Download Nutrition - Management of Enteral Feeding

Guideline Title:
Clinical Nutrition Steering Group (CNSG)
Guidelines and Procedures for Management of Enteral Feeding
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via an enteral
feeding tube under the care of East Cheshire NHS Trust.
Supersedes:
Version 1.2
Description of
Guidelines reviewed and updated
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal patient nutrition.
Guideline Area:
Nutrition
Document Reference:
CNSG guidelines
Version Number:
1.3
Effective Date:
August 2012
Issued By:
Departments of Dietetics
and Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group
Date
Clinical Nutrition Steering Group
August 2011
Consultation:
Departments of Dietetics and
Gastroenterology
Clinical Nutrition Steering Group
Infection prevention and control
June 2015
Approved by:
Clinical Nutrition Steering Group
July 2015
AMENDMENTS RECORD
August 2011 - Version 1.1
August 2012 -Version 1.2
June 2015 – Version 1.3
CNSG007 CNSG 008 and CNSG 012 guidelines updated for
NPSA/2011/PSA002 alert compliance
CNSG007 CNSG 008 and CNSG 012 guidelines updated for
NPSA/2012/RRR001 alert compliance
Guidelines reviewed and updated
CNSG Guidelines and Procedures for Management of Enteral Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
.
Page 1 of 172
The following guidelines are to be used in association with CNSG 006 East Cheshire NHS
Trust Enteral Feeding Policy for Adults
MAIN INDEX
SECTION
CONTENTS
PAGE
CNSG007
GUIDELINES FOR INSERTION AND MANAGEMENT OF
NASOGASTRIC TUBES
GUIDELINES FOR INSERTION AND MANAGEMENT OF NASAL
BRIDLES
GUIDELINES FOR INSERTION AND MANAGEMENT OF
GASTROSTOMY TUBES
PROTOCOL FOR FIRST ASSISTANT ROLE IN PEG INSERTION
3-26
80-81
CNSG 012
GUIDELINES FOR SUSPECTED PERITONEAL LEAK POST PEG
INSERTION
GUIDELINES FOR MANAGEMENT OF A JEJUNAL TUBE
CNSG 013
GUIDELINES FOR ADMINISTRATION OF FEED
99-111
CNSG 014
GUIDELINES FOR ENTERAL FEEDING COMPLICATIONS AND
MANAGEMENT
MICROBIOLOGICAL GUIDELINES FOR ENTERAL FEEDING
112-130
CNSG 016
GUIDELINES FOR ADMINISTRATION OF MEDICATION VIA
ENTERAL TUBES
140-153
CNSG 017
GUIDELINES FOR ASSESSMENT AND MONITORING OF
PATIENTS RECEIVING ENTERAL FEEDING
CNSG 018
GUIDELINES FOR ENTERALLY FED PATIENTS ADMITTED TO
HOSPITAL
Available
on Trust
Intranet
154-156
CNSG 008
CNSG 009
CNSG 010
CNSG 011
CNSG 015
27-37
38-70
71-79
82-98
131-139
PATIENT INFORMATION AND FORMS FOR PRINTING
CARE PATHWAY FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY
(PEG) TUBES
158-165
ADVICE POST PEG REMOVAL
167
PRE-DISCHARGE TRAINING CHECKLIST- GASTROSTOMY FEEDING
167-168
NASOGASTRIC (NG) TUBE INSERTION AND MONITORING FORM
169-171
CNSG Guidelines and Procedures for Management of Enteral Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
.
Page 2 of 172
Guideline Title:
Guidelines for Insertion and Management of Nasogastric Tubes
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via a
nasogastric tube under the care of East Cheshire NHS Trust.
Supersedes:
Version 1.2
Description of
Guidelines reviewed - no major changes
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal patient nutrition.
Guideline Area:
Nutrition
Document Reference:
CNSG 007
Version Number:
1.4
Effective Date:
August 2011
Issued By:
Departments of Dietetics
and Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group
Date
Clinical Nutrition Steering Group
August 2011
Consultation:
Departments of Dietetics and
Gastroenterology
Clinical Nutrition Steering Group
October 2010- August
2011.
June 2015
Approved by:
Clinical Nutrition Steering Group
July 2015
AMENDMENT RECORDS
August 2011 - Version 1.1
Guidelines updated for NPSA/2011/PSA002 alert compliance.
May 2012 -Version 1.2
CNSG007 CNSG 008 and CNSG 012 guidelines updated for
NPSA/2012/RRR001 alert compliance.
June 2015 – Version 1.3
Guidelines reviewed
April 2016 – Version 1.4
Addition to NG insertion and monitoring chart – to add ‘decision
maker, name, date and time’.
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 3 of 172
GUIDELINES FOR INSERTION AND MANAGEMENT OF NASOGASTRIC TUBES
INDEX
Section
Contents
Page
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
8.1
9.0
9.1
9.1.1
9.1.2
9.1.3
9.1.4
9.1.5
9.2
9.2.1
9.2.2
9.2.3
9.2.4
9.3
9.4
9.5
10.0
10.1
10.2
10.3
10.4
11.0
12.0
13.0
13.1
13.2
13.3
14.0
Definition
Indications
Contraindications
Assessment
Referral
Consent
Types of tubes and tube selection
Insertion of nasogastric tubes
Procedure
Confirmation of position
pH Testing
Obtaining and checking aspirate
Methods for successfully obtaining gastric aspirate
Recommended pH strips and usage
PH Values
Documentation of pH result
X-ray testing
When to X-ray
How to X-ray
Who should read the X-ray
Documentation of X-ray
Who should check the position of the tube
When to check the position of the tube
Unsafe methods for checking NG position
Management of a nasogastric tube
When to replace a should a nasogastric tube
Securing a nasogastric tube
Flushing
Blocked tube
Nasal care
Mouth care
Removal of a nasogastric tube
Planned
Accidental
Repeated unplanned removal
Escalation procedure for patient requiring NG tube
insertion
Discharge of patients on NG feeding
References and bibliography
5
5
5
6
6
6
7
8-10
8-10
11-15
12
12-13
13
13
13
13
13-14
13
14
14
14
14
15
15
16
16
16
16
16
16
17
17
17
17
17
18
15.0
Appendix 1
Appendix 2
Appendix 3
Appendix 4
19
20-21
22
Links to supporting documents
 Nasogastric insertion and monitoring form
 NPSA alerts relating to NG use
 Manufacturer’s information
 Patient information
Algorithm to check NG position
Flow chart to guide decision making for tube feeding route
23-24
25
Back to main index
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 4 of 172
1.0 DEFINITION
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A Nasogastric (NG) tube is a flexible tube that can be inserted transnasally into the stomach. It is
commonly used for delivery of feed, fluids, medication, or drainage of gastric contents.
Table 1
ADVANTAGES





Readily available
Easily inserted
Easily reversed
Rapid start of enteral
feeds
Few contraindications
to placement
DISADVANTAGES COMMON
COMPLICATIONS
 Easily
 Pulmonary
dislodged
intubation
 Uncomfortable
 Pulmonary
aspiration
 Aesthetically
displeasing
 Reflux
 Nasal and
mucosal
ulceration
RARER
COMPLICATIONS
 Epistaxsis
 Gastrointestinal
bleeding
 Oesophageal gastric
and duodenal
perforation
 Pneumothorax
2.0 INDICATIONS
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Nutritional support and hydration.
Nasogastric feeding is the most common method of providing short-term artificial nutritional
support in the acute setting. Decision to feed with a nasogastric tube should be a multidisciplinary
approach.
NG tube feeding should be considered for patients who:  are malnourished.
 have a functioning gastrointestinal (GI) tract.
 require short-term tube feeding (up to 4-6 weeks).
 require long-term tube feeding (if an alternative route is inappropriate or not possible i.e.
Percutaneous Endoscopic Gastrostomy (PEG) Radiologically Inserted Gastrostomy (RIG) or
Parenteral Nutrition (PN).
 are unable to fulfil their nutritional requirements with normal /modified diet  nutritional
supplements.
 are not predicted to fulfil their nutritional requirements with normal / modified diet  nutritional
supplements.
 have increased nutritional requirements e.g. sepsis, trauma, post-op stress & burns.
See appendix 5 for flow chart to guide decision making for tube feeding route
3.0 CONTRAINDICATIONS
Table 2
Absolute



Non-functioning GI tract e.g. ileus.
Large gastric aspirate and/or high risk of
aspiration.
Intractable vomiting not resolved by anti-emetics.
Basal skull fracture, as the tube may enter the
brain if incorrectly positioned (oro-gastric
positioning may be appropriate).
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Relative






Oesophageal varices
Mucositis
Vomiting responding to anti-emetics
Recent radiotherapy to head and neck
Advanced neurological impairment
Obstructive pathology in oropharynx or
oesophagus preventing passage of the
tube e.g. stricture, tumour, pharyngeal
pouch. Procedure may need to be
done under endoscopic or fluoroscopic
control. Specialist input advised.
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 5 of 172
4.0 ASSESSMENT
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Before a decision is made to insert a nasogastric tube, an assessment is undertaken to identify if
nasogastric feeding is appropriate for the patient, and the rationale for any decision is recorded in
the patient’s medical notes.
 The decision to insert a nasogastric tube for the purpose of feeding must be made following
careful assessment of the risks and benefits by at least two competent health care
professionals including the senior doctor responsible for the patient’s care.
 The decision to initiate enteral feeding should involve the patient, carer/family, and
members of the multi-disciplinary team including speech and language therapists and
dietitians as appropriate.
 The patient must be assessed for the most suitable route of enteral feeding e.g. stomach or
small bowel and most suitable type of tube.
The indication and rationale of the route and type of tube for enteral feeding will be clearly written
in the patient’s medical notes. As a minimum, documentation should include signed, dated and
timed entry, of the process of initial risk assessment that evaluates the benefits against the risks of
introducing a nasogastric tube for the purpose of feeding.
The following group of patients are at a high risk of incorrect tube positioning, dislodgement and
aspiration. Appropriate specialist advice should be taken if the patient has:





Maxillo-facial disorders
Laryngectomy
Recent radiotherapy to head and neck
Any disorder of the oesophagus/pharynx e.g. varices, stricture, pharyngeal pouch.
Nasal C.P.A.P.
Oro-gastric positioning may be indicated following head injury or neuro surgery.
High Risk also includes patients who: 




Are comatose/semi-comatose
Are ventilated/sedated
Have a swallow dysfunction
Have recurrent retching/vomiting
Need to be nursed prone
5.0 REFERRALS


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All patients requiring NG feeding should be referred to a dietitian. This may not be possible if
the decision to feed is made out of hours. In this case the dietetic referral should be phoned
through to the dietetic answer machine x1126.
Patients with the any of the above conditions or requirements as seen above in section 4
above will be referred a Trust employee with expert knowledge of insertion of NG tubes.
6.0 CONSENT
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Informed consent must be obtained from the patient prior to the procedure as per Trust policy for
consent. The consent must be recorded in the patient’s medical notes. If the patient lacks capacity
for consent, the decision to treat must be made within the patient’s best interests. The goals of the
treatment should be clearly identified in the patient’s medical notes. The procedure should also be
discussed with the family where appropriate.
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 6 of 172
7.0 TYPES OF TUBES AND TUBE SELECTION
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Nasogastric tubes are manufactured in a range of sizes and materials (polyvinal chloride (PVC),
polyurethane and silicone.
Feeding tubes must comply with: 1. National Patient Safety Alert (NPSA) 19 (2007) Promoting safer measurement and
administration of liquid medicines via oral and other enteral routes.


Enteral feeding systems should not contain ports that can be connected to intravenous
syringes, or that have end connectors that can be connected to intravenous or other
parenteral lines.
Enteral feeding systems should be labelled to indicate the route of administration.
2. National Patient Safety Alert (NPSA 2011) Reducing the harm caused by misplaced
nasogastric feeding tubes in adults, children and infants.

The tubes should be fully radio-opaque with externally visible markings to enable accurate
measurement, identification and documentation of their position (NPSA 2011).
NB. PVC tubes (e.g. Ryles) are not recommended for feeding as they harden in contact with
gastric acid and can cause internal ulceration (Payne-James et al 2001). In addition, they do not
comply with NPSA guidance.
Recommended tube size
8 Fr - recommended for standard use
10Fr - recommended if large volumes of medication are required via the tube (increased risk of
blockage).
Rationale for use of fine bore feeding tube




More comfortable
Less likely to interfere with eating and drinking
Less risk of reflux
Less likely to delay the return of swallowing mechanism
Guidewires
Fine bore tubes usually have a guidewire to aid insertion. The manufacturer’s guidance should be
adhered to, primarily, to ensure the guidwire is firmly positioned prior to use and never reinsert the
guidewire whilst the tube is within the patient.
back to index
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 7 of 172
8.0 INSERTION OF NASOGASTRIC TUBES
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The procedure will be carried out by an appropriate healthcare professional who has received
training in the procedure and has been assessed as competent. More advanced skills may be
required if the patient is at a high risk of a tube being misplaced during insertion (see section 4)
Additional training or expert input should be sought if required.
Placement should be delayed if there is insufficient experienced support available to
accurately confirm nasogastric tube placement (e.g. at night), unless clinically urgent, and
that the rationale for any decisions made is recorded in the patient’s medical notes.
8.1 Procedure
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Equipment
Clinically clean surface, CE accredited pH indicator strips, tissues, 60ml enteral/oral syringe,
gloves/apron, nasogastric tube.
Freshly drawn tap water to flush the tube once position confirmed.
Lubricating Jelly (may not be necessary if the tube has a water activated lubricant coating e.g.
Corpak Corflo tubes
Nasal/cheek dressing to secure tube (included in some packs).
Glass of water/coloured fluid and a straw (only if the patient has a safe swallow reflex)
Table 3
Action
Prior to the procedure, check the medical and
nursing notes for complications, e.g.
anatomical variations due to surgery or
cancer.
Assess the patient’s requirements.
Explain the procedure to the patient (even if
the patient appears not to understand).
Arrange a signal so that the patient can
communicate with the nurse during the
procedure e.g. raise a hand.
Assist the patient in a semi-upright position.
Support the head in a slightly forward
position.
Check that the nostrils are patent by asking
the patient to sniff with one nostril closed.
Repeat with the other side.
Alternate nostrils if replacing a tube.
Wash hands and put on non-sterile gloves
and an apron.
Unpack the tube, close the end connectors. If
the tube has a guide wire, gently push it into
the tube until it is fixed (see manufacturer’s
guidelines in packet).
Rational
These may affect the procedure and result in
further complications.
Patients with head injury or facial trauma may
have the feeding tube passed through the mouth
and down into the stomach to bypass nasal
damage and cerebral oedema.
The appropriate tube is inserted to meet the
patient’s needs and clinical condition and that the
tube is acceptable and comfortable.
To ensure that the patient understands and is able
to give consent, also to co-operate with the
procedure.
Helps to alleviate fear as the patient has some
control over the procedure.
Assists swallowing and helps prevent tracheal
placement if the swallow is compromised.
Helps identify potential obstruction.
Prevents nasal irritation and potential ulceration.
Minimises cross infection (Anderton 1995).
Prevents the tube from coiling back on itself during
insertion.
Check that the tube is not kinked.
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 8 of 172
Table 3 continued
Action
Rational
Place the tip of the tube (the distal opening, if
the tube is weighted) at the xiphisternum and
measure up to the tip of the nose and then to
an ear lobe (NEX measurement). Note the
measurement on the tube.
Lubricate the tube. Use a thin coating of
water based jelly. If the tube is hydrophilic
e.g. Corpak Corflo immerse the distal end
of the tube in water to activate the lubricant.
If re-passing a Corflo, use a lubricant.
Ensures that the correct length of tube is placed in
the stomach.
Insert the tip of the tube into the chosen
nostril, advancing it, horizontally, gently along
the floor of the nostril, parallel to the nasal
septum, to the nasopharynx and then
oropharynx. The patient may sneeze.
Reassure.
If resistance is met, withdraw slightly and
alter the angle of insertion, otherwise try the
other nostril.
Follow the natural anatomy of the nose.
If the patient is able to swallow small sips
should be taken at this stage. An assistant
may be required to help give thickened fluids
to swallow.
The swallowing action places the epiglottis over
the trachea so allowing the tube to enter the
oesophagus. Also the patient has something else
to focus on.
Facilitates easy passage of the tube.
If liquids are contra-indicated, sometimes
placing a cold spoon on the tongue may
initiate a swallowing reflex.
Advance the tube down the oesophagus with
successive swallows until the correct
measurement or mark is seen at the nostril.
If the tip of the tube is in the oesophagus there is a
high risk of aspiration. If too much tube is inserted
it might kink in the stomach, or pass through the
pylorus into the duodenum.
Check the position (see section 9.0 below)
To verify position in the stomach
NB
 DO NOT FLUSH the tube before gastric
placement has been confirmed.
 Internal guidewires/ stylets should NOT
be lubricated before gastric placement
has been confirmed.
Fix the tube in position (See section 10.2)
Water activation of the lubricant may give an
inaccurate low pH result. NPSA/2012/RRR001
Helps prevent dislodgement.
NB. This should be done after successful verification of the tube’s position, as it may need to be
moved to obtain aspirate. If X-ray is required, the tube should be secured to the nose/cheek.
back to index
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 9 of 172
Table 3 continued
Action
Document
 Type of tube, size and lot number
 Name of person inserting the tube
 The cm measurement on the tube at the
exit point from the nostril.
 The pH value (if gastric aspirate obtained)
 Which nostril
 The health care professional (HCP)
reading the X-ray should record the result
in the patient’s notes (See section 9.2.4 for
further guidance)
 Ease of insertion
back to index
Rational








Tracking and traceability
For audit and training requirements
Allows the user to assess whether the tube
has changed position.
Allows staff to compare with previous
readings
Prevents the same nostril being used
To identify whether the tube is safe for use.
For tracking and accountability.
Useful information for other healthcare
professionals inserting subsequent tubes.
Dispose of clinical waste as per Trust policy.
The guide wire must be placed in the sharps
bin.
Prevent contamination and sharps accident.
Wash hands as per Trust policy
Minimise risk of contamination
CAUTION
 Never advance the tube against resistance, pull back slightly and retry.
 If the patient shows signs of respiratory distress i.e. coughing gasping or cyanosis, the
tube may have entered the trachea. Pull the tube back or remove to allow time to
recover. If respiratory distress is prolonged or worsens, seek medical assistance.
Top tips (expert opinion):


back to index
Hold the tube straight rather than coiled in your hand.
If the patient has a swallowing difficulty, altered consciousness or inability to cooperate:
a) rotate the tube in your hand so that the tip points slightly upwards. This will position the
tip in the correct position on the nasopharyngeal wall.
b) tip the patient’s chin towards the chest.
c) advance the tube through the nostril and into the nasopharynx until resistance is felt
(usually 12-14cm marking on tube), there may be an involuntary swallow reflex
stimulated by the tube. Advance the tube with the swallow. If no reflex, advance the
tube slowly or the tube will back up into the mouth. Gentle pressure will allow the tube
to pass into the oesophagus.
If after 3 attempts NG insertion has failed or pulled out by the patient on three consecutive
occasions, escalate as soon as possible to an experienced practitioner (senior
nurse/clinician/nurse specialist).
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 10 of 172
9.0 CONFIRMATION OF TUBE POSITION
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
NOTHING should be introduced down the tube before gastric placement has been
confirmed;
 DO NOT FLUSH the tube before gastric placement has been confirmed;
 Internal guidewires/ stylets should NOT be lubricated before gastric placement has been
confirmed.
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441



pH testing is used as the first line test method, with pH between 1 and 5.5 as the safe
range, and that each test and test result is documented on a chart kept at the patient’s
bedside.
An attempt at pH testing must be carried out following every nasogastric tube insertion
even if the criteria for x-ray testing are met. This will allow for a baseline recording.
Studies suggest a 90% + success rate in obtaining aspirate.
X-ray is used only as a second line test when no aspirate could be obtained or pH
indicator paper has failed to confirm the position of the nasogastric tube.
NPSA/2011/PSA002 alert: Reducing the harm caused by misplaced nasogastric feeding tubes in
adults, children and infants.
9.1 pH Testing
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9.1.1 Methods for successfully obtaining gastric aspirate
Aspiration of gastric contents is sometimes difficult. The table below offers suggestions. A
combination of these may be required. Refer to algorithms 1 and 2 in appendix 3 for further
guidance. Patience is required.
Table 4
ACTION
RATIONAL
Always use a large enteral syringe (50cc min).
Small syringes have insufficient draw.


Insert 20 – 30mls of air, then aspirate.
Repeat several times, aspirating after each
injection of air.
 If unable to aspirate air, move the tube in or out
until air is returned. Usually a small amount of
fluid will be returned with the air (0.5mls is
sufficient to cover the pH strip).
The most common position for a return of aspirate is
when the tube markings show between 52-60cm at
the exit from the patient’s nose (expert opinion).

Lie the patient on their left side.
Gastric fluid will pool in a different position.
Alter the position of the tube and retry.
The tube may be positioned insufficiently,
or too far into the stomach.
Flush the tube with water following aspiration
Gastric acid causes the protein in the feed
to coagulate and increases the risk of tube
blockage.

Pushes the tube away from the gastric
mucosa, which may occlude the tube.
Allows the stomach to inflate and
redistribute the position of fluid slightly
(Colagiovanni 1999).
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 11 of 172
9.1.2 Recommended pH strips and usage

Tube position must be checked using pH indicator strips that are CE marked, intended by the
manufacturer to test human gastric aspirate and have a clear definition between pH 5-6 (NPSA
2005, 2011).
 pH strips must be used and stored according to manufacturer’s instructions. The reagent
section should not be contaminated before use through handling or inappropriate storage.
 It is not accepted practice to put gastric aspirate onto the syringe wrapping/cover and then to
run reagent strips through the aspirate. This may alter the pH reading (NPSA 2005).
NB.
 The lids must be kept on the containers when not in use.
 One box per patient – sharing has a high risk of cross contamination.
 The box must be decontaminated once it is no longer required for a patient.
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9.1.3 pH Values
A pH of less than 5.5 is a reasonable indicator of gastric placement. (NPSA 2005)
The pH of pulmonary fluid is normally above 6
The pH of intestinal fluid is normally above 6
Gastric pH levels may be elevated above 5.5 due to: a) Medication i.e. H2 antagonists and proton pump inhibitors which inhibit or reduce acid
production; antacids temporarily reduce gastric acidity by neutralising hydrochloric acid.
b) Reflux of intestinal contents into the stomach (Metheny et al 1994b).
c) Dilution of gastric acid due to:
 recent feed/flush: wait half an hour and retry.
 continuous feeds: consider stopping the feed for half an hour (Colagiovanni 1999).
CAUTION: Stopping feed should be carried out with extreme caution for patients on insulin
infusions for tight glycaemic control and only if other methods have failed. Stop insulin
infusion whilst the feed is turned off (NPSA 2005).
If aspirate values are higher than normal, it can be hard to assess the position of the tube. Using
algorithms 1 and 2 in appendix 3 will help individuals to assess and rationalise their decision
making in order to make NG tube management as safe as possible.
9.1.4 Documentation of pH result
Each pH test and result must be documented on the nasogastric monitoring form kept at the
patient’s bedside.
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East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 12 of 172
9.2 X-Ray testing
Table 5
Method
X-ray
2nd line testing
method. See section
9.2 for indications
Advantages
Disadvantages
This is the most
accurate method of
confirming
positioning.





