Download Deciding to initiate gastrostomy feeding

Deciding to initiate gastrostomy feeding
Dr Usha Krishnan
Paediatric Gastroenterologist
Sydney Children’s Hospital
 The decision to recommend the insertion of a
gastrostomy should always be based on:
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Multidisciplinary team assessment
Evidence based practice
Clear communication regarding goals of treatment
Ensure adequate resources are available for
ongoing optimal support and management
Indications for gastrostomy
 Need for prolonged enteral tube feeding (>4-6
weeks)
 Other causes of malnutrition/growth faltering
(apart from inadequate intake) have been
excluded by appropriate investigations
 Provision of gastric access for:
 Gastrointestinal decompression
 Hydration
 Administration of medication
Selection of appropriate feeding route
Potential benefits of a gastrostomy
vs
Naso-gastric/naso-jejunal tube
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Less tube displacement/re-insertion
Reduced aspiration risk
Better cosmetic appearance
Safer, more reliable enteral access
Optimises development of oral skills
Larger diameter, shorter tube length: less blockage
Cost effective longer term solution
Less interference in daily activities, better quality of life
Avoids nasal irritation/congestion/septal trauma
Reduced anxiety at meal times, shorter feeding times
Ethical Considerations
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Benefit to patient
Will not cause harm
Benefits outweigh risk of procedure itself
Should never replace attempts to make oral feeding easier
Challenging ethical decisions:
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terminal conditions
stroke
progressive dementia
intellectual disability
impaired neurological condition impacting on decision making ability
persistent vegetative states
 Seek formal advice about ethical issues
 Living will/advanced care directives
 Informed consent should include information on insertion procedure and
ongoing care
Selecting appropriate gastrostomy device
 Patient factors
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Patient/carer preference
Patient/carer abilities and support available
Age of patient
Anesthetic risk
Risk of patient pulling device/tube out
Patient mobility
Need for concealment
Access to services for tube/device replacement
Insertion site (anatomical)
 Tube/device characteristics
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Size/diameter of device
Low profile device or longer tube
Balloon retention for ease of change or non ballooned/internal bumper device
Availability of device and feeding adaptors
Familiarity with device types
Choosing an appropriate gastrostomy device
Types of Gastrostomy tubes
Types of Low Profile Gastrostomy buttons
Insertion Methods
Insertion Methods
Referral Pathway
 Indication for gastrostomy
 Insertion date
 Pre assessment of co-morbidities, medications (anti
coagulants) and prior surgery
 Pre procedure protocol (Anesthetic consult)
 Screening for MRSA as per local policy
 Informed consent
 Nutrition assessment
 Notification of appropriate staff to prepare for education
and care of patient with new gastrostomy
 Education of carers/patients pre insertion on care of
gastrostomy
 Ensuring equipment is in place ready to use
Patient/Parent/Carer Education
 What is a gastrostomy device?
 Why it has been recommended and type of device recommended
 Whether oral intake is recommended in conjunction with tube feeding and
whether any feed modification is recommended by the speech pathologist
 Oral desensitisation/stimulation as per speech pathologist in paediatric
patients in whom oral intake is not recommended in the short term to
avoid oral aversion
 Pre procedure review of bowel management, weight
 Procedure
 Medication management
 Education on:
 Basic device care
 Feeding regimens
 Equipment costs
 Plans for future feeding provisions:
 Supply of feeds
 Feeding equipment
Case Study
EP
3 months old
Severe gastroesophageal reflux with vomiting
On PPI and prokinetics
Intolerance to to dairy and soy
Failure to thrive
Poor weight gain and episodes of vomiting/choking even on
continuous naso-gastric feeds
 Dependent on continuous Naso-jejunal feeds of elemental
formula
 Side effects of prolonged NJ feeds
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 Oral aversion
 NJ tube displacement requiring repeated insertions under
fluoroscopic control
Case Study: EP
 Multidisciplinary team involvement
 Paediatrician
 Gastroenterologist: Gastroscopy and pH probe confirmed diagnosis of
reflux and excluded conditions like eosinophilic esophagitis
 Dietician: Ensured adequate caloric intake and appropriate elemental
feed also helped with mothers diet when mother was trying to breast
feed EP and was on dairy and soy free diet
 Speech Pathologist: Assessed safety of swallow and performed
Modified Barium Swallow to help exclude direct aspiration given
history of choking with feeds. Also helped to minimise development of
oral aversion when EP was on prolonged enteral feeds
 Social worker was of great help to family. EP was also diagnosed with
neurodevelopmental delay
 Surgeon: performed fundoplication with gastrostomy
 Clinical nurse consultant: helped the mother decide on appropriate
gastrostomy device and education on day-to-day care of gastrostomy
and continuous pump feeds
Weaning from tube feeds
 When a decision to insert a gastrostomy is made it
should always be made clear from the outset whether
the device is to be placed permanently or temporarily.
 If the device is temporary goals should be set by a
multidisciplinary team (dietician, speech
pathologist,paediatrician, gastroenterologist) to work
towards its eventual removal once adequate oral intake
resumes.
 This is especially important in paediatric patients
 In EP too the gastrostomy has now been removed at
age 2 and she is now thriving on oral intake alone.
Thank You