Gastrostomy Tube Management
This Clinical Information Sheet has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the management of residential aged care patients requiring enteral feeding via gastrostomy tube.
It covers:
About Gastrostomy Tubes; Assessment of the Resident; Management of Enteral Feeds; Gastrostomy Care and Complications; and Sources of Information
Reference Card: Gastrostomy Tube Dislodgement or Blockage Management
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Gastrostomy Tubes
Studies indicate that over 70% of gastrostomy tube recipients are aged over 70 years and 91% have a primary neurological disorder, suggesting that gastrostomy tube recipients will frequently reside in RACFs [1]. Minor complications such as tube occlusion, skin maceration from leakage of gastric contents and peri-stomal pain are reported in 13-43% of individuals with gatrostomy tubes. Major complications such as wound infection, aspiration, bleeding and injury to internal organs occur in 0.4% - 20% of individuals with gastrostomy tubes [2]. The most common gastrostomy tube problems that result in a resident attending an emergency department are blocked feeding tubes, deteriorated tubes and gastrostomy tubes that have been inadvertently removed [1]. RACF staff need the skill to manage gastrostomy tube problems as they can be uncomfortable for the resident, interrupt nutrition and hydration, require a distressing and costly attendance at an emergency department and lead to major complications [1].
Enteral feeding tubes
Enteral feeding is a method of maintaining hydration and nutrition for residents, who are suffering from an illness that affects the ability to take in an adequate oral intake to maintain nutritional status. A feeding tube is passed directly into the resident’s stomach or small bowel and liquid nutrition is provided [3, 4, 11].
Nasogastric tubes, which pass through the nasal cavity to the stomach, are used for short term (<30 days) enteral feeding [3, 4, 6]. They are not commonly used in RACFs and are not the focus of this clinical information sheet.
Gastrostomy tubes are placed through the abdominal wall into the stomach. Gastrostomy tubes can be inserted via open surgery, laparoscopy, endoscopy or radiology. The most commonly used technique is the percutaneous endoscopic gastrostomy (PEG). This method of tube insertion can be done under mild sedation, has a quick recovery period for the resident and there is a low level of mortality and morbidity from the procedure [1-3, 6]. Gastrostomy tubes are usually 12-30G and have a balloon, mushroom tip or disc securing internally. Externally the tube has a disc or bumper at skin level and at the distal end an adapter that connects to a feeding tube or syringe and has a side port for medication administration [4].
Jejunostomy tubes are placed through the abdominal wall into the small bowel either directly or via the stomach (gastrojejunostomy). They are used when the resident has a high risk of aspiration [6]. Jejunostomy tubes have the same appearance as a gastrostomy tube but are usually 8-24G [4].
Care and management of all kinds of gastrostomy and jejunostomy tubes is essentially the same and the information in this clinical information sheet is relevant to all (unless specifically stated). The term gastrostomy tube will be used to refer to all kinds of gastrostomy tubes.
Assessment of the resident
Indications and risks of enteral feeding
The decision to insert a gastrostomy tube should be made via consultation between the resident, next-of-kin or Power of Attorney, relatives, GP and RACF staff. Consideration should be given to any advance care planning. The health care team, resident and representatives should consider whether the possible benefits of treatment outweigh the burden to the resident [2].
Indications for a gastrostomy tube include [1-4]:
Intact GI tract but unable to consume sufficient calories to meet nutritional needs; Impaired swallowing related to neurological conditions e.g. stroke, Parkinson’s Disease; and Obstruction related to neoplasm or surgery.
Careful consideration should be given to the insertion of a feeding tube. Tube placement is an invasive procedure and common risks of tube feeding include:
Pain at the tube site [2, 11, 12]; Discomfort from tube repositioning [2, 11, 12]; Local infection [3, 6, 12]; Aspiration pneumonia [6, 12]; Tube occlusion [3, 6, 12]; Nausea, vomiting, constipation and diarrhoea [3, 6, 12]; and Loss of pleasure from eating [12, 13].