No guarantee that the tube is still in position once the
patient has returned to the ward and for the subsequent
duration of NG feeding.
Risk of frequent exposure to X-rays.
Delay in commencing feeding via the tube.
Cost and resource implications.
Impractical for patients based in the community
(Colagiovanni 1999).
9.2.1 When to X-ray
back to index
X-ray following insertion is only indicated if:








The patient is unconscious with no gag reflex (ICU protocol).
The patient has altered anatomy e.g. known large hiatus hernia, pharyngeal pouch, previous
surgery on the upper GI tract.
There is absence of aspirate
pH testing is inconclusive.
Difficult tube insertion.
Fractured base of skull.
Recent radiotherapy to head and neck.
Recent surgery to head and neck.
X-ray should not be used routinely to confirm tube position during subsequent use. If you are
unable to confirm position using the above guidelines, refer to algorithms 1 and 2 in appendix 1
for further guidance for checking the tube position following failure to obtain aspirate or
inconclusive pH values.
An attempt at pH testing must be carried out following every nasogastric tube insertion even if the
criteria for x-ray testing are met. This will allow for a baseline recording.
Studies suggest a 90% plus success rate in obtaining aspirate.
(NPSA 2011).
9.2.2 How to X-ray
back to index
When ordering an X-ray check, the request form must clearly state that the purpose of the x-ray is
to establish the position of the nasogastric tube for the purpose of feeding.
The radiographer is responsible for:  Ensuring that the nasogastric tube can be clearly seen on the x-ray to be used to confirm
tube position.
 Adjusting the exposure of the x-ray to allow the nasogastric tube to be visible to the bottom
of the film.
 Ensuring that the film is centred lower than would normally be appropriate for a chest x-ray
so that it shows the abdomen as far as possible below the diaphragm.
 Adjusting the x-ray film to show the bottom of both hemi-diaphragms in the midline.
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 13 of 172
X-rays that are not as described above will not allow accurate interpretation of nasogastric tube
placement and should not be allowed out of the x-ray department.
If there is any difficulty in interpretation the advice of a radiologist should be sought.
Any nasogastric tubes identified to be in the lung should immediately be removed whether in the xray department or clinical area.
9.2.3 Who should read the X-ray?
back to index
X-rays must be checked by an appropriately trained clinician/advanced nurse practitioner, with
evidence to support this skill.
9.2.4 Documentation of X-ray
Documentation following X-ray should include:
 who authorised the x-ray
 who confirmed the position of the nasogastric tube. This person must be evidenced as
competent to do so
 confirmation that any x-ray viewed was the most current x-ray for the correct patient
 the rationale for the confirmation of position of the nasogastric tube, i.e. how placement was
interpreted, and clear instructions as to required actions. For example:
19 January 2011, 10:30 – Dr A. Smith – core surgical trainee
X-ray taken at 10:15 today
NG tube passed down midline, past level of diaphragm and deviates to left
Tip is seen in stomach
Plan: NG tube safe to use for feeding
Dr A. Smith
9.2.5 Cautions
 There is no guarantee that the tube is still in position once the patient has returned to the ward
and for the subsequent duration of NG feeding. The tube position i.e. centimetre marking at the
tube’s exit from the nostril, should be checked and compared with the position post insertion,
by the member of staff using the tube immediately prior to use.
 Risk of frequent exposure to X-rays.
 Delay in commencing feeding via the tube.
 Cost and resource implications.
 Impractical for patients based in the community
9.3 Who should check the position of the tube?


back to index
Any health professional/carer/patient prior to using the tube.
In the majority of cases nurses pass the tube and manage subsequent feeding. A nurse may
be involved in training a patient/carer to manage the tube.
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 14 of 172
9.4 When to check the position of the tube
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After initial tube insertion
 At least once per shift if continuous feeds are in progress
 Before each bolus feed, fluid or drug administration.
 If the patient complains of discomfort or feed reflux in the throat or mouth.
 If the patient suddenly shows signs of respiratory distress, e.g. breathlessness, strider,
cyanosis or wheezing.
 Vomiting or violent retching.
 Severe coughing bouts.
 If the measurement marking the tube’s exit from the nose has changed.
 If the tube length appears to have changed.
 Following transfers from other clinical areas if feed in progress.
9.5 Unsafe methods for checking NG position
Table 6
METHOD
Auscultation – the injection of 20 –30mls of air
into the tube via a syringe whilst listening with a
stethoscope over the left upper quadrant or
epigastrium for a distinctive sound whooshing
sound.
back to index
REASON WHY UNSAFE




Checking ability to speak
Signs of respiratory distress
Auscultation cannot predict whether tube tip
location is in the oesophagus, stomach or
respiratory tract (Metheny et al 1990a and
Neumann and Meyer 1995).
Unsuitable for obese patients, as no sound
may be heard.
There are reported cases showing that NG
tubes checked by air auscultation were later
shown to have tracheopulmonary
placement. (Rassias et al 1998).
Eleven deaths reported between 2002-2004
due to misplaced NG tubes following
auscultation tests and using litmus paper
(NPSA 2005, Colagiovanni 1999).
Fine bore tubes are small enough not to affect
speech
(Colagiovanni 1999).
 Fine bore tubes might not cause respiratory
distress.
 Patients with a poor gag reflex, or altered
consciousness might not demonstrate these
signs.
Using Litmus paper to test aspirate


Insufficiently accurate
Turns pink/red in contact with aspirate that
has a pH value as high as 6.5 (NPSA 2005).
Placing the proximal end of the nasogastric
tube in water and watching for bubbles to
indicate placement in the lungs. If no bubbles,
the tube is in the stomach.

Inaccurate and unsafe (Colagiovanni 1999).
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 15 of 172
10.0 MANAGEMENT OF A NASOGASTRIC TUBE
back to index
10.1 When to replace a nasogastric tube
Refer to manufacturer’s guidelines and individual patient assessment.
Table 7
TUBE
TIME
Ryles tube
10 days, or sooner, if causing discomfort (Dougherty and Lister 2004)
Used for aspiration
only
Corpak Corflo
tube
Other tubes
The manufacturers of Corflo tubes do not state a time limit for usage and
suggest that they can be used as long as they are functional. (Merck
communication). Decision to replace will depend on:  Viability of the tube
 Tolerance of the procedure by the patient
 Difficulty in insertion
Check with manufacturer/nurse specialist
10.2 Securing a nasogastric tube
back to index
 The tube should be fixed at the nose with a plaster.
 If tube has already been accidentally removed on multiple occasions a nasal retention device
(bridle) should be considered (NICE Clinical Guidelines (32)
 2006) . .See Guidelines for Insertion and Management of Nasal Bridles for further
information.
 The external part of the tube should be brought to the same side of the face as the insertion
nostril and allowed to rest over the ear.
- A dressing (preferably clear for aesthetic reasons) should be placed over the tube along
the cheek. This is recommended for the following reasons: Less irritating for the patient
as it secures the tube out of their line of sight.
- Does not interfere with the patient’s eating, by keeping the tube away from the mouth.
- A confused patient is less likely to pull the tube out as they cannot see it or feel it when
they bring their hands up to the mouth area.
- Patients receiving humidified oxygen (excess moisture makes the nasal tape slip).
 The dressings should be checked regularly and replaced if dirty or peeling off.
 The skin should be cleaned of any residual adhesive prior to replacing the tape/dressing.
10.3 Flushing
back to index
Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
10.4 Blocked tube
See CNSG 014 Guidelines for Enteral Feeding Complications and Management.
11.0 NASAL CARE


The nose should be checked and cleaned daily.
If the nose appears sore or ulcerated, consider re-passing the tube via the other nostril.
back to index
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 16 of 172
12.0 MOUTH CARE
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Maintenance of oral hygiene is essential, particularly is a patient is unable to
 have oral food and fluids
 attend to their own oral care
Table 8
PROBLEM
REASON
ACTION
Dry sore mouth




Inadequate mouth care
Mouth breathing
Poor dental condition

Saliva : Tenacious
Hyper-salivation



Dehydration
Neurological condition
Unable to swallow oral
secretions






Clean teeth/dentures with a soft toothbrush
or a damp swab wrapped around a gloved
finger (depending on patient). The frequency
will depend on the condition of the patient,
twice daily minimum).
Check the tongue and the hard palate for
thickened secretions and remove.
Use lip salve to protect lips from chapping.
Consider use of artificial saliva if appropriate
Refer to dentist if necessary.
Ensure adequate fluids.
Consider drug therapy. Consult doctor.
Maintain good oral hygiene.
Refer to Guidelines for the Oral Healthcare of Stroke Survivors by the British Society of
Gerodontology for comprehensive guidance as to management of oral hygiene.
http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf
13.0 REMOVAL OF A NASOGASTRIC TUBE
13.1 Planned
The patient must be referred to the dietitian prior to discontinuation of enteral feeding for review as
to whether oral intake is sufficient and whether oral supplements may be required.
13.2 Accidental
If the tube is still required for nutrition, fluids or medication, it should be reinserted as soon as
possible – within a 6 hour period is recommended. See below for Escalation Procedure (section
14.0) for patient requiring NG tube insertion. In addition: 


Ensure that the tube is correctly positioned and secured, as above, when reinserted.
Arrange for alternative fluid support as necessary.
Arrange for an alternative route for medication as appropriate.
13.3 Repeated unplanned removal
If unplanned removal is repeated, refer to CNSG 008 Nasal Bridle guidelines Appendix 1 flow
chart to manage repeated unplanned removal of nasogastric tube.
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East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 17 of 172
14.0 Escalation procedure for patients requiring NG tube insertion with or without
introducer.
Patient requires NG tube
Competent Nurse
identified and inserts
as per Trust
Guidelines for
Insertion and
Management of
Nasogastric Tubes
Competent nurse
unavailable
Competent Medical
F1/F2 to insert
Fully document
procedure in medical
and nursing notes
NG tube becomes
 Blocked
 Dislodged
 Accidentally
removed
Refer to competent
nurse within area if
unavailable escalate
F1 /F2 unavailable or
do not have skill to
insert within two hours
of request: Escalate
Escalate to:
In hours
 Senior nurse
/Matron for area.
 MNP/PSP
 Registrar
 GI specialist nurse
 Outreach team
Out of hours
 Senior nurse for
area
 Hospital senior
nurse/Night sister
 Registrar
Competent in the
procedure
Matrons Sam Leonard and Hayley Readiing August 2010
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East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 18 of 172
15.0 Discharge of patients on NG feeding
Patients must have prior to discharge:  A multidisciplinary risk assessment to assess needs (Appendix 5 Flow chart to guide
decision making for tube feeding route)
 Referral to a dietitian
 Training and assessment of competency for them and/or their carers for tube care and
feeding.
 An agreed plan if tube removed accidentally or blocked.
 A discharge pack to include: o Care of NG tube
o Care of equipment
o Contact numbers
o Feeding regimen
o Position monitoring form
o CE accredited pH strips
o Manufacturer’s guidelines for using pH strips
o Spare NG tube
o 7 days feed and equipment
o How to maintain oral hygiene
Action plan if tube removed
The plan will depend on the patient’s circumstances and the support available in the community




If tube comes out overnight wait until daytime for replacement
If the patient has had recent radiotherapy treatment at Christie, they will be at a high risk of
procedure related complications. In the absence of specialist support, refer them back to
Christie hospital.
If the patient has head and neck cancer and has had treatment at Leighton hospital, they
have open access to ward 10 and should return there for tube placement.
Any other patients should come to come to A&E bringing their spare tube with them.
back to index
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 19 of 172
APPENDIX 1 - REFERENCES AND BIBLIOGRAPHY
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Anderton A. (1995). Reducing bacterial contamination in enteral tube feeds. British Journal of
Nursing 4(7); 368-376
BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners
and Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead.
BAPEN (1996) Standards and Guidelines for Nutritional Support in Hospitals (ed. T. Sizer). British
Association for Parenteral and Enteral Nutrition, Maidenhead.
Boyes, R.J., Kruse, J.A. (1992) Nasogastric and nasoenteric intubation. Critical Care Clinics 8(4):
865-867.
British Society of Gerodontology (2010) Guidelines for the Oral Healthcare of Stroke Survivors.
http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf
Colagiovanni L. (1999) Taking the tube. Nursing Times 95:21 Supplement.
Colagiovanni L. (2000) Preventing and clearing blocked feeding tubes. Nursing Times. 96(17): 3-4.
Dougherty, L. & Lister S. (eds) (2004) The Royal Marsden Manual of Clinical
Nursing Procedures, 6th edn. Blackwell Science Ltd, Oxford.
Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in
Partnership with Nutricia.
Fater, K.H. (1995) Determining nasoenteral feeding tube placement. MedSurg Nursing, 4(1): 2732.
Human Rights Act 1998
Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical Devices:
Implications and Consequences of Reuse. MDA DB2000(04)
Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding Systems.
MDA SN2000(27).
Medicines and Healthcare products Regulatory Agency (MHRA2004) Enteral feeding tubes
(nasogastric) MDA/2004/026
Mental Capacity Act 2005
Metheny N. et al. (1990a) Detection if inadvertent respiratory displacement of
small bore feeding tubes: a report of 10 cases. Heart Lung 19(6): 631-638.
Metheny N. et al. (1990b) Effectiveness of the ausculatory method in predicting feeding tube
location. Nursing Research 39:262-7.
Metheny N. et al. (1993) How to aspirate from small bore feeding tubes. American Journal of
Nursing, May 86-89.
Metheny N. et al. (1993) Effectiveness of pH measurements in predicting feeding tube placement:
an update. Nursing Research 42(6): 324-331.
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East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 20 of 172
Metheny N. et al. (1994a) Visual characteristics of aspirates from feeding tube as a method for
predicting tube placement. Nursing Research 43(5): 282-287.
Metheny N. et al. (1994b) pH testing of feeding tube aspirates to determine placement. Nutrition in
Clinical Practice 9(5): 185-190.
National Institute for Clinical Excellence (NICE) (2013) Nutrition support in adults
Evidence Update August 2013. A summary of selected new evidence relevant to NICE clinical
guideline 32 ‘Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral
nutrition’ (2006) Evidence Update 46
National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation
of placement NPSA/2012/RRR001 22/03/12
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441
National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric
feeding tubes in adults, children and infants. NPSA/2011/PSA002
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric
feeding tubes NPSA/2005/05
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59794&p=4
National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139
Infection Prevention and control of healthcare-associated infections in primary and community care
http://guidance.nice.org.uk/CG139
National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral
supplements, parenteral and enteral feeding. London.
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
Neumann M.J., Meyer C.T. (1995) Hold that X-ray: aspirate pH and auscultation prove enteral tube
placement. Journal of Clinical Gastroenterology 20(4): 293-295
Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour
for nurses and midwives. London, NMC.
Payne-James, J., Grimble, G. & Silk, D. (2001) Enteral nutrition: tubes and techniques of delivery.
In: Artificial Nutritional Support in Clinical Practice, 2nd edn (eds J. Payne-James, G. Grimble & D.
Silk). Greenwich Medical Media, London.
Powell K.S. et al (1993) Aspirating gastric residuals causes occlusion of small bore feeding tubes.
Journal of Parenteral and enteral Nutrition. 17(3): 243-246
Rassias A.J. et al (1998). A prospective study of tracheopulmonary complications associated with
the placement of narrow bore feeding tubes. Critical Care 2: 25-28.
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East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 21 of 172
APPENDIX 2 LINKS TO SUPPORTING DOCUMENTS/NG CAREPLAN
back to index
NASOGASTRIC (NG) TUBE INSERTION AND MONITORING FORM – click on to access.
Patient Information leaflets
Drug administration via enteral feeding tubes
http://www.bapen.org.uk/pdfs/d_and_e/de_pat_guide.pdf
NPSA alerts relating to Nasogastric feeding
National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation
of placement NPSA/2012/RRR001 22/03/12
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441
National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric
feeding tubes in adults, children and infants. NPSA/2011/PSA002
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric
feeding tubes NPSA/2005/05
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798
Manufacturer’s websites
Abbott Nutrition home page – access to pump instruction manuals and training
Videos
http://www.abbottnutritionuk.com/
Corpak Medsystems – access to information about enteral tubes and company guidelines
http://corpakmedsystemsuk.com/
Medicina – information about enteral syringes and feeding devices
http://www.medicina.co.uk/
back to index
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 22 of 172
APPENDIX 3
NG TUBE
?
IN POSITION
pH 6
OR
ABOVE
?
CONSIDE
R
COLOUR OF
ASPIRATE
Yellow/green stained
aspirate is suggestive
of bile (higher pH)
MEDICATION
See box B
RECENT FEED
ALGORITHM 1 - TO CONFIRM NG POSITION FOLLOWING INSERTION AND PRIOR TO USE
ASPIRATE
OBTAINED?
No
Yes
Yes
TRY A
COMBINATION OF
THE FOLLOWING
pH 5.5
OR
LESS?
TEST ON pH
PAPER
See box A
ASPIRATE
OBTAINED?
No
IF NEW INSERTION - X-RAY
(see box C)
IF ROUTINE CHECK - REFER TO
ALGORITHM 2 FOR
INCONCLUSIVE ASPIRATE ACTION B
Yes
X-RAY
CHECK
See box C
GIVE FEED, FLUID AND
MEDICATION AS
PRESCRIBED
See box C for whether
X-ray is indicated
Yes
TUBE POSITION
CORRECT ON X-RAY?
See box C.
IF NEW INSERTION - X-RAY
(see box C)
Box A. HOW TO USE pH STRIPS
1. Place a small amount of aspirate onto the pH strip-avoid touching the area to be
read.
2. Allow 10 seconds and compare the resulting colour with the colour chart on the pH
strip container.
ALTER TUBE POSITION SLIGHTLY
Aspirate is most commonly obtained when the
tube is positioned between 52-60cm (mark at
exit from nose)
IF UNSUCCESSFUL REPEAT INSERTION OF
AIR AS ABOVE
ALTER POSITION OF PATIENT - TURN ONTO
LEFT SIDE AND REPEAT AS ABOVE
No
REFER TO ALGORITHM 2 FOR
INCONCLUSIVE ASPIRATE ACTION C
IF NEW INSERTION
WAIT ½ - 1 HOUR AND RETRY
IF NO CHANGE X-RAY
(see box C)
IF ROUTINE CHECK - REFER TO
ALGORITHM 2 FOR
INCONCLUSIVE ASPIRATE ACTION D
FLUSH 20-30MLS AIR WITH A SYRINGE
THEN ASPIRATE
REPEAT 2-3 TIMES
IF TUBE IS IN THE LUNG REMOVE AND START
AGAIN
IF IN GI TRACT BUT IN INCORRECT PLACE,
REPOSITION AS PER EXPERT CLINCAL GUIDANCE.
Box C. X-RAY FOLLOWING INSERTION IS INDICATED FOR THE FOLLOWING HIGH RISK
GROUPS:
1. Unconscious with no gag reflex (ICU protocol)
2. Altered anatomy e.g. known large hiatus hernia
3. Testing of aspirate is inconclusive

4. Difficult insertion
5. Fractured base of skull
6. Recent radiotherapy/surgery to head and neck.
X-ray should not be used routinely to confirm tube position during subsequent use. If you are unable to confirm position
using the above guidelines, see algorithm 2 for checking tube position following no aspirate or inconclusive pH values.

When ordering X-rays, please specify ‘to check NG position’ on request form.
EastB.
Cheshire
NHS Trust
CNSG 007pH
Guidelines
InsertionBY:
and Management of Nasogastric Tubes
23 of by
172
Box
VARIATIONS
IN GASTRIC
MAY BEfor
CAUSED

X-rays mustPage
be checked
an appropriately trained clinician/advanced nurse practitioner. The result must be recorded
Created by Maggie Allen, October 2010. Updated March 2015.
in the patient’s notes.
1. Medication i.e. H2 antagonists and proton pump inhibitors which inhibit or reduce
acid production. PH value will be raised.
NB. High risk patients requiring X-ray following insertion should have a pH check of aspirate carried out as well, to
2. Bile/ Recent feed/Lung placement – less acidic, therefore will show a higher pH
provide a baseline for subsequent checks.
value.
ALGORITHM 2 - TO ASSIST IN CONFIRMING NG POSITION IF NO ASPIRATE OR PH VALUE INCONCLUSIVE
NO ASPIRATE
INCONCLUSIVE ASPIRATE (Ph GREATER THAN 5.5) - COMBINE THE
FOLLOWING WITH TUBE DISPLACEMENT CHECKS.
ACTION A. CHECK FOR TUBE DISPLACEMENT
ACTION A.
HAS THE EXTERNAL LENGTH OF THE TUBE CHANGED?
FLUSH A SMALL AMOUNT OF AIR THROUGH THE TUBE TO CLEAR RESIDUAL FEED/FLUID THEN
RETRY
Check cm mark at exit from nose and compare with
insertion data on monitoring charts/NG care plan.
ACTION B.
No
HAS THE MARK AT THE EXIT FROM THE NOSE SLIPPED?
No
Yes
CONSIDER THE VOLUME OF ASPIRATE: LARGE VOLUMES SUGGEST GASTRIC PLACEMENT.
CAUTION: There have been reported high volumes of aspirates from tubes that have been located in
the lungs. Request senior input.
CONSIDER THE COLOUR OF ASPIRATE: YELLOW/YELLOWY-GREEN/DARK GREEN ASPIRATE IS
SUGGESTIVE OF BILE.
CAUTION: Lung aspirates shave been described as the above colours. Look at previous pH readings, if
consistently high, treat as normal, if a one off, consider why. Request senior input.
HAS THE PATIENT VOMITED?
No
ACTION C.
HAS THERE BEEN AN INCREASE IN THE PATIENT’S
RESPIRATORY DISTRESS e.g. breathlessness, strider, cyanosis
MEDICATION: IF ON A PPI e.g. LANSOPRAZOLE/OMEPRAZOLE OR H2 ANTAGONIST e.g. RANITIDINE,
Look at previous pH readings, if consistently high, treat as normal, if a one off, consider why. Request
senior input.
or wheezing.
No
ACTION D.
CONSIDER DILUTION OF GASTRIC ACID.
IS THE NG TUBE VISIBLE IN THE MOUTH?
1. RECENT FEED/FLUSH: WAIT HALF AN HOUR AND RETRY
2. CONTINUOUS FEEDS: CONSIDER STOPPING THE FEED FOR HALF AN HOUR.
CAUTION: If the patient is having insulin infusions for tight glycaemic control . Consult with senior
doctor/specialist before stopping the feed.
No
ACTION B.
IF NO CHANGE, DOCUMENT
RESULTS AND CONTINUE TO
USE THE TUBE - if unsure,
consult a senior/more
experienced member of staff.
Document decision and
rationale.
ACTION C.
REPOSITION TUBE
OR REMOVE AND
REPLACE – repeat
ACTION E.
confirmation checks
as seen in algorithm1
Yes
IF REMAIN UNSURE AFTER THE ABOVE, CONSIDER X-RAY.
Consult a senior/more experienced member of staff prior to requesting an X-ray. Document decision
and rationale.
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 24 of 172
APPENDIX 4: FLOW CHART TO GUIDE DECISION MAKING FOR TUBE FEEDING ROUTE
Enteral tube feeding support required (see indications section 2.0)
Long term requirement
– more than 6 weeks
Consider referral for:  PEG feeding (see
Trust PEG
guidelines)
Start NG feeding if
appropriate whilst
waiting for PEG
insertion.

