroxide may be used to lift crusty drainage if needed, but it should be followed immediately by a water rinse. Keeping the site as dry as possible will help lower the risk for skin breakdown and hypertrophic or granulation tissue growth. The external (bolster, disc, bumper, phalange, anchor) should ideally be about a dime s width from the skin. Patients may take tub baths or swim after 2 6 weeks depending on provider s instructions. Stomal Feeding Tubes: Replacement Stomal tubes may eventually tear, malposition, or dislodge, so they should be periodically replaced to avoid emergency department visits and the potential for missed nutrition, fluids, and medications. The balloon volume of balloon

12 Lord 27 G and J tubes tends to shrink over time, or the balloon may rupture and spring a leak, leading to tube malposition and dislodgement. Balloon G tubes should generally be replaced every 3 6 months, depending on manufacturer s guidelines and patient history of tube malfunction and dislodgements. Nonballoon G tubes (includes PEG tubes) should be replaced every 6 12 months, depending on manufacturer s guidelines. With nonballoon G tubes, the internal (bolster, disc, bumper, mushroom, or dome) may deteriorate and separate either while in situ or when removing the entire tube through the abdominal wall by the traction pull technique. Tube Patency To keep feeding tubes patent and avoid sludge buildup and clogs, they need to be flushed regularly with water (Figure 27), pump alarms need to be responded to quickly, viscous solutions and slow flow rates need to be avoided, and medications should not be mixed with each other or with the tube feeding formula. According to the American Society for Parenteral and Enteral Nutrition (ASPEN) 2017 Safe Practices for Enteral Nutrition Therapy, feeding tubes should be flushed with at least 30 ml pf water every 4 hours during continuous tube Figure 27. Water flush. C Nestlé Health Science, reprinted with permission. feedings, before and after intermittent feedings, and after GRV checks. 58 They also should be flushed with at least 15 ml of water before, after, and in between each medication. In hospital and clinic settings, sterile water is generally used for water flushes, medication dilution, and reconstitution of powdered formulas. In the home setting municipal tap water can be used for routine water flushes; however, distilled or sterile water is recommended for powdered formula reconstitution, medication dilution, and flushes before and after medication delivery. These solutions are free of heavy metals and other contaminants that can cause untoward interactions and alter the pharmacodynamics of administered drugs. 59 Because sterile water is not generally covered by insurance in the home setting, distilled water is acceptable. Juices or sweetened sodas should not be used for flushes because their acidic nature can coagulate the protein in feeding formulas and form clogs Medication Delivery Through Feeding Tubes Medications administered through feeding tubes should be given in liquid form or, if allowed, crushed to a fine powder and dissolved completely in water. Crushed and dissolved tablets in water are preferred as the liquid forms of medications are manufactured for oral consumption and contain added sugars and flavoring agents, making them more viscous and hypertonic. Some liquid medications contain sorbitol, which has a laxative effect and may cause diarrhea, bloating, and gas. As noted earlier, medications should be diluted with sterile water, or in the outpatient setting distilled water may be used. Delayedreleased, enteric-coated, or microencapsulated medications cannot be crushed because it alters the drug bioavailability. Medications should not be mixed with each other or with the tube feeding formula, and the tube feeding may need to be held around the administration time of some medications. Administering each medication separately with at least a 15 ml of water flush in between prevents physical and chemical incompatibilities that can alter the actions of the drugs and can cause clumping and tube clogging. 58,59,63 Medications should be administered via G ports if possible. If a small-bowel port needs to be used for medication delivery, be sure that the solution is intended for immediate-release systemic absorption, that it is not too viscous or hyperosmolar, that the drug is not meant for direct action in the stomach or require the acidity of the stomach, and that the alkaline environment of the small bowel does not inhibit drug absorption. It would be prudent to consult with a pharmacist for any concerns related to medication administration via feeding tubes. Tube Declogging One complication that interferes with the timely delivery of the nutrition formula, free water, and medications is the