Gastrostomy feeding in advanced dementia
The use of enteral feeding for residents in the end stages of dementia is a controversial and an emotional issue, and it is a decision that requires individual and careful consideration by the resident’s representative and the health care team [12, 13]. Common reasons cited for the initiation of gastrostomy feeding in advanced dementia include prolonging survival; improving function and quality of life; prevention of aspiration, pressure sores and infections; and for palliative care [12, 13]. However, systematic review of the evidence suggest:
Residents with advanced dementia and gastrostomy tubes are more likely to be restrained [3, 12, 13]. Weight loss and malnutrition persists in advanced dementia even when gastrostomy feeding of generous enteral feeding supplements is instigated [12, 13]. No data indicates that tube feeding decreases the risk of aspirate pneumonia, and in some studies the rate of aspirate pneumonia has been reported as 58% higher in residents with gastrostomy tubes [6, 12, 13, 16]. Evidence linking malnutrition to the development of pressure sores is weak, and no evidence suggests that tube feeding decreases the risk of pressure sores [12, 13]. Survival rate of residents with advanced dementia is not improved by placement of a gastrostomy tube [12, 13]. Median survival rate after gastrostomy insertion is less than 1 year, with less than 40% of gastrostomy tube recipients surviving more than 1 year. The mortality rate from PEG procedure is 2% [12]. Studies have shown that a carefully hand-fed resident with advanced dementia has the same survival rate of a non-demented RACF resident [12]. No evidence suggests that the rate of other infections (e.g. UTI) is reduced by insertion of a gastrostomy tube, and having a gastrostomy tube may increase the risk of infection (e.g. infectious diarrhoea, wound infection) [12]. Gastrostomy tube feeding has no been shown to improve physical function, strength, bowel or bladder function, ambulation, mental status or performance of ADLs in RACF residents [12, 13]. Studies suggest that terminally ill residents generally do not experience significant hunger and thirst, therefore tube feeding does not improve comfort in this respect [12, 13]. Placing a PEG tube exposes the resident to risk of skin breakdown, diarrhoea, constipation, tube occlusions and a variety of other risk factors that are often uncomfortable and may decrease quality of life [1, 3, 12, 13].
Ongoing assessment
Weekly or twice weekly weighing is more effective than daily weighing, which is influenced by variations in fluid balance [7]. The health care team, including RACF staff, GP, pharmacist, dietician and the resident and/or representatives should review the resident’s progress, indication and needs for enteral feeds on an ongoing basis [15].
Management of Enteral Feeding
Management of a resident’s enteral feeding involves:
Selecting a feeding regime and formula; Preparing and storing formula; Administering gastrostomy feeds; Administering medication via a gastrostomy tube; and Education of RACF staff and residents.
Feeding regime
It is recommended that residents requiring enteral feeding be assessed, by a dietician or nutrition support team, to determine the most appropriate formula and feeding regime. The dietician should aim to meet the resident’s specific nutritional requirements, minimise complications and maintain cost-efficiency [6].
Feeding regimes are either continuously or intermittently. Continuous feeds are indicated for residents who are at a high risk of aspiration, have gastro-intestinal tolerance (e.g. diarrhoea) or for small bowel feeding [3, 6]. If feeding intermittently a volume of 300-400ml of formula is usually administered for each feed [6]. Feeds are either delivered by bolus, gravity flow or using pump-control. Bolus feeds are administered over 5-10 minutes, usually via a syringe. Bolus administration has the advantage of being a quick administration technique and frees the resident from tube lines [6].
Types of formula
Feeding formulas are made up of carbohydrate; protein; fat; minerals and vitamins including sodium and potassium; and fibre [3]. Free water is also an important component and constitutes up to 85% of the formula [3, 6]. Selection of a formula type depends on the resident’s nutritional requirements, gastrointestinal function, occurrence of diarrhoea or constipation and any special disease considerations (e.g. fluid restriction for a resident with cardiac disease) [3].