NG tube with nasal
bridle (see Trust
nasal bridle
guidelines)
Short term requirement
HIGH RISK of
complication
Yes
Assess for risk and
appropriateness of
nasogastric tube (NGT)
No
Insert NGT as per Trust
guidelines
Refer to specialist/expert
practitioner for insertion
and management advice
Confused and pulling out
NGT (see flowchart to
manage repeated
unplanned removal of NG
tubes)
.
PEG/nasal bridle
contraindicated or
refused by patient
Yes
Consider:  Referral for radiologically inserted gastrostomy (RIG) (see section 12.0 of Trust PEG
guidelines)
 Continuing NG feeding +/- nasal bridle (unless contraindicated or refused by patient)
 Limited oral feeding with palliative care
Risk/benefit assessment required as to best modality for patient plus patient choice where possible
If for oral feeding repossible
If for oral feeding, refer
to SALT for safe
feeding techniques and
to dietetics for
maximising calorific
value of meals.
back to index
If for palliative care,
organise MDT to discuss
plan of care and refer to
relevant healthcare
professionals.
If for NG feeding organise MDT
assessment prior to discharge to
plan: Care requirements in
community
 Who will provide care
 Training required to minimise
risks
 Agree action plan if NGT comes
out
Refer to section 15.0 above
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 25 of 172
END OF EAST CHESHIRE NHS TRUST CNSG 007 GUIDELINES
FOR INSERTION AND MANAGEMENT OF NASOGASTRIC
TUBES
back to index
back to main index
East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
Created by Maggie Allen, October 2010. Updated March 2015.
Page 26 of 172
Guideline Title:
Guidelines for Insertion and Management of Nasal Bridles
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via a
nasogastric tube under the care of East Cheshire NHS Trust.
Supersedes:
Version 1.1
Description of
Guidelines reviewed - no major changes
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal patient nutrition.
Guideline Area:
Nutrition
Document Reference:
CNSG 008
Version Number:
1.2
Effective Date:
August 2011
Issued By:
Departments of Dietetics
and Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group
Date
Consultation:
Departments of Dietetics and
Gastroenterology
Clinical Nutrition Steering Group
October 2010-August 2011
June 2015
Approved by:
Clinical Nutrition Steering Group
July 2015
AMENDMENT RECORDS
August 2011
Guidelines updated for NPSA/2011/PSA002 alert compliance
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 27 of 172
GUIDELINES FOR INSERTION AND MANAGEMENT OF NASAL BRIDLES
INDEX
SECTION
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
Appendix 1
Appendix 2
Appendix 3
Appendix 4
CONTENTS
Introduction
Definition
Indications
Contraindications
Assessment and referral
Consent
Equipment
Procedure
Potential complications
Aftercare
Discharge with a nasal bridle in situ
Displacement within the community
Planned Removal
Disposal
References
Flow chart to manage repeated unplanned removal of a
nasogastric tube
Nasal Bridle Fixation device request form
Flow chart to guide management if nasogastric tube or nasal
bridle displaced
Links to supporting documents/information
 Patient information
 NPSA alerts relating to NG use
 Manufacturer’s websites
PAGE
29
29
29
29
30
30
30
30
31
31
31
31
31
31
32
33
34
35
36
Back to main index
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 28 of 172
The following guidelines should be used in association CNSG 007 Guidelines for the Insertion
and Management of Nasogastric Tubes.
1.0 Introduction
back to index
Nasogastric feeding is the most common method of providing short-term artificial nutritional
support in the acute setting. There is a high risk of accidental removal either by the patient or by
staff caring for the patient. Unplanned removal impacts in the following ways:  The patient does not meet their nutritional and fluid requirements
 The patient requires another tube placing
 Increased incidence of chest x-rays.
2.0 Definition
back to index
A nasal bridle is the positioning of a tape around the nasal septum to secure a nasogastric tube
where it exits the nostril. If required, the bridle can remain in place for the duration of nasogastric
feeding. The use of a nasal bridle to secure a nasogastric feeding tube was first described in 1980
and has since been demonstrated to be safe and effective (Donaldson et al 2007).
The aim of a nasal bridle is to:  Prevent unplanned removal by patients and staff caring for the patient.
 Eliminate inappropriate gastrostomy insertion and associated risks.
 Maintain nutritional intake.
 Allow time for assessment as to the best method of nutritional support for a patient.
3.0 Indications
back to index
Patients who require delivery of medication/feed/fluid via the enteral route with the following
criteria: 




Poor tolerance of the nasogastric tube i.e. pulled out on at least 3 occasions in short
succession.
Sub optimal nasal fixation tape as a result excessive moisture e.g. patient receiving
humidified oxygen therapy (tube displaced on at least 3 occasions as a result of this).
Skin irritation caused by adhesive securing tape.
Long term nasogastric feeding required if gastrostomy insertion inappropriate.
Known difficult insertion procedure involving videofluroscopy or endoscopic insertion
4.0 Contraindications
back to index
Patients excluded from nasal bridle placement include:
 Severely agitated patients who are likely to cause damage to their nasal septum due to
excessive pulling on the tube.
 Facial or cranial trauma.
 Basal skull fracture.
 Severely deviated, structural deformity, or obstructed nasal septum or passage.
 Nasotracheal tubes in situ.
 Advanced dementia (as well as being highly likely to pull on the tube due to confusion,
these individuals may not benefit from enteral nutrition support – see CNSG 009
Guidelines for Insertion and Management of Gastrostomy Tubes for further guidance).
 Thrombolytic therapy for acute stroke or MI in the last 5 days (relative - discuss with
consultant)
 Warfarin therapy (relative - discuss with consultant)
 Recent radiotherapy to the nose
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 29 of 172
5.0 Assessment and Referral




back to index
If the patient is pulling out a nasogastric tube, try to identify the cause
Rule out medical reasons for confusion such as infection, dehydration.
The decision to place a nasal bridle should be within an MDT setting
The patient should be referred to an appropriately trained doctor or nurse for assessment
and insertion of the nasal bridle.
See appendix 1 for flowchart for recommended management plan.
6.0 Consent
back to index
Informed consent must be obtained from the patient prior to the procedure as per Trust policy. The
consent must be recorded in the patient’s notes. If the patient lacks capacity for consent, the
decision to treat must be made within the patient’s best interests. The goals of the treatment
should be clearly identified in the patient’s medical notes. The procedure should also be discussed
with the family where appropriate.
7.0 Equipment
AMT nasal bridle - kept on ETU/Ward 3/Ward 11
Nasogastric tube insertion equipment (Refer to CNSG 007 Guidelines for the Management of
Nasogastric Tubes).
8.0 Procedure





back to index
The bridle must be inserted by an appropriately trained doctor or nurse.
The patient should be prepared as per CNSG 007 Guidelines for the Management of
Nasogastric Tubes) and a nasogastric care plan completed.
The nasogastric tube must be inserted and the position checked prior to insertion of the bridle.
National Patient Safety Agency Alert 19 guidance must be observed when assessing the tube’s
position (www.npsa.nhs.uk) Also refer to CNSG 007 Guidelines for the Management of
Nasogastric Tubes.
Insert bridle following manufacture’s guidelines. Follow link
http://www.appliedmedical.net/amtbridle.htm for pictorial guidelines and link
http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm for a video of
the procedure (click on the appropriate tube French size directions for use).
When finished, dispose of clinical waste and wash hands as per Trust policy.
back to index
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 30 of 172
9.0 Potential complications
back to index
Anterior epistaxis
Bleeding may occur during insertion of a nasal bridle device. Any bleeding lasting longer than 15
minutes or greater than 100mls should be discussed with the medical team.
Pressure necrosis
If the nasal bridle is fastened too tightly or becomes twisted, pressure sores may lead to necrosis
of the nasal septum. If a pressure sore develops, the bridle tape should be cut and removed (see
section 13.0 below). The area should be checked, cleaned daily and a dressing applied where
indicated. The condition of the patient’s nostrils should be recorded daily in the patient’s care plan.
Dislodged Nasogastric tubes
It is still possible for a tube to become dislodged despite a bridle, either deliberately by the patient
or accidentally during vomiting. The tube position must continue to be checked prior to each
episode of use as per CNSG 007 Guidelines for the Management of Nasogastric Tubes.
10.0 Aftercare
back to index
The patient should be monitored as per CNSG 007 Guidelines for the Management of
Nasogastric Tubes. In addition, the patient should be monitored closely for signs of nasal trauma
as a result of the patient pulling on the tube, or irritation caused by the tape rubbing against the
nasal passage. The nasal passage and tape should be cleaned daily.
11.0 Discharge with a nasal bridle in situ
If the patient is to be discharged with a bridle in situ the following should be in place:  A written care plan provided for carers.
 Plan of action if the tube becomes displaced.
 Support from dietetics to continue with nutritional monitoring.
12.0 Displacement within the community
back to index
District nurses or out of hours nurses should be contacted to assess whether the patient needs to
attend the A&E department.
13.0 Planned removal
Cut one side of the tape (usually the side exiting the nostril opposite the nasogastric tube) and pull
the nasogastric tube out. The tape will follow with the tube. See video link for a demonstration.
http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm
14.0 Disposal
The tube and bridle should be disposed of as per East Cheshire NHS Trust policy for disposal of
clinical waste.
back to index
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 31 of 172
15.0 References
back to index
Donaldson, E., Early, T., Sheilds, P (2007) The Nasal Bridle – It’s place within an integrated
nutrition service: a prospective audit of one year’s data. Gut (56) Suppl 56 A137
Johnston RD et al. (2008). Outcome of patients fed via a nasogastric tube retained with a bridle
loop: do bridle loops reduce the requirement for percutaneous endoscopic gastrostomy insertion
and 30-day mortality?
Proceedings of the Nutrition Society 67, E116.
Lancashire Teaching Hospitals NHS Trust (2006). Safe practice for insertion and management of a
nasal bridle to secure nasogastric tubes.
National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral
supplements, parenteral and enteral feeding. London.
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
Russell KL et al. (2006). Bridle fixation of nasogastric tubes – the Addenbrooke’s experience.
Proceedings of the Nutrition Society 65, 14A.
Popovich MJ et al. (1996). Nasal bridle revisited: An improvement in the technique to prevent
unintentional removal of small-bore nasoenteric feeding tubes. Critical Care Medicine 24, 429-431.
back to index
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 32 of 172
APPENDIX 1.
back to index
FLOW CHART TO MANAGE REPEATED UNPLANNED REMOVAL OF A NASOGASTRIC
TUBE
Patient pulled out NG tube on more
than three occasions
Yes
Is the patient confused?
No
Establish reason for confusion and treat
accordingly
Identify why the patient is
pulling the tube out.
Wait 24 hours
If the patient refuses the tube,
they should have the risks
and consequences explained
to them so that they can make
an informed choice.
Reassess for a nasal bridle. MDT discussion to
discuss appropriateness. To include
Doctor/nurse/SALT/dietitian
Doctor/specialist nurse to discuss the procedure,
pros and cons with the patient/relatives and
obtain consent.
Document consent in medical notes
Nasal bridle to proceed
Yes
No
Refer to flow chart to guide
decision making making for
tube feeding route
Insert NG tube and check tube position as per
Trust guidelines prior to inserting the bridle as
per manufacturer’s guidelines
http://www.appliedmedical.net/bridleVideo/br
idleVideosWindow.htm
Monitor for complications. Refer to flow chart
to guide management if displacement of
nasal bridle/tube.
back to index
back to NG guidelines
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 33 of 172
APPENDIX 2
Nasal Bridle Fixation Device Request Form
To be used alongside the NG care plan document. Please complete all the information requested on
this form. Fax the form to x1904, Gastroenterology Department.
Patient Details:
Name: ……………………………………………………… Hospital No:...........................
Date of Birth:…………………….. Ward.................................
Consultant...................................................................
Is the patient
NBM
On NG Feed
Eating orally
Date of last SALT review ............................ Date of last dietetic review.......................
Number of NGs pulled out by the patient?.................................
Can the patient consent to the bridle Yes/No
Has the bridle been discussed with the patient relatives (if appropriate)
Yes/No
Is the patient receiving or has had recent anticoagulation therapy
Yes/No
If the patient has any of the following conditions nasal bridle is not appropriate
Extreme confusion and likely to pull at the tube
Known basal skull fractures
Deviated or perforated nasal septum
Structural deformity of the nose or nasopharynx Yes/No
Advanced dementia
Recent radiotherapy to the nose or nasopharynx
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Bridle requested by (name/title)..................................................................................
Doctor’s signature................................................ Contact number.............................
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 34 of 172
APPENDIX 3. FLOW CHART TO GUIDE MANAGEMENT IF NASAL BRIDLE AND / OR NASOGASTRIC TUBE DISPLACED
NG still in
Bridle out
No
Yes
Bridle and
NG out
Review
patient
condition and
reason for
removal.
NB. There
may be
damage to
nasal septum
if bridle
removed
forcefully.
No
NG out
Bridle still in
Yes
Review patient
condition and
reason for removal
Bridle still
required**
No
Yes
Refer to specialist/HCP trained in the
procedure for reinsertion of bridle*
Check NG tube still in position prior to
reinsert bridle as per Trust
guidelines and secure to NG tube.
NG still
required**
If NGT also pulled out, reinsert NG
tube and check position as per Trust
guidelines, then secure to bridle.
No
Remove NGT and continue with oral
diet.
Bridle still
required**
Yes
Reinsert NG tube and check position
as per Trust guidelines, then secure
to bridle.
No
NG still required**
Yes
Reinsert NG tube as per Trust
guidelines and consider whether
bridle still required, if not, remove
bridle.
Remove bridle and continue with oral
diet.
No
*If there is a delay for specialist/trained intervention – continue with NG therapy and monitor carefully for unplanned tube removal. Bolus administration only
recommended.
**Refer to flow chart to guide decision making making for tube feeding route.
back to index
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 35 of 172
APPENDIX 4 SUPPORTING INFORMATION
back to index
NPSA alerts relating to Nasogastric feeding
National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation
of placement NPSA/2012/RRR001 22/03/12
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441
National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric
feeding tubes in adults, children and infants. NPSA/2011/PSA002
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric
feeding tubes NPSA/2005/05
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798
Manufacturer’s websites
Applied Medical Technology (AMT ) nasal bridle
http://www.appliedmedical.net/amtbridle.htm
http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm
Abbott Nutrition home page – access to pump instruction manuals and training
Videos
http://www.abbottnutritionuk.com/
Corpak Medsystems – access to information about enteral tubes and company guidelines
http://corpakmedsystemsuk.com/
Medicina – information about enteral syringes and feeding devices
http://www.medicina.co.uk/
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East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen. October 2010. Updated July 2015.
Page 36 of 172
END OF EAST CHESHIRE NHS TRUST CNSG 008 GUIDELINES
FOR INSERTION AND MANAGEMENT OF NASAL BRIDLES
back to index
back to main index
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen. October 2010. Updated July 2015.
Page 37 of 172
Guideline Title:
Guidelines for Insertion and Management of Gastrostomy Tubes.
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via a
gastrostomy tube under the care of East Cheshire NHS Trust.
Supersedes:
Version 1.0
Description of
Amendment(s):
Guidelines reviewed - New guidance: Stop Clopidogrel 7 days prior to PEG insertion and to omit new
anticoagulants dependent on specific anticoagulant and patient’s renal
function.
Updated advice on optimum positioning of gastrostomy tube.
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal patient nutrition.
Guideline Area:
Nutrition
Document Reference:
CNSG 009
Version Number:
1.1
Effective Date:
November 2010
Issued By:
Departments of Dietetics
and Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Consultation:
Approved by:
Committees / Group
Date
Departments of Dietetics and
Gastroenterology
Clinical Nutrition Steering Group
Infection prevention and control
October 2010
Clinical Nutrition Steering Group
July 2015
June 2015
AMENDMENTS RECORD
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen. October 2010. Updated July 2015
Page 38 of 172
GUIDELINES FOR INSERTION AND MANAGEMENT OF GASTROSTOMY TUBES
INDEX
SECTION CONTENTS
1.0
2.0
3.0
3.1
4.0
5.0
5.1
5.2
6.0
6.1
7.0
7.1
7.2
7.3
7.4
7.5
7.6
7.6.1
7.6.2
7.6.3
7.6.4
7.6.5
7.6.6
8.0
8.1
8.2
8.3
9.0
9.1
9.2
9.3
10.0
10.1
10.2
10.3
10.3.1
10.3.2
10.4
10.5
10.6
10.7
PAGE
Definition
Indications
Contraindications
Advanced dementia
Referral
Information giving and informed consent
Capacity and consent
Multidisciplinary team
Preparation and Assessment
Type of tube
Patient care post gastrostomy insertion
Peri and postoperative complications of PEG insertion
Monitoring
Commencing feed/oral diet
Mouth care
Pain control
Gastrostomy site care
Procedure to clean a gastrostomy site
Bathing and showering
Gastrostomy site dressings
Positioning the fixation device
Prevention of buried bumper syndrome
Sutures
Maintenance of the gastrostomy tube
Flushing
Syringes
General maintenance of the tube
Removal of a gastrostomy tube
Accidental removal
Planned removal
Procedure for traction removal of a Merck Corflo gastrostomy tube
Management of balloon gastrostomy tubes
Definition
Low profile gastrostomy tubes – buttons
General management of balloon gastrostomy tubes, buttons and
extension sets
Preparation of an extension set for administering fluids via a low
profile device
Cleaning an extension set after use and replacement
Checking the balloon volume
Removal of a balloon gastrostomy tube
Discontinuing balloon gastrostomy feeding
Replacement of a balloon gastrostomy tube
41
41
42
42
43
43
43-4
44
45-7
47
48
48
48
49
49
49
50
50
51
51
51
51
52
52
52
52
52
53
53
53
53-4
54
54
54
54-5
55
55
56
57
58
58
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 39 of 172
INDEX CONTINUED
SECTION
CONTENTS
PAGE
10.8
10.9
10.10
10.11
10.12
10.13
10.14
11.0
Insertion procedure for a balloon gastrostomy tube
Insertion of a low profile device
Measurement of a gastrostomy stoma
Complications
Accidental removal of gastrostomy tube
Temporary gastrostomy tubes
Spare tubes
Management of an intestinal tube within a PEG tube for buried
bumper
Insertion/replacement of an intestinal tube within a PEG tube
Care of an intestinal tube within a PEG tube
Radiologically inserted gastrostomy tubes (RIG)
Referrals
Sutures
Discontinuation of tube feeding
Discharge of patients on enteral feeding
Discharge within 72 hours of PEG insertion
Information required for discharge within 72 hours of insertion
Training required prior to discharge
Information and contact details required prior to discharge
Referrals required prior to discharge
Equipment required for discharge
References and bibliography
Linked supporting documents:  Discharge check list
 Patient information
 NPSA alerts relating to PEG
 Manufacturer’s information
 Care Pathway for Percutaneous Endoscopic Gastrostomy
(PEG) Tubes
58-60
60
60
60
61
62
62
63
11.1
11.2
12.0
12.1
12.1
13.0
14.0
14.1
14.2
14.3
14.4
14.5
14.6
Appendix 1
Appendix 2
63-4
64
65
65
65
65
65-6
65
66
66
66
66
66
67
68
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 40 of 172
1.0 DEFINITION
back to index
A gastrostomy tube is the generic term for a feeding tube that is inserted into the stomach either,
surgically, endoscopically (PEG) or radiologically (RIG). The gastrostomy tube allows delivery of
nutrients, fluid and medication directly into the stomach.
Percutaneous Endoscopic Gastrostomy (PEG) is the insertion of a small plastic tube through the
abdomen and into the stomach under endoscopic vision. The following guidelines are biased
towards this type of procedure as radiological insertion of a gastrostomy (RIG) is not currently
undertaken at the Trust.
2.0 INDICATIONS
back to index
When selecting patients for gastrostomy/PEG insertion the following should be considered:




Artificial nutrition is appropriate for the individual
Patients require enteral nutritional and hydration support (partial or complete) for more than 6
weeks.
The individual has a functional gastrointestinal tract.
Nasogastric (NG) tube feeding has not been tolerated or is thought to be unsafe.
-

The patient has pulled out the NG tube on at least 3 occasions in short succession and use
of a nasal bridle is contraindicated. Refer to CNSG 008 guidelines for management of
nasal bridles for further information.
The patient demonstrates significant distress during NG insertion.
The patient refuses nasogastric tube insertion.
Altered anatomy e.g. large hiatus hernia, increasing the risk of aspiration.
Basal skull fracture, as the tube may enter the brain if incorrectly positioned (oro-gastric
positioning may be appropriate).
Obstructive pathology in oropharynx or oesophagus preventing passage of the tube e.g.
stricture, tumour.
The patient is fit enough and will benefit from the procedure
back to index
- Procedure related mortality 0.7-2%.
- 30-day mortality rate
2-28%
- Complications post PEG
15-70%
(NCEPOD 2004 and BSG Guidelines 2006)
http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complicati
ons.pdf
http://www.ncepod.org.uk/2004report/index.htm
High risk groups include individuals with significant co-morbidity, in particular those with
aspiration pneumonia prior to PEG insertion. See section 6 below for further information.

Tolerance of the gastrostomy tube by patient/partner.
- Physical implications – changes to body image, foreign object in body, feel unable
undertake activities such as swimming.
Psychological implications - changes to body image which may affect the individual and their
partner, unable to engage in normal social activity such as eating, regular interference with the
body by others accessing the gastrostomy tube to deliver feed and fluids.
back to index
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 41 of 172
3.0 CONTRAINDICATIONS
Table 1
Absolute



Tense ascites
Peritoneal dialysis
Total gastric outflow obstruction
back to index
Relative








Morbid obesity
Treatment with high dose steroids
Previous upper GI surgery
Partial gastric outflow obstruction
Advanced dementia (see below)
Coagulopathy disease/drugs
Gastro-oesophageal reflux with risk of
aspiration
Recurrent aspiration pneumonia due to
severe dysphagia following a stoke
3.1 Advanced dementia
back to index
The following summary illustrates the problems faced in deciding whether a gastrostomy tube is
appropriate for an individual with advanced dementia.
There is insufficient evidence to suggest that enteral tube feeding is beneficial in
patients with advanced dementia. Data are lacking on the adverse effects of this
intervention
Patients with advanced dementia often develop dysphagia (difficulties swallowing). They
also experience changes in appetite and apraxia (difficulty co-coordinating movements) and
may have difficulties feeding themselves. Two methods of enteral tube feeding are
commonly used: the administration of food and fluids via a nasogastric tube (a tube that is
passed through the nose and into the stomach) or via a percutaneous endoscopic
gastrostomy (PEG) where a feeding tube is inserted into the stomach and is accessed
through a permanent incision in the abdominal wall. The decision to use artificial hydration
and nutrition in someone with dementia is often emotive and complex. Relatives and carers
may request the intervention because they are concerned that the patient may starve;
clinicians may be aware of the risks but feel pressurised by institutional, societal or even
legal directives to intervene. We found no conclusive evidence that enteral tube nutrition is
effective in terms of prolonging survival, improving quality of life, or leading to better
nourishment or decreasing the risk of pressure sores. It may actually increase the risk of
developing pneumonia due to inhaling small quantities of the feed and even death. This
area is difficult to research but better designed studies are required to provide more robust
evidence
Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane
Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007209. DOI: 10.1002/14651858.CD007209.pub2
Further information and guidance regarding the difficulties in providing nutrition support can be
found in:
Oral feeding difficulties and dilemmas. A guide to practical care, particularly towards the end of life.
Report of a joint RCP/BSG Working Party - January 2010.
https://www.rcplondon.ac.uk/sites/default/files/documents/oral-feeding-difficulties-anddilemmas.pdf
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 42 of 172
4.0 REFERRAL
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The patient should be referred to:  Gastroenterologist/Specialist nurse
 Dietitian
 Speech and language therapists (where appropriate)
 Independent mental capacity advocate (IMCA)(If the patient lacks capacity to make an
informed decision and does not have any family or friends with whom it is ‘appropriate to
consult’ about the decision – see section 5 below for further information)
5.0 INFORMATION GIVING AND INFORMED CONSENT
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Decision-making and consent may be affected by previous experiences and/or by fear. Time
should be spent explaining about gastrostomy feeding to the individual and family. They may find it
useful to meet someone else with a gastrostomy tube. Information about support groups should
also be offered.
Key information to be discussed includes:  Full explanation of the procedure and associated complications (see section 7.1 below).
Written information should also be offered (EIDO E09 PEG leaflet, accessible from the Trust
front page. Click on Patient information, then EIDO link and log in following instructions. Once
logged in, scroll down to Endoscopy and click on PEG, print off as required.
 Benefits and disadvantages of gastrostomy feeding
 Aftercare
 Major impact on lifestyle, for instance if alternative accommodation needs to be considered if
the patient needs specialist care post gastrostomy.
The patient’s consent should be written where possible on the Trust consent form (Form 1). If this
is not possible, verbal consent should be witnessed on the Trust consent form (Form 1). Refer to
East Cheshire NHS Trust consent policy for further information regarding the validity of consent. If
communication is impaired, every effort should be made to communicate with the individual,
including the use of drawings/props where necessary. In some cases repeated sessions to impart
information may be necessary. Evidence of these conversations should be documented in the
patient’s notes. Liaison with other healthcare professional e.g. speech and language therapists
(SALT) may be indicated to maximise communication techniques.
5.1 Capacity and consent
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Assessment of capacity to make informed decisions should be made prior to PEG insertion. If the
individual is thought not to have capacity for informed consent, it is important to have early,
sensitive discussions with relatives or individuals close to the patient, to try to determine whether
the individual has previously expressed any views on the subject, or if they have a legitimate
advanced decision, or have appointed a lasting power of attorney to make decisions for them, as
legislated for within the Mental Capacity Act (MCA) 2005. In absence of a valid advanced decision
or lasting power of attorney (welfare), the family should be reassured that the decision making is
not their responsibility, but that of the clinician (Decision Maker) in charge of their relatives care, to
make the decision regarding PEG based on the individual’s best interests. Under these
circumstances an additional safeguard has been implemented by the Act which requires clinicians
to involve an independent mental capacity advocate (IMCA) for serious medical treatment
decisions when:  a best interests decision is required because the doctor has assessed the person as not
having the capacity to make the decision themselves.
 the person does not have family or friends with whom it is ‘appropriate to consult’ about the
decision.
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 43 of 172
Serious medical treatment is defined in the Mental Capacity Act 2005 (Independent Mental
Capacity Advocates) (General) Regulations 2006 as treatment which involves providing,
withdrawing or withholding treatment in circumstances where one or more of the following apply:



in a case where a single treatment is being proposed, there is a fine balance between its
benefits to the patient and the burdens and risks it is likely to entail for them
in a case where there is a choice of treatments, a decision as to which one to use is finely
balanced
what is proposed would be likely to involve serious consequences for the patient.
The MCA Code of Practice states that ‘serious consequences’ may include treatment options
which:



