Gastointestinal Feeding Tubes

Gastointestinal Feeding Tubes

1. Gastrointestinal intubation

   • Insertion of tube through mouth, nose, abdominal wall in the stomach, duodenum or jejunum.
     • nasoenteric: gose to jejunum and duodenum Nasogastric: stomach
     • Function
       • Decompression
         • orogastric tube
         • Remove gas and fluid from the stomach
           • prevent from distending the coisl of the intestine
       • Lavage
         • orogastric tubeflush the stomach via gastric tube water or fluids to clear it
         • Remove ingested toxins
       • Gavage
         • orogastric tubes
         • Meds, feedings
       • DX
         • Disorders,
           • gi motility..
           • Aspirate content for lab
       • Compression
         • Stop hemorrhage w/ pressure
           • Sengstaken Blakemore tube
             • 3  ports (aspiration, inflate ball0on, putting in ice cold water    
     • Solution given by gravity, electric pump. Aspiration w/ syringe, electric suction machine or wall suction outlet.

2. Gastric tubes

   • 2.5-5/0 Fr for neonates 14-20 FR for adults Gastrostomy tube, duodenal tube, jejunostomy tube, gastojejunostomy tube (in through stomach and terminates in jejunum), gastroduodenal tube Medium length: feedingLong: decompression, aspirationLow profile feeding tube: pt confused or children, kept in place with baloon filled with water that must be checked and filled. Has an adapter
   • Levin
     • plastic or rubberfor feeding
     • Single lumen
       • 125cm, 14-18Fr
         • Feeding for pt that are confused, can be use for decompression but no air vent.
           • Used for decompression on low intermittent suction (30-40 mmHg).
   • Gastric Sump or Salem
     • Salem sump Intermittent or continuous suction
     • Double lumen blue pigtail
       • 120cm, 12-18FR
         • #1 for decompression lavage (blue pig tail air to circulate to not damage tissue when using for decompression (25mmHg), gavage, lavage
           • Antireflux valve: to not reflux into the blue pigtail and block it
           • Low continuous or intermittent suction 25mmHg. Inserted and placement confirmed at bedside
   • Sengstaken Blakemore
     • Triple lumen
       • 2 used to inflate gastric and oesophageal ballon, one for suction and drainage
   • Moss
     • Triple lumen
       • 90cm, 12-16 FR
         • Decompression gavage
   • Nasoenteric
     • Dobbhoff or EnteraFlo
       • polyurethane or sillicone rubber
       • Single lumen
         • 160-175cm, 8-12 fr
           • Tungsten weighted tip
     • Kaofeed or Corpak
       • prevents aspiration
       • Single lumen
         • 56-140cm, 5-12FR
           • Smaller in diameter, made of flexible substances such as silicone or polyurethane lumen – closed system.
             • Weighted bottom to allow peristalsis to pull feeding tube down (to place wherever we want
               • guidance
               • Feeding only, cooperative pt Must be x-rayed to determine placement. Placement in Stomach/jejunu
   • PEG tube
     • percutaneous endoscopic gastrostomy tube feeding, administering meds   •Check placement aspirating •Check measurement w/ ruler Don't put dressing under tube: infection, tension, decrease healing, site leaking, ulceration, inadvertent removal     
     • Passes through abdominal wall, sits in stomach or intestines
       • 3 ports
         • one for meds, one for feeding and one to inflate ballon

3. Terms

   • Antireflex valve
     • valve prevents return or backup flow of fluid
     • LPGD
       • Low profile gastrostomy device, G button enteral feeding access device flush w/ the skin used for long term feeding
       • PEG
         • percutaneous endoscopic gastrostomy endoscopic procedure to insert feeding tube in stomach to give longterm nutritional support
   • Aspiration
     • removal of substance by suction, breathing fluids of foods in trachea and lungs
     • Nasoduodenal tube
       • through nose to duodenum
   • CVAD
     • central venosu access device device fro lognterm admin of meds and fluid in central veins
     • NG tube
       • nasogastric nose to stomach
   • Cyclic feeding
     • periodic feeding or infusion for short period 8-12 hours
   • Dumping syndrome
     • rapid emptying of stomach contents in small intestine, sweating and wreakness
     • Nasojejunal tube
       • nose to jejunum
   • Gastrostomy
     • sx creation of opening in the stomach to give foods and fluids
     • PN
       • administration of nutritents IV
       • TNA
         • total nutrient admixture lipid,emulsions,protein, carbs,electroytes, vits, trace minerals and water 
   • IVFE
     • intravenous fat emulsion, intralipids: oil in water emulsion of oils, egg phospholipids and glycerin