The most commonly used formula products are lactose-free (e.g. Osmolite, Ensure). Some formula products are milk-based (e.g. Sustagen) or elemental formulas that provide nutrients in simple protein forms for easier digestion (e.g. Vital HN) [3, 6]. Special formulas are generally more expensive than standard formulas and have not been conclusively shown to be of advantage [6] so their used should be considered carefully.
Enteral feeds can be administered using a ready-to-hang feeding system (‘closed system’), or decanted (‘open system’) into a feeding bag or syringe. Pre-packaged, ready-to-use feeding formulas should be used in preference to those that require decanting, reconstituting or diluting [8, 14]. Use of pre-packaged, ready-to-use feeding formulas decreases bacterial contamination of the formula and has been demonstrated to be more cost-effective [14].
Preparation and storage of formula
Procedure for preparing formula
When formula products that require preparation are used, the following guidelines should be adhered to.
|
Procedure for preparing formula
|
|
1. |
Prepare enteral feeds in a clean working area and wash hands thoroughly before commencing [3, 8]. Wash the top of the can before opening and use a no-touch technique in preparing formula to reduce the risk of bacterial contamination [8, 14]. |
|
2. |
Use equipment that is dedicated to enteral feeding and use an individual set of feeding equipment for each resident [3, 8]. |
|
3. |
In RACFs, residents should have their own supply of enteral feeding formula. Check the formula is the correct type ordered for the resident; the manufacturing and use-by dates; and the date and time the product was opened [3]. Discard any products open for longer than 24 hours [3, 5, 8]. |
|
4. |
If opening a new product, label with the time and date of opening [3]. |
|
5. |
Reconstituted powder
Prepare in a feeding jug using freshly opened sterile water or cooled, boiled water [8]. Follow the dietician’s instructions or the product information on quantity of water. Ensure the powder is fully dissolved to prevent tube clogging [3]. |
|
6. |
Sterilised canned milk formula
Shake contents thoroughly. Pour the ordered amount into the feeding jug [3]. |
|
7. |
Cover the feeding jug immediately after preparation to avoid contamination by airborne organisms [3]. |
|
8. |
Do not administer cold formula. Feeds should be prepared to a temperature of 25-30C. Either remove formula from refrigerator for 1 hour before administration [7], or immerse feeding jug in warm water for 10-15 minutes [3]. |
Storage of formula
It is important that formula products are stored and used correctly to reduce the potential for bacterial contamination. Follow these guidelines:
Opened formula products must be kept refrigerated [3]; Label products with the data and time of opening [3]; Check labels on a daily basis and discard any unlabeled or expired products [3]; Opened cans should be used within 24 hours [3, 8]; Opened cans should be covered properly even in the refrigerator (e.g. using plastic lids) [3]; and Do not leave formula products at room temperature (including during administration) for longer than recommended. Check the product information. As a general guide reconstituted milk products should not be at room temperature for longer than 4 hours; sterilised can formula for longer than 8 hours; and closed system formulas for longer than 24 hours [3, 5, 8].
RACFs should develop auditing and stock rotations systems to ensure the safe use and storage of enteral feeding formulas and to comply with Accreditation requirements [15].
Procedure for Administering a Gastrostomy Feed
Equipment
Use equipment that is dedicated to enteral feeding and use an individual set of feeding equipment for each resident [3, 8]. Whilst some sources recommend that feeding tubes, bags and syringes should be for single use only [7, 8] no evidence suggests that there is a higher incidence of bacterial infection in residents who are fed using a routine, non-sterile protocol than those fed using an aseptic protocol [6, 14]. If equipment is reused it should be cleaned according to the manufacturer’s instructions or washed in detergent and warm water and hung to dry [7]. It should be replaced every 24 hours [5] and clearly labeled with the resident’s identification.
The following equipment is required:
50-100ml syringe for aspiration; Enteral feeding bag with tubing if administering bag feed; Giving set with burette if administering a continuous feed; Enteral pump and compatible line if administering feed via a pump; 50-100ml syringe if administering bolus feed via syringe; Water for flushing; and Warm prepared formula (see above)
Administering a gastrostomy feed
|
Administering a gastrostomy feed
|
|
1. |
Explain the procedure, answer questions and prepare the resident by raising the head of bed 30°-45° [3, 5-7, 16]. |
|
2. |
Wash hands. |
|
3. |
Confirm the length of the tube. |
|
4. |
Aspiration [3, 5, 7]
Using a 50ml syringe, aspirate the contents of the resident’s stomach.
