GI WORKSHOP. GASTRIC/GASTROINTESTINAL TUBES Indications for use Types of tubes Tube feeding methods...

GI WORKSHOP

GASTRIC/GASTROINTESTINAL TUBES

• Indications for use

• Types of tubes

• Tube feeding methods

• Safety and Infection Control issues

• Miscellaneous issues

INDICATIONS FOR GASTRIC/GASTROINTESTINAL TUBES

• Decompression and gastric emptying

• Enteral feeds - OG/NG/ND/GT

• Diagnostic studies

• Medication administration

DECOMPRESSION AND GASTRIC EMPTYING

• What is it:

– The removal of air and gastric contents from the stomach

– A means of preventing intestinal distension by decreasing the amount of air & gastric secretions passing to intestines

– Accomplished by placing a tube into the stomach and connecting this tube to a suction source


• Why we do it:

– Many surgical & medical procedures can cause a great decrease in intestinal motility. Air & secretions can accumulate and overwhelm a sluggish GI tract causing gastric and intestinal distension.


• SURGICAL INDICATIONS :

-To protect a surgical suture line from the effects of over distension: i.e. TE fistula repair, diaphragmatic hernia repair

-To provide bowel rest after invasive abdominal procedures: ie. exploratory laparotomy, creation of an ostomy –any procedure where the abdominal cavity is invaded and there is “mechanical manipulation” of the bowel


• SURGICAL INDICATIONS :

– “Mechanical manipulation” causes peristalsis of the bowel to slow down significantly leading to distension

– To provide bowel rest after abdominal trauma i.e. liver/splenic laceration which leads to decreased peristalsis and distension

DECOMPRESSION/GASTRIC EMPTYING

• MEDICAL INDICATIONS :

– To provide bowel rest for certain medical conditions: i.e. Crohn’s disease, ulcerative colitis

– For patient’s with an ileus or bowel obstruction

DECOMPRESSION/GASTRIC EMPTYING

• MEDICAL INDICATIONS :

– For patients in shock and on high dose epinephrine/norepinephrine drips

• These shunt blood flow away from the GI tract and therefore decrease motility and absorptive capability of the GI tract which can cause distension

– Shock, arrest scenarios

• The body automatically shunts blood from GI tract and redirects it to vital organs for organ preservation resulting in the same effect as above

TUBES USED FOR DECOMPRESSION AND GASTRIC EMPTYING

REPLOGLE/SUMP TUBE

Vent Port

Aspiration Port

REPLOGLE TUBE

• REPLOGLE TUBE—also called a “Salem Sump” tube

– Uses: • Prevention of gastric distension, vomiting and aspiration

REPLOGLE TUBE

• This is the only tube used for gastric decompression!!

– Why?

• It has both an aspiration port and a vent port (blue)

– What do these do ?

• As gastric contents are suctioned from the aspiration port, atmospheric air enters the blue vent port preventing a vacuum effect from occurring inside the stomach

REPLOGLE TUBE

– What does that do?

• Prevents the suction pressure that the stomach is exposed to from exceeding 25 mmHg

– Thereby:

• Preventing the replogle tube from adhering to the stomach wall & causing mucosal damage to stomach lining which can cause bleeding

REPLOGLE TUBE

And with surgical repairs:

- Protects esophageal and gastric suture lines from the trauma of

excessive suction

DO NOT FEED THROUGH THIS TUBE!!!

REPLOGLE TUBE: USER GUIDE

• Use LOW CONTINUOUS wall suction only

• Replogle is working properly if you see a constant “MARCHING” of secretions up the tube

• NEVER occlude blue vent port: – No syringes, clamps, claves - must be kept open to air

REPLOGLE TUBE: USER GUIDE

• NEVER vent the blue port with a syringe. If secretions are coming up the blue vent port then the port needs to be cleared with air. If this occurs repeatedly, the replogle may need to be replaced. Check with MD.