13 28 Nutrition in Clinical Practice 33(1) clogging of the feeding tube. Nasoenteric feeding tubes and J tubes are more likely to clog than G tubes because of their longer lengths and narrow diameters. The initial recommendation regarding tube declogging is to work on the clog as soon as possible. The longer the wait, the less likely the tube declogging technique will be successful. 64 Address pump alarms and reported difficulties with infusions as soon as possible. Initially an attachment of a water-filled syringe and plunger movement back and forth can be used to help loosen up a clog and encourage clog withdrawal from the tube s lumen. 65 If it does not clear, water penetration 66,67 may be initiated while supplies are gathered for the selected tube declogging procedure. Pancreatic enzymes activated with baking soda and water have been shown to dissolve clogs more effectively compared with solutions such as sugared sodas, cranberry juice, or meat tenderizer. 68 The following subsections provide some suggested techniques. (Note: If any of these techniques are successful in loosening a clog, the clog should be withdrawn if able and the tube flushed immediately afterward with at least 30 ml water.) Initial Water Flush Withdraw all fluid from the tube so that the water to be instilled is in closer proximity to the clog; then attach a 30- to 60-mL syringe of water and use a back-and-forth motion to loosen the clog and then attempt to withdraw the clog. Water Penetration Withdraw all fluid from tube so that the water to be instilled is in closer proximity to the clog; then attach a 30- to 60- ml syringe of water, instill as much water as the tube will allow under mild pressure, and use a back and forth motion to loosen then clog, then leave in place minutes. Periodically move syringe back and forth during this period. Try to withdraw; repeat if needed. Activated Pancreatic Enzyme Activated pancreatic enzyme uses the same technique for water penetration described earlier but substitutes a declogging solution: Dissolve a crushed 650-mg non-entericcoated sodium bicarbonate tablet or ¼ tsp baking soda in 10 ml of warm water. Add the contents of an opened 12,000-U pancrelipase capsule (Creon) or a crushed 10,440- U pancrelipase tablet (Viokace) and allow to dissolve (may take minutes). Withdraw all fluid from tube so that the declogging solution is in closer proximity to then clog and then follow the water penetration technique. The declogging solution can be repeated once, but if unsuccessful the tube will likely need to be replaced. This solution can also be used as a prophylactic lock to prevent sludge buildup in the highrisk tubes. 72 A short-term periodic lock such as a 1-hour instillation once weekly, not continuous, would be prudent to avoid any potential interactions between the solution and the material composition of the tube. 73 Commercial Declogging Devices Commercial declogging devices are those manufactured by industry to declog feeding tubes. Enzyme cocktail in preloaded syringe: patented powder containing α-amylase, papain, cellulase, enzyme enhancers, and antibacterial agents preloaded in a syringe that is activated with water. The solution is then instilled through a narrow-bore applicator tube that is inserted in the feeding tube for closer proximity to the clog. It remains in the tube for minutes to exert its declogging action. It can be used in all enteral tube types. A company trial states 100% success rate on the first or second try in 17 patients with formula clogs. 74,75 Machine-operated declogger: a flexible wire encased in a sheath that is attached to a machine that causes a rapid back-and-forth motion to mechanically break up clogs. 76 It can be used with nasally inserted G and J feeding tubes. The advantage of this method, according to the company, is the average procedure time of 2.8 minutes compared with water penetration and enzymatic methods that can take minutes. Corrugated plastic rod: A long, flexible plastic rod with corrugations that is inserted into the tube and twists into a clog to mechanically break it up. This can only be used for larger-bore G and J tubes, and the length to be inserted needs to be predetermined so as not to exceed the length of the tube. 77 Tube Position Most enteral access devices have incremental markings on the tube that identify the length of tubing beginning from the tip, or for stomal tubes from the point just above the internal retention device, continuing to the distal end (Figures 28 and 29). Documentation of the incremental marking on the tube at the exit site (nares, mouth, or stoma) just after initial insertion can assist in determining tube migration inward or outward. The tube could also be marked with an indelible marker at the exit site, but these markings fade so the initial marking should be periodically redrawn. For nasoenteric feeding tubes, standard G tubes, standard G/J tubes, or J tubes, the visible tube length can also be measured and documented for future comparison. GRV and Small-Bowel Residual Volume Checks For patients who are unable to communicate symptoms of GI upset, the aspiration of GRVs from feeding tubes