Confirm the position of the gastrostomy tube in the stomach by checking the pH of stomach contents. Stomach contents pH should be less than 4 and turns blue litmus paper to red.
If the pH of gastric contents is not less than 4 the PEG tube may have migrated from the stomach. Cease feeding and contact the resident’s GP, locum GP services or the emergency department to arrange for radiology confirmation of tube position [3, 5-7]. Checking residual gastric contents volume is only performed if there are indications to do so, such as vomiting, tolerance and absorption problems. If the residual volume is consistently more than 150ml request the resident’s GP or dietician conduct a review of the feeding regime.
Whilst a single high residual volume prompts concern about feeding intolerance and indicates a need to closely monitor further residual volumes, often the next residual volume is normal. Automatically postponing or ceasing tube feeding puts the resident at risk of inadequate nutrition [6]. Return the aspirated gastric contents to the resident’s stomach.
|
|
5. |
Flush the PEG tube with 30ml water [3-5, 7, 11]. |
|
6. |
Bag Feeding [3, 5, 7]
detach the line from the feeding bag pour the prepared formula into the feeding bag ensure the line is closed, reattach and prime line with feed attach line to the resident’s gastrostomy tube hang the feeding bag higher than the resident for intermittent feeding, administer feed over 20-40 minutes. For continuous feeding use a burette on the feeding line. Run the prescribed amount per hour into the burette and adjust rate. For pump feeding position the feeding line in the enteral feeding pump and set volume and rate of infusion according to the manufacturer’s instructions.
|
|
7. |
Bolus Syringe Feeding [3, 5, 7]
remove the plunger from a 50-100ml syringe attach barrel of syringe to gastrostomy tube pinch PEG tube pour prepared formula into feeding syringe and using gravity, allow the feed to flow do not allow the feeding syringe to completely empty before adding more formula adjust rate of flow by lowering or raising height of syringe
|
|
8. |
Detach feeding line or feeding syringe from gastrostomy tube. |
|
9. |
Flush gastrostomy tube with 30ml water [3-5, 7, 11]. |
|
10. |
Ensure the resident is comfortable. Observe for signs of vomiting, respiratory distress or signs of feeding intolerance e.g. diarrhoea, bloating, fullness[3, 5, 7]. |
|
11. |
Maintain the resident in an upright position (head of bed elevated 30-45 degrees) for at least 30 minutes post-feeding to reduce the risk of aspiration [3, 6]. |
|
12. |
Remember to attend to the oral hygiene of residents receiving enteral feeding on a regular basis. |
|
13. |
Dispose of single-use equipment and wash reusable equipment in warm water and detergent and hang to dry [5, 7]. |
|
14. |
Document in the resident’s notes and communicate to other staff according to RACF policy. |
Administering Medication via a gastrostomy tube
The goal of medication administration via gastrostomy tube is to maximise the therapeutic effect of medication without adversely affecting the delivery of enteral feeding. Administration of medications via the gastrostomy tube can be problematic. Altering the form of the medication (e.g. by crushing) may interfere with the drug’s efficiency or potency or the resident’s tolerance of the medication. Changes may occur in the absorption, distribution, metabolism or excretion of altered medications. Physical changes may occur if the medication is combined with enteral feeding formula (e.g. curdling or separation) and there is a risk of PEG tube occlusion [4].
To prevent unnecessary complications with administration of medication via the gastrostomy tube, it is recommended that the pharmacist review the medication of any resident receiving medications via a gastrostomy tube. The pharmacist should recommend dosage forms that are appropriate for administration and provide guidelines for the administration of specific medications [3, 4, 11].