cause serious and prolonged pain, distress or side effects
have potentially major consequences for the patient (for example, major surgery or
stopping life-sustaining treatment)
have a serious impact on the patient’s future life choices.
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Patients who have been referred for PEG and lack capacity for decision making and do not have
any family or friends with whom it is ‘appropriate to consult’ about the decision, should be referred
to an IMCA as they fall within several of the above criteria. The IMCA ensures that the Decision
Maker (clinician) considers what the wishes and beliefs of that person would be when deciding
what course of action to take. This is done by questioning all the people involved with that person,
investigating the medical condition and treatment options and making recommendations based on
these findings. This statutory IMCA service is provided by qualified Independent Mental Capacity
Advocates.
For further information please contact East Cheshire Advocacy on:
Tel. 01625 534889
Online. www.ecadvocacy.co.uk
Email: [email protected]
East Cheshire Advocacy, 81 Park Lane, Macclesfield, SK11 6TX.
If an individual is assessed as lacking capacity to give informed consent, the ‘Form for adults who
are unable to consent to investigation or treatment’ (Consent Form Four) should be completed.
The form should be signed by the clinician in charge of care, the clinician undertaking the
procedure and the patient’s family/carers to indicate that they have been involved in the discussion
process. If the family are unable to sign the form, there should be documented evidence in the
patient’s medical notes regarding the discussion process.
5.2 Multidisciplinary team (MDT) approach
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For patients who lack capacity to make an informed choice, there are potentially difficult ethical
decisions to be made. Each patient considered for PEG feeding should be assessed on his or her
own merits. They may not fall within the above criteria. The decision should be made within an
MDT approach and based on the patient’s best interests. The team should consist of healthcare
professionals involved with the patient, e.g. speech and language therapist, dietitian, doctor
(including GP if appropriate), nurse (ward level and specialist), physiotherapist, occupational
therapist, social worker, community carers. Where the situation is particularly complex, or the MDT
decision is equivocal, consider referral to the palliative care consultant.
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 44 of 172
6.0 PREPARATION AND ASSESSMENT PRIOR TO PEG
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Clinical assessment
In addition to assessing for contraindications, the following should be considered: Table 2
CONDITION
RATIONALE
Relevant co-morbidity
Increases risk of complications during or post
PEG insertion.
Infection prior to PEG
Increases risk of complications during or post
PEG insertion.
If patient is MRSA positive –follow MRSA Trust
policy. In relation to antibiotics/treatment refer to
Trust antibiotic policy, contact the IPCT and/or
the Microbiologist.
Cervical/Neck problems
May affect positioning during PEG insertion.
Tracheostomy
Requires specialist support and suctioning
during the procedure.
Previous abdominal surgery
Altered anatomy and adhesion increases the
risk of bowel perforation.
Known aspiration pneumonia or respiratory
problems prior to the procedure carries an
increased risk of fatality post procedure. Local
audit 2001-2004 indicated that 66% of patients
diagnosed with aspiration pneumonia prior to
PEG insertion, died within 30 days of the
procedure.
Respiratory condition
Allergies
Ensure the patient is prepared safely for the
procedure.
Unable to open mouth/ poor dentition
PEG is contra-indicated if INR >1.3
Increased risk of damage to teeth during
endoscopy. Poor dentition will increase the
amount of bacteria in the mouth which if
aspirated will result in an increased risk of
respiratory infection. Referral to a dentist may
be required.
Severely malnourished patients may have a
vitamin K deficiency which will need correcting
prior to PEG.
Anticoagulant therapy
PEG is contra-indicated if INR >1.3
Anticoagulants need to be stopped prior to PEG
See below.
Severely malnourished - risk of re-feeding
syndrome
Increased risk of electrolyte imbalance once
feeding starts.
Thrombocytopenia
PEG is contra-indicated if platelet count <100
Low platelet count causes increased risk of periprocedural bleeding.
Coagulopathy
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 45 of 172
6.0 PREPARATION continued
Preparation
Bloods
Action
FBC
INR
Review
medication
U& Es inc calcium
group, phosphate
and magnesium and
levels
Anticoagulants
Current drug therapy
Medication
required
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Prophylactic
antibiotics
If platelet count <100 consider correcting with 1 -2 units of
platelets within 4 hours of the procedure.
If INR > 1.3: Correct and recheck
Correct any electrolyte disturbances before commencing
nutritional support. Re-feeding drugs, if required, should be
prescribed according to CNSG Guidelines for Re-feeding
management.
PEG is classified as a high risk procedure with regards to
risk of bleeding and anticoagulation therapy.
NB. Some anticoagulants need stopping up to 7 days
prior to PEG e.g Clopidogrel 7 days, Warfarin 5 days.
New anticoagulants - the stoppage time will depend on
the particular anticoagulant and the patient’s renal
function. Alternative anticoagulation therapy may be
required depending on the patient’s medical condition.
Check with gastroenterology/haematology team for further
advice.
Refer to pharmacist as the patient’s drug formulations may
need to be changed. Timing and dosage of drug
administration may need to be altered due to altered drug
formulation and/or potential interaction with feed, particularly
in the drug has a narrow therapeutic index. Refer to CNSG
016 Guidelines for Administration of Medication via
Enteral Feeding Tubes.
Patients should have a single dose of intravenous Coamoxiclav 1.2g, just before the procedure.
British Society of Gastroenterology (BSG) 2009. Antibiotic
prophylaxis in gastrointestinal endoscopy.
If penicillin allergic, give a single dose of Gentamicin 3mg/kg
(max 300mg), just before the procedure (maximum of 1
hour). If MRSA discuss with microbiologist.
MRSA eradication
therapy (if known
MRSA colonisation
or infection)

Analgesia
Prescribe prn soluble oral and IM analgesia for pain post
PEG insertion (arrange for a take home prescription if for
discharge post PEG).
Doctor/dietitian to write up feed on prescription chart and
feeding regimen.
To start 48 hours prior to procedure. Aim to reduce bacterial
load in mouth, as the tube is pulled though the mouth and
into the newly formed stoma.
Feed
Corsodyl mouthwash
(chlorhexidine
gluconate 0.2%)

If the patient is MRSA positive contact the
IPCT/Microbiologist for advice regarding suppression
therapy prior to insertion (as per Trust MRSA policy).
If antibiotics are required, they should be prescribed as
per Trust antibiotic policy.
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 46 of 172
6.0 PREPARATION continued
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Preparation
Action
Weight
A baseline and regular weight is required in order to:  accurately assess nutritional and fluid requirements
 assess weight following PEG insertion (barometer of the patient’s
nutritional requirements and monitors for potential fluid overload).
Fasting
Fasting (mouth and tube) 6 hours prior to procedure.



Hygiene
Venous access
Mouth Care
Full wash
Clean theatre gown
Clean sheets.
Must be established before the patient arrives on the Endoscopy Unit
(except for outpatients).
 Regular mouth care required with Corsodyl mouthwash - to reduce
risk of stoma infection. The mouth must be clear of dried secretions
prior to PEG insertion. There is an increased risk of stoma infection if
the mouth is not clean at the time of PEG insertion. If mouth care is
difficult, inform specialist nurse.
 Advise endoscopy staff of loose/broken teeth.
Equipment
required
Pump, giving sets, oral/enteral syringes, recommended feed, sterile water
for first flush, tap water for subsequent flushes.
Subcutaneous
fluids
Avoid siting the butterfly cannula in the upper central abdomen as this can
result in skin infections or abscesses that may affect PEG insertion.
(Insertion of sub cut cannula must be done using aseptic technique).
Documentation
required
The following
documents must be
sent with the patient
to the endoscopy
unit at the time of
the procedure:





Signed consent form
Patient notes
Nursing Kardex
Drug charts
Completed PEG pathway (Click for link)
6.1 Type of tube
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The tube of choice at East Cheshire NHS Trust is a Merck Corflo traction removable tube. It is
available in 12Fr, 16Fr and 20Fr sizes. Most patients have a 16Fr tube inserted. Other sizes may
be used depending on the patient’s requirements. The most appropriate type of tube and size will
be decided at the time of assessment. Greater than 16Fr tubes should be avoided due to
increased risk of stoma leakage.
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 47 of 172
7.0 PATIENT CARE POST PEG INSERTION
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7.1 PERI AND POST PROCEDURAL COMPLICATIONS ASSOCIATED WITH PEG
 Perforation
 Haemorrhage
 Sepsis
 Peritonitis
 Respiratory depression due to sedation
 Pulmonary aspiration
 Peristomal site infection
 Ischaemic pressure necrosis
 Gastrocolic fistulae
 Tube blockage
 Accidental displacement of the PEG
Monitor patient post PEG for development of complications and report promptly.
Link to management of suspected peritonitis
Link to flow chart for complications post PEG and management
7.2 MONITORING
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Observations
 Half hourly for a minimum of 2 hours.
o Blood pressure, pulse and temperature
o Oxygen saturation and respiratory rate
o Wound check
o Pain assessment
o PEG position unchanged
 Hourly for a minimum of 2 hours.
o As per half hourly assessments
 2 - 4 hourly (depending on clinical status).
o As per half hourly assessments
Discontinue as clinical condition allows
Bloods
 Repeat full profile if at risk of re-feeding syndrome. See CNSG re-feeding guidelines or contact
the dietitian.
 Repeat U& Es. Refer to CNSG Guidelines for Assessment and Monitoring for further guidance.
Contact dietitian for information.
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Bowels
 Document and monitor bowel movements
 Consider aperients if constipated
NB. Constipation presents serious hazard for a patient following PEG insertion. A build up of
pressure within the abdomen may increase the risk of leakage from the stomach into the peritoneal
cavity with subsequent peritonitis. There is also an increased risk of vomiting which places the
patient at greater risk of aspiration, particularly if they have an unsafe swallow.
Weight
As requested by dietitian.
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
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Page 48 of 172
7.3 COMMENCING FEED/ORAL DIET

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NBM or tube until 4 hours post insertion then flush tube with 50mls sterile water.
NB. If pain or difficulty flushing, stop and seek immediate senior medical or surgical advice.
Refer to:  CNSG 014 Guidelines for Enteral Feeding Complications and Management for
further information.
 Rapid response Report NPSA/2010/RRR010: Early detection of complications after
gastrostomy
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457





Administer medication for re-feeding if applicable.
Commence feed/fluids as per dietetic regimen.
The patient should be positioned in semi-raised position during feed - upright if known history
of reflux and vomiting (the patient may require day time feeding in this instance).
Oral diet/fluids (if applicable) can restart as the individual wishes, after the first flush of water
has been given without complications.
The patient should have regular reassessment of swallowing ability, where applicable.
7.4 MOUTH CARE
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Maintenance of oral hygiene is essential, particularly is a patient is unable to:  have oral food and fluids
 attend to their own oral care
Table 3
PROBLEM
REASON
ACTION
Dry sore mouth




Inadequate mouth care
Mouth breathing
Poor dental condition





Clean teeth/dentures with a soft toothbrush
or a damp swab wrapped around a gloved
finger (depending on the patient). The
frequency will depend on the condition of the
patient, twice daily minimum.
Check the tongue and the hard palate for
thickened secretions and remove.
Use lip salve to protect lips from chapping.
Consider use of artificial saliva if appropriate
Refer to dentist if necessary.
Ensure adequate fluids.
Consider drug therapy. Consult doctor.

Maintain good oral hygiene.

Saliva : Tenacious
Hyper-salivation



Dehydration
Neurological condition
Unable to swallow oral
secretions
Refer to Guidelines for the Oral Healthcare of Stroke Survivors by the British Society of
Gerodontology for comprehensive guidance as to management of oral hygiene.
http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf
7.5 PAIN CONTROL
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Administer analgesia as required. Intravenous or intramuscular analgesia is sometimes required
within the first 24 hours of insertion. Increasingly severe pain should be reported and investigated
(see Guidelines for Management of Suspected Peritonitis Post Percutaneous Endoscopic
Gastrostomy (PEG) Insertion).
Oral/via PEG analgesia may be required for a few days post PEG and should be offered regularly.
If the patient is unable to communicate and is showing signs of discomfort or restlessness, give
analgesia regularly for a few days post PEG. Use the pain score on the PEG care pathway to
assess the level of pain.
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 49 of 172
7.6 PEG SITE CARE


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The gastrostomy stoma must be cleaned daily in order to maintain comfort and minimise risk of
infection. Management should be as per the PEG care plan.
For the 72 hours, the PEG stoma should be cleaned with a saline or antiseptic solution using
an aseptic non touch technique (ANTT).
7.6.1 Procedure to clean a PEG site
Use aseptic technique for 72 hours post PEG insertion.










Assemble equipment required onto a clean trolley
Explain the procedure to the patient and obtain consent
Wash hands and put on sterile gloves as per Trust policy.
Remove the dressing (if in situ) and discard into the yellow clinical waste bag
Clean the stoma site and fixation device with Normasol and gauze swabs, removing any
exudate.
Slide a swab under the fixation to remove any dried blood.
Dry the skin and fixation device thoroughly.
When finished, dispose of clinical waste and wash hands as per Trust policy.
Do not undo the fixation device until 2 weeks post insertion, unless too tight. See below for
further information regarding the position of the fixation device.
A small dressing can be applied until the site dries up. (NB. Gastric leakage is extremely
acidic. The dressing must be observed regularly and changed if wet).
After 72 hours










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Assemble equipment required onto a clean trolley
Explain the procedure to the patient and obtain consent
Wash hands as per Trust protocol and wear gloves. Non-sterile gloves are adequate once
the stoma has dried up.
Use mild soap with a clean cloth and clean water.
Remove secretions as above.
Dry thoroughly.
Do not apply talcum powder as this increases the risk of infection.
Observe for infection/leakage/granulation tissue – document any variances in the patient’s
nursing and/or medical notes.
When finished, dispose of clinical waste and wash hands as per Trust policy.
After 2 weeks the tube should be pushed into the stomach and rotated, in order to prevent
buried bumper syndrome (see section 7.6.5). Ideally, this should be done prior to cleaning.
NB. Exceptions include balloon tubes and tubes with the distal tip placed in the
small intestine i.e. jejunal tubes.)
Where possible, teach the patient to clean his or her own PEG site using a socially clean
technique.
If the stoma is infected, continue with aseptic technique until infection resolved. Refer to CNSG
014 Guidelines for Enteral Feeding Complications and Management for further guidance.
Document any variances in the patient’s nursing and/or medical notes.
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 50 of 172
7.6.2 Bathing and showering
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Do not immerse in water i.e. bath, or swimming, for 3 weeks post insertion. If showering, for the
first few days a large waterproof dressing can be used to cover the stoma and removed afterwards.
The stoma will still need cleaning if covered with a waterproof dressing.
7.6.3 Dressings
Dressings are not recommended unless the leakage is profuse or distressing to the patient.
 If a dressing is used, it should be absorbent (foam), checked regularly and changed if wet. A
barrier cream, applied under the dressing, is also advised in order to protect the skin against
the harmful effects of gastric aspirate.
 Do not place a foam dressing under the fixation device without changing the position of the
fixator as it will increase the pressure on the internal retention bumper/balloon, resulting in
localised ischaemia (see section 7.6.4 below)
Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management for further
advice on management of leakage and dressings.
7.6.4 Positioning of external fixation device
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The positioning of the fixation device is crucial especially post insertion. Too tight and localised
ischaemia may occur, increasing the risk of infection and buried bumper (O’Toole 2006, Wong and
Ladabaum 2013), Too loose and the stoma layers will not adhere together, increasing the risk of
peritonitis.
Following endoscopy, the external fixator will be fixed at approximately 1cm from the abdominal
wall. It should be left in position for 1-2 weeks post PEG insertion to allow healing and reduce the
risk of peritonitis. However, the fixation device may become too tight post PEG insertion as a result
of inflammation and/or re-hydration. If repositioning of the fixation device is required, release the
fixation device and slide it backwards up the tube to the optimum position (approximately 1cm)
then secure the tube within the device. Recheck the position after closing the device whilst gently
pulling back on the tube. Document the adjusted measurement in the patient’s care pathway/notes.
If there is any doubt about the correct position of the fixation device, expert advice should be
sought.
Within 1-2 weeks of insertion, the PEG tube can be turned to allow cleaning under the fixation
device, after this period, the fixation device can be undone and moved away from the skin to allow
thorough cleaning. After cleaning, pull back gently on the tube until slight resistance is felt and
reposition the fixation device so that it sits 1cm away from the skin, unless recommended
otherwise by specialist.
7.6.5 Prevention of buried bumper
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If the gastrostomy tube is left in the same position permanently, or pulled too tight, there may be
internal ulceration and subsequent migration of the internal bumper through the gastric wall. This
can result in in potential occlusion of the tube, pain and difficulties in removal or replacement.
In order to prevent this, from within one to two weeks post insertion, the external fixator should be
released and the gastrostomy tube pushed into the stomach a couple of centimetres and rotated in
a full circle. The external fixator should then be refixed as above. This procedure should be carried
out on a regular basis i.e. prior to daily cleaning. NB. Does not apply to balloon gastrostomy
tubes or PEG-J tubes.


Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management
for further guidance.
Document any variances in the patient’s nursing and/or medical notes.
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 51 of 172
7.6.6 Sutures
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The use of sutures to secure a gastrostomy tube is not recommended. Exceptions to this rule are
radiologically inserted gastrostomy tubes. Refer to section 12.1 below for further guidance. Do not
remove the sutures until the method of tube insertion is known. Refer to specialist
nurse/gastroenterologist.
8.0 MAINTENANCE OF THE GASTROSTOMY TUBE
8.1 Flushing
Correct flushing is essential in order to keep the tube patent. Refer to CNSG 013 Guidelines for
Administration of Feed and Fluid via Enteral Tubes for more information regarding best
practice for flushing and type of water.
8.2 Syringes


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Enteral syringes for oral / enteral use should have a purple barrel, and be labelled ‘oral /
enteral’ use only.
Enteral syringes should only connect to tubes for enteral use, and not to tubes for IV use.
The syringes are available with different connectors to fit the various enteral feeding tube ports.
The recommended syringes should have either:  a female luer connector to fit male luer ports on enteral feeding tubes (reverse luer
connector combination)
 a catheter tip connector to fit catheter tip ports on enteral feeding tubes
 non-luer (non-standard connector that does not fit any non-flexible port)
Where the guidance above cannot be followed for an individual patient (e.g. if the patient has a non
standard tube), a risk assessment for the equipment to be used should be undertaken prior to use.
Non standard equipment should be stored separately, clearly labelled, with restricted access. Only
staff with specialist knowledge and skills should have access to these devices.
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808&p=3
NB. All syringes are to be single use only in the hospital setting even if they specify that
they are reusable. The syringe must be discarded after the episode of use.
8.3 General care of the tube
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 Always wash hands before and after handling the tube, or preparing the feed (MHRA 2000).
 Regularly change the position of the reflux clamp to prevent wearing a hole in the tube.
 Avoid handling the tube unnecessarily.
 The long-term use of steroid creams/ointments around the stoma is not advised as they
weaken the tube.
 If the accessories break, replacement parts are available.
 If the accessories are soiled, they should be cleaned or replaced.
 The tube should be positioned where it is comfortable and convenient for the patient.
 Do not tuck the tube into under garments or incontinence pads, as it is unhygienic – consider
the gastrostomy tube port as a knife and fork.
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen October 2010. Updated July 2015.
Page 52 of 172
9.0 REMOVAL OF A GASTROSTOMY TUBE
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9.1 Accidental
Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management for further
guidance.
9.2 Planned
Gastrostomy tubes can be taken out by either, endoscopic removal, or by pulling, depending on
the type of tube. All non balloon tubes should be referred to a specialist for removal.
Patients should have a dietetic review prior to removal. They should have maintained their weight
on oral diet and be able to drink sufficient fluids.
9.3 Procedure for traction removal of a Merck Corflo gastrostomy tube
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Preparation
Pull tubes - no preparation necessary
Endoscopic removal – NBM 6 hours prior to procedure.
Equipment
Dressing pack
Inco sheet
Normasol
Instillagel
Adhesive dressing
Jelonet
Apron
Gloves
Procedure
1. Explain the procedure to the patient and obtain consent as per East Cheshire NHS Trust
policy.
2. Wash hands, wear gloves and apron as per East Cheshire NHS Trust policy.
3. Protect the patient’s clothes with an inco sheet.
4. Release the fixation device and move away from the skin. Insert some Instillagel around the
tube and manoeuvre the tube in and out in order to coat the stoma in instillagel.
5. Whilst waiting for the instillagel to take effect, remove the end connector.
6. When ready, remove the clamp and fixation device. NB. Be prepared for air and gastric
contents refluxing up the tube.
7. Hold the tube firmly in your hand – do not wrap the tube around your hand or the air line will
be occluded. Use a gauze swab to help grip the tube if necessary.
8. Apply continuous traction to the tube (if the patient is able to co-operate, ask them to cough
on a count of three, as they cough, pull the tube out.
9. The stoma may bleed slightly after removal, especially if the patient has granulation tissue
around the stoma. Apply pressure with a gauze swab until settled.
10. Clean the stoma.
11. Place a folded square of Jelonet over the stoma, then some gauze dressing and secure.
12. When finished, dispose of clinical waste and wash hands as per Trust policy.
13. Give the patient some spare dressings for replacement as necessary.
14. Give the patient an East Cheshire NHS Trust gastrostomy tube removal advice sheet (See
Patient Information and forms to download or print)
15. Document the procedure in the patient’s medical notes.
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Created by Maggie Allen October 2010. Updated July 2015.
Page 53 of 172
Aftercare
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The patient may eat and drink normally immediately after gastrostomy tube removal (expert
opinion).
 Place a dressing over the stoma site until healed over (should heal over within 24-48hrs).
 Check the dressing regularly for leakage.
 Change the dressing if leakage is evident (gastric leakage is acidic and will harm the skin).
 A barrier cream may need to be applied under the dressing in order to protect the skin.
The stoma may take longer to close if the patient has an infection in the stoma site or
overgranulation. A course of antibiotics may be required if the stoma does not close. Seek expert
advice if unsure.
10.0 MANAGEMENT OF BALLOON GASTROSTOMY TUBES
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10.1 Definition
Balloon gastrostomy tubes are made of silicone and are available as catheter type tubes (G-tubes)
or as low profile devices (buttons). They are generally used as a replacement device and can be
inserted without endoscopy or X-ray (mature stomas only. See section 10.8 below for further
information). Balloon gastrostomy tubes can also be inserted surgically or radiologically (RIG). RIG
procedures are not undertaken at MDGH; if a patient has been referred for a RIG, always follow
the inserting hospital’s postoperative guidelines following initial radiological placement (these will
have been sent with the patient/carer).
Balloon tubes are available in a range of sizes and are kept in position by a fluid inflated balloon.
The balloon volume varies depending on the make/size of tube. Check the manufacturer’s
guidelines prior to use. In general, the minimum amount of fluid specified by the manufacturer
should be inserted and increased only if leakage evident.
10.2 Low profile gastrostomy tubes
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Low profile tubes are designed to sit close to the skin. They are available in different French (Fr)
sizes and shaft lengths. The gastrostomy stoma will need to be measured in order to select the
correct sized tube. They require an extension set to enable administration of feed, fluid and
medication. There is an anti-reflux valve built in, to prevent leakage following removal of the
extension set.
10.3 General management of balloon gastrostomy tubes, buttons and extension sets
Table 4
ACTION
REASON
Always close the cap when not in use.
Balloon gastrostomy tubes may not have a
reflux clamp. Spillage will occur especially
after a feed.
Ensure the external fixation device is placed in
the correct position. It should sit lightly on the
skin.
Prevents the tube from sliding in and out of
the stomach.
 Too loose – increases the risk of leakage.
 Too tight – causes tissue necrosis.
Check and change the fluid content in the balloon
weekly.
Balloons are inflated with sterile or cooled, boiled
Manufacturers recommend that the balloon is
checked on a regular basis to prevent
accidental removal of the tube caused by
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen, October 2010. Updated July 2015
Page 54 of 172
water. Check manufacturer’s guidelines.
deflation of the balloon.
Replace the tube 3-4 monthly
To prevent accidental displacement due to
balloon failure.
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10.3.1 Preparation of an extension set for administering fluids via a low profile device
1.
2.
3.
4.
5.
6.
7.
8.
Prime the extension set with water prior to attachment.
Close the clamp to prevent the water escaping.
Align the black line on the extension set with the black line on the button device.
Push the extension set into the button and rotate it a three-quarters turn clockwise until
resistance is felt. Do not turn beyond this point. Each manufacturer has a slightly different
system. Refer to manufacturers guidelines.
Attach the syringe/giving set to the extension set, open the clamp and commence
administration of feed/fluids.
When finished, flush the extension set thoroughly and remove it following point 4 in reverse.
Wipe up any drops of fluid that escape from anti-reflux valve, prior to replacing the cap.
When finished, dispose of clinical waste and wash hands as per Trust policy.
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10.3.2 Cleaning an extension set after use and replacement
The extension set should be cleaned after each use following manufacturer’s instructions.
1.
2.
3.
4.
5.
6.
7.
8.
Remove and open the reflux/roller clamp on the tube.
Immerse in hot soapy water and flush through several times using a syringe.
Rinse through with clear water.
Using a syringe, plunge air through the tube and leave to air dry.
If conditions do not allow air-drying, store in a lidded container in the fridge.
Do not store in Milton
When finished, dispose of clinical waste and wash hands as per Trust policy.
Replace fortnightly.
Refer to CNSG 015 Microbiological Guidelines for Handling of Enteral Feeds and Fluids.
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen, October 2010. Updated July 2015
Page 55 of 172
10.4 Checking the balloon volume
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Table 5
ACTION
REASON
Step
1
Explain the procedure to the patient and
obtain consent. (The procedure should
be explained even if the patient appears
not to understand). Position the patient
so that the tube is in an accessible
position.
To ensure that the patient understands and is
able to give consent, also to co-operate with
the procedure.
Step
2
Wash hands and put on non-sterile
gloves.


