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 Management: Flush with 5-10ml warm water May use push-pull technique Cholestyramine Iron Kayexalate Lactulose
Keep area dry Absorptive gauze or foam dressing Stabilization of tube Mepilex or Mepilex AG AgNO3 Stick Triamcinilone Excision GRANULATION TISSUE
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 [ ] Dietitian [ ] Consult Case Management Consults/Notifications T;N, Reason: Gtube: Enteral feeding management T;N, Reason:Home Gtube supplies
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