Medication forms
The following medication forms can be administered via the PEG tube:
Liquid medication: this is the best option as there is a decreased risk of tube occlusion and increased absorption of the medication [3, 4, 11]. However, certain preparations may cause GI distress, especially those with a high osmolality or high levels of sorbitol. Complications can be minimised by diluting liquid medications in 30ml of water [4]. Immediate release oral tablets: tablets should be crushed finely and mixed with 10- 30ml water. Visually check the preparation to ensure the tablet particles are fully dissolved before administration [3, 4, 11]. Soft gelatin capsules: prick the capsule with a pinhole and squeeze out the contents for administration [4].
The following medication forms cannot be administered via the gastrostomy tube:
Enteric-coated medications: enteric coating protects the integrity of the medication from destruction by the stomach acid, therefore crushing the medication reduces its effectiveness [3, 4]. Sustained release medications: altering the form of sustained release medications changes the medication properties [3, 4]. Sublingual medications [3, 4]. Acidic liquid medications: many syrup medications are too acidic for administration via the gastrostomy tube. Elixir and suspension liquids should be used rather than syrups [4, 11].
General rules for administering medication via the gastrostomy tube
Before administering any medication via the gastrostomy tube ensure the pharmacist has reviewed the resident’s medications and provided the most appropriate form. Follow any specific instruction provided by the pharmacist [3, 4, 11].
To minimise complications adhere to the following principles:
Use liquid medications as a first priority [4] Prepare medication forms as described above Consider the timing of medication administration in relation to enteral feeding (e.g. full or empty stomach) [4] Verify the position of the gastrostomy tube before administering medication [4, 17] Use the medication port on the gastrostomy tube to administer medications [4, 17] Use a syringe size greater than 30mls as smaller syringes create too much pressure on gastrostomy tube [4, 17] Do not mix medications with enteral feed formula [3, 4, 11] Do not mix medications with other medications to avoid drug-drug incompatibilities [3, 4, 11] Flush the gastrostomy tube with 30mls water before and after medication administration [3-5, 7, 17] Flush the gastrostomy tube with 15mls water in between administration of different medications [4, 7, 11, 17]
Education
RACF staff and other health professionals should be provided regular education on hand decontamination, infection control principles, enteral feeding and management of the feeding administration system [8]. Residents and their relatives should be given ongoing education about the purposes of enteral feeding and taught strategies to reduce manipulation of the gastrostomy tube.
Gastrostomy Care and Complications
Routine Gastrostomy Care
PEG site care
New PEG sites should be cleaned daily with gauze and sterile normal saline in an outward circular motion. Ensure the site is dried thoroughly and cover with a single gauze dressing. For the first 2 weeks the PEG tube should not be rotated [7, 17].
Mature gastrostomy tube exit sites should be cleaned daily during normal hygiene with soap and warm water. Use a cotton tip to clean around the external bumper and ensure the area is dried thoroughly [3, 7, 8]. Observe the site for tenderness, irritation, redness or pressure and for the presence of any discharge or leakage. Unless there is a large amount of gastric leakage the site should be left uncovered [3, 17].
Gastrostomy tube care
Problems can occur if the tube tension is incorrect. Excessive tension between the internal and external bumpers can cause ulceration at the tube exit site or internally in the mucosal layer of the stomach (“buried bumper syndrome”). To prevent this occurring, after initial healing (2 weeks) the PEG tube should be rotated 180-360 degrees each day (or according to manufacturer’s instructions). Ensure the tension is right between the two bumpers and that a small amount of tube remains between the external bumper and the resident’s skin [3, 5, 7, 17]. Check the tube on a daily basis for cracking, distortion or deterioration and request replacement of worn PEG tubes to prevent emergencies [17].
Managing Common Complications
Refer to Reference Card: Gastrostomy Tube Blockage and Dislodgment.