Step
3
Observe the cm measurement on the
tube where it exits from the abdomen.
Helps identify correct positioning post-fluid
change.
Step
4
Push the tube into the stomach a couple
of centimetres.


Minimises cross infection (Anderton 1995).
Guidelines from MHRA SN 2000 (27)
Enteral Feeding Systems.
Helps prevent the tube falling out
accidentally whilst changing the fluid.
Helps prevent inflation of the balloon whilst
in the stoma tract.
Step
5
Place a luer slip syringe into the balloon
port and pull back on the syringe until all
the fluid has been removed. Discard the
fluid and repeat.
Ensures that all fluid is removed. Failure to
completely empty the balloon may result in:  the balloon rupturing due to over-inflation.
 discomfort and/or damage to the stoma.
Step
6
Record the amount of fluid aspirated.
A small amount of loss is normal (0.51.5ml/fortnight). Increased loss may indicate
balloon failure.
Step
7
Draw up the required amount of
replacement fluid (water/saline
depending on manufacturer’s guidelines)
into the syringe, then insert it into the
balloon port and inflate the balloon.
Check the amount of fluid required on the
balloon port. Different tubes and sizes
have varying balloon volumes.
Under filling a balloon may result in the tube
falling out accidentally.
Overfilling will split the balloon.
Step
8
Pull back gently on the tube, check that
the cm measurement at the abdomen is
correct and reposition the fixation device.
Ensures the tube is correctly positioned in
order to reduce leakage.
Step
9
When finished, dispose of clinical waste
and wash hands as per Trust policy.
Minimise risk of contamination
Step
10
Document the total amount of water used
in the patient’s medical/nursing notes
Information for the next individual who
changes the water, or in the event or
complications.
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Created by Maggie Allen, October 2010. Updated July 2015
Page 56 of 172
10.5 Removal of a balloon gastrostomy tube
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Table 6
Step
1
ACTION
REASON
Explain the procedure to the patient and
obtain consent. (The procedure should
be explained even if the patient appears
not to understand). Position the patient
so that the tube is in an accessible
position.
Wash hands and wear gloves.
To ensure that the patient understands and is
able to give consent, also to co-operate with
the procedure.
Step
3
Before removal, check that the tube is
definitely a balloon tube. Seek advice if
unsure.
 Minimises cross infection (Anderton 1995).
Guidelines from MHRA SN 2000 (27) Enteral
Feeding Systems.
To ensure that the tube is safe to be removed
by traction. The port will be marked with ‘5cc
or 20cc inflation’.
Step
4
Flush 30 - 50mls fluid down the tube prior
to removal (replacement only).
Ensures that there is fluid in the stomach to
check the position of the new tube.
Step
5
Record the cm measurement where the
tube exits from the abdomen.
Helps to correctly position the new tube.
Step
6
Place a Luer tipped syringe into the
balloon port and withdraw all the fluid.
Check that the amount of fluid withdrawn
corresponds with the amount on the
written on the balloon port.
Discard the fluid and repeat.
Ensures that all fluid is removed. Pulling a
partly deflated tube out of the patient may
cause discomfort and/or harm the stoma.
Step
7
If the balloon does not deflate, cut the
tubing below the balloon port. If the tube
is a low profile device/button, push the tip
of a pen into the valve to release the
fluid.
Helps to deflate the balloon completely.
Step
8
With gentle traction pull the tube out of
the stomach.
There may be slight resistance caused by the
deflated tube cuff.
Step
9
Expect a small amount of gastric
leakage. Wipe away immediately.
Gastric contents are very acidic and will harm
the skin. See below for discontinuation of tube
feeding.
Step
2
If replacing a balloon tube, continue to section 10. 9, step 3.
Step
10
When finished, dispose of clinical waste
and wash hands as per Trust policy.
Minimise risk of contamination
Step
11
Document procedure in the patient’s
medical/nursing notes
Evidence of procedure. Information as to
when next tube change due.
NB. Some gastrostomy tubes including low profile devices have a plastic flexible retention
device to hold the device within the stomach rather than a balloon. These are easily
identified by the lack of balloon port. Specialist advice should be sought prior to removal.
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Created by Maggie Allen, October 2010. Updated July 2015
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10.6 Discontinuing balloon gastrostomy feeding
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If tube feeding is to be discontinued, refer to section 9.3 from procedure point No. 10 for
guidelines regarding skin care management and aftercare.
10.7 Replacement of a balloon tube (G–tube)
This is normally a straightforward procedure; however, the practitioner should be aware that
inadvertent intraperitoneal insertion of replacement G-tube is a reported risk in newly formed
stomas and less commonly in a mature stoma. Misplaced G-tubes can result in significant
morbidity and death.
Available literature suggests 2 to 4 weeks for a stoma to reach maturity. The time for maturity will
depend on the patient’s condition and drug therapy, for instance if a patient is malnourished or on
steroid therapy the stoma will take longer to establish. Elective replacements should be avoided
until the stoma has reached the expected maturity for the patient in question.
A radiological check of the tube’s position following insertion is recommended:  If a tube is being replaced within 4 weeks of a new gastrostomy (PEG, RIG, surgical)
insertion,
 The tube is difficult to insert and accompanied by pain (new and mature stomas).
 Refer for specialist input.
10.8 Insertion of gastrostomy balloon tube
Equipment required
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Dressing pack
Gloves
Normasol
Luer slip syringe 5 or 10ml
Lubricant and/or Instillagel*
60 ml catheter tipped enteral syringe
Apron
Merck pH strips
Water for flushing (sterile or recently drawn tap water or cooled, boiled water if at home)
Water/saline for injection, if not included in the gastrostomy tube pack.
* Some tubes have lubricant within the pack. Instillagel may be required if the patient has
inflammation at the site and is experiencing discomfort.
Procedure
Table 7
ACTION
Step 1
Step 2
Step 3
Explain the procedure to the patient and
obtain consent. (The procedure should
be explained even if the patient appears
not to understand). Position the patient
so that the tube is in an accessible
position.
Wash hands and put on non-sterile
gloves.
Open the dressing pack and the
equipment required on to a clean trolley.
Remove the new tube from the
packaging, slide the fixation device up
the tube, nearer to the cap end and
close the cap.
REASON
To ensure that the patient understands and is
able to give consent, also to co-operate with
the procedure.
Minimises cross infection (Anderton 1995).
Guidelines from MHRA SN 2000 (27) Enteral
Feeding Systems.
Allows adequate tube to be inserted into the
stomach before inflating the balloon.
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen, October 2010. Updated July 2015
Page 58 of 172
Procedure continued
Table 7
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10
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ACTION
REASON
Prepare the new tube by checking that
the balloon is intact.
Draw up the correct amount of fluid as
specified by the manufacturers. The
recommended amount is written on the
balloon port.
Place the syringe in the balloon port and
inflate the balloon.
If the balloon sticks to the tube, roll it
between your fingers and re-inflate.
Deflate once checked.
If the tube has introducer e.g. Fresenius
tubes, assemble as per manufacturer’s
guidelines.
Lubricate the tip of the new tube with a
fluid-soluble agent. Use a topical
anaesthetic gel e.g. Instillagel, if the
patient is in discomfort.
Place one hand on the abdomen to pull
the skin around the stoma reasonably
taut. Hold the tube just above the
balloon, then insert the tip of the tube
into the stoma and push gently.
 Slight resistance may be felt; a slight
twist of the tube may aid insertion.
There is usually a feeling of sudden
give when the tube enters the
stomach.
 The tube may need to be angled
slightly so that the tip points towards
the diaphragm.
Prevents insertion of a faulty device.
Under-filling a balloon may result in the tube falling
out accidentally. Overfilling may cause the balloon
to split.
Observe for leaks and correct inflation.
Incorrect inflation may result in increased leakage.
Helps insertion.
Helps insertion.
Holding the tube near to the tip will increase the
stability during insertion.
Radiologically inserted gastrostomy stomas are
usually always angled.
NB.
If insertion is difficult due to the stoma tract being angled or very long, a Seldinger technique may be
required. This involves passing a wire into the stomach via the existing tube and inserting a new tube over
the wire. Refer to a specialist. In the interim, if possible, insert a fine bore tube e.g. 6-10 Fr Ryles (with
Spigot) and secure on the abdomen. This will keep the stoma patent until expert help available. Do not use
the tube until the tube has been established as being correctly placed in the stomach.
A radiological check of the tube’s position following insertion is recommended if the tube is being
replaced within 4 weeks of the original placement of the tube and if the stoma is mature and the
insertion procedure difficult. This applies to PEG, RIG and surgically placed tubes. See section 10.8
above.
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Created by Maggie Allen, October 2010. Updated July 2015
Page 59 of 172
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Step
11
NB.


Step
12
ACTION
REASON
Insert the tube a couple of inches into
the stomach then inflate the balloon.
Inflating the balloon whilst within the stoma
tract may force the stomal layers apart,
resulting in potential development of fistulas
and subsequent peritonitis.
Do not push the tube too far into the stomach, as it is possible to inflate the balloon
beyond the pylorus. This will prevent gastric emptying, resulting in excessive
vomiting and leakage.
Ensure that the balloon is positioned in the stomach and not the stoma tract. If you
feel any resistance whilst inflating the balloon stop and check the position of the
tube. Inflating the balloon whilst within the stoma tract may force the stomal layers
apart, resulting in potential development of fistulas and subsequent peritonitis.
Insert a 60cc syringe in the tube and
draw back to obtain aspirate. Test with
pH paper.
If unable to obtain aspirate move the
tube in or out whilst withdrawing on the
syringe. If still unsuccessful flush 2030mls air down the tube and retry. If this
causes pain, stop and seek expert
advice.
Ensures that the tube is in the stomach.
Gastric pH should be less than pH 5.5. It may
be higher following recent feed, fluid or
certain medications e.g. Proton pump
inhibitors and H2 antagonists. Seek expert
advice if unsure.
NB.
A radiological check of the tube’s position following insertion is recommended if the tube is
being replaced within 4 weeks of the original placement of the tube. This applies to PEG,
RIG and surgical insertion procedures. See section 10.8 above.
Step
12
Wipe away any fluid or lubricant from the
skin and dry thoroughly.
Gastric leakage is acidic and harmful to skin.
Step
13
Pull back gently on the tube, check that
the cm measurement at the abdomen is
correct and reposition the fixation device
so that it sits lightly on the skin. Pull back
gently again to recheck the position.

Step
14
Flush the tube with fluid if there is gastric
aspirate in the lumen.
Prevents tube blockage.
Step
15
When finished, dispose of clinical waste
and wash hands as per Trust policy.
Minimise risk of contamination
Step
16
Record type, size and Lot number of the
tube in the patient's notes.
Required for tracking and is a useful
reference for subsequent replacement and
audit.


Prevents the tube from sliding in and out
of the stomach.
Prevents leakage.
Prevents tissue necrosis.
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Created by Maggie Allen, October 2010. Updated July 2015
Page 60 of 172
10.9 Insertion of a low profile device e.g. MIC-KEY button
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The same principles for removal, replacement and checking the fluid apply as for a balloon
gastrostomy tube.
The tube may need to be replaced if it becomes too tight or too loose (due to weight loss/gain or
growth). The stoma should be measured in order to select the correct sized tube.
10.10 Measuring a gastrostomy stoma (based on Vygon measuring device)
1. Explain the procedure to the patient and obtain consent as per Trust policy.
2. Wash hands, wear gloves and apron.
3. Remove the current tube as per guidelines
4. Lubricate the end of the measuring device
5. Gently insert approx 5-6cm of the measuring device into the stoma
6. Inflate the balloon with 3-4mls of air
7. Pull back on the tube until slight resistance is felt
8. Push down the disc on the device so that it sits lightly on the skin
9. Read the measurement above the disc to give the correct shaft length
10. The French size of the button should correspond with the current gastrostomy tube unless
there is a plan to reduce the stoma size.
11. Record the measurements in the patient's notes.
Alternative measuring devices are available. Follow the manufacturer’s instructions as measuring
instructions vary.
10.11 Complications
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Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management for a
comprehensive guide to managing complications.
10.12 Accidental removal of a balloon gastrostomy
A replacement tube should be inserted as per section 10.8, as soon as possible, to prevent the
stoma from closing over.
A gastrostomy stoma will start to close from the inside within a few hours. There may still be
access up to 24-48 hours post removal, however a smaller tube will be required. The stoma can
then be dilated up to its original size by a specialist. Insert a fine bore tube e.g. 6 Fr, if possible,
and refer the patient to the gastroenterologist/specialist nurse for further management.
NB.
If the tube becomes displaced before the stoma is fully established (i.e. within the first 4 weeks of
insertion), there is a possibility of feed or gastric contents leaking into the peritoneal cavity. This
may result in peritonitis and is a life threatening condition.
 Do not put anything through the tube seek medical help immediately.
 A radiological check of the tube’s position following insertion is recommended if the tube is
being replaced within 4 weeks of the original placement of the tube. This applies to PEG, RIG
and surgical insertion procedures.
A radiological check is also advised for a mature stoma if the insertion procedure is difficult, as
there are case reports of inadvertent intraperitoneal insertion of replacement G-tube resulting in
significant morbidity and death.
For further information, please refer to CNSG 014 Guidelines for Enteral Feeding
Complications and Management and section 10.14 below on temporary gastrostomy tubes.
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Created by Maggie Allen, October 2010. Updated July 2015
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10.14 Temporary gastrostomy tubes
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Patients usually have a spare tube and are asked to bring it with them if they need to come to
A&E/ETU for replacement. If not and it is not possible to source a new balloon gastrostomy tube, a
catheter can be inserted for short-term use.
If using a catheter: 1. Check when the initial gastrostomy was inserted, if less than 4 weeks see section 10.12
above.
2. Insert as per guidelines in section 10.8
3. Fix the catheter in position at the exit from the stomach. This will prevent migration into the
stomach and subsequent leakage at the stoma site. Fixation with tape is required as a
catheter does not have an external fixation device.
4. Use a spigot to seal the tube.
5. When finished, dispose of clinical waste and wash hands as per Trust policy.
6. The catheter can be used for feed, fluid and medication, providing the aspirate has been
checked as per guidelines in section 10.8.
7. Inform GI nurse specialist, dietician or ETU, so that the catheter can be replaced as soon
as a suitable tube is available.
8. Record the procedure in the patient’s notes
NB.
MHRA one liners caution against the use of a Foley catheter as a gastrostomy tube, however in
emergency situations it more acceptable to use a Foley catheter for temporary use than to allow a
gastrostomy stoma to close over. A Foley catheter can be used within the remit of these guidelines
providing the above conditions are met.
10.15 Spare tubes
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Balloon gastrostomy tubes are available from: Endoscopy Unit
Dietitians.
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Created by Maggie Allen, October 2010. Updated July 2015
Page 62 of 172
11.0 MANAGEMENT OF AN INTESTINAL TUBE WITHIN A PEG TUBE FOR BURIED BUMPER
A known complication of gastrostomy tubes is when the gastric mucosa migrates across the
internal bumper, eventually completely occluding it. Increased resistance during flushing and more
leakage around the stoma site may be an indicator of a buried bumper.
Prior to referring for endoscopy, an initial assessment should be made to determine buried
bumper.
1. Explain the procedure to the patient and obtain consent as per East Cheshire NHS Trust
policy.
2. Wash hands, wear gloves and apron.
3. Undo the fixation device move it up the tube away from the skin.
4. Take hold of the tube and push it into the stomach. The tube should slide easily into the
stomach without bending or kinking.
5. If the tube does kink, or the patient experiences pain, refer for specialist advice.
6. When finished, dispose of clinical waste and wash hands as per Trust policy.
7. Record procedure in the patient’s notes.
If the tube is a Fresenius Freka tube, it cannot be pulled out and may need surgical removal. If the
patient is unsuitable for surgery, it may be possible to insert a smaller bore tube via the PEG and
into the stomach through the remaining fistulae. Refer to specialist.
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11.1 Inserting/replacing an intestinal tube within a Fresenius 15Fr PEG tube
The initial procedure may need an endoscopic view to assess whether there is still a patent tract.
The tract can be established endoscopically by syringing water through the PEG tube and
watching for the entry point in the stomach.
Equipment
Dressing pack
Scissors
Fresenius 9Fr intestinal tube pack
Lubricant
60ml enteral syringe
Water for flushing (sterile or recently drawn tap water or cooled, boiled water if at home)
Merck pH strips
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Created by Maggie Allen, October 2010. Updated July 2015
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Procedure – with or without endoscopy
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1. Explain the procedure to the patient and obtain consent as per East Cheshire NHS Trust
policy.
2. Wash hands, wear gloves and apron.
3. Remove the end connecters from the PEG tube.
4. Release the external fixation device
5. Remove the 9Fr tube from the packet and advance the guide wire to the end of the tube.
6. Release the clamp on the PEG tube
7. Insert the 9Fr tube into the PEG tube and advance until approx 4-5” of the tube is in the
stomach. Avoid inserting too much tubing as it may form a knot.
8. If it is difficult to advance the internal tube it may be trapped in the mucosal pouch. Try to
change the angle of insertion by manipulating the PEG tube.
9. Once successfully in the stomach, withdraw the guide wire.
10. Cut the internal tube so that it sits 2-3” proud of the PEG tube.
11. Put on the adapters as shown in the booklet provided with the intestinal tube (inside front
leaf).
12. Reposition the external fixation device.
13. When finished, dispose of clinical waste and wash hands as per Trust policy.
14. Give care instructions to the patient/carer.
15. Document procedure in the patient’s medical/nursing notes.
If the tube has not been replaced under endoscopic vision, the internal tube should be aspirated
and the contents tested on pH paper to indicate correct gastric placement.
The pH value should be less than 5.5. Refer to CNSG 007 Guidelines for Insertion and
Management of Nasogastric tubes for more information on pH values.
11.2 Care of the PEG and intestinal tube
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The Y connector at the top of the tube has two ports;
‘I’ for the intestinal tube and ‘g’ for the gastric tube (markings on Y connector).
Only use the port marked ‘I’ (The ‘g’ port is for the PEG tube and must not be used as this is
the part that is buried within the gastric mucosa).
Do not rotate the PEG tube as the internal tube may become twisted and knotted.
Feed and water can still be given as normal, however the system is at a much greater risk of
blocking, as the intestinal tube within the PEG tube is only 9Fr. Correct flushing is very important!
Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes for
more information regarding best practice for flushing and type of water.
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen, October 2010. Updated July 2015
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12.0 RADIOLOGICALLY INSERTED GASTROSTOMY (RIG) TUBES.
Gastrostomy tubes are inserted radiologically when endoscopic placement of a gastrostomy tube is
contraindicated, or has been unsuccessful. They are not inserted at Macclesfield hospital. The
majority of patients with these in situ will come from Salford Royal or Wythenshawe Hospital. The
tubes used at these centres may vary.
12.1 Sutures
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The tube may be sutured in position post insertion. The sutures will depend on the insertion
method, the type of tube and the practitioner’s preference. Some sutures are inserted as a failsafe
to prevent the tube from falling out (more typical if the tube has been inserted surgically) and are
non essential. Others however are essential to hold the stomach adjacent to the abdominal wall
until healed.
The sutures must be removed as per the inserting hospital guidelines.
If unsure, refer to specialist for advice.
General care is as per a PEG.
13.0 Discontinuation of tube feeding
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The patient may eat and drink normally immediately after gastrostomy tube removal (expert
opinion).