14 Lord 29 Figure 28. Weighted feeding tube with incremental markings. Figure 29. Balloon G tube with incremental markings. with a syringe has been an age-old and widely accepted method to help determine tolerance to EN support. Enteral tube feedings have been held 1 hour for a variety of GRVs ranging from 50 ml or twice the hourly rate, to more recent recommendations allowing values as high as ml. Standardized GRV protocols were not established with their widespread use because GRV measurements and the subsequent holding of tube feedings were not investigated for the ability to prevent aspiration or aspiration pneumonia until recently. Researchers over the last couple of decades have begun to compare different levels of GRV used to hold enteral formula delivery with the incidence of aspiration and aspiration pneumonia, percentage of goal formula delivered, and associated GI symptoms in the intensive care unit (ICU) patient population. There was a recent review by Elke et al 78 of these randomized controlled trials and various observational studies related to GRV monitoring. This group advised examining patient characteristics and the delivery strategy of the EN support when developing protocols for the use or nonuse of GRV checks. They noted that a multicenter trial of critically ill patients on a ventilator that showed no benefit of adjusting EN for GRV checks >250 ml on nosocomial pneumonia rates had enrolled 93% medical ICU patients. 79 In this investigation, surgical and trauma patients, who are at higher risk for aspiration pneumonia, were not fully evaluated. In addition, they noted that in trials where feedings continued despite GRVs, strict protocols were applied to prevent gastric reflux and aspiration of contaminated oral secretions including head of bed (HOB) elevation, regular oral decontamination, and use of prokinetic agents. In an investigation using an aspiration risk protocol by Metheny et al, 80 it was found that the combination of HOB elevation (by medical order and hourly documentation in the medical record) and bedside insertion of smallbowel feeding tubes for patients determined to be at high aspiration risk, decreased aspiration prevalence rate from 88% to 39% and pneumonia from 48% to 19%. GRVs were obtained, and only 3 patients (2%) in the study group using the aspiration risk protocol had a residual volume of 200 ml. EN Delivery Schedules The traditional tube feeding delivery strategy is the gradual increase of the hourly infusion rate until reaching the goal rate. The goal rate is determined by dividing the total volume to be infused per day by 24 hours. However, when the feeding is interrupted, less formula is infused and the goals frequently are not met. Newer, more aggressive approaches have been suggested, and some may initiate feedings at goal rates, use promotility agents, or allow for higher hourly rates to make up lost infusion times Elke et al 78 have suggested that those patients who are undergoing these more aggressive schedules are more likely to benefit from GRV checks because higher amounts of formula are being infused more swiftly and may not be tolerated as well. Although not all elevated GRVs will lead to a clinically significant aspiration, it has been shown that the probability of aspiration is higher when GRVs are elevated. 86 Guidelines for GRV Checks Published guidelines for GRV checks generated by various countries have not been identical in their recommendations. The National Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient submitted in February 2016 by the Society of Critical Care and the ASPEN suggest that GRVs not be

15 30 Nutrition in Clinical Practice 33(1) used as part of routine care to monitor ICU patients receiving EN. 87 They also state that for those ICUs where GRVs are still utilized, holding EN for GRV <500 ml in the absence of other signs of intolerance should be avoided. The Canadian Practice Guidelines suggest a GRV threshold of ml and contend that abandoning GRV checks or using a 500-mL threshold was premature and questioned the external validity of the current trials. 88 The German Nutrition Society suggests abandoning GRV checks in medical ICU patients provided that the medical team has the ability to adjust the enteral infusion, such as when vomiting occurs. 89 However, in the surgical ICU patients, they suggest obtaining GRV checks and adjusting the EN delivery rate with a threshold of 200 ml. The 2006 ESPEN (European Society for Parenteral and Enteral Nutrition) Guidelines on Enteral Nutrition: Intensive Care do not address GRVs except that IV administration of metoclopramide or erythromycin should be considered in patients with intolerance to enteral feeding e.g. with high gastric residuals. 90 Notably, published guidelines are based upon investigations of nasally inserted feeding tubes with tips ideally well into the stomach, but do not address G tubes situated in the anterior portion of the stomach. It would appear that a given GRV from a G tube would be more worrisome and, therefore, should have lower GRV limits. GRV: Discard or Reinstill? A randomized, prospective clinical trial was conducted in an adult medical-surgical ICU of a public university hospital comparing various outcomes of patients randomized to the discarding vs the reinstilling of GRV (up to 250 ml, remaining volume discarded). 91 They were identified as the discard and return group. The return group surprisingly had a significantly lower incidence of subsequent high GRV (>350 ml), and the authors suggested that the reinstilling ofthegrvmayhavesomeeffectatmaintaininggrv at closer physiological levels. 