Tube dislodgment
Tube dislodgment can occur when the gastrostomy tube either slides in or out of the GI tract. If the tube slides too far in to the GI tract it can obstruct the gastric outlet leading to nausea and vomiting. If the internal balloon deflates or the external bumper or disc are inadvertently removed the gastrostomy tube can slide out and the tract can quickly close [17]. Severe vomiting or coughing may also cause tube dislodgment [7]. The following strategies reduce the risk of tube dislodgement and detect any tube migration:
Check the security of the external disc every shift [3, 17]. Use a gastrostomy anchoring device to secure the tube [3, 17]. Provide education to the resident and staff members on avoiding any pulling on the tube [3, 17]. Measure and document gastrostomy tube markers to record the length of tube outside the resident’s body. Verify the length of the tube each shift and report discrepancies [7, 17]. Assess residual gastric fluid each shift to determine correct positioning of the PEG tube [3, 7, 17].
If incorrect internal placement of the tube is suspected, cease feeds immediately and contact the resident’s GP, locum GP services or the emergency department to arrange for radiology assessment and replacement of gastrostomy tube if required. If a gastrostomy tube falls out [3]:
Provide comfort and reassurance to the resident and assist the resident to bed. If the tract is immature (< 2 weeks) clean the exit wound with normal saline, apply a sterile dressing and contact the emergency department to organise for replacement of the gastrostomy tube. If the tract is mature (> 2 weeks) insert a similar size sterile Foley’s catheter as soon as possible to maintain patency of the tract and cover the site with gauze. Contact the emergency department to organise for replacement of the PEG tube.
Although replacement of a gastrostomy tube may be performed as a bedside procedure [3], air auscultation, visualisation of aspirate, and pH testing of aspirate have been reported as unreliable indicators of placement [7] and clarification of the gastrostomy tube position is best achieved using radiology services [6, 7].
Tube Blockage
Tube occlusion occurs frequently, especially with small-bore feeding tubes. Causes of tube occlusion include [4, 7, 11, 17]:
Thick formulas and/or formula residue adhering to the tube; Reflux of gastric contents into the feeding tube; Inadequately crushed medications; Incompatibilities between medications and enteral feeds; and Inadequate tube flushing.
Prevention of blockage should be a priority. Administer medications according to the guidelines provided in this clinical information sheet, flush gastrostomy tubes with 20-50ml warm water every 4-8 hours, before and after each medication, before and after administering feeds and before and after aspirating residuals [4, 7, 8, 11, 17].
If a tube becomes occluded:
Address the blockage as soon as possible for a better chance of unblocking the tube; Check the tube for kinking [4]; Avoid cranberry juice and fizzy drinks that are acidic and may contribute to clogging rather than relieve it [4, 7, 17]; Place a flushing syringe in the tube end and gently pull back on the plunger to dislodge clogging [4]. Use a syringe larger than 30ml as the pressure exerted by smaller syringes can damage the tubing [4, 7, 17]; If the blockage remains, instill 20-50ml warm water [3, 4, 7]; Using a syringe, exert pressure alternating with suction [4]; Milk the tubing from the insertion site outwards with care not to pull on the tube [4]; Pancreatic enzymes can be used and are the most effective method of unclogging the tube [4, 7] – ‘Coke’ has been anecdotally reported to be effective; and If unsuccessful, contact the resident’s GP, locum GP services or the emergency department to arrange for replacement of the gastrostomy tube [3].
Leakage from the tube site
A poorly secured gastrostomy tube can pivot, resulting in skin granulation and widening of the tract. Gastric fluid leakage can result in skin excoriation and potential wound infection [5, 17]. Use the following prevention and management principles:
To prevent leakage stabilise the gastrostomy tube and position the bumper just above skin level, not taunt against the skin [5, 17] Maintain the resident in an upright position following a feed, then lie the resident on his or her right side [5] Frequently inspect the exit site for redness, tenderness, swelling and signs of leakage [5, 17] Only use a dressing if there is a large amount of leakage [17] Protect skin from breakdown using protective barrier creams [17] Consider tube replacement if there is a large amount of leakage or severe skin breakdown [17].
Vomiting
Vomiting may occur due to enteral feeding or from an unrelated cause. If the resident vomits, withhold enteral feeds and identify possible causes of the vomiting. Check the placement of the gastrostomy tube to determine if the tube has dislodged and caused gastric outlet obstruction [17]. Reduce the feeding rate and gradually increase it until the regular feeding rate is resumed. If the resident continues vomiting contact the resident’s GP or locum GP services [3].