Place a dressing over the stoma site until healed over (should heal over within 24-48hrs).
Check the dressing regularly for leakage.
Change the dressing if leakage is evident (gastric leakage is acidic and will harm the skin).
A barrier cream may need to be applied under the dressing in order to protect the skin.
The stoma may take longer to close if the patient has an infection in the stoma site or
overgranulation. A course of antibiotics may be required if the stoma does not close. Seek expert
help if unsure.
Give the patient an East Cheshire NHS Trust gastrostomy tube removal advice sheet (available
from ETU Ext 1044).
14.0 DISCHARGE PLANS
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14.1 Discharge within 72 hours of PEG insertion
The patient must have a senior review prior to discharge to check that there are no serious
complications following PEG insertion (NPSA 2010).
The review should be carried out by: the clinician/practitioner inserting the PEG - if unavailable,
 the SpR for gastroenterology - if unavailable
 the on call medical registrar
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen, October 2010. Updated July 2015
Page 65 of 172
14.2 Information required for discharge within 72 hours of insertion
•
•
•
Verbal and written warning given to patient/carer
24 hour telephone contact number given to patient for urgent aftercare advice
NPSA alert stickers will be on the patient discharge documentation regarding PEG feeding.
IF THERE IS PAIN ON FEEDING,
OR EXTERNAL LEAKAGE
OF GASTRIC CONTENTS,
OR FRESH BLEEDING,
ADVISE CARERS TO STOP
FEED IMMEDIATELY AND
URGENTLY REFER TO A&E
01625 661451/2
14.3 Training required prior to discharge
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Prior to discharge the patient and/or carers will be taught how to:  Care for the PEG site
 Care for the tube
 Set up and administer feed
 Store and dispose of equipment
See pre-discharge training proforma
14.4 Information and contact details required prior to discharge
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The patient will be given contact details for
 Dietitian
 Specialist nurse
 Company providing the feed and equipment
The patient will be given written information for the following:  Pump manual
 Gastrostomy care booklet
 Syringe reprocessing leaflet
 Information Booklet for ordering replacement equipment
14.5 Referrals required prior to discharge
 Dietitian
 District nurses
 Pharmacist (if medication needs modifying)
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14.6 Equipment required for discharge
The patient will be discharged with sufficient feed and equipment to last until the first home
delivery. To include:  Feed
 Syringes
 Giving sets
 Pump (not ward stock - contact dietitians)
East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen, October 2010. Updated July 2015
Page 66 of 172
APPENDIX 1 - REFERENCES AND BIBLIOGRAPHY
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Arrowsmith, H. Nursing Management of patients receiving gastrostomy feeding. British Journal of
Nursing 1996; 5(5): 268-273.
BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners
and Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead.
BAPEN (1996) Standards and Guidelines for Nutritional Support in Hospitals (ed. T. Sizer). British
Association for Parenteral and Enteral Nutrition, Maidenhead.
British Society of Gastroenterology (2006) Guidelines on Complications of Gastrointestinal
Endoscopy. London.
http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complications.pdf
British Society of Gerodontology (2010) Guidelines for the Oral Healthcare of Stroke Survivors.
http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf
Colagiovanni L. (2000) Preventing and clearing blocked feeding tubes. Nursing Times. 96(17): 3-4.
Curzio, J, McGowan, M. Getting research into practice: developing oral hygiene standards. British
Journal of Nursing. 2000; 9(7): 434-438.
Dougherty, L. & Lister S. (eds) (2004) The Royal Marsden Manual of Clinical
Nursing Procedures, 7th edn. Blackwell Science Ltd, Oxford.
General Medical Council (GMC) Management for Doctors (2006)
Human Rights Act 1998
Hussain A, et al. (1995). The team approach to percutaneous endoscopic gastrostomy feeding.
British Journal of Hospital Medicine: 54(7) 308-312
Hussain A et al (1996). Percutaneous Endoscopic Gastrostomy. Postgrad Med J 72:581-585
Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in
Partnership with Nutricia
Jones, C. The importance of oral hygiene in nutritional support. British Journal of
Nursing 1998; 7(2): 74-83
Joint Advisory Group for Gastrointestinal Endoscopy (JAG 2004). Guidelines for the training,
appraisal and assessment of trainees in GI endoscopy.
Lennard-Jones JE. Ethical and Legal Aspects of Clinical Hydration and Nutritional Support. British
Association for Parenteral and Enteral Nutrition 1998.
Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical Devices:
Implications and Consequences of Reuse. MDA DB2000(04)
Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding Systems.
MDA SN2000(27).
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen, October 2010. Updated July 2015
Page 67 of 172
back to index
Mental Capacity Act 2005
the Mental Capacity Act 2005 (Independent Mental Capacity Advocates) (General) Regulations 2006
National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139
Infection Prevention and control of healthcare-associated infections in primary and community care
http://guidance.nice.org.uk/CG139
National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral supplements,
parenteral and enteral feeding. London.
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
National Patient Safety Agency (2010). Early detection of complications after gastrostomy
NPSA/2010/RRR010
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines
via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808NCEPOD (2004) Scoping our practice.
The 2004 Report of the National Confidential Enquiry into Patient Outcome and Death. London
http://www.ncepod.org.uk/2004report/index.htm
Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for
nurses and midwives. London, NMC.
Oral feeding difficulties and dilemmas. A guide to practical care, particularly towards the end of life. Report of
a joint RCP/BSG Working Party - January 2010.
http://bookshop.rcplondon.ac.uk/contents/pub295-ca2ff0c8-85f7-48ee-b857-8fed6ccb2ad7.pdf
O’Toole P. (2006) Complications Associated with the Placement of Percutaneous Endoscopic Gastrostomy.
Guidelines in Gastroenterology. British Society of Gastroenterology (BSG). London.
Payne-James, J., Grimble, G. & Silk, D. (2001) Enteral nutrition: tubes and techniques of delivery. In:
Artificial Nutritional Support in Clinical Practice, 2nd edn (eds J. Payne-James, G. Grimble & D. Silk).
Greenwich Medical Media, London.
Rollins, H. Hypergranulation tissue at gastrostomy sites. Journal of Wound Care 2000; 9(3): 127-129
Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane
Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007209. DOI:
10.1002/14651858.CD007209.pub2
Smedley F, Bowling T, James M, Stokes E, Goodger C, O’Connor O et al. Randomized clinical trial of the
effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care.
British Journal of Surgery 2004, 91(8): 983-90.
Stroud M, Duncan H, Nightingale J. (2003) Guidelines for enteral feeding in adult hospital patients. British
Society of Gastroenterology (BSG). London.
Wong, Robert, and Uri Ladabaum. "An uncommon complication of percutaneous endoscopic gastrostomy
tubes." Clinical gastroenterology and hepatology: the official clinical practice journal of the American
Gastroenterological Association 11.2 (2013): A25.
DeLegge, MH Gastrostomy tubes: Complications and their management. In UpToDate. Saltzman, J, Lipman
T (Eds). UpToDate, Waltham, MA, 2015.
DeLegge, MH Gastrostomy tubes: Gastrostomy tubes: Placement and routine care. In UpToDate. Saltzman,
J, Lipman T (Eds). UpToDate, Waltham, MA, 2013.
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East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes
Created by Maggie Allen, October 2010. Updated July 2015
Page 68 of 172
APPENDIX 2 LINKED SUPPORTING DOCUMENTS
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Care Pathway for Percutaneous Endoscopic Gastrostomy (PEG) Tubes
Patient Information leaflets
Patient information for consent - EIDO healthcare.com. E09 PEG. Available from Trust Intranet
front page, click on Patient information, then EIDO link and log in following instructions. Once
logged in, scroll down to Endoscopy and click on PEG, print off as required.
Information post PEG removal
Drug administration via enteral feeding tubes
http://www.bapen.org.uk/pdfs/d_and_e/de_pat_guide.pdf
NPSA alerts relating to PEG
National Patient Safety Agency (2010) Early detection of complications after gastrostomy
NPSA/2010/RRR010
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
Manufacturer’s websites
Abbott Nutrition home page – access to pump instruction manuals and training
Videos
http://www.abbottnutritionuk.com/
Corpak Medsystems – access to information about enteral tubes and company guidelines
http://corpakmedsystemsuk.com/
Medicina – information about enteral syringes and feeding devices
http://www.medicina.co.uk/
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East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
Created by Maggie Allen. October 2010. Updated July 2015.
Page 69 of 172
END OF EAST CHESHIRE NHS TRUST CNSG 009 GUIDELINES
FOR INSERTION AND MANAGEMENT OF GASTROSTOMY
TUBES
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East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
Created by Maggie Allen. October 2010. Updated July 2015.
Page 70 of 172
Protocol Title:
Protocol For First Assistant Role In Percutaneous Endoscopic
Gastrostomy ( PEG) Insertion
Executive
Summary:


Supersedes:
To ensure that the insertion of a PEG tube is safe, effective and
comfortable for the patient.
To provide authorisation and guidance for approved qualified nursing
staff to act as first assistant in the endoscopic placement of
gastrostomy tubes.
Version 1.0
Description of
Guidelines reviewed - no major changes
Amendment(s):
This guideline will impact on:
Staff undertaking insertion Percutaneous Endoscopic Gastrostomy ( PEG) Insertion
for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in standards of care should reduce costs and risks
associated with sub-optimal patient care and procedures.
Guideline Area:
Nutrition
Document Reference:
CNSG 010
Version Number:
1.1
Effective Date:
November 2010
Issued By:
Department of
Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Consultation:
Approved by:
Committees / Group
Date
Department of Gastroenterology
Clinical Nutrition Steering Group
October 2010
Clinical Nutrition Steering Group
July 2015
June 2015
AMENDMENTS RECORD
East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
Created by Maggie Allen. October 2010. Updated July 2015.
Page 71 of 172
PROTOCOL FOR FIRST ASSISTANT ROLE IN PEG INSERTION
INDEX
SECTION
CONTENTS
PAGE
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
Introduction
Aim of protocol
Roles and responsibilities
Standards
Assessment
Equipment
Preparation
Procedure
Documentation
Special conditions
References
73
73
73
73
74
74
74
75-7
78
78
78
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East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
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Page 72 of 172
PROTOCOL FOR FIRST ASSISTANT ROLE IN PEG INSERTION
1.0 Introduction


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This protocol is for a competent qualified nurse to act as ‘first assistant’ to the endoscopist
during the insertion of a Percutaneous Endoscopic Gastrostomy (PEG) tube.
The protocol is to be used in conjunction with CNSG 006 Policy for Enteral Feeding and CNSG
009 Guidelines for Insertion and Management of Gastrostomy Tubes.
2.0 Aim of protocol




To ensure that the insertion of a PEG tube is safe, effective and comfortable for the patient.
To provide authorisation and guidance for approved qualified nursing staff who have been
assessed as competent by a Consultant Gastroenterologist or approved Nurse Specialist to act
as first assistant in the endoscopic placement of gastrostomy tubes.
To clarify the tasks that can be undertaken by the first assistant
To identify training requirements
3.0 Roles and responsibilities






East Cheshire Trust acknowledges that changes in medical and nursing roles within many
areas of clinical practice are necessary to meet governmental and professional targets.
East Cheshire Trust has therefore identified the need for nurses to develop their scope of
professional practice.
The first assistant must acknowledge any limitations of personal knowledge and skills
(Code of Conduct, NMC 2015), and will refer any patient back to medical staff if necessary.
The first assistant is professionally and legally accountable for his/her own actions and
omissions (Code of Conduct, NMC 2015).
The first assistant must maintain updated personal and professional training, by ongoing
education and regular clinical updates.
The Trust will provide vicarious liability whilst the first assistant is working within the
parameters of this protocol.
4.0 Standards






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Level 1 or level 2 registered general nurse.
2 years post basic experience in endoscopy.
ENB 906 or equivalent course preferred.
Sound knowledge of the anatomy of the abdomen
Knowledge of the PEG equipment
Compliance with British Society of Gastroenterology (BSG) and Joint Advisory Group (JAG)
standards for endoscopic procedures and training.
East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
Created by Maggie Allen. October 2010. Updated July 2015.
Page 73 of 172
5.0 Assessment
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The following skills and knowledge will be formally assessed by a consultant gastroenterologist or
approved nurse specialist, prior to a nurse acting as a first assistant: 1. Demonstrate knowledge of the: a. criteria for PEG insertion
b. contraindications for PEG insertion
c. complications associated with PEG insertion
d. anatomy of the stomach and abdomen
e. aftercare post insertion
2. Sterile technique
3. Preparation of a patient's abdomen
4. Digital indentation of the stomach
5. Infiltration of the patient's abdomen with local anesthetic
6. Make a small incision in the abdominal wall with a scalpel
7. Insert a trocar though the abdominal wall into the stomach cavity
8. Insert a guide wire through the trocar and into the stomach cavity
9. Pulling the PEG tube into the correct position.
10. Correct positioning of the fixation device
The first assistant will be required to successfully complete the East Cheshire NHS Trust PEG
insertion competency work book prior to being recognised as competent.
6.0 Equipment
Trolley
Dressing pack
Extra gauze
9x10cm Mepore dressing
2% Chlorhexidine (ChloraPrep)
1% Lidocaine (10mls)
Scissors
PEG kit
Sterile gloves
10ml syringe
Green and orange needle
Filter needle
Endoscope – preferably 9mm
Small mouth guard
Snare
Lubricant
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7.0 Preparation
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Check that the PEG care pathway has been completed. Confirm the following with the
endoscopist:  patient’s name
 allergies
 anticoagulants withheld
 INR not greater than 1.3
 Platelet count above 100
 observations including oxygen saturation are within normal limits
 prophylactic antibiotics given
 indication for PEG
 previous abdominal surgery
East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
Created by Maggie Allen. October 2010. Updated July 2015.
Page 74 of 172
8.0 Procedure
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PEG insertion should be undertaken following East Cheshire NHS Trust aseptic policy.
Step
Action
Rational
1.
Wash hands thoroughly and wear sterile gloves as
per East Cheshire NHS Trust aseptic policy
Apply strict aseptic technique throughout the
procedure.
Prepare the equipment and draw up the Lidocaine
whilst the endoscopist is examining the upper GI
tract and inflating the stomach with air.
Reduce the risk of surgical site
infection and sepsis
The endoscopist will locate the appropriate place on
the abdomen by pressing a finger into the upper left
epigastrium (the indentation should be clearly seen
on the monitor) the position will then be clarified by
boosting the endoscopic light and observing the red
glow from the endoscope light on the abdominal wall
(trans-illumination) (O’Toole 2006).
Clean the insertion site and surrounding area with
2% Chlorhexidine (ChloraPrep).
To clarify the position of the
stomach on the abdomen and
reduce the risk of the puncturing the
colon and causing a gastro-colic
fistulae.
2.
3.
4.
Full inflation ensures maximum
views of the stomach and raises it
towards the abdomen.


5.
Wait until dried.
Place the sterile drape over the abdomen, ensuring
that the hole is over the planned insertion area.
Reduces skin microorganisms
so minimising the risk of surgical
site infection and sepsis.
Drying kills the bacteria
Reduces the risk of contamination
of the surgical site.
6.
Using an orange needle, insert the Lidocaine primed
syringe subcutaneously at the planned site and draw
back the plunger. If no blood is returned, inject 12mls.
Anaesthetise the insertion site.
Checking for blood within the
syringe minimises the risk of
injection of Lidocaine into the blood
stream.
Longer length needle allows
optimum local anaesthesia and
visibility in the stomach when
inserted through the abdomen.
7.
Remove the syringe and connect the green needle.
8.
Place the syringe perpendicular to the abdomen at
the previously injected site.
Optimum position for entry into the
stomach.
9.
Advance the syringe into the abdomen whilst
drawing back on the plunger – continue to watch the
monitor during insertion.
Allows the monitoring of air back
into the syringe. If air is seen
without the needle being visible in
the stomach then the needle may
be in the colon.
10.
When the needle is visible in the stomach pull back
slightly and inject a further 3-4mls.
Ensures that insertion site is
adequately anaesthetised.
NB. If unsuccessful, tilt the bed to lower the feet and retry.
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East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
Created by Maggie Allen. October 2010. Updated July 2015.
Page 75 of 172
8.0 Procedure continued
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Step
Action
Rational
11.
Test that the Lidocaine has worked by pricking the
skin with the scalpel.
Make a small incision of approx 3-4mm.
Checks that insertion site is
adequately anaesthetised.
Avoid too large an incision as there
is a greater risk of skin infection.
13.
Place the tip trocar (with introducer) into the small
incision site. The angle of the trocar should be
perpendicular to the abdomen.
Optimum position for entry into the
stomach.
14.
Place the other hand on the abdomen so that the
fingers are positioned on either side of the insertion
site. Keep the site relatively taut and gently advance
the trocar into the stomach cavity – observe the
monitor whilst advancing the trocar.
Aids insertion.
12.
NB. If the trocar is not visible in the stomach despite full insertion, pull back the trocar and
alter the angle so that the tip of the trocar is slightly angled towards the diaphragm, then
reinsert the trocar. If still unsuccessful, remove the trocar and start again with finger
palpation, followed by the green needle.
15.
Once in the stomach remove the introducer
immediately.
16.
Continue to hold the trocar until it has been secured
with a snare by the endoscopist.
17.
Pass the guide wire (in the PEG pack) through the
trocar and advance approx 10cms so that it is visible
in the stomach.
18.
The endoscopist will release the snare slightly and
grasp hold of the guide wire.
To allow the guide wire to be pulled
back with the endoscope.
19.
Allow the guide wire to run freely whilst the
endoscopist withdraws the endoscope and guide
wire, until the wire is seen coming out of the mouth.
Prevents garrotting whilst the
endoscope is removed.
20.
Once the endoscopist has secured the PEG tube to
the guide wire exiting the mouth, pull gently on the
guide wire exiting the stomach and pull the tube
though until slight resistance is felt. The
measurement on the exterior of the PEG tube at the
exit point will depend on the size of the patient
(normally between approximately 3-5 cms).
Pull gently to avoid garrotting the
patient with the wire.
To reduce the risk of puncturing the
gastric wall and blood vessels if the
patient suddenly expels air from the
stomach.
Violent expelling of air can dislodge
the trocar if not secured. Reinflation of the stomach may be
impaired due to the puncture,
resulting in a failed procedure.
Optimal position for endoscopist.
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East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
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Page 76 of 172
8.0 Procedure continued
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Step
Action
Rational
21.
The endoscopist should verify the correct position by
reinserting the endoscope and checking that the
internal PEG bumper is close to the abdominal wall.
If this is not possible i.e. intubation is difficult and
presents a risk of serious complication e.g.
perforation or aspiration, careful assessment of the
exit position and measurement should be made to
determine correct positioning of the PEG and agreed
by the endoscopist and first assistant.
Incorrect positioning of the internal
bumper can increase the risk of
peritonitis.
22.
Cut the PEG tube at the required length (usually at
the end of the markings on the tube, the tube can be
shortened at a later date if required) and attach the
fixation device to the tube as per manufacturer’s
guidelines.
Allows the PEG to be secured
properly.
23.
Position the fixation device so that it sits lightly on
the skin. Pull back gently on the tube to ensure that
there is not too large a gap between the abdomen
and the device. There should be no more than 34mm gap between the device and the skin.

24.
Inform the endoscopist of the cm measurement at
the point where the tube exits the abdomen.
The exit cm marking will be
documented on the endoscopy
report and PEG care pathway. This
facilitates checks for tube
displacement post insertion and
ensures that the tube is repositioned
correctly following daily cleaning.
25.
Place the clamp and the ‘Y’ connector on the tube.
To allow connection of syringes and
the giving set for administration of
feed and fluids.
26.
Clean around the site with 2% Chlorhexidine and
allow to dry.
Reduce risk of surgical site
infection.
27.
Position the tube to either side of the abdomen and
place a dressing over the PEG tube and site. The
PEG tube should not be positioned down towards
the pelvic area.
To prevent contamination of the
PEG site and the PEG end.
28.
Dispose of sharps in the sharps bin and clinical
waste in a yellow bag.
Comply with Trust policy
29.
Wash hands as per Trust policy
Minimise risk of contamination

Incorrect positioning of the
internal bumper can increase
the risk of peritonitis.
If the fixation device is too tight,
there is an increased risk of
necrosis and stoma infection.
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East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
Created by Maggie Allen. October 2010. Updated July 2015.
Page 77 of 172
9.0 Documentation







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Record the type and size of tube on the endoscopy report.
Place the manufacturer’s lot number label on the endoscopy report.
Record the centimetre measurement on the tube at the exit point from the abdomen on
the endoscopy report and PEG care pathway.
Place the correct NPSA alert sticker (inpatient/outpatient) on the endoscopy report.
Ensure that PEG care pathway and endoscopy report are sent back to the ward with
the patient.
Ensure that the staff/carers are aware of the importance of regular observations post
gastrostomy insertion and why.
Record any complications related to the procedure on the endoscopy report.
10.0 Special Conditions




The first assistant will practice within the scope of this protocol.
At no time will the first assistant take over the role of endoscopist unless recognised by the
Trust as a competent endoscopist.
Any amendments to the procedure should be documented.
The protocol will be reviewed annually by the consultant gastroenterologist and/or approved
advanced nurse practitioner.
11.0 References
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British Society of Gastroenterology (2006) Guidelines on Complications of Gastrointestinal
Endoscopy. London.
http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complications.pdf
Joint Advisory Group for Gastrointestinal Endoscopy (JAG 2004). Guidelines for the training,
appraisal and assessment of trainees in GI endoscopy.
O’Toole P. (2006) Complications Associated with the Placement of Percutaneous
Endoscopic Gastrostomy. Guidelines in Gastroenterology. British Society of Gastroenterology
(BSG). London.
National Patient Safety Agency (2010) Early detection of complications after gastrostomy
NPSA/2010/RRR010
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457
NCEPOD (2004) Scoping our practice. The 2004 Report of the National Confidential Enquiry into
Patient Outcome and Death. London
http://www.ncepod.org.uk/2004report/index.htm
Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour
for nurses and midwives. London, NMC.
back to index
East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
Created by Maggie Allen. October 2010. Updated July 2015.
Page 78 of 172
END OF EAST CHESHIRE NHS TRUST CNSG 10 PROTOCOL
FOR FIRST ASSISTANT ROLE IN PEG INSERTION
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back to main index
East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion
Created by Maggie Allen. October 2010. Updated July 2015.
Page 79 of 172
Guidelines Title:
Guidelines for Management of Suspected Peritonitis Post Percutaneous
Endoscopic Gastrostomy (PEG) Insertion
Executive
Summary:
To provide guidance for Trust staff to enable early recognition of
complications following PEG insertion and recommended action required.
Guidance complies with National Patient Safety Alert (NPSA) Early
detection of complications after gastrostomy. NPSA/2010/RRR010:
Supersedes:
Version 1.0
Description of
Guidelines reviewed - no major changes
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients post insertion of Percutaneous Endoscopic Gastrostomy (PEG)
tubes under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in standards of care should reduce costs and risks
associated with sub-optimal patient care and procedures.
Guideline Area:
Nutrition
Document Reference:
CNSG 011
Version Number:
1.1
Effective Date:
November 2010
Issued By:
Department of
Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Consultation:
Approved by:
Committees / Group
Date
Department of Gastroenterology
Endoscopy Users Group
Clinical Nutrition Steering Group
October 2010
Clinical Nutrition Steering Group
July 2015
June 2015
AMENDMENTS RECORD
Back to main index
East Cheshire NHS Trust CNSG 011 Guidelines for management of suspected peritonitis post PEG insertion
Created by mallen Allen. October 2010. Updated July 2015.
Page 80 of 172
GUIDELINES FOR SUSPECTED PERITONEAL LEAK POST PEG INSERTION
Symptoms within 72 hours of PEG insertion








Increasing severity of pain
Tachycardia
Nausea and vomiting
Pyrexia
Pain during administration of fluids via the PEG tube
Leakage during administration of fluids via the PEG tube
Leakage of gastric contents
Fresh bleeding
Yes
STOP FEED/FLUSH IMMEDIATELY
Refer urgently to on call surgical registrar
Recommended monitoring includes: -









Blood pressure
Pulse
Oxygen saturation
Respiratory rate
Temperature
Pain assessment
Wound check
PEG tube position
Bloods +blood cultures if temperature >37.5
Also Consider



IV fluids
IV antibiotics
Urgent X-ray/CT scan (with
gastrografin contrast)
Keep NBM
Once the cause of the patient's symptoms has been identified and treated,
recommence feed as per doctor/dietitians instructions. Monitor for complications.
Increase feed as clinical condition allows.
Back to main index
East Cheshire NHS Trust CNSG 011 Guidelines for management of suspected peritonitis post PEG insertion
Created by mallen Allen. October 2010. Updated July 2015.
Page 81 of 172
Guideline Title:
Guidelines for Management of Jejunal Feeding
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via a jejunal
tube under the care of East Cheshire NHS Trust.
Supersedes:
Version 1.1
Description of
Guidelines reviewed - no major changes
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal patient nutrition.
Guideline Area:
Nutrition
Document Reference:
CNSG 012
Version Number:
1.2
Effective Date:
August 2011
Issued By:
Departments of Dietetics
and Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Consultation:
Approved by:
Committees / Group
Date
Departments of Dietetics and
Gastroenterology
Clinical Nutrition Steering Group
Matrons
October 2010 – August
Clinical Nutrition Steering Group
July 2015
2013
June 2015
AMENDMENTS RECORD
August 2011
Guidelines updated for NPSA/2011/PSA002 alert compliance
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 82 of 172
GUIDELINES FOR MANAGEMENT OF JEJUNAL FEEDING
INDEX
SECTION
1.0
1.1
1.2
1.3
1.4
1.5
2.0
3.0
4.0
4.1
4.2
4.3
4.4
5.0
6.0
6.1
6.1.1
6.2
6.3
7.0
7.1
8.0
8.1
8.2
8.3
9.0
10.0
11.0
12.0
13.0
14.0
Appendix 1
Appendix 2
CONTENTS
Introduction
Definition
Types of tubes
Indications for jejunal feeding
Contraindications for jejunal feeding
Contraindications relative to specific tube categories
Referrals
Consent
Preparation and assessment prior to insertion of a endoscopic
insertion of a jejunal tube
Preparation and assessment prior to endoscopic insertion of a
jejunal tube (PEJ)
Preparation and assessment prior to endoscopic insertion of a
nasojejunal tube
Preparation and assessment prior to surgical insertion of a
nasojejunal tube
Preparation and assessment prior to bedside insertion of a
nasojejunal tube
Patient care post endoscopic and surgical insertion of jejunostomy
tubes
Management of a jejunal tube
Confirmation of placement of jejunal tubes prior to commencing
feed
Use of X-ray to confirm tube position
Routine checking of the tube position prior to use
Flushing
Administration of feed via a jejunal tube
Position of the patient during administration of feed
Individual care related to tube type
Nasojejunal tube and nasal care
Management of a jejunal extension tube via a PEG (PEG - J)
Management of Endoscopically and surgically placed tubes
Complications of jejunal feeding
Administration of medication via jejunal tubes
Monitoring of patients on jejunal feeds
Mouth care
Removal of jejunal feeding tubes
Discharge planning of patients on jejunal feeds
References and bibliography
Links to supporting documents/information
 Patient information
 Training aids
 NPSA alerts
 Manufacturer’s websites
PAGE
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85
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86
87
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87
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88
89
89
89
89
89
90
91
91
91-2
92
92
92
93
93
94
94
94
95
96
97
Back to main index
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 83 of 172
1.0 INTRODUCTION
back to index
1.1 DEFINITION
Jejunal feeding is administration of enteral feed via a tube that has been placed into the proximal
jejunum distal to the ligament of trietz*. This can be achieved using the following methods:  Naso-jejunal (NJ) tube – insertion of a flexible, hollow tube through the pyloric sphincter into
the jejunum via the nasal passage. This can be placed under direct vision endoscopy or by
bedside tube manipulation technique.
 Surgical jejunostomy (Surgical JEJ) - insertion of a polyurethane tube through the
abdominal wall into the jejunum during laparotomy.
 Percutaneous Endoscopic Jejunostomy (PEJ) – insertion of a polyurethane tube through
the abdominal wall into the jejunum under endoscopic vision.
 Percutaneous Endoscopic Gastrostomy conversion (PEG-J) tube - a polyurethane tube is
passed through the existing gastrostomy tube and pulled through to the jejunum with an
endoscope.
* Some tubes may be placed into the duodenum only, depending on the indication. Refer to the
patient’s medical notes for information regarding the insertion procedure.
Table 1
Advantages



Disadvantages
Limits the need for parenteral nutrition
with its associated risks, complications
and costs.
Reduced risk of aspiration
Feed delivery is improved with small
bowel feeding versus gastric (Glencourse
1998).