91 There was a statistically higher frequency of hyperglycemia episodes in the return group. There was no difference in obstruction of the nasally placed feeding tubes, enteral feeding delays (defined as >20% difference between prescribed and amount administered per day), intolerance episodes (nausea, vomiting, diarrhea, and abdominal distention), discomfort episodes, or hypokalemic episodes. The authors also stated that there was no difference in pulmonary aspiration between groups; however, the definition of this was not well defined. It appears that they checked blood glucose in tracheal aspirates to determine the aspiration of glucose-containing formula. This method has been shown not to correlate with aspiration of formula, but has a correlation with blood glucose levels and, therefore, is not useful for detection of tube-feeding formula aspiration. 92 Notably, all patients had HOB elevated 30 degrees, were on continuous tube feeding schedules, and received 40 mg of omeprazole per day. These practices have been shown to lower GRVs, and study results showed only a 2.3% incidence rate of GRV >250 ml in the return group and a 4.1% incidence rate of GRV >250 ml in the discard group. The GRVs were <150 ml in 93% of the return group and 88% of the discard group. This study gives some evidence that reinstilling up to 250 ml of GRV poses no additional risk for increased accumulation of gastric fluid levels, GI intolerance, or hypokalemia, but did not address the incidence of pulmonary aspiration between groups. Minimizing Aspiration Risk This leaves institutions still in a quandary of what GRV amount warrants holding EN and for how long. The practice of GRV checks is time consuming, may increase the risk for contamination and tube clogging, and may promote the holding of EN unnecessarily. Institutions should examine these various guidelines and research investigations closely, and develop protocols or algorithms based on their patient population and EN delivery schedules. It should also be noted that oropharyngeal and gastric secretions also contribute to aspiration risk. Protocols to minimize aspiration risk should not weigh heavily on GRVs but include measures that prevent the movement of enteral feedings and contaminated secretions into the lung. Protocol or algorithm development geared toward minimizing aspiration risk in hospitalized tube-fed patients should consider the following: HOB elevation degrees with documentation at least every 4 hours. If HOB is contraindicated, consider reverse Trendelenburg position. 87,93,94 Routine oral care with chlorhexidine twice daily 87,94,95 Performance of oropharyngeal suctioning when handling of secretions is difficult, before the HOB is lowered, before the endotracheal tube cuff is deflated, and prior to extubation Use continuous tube feedings by pump instead of bolus feedings for patients at high aspiration risk 81,83 GRV frequency, 4-hour intervals are suggested in critically ill patients 92,96 GRV levels at which to: o hold tube feedings and for how long o perform a GI review of systems and an abdominal examination o consider a promotility agent 87 o convert to a small-bowel feeding tube 87 Guidelines for volume of GRV to reinstill back to the patient 91

16 Lord 31 Assess for position of enteral access device: noting that the initial marking on tube is still positioned at the exit site or that the premeasured external tube length is the same, 4-hour intervals are suggested. 96 Tube position should also be checked if the patient has emesis, retching, or a coughing episode, tube has been tugged on, or tube length appears too long or short. Frequency of GI review of systems that includes presence of nausea, emesis, reflux, feelings of fullness, abdominal discomfort, pain, or cramping: 4- hour intervals are suggested 96 Frequency of abdominal assessments that include evidence of distention and abnormal or absence of bowel sounds, and tracking of bowel movements/ostomy outputs: 4-hour intervals are suggested 96 Utilization of minimal sedation techniques Discontinuation of GRV checks When patients become alert and communicative, they can be questioned on GI symptoms to determine tolerance to EN. They can report their feelings of fullness, nausea, bloating, and abdominal discomfort, and it can be noted if they are having regurgitation or emesis. These interventions can be used instead of GRV checks to assess adequate gastric emptying of EN infusions. Residual Volume Checks From Small-Bowel Feeding Tubes Clinicians may want to check residual volumes from nasally placed small-bowel feeding tubes or the J port of a G/J tube in patients who are at high risk for aspiration, having reflux, vomiting, or having shortness of breath to detect potential tube-tip malposition back into the stomach. The clinician may detect a significant increase in the volume and change in color of the aspirate. These checks may also help determine whether there may be a distal obstruction, because small-bowel residuals should typically be of a low volume. However, it is especially important that J tubes be flushed with water before and after these checks to maintain tube patency because they can clog easily and require a higher level of skill to replace. Enteral Connections Enteral access devices require connection to a syringe or feeding bag to administer the feeding formula, medication, or water to the patient. Misconnections between unrelated delivery systems need to be avoided because deleterious outcomes have occurred when, for example, enteral feeding formulas have been inadvertently infused into IV catheters. 