• Secretions can vary in color: clear, yellow, light green can be seen

• Call MD immediately if secretions are coffee ground or red in color – this indicates bleeding

REPLOGLE TUBE: TROUBLESHOOTING

Problem #1: No “marching” of secretions up the tube

– Solution: Clear both blue vent port and aspiration port with 3-10 ml of air

• Still not working? Check with MD and see if they want the tube replaced

• If so, clarify with the MD as to whether the RN or the physician is to replace

• Be sure you get a physician order if RN is to replace tube

REPLOGLE TUBE: TROUBLESHOOTING

Problem #2: Gastric secretions leaking out blue port

– Trouble Shooting:

• Flush blue port with 3-10 ml of air

• Keep blue vent lumen above patient’s midline or it will act as a siphon and leak

– Blue port still leaking? Check with MD to replace tube using previous guidelines

• Never occlude blue port because of leakage of gastric secretions as this defeats the intended purpose of the vent port which is to prevent excessive suction. Troubleshoot and/or contact MD

REPLOGLE: MISCELLANEOUS INFORMATION

• Document output every 4 hours on nurses notes

• Check patency and aspirates every 4hrs

• Be aware of patient’s fluid and electrolyte balance

REPLOGLE: MISCELLANEOUS INFORMATION

• Notify MD of large amounts of output from replogle.

– If deemed excessive, this volume may need to be replaced intravenously with appropriate IV fluids

• NG charcoal can be administered via the replogle to counteract the effects of some types of ingestions if:

– An ETT tube is in place to protect the airway in a patient with an altered LOC

or

– The patient’s own natural airway protective mechanisms are intact

USES FOR TUBES: ENTERAL FEEDING

WHY ENTERAL (TUBE) FEEDS?

• Provide supplemental calories: i.e. patient’s with FTT (failure to thrive)

• For patient’s with impaired intestinal digestion/absorption: i.e. Cystic Fibrosis

• To bypass an anatomic abnormality: i.e. TE fistula

• For patient’s who are unable to swallow/protect airway: i.e. neuromuscular disease

WHY ENTERAL (TUBE) FEEDS?

• For patient’s experiencing cyanosis/apnea with feeds due to reflux

• For patient’s on mechanical ventilation as they are unable to take nutrition orally

• Promote wound healing

• Speed recovery of patient—nutrition=strength

ENTERAL FEEDS: SHORT TERM VS. LONG TERM USE

• Delivering feeds enterally (via tube) can be accomplished using an OG/NG/ND if the feeding problem is a temporary one

• If long term feeds are required , special feeding devices that are introduced surgically will be used i.e. Mickey, Peg, Bard (GT feeds), and GJ tubes

TUBE PLACEMENT

TUBES FOR SHORT TERM ENTERAL FEED USE: OG/NG

OG/NG TUBE

OG/NG TUBE PLACEMENT: GENERAL SIZE GUIDELINES

• < 2kg: use 5 French tube

• 3 - 9kg: use 8 French tube



• 30 - 50kg:use 14 French tube

• >50kg: use 16 French tube

OG/NG TUBE PLACEMENT METHOD

• Nurse can insert with an MD order

Method:– NG:

• Place distal end of tube from tip of nose to ear lobe and then down to a point midway between xiphoid and umbilicus

– OG: • Place distal end of tube from corner of mouth to earlobe and then down to

a point midway between xiphoid and umbilicus

– Place a piece of ¼ inch tape here

– Lubricate distal tip of tube


• Insert tube into nostril or mouth and pass into pharynx aiming down and back

• Advance to premeasured mark (tape)

• **Key point: If patient becomes dusky with tube placement - STOP IMMEDIATELY and remove tube -you may have entered the AIRWAY


• When the pre-determined depth is reached, check for proper placement of tube in stomach by BOTH:

– Aspirating for stomach contents AND

– Instilling 1-5 ml of air and listening for a whoosh of air over gastric region with stethoscope


• Finish by:– Taping NG in place in the space between the upper lip nose – Tape OG on chin

– For NG/OG: • Use tube to vent/feed• Cap off if for prn use

– *Note: • Replogle tube placed using same method but place tube to low

continuous suction

TUBES FOR INTERMEDIATE TERM ENTERAL FEED USE:

ND TUBES

NASODUODENAL (ND) TUBES

Guide Wire

Weight

ND TUBE: DESCRIPTION

• ND tubes are placed nasally or orally and extend into the DUODENUM

• ND tubes are made of a flexible polyurethane material that is yellow in color

• The wire stylet inside the tube and the tungsten weight at the end of the tube are designed to assist with proper placement

ND TUBES: USES

• Used for:

– Patients who will require feeds for an extended (not permanent) period of time

– Patients with reflux/aspiration issues

– Patients on ventilator support

ND TUBES

• Only a PHYSICIAN may place an ND

• ND tubes may be placed by a physician at the bedside or in fluoroscopy

• The ND tube’s internal guide wire must be removed by MD before tube can be used—DO NOT reinsert guide wire