Risk of bile reflux
Risk of aspiration
Risk of ‘dumping syndrome’
Risk of blocked tube
Increased risk of infection due to post
pyloric feeding
Complications associated with insertion
and tube management (see table 2)
1.2 TYPES OF TUBES
back to index
The choice of jejunal tube placed is dependent upon several factors including indication, condition
of patient, duration of nutritional support required and access to endoscopy/ theatre.
Table 2
Type of tube
Naso-jejunal tube
Advantages
Disadvantages




Low risk insertion procedure
Suitable for short term use




East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Difficulty of insertion
X-ray confirmation of
position required
Risk of perforation
Naso-pharynx
discomfort
Risk of displacement
Aesthetically
displeasing
Page 84 of 172
Table 2 continued
back to index
Type of tube
Advantages
Disadvantages
Surgical jejunostomy

Can be placed adjunctly with GI
surgery
Reduced risk of aspiration
Suitable for long term feeding
Cosmetically more acceptable to
patient
Low risk of displacement

Reduced risk of aspiration
Suitable for long term feeding
Cosmetically more acceptable to
patient
Low risk of displacement





Percutaneous
Endoscopic
Jejunostomy (PEJ)














Percutaneous
Endoscopic
Gastrostomy
conversion (PEG-J)



Reduced risk of aspiration
Suitable for short to medium term
feeding
Cosmetically more acceptable to
patient
1.3 INDICATIONS


Surgical / radiological
procedure
Risk of perforation
Risk of infection
Increased risk bacterial
overgrowth
Risk of bleeding
Endoscopic procedure
required
Risk of perforation
Risk of jejuno-colonic
fistula
Risk of infection
Risk of bleeding
Risk of respiratory
depression due to sedation
Risk of aspiration during
procedure
Endoscopic procedure
required with associated
risks
Risk of displacement
back to index
Jejunal feeding (e.g. Naso-Jejunal tube or Jejunostomy) should be considered for patients with:  documented gastroparesis
 gastric stasis secondary to paralysing agents required for ventilation
 delayed gastric emptying despite treatment with prokinetics
 severe acute pancreatitis
 pancreatic or duodenal injury
 carcinoma of oesophagus or stomach (where NG or gastrostomy feeding is inappropriate)
 upper gastro-intestinal fistulae
 recent upper GI surgery
 recent hepatobilliary surgery
1.4 CONTRAINDICATIONS FOR JEJUNAL FEEDING





back to index
Gastric stasis not treated with gastric motility agents
Gastric stasis secondary to constipation
Advanced dementia (Refer to CNSG 009 Guidelines for Insertion and Management of
Gastrostomy Tubes.
Malabsorption
Intestinal obstruction
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 85 of 172
Relative contraindications include the following:








back to index
Patients with severe immuno-suppression during chemotherapy
Diabetics with neuropathy
Hypothyroidism
Neuromotor deglutition disorders
Neuro-surgical patients
Impaired gastrointestinal motility
Neuromuscular blocking agents
Post abdominal surgery
See below for contraindications specific to type of jejunal tube
1.5 Contraindications relative to specific tube categories
back to index
Absolute contraindications
Table 3
Nasojejunal feeding


Obstructive pathology in
oropharynx or oesophagus
preventing passage of the
tube e.g. stricture, tumour.
Basal skull fracture, as the
tube may enter the brain if
incorrectly positioned (orogastric positioning or
endoscopic insertion may be
appropriate).
Surgical Jejunostomy





Crohn's disease
Radiation enteritis
Ascites
General peritonitis
Patient unfit for
surgery
Percutaneous
Endoscopic Jejunostomy
 Ascites
 General peritonitis
 Patient unfit for
endoscopy
Relative contraindications
Table 4
Nasojejunal feeding




Agitated patient who is
unlikely to tolerate a nasal
tube (consider use of a nasal
bridle to secure the tube.
Refer to CNSG 008
guidelines for management
of nasal bridles)
Oesophageal varices
Mucositis
Recent radiotherapy to head
and neck
Surgical Jejunostomy



Morbid obesity
Treatment with high
dose steroids
Coagulopathy
disease/drugs
Percutaneous
Endoscopic Jejunostomy
 Morbid obesity
 Treatment with high
dose steroids
 Previous upper GI
surgery
 Coagulopathy
disease/drugs
back to index
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 86 of 172
2.0 REFERRALS
back to index
The patient should be referred to:  Consultant gastroenterologist/surgeon
 Specialist nurse
 Dietitian
 Independent mental capacity advocate (IMCA) (If the patient lacks capacity to make an
informed decision and does not have any family or friends with whom it is ‘appropriate to
consult’ about the decision. Refer to CNSG 009 Guidelines for Insertion and
Management of Gastrostomy Tubes for further guidance for information giving and
informed consent.
3.0 CONSENT








back to index
Prior to insertion of an enteral tube, the procedure and any risks should be explained to the
patient so that informed consent, written/verbal/signage, can be obtained from the patient.
The patient’s consent must be recorded in the patient’s notes, in compliance with Trust
Policy.
Written information regarding the procedure should be given to the patient where available.
Written consent is required for procedures that carry a greater degree of risk to the patient
e.g. endoscopic insertion of an enteral tube. If the patient is unable to sign, the patient’s
verbal consent must be witnessed and the witness sign the consent form.
If the patient is unable to give informed consent and in the absence of a patient’s advanced
decision regarding treatment, or a registered individual who has lasting power of attorney
(Mental Capacity Act 2005), the lead clinician is responsible for any decision to withhold,
give, or withdraw, a medical treatment, which includes provision of food and fluid via a
feeding tube.
Where possible a multidisciplinary approach should be taken when deciding on jejunal tube
insertion for a patient. For severely debilitated patients, ethical, medical and legal
implications of long term tube feeding needs to be considered. For patients in the terminal
phase of their illness, consideration should be given to the effect of undergoing an invasive
procedure which carries significant morbidity and mortality risks.
The goals of the treatment should be clearly identified in the patient’s medical notes.
Evidence of discussion with family members, where appropriate, is required.
Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes for
further guidance for information giving and informed consent.
4.0 PREPARATION AND ASSESSMENT PRIOR TO INSERTION OF AN ENDOSCOPIC
INSERTION OF A JEJUNAL TUBE
The preparation required will depend on the type of tube being inserted.
4.1 Preparation and assessment prior to endoscopic insertion of a jejunal tube (PEJ)
The patient should be assessed and prepared as per CNSG 009 Guidelines for Insertion and
Management of Gastrostomy Tubes.
back to index
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 87 of 172
4.2 Preparation and assessment prior to endoscopic insertion of a nasojejunal tube
Patients requiring nasojejunal tubes should be assessed for contraindications, see tables 3 and 4
above and any other medical conditions that will place them at high risk of developing
complications related to Nasojejunal feeding.
Refer to section 4 in CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
above for information regarding decision making as to whether tube feeding is appropriate.
The following group of patients are at a high risk of incorrect tube positioning, dislodgement and
aspiration.





Maxillo-facial disorders
Laryngectomy
Recent radiotherapy to head and neck
Any disorder of the oesophagus e.g. varices, stricture.
Nasal C.P.A.P.
back to index
Oro-gastric positioning may be indicated following head injury or neuro surgery.
High Risk also includes patients who: 




Are comatose/semi-comatose
Are ventilated/sedated
Have a swallow dysfunction
Have recurrent retching/vomiting
Need to be nursed prone
The patient will require: 


back to index
A venflon for sedation, if required
Baseline observations – to check that the patient is fit enough for the procedure
Recent U&Es – for accurate assessment of nutritional and fluid requirements.
The following documents must be sent with the patient to the endoscopy unit at the time of the
procedure:
 Signed consent form
 Patient notes
 Nursing notes
 Drug charts
 Procedure checklist/care plan.
4.3 Preparation and assessment prior to surgical insertion of a nasojejunal tube
The patient will be assessed and prepared for surgery as per East Cheshire NHS Trust policy and
guidelines.
4.4 Preparation and assessment prior to bedside insertion of a nasojejunal tube
The patient will be assessed and prepared as per CNSG 007 Guidelines for Insertion and
Management of Nasogastric Tubes.
back to index
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 88 of 172
5.0 PATIENT CARE POST ENDOSCOPIC AND SURGICAL INSERTION OF JEJUNOSTOMY
TUBES
Endoscopic insertion – as per CNSG 009 Guidelines for Insertion and Management of
Gastrostomy Tubes.
Surgical insertion
back to index
Follow surgical plan as recommended by individual consultant surgeons and Trust guidelines.
6.0 MANAGEMENT OF A JEJUNAL TUBE
6.1 Confirmation of placement of jejunal tubes prior to commencing feed



If a jejunal tube has been placed ‘blind’ at the bedside, the position of the tube should be
confirmed by abdominal X-ray prior to using the tube.
Endoscopically placed tubes may not need to be x-rayed prior to use. The endoscopist
should state whether x-ray is required on the endoscopy report.
The external length of all jejunal tubes should be measured, marked and documented.
6.1.1 Use of X-ray to confirm tube position
Refer to section 9.2 in CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes
for further guidance
6.2 Routine checking of the tube position prior to use
back to index
Aspiration
Aspirate is not normally obtainable from the jejunum. Therefore the absence of aspirate is not a
contra-indication to feeding. Routine aspiration is, therefore, not required.
If the patient is nauseated or vomiting, the NJ tube should be aspirated. If an aspirate is obtained,
this may indicate that the tip of the tube has migrated to the stomach. Any feed or medication being
administered through the tube at this time should be stopped and advice sought from medical
staff/specialist nurse.
Assessment for tube displacement
Check the length and position of the marking on the tube and compare with the position
documented following initial placement.
If position of the tube is in doubt consider abdominal X-ray.
NB.
Jejunal tubes can be more complex to insert and may involve procedures that carry a
degree of risk of complications to the patient. Therefore every effort must be made to
minimise the need for replacement in the instance of blocked or displaced tube.
back to index
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 89 of 172
6.3 Flushing
back to index
Jejunal tubes are mainly fine bore and have a higher potential to block. Regular and effective
flushing is essential. Prior to flushing Full compliance with hand hygiene and personal
protective equipment must be maintained as per Trust Infection Prevention and Control Good
Practices Policy.
When to flush
Using a 60ml enteral feeding syringe, flush the tube with a minimum of 30-50mls water:





Before and after administration of feed
Before and after administration of each type of medication (if the patient is on a strict fluid
restriction – liaise with the pharmacist and dietitian for advice)
If the patient is disconnected from the feed for a short period of time.
4 hourly if the tube is at high risk of blocking e.g. a nasojejunal tube
Leave a column of water in the tube during the rest period.
What to flush with



Sterile water – hospital use.
Cooled boiled water – community use (should be prepared fresh daily, dated, named (if in a
care setting) and stored at room temperature.
Enteral syringes only. They should have a purple barrel, and be labelled ‘oral / enteral’ use
only. Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral
Tubes for further guidance.
How to flush
back to index
Moderate pressure should be applied with the plunger when flushing feeding tubes.
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 90 of 172
7.0 ADMINISTRATION OF FEED VIA A JEJUNAL TUBE
back to index
Patients should be referred to the Department of Nutrition and Dietetics for assessment of
nutritional requirements and recommendation of an appropriate feed.
Whereas the stomach can tolerate administration of intermittent boluses of feed, the duodenum
and jejunum are not designed to receive food in this way. In the normal gut a gradual continuous
flow of diluted and partially digested is slowly released from the stomach. To simulate this when
feeding directly into the duodenum or jejunum, the feed should be administered by slow continuous
infusion.
 A slow rate of administration must be used initially and the volume and rate increased
gradually.
 The rate of infusion should be carefully controlled using an enteral feeding pump.
 Too rapid an infusion is likely to cause diarrhoea and other gastrointestinal side effects as the
reservoir of the stomach is bypassed.
 Feed can be administered over 24 hours as a rest period is not essential. Once a patient is
established on jejunal feeding (i.e. tolerating the feed and meeting nutritional requirements) the
rate of infusion can be increased to enable the hours of feeding to be reduced.
 Feed administered should be documented on a fluid balance chart.
 The enteral feed should be labelled with patient's name, date and time the feed was opened.
back to index
Post-pyloric feeding by-passes the anti-microbial effects of gastric acid. In order to prevent
contamination and infection: Full compliance with hand hygiene and personal protective equipment must be maintained
as per Trust Infection Prevention and Control Good Practices Policy.
 Staff should use a Non-Touch Aseptic Technique. This means avoiding touching the
connection parts of feeding systems or unnecessarily opening feeding systems.
 Follow the procedure for administration of feed as recommended in CNSG 013 Guidelines
for Administration of Feed and Fluid via Enteral Tubes.
 Store, prepare and dispose of feed and equipment as per CNSG 015 Microbiological
Guidelines for Handling of Enteral Feed and Fluids.
7.1 Position of the patient during administration of feed
Although there is less risk of reflux with jejunal feeding, patients at risk of aspiration due to a
swallow disorder, should be in a sitting or elevated position (at least 30 o), during feeding and for an
hour afterwards, to help to reduce the risk of reflux and aspiration.
8.0 INDIVIDUAL CARE RELATED TO TUBE TYPE
back to index
8.1 Nasojejunal tube
Securing the Tube
Once the tube has been confirmed as being correctly placed, it must be secured to the side of the
face by a hypoallergenic adherent dressing and looped over the ear. This is recommended for the
following reasons: 




Less irritating for the patient as it secures the tube out of their line of sight.
Does not interfere with the patient’s eating, by keeping the tube away from the mouth.
A confused patient is less likely to pull the tube out as they cannot see it or feel it when they
bring their hands up to the mouth area.
Patients receiving humidified oxygen (excess moisture makes the nasal tape slip).
The external part of the tube should be brought to the same side of the face as the insertion
nostril and allowed to rest over the ear.
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 91 of 172




An addition narrow piece of tape can be placed to secure the tube at the exit from the nostril.
Avoid pulling the tube too tight so that it causes pressure on the nostril; localised cyanosis and
necrosis can occur if blood flow is impaired.
The securing dressing should be checked regularly and replaced if dirty or peeling off.
A nasal bridle may be appropriate.See Guidelines for Insertion and Management of Nasal
Bridles for further guidance.
Nasal care


back to index
Monitor the patient’s nose daily for signs of friction abrasions and clear away dried secretions.
If the nose appears sore or ulcerated refer to specialist
8.2 Management of a jejunal extension tube via a PEG (PEG - J)
An intestinal tube can be passed through an existing PEG tube and pulled through into the small
intestine with an endoscope. A ‘Y’ adapter placed on the end of the PEG tube allows administration
of liquid via the intestinal tube, or the PEG tube. The indication for this procedure is to feed into the
small intestine rather than the stomach to help reduce reflux and vomiting.
The Y connector on the PEG tube has two ports, ‘I’ for the intestinal tube and ‘g’ for the gastric
tube (markings on Y connector).
 Use the ‘I’ port for administration of feed and water
 Use the ‘g’ port for administration of medication into the stomach
Both lumens are narrow so there is a high risk of blockage. Correct flushing is essential. See
section 6.3 above.
Rotation of the tube
back to index
Normally a gastrostomy tube is rotated in order to prevent the internal bumper form becoming
buried in the gastric mucosa. Do not rotate the gastrostomy tube in this instance as it will displace
the jejunal tube – the gastrostomy tube can be pushed into the stomach a couple of centimetres
then pulled back (reduces the risk of buried bumper).
Refer to specialist for advice.
8.3 Management of Endoscopically and surgically placed tubes
Tube management will depend on the type of tube. Refer to specialist.
back to index
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 92 of 172
9.0 COMPLICATIONS OF JEJUNAL FEEDING
back to index
For advice regarding management of enteral feeding complications refer to CNSG 013
Guidelines for Administration of Feed and Fluid via Enteral Tube.
Specific advice relating to jejunal tubes is seen below.
PROBLEM
POSSIBLE CAUSES
INTERVENTION
NJ tube partially
pulled out
Accidental removal by staff
or patient

NJ tube
completely pulled
out
PEJ pulled out
Accidental removal by staff
or patient
Request abdominal X-ray to confirm
exact position.
 If still in small intestine continue
feeding.
 If in the stomach will need to be
replaced
 Contact gastroenterologist if
endoscopic placement required.
Contact gastroenterologist if endoscopic
placement required.
Accidental removal by staff
or patients
Accidental removal by staff
or patients
Contact gastroenterologist/specialist
nurse for advice immediately
Contact Medical / Surgical team for
advice immediately
Surgical
Jejunostomy
pulled out
Infected PEJ or
Jejunostomy site
Leaking
Jejunostomy
stoma
Refer to CNSG 014 Guidelines For Enteral Feeding Complications
and Management for causes and recommended management.
Refer to CNSG 014 Guidelines For Enteral Feeding Complications
and Management for causes and recommended management.
10.0 ADMINISTRATION OF MEDICATION VIA JEJUNAL TUBES
back to index
Administration of some medications via a jejunal tube may be contraindicated for the following
reasons:


The risk of blockage is high
Most drugs are not licensed to be given via the jejunum or duodenum, as the mode of action
and absorption in the small bowel is not known.
Some drugs may not be absorbed as effectively in the duodenum as the stomach, resulting in
sub-therapeutic doses.
The patient must have their medication reviewed by a pharmacist and the prescribing clinician
must be aware that the tube is placed in the jejunum. If the patient has jejunal tube, it may be
necessary to consider passing a second tube into the stomach or use a double lumen tube so that
drugs can be administered into the stomach.
Refer to CNSG 016 Guidelines for Administration of Medicines via Enteral Feeding Tubes for
further information.
back to index
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 93 of 172
11.0 MONITORING OF PATIENTS ON JEJUNAL FEEDS
back to index
Refer to CNSG Guidelines for Assessment and Monitoring for further guidance. Contact
dietitian for information.
12.0 MOUTH CARE
Maintenance of oral hygiene is essential, particularly is a patient is unable to
 have oral food and fluids
 attend to their own oral care
PROBLEM
REASON
ACTION
Dry sore mouth




Inadequate mouth care
Mouth breathing
Poor dental condition



Saliva : Tenacious
Hyper-salivation



Dehydration
Neurological condition
Unable to swallow oral
secretions




Clean teeth/dentures with a soft
toothbrush or a damp swab wrapped
around a gloved finger (depending on
the patient. The frequency will depend
on the condition of the patient, twice
daily minimum).
Check the tongue and the hard palate
for thickened secretions and remove.
Use lip salve to protect lips from
chapping.
Consider use of artificial saliva if
appropriate
Refer to dentist if necessary.
Ensure adequate fluids.
Consider drug therapy. Consult doctor.
Maintain good oral hygiene.
Refer to Guidelines for the Oral Healthcare of Stroke Survivors by the British Society of
Gerodontology for comprehensive guidance as to management of oral hygiene.
http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf
13.0 REMOVAL OF JEJUNAL FEEDING TUBES
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Jejunal tubes should only be removed if patients are meeting their nutritional requirements via an
alternative route. The method of removal will depend on the type of tube.



Naso-jejunal tubes can be removed by pulling.
Surgical Jejunostomy tubes may need further surgical intervention for removal, particularly if
the tube has an internal retaining cuff. Refer to surgeon. If the tube is a balloon tube, the
balloon should be deflated and the tube removed by traction. If the type of tube is unknown,
refer to specialist for advice.
PEJ tubes can be removed by traction. The procedure should be undertaken by a trained
practitioner.
For further guidance about tube removal, including skin care, refer to CNSG 009 Guidelines for
Insertion and Management of Gastrostomy Tubes.
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East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 94 of 172
14.0 DISCHARGE PLANNING OF PATIENTS ON JEJUNAL FEEDS
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Patients must have prior to discharge:  A multidisciplinary risk assessment to assess needs (Appendix 5 Flow chart to guide
decision making for tube feeding)
 Referral to a dietitian
 Training and assessment of competency for them and/or their carers for tube care and
feeding.
 An agreed plan if tube removed accidentally or blocked.
 A discharge pack to include: o Care of NJ tube
o Care of equipment
o Contact numbers
o Feeding regimen
o Position monitoring form
o CE accredited pH strips
o Manufacturer’s guidelines for using pH strips
o Spare NG tube
o 7 days feed and equipment
o How to maintain oral hygiene
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 95 of 172
APPENDIX 1 REFERENCES AND BIBLIOGRAPHY
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BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners
and Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead.
British Society of Gerodontology (2010) Guidelines for the Oral Healthcare of Stroke Survivors.
http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf
Human Rights Act 1998
Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in
Partnership with Nutricia.
Mental Capacity Act 2005
National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139
Infection Prevention and control of healthcare-associated infections in primary and community care
http://guidance.nice.org.uk/CG139
National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral
supplements, parenteral and enteral feeding. London.
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation
of placement NPSA/2012/RRR001 22/03/12
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441
National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric
feeding tubes in adults, children and infants. NPSA/2011/PSA002
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour
for nurses and midwives. London, NMC.
Payne-James, J., Grimble, G. & Silk, D. (2001) Enteral nutrition: tubes and techniques of delivery.
In: Artificial Nutritional Support in Clinical Practice, 2nd edn (eds J. Payne-James, G. Grimble & D.
Silk). Greenwich Medical Media, London.
The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7th edition. Available from the
Trust Intranet.
East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 96 of 172
APPENDIX 2 LINKS TO SUPPORTING DOCUMENTS
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NPSA alerts relating to Nasogastric feeding
National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation
of placement NPSA/2012/RRR001 22/03/12
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441
National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric
feeding tubes in adults, children and infants. NPSA/2011/PSA002
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric
feeding tubes NPSA/2005/05
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798
Manufacturer’s websites
Abbott Nutrition home page – access to pump instruction manuals and training
Videos
http://www.abbottnutritionuk.com/
Corpak Medsystems – access to information about enteral tubes and company guidelines
http://corpakmedsystemsuk.com/
Medicina – information about enteral syringes and feeding devices
http://www.medicina.co.uk/
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East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 97 of 172
END OF
EAST CHESHIRE NHS TRUST CNSG 012 GUIDELINES FOR
MANAGEMENT OF JEJUNAL FEEDING
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East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding
Created by Maggie Allen. October 2010. Updated July 2015.
Page 98 of 172
Guideline Title:
Guidelines for Administration of Feed and Fluid via Enteral Tubes
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via an enteral
tube under the care of East Cheshire NHS Trust.
Supersedes:
Version 1.0
Description of
Guidelines reviewed - no major changes
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal patient nutrition.
Guideline Area:
Nutrition
Document Reference:
CNSG 013
Version Number:
1.1
Effective Date:
October 2010
Issued By:
Departments of Dietetics
and Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Consultation:
Approved by:
Committees / Group
Date
Departments of Dietetics and
Gastroenterology
Clinical Nutrition Steering Group
Matrons
Infection prevention and control
department
October 2010
Clinical Nutrition Steering Group
July 2015
June 2015
AMENDMENTS RECORD
East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 99 of 172
GUIDELINES FOR ADMINISTRATION OF FEED and FLUID VIA ENTERAL TUBES
INDEX
SECTION
CONTENTS
PAGE
1.0
1.1
1.2
1.3
1.4
2.0
3.0
3.1
4.0
5.0
6.0
6.1
6.2
6.3
6.4
6.5
7.0
7.1
7.2
8.0
Appendix 1
Appendix 2
Method of feeding
Continuous feeding
Cyclic feeding
Bolus feeding
Preparation of feed
Administration of bolus feeding
Administration of feed via a pump
Split feeding
Feeding position
Hanging times for feeds
Enteral feeding equipment
Single use and single patient use equipment
Syringes
Tubes
Adaptors
Feeding pumps
Administration of water
Type of water
Flushing enteral feeding tubes
Disposal of equipment
References
Links to supporting documents/information
 Patient information
 Training aids
 NPSA alerts
 Manufacturer’s websites
101
101
101
101
101
102-2
104-5
105
105
105
106
106
106
107
107
107
108
107
108
109
109
110
Back to main index
East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 100 of 172
GUIDELINES FOR ADMINISTRATION OF FEED and FLUID VIA ENTERAL TUBES
Enterally fed patients are susceptible to infections of the gastro-intestinal tract, infections
around the tube insertion site, chest infections and septicaemia.
(Arrowsmith 1996, Pien et al. 1996).
The following guidelines must be used in association with CNSG 015 Microbiological Guidelines
for Enteral Feeding.
1.0 METHOD OF FEEDING
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A dietitian will tailor the feeding regimen to suit individual needs. This will take into account the
clinical condition, lifestyle, mobility and the route of administration.
The feed can be given continuously, intermittently, overnight or as bolus feeds. Enteral feeds may
provide all the nutritional requirements or may be used to supplement an inadequate oral intake.
1.1 Continuous feeding
This is normally used for patients who are critically ill, requiring tight glucose control, or for patients
requiring the lowest possible feeding rate due to slow gastric emptying or gastro-oesophageal
reflux.
1.2 Cyclic Feeding
Allows the patient to be fed continuously via a pump over only part of the day. A higher rate of
feeding is required compared to someone on continuous feeding.
Cyclic feeding is generally given overnight to free up the daytime for normal activities. It also allows
for the patients to eat at mealtimes, if an oral diet is still being taken.
Discontinue the feed at least 1 hour prior to strenuous activity e.g. physiotherapy.
1.3 Bolus Feeding
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This involves the administration of a specific volume of feed, via a syringe or a Paediatric Feeding
Set, at intervals throughout the day. This method of feeding may be preferable to continuous
feeding for some patients. This method can: 



