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Feeding Tubes-More Info
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One more word on feeding tubes
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Volume 6, Number 4, August 1999
SURGERY

If all other methods fail and the patient isn't getting sufficient nutrition and hydration, a percutaneous gastrostomy tube (PEG), also known as a feeding tube, may be necessary.

Dr. Robert McMichael, a neurologist and MDA clinic director in Arlington, Texas, believes that with diseases such as ALS there are advantages to performing a PEG placement soon after dysphagia symptoms appear.

One reason is to stop the debilitating effects of malnutrition. Also, the patient may have greater tolerance for the procedure early in the disease process, before respiratory problems have become advanced.

Although it's possible for the procedure to be done on an outpatient basis, McMichael likes to have patients stay in the hospital a day or so before and after the procedure. This allows him to correct dehydration and offer respiratory therapy before the surgery, and gives him a chance to teach the patient and family how to use the PEG after the tube is in place.

The decision to get a PEG is highly personal. Patients are understandably reluctant to undergo an invasive procedure that bypasses the normal eating process, yet some are ultimately relieved after the surgery and find they get some of their strength back after receiving adequate nutrition again.

"The decision to get a PEG (feeding tube) is highly personal."

There's also a procedure to help control excessive saliva production, which involves cutting the nerves to the major salivary glands.

Another surgical procedure that may be considered in some cases of dysphagia is the cricopharyngeal myotomy, which involves cutting one of the muscles of the pharynx.

This muscle is meant to serve as a kind of gatekeeper as food passes from the pharynx into the esophagus. However, if the muscle fails to relax properly and allow food passage, it may become more of an impediment than a help. In such cases, the muscle's surgical removal may cause marked improvement in the ability to swallow.
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Enturostomal tubes for the long haul

An enterostomal device, which is inserted percutaneously through a stoma created on the abdomen (gastrostomy or jejunostomy), can be placed by surgical, endoscopic, laparoscopic, or radiologic techniques. It's indicated when the nasal route is contraindicated or when the patient is expected to need long-term enteral feedings.


An enterostomal device may be used temporarily or for permanent feedings, based on the patient's needs. If the tube will be used for permanent feedings, it will probably require periodic replacement because the tube material deteriorates over time. The replacement device should be the same style and diameter as the original device to avoid leakage.

Now let's review the various enterostomal devices available. Always know which type of tube your patient has and refer to your institution's policies and the product literature for information about managing it in your facility.

* Gastrostomy tubes. After creating a stoma in the abdominal wall using an open surgical, laparoscopic, or endoscopic approach, the physician inserts a short feeding tube into the stomach. Surgically created stomas are placed under general anesthesia with an abdominal incision. A surgeon opts for surgical placement if the patient's condition is complex and he wants to view the anatomy more clearly or create a stoma as a secondary procedure during abdominal surgery for another condition. A laparoscopic gastrostomy also requires general anesthesia or monitored conscious sedation, but it's less invasive, less painful, and associated with fewer complications.

If the patient underwent general anesthesia, he may have an ileus for the first 24 hours. Gastric decompression is usually ordered until bowel motility returns to normal. Wait at least 24 hours after placement to begin feedings, as ordered.

If your patient has a gastrostomy tube with a balloon, check the balloon volume every 7 to 10 days. Consult the manufacturer's literature to determine what the balloon volume should be and make sure the fluid volume is the same amount as originally instilled. If the volume is less, visually assess for a leak and refill to the manufacturer's recommended volume.

* Percutaneous endoscopic gastrostomy (PEG) and dual access gastrostomy-jejunostomy (PEG/J) tubes. The PEG method has become one
of the most popular approaches for gastrostomy placement. The physician places the PEG and PEG/J tube endoscopically under local anesthesia and conscious sedation. The gastrostomy lumen of the PEG/J is used for gastric decompression, the jejunostomy lumen simultaneously delivers enteral feedings.

A PEG/J tube doesn't necessarily provide the same protection against aspiration as a jejunostomy tube because the pylorus is partially compromised by the larger catheter, increasing the risk of duodenalgastric reflux. The jejunal portion of the PEG/J may migrate back into the stomach, which may lead to kinking, luminal occlusion of the catheter, reflux, and aspiration.

Both PEG and PEG/J tubes are held in place by internal and external retention devices. The internal retention device may be a crossbar or balloon with a mushroom catheter and antireflux valve. It rests snugly in the stomach, preventing tube migration and leakage of gastric contents. An external retention disk, bumper, or crossbar sleeve secures the device to the abdomen. Holes on the external piece allow air to reach the skin, decreasing the risk of maceration.