Diarrhoea
Diarrhoea in residents receiving enteral feeds may be a sign of intolerance or infection, however the most common causes are drug related [6]. Antibiotics are the major cause of diarrhoea, as well as liquid medications with a high level of sorbitol [4, 6]. If the resident’s medication regime or past medical history does not indicate a cause for diarrhoea, other possible reasons include osmolality of the formula, feeding rate (a common cause for diarrhoea is too much formula too fast – slow down the feed) or bacterial contamination of the feed [6]. The resident should be reviewed by the GP and dietician, and infection control processes should be audited.
Constipation
If constipation is a regular occurrence the resident should be reviewed by the dietician and GP. Feeding regime may require alteration to increase fibre or fluid intake. Laxatives may be ordered by the resident’s GP. Constipation should be avoided through establishing regular bowel management regimes and preventative measures such as encouraging ambulation [3].
Aspiration
Aspiration occurs when materials such as gastric contents, food or saliva is inhaled into the airway. It may present silently, or the resident may have signs and symptoms including cough, choking or acute respiratory distress [16]. Aspiration may be inconsequential or may lead to pneumonia and death [6, 16]. There is an increased risk of aspiration in residents with impaired consciousness, altered airway defenses and depressed immune systems [7, 16]. Jejunostomy feeding has a lower risk of aspiration than gastrostomy [6, 16], and using intermittent or continuous gravity feeding regimes rather than bolus administration has also been shown to lower the risk of aspiration [5, 6].
The following precautions should be taken to reduce the risk of aspiration:
Raise head of bed 30?-45? during feeding [5-7, 16] Maintain the resident in the upright position for at least 30minutes following feeding [3, 6] Routinely test residual gastric volumes [6, 7] Infuse formulas slowly [5, 6] Monitor the resident for abdominal distension, altered bowel function, complaints of bloating or fullness [6, 7, 16].
Sources of Information
Where to go for more information
Percutaneous Endoscopic Gastrostomy (PEG) Care Service
This is a service provided by Flinders Medical Centre, Sth Australia for individuals with PEG tubes. The service provides support and advice with managing PEG problems as well as education and support for carers, individuals and their families.
Contact: (08) 8204 5511 Pager 2386
Digestive Health Foundation (DHF)
Educational branch of the Gastroenterological Society of Australia (GESA) responsible for community awareness and education related to the digestive system.
Contact: (02) 9256 5454
Website: http://www.gesa.org.au/index.htm
References
K Dollard,G Young, PEG Care and Support Service. 1999, Adelaide: Flinders Medical Centre. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, Role of endoscopy in enteral feeding. Gastrointestinal Endoscopy, 2002. 55(7): p. 794-797. Hong Kong Geriatrics Society, Clinical Guidelines on Enteral Tube Feeding. Amended ed. 2003, Hong Kong: Hong Kong Geriatrics Society. P Guenter, Administering medications via feeding tubes: what consultant pharmacists need to know, in http://www.ascp.com/public/pubs/tcp/1999/jan/tubes.shtml (accessed April 2004), Inc American Society of Consultant Pharmacists. 1999 Unversity of Texas Medical Branch, Nursing Practice Standards: care of the patient receiving enteral feedings through long term feeding devices. 2001 American Gastroenterological Association, American Gastroenterological Association medical position statement: guidelines for the use of enteral nutrition. Gastroenterology, 1995. 108: p. 1280-1301. Joanna Briggs Institute, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI. National Collaborating Centre for Nursing and Supportive Care, Infection Control: Prevention of healthcare-associated infection in primary and community care: (No. 3) Care during enteral feeding. 2003, London: National Institute for Clinical Excellence. Australian Nursing Council, Guidelines on Delegation and Supervision for Nurses. 2003 Australian Nursing Federation and the Royal College of Nursing Australia, Joint position statement an assistants in nursing and other unlicensed wokers. 2004 M Mateo, Maintaining the patency of enteral feeding tubes. The Online Journal of Knowledge Synthesis for Nursing, 1994. 1(9). T Finucane, C Christmas, K Travis, Tube feeding in patients with advanced dementia: a review of the evidence. JAMA, 1999. 282(14): p. 1365-1370. I Li, Feeding tubes in patients with severe dementia. American Family Physician, 2002. April. N Jackson, ‘Open’ versus ‘closed’ systems for enteral feeding, in http://www.med.monash.edu.au/healthservices/cce (accessed April 2004), Centre for Clinical Effectiveness. 2002 Aged and Community Care Division Commonwealth Department of Health and Aged Care, Standards and Guidelines for Residential Aged Care Services Manual. 2nd ed. 2001, Canberra: Australian Government Department of Health and Ageing.