97 The Stay Connected initiative was created by GEDSA Figure 30. ENFit design. Image from stayconnected.org website. (Global Enteral Device Supplier Association) to help introduce new small-bore connectors in medical devices to prevent misconnections between unrelated delivery systems. The Stay Connected initiative is assisting in the gradual introduction of new standard connectors for delivery of specific liquids and gases, starting with enteral access devices. With the new ENFit design, enteral feeding containers, enteral syringes, and the distal end of extension sets (low profile devices) will contain the female connector end, and enteral access devices will contain the male connector end (Figure 30). This new ENFit design will not allow enteral delivery system connections to IV catheters, IV solutions, respiratory equipment, neuraxial analgesia/anesthesia, or limb cuff inflation devices. Information and updates on the initiative can be found at 98 Tube Complications Tube Malposition A tube can malposition anytime after tube placement when the tip of the nasally placed feeding tube migrates from the small bowel to the stomach, or from the stomach to either the esophagus or small bowel. The tube is unlikely to malposition to the bronchial tree once positioned properly in the GI tract. 22 If a small-bowel tube advances farther into the small bowel over time, this is generally considered desirable because it would further decrease the aspiration risk. Malposition may be detected by a change in length of visible tubing or movement of a predetermined marking on the tube; however, the tube may also malposition up and down the GI tract without any evidence of shifting on the outside. 22 The small-bowel lumen of a transgastric G/J tube or a transgastric J tube may also migrate back into the stomach without any visual changes in the position of the tube on the abdomen. Placement of a G tube directly into a

17 32 Nutrition in Clinical Practice 33(1) gastric stoma or a J tube via a jejunal stoma lowers the risk for tube malposition. Visualization and ph testing of tube aspirates may help determine the tube tip location Once continuous drip tube feedings are initiated, the appearance and ph of the aspirates change because creamy tan formulas will obscure the color, and the higher ph (>6.0) will affect the ph of the aspirate. 23,99 Gastric aspirates will tend to be curdled formula, off-white with sediment, green, brown, or bloody, whereas small-bowel aspirates could be clear golden yellow thicker than water, yellow-brown or greenish brown, or either could emerge like unchanged formula. If the patient is receiving intermittent feedings, an aspirate check just before a feeding for visualization and ph check may help determine gastric vs small-bowel placement. One investigation showed that the use of 3 indicators for tube position resulted in the ability to determine tube location 81% of the time in critically ill patients on continuous tube feeding schedules in either the stomach or small bowel. 99 These were observing for tube length changes and the volume and color of the aspirates, 5 times daily. They also observed for ph values; however, 98.4% of patients studied were receiving either an H2 receptor antagonist or a proton pump inhibitor. The ph value was significantly lower in the gastric compared with small-bowel aspirates, but the means were 6.4 vs 6.8, respectively. Despite the use of gastric acid inhibitors, in about 50% of the cases where the tube malpositioned from the small bowel to the stomach (11/23), the ph value decreased from 6 7 to 5.5. In the remaining patients, the ph remained 7 in both locations. Observation of a substantial increase in the volume of aspirate from a tube originally positioned in the small bowel may indicate malposition of the tube tip into the stomach. Of concern is a tube tip that malpositions from the stomach upward near the gastroesophageal junction or into the esophagus, or a small-bowel tube that malpositions in the stomach because these can increase aspiration risk. When a patient vomits or refluxes formula, the mouth should be checked for excess tubing, and if the tube is not visibly malpositioned, tube-tip location should be checked by radiographic film before restarting the tube feeding infusion. Alternatively, if a gastric tube malpositions into the small bowel, an intermittent drip or bolus feeding schedule could cause dumping syndrome, as evidenced by abdominal pain and bloating, diarrhea, dizziness, flushing of the skin, and diaphoresis. Exit Site Issues Nasally inserted feeding tubes. Nasoenteric tubes may cause skin breakdown and ulcerations at nares or mouth. Other complications surrounding these tubes include otitis media, epistaxis, or sinusitis. Sinusitis may occur because of the tube blockage of normal sinus drainage and can present as nasal pain or pressure, redness, edema, fever, and/or purulent discharge. One investigation showed as many as 16% of surgical ICU patients had fever of unknown etiology due to sinusitis that resolved after drainage. 