Made of silicone and polyurethane, PEG and PEG/J tubes are very durable and less likely to be damaged by gastric secretions than latex tubes (such as an indwelling urinary catheter), which are sometimes used as temporary feeding devices.

* Low-profile gastrostomy devices (LPGDs). An alternative to the traditional gastrostomy or PEG tube, an LPGD is usually placed into a mature gastrostomy tract; it's anchored in the stomach and protrudes just above the skin. Many patients say it's more acceptable cosmetically and gives them greater independence.

LPGDs are available with a firm internal bumper or with a balloon-style internal bumper that's inflated after insertion. An antireflux valve keeps gastric contents from leaking onto the skin. The LPGD is very durable, unlikely to irritate surrounding skin, and difficult to accidentally dislodge, so it's a good choice for children and confused adults who tend to pull at their
tubes.

You'll need a special adapter provided by the manufacturer to connect the LPGD to the feeding tubing set, to check gastric residuals, or to use the tube for gastric decompression.

* Jejunostomy tube. This device (see page 46) may be placed for long-term postpyloric enteral feedings when bypassing the stomach is desirable. Patients who will benefit from jejunostomy feedings include those with gastric disease, abnormal gastric and duodenal emptying, upper GI obstruction or fistula, absent gag reflex, or significant risk of esophageal reflux and aspiration.
Jejunostomies are contraindicated for patients with primary small-bowel disease (such as radiation enteritis or Crohn's disease) due to the high risk of enterocutaneous fistula formation.

The physician may place the jejunostomy tube surgically or with laparoscopic, radiologic, or endoscopic guidance.

Securing a tube

Carefully secure the feeding device to avoid dislodgment or internal migration into the GI tract. After initial placement, mark a NET with tape or indelible ink at the insertion site so you can see any migration. Most long-term tubes have markings imprinted onto the tubing. Document the external length of tubing.
Flushing facts

To avoid a clogged feeding tube, thoroughly flush enteral feeding devices every 4 to 6 hours during continuous feedings and whenever feedings are on hold, before and after administration of feedings and medications, and after checking residuals.
 
Always use a large syringe (30 to 60 ml) for flushing to prevent rupturing the tube. Irrigate the tube with 20 to 30 ml of tepid water. No fluid has been found to be superior to water for maintaining patency.

If the feeding tube has a Y port connector, flush through the side port. Otherwise, disconnect the feeding infusion and flush
directly into the tube.

Skin care considerations

Inspect the skin around a gastrostomy or jejunostomy site daily for signs of skin breakdown, infection, tenderness, orexcoriation. Leakage of gastric contents onto surrounding skin will cause maceration. Always look for the cause of a leak rather than simply patching up the area with a new dressing.

For the first week after placement, clean the skin and external retention device daily (typically with 0.9% sodium chloride and sterile cotton-tipped applicators). Apply half-strength hydrogen peroxide to remove crusty debris. In some institutions, nurses also apply an ointment such as povidone-iodine.
 
After the first week, clean the stoma site daily with soap and water. You may want to apply a bland ointment such as zinc oxide or petrolatum to protect the skin from moisture. Continue to gently clean under the
external retention device with a cotton-tipped applicator.

Gently rotate a gastrostomy tube 360 degrees daily, according to manufacturer's recommendations, and check for an in-and-out play
of about 1/4 inch (about 0.5 cm). If the anchoring device is pressing too tightly into the abdominal wall and you can't move the tube in and out even slightly, notify the physician. This may indicate "buried bumper syndrome," which means the retention disk has become imbedded in surrounding tissue and erodes into the stomach or abdominal wall.

Author/s: Sybil Bowers
Issue: Dec, 2000
http://www.findarticles.com/cf_0/m3231/12_30/68504986/p1/article.jhtml?term=Tube+feeding+%2F+Safety+and+security+measures
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Feeding Tube & Deadly Germs

Not of interest to a lot of people, except those you know on tubes or even
late stage HD where susceptibility to germs/infections are more common
(touches on high bacteria in milk products).

This study shows a high risk factor for those on feeding tubes for pneumonia, fever, infection and sepsis all which can be deadly in themselves, mostly caused by bacteria/germs associated with the feeding tube and it's handling.

Full article lists all the nitty gritty stuff, but below captures some of the
highlights on causes of bacteria and possible solutions in avoiding getting
them.

Most people handling feeding tubes are aware of the need to wash hands
etc.  But considering the probably bacteria/possible contaminiation in tap water, adding medication or even food dye (for tests) etc isn't  thought about.  Even the high risk of bacteria to the tube itself.   I.e. when  flushing the tube I've seen nurses stick the little plastic tip from the bag into the tube itself, (after it's been lying on the bed or table) rather then use the little cap which is part of the tube because it was faster!

