Button, Button. Where s The Button?

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1 Button, Button. Where s The Button? A Discussion of Gastrostomy Tubes Elizabeth Paton, RN, MSN, PNP, FAEN

2 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

3 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

4 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

5 TROUBLESHOOTING Leaking Clogged tube Local skin irritation Granulation tissue

6 CLOGGED TUBE Medications that may cause clogging: Ciprofloxacin Clarithromycin Management: Flush with 5-10ml warm water May use push-pull technique Cholestyramine Iron Kayexalate Lactulose

7 Keep area dry Absorptive gauze or foam dressing Stabilization of tube Mepilex or Mepilex AG AgNO3 Stick Triamcinilone Excision GRANULATION TISSUE

8 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 , 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

9 OTHER GASTROSTOMY TUBE SUPPLIES Benik Belt Button Buddies Farrell Valve

10 NOW, LET S TALK ABOUT BUTTONS.

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12 SOMETHING ELSE FOR US TO NIBBLE ON...

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14 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

15 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 [ ] Dietitian [ ] Consult Case Management Consults/Notifications T;N, Reason: Gtube: Enteral feeding management T;N, Reason:Home Gtube supplies

16 POST-OP DAY 1 GASTROSTOMY TUBE ORDERS Food/Nutrition [ ] [ ] [ ] [ ] [ ] [ ] [ ] Tube Feeding Titrate Peds Formula: Gastrostomy Tube Care Nursing Communication Nursing Communication Nursing Communication Nursing Communication 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 T;N, Clamp Gastrostomy tube, measure and record residuals q4 hours T;N, If after second check of gtube residuals, residual is less than, and child tolerating clamping, please initiate feeds as ordered T;N, Please vent gtube q4 hours and prn gastric bloat, abdominal distention, or wretching T;N, If Gtube residual is >hourly volume infused for 2 consecutive hours, please hold feed for 1 hour then resume at previous rate 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 [ ] Dietitian [ ] Consult Case Management Consults/Notifications T;N, Reason: Gtube: Enteral feeding management T;N, Reason:Home Gtube supplies

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