4. Administering medications

   • hand hygien, check everything before, gather supplies
   • Check order and confirm with pharmacist that med can be given via EFT
     • dru-drug, drug-nutrient, drug-tube(ocmposition od drug bind to tube), drug-efficiency(may need higher or lower doese d/t/ route) interactions
     • Tell pharmacy type of feeding pt is getting determine amount of time to hold feeding before and after giving meds
       • Some meds need to be taken on an empty stomahc: Levothyroxine,Phenytoin, Ciprofloxacin, Penicillin... 
     • Confirm bioavailability if given via EFT and any drug interactions, how to prepare med, other form if pill is enteric coated
       • check allergies Medication are best absorbed is some places: iron primarily in duodenum, warfarin small intestines, if dose has been detemined based on large first pass effect it can lead to toxicity and increased bioavailability if it's given in the jejunum rather than the stomach
     • Confirm tube placement
       • X-ray at first insertion but after that 
       • X-ray
       • Aspiration
         • Observation, visual charac of aspirate
           • Gastric
             • Clea, colorless, pale, yellow, green
               • pH less than 4, unless pt is on acid reducing meds or continuous enteral feeds.
           • Duodenal
             • Brown, yellow due to bile
               • pH greater or equal to 6
       • Auscultation
         • assessment fr signs of distension 200mL of air and auscultate
       • Check 10 rights of medications
         • Medications should not be added to enteral feeding formula
         • Liquid and immediate release tablets(diluted) only can be given
           • May need to dilute liquids: hyperosomlar meds (?600 mOsm), high sorbitol content cna cuse diarrhes, stomach tolerates better hyperosmolar meds Dilute with sterile water, do not crush sublngual meds
         • Administer
           • Pt positioning imp ,semi or high fowlers position or reverse trendelenburg for those who can't tolerate hip flexion
           • Give meds one at a time
             • one at a time: physical  and chemical incompatibilities, altered therapeutic response, tube obstruction
           • For oral, enteral use only syringes 30mL or above
           • Don't use large volume syringe to measure small doses of meds d/t/ innacuracy
           • Dilute all meds in 10 mLs of sterile H2O. Flush 30 mLs of H2O, administer all medications separately and flush in between with 10 mls sterile H2O, Finish with a 30mLs flush of sterile H2O.
           • Complications
             • mechanical (e.g., aspiration, tube displacement/dislodgement or obstruction; post-operative complications, such as hemorrhage, wound dehiscence, and leakage of stomach contents; leakage due to inadequate attachment of infusion tubing to the feeding tube; tube displacement/recoil which increases the risk of aspiration )infectious (e.g., infection of the insertion site, pneumonia by aspiration, contamination of the diet)GI (e.g., abdominal distention, colic, diarrhea, constipation, nausea, vomiting, pain)metabolic (e.g., fluid/electrolyte imbalances; hypokalemia, especially in patients with insulin resistance; hyperglycemia, most often observed in patients with a high-carbohydrate diet)
             • Diarrhea
               • antibiotic preparations or antacidsliquid formulations containing sorbitolhyperosmolar solution
             • Nausea/vomiting
               • edication precipitation (e.g., congealing) and subsequent change in consistencyinsufficient flushing of tubing before and after feedings or medication administrationinadequately crushed medicationantacids, which should be avoided if possible due to an increased risk of interacting with enteral feedings, leading to tube obstruction
             • Tube obstruction
             • Intestinal obstruction
             • Re-feeding syndrome
               • feeding too fast
             • Replace irrigation trays used to flush every 4-8hrs
             • Patient, family teaching
               • -Why EFT is being used -Purpouse of med and action -Before discahrge: how to care fro EFT, use and give feeds and meds written instructions -Demonstrate how to give meds and feeds and how to assess -Seek help if: nausea, vomitting, distention, pain, EFT becomes occluded To flush with warm sterile water using push pull technique, after 4-6 failed attempts call fro help
               • Document med admin in MAR and procedure in chart
                 • Consultation with pharmacist
                 • Confirmation of correct tube placement
                 • How procedure was performed
                 • Pt tolerance to procedure
                 • Unexpected events, interventions, whether physician was notifyd
                 • Pt, family education
             • Oral discomfort -Fluid volume deficit -Movement of tube- aspiration -Necrosis of nares, oral mucosa, oesophagus and trachea

5. Enteral nutrition

   • pt and family teachiing, explain rationale hanga nd set like IV
   • Open system
     • Hang time 4-8 hours, bag changed every 24hours
   • Closed system
     • 48hrs hang time
   • Monitoring
     • Continuous
       • Tolerance: check gastric residual volume (GRV) (q4-6hr)
         •     Aspirate every 4-6hours and get all stomach contents out of pt (no more than 100 ml about) w/ continuous feed- hold tube feed fro 4 hours to give change to digest otherwise pt increased risk aspirate- continuous     
         • GRV> 250mL hold feeds
           • Return RV to max of 250mL and discard rest
             • Monitor for aspiration, reassess in 4hr
     • Intermittent
       • Check GRV before feed until tolerance is established
         • Flush 30mL of sterile water b4 and after each feed
           • Elevate HOB 30-45degrees until 30min after feed

6. Removal of gastric tubes

   • Maybe clamped b4 removal to ensure pt has no nausea (no throwing up you can remove it)
   • Ensure placement and flush with 10mL of sterile water
   • Wear gloves, conceal tube w/ towel, withdraw tub slowly until tip in oesophagus then remove quickly
   • Oral, nose hygiene +++

Images and files in the map