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From Abbott Laboratories:
Why should you be concerned about contaminated tube feedings?
http://www.ross-ce.com/ce_rn/haccp/haccp01.cfm

Microbial standards for food and milk appropriate for the general public may not be stringent enough to protect the tube-fed population. Clinicians say that because tube-fed persons often are immunocompromised, they are at greater risk from foodborne illness.
 

Tube-fed persons who are particularly vulnerable to  microbial contamination include those immunocompromised due to: (some listed)

Malnutrition
Debilitation
Critical illness
Chronic disease

Because GI symptoms, fever, infection, pneumonia, and sepsis can arise from many causes, it is difficult to identify the particular contribution of microbially contaminated tube feedings to these poor outcomes. 

Clinicians, however, are highly suspicious that microbially contaminated
tube feedings may contribute to the incidence of complications, increasing the length of hospitalization and mortality.

Respiratory tract infections are a major cause of morbidity and mortality in critically ill patients. Studies have linked tube feeding and pneumonia in critically ill populations

Another study specifically links mortality with contaminated feedings. This study of 33 tube-fed patients revealed that 12 (36%) received contaminated tube feedings; 5 of these patients (42%) had the same microorganism isolated from blood or sputum cultures and from their tube feeding. Two patients had S marcescens in both their feeding and sputum. One of those patients had several positive blood cultures for S marcescens and, ultimately, expired from septic shock.

In view of these grave consequences, the authors stated, "Further investigation to examine the effects of contamination, and devise better methods in continuous feeding systems is warranted."

Why is microbial contamination a hazard?

Tube-feeding formulas are highly nutritious and are used in conditions conducive to exponential microbial growth. Therefore, once tube feedings are contaminated, levels of contamination can quickly reach those
associated with  GI colonization, food poisoning, sepsis, and other hazards. 

Before they are opened,  ready-to-use tube-feeding formulas are commercially sterile. Once opened, however, these products can
be contaminated in clinical settings by improper handling, holding, and/or administration techniques.

Many studies of the microbial quality of tube feedings in the clinical setting have identified levels of contamination exceeding the FDA upper limit of 104 organisms/g.    Tube feedings containing levels as high as 2 x 106 (2,000,000) organisms/mL have been delivered to patients and have been clearly associated with GI illnesses.

Sources of Contamination in Enteral Feedings and Delivery Systems

    Nonsterile ingredients
    Touch contamination
    Prolonged hangtime of contaminated formula
    Prolonged use or reuse of delivery system components

-For example, Anderson et al1 reported that both tube feedings made with blenderized foods and commercial formulas that had been manipulated harbored a significantly greater number of organisms than commercial formulas that had not been manipulated. The blenderized and manipulated
formulas contained between 103 and 105 CFU/mL, predominantly coliforms.

-microbial contamination is correlated with development of fever and nosocomial infections. Patients showed a statistically significant correlation between tube-fed patients receiving contaminated tube feedings who developed fever (6 or 13.9%) compared with patients not receiving contaminated feedings

Touch Contamination During Preparation and Administration

Poor design of connectors, caps, etc, makes it easy  during setup to touch parts that will be in contact with the formula. Microbial contamination may occur when  people handle the system.

  • Wash hands thoroughly with soap and water before handling formula administration set or feeding tube.
  • Sanitize all equipment (blenders, mixing utensils, etc) and surfaces used for formula preparation.
  • When using decanted formula, sanitize the container before opening it.
  • Avoid touching any part of the container or the administration set that will come in contact with the formula (eg, the container, feeding port, the piercing pin on the feeding set).
  • Use disposable gloves.

Prolonged Hangtime

Ready-to-use tube-feeding formulas are commercially sterile when they come from the manufacturer.  If they become microbially contaminated, they readily support microbial growth.  Prolonged hangtime of
contaminated formula is  associated with unacceptable microbial levels.

  • Limit hangtime of reconstituted powder formulas to 4 hours.
  • Limit hangtime of decanted formulas to 8-12 hours.
  • When using decanted formula, allow the feeding container to empty completely prior to refilling.
  • To achieve maximum safe hangtime with prefilled containers follow manufacturer's Instructions for Use.
  • If Instructions for Use are not followed, limit hangtime to 8-12 hours.

Formula Manipulation

Adding water or other substances, or using procedures that increase handling of formulas or administration systems, increases the potential for contamination

  • Avoid manually adding water, medications, colorants, or other substances directly to the formula
  • Use commercially sterile formulas; avoid blenderized foods because of their naturally high microbe load.
  • Avoid manually adding water, colorants, medications, or other substances directly to formula
  • Use full-strength formula.
  • When necessary for GI tolerance, reduce the administration rate instead of diluting the formula.
  • Use clean technique to add medications to the feeding tube if they cannot be given by another route.
  • Reduce handling by using prefilled feeding containers.