M Opilla, Aspiration risk and enteral feeding: A clinical approach. Practical Gastroenterology, 2003. April: p. 89-96. P Guenter, Mechanical complications in long-term feeding tubes, in http://nsweb.nursingspectrum.com/ce/ce201.htm (accessed April 2004), University of Chicago Hospitals. 2004 National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS. Levels of Evidence
The information presented is developed from Level I evidence produced by the American Gastroenterological Association and reputable Level IV evidence, including the JBI Aged Care Manual that was developed from a comprehensive literature review, and consensus guidelines produced by the Hong Kong Geriatrics Society. Information presented on the role of enteral feeding in advanced dementia is based on Level I evidence.
|
|
Reference |
Year |
Level of Evidence |
|
1 |
K Dollard,G Young |
1999 |
Level IV evidence |
|
2 |
The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy |
2002 |
Level I evidence |
|
3 |
Hong Kong Geriatrics Society |
2003 |
Level IV evidence |
|
4 |
P Guenter |
1999 |
Level IV evidence |
|
5 |
University of Texas Medical Branch |
2001 |
Level IV evidence |
|
6 |
American Gastroenterological Association |
1995 |
Level I evidence |
|
7 |
Joanna Briggs Institute |
2003 |
Level IV evidence |
|
8 |
National Collaborating Centre for Nursing and Supportive Care |
2003 |
Level IV evidence |
|
9 |
Australian Nursing Council |
2003 |
Level IV evidence |
|
10 |
Australian Nursing Federation and the Royal College of Nursing Australia |
2004 |
Level IV evidence |
|
11 |
M Mateo |
1994 |
Level IV evidence |
|
12 |
T Finucane, C Christmas, K Travis |
1999 |
Level I evidence |
|
13 |
I Li |
2002 |
Level IV evidence |
|
14 |
N Jackson |
2002 |
Level I evidence |
|
15 |
Aged and Community Care Division Commonwealth Department of Health and Aged Care |
2001 |
Level IV evidence |
|
16 |
M Opilla |
2003 |
Level IV evidence |
|
17 |
P Guenter |
2004 |
Level IV evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) scale [18] for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (Level V) for non-referenced material developed in local RACFs. The scale was adapted by adding a level of evidence (Level V) for non-referenced material, eg developed in RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Gastrostomy Tube Management
The following reference cards are designed to be used in conjunction with the Gastrostomy Tube Management Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
Viewing Reference Cards
To view the reference cards, click on the link and select open with.... The document will open in Microsoft Word (for .doc) or Adobe Acrobat for (.pdf).
Printing Reference Cards
To print the reference card, select follow the steps for viewing a reference card, then select print in either Microsoft Word or Adobe Acrobat.
Downloading Reference Cards
To download the reference cards, click on the link and select save to disk. You will be asked to select a folder in which to save the reference card. To download all the reference cards together, use the link under Downloads and Printing.
Reference Cards:
Gastrostomy Tube Dislodgement or Blockage Management
Downloads and Printing
See note on viewing and printing documents.
To download the Clinical Information Sheet and/or the entire Reference Card package for this CIS, use the buttons below. To download, click on the link and select save to disk. You will be asked to select a folder in which to save the document. To download individual Reference Cards use the links above. Downloads are in printable formats.
|