100 Largerbore 18 Fr nasogastric tubes have been associated with an increased incidence of middle-ear effusions in intubated patients. 101 Stomal tubes. Site drainage. Stomal tubes may have site drainage that could be normally clear, tan, cloudy, yellow, green, and brown. If the drainage is excessive, then tube position and internal balloon volume, if present, should be checked. If the external (bolster, disc, bumper, phalange, anchor) is positioned more than a dime s width from the skin, then it should be repositioned by an experienced clinician/individual. If excess leakage continues despite proper tube positioning and balloon volume fluid content, the clinician could consider transitioning a G tube to a G/J tube instilling formula and fluids distally, allowing healing of the G tube site with good site care (see later). Proton pump inhibitor therapy should be considered to prevent or treat site irritation from excessive acidic gastric leakage. Skin breakdown and site infection. If there is redness or excoriation at the exit site, zinc-based products, such as diaper rash creams or absorptive powders, can be applied and the site covered with a split-gauze dressing. If there is excessive site leakage, a dressing that is manufactured to wick away moisture is preferable to gauze. Nonalcohol skin barrier films or skin barrier wafers can be used. 102 If there are scattered reddened raised papules spreading from the stoma outward, a fungal infection is suspected. This can be treated with a topical antifungal such as nystatin powder or cream applied directly and a zinc oxide cream coating covered with a split-gauze dressing, twice daily. A wound consult can be obtained and should be if these first-line treatments are ineffective. To evaluate for a stomal-site infection, observe for redness, induration, edema, pain, and sometimes fever. The color of the site drainage does not determine an infection because normal gastric fluid can be a variety of colors including green. If an infection is suspected, a thin layer of an antibiotic ointment can be applied, or if severe, a broadspectrum antibiotic may be warranted. Site pain. Excessive pain at stomal tube sites may be caused by an external (bolster, disc, bumper, phalange, anchor) that is positioned too tight, tube dislodging, skin breakdown, or a site infection. Hypertrophic or granulation tissue growth. Over time, there may be the development of reddened, lumpy, moist, shiny

18 Lord 33 Figure 31. Granulation tissue. tissue growth protruding from the stoma site of stomal tubes. This is called hypertrophic or granulation tissue,sometimes referred to as proud flesh, and may emerge from the internal stoma because of moisture and tube movement (Figure 31). The presence of this excess tissue usually leads to increased site drainage as the seal around the tube is compromised and continued drainage provides more moisture for continued tissue growth. The treatment involves dissolution, commonly with silver nitrate applicators, and continued treatment with a topical corticosteroid that can be applied with a cotton tip applicator as needed. 103 Mometasone furoate 0.1% can be used once daily or triamcinolone acetonide 0.1% 3 times daily. Care must be taken not to apply the corticosteroid on healthy skin because it will cause thinning of the skin over time. As a last resort, surgical removal of granulation tissue can be undertaken, but should be performed only by a skilled clinician because it can bleed easily and a thorough assessment is needed to rule out malignancy. 104 Prevention of granulation tissue growth around a stomal tube consists of keeping the site as dry as possible, securing the tube to prevent movement, and ensuring that the movable external attachment device or low profile tube is positioned about a dime s width from skin. Tumor implantation and metastasis at PEG tube site. A rare but potential complication in patients with throat cancer appears to be the shearing of cancer cells during PEG tube placement and subsequent tumor seeding at the abdominal wall and PEG tube site. 105 In 1 report of 218 patients with head and neck cancer with active disease and a viable tumor in the oropharynx or hypopharynx at the time of PEG placement, 2 patients (0.92%) experienced PEG site metastasis. 106 This can be treated with palliative radiation or resection, but prognosis is poor. 105 Because this complication has for the most part been reported Figure 32. Buried bumper syndrome. C Nestlé Health Science, reprinted with permission. with endoscopically placed G tubes using the transoral approach, alternate methods of tube placements, such as radiologic percutaneous tubes using the transabdominal approach, could be considered in patients with head and neck cancer, and an overtube technique has also been suggested. 