Guide Wire

ND TUBES

• The RN may ADVANCE an existing ND tube- (see policy and procedure PED_11 PCD for instructions)

• When an ND tube is properly placed you will not be able to aspirate feeds

• **DO NOT use ND until placement has been confirmed by MD with an abdominal X-ray

TUBES FOR LONG TERM ENTERAL FEED USE:

MIC-KEY TUBE

ABOUT THE MIC-KEY

• The Mic-key is a type of “GT” feeding tube

• The Mic-key device is inserted into stomach through the abdominal wall via a gastrostomy opening which has been previously surgically created

• The Mic-key utilizes a feature whereby the feeding tube extension set locks into the Mic-key base “like a key in a lock”

MIC-KEY TUBE: FEATURES

• The external base- which extends above the skin

• The anti reflux valve inside the base - helps prevent stomach contents from leaking out of the Mic-Key

• The silicone water filled balloon - sits inside the stomach - 5ml is usual volume-- do not fill with air!

Balloon

External Base

MIC-KEY TUBE: FEATURES

• There are 2 types of feeding tube extension sets: one for continuous feeds and one for bolus feeds

• Both can be used for venting (see picture-middle and left tube respectively)

MIC-KEY TUBE: USE

• Check for proper placement before each feed by:– Connecting the extension set to button and – Aspirating for stomach contents or – Instilling 5-10 ml of air into extension set and listen for air

entry into stomach with stethoscope

• Aspirate and check for residual feed amount: – Establish guidelines with MD as to whether residual is to be

returned or discarded. – Remember, residuals contain important nutrients and

electrolytes!

MIC-KEY TUBE: USE

• Attach the appropriate extension set - continuous or bolus feeds

• The bolus feed set is straight and has a larger diameter than the continuous feed extension set

• Begin feeds– For continuous use kangaroo or medfusion pump

– For bolus use a 60 ml syringe and gravity

MIC-KEY TUBE: USE

• After feed, flush extension set with the amount of water specified by MD to prevent clogging of both extension set and Mic-key button

• Both the continuous feed extension set and the bolus extension set can be used for venting

• NEVER “hand-deliver” feeds by actively injecting them into any type of feeding device!

MIC-KEY TUBE: CARE

• Inspect stoma site and surrounding skin after each feed - it should be dry and intact

• Proper tube placement:– There should be no more than a dimes’ width of space between

the base of the Mic-key and the skin

• Stoma site care: – For a well healed stoma-soap and water– For a newer stoma see Policy PED_11_PTC

MIC-KEY TUBE: CARE

• Rotate the Mic-key in a full circle when you do your daily tube care

• A well healed Mic-key does not require a split 2x2 gauze placed between base and skin

MIC-KEY TUBE: TROUBLESHOOTING

• Problem: Feeds leaking out around stoma site– Trouble Shooting:

• Is the residual large?

• Can you aspirate a lot of gas?

• Are the feeds going in too fast?

– Consider switching from bolus to continuous feeds

• Does patient have a history of delayed gastric emptying?

– Report findings to MD and await instructions

MIC-KEY TUBE: TROUBLESHOOTING

• Problem: bleeding around stoma– Call MD immediately

• Problem: Granulation tissue build up (results from body trying to repair the surgical incision)– May need to be treated by MD

• Problem: Mic-key falls out: – Cover with gauze and call MD immediately. Nurses DO NOT

replace Mic-key’s

OTHER LONG-TERM FEEDING DEVICES

BARD FEEDING TUBE

BARD TUBE

• Lower profile than Mic-key– Less chance of accidental dislodgement (see picture-top middle is

actual device)

• Has bolus or continuous extension set option (see picture - middle and far left respectively)

• Has a SEPARATE extension set for venting– The feeding extension sets do not vent (see picture-far right)

• Usually patient/ parent preference re: Mic-key or Bard tube

ENTERAL FEEDS

• CONTINUOUS VS BOLUS

ENTERAL FEEDS: CONTINUOUS

• Delivered via feed pump at a set rate using kangaroo pump and bag (see below)

• Can be delivered OG, NG, ND, GT

• Check residuals every 4 - 6 hr

• Define parameters for residuals with House Officer re: return, discard, hold feeds

