“Button, Button. Where’s The Button?” A Discussion of Gastrostomy Tubes

Elizabeth Paton, RN, MSN, PNP, FAEN

OBJECTIVES Discuss History of Gastrostomy Tubes in Pediatrics

List Types of Gastrostomy Tubes

Troubleshoot Basic Problems with Gastrostomy Tubes

Discuss Feeding After G-tube Placement and Formulation of Postoperative CPOE

GASTROSTOMY TUBES IN PEDIATRICS: A BRIEF HISTORY

Surgical placement of gastrostomy tube since 1870s

First Percutaneous Endoscopic Gastrostomy (PEG) Tube was placed June 12, 1979

Laparoscopic gastrostomy since mid 1990s

Other techniques:

Percutaneous radiological gastrostomy (PRG)

Single site laparoscopic gastrostomy

COMPLICATIONS

MAJOR

Peritonitis

Pneumoperitoneum

Colonic fistula/perforation

Bleeding

Obstruction

Failure to insert in stomach

Sepsis

MINOR

Tube dislodgement

Tube blockage

Tube leakage

Tube migration

G-tube site infection

Intussusception

TROUBLESHOOTING

Leaking

Clogged tube

Local skin irritation

Granulation tissue

CLOGGED TUBE

Medications that may cause clogging:

Ciprofloxacin

Clarithromycin

Cholestyramine

Iron

Kayexalate

Lactulose

Management:

Flush with 5-10ml warm water

May use “push-pull” technique

GRANULATION TISSUE Keep area dry

Absorptive gauze or foam dressing

Stabilization of tube

Mepilex or Mepilex AG

AgNO3 Stick

Triamcinilone

Excision

HOME GASTROSTOMY SUPPLIES

For MIC-KEY G-tube

MIC-KEY G replacement kit, same size(Fr and cm), 1 now, 4 per year

MIC Secure-Lok extension set 0124-12, 4 per month

60cc catheter-tip syringes- 10 per month if bolus-fed, 2 if continuous feeding

For continuous feedings or intermittent feeds with a pump: feeding pump and appropriate feeding bags, 30 per month

OTHER GASTROSTOMY TUBE SUPPLIES Benik Belt

Button Buddies

Farrell Valve

NOW, LET’S TALK ABOUT BUTTONS….

SOMETHING ELSE FOR US TO NIBBLE ON...

PROPOSED FEEDING REGIMEN Gravity drainage POD 0

POD 1:

Clamp G-tube, check residuals q4 hours X2

If tolerates, and low residuals:

Initiate formula feeds at ¼ of goal, continuous

Increase by ¼ of goal every 6 hours to goal (should be reached in 24 hours)

Nursing communication to include:

Volume of residuals to delay initiation of feeds

Instructions for prn venting

OK to use for medications

Items for notification of MD

POST-OP GASTROSTOMY TUBE ORDERS

Vital Signs

[ ] Vital signs T;N, Temperature,Pulse,Respirations,Blood Pressure every 4 hours

Activity

[ ] Activity as Tolerated T;N, ad lib

Food/Nutrition

[ ] NPO T;N,

Patient Care

[ ] Gastrostomy Tube Care T;N, Gastrostomy tube to gravity

[ ] Nursing Communication T; N: OK to use gastrostomy tube for medications

Respiratory Care

[ ] O2 Sat- Continuous Monitoring (RT) T;N, q2h

Continuous Infusions

[ ] D5 1/2NS KCL 20mEq/L 1000mL,IV,Routine,T:N, at____mL/hr

Medications

[ ] heparin flush 3mL (10 units/mL), injection, IVPush, PRN, routine,T;N, peripheral or central line per nursing policy

[ ] morPHINE _____ mg, (0.1 mg/kg), Injection, IV, q3h, PRN Pain, Routine, T;N

Consults/Notifications

[ ] Dietitian T;N, Reason: Gtube: Enteral feeding management

[ ] Consult Case Management T;N, Reason:Home Gtube supplies

POST-OP DAY 1 GASTROSTOMY TUBE ORDERS

Food/Nutrition

[ ] Tube Feeding Titrate Peds

[ ]

Formula: If child has tolerated clamping of gtube, please start gtube feeds (1/4 of goal volume continuous, increase by 1/4 of goal q6 hours to goal of ___cc/hr)

Patient Care

[ ] Gastrostomy Tube Care T;N, Clamp Gastrostomy tube, measure and record residuals q4 hours

[ ]

Nursing Communication

T;N, If after second check of gtube residuals, residual is less than ___, and child tolerating clamping, please initiate feeds as ordered

[ ] Nursing Communication T;N, Please vent gtube q4 hours and prn gastric bloat, abdominal distention, or wretching

[ ]

Nursing Communication

T;N, If Gtube residual is >hourly volume infused for 2 consecutive hours, please hold feed for 1 hour then resume at previous rate

[ ] Nursing Communication T; N: OK to use gastrostomy tube for medications

Continuous Infusions

[ ] D5 1/2NS KCL 20mEq/L 1000mL,IV,Routine,T:N, at____mL/hr

Medications

[ ] Acetaminophen/Hydrocodone 0.2mg/kg gtube q4h hours prn pain

Consults/Notifications

[ ] Dietitian T;N, Reason: Gtube: Enteral feeding management

[ ] Consult Case Management T;N, Reason:Home Gtube supplies