105,107,108 Buried bumper syndrome. At times, the internal (bolster, disc, bumper, dome) of stomal tubes may embed into the gastric wall from excessive traction and become buried (Figure 32). This may occur with nonballoon stomal tubes but is not likely with balloon stomal tubes. Symptoms of this syndrome include pain during infusions, resistance to infusions, and inability to rotate G tube 360 degrees. Transgastric G/J tubes should not be rotated because the J tube portion could malposition. Treatment is tube removal. This untoward event can be prevented by rotating G tubes 360 degrees daily and loosening the external (bolster, disc, bumper, anchor) slightly if it is determined to be too tight to the skin. Leaking or broken caps of G tubes. The distal caps of G tubesmaylosetheirgripovertimeandbegintoleakormay begin to rip off the tube. Some tubes have replacement Y connector caps, so the faulty cap may be exchanged with a new cap. These are available for nonballoon G tubes and some balloon G tubes. In balloon G tubes where the balloon port is congruent with the tube s lumen, the distal Y connector cap cannot be replaced because severing the end of the tube would deflate the internal balloon (Figure 33). The distal Y connector replacement caps are only available for balloon G tubes where the balloon port is positioned beyond the Y connector (Figure 34). Stomal tube dislodgement. Early dislodgement of a G tube is a medical emergency because the stomach lining can

19 34 Nutrition in Clinical Practice 33(1) Figure 33. Y connector congruent with tube. Figure 34. Y connector separate from tube. separate from the abdominal wall, leading to internal gastric leakage into the peritoneum and peritonitis. 109 Patients usually need to go to the emergency department for replacement under the appropriate visual guidance. If tubes are blindly replaced before complete healing, the new tube could potentially malposition outside the stomach or intestine and also cause peritonitis. The maturity of a stomal tract depends on tube type, insertion method, and provider discretion. Balloon G tubes that have gastropexy sutures (retention sutures or T-fasteners) applied initially securing the stomach to the peritoneum develop a mature or established stomal tract in about 4 6 weeks. Nonballoon G tubes without the gastropexy suture securement are dependent solely on the pressure between the external (bolster, disc, bumper, phalange, anchor) and the internal (bolster, disc, bumper, dome), and it may take 6 weeks up to 3 months before it is considered mature or established. J tube stoma tract maturity also takes up to 3 months. Once a tract is considered mature or established and the tube dislodges, a new tube may be inserted at the bedside or in a clinic setting by a credentialed provider or trained caregiver. Healthcare facilities should establish policies that address who can replace stomal tubes and the designated wait period for tract maturity. Clinicians who replace G and J tubes should be credentialed for this procedure. In our medical facility, we wait 8 weeks for necessary balloon G tube replacements at the bedside or in a clinic setting in the adult patient population. For the nonballoon PEG and J tubes that do not have the added securement of gastropexy sutures, we wait a full 3 months for needed tube replacement at the bedside. Stoma tracts may begin to narrow and close within a few hours when a stomal tube dislodges, even in a mature tract. Clinicians who are not credentialed may consider placing a temporary Foley (balloon deflated) or red rubber urethral catheter of the same Fr size as the original tube to prevent closure. This temporary tube should not be used until a replacement G or J tube is safely placed by a credentialed clinician. If a patient s caregivers are trained on tube replacement in a mature stoma tract, they should replace tubes only in the individual on which they were trained. A G or J tube also should not be replaced blindly if there are signs of infection at the site. Tube replacement generally does not require analgesia but does benefit from either a topical water-soluble lubricant or anesthetic jelly to ease the new tube through the stoma tract. The new tube should be of the same Fr size and the same centimeter shaft length if a low profile tube unless it has been determined that an alternate shaft length would be more appropriate. Shaft lengths may change if a patient s abdominal girth decreases or increases. After blind insertion of a new G tube, placement could be checked by an attempt to aspirate fluid, but this may not always be possible because typically patients who undergo a planned procedure have been instructed to have no food or tube feedings for at least 4 hours beforehand. In addition, the position of a G tube on the anterior surface of the stomach is not conducive for access to GRVs. A water flush should be instilled through the tube after placement to be sure there is no resistance or discomfort. There should be the ability to rotate the G tube a full 360 degrees. J tubes should not be rotated because this could cause tube malposition. If any difficulty occurs with tube insertion, resistance to a water flush afterward, or pain with infusions, confirm placement with radiographic film.