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How to keep feeding tubes flowing freely.
Author/s: Carol Kohn-Keeth
Issue: March, 2000


How to clear the way if clogging occurs.

WHEN CARING for a patient who's receiving tube feedings, you need to know how to deal with potential occlusions. First, be alert for signs of trouble. You should suspect an obstruction if:

* you can't flush the tube
* you can't aspirate from the tube
* you see formula leaking from the insertion site
* formula that's being given by gravity won't flow through the tube
* the occlusion alarm sounds repeatedly when formula is given by pump.

If an occlusion occurs, try flushing the tube with warm water and a large piston syringe using a gentle push-and-pull motion. Don't use carbonated beverages or juices; their efficacy in unclogging a feeding tube is unproven.

Never use a stylet to unclog a tube. It can puncture the tube or, worse, part of the gastrointestinal tract. You may want to try one of the newer plastic declogging devices to mechanically unclog a feeding tube.

Only someone with expertise in nutrition support should attempt other methods. For tips on keeping tubes clear, see the accompanying chart. A multidisciplinary approach --working in conjunction with physicians, nutritionists, and pharmacists--will help ensure successful outcomes when caring for patients receiving tube feedings.


Common causes of                          How to
feeding tube obstructions               prevent problems

Tubing or delivery set kinked       * Examine the feeding tube and
                                                       delivery system regularly to
                                                       ensure that it's stabilized, it's
                                                       anchored properly, and it has no
                                                       kinks or twisted tubing.

Percutaneous endoscopic           * Make sure the tube rotates
gastrost (PEG) tube                       freely. If a PEG tube is immobile,
kvembedded internally                   notify the physician immediately.
("buried bumper" syndrome)

Inadequate or infrequent           * Institute a routine flushing
of the flushin feeding tube;           protocol: Flush the tube with
formula residue adhering              about 30 ml of warm water every
to tube lumen                                4 hours during continuous feeding
                                                      or before and after
                                                      intermittent feedings.

Administration of inadequately   * Ask the pharmacist if a liquid
crushed                                         form is available and appropriate.
and dissolved pills                      * Notify the physician to discuss
                                                      any possible changes in
                                                      medication.

Administration of viscous          * Flush the tube with about 30 ml
formula (those with higher          of water before giving medication.
calorie content or                     * Give each medication separately
containing  fiber)                         and flush with about 10 ml of
or medications, particularly         water between each.
medications known to              * Flush the tube with about 30 ml
cause clogging, such as              of water after you've given
antacids, psyllium                       all medications.
(Metamucil), or sucralfate        * Don't add medications directly
                                                   to the feeding bag or container
                                                   of formula.
                                                * Consult a nutritionist to
                                                   evaluate the type of formula
                                                   being administered.

Incompatibility between the    * Consult a pharmacist to evaluate
formula and medications             for incompatibilities.
or incompatibility of                 * Give medications as described
medications given in the            above.
same syringe

Formula coagulating when       * Flush the tube with 30 ml of
coming contact in                        water before and after checking
with gastric secretions                residual volumes.

Giving feeding by gravity          * Consider using a pump to
(especially continuously)             administer feedings if gravity
 rather than using                       feedings result in obstruction.
                                                    Some pumps automatically flush
                                                    the tube.

Small tube lumen                       * Flush routinely (every 4 hours)
                                                     to avoid clogging. Small-bore
                                                     tubes tend to clog more easily.

Bacteria contaminating the        * Wash your hands before handling
formula, leading to                       the feeding equipment and minimize
coagulation                                  handling the formula.
                                                  * Discard expired product.
                                                  * Change the delivery set every
                                                     24 hours (or per manufacturer's
                                                     recommendation).
                                                  * Follow recommended hang times
                                                     for formula.
                                                  * Store unopened cans of formula
                                                     in a cool, dry place.
                                                 * Mark opened cans of formula
                                                    with date and time and
                                                     refrigerate. Discard unused canned
                                                     formula after 48 hours.
                                                 * Refrigerate formula that's
                                                    in powder form and reconstituted
                                                    with water.
                                                    Discard unused reconstituted
                                                    formula after 24 hours.
                                                  * Don't dilute formula.

Yeast forming in the tube         * Observe for changes in
                                                    the tube, such as dark
                                                   discoloration, opaque tube,
                                                   or nodules in the tube.
                                                * An occluded tube probably
                                                   will need to be replaced.
                                                    Notify physician

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