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Medical Equipment Problems: Tracheostomies and Gastrostomies Nightfloat Curriculum 2010-2011 Lucile Packard Children’s Hospital Residency Program Teaching Goals • Review the critical components of tracheostomy and gastrostomy tubes • Begin initial management of tracheostomy emergencies • Troubleshoot problems with gastrostomy tubes Obturator and Uncuffed Trach Cuffed Tracheostomy Tube Bleeding in a Patient with a Tracheostomy: Differential Diagnosis Causes Treatment/Prevention Bleeding from stoma Trauma at stoma site Granuloma at stoma site Infection at stoma site Apply pressure, avoid trauma Triamcinolone, silver nitrate Antibiotics Internal bleeding Trauma from suctioning Tracheal wall granuloma Tracheal wall erosion Tracheal erosion into an artery Pulmonary hemorrhage Measure suction catheter; ensure it does not extend beyond length of trach tube; suction for 10 sec or less at a time. ENT eval, possible excision ENT eval Emergent ENT eval Respiratory/ventilator support Desaturation in a Patient with Tracheostomy: Differential Diagnosis Causes Obstruction Mucous plugging Tube improperly placed against tracheal wall Treatment Suction; replace trach if needed Reposition trach Decannulation Replace trach Pneumothorax Needle decompression Gastrostomy Tube Gastrostomy Problems: Tube blockage • Usually clog as a result of medications • Treat with: – Water – Carbonated beverage – Pancreatic enzymes – Replace tube (last resort) – Change to liquid medications, if possible Tube Displacement • Stoma can close within hours if not held open • Management: Keep site open!!! – Use a foley catheter – After new tube is placed, ensure that it is in the stomach before using – A false passage may be formed between the abdominal wall and stomach, leading to peritonitis. This is especially important in new gastrostomy tubes less than 4 weeks old. Drainage around Gastrostomy Tube • A small amount of drainage is acceptable. • Keep area dry using nonadherent gauze or foam; do not use occlusive dressings • Ensure no cracks in tubing • Ensure no excessive traction on tube which can stretch the stoma • If drainage persists, may need to upsize tube • In severe cases, may require surgical repair Redness Around Gastrostomy Site Causes Treatment Granulation tissue Triamcinolone cream > silver nitrate > surgical excision Prevention: avoid traction and avoid occlusive dressings Infection Yeast infection Cellulitis/necrotizing fasciitis Irritation from gastric fluid leakage Topical vs. systemic antifungals Systemic antibiotics Barrier creams; gastric acid suppression Tape sensitivity Avoidance of tape Gastrostomy Problems: Vomiting • Causes – GERD (may worsen after gastrostomy placement) – Balloon obstructing gastric outlet – Other medical causes • Treat underlying cause Case # 1 • 8-year-old girl with tracheostomy suddenly desaturates and becomes cyanotic. The first thing you should do is: a) Begin chest compressions b) Administer 100% oxygen by tracheostomy c) Perform needle decompression d) Check for tracheostomy tube patency Case # 1 • 8-year-old girl with tracheostomy suddenly desaturates and becomes cyanotic. The first thing you should do is: a) Begin chest compressions b) Administer 100% oxygen by tracheostomy c) Perform needle decompression d) Check for tracheostomy tube patency Case #2 • 18-month-old boy post-op day 7 after a Gtube and Nissen fundoplication pulls his tube out. All of the following should be performed EXCEPT: a) Call surgery b) Place a deflated foley in the stoma c) Place an NG tube and start pedialyte to maintain hydration d) Check new tube placement using a dye study Case #2 • 18-month-old boy post-op day 7 after a Gtube and Nissen fundoplication pulls his tube out. All of the following should be performed EXCEPT: a) Call surgery b) Place a deflated foley in the stoma c) Place an NG tube and start pedialyte to maintain hydration d) Check new tube placement using a dye study