ENTERAL FEEDS: BOLUS

• Can be delivered NG, OG, GT only -NOT ND– Cannot gravity flow into ND tube - (ND needs continuous

method of delivery)

• Check residuals before giving feed by aspirating feeding tube prior to feed

• Check MD order for instructions for residuals: ie. discard/give back/ hold feed

• Delivered via “CHIMNEY” – That is, connect a 60 ml syringe (WITHOUT the barrel inside)

to the feeding tube. Attach syringe to bed above level of

patient’s head but no more than 18 inches above stomach

ENTERAL FEEDS: BOLUS

• ***Remember, the HEIGHT OF THE CHIMNEY dictates how fast the feeds will be delivered. The higher the chimney, the faster the feeds are delivered and visa versa

• Deliver bolus feed over 15 - 30 minutes by adjusting the height of the chimney &/or putting small amounts of feed in at a time

• Flush and clamp when feed complete or vent to allow excess gas to escape

ENTERAL FEEDING: GENERAL GUIDELINES

• Always confirm feed rate, method and type

• Check Kardex to confirm depth at which tube placement documented– Number visible on tube at nare for NG/ND and at the corner

of the mouth for OG/OD – Charted on Kardex

• Confirm tube placement via auscultation and aspiration for stomach contents (auscultation and X- ray confirmation for ND)

ENTERAL FEEDING: GENERAL GUIDELINES

• Check tape on tube is secure to both face and tube– Be aware tube can slide through tape out of stomach and into

upper esophagus or posterior pharynx resulting in a high risk of ASPIRATION!

• HOB up 30-45 ° during feed

• After bolus feeds– Instill 1-2 ml sterile H20 for small tubes– 5 - 15 ml for larger tubes

– Prevents clogging

DISCONTINUING OG/NG TUBES

• Wait a minimum of 30 minutes after a feed before discontinuing to prevent emesis

• Position patient HOB up 30-45 °

• Drape patient (chux)

• Flush tube with 1-3 ml H20

DISCONTINUING OG/NG TUBES

• Clamp

• Remove tape from face

• Withdraw tube and discard

• Provide oral/nare care

ENTERAL FEEDS: SAFTEY & INFECTION CONTROL

SAFTEY/INFECTION CONTROL

• Always check tube placement before use

• HOB up 30-45 ° during and after feeding

• Stop feeds ½ hour before and after CPT

• Kangaroo pump– Change bag every 24, only 4 hours of feed in bag

SAFTEY/INFECTION CONTROL

• No microwaving of formula or breast milk

• Breast milk - 2RN’s check and document

• **DO NOT modify the feed tubing in any way– Prevents inadvertent IV delivery of enteral feeds

• Use special orange-striped “safety” tubing if using Medfusion pump to deliver feeds

WHAT TO DOCUMENT WITH EACH FEED

• Size and type of tube/device

• Confirmation of placement, patency of tube/device

• Amount, color, consistency of residuals

WHAT TO DOCUMENT WITH EACH FEED

• Type of feed, amount, rate, method used to deliver (continuous/bolus)

• Tolerance of feed

• Complications/adverse side effects

REPORTABLE EVENTS

• Stop feeds and call MD for:

– Abdominal distension or pain

– Signs/symptoms of respiratory distress: gasping, coughing, cyanosis, excessive drooling

– Decreased or absent bowel sounds

– Altered skin integrity around tube site

– Accidental removal or slippage of tube

– Increased residuals

– Diarrhea or cramping

GASTRIC TUBES AND DIAGNOSTIC STUDIES

DIAGNOSTIC STUDIES

OG/NG Tubes can be used for :

– Administration of barium for upper GI studies

– Administration of contrast medium (i.e. radioisotope) for special CT studies

– To withdraw gastric contents for specimen collection and examination

TUBES AND MEDICATION ADMINISTRATION

MEDICATION ADMINISTRATION

• OG/NG/ND/GT TUBES CAN BE USED TO:• Give scheduled OG/NG/ND/GT medications

NOTE: If patient is on bolus feeds or is NPO except for medications, keep tube clamped x 20-30 minutes after medication administration to ensure absorption

• OG /NG/GT tubes can be used to deliver medications which:• Counteract the effects of overdose or ingestion (charcoal and

mucomyst for example)

THE END!!!!!!!

GI WORKSHOP. GASTRIC/GASTROINTESTINAL TUBES Indications for use Types of tubes Tube feeding methods...

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