release mobile patients from long periods attached to feeding equipment
allow individuals to have "normal mealtimes"
help regulate appetite and help transition to oral feeding
be a safe method of feeding for agitated and restless patients who would have a tendency to
pull at and displace tubing if fed via a pump .
Not all patients can tolerate bolus feeds. The dietician will discuss the choice of bolus versus
pump feeding. Some patients use a combination of both methods.
1.4 Preparation of feed
Refer to sections 2 and 3 in CNSG 015 Microbiological Guidelines for Enteral Feeding for best
practice for storage and preparation of feed.
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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 101 of 172
2.0 ADMINISTRATION OF BOLUS FEEDING
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Equipment
 Feed as stated on feeding regimen
 Water (fresh tap water in hospital/ cooled boiled water in community, sterile water if the
patient is immuno-compromised or if the tube is placed in the duodenum/jejunum)
 60ml enteral syringe (purple)
 Alcohol wipe
 Gloves
 Always use the designated bottle opener. Abbott Nutrition supply foil cutters for the feed
bottles.
Procedure for bolus feeding
ACTION
RATIONALE
Wash hands and assemble equipment required.
Minimise cross infection.
Check feed and volume on prescription chart
and dietetic feeding regimen.
To reduce risk of incorrect feed being given.
Explain procedure to patient.
To ensure patients co-operation and promote
confidence.
Position the patient in a semi-upright or upright
position, 30-45o angle.
To reduce risk of reflux and aspiration and
ensure patient is comfortable.
Wash hands thoroughly and put on gloves (nonsterile) as per East Cheshire NHS Trust policy.
To minimise risk of cross-infection.
Check expiry date of feed and check for
damage.
To ensure contents are sterile and within use-by
date.
Shake feed container well.
To ensure contents are thoroughly mixed.
Wipe container with alcohol wipe and open
using a sterile foil cutter (Abbott bottles) or
sterile scissors.
Reduce risk of contamination.
If using a nasogastric tube, check position prior
to use. Refer to CNSG 007 Guidelines for the
Management of Nasogastric Tubes.
Prevents feeding into the lungs.
Flush tube with 50mls of water (or as volume
recommended on dietetic regimen). Use the
plunger for flushing. See section 7.2 below for
further guidance.
To check patency of tube and clear gastric
juices. Using the plunger achieves optimum
flushing of the tube.
Close the clamp on the gastrostomy tube prior
to disconnecting the syringe from the tube.
Prevents leakage of gastric contents.
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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 102 of 172
Procedure for bolus feeding continued
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ACTION
RATIONALE
Method of administrating feed: gravity versus pushing with the plunger
Feed can be given by gravity i.e. removing the plunger from the syringe and pouring the feed
directly into the syringe casing and allowing it to drain into the stomach. The speed can be
controlled by the height of the syringe in relation to the body (the higher the syringe the quicker it
will empty). The alternative method is to draw up the feed in the syringe by pulling back on the
plunger then attach the syringe to the enteral tube and push using a slow steady action.
NB. Using the plunger will not harm the patient or the tube. Some individuals may be
hypersensitive and feel slightly nauseous with ‘push’ feeding in which case, gravity feeding will be
better for them.
With either method, continue until the recommended dose has been given, unless the patient
cannot tolerate the amount in which case rest and then recommence after reviewing the patient. If
the patient has pain during administration of feed/fluid, stop immediately and assess for
complications. Refer to CNSG 014 Guidelines for Enteral Feeding Complications and
Management for further guidance.
On completion of feed, flush the tube with at
least 50mls of water (or volume as
recommended on dietetic regimen). The plunger
must be used for flushing.
Using the plunger achieves optimum flushing of
the tube and prevents blockage.
See section 7.2 below for further guidance.
On completion of the flush, close the clamp on
the gastrostomy tube then disconnect the
syringe and recap the feeding port.
Prevents leakage of gastric contents.
Opened feed must be stored in a refrigerator.
Discard after 24 hours. Refer to CNSG 015
Microbiological Guidelines for Enteral
Feeding for further information.


Dispose of used equipment in accordance with
East Cheshire NHS Trust policy.
To minimise risk of cross infection.
Wash and dry hands thoroughly as per Trust
policy.
To minimise risk of cross infection.
Complete appropriate documentation: 1. Sign prescription chart for feed given.
2. Enter water and feed volume on fluid
balance chart.
3. Record pH value on the nasogastric
monitoring form if NG feeding.
4. Record any complications.
To ensure accurate records are maintained.
Wash hands and assemble equipment.
To minimise risk of cross-infection.
Check feed and volume on prescription chart
and dietetic regimen.
To reduce risk of incorrect feed being given.
To minimise risk of bacterial contamination.
To minimise risk of feed contamination.
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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 103 of 172
3.0 ADMINISTRATION OF FEED VIA A PUMP
ACTION
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RATIONALE
Wash hands as per East Cheshire NHS Trust
policy and put on gloves (non-sterile).
To minimise risk of cross-infection.
Check expiry date of feed and check for
damage.
Shake feed container well.
To ensure contents are sterile and within use-by
date.
To ensure contents are thoroughly mixed.
Set up feed and pump following the
manufacturer’s instructions and using an
Aseptic Non Touch technique (ANTT) i.e. do not
allow any part of the equipment that comes in
contact with feed, to touch hands, skin or
clothing.
To minimise risk of cross-infection.
See section 6.5 below for further information on
pumps.
Set the pump rate and feed volume (as
recommended by the dietitian).
If using a nasogastric tube, check position prior
to use and record the pH value on the
Nasogastric Tube Insertion and Monitoring
Form. Refer to CNSG 007 Guidelines for the
Management of Nasogastric Tubes.
Prevents feeding into the lungs.
Flush tube with 50mls (or as volume
recommended on dietetic regimen) of water.
Use the plunger for flushing.
To check patency of tube and clear gastric
juices. Using the plunger achieves optimum
flushing of the tube.
Close the clamp on the gastrostomy tube prior
to disconnecting the syringe from the tube.
Attach the giving set to the feeding tube.
Prevents leakage of gastric contents.
Undo the reflux clamp (gastrostomy tubes).
Turn pump dial to run.
On completion of feed, close clamp on
gastrostomy tube then disconnect the giving set
and flush the tube as volume recommended on
dietetic regimen.
To prevent blockage
On completion of the flush, close the clamp on
the gastrostomy tube then disconnect the
syringe and recap the feeding port.
Prevents leakage of gastric contents.
Dispose of used equipment in accordance with
East Cheshire NHS Trust policy.
Act in accordance with "Waste Disposal Policy"
to be found in the East Cheshire NHS Trust
Health and Safety Policy.
Wash and dry hands thoroughly.
To minimise risk of cross infection
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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 104 of 172
ADMINISTRATION OF FEED VIA A PUMP – continued
ACTION
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RATIONALE
Complete appropriate documentation.
1. Sign prescription chart for feed given
2. Enter water and feed volume on fluid
balance chart
3. Record pH value on Nasogastric Tube
Insertion and Monitoring Form if NG
feeding
4. Document any complications.
To ensure accurate records are maintained.
3.1 Split feeding
If the patient has a break in the feeding regime i.e. a few hours in the morning, followed by a few
hours in the evening, during the rest period:  Disconnect the giving set from the feeding tube
 Place the purple connector and dust cover on the end of the giving set and store in the slot at
the back of the pump.
 Flush and close the cap on the feeding tube.
 Discard the feed after 24 hours
4.0 FEEDING POSITION
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The individual receiving enteral feed must be in a sitting or elevated position (at least 30o), during
feeding and for an hour afterwards. This helps to reduce the risk of reflux and aspiration. When
feeding overnight, ensure that the upper body is propped up with pillows, or the bed head elevated.
If the individual has a history of reflux or a known large hiatus hernia, daytime feeding should be
considered so that the patient can be fed sitting upright in a chair.
5.0 HANGING TIMES FOR FEEDS



The hanging time is the total time the opened feed is kept at room temperature.
Storage time in a refrigerator below 5ºC is not included in the hanging time.
There should be individual risk assessment and the hanging times reduced if necessary.
FEED TYPE
MAXIMUM HANGING
TIME
24 hours
MAXIMUM STORAGE TIME
IN REFRIGERATOR
Not applicable
Sterile feeds decanted into a sterile
reservoir using aseptic/non-touch
technique (ANTT).
24 hours
24 hours
Non sterile feeds e.g. reconstituted
powders and mixed feeds decanted
into a sterile reservoir.
4 hours
24 hours
Sterile, ready-to-use feeds if not
decanted.
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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 105 of 172
6.0 ENTERAL FEEDING EQUIPMENT
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Devices used for enteral feeding, must not compromise the health and safety of the patient, user,
or any other person. Any risks associated with the device must be compatible with patient health
and protection. Medical Devices Regulations 2002.
The principles governing the use of enteral feeding equipment are outlined in National Patient
Safety Alert (NPSA) Alert 19 (2007): Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes.
6.1 Single use and single patient use equipment
Single use equipment is recommended in the hospital setting. An exception to this rule is extension
sets or specialist adapters for gastrostomy tubes. Refer to CNSG 015 Microbiological Guidelines
for Handling of Enteral Feeds and Fluids, for further information regarding cleaning and storage.
6.2 Syringes
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Enteral syringes for oral / enteral use should have a purple barrel and be labelled ‘oral / enteral’
use only.
Enteral syringes should only connect to tubes for enteral use and not to tubes for IV use.
The syringes are available with different connectors to fit the various enteral feeding tube ports.
The recommended syringes should have either: 


a female luer connector to fit male luer ports on enteral feeding tubes (reverse luer connector
combination)
a catheter tip connector to fit catheter tip ports on enteral feeding tubes
non-luer (non-standard connector that does not fit any non-flexible port)
Where the guidance above cannot be followed for an individual patient (e.g. if the patient has a non
standard tube), a risk assessment for the equipment to be used should be undertaken prior to use.
Non standard equipment should be stored separately, clearly labelled, with restricted access. Only
staff with specialist knowledge and skills should have access to these devices.
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808&p=3
NB.
Some companies e.g. Medicina, provide single use enteral syringes for hospital use and reusable
syringes for community use. Caution is required, as they are the same colour. The single use
syringes are labelled with the single use logo, both on the packet and the syringe. All syringes are
to be single use only in the hospital setting even if they specify that they are reusable. The
syringe must be discarded after the episode of use i.e. flushing followed by administration of fluid/
medication, followed by flush, then dispose of the syringe. Wards should order the single use only
enteral syringes.
Refer to CNSG 015 Microbiological Guidelines for Enteral Feeding for information regarding
use of ‘single use’ and ‘single patient use’ devices.
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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 106 of 172
6.3 Tubes



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All tubes for enteral use must be labelled ‘for enteral use only’.
All tubes for enteral use should only connect to syringes for enteral use, and not to
syringes for IV use.
The patient should be assessed for the correct enteral tube. Refer to CNSG Guidelines for
Assessment and Monitoring for Patients receiving Enteral Nutrition.
6.4 Adaptors
Three way taps and syringe tip adaptors should not be used as routine. The correct enteral syringe
should be ordered to fit the tube.
6.5 Feeding pump
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Pumps are on loan from Abbott Nutrition as part of a contract. Each ward is allocated a supply of
pumps and is responsible for their use decontamination and retention.
Type
FreeGo pump
Available from:
Wards
Before using the pump, always check that:


back to index
Staff are trained to use the equipment.
The pump and cable are clean and undamaged.
General care
ACTION
RATIONALE
Clean spilt feed off the pump immediately with a
disposable damp cloth.
Battery lasts 6 – 8 hours. The pump needs to be
fully charged in case of electrical failure.
Source of bacterial contamination and may
prevent the pump from functioning accurately.
Report faults to medical electronics ext 1930.
To allow prompt repair/replacement.
When no longer required, clean the pump
thoroughly and return to designated storage
area. Refer to manufacturer’s pump manual for
correct decontamination procedure.
Pump should be decontaminated prior to being
used for the next patient in order to prevent
cross infection.
Keep plugged in
The pump comes with a comprehensive manual with step by step pictures for setting up a feed and
a useful troubleshooting section in the event of problems.
There is also a free phone number in the front of the manual if you are unable to solve the
problem.
The following link is the home page of Abbott Nutrition for access to the pump manual and training
videos. https://www.abbottnutrition.co.uk/media/70612/freego_operating_manual.pdf
East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 107 of 172
7.0 ADMINISTRATION OF WATER
7.1 Type of Water
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In the hospital setting tap water is suitable for flushing, providing that it is:  Kept in a lidded container
 Changed twice a day
 Not contaminated by dipping the syringe into the jug to draw up water (pour the water into a
cup first).
Use sterile water if:  The patient is immuno-compromised.
 The feeding tube is positioned in the duodenum or jejunum.
 Large volumes of water are required to be given via a reservoir i.e. an Abbott
Flexitainer.
 It is the first flush following PEG insertion
The sterile water bottle must be labelled with the patient’s name, date and time of opening. It
must be discarded after 24 hours. Refer to CNSG 015 Guidelines for Handling of Enteral
Feeds and Fluids, for further information.
7.2 Flushing enteral feeding tubes
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When to flush
Using a 60ml enteral feeding syringe, flush the tube with a minimum of 30-50mls water:
 Before and after administration of feed
 Before and after administration of each type of medication (if the patient is on a strict fluid
restriction – liaise with the pharmacist and dietitian for advice)
 If the patient is disconnected from the feed for a short period of time.
 Following aspiration to check tube position
 Leave a column of water in the tube during the rest period.
Omitting to flush after halting the feed or after giving a medication is a common cause of tube
blockage
How to flush
Moderate pressure should be applied with the plunger when flushing feeding tubes.
East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 108 of 172
8.0 DISPOSAL OF EQUIPMENT
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Clinical waste should be disposed of as per Trust policy.
APPENDIX 1
REFERENCES AND RELATED READING
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Arrowsmith, H. Nursing Management of patients receiving gastrostomy feeding. British Journal of
Nursing 1996; 5(5): 268-273.
Food safety Act 1990
Food Standard Agency (2007) Guidance on Temperature Control Legislation in the United
Kingdom EC Regulation 852/2004
Food Hygiene Regulations (2006)
Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in
Partnership with Nutricia
Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical Devices:
Implications and Consequences of Reuse. MDA DB2000(04)
Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding Systems.
MDA SN2000(27).
National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139
Infection Prevention and control of healthcare-associated infections in primary and community care
http://guidance.nice.org.uk/CG139
National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral
supplements, parenteral and enteral feeding. London.
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric
feeding tubes NPSA/2005/05
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798
Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour
for nurses and midwives. London, NMC.
Pien, Hume & Pien. (1996) Gastrostomy Tube Infections In A Community Hospital. American
Journal of Infection Control; 24: 5: 353-358
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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 109 of 172
APPENDIX 2 SUPPORTING DOCUMENTS
back to index
Patient Information leaflets
Drug administration via enteral feeding tubes
http://www.bapen.org.uk/pdfs/d_and_e/de_pat_guide.pdf
NPSA alerts relating to enteral feeding
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National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation
of placement NPSA/2012/RRR001 22/03/12
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441
National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric
feeding tubes in adults, children and infants. NPSA/2011/PSA002
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640
National Patient Safety Agency (2010) Early detection of complications after gastrostomy
NPSA/2010/RRR010
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric
feeding tubes NPSA/2005/05
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798
Manufacturer’s websites
Abbott Nutrition home page – access to pump instruction manuals and training
Videos
https://www.abbottnutrition.co.uk/media/70612/freego_operating_manual.pdf
Corpak Medsystems – access to information about enteral tubes and company guidelines
http://corpakmedsystemsuk.com/
Medicina – information about enteral syringes and feeding devices
http://www.medicina.co.uk/
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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 110 of 172
END OF
EAST CHESHIRE NHS TRUST CNSG 013 GUIDELINES FOR
ADMINISTRATION OF FEED AND FLUID VIA ENTERAL TUBES
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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
Created by Maggie Allen. October 2010. Updated July 2015.
Page 111 of 172
Guideline Title:
Guidelines For Enteral Feeding Complications and Management
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via an enteral
tube under the care of East Cheshire NHS Trust.
Supersedes:
Version 1.0
Description of
Guidelines reviewed – updated advice for managing infected PEG sites.
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal patient nutrition.
Guideline Area:
Nutrition
Document Reference:
CNSG 014
Version Number:
1.1
Effective Date:
November 2010
Issued By:
Departments of Dietetics
and Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group
Date
Consultation:
Departments of Dietetics and
Gastroenterology
Clinical Nutrition Steering Group
Infection prevention and control
department
October 2010, June 2015
Approved by:
Clinical Nutrition Steering Group
July 2015
AMENDMENTS RECORD
East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 112 of 172
nGUIDELINES FOR ENTERAL FEEDING COMPLICATIONS AND MANAGEMENT
INDEX
SECTION
CONTENTS
PAGE
1.0
Systemic problems – causes and intervention
Abdominal pain and distension
Diarrhoea
Nausea & vomiting
Dehydration
Weight change
Reflux and aspiration.
Constipation
Electrolyte imbalance
Gastrostomy stoma complications and management –
causes and intervention
Recommended treatment for an infected stoma
Cleaning and dressing an infected stoma
Dressings
Use of topical treatments and barrier products
Leakage – causes and intervention
Recommended skin care for a leaking PEG/PEJ site
Overgranulation – causes, intervention and treatment
Blocked nasogastric and gastrostomy tubes – causes and
intervention
Guidelines for unblocking the tube
Unblocking a PEG tube with a brush
Review of why the tube blocked
Gastrostomy tube related problems – causes and
intervention
Accidental tube displacement
Adaptor problems
Split tubes
Discolouration of the tube
Buried bumper
References and bibliography
Links to supporting documents/information
 Patient information
 NPSA alerts
 Manufacturer’s websites
114-17
114
115
116
116
116
117
117
117
118-122
Flow chart for post PEG management of complications
129
2.0
2.1.1
2.1.2
2.1.3
2.1.4
2.2
2.1.1
2.3
3.0
3.1
3.2
3.3
4.0
Appendix 1
Appendix 2
Appendix 3
119
119
119
119
120-22
121
122
123-4
123
124
125
125-6
125
126
126
126
126
127
128
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 113 of 172
GUIDELINES FOR ENTERAL FEEDING COMPLICATIONS AND MANAGEMENT
Complications should be dealt with as soon as possible. If you are unsure about how to resolve a
complication, seek specialist advice. Any intervention and outcome should be recorded in the
patient’s medical/nursing notes.
Link to flow chart for post PEG management of complications
1.0 SYSTEMIC PROBLEMS – Abdominal pain and distension
back to index
PROBLEM
POSSIBLE CAUSES
INTERVENTION
Abdominal Pain
New insertion – surgical trauma
If pain is localised to wound area, give
appropriate analgesia and monitor
effectiveness. If the pain increases, seek
medical review and consider stronger
analgesia.
Peritoneal leak (normally within
72 hours of the PEG/PEJ
insertion)


Observe for increasing severity of
abdominal pain, pyrexia, tachycardia,
nausea and vomiting. If suspected,
seek urgent senior medical or surgical
advice.
If pain or resistance when flushing,
stop immediately and seek urgent
senior medical or surgical advice.
Rapid response Report NPSA/2010/RRR010:
Early detection of complications after
gastrostomy
Abdominal
distension
Infection
Check and clean the PEG/PEJ site daily,
monitor for erythema and exudate. Inform
doctor if infection suspected and manage
as per guidelines in section 2 below.
Constipation
Monitor bowel movements. Give aperients
if constipated.
Feed intolerance
If no other obvious cause for pain and
associated with diarrhoea. Refer to
dietitian for review of feed regimen.
Delayed gastric emptying
Reconsider choice of feeding
route/regime. Consider drugs to alter gut
motility.
Over rapid infusion rate
Reduce rate
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 114 of 172
1.0 SYSTEMIC PROBLEMS – Diarrhoea
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PROBLEM
POSSIBLE CAUSES
INTERVENTION
Diarrhoea
Contaminated feed/equipment
Refer to East Cheshire NHS Trust
Infection Prevention and Control Policies
and CNSG 015 Microbiological Guidelines
for Handling of Enteral Feed and Fluids.
Over rapid infusion of feed
Reduce rate. Do not dilute feed. Once
the diarrhoea settles, aim to increase the
rate until the recommended rate is
reached.
Send a stool specimen and treat as per
Trust guidelines if positive.
Diarrhoea in
enteral
feeding is
common,
affecting 1020% of
patients on
general wards
(Bowling
2004).It can
be linked to a
number of
causes such
as
malabsorption,
infection, drug
interaction
and faecal
impaction.
Infection e.g.: Clostridium
Difficile, Enteropathic E coli
Pharmaceutical e.g. antibiotics,
laxatives, antacids, multiple
elixirs. Some elixirs have a high
sorbitol content. Cumulative
sorbitol doses of 7.5 to 30mg
may cause adverse effects, with
symptoms being severe above
20g.
Review medication. Consult
pharmacist/doctor.
Malabsorption e.g. IBD, short
bowel syndrome, pancreatic
insufficiency.
Consider elemental/semi-elemental
feeding. Consult dietitian.
If there is a history of pancreatic disease,
consider sending a sample for faecal
elastase test for pancreatic exocrine
insufficiency.
Consider
elemental/semi-elemental
feeding. Consult dietitian.
Intestinal mucosal atrophy e.g.
radiation enteritis or after NBM.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 115 of 172
1.0 SYSTEMIC PROBLEMS – Nausea & vomiting, dehydration weight change
PROBLEM
POSSIBLE CAUSES
INTERVENTION
Nausea/vomiting
Delayed gastric emptying
Reconsider choice of feeding
route/regime. Consult dietitian.
Consider drugs to alter gut motility.
Constipation
Treat constipation
Drug therapy
Check drug/nutrient interactions
Over rapid infusion rate
Reduce rate
Electrolyte imbalance
Review blood profile and correct levels.
Consult dietitian/doctor
Refer to East Cheshire NHS Trust
Infection Prevention and Control Policies
and CNSG 015 Microbiological
Guidelines for Handling of Enteral Feed
and Fluids.
Contaminated feed
NB. In severe cases, stop the feed and give water/hydration solution for 24 hours. Gradually
reintroduce feed. Consult dietitian/doctor.
Excessive
vomiting and site
leakage with no
other sign of
gastroenteritis
If the patient has a balloon
gastrostomy in situ and the
majority of the shaft of the tube is
inserted into the stomach, the
balloon may have been inflated
beyond the pyloric sphincter.
This can cause gastric outlet
obstruction.




Dehydration
Weight
above/below
ideal/target
weight.
Deflate balloon
Pull back on tube to approximately the
5cm mark
Re-inflate the balloon and reposition
the tube (Refer to CNSG 009
Guidelines for Insertion and
Management of Gastrostomy Tubes
for correct positioning)
Seek expert advice if unsure.
Inadequate water flushes.
Always give the recommended amount of
water through the tube.
Vomiting/diarrhoea/pyrexia.
Contact doctor/dietitian
Record fluid balance.
Hot weather
If unintentional loss/gain is
>1kg(2lb) in a week. Contact
dietitian. Sharp fluctuation in
weight may be due to fluid
balance.
Increase fluid as medical condition allows.
 Weigh patient if possible.
 Record volume of feed administered,
and if applicable oral intake.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 116 of 172
1.0 SYSTEMIC PROBLEMS – reflux and aspiration, constipation, electrolyte imbalance.
back to index
PROBLEM
POSSIBLE CAUSES
INTERVENTION
Reflux and
aspiration
Over rapid infusion rate
Reduce rate
Volume too large
Decrease volume of feed; consider
changing to a more energy dense feed.
Consult dietitian.
Feed in an elevated position at least 3045 whilst feeding and for 30 minutes post
feed.
Poor positioning/poor
swallow/unconscious patient
Hiatus hernia
May need elevating to 90 during feeding,
if evidence of reflux.
Delayed gastric emptying
Reconsider choice of feeding
route/regimen.
Decreased GI function
Consult doctor/dietitian.
Consider drugs to alter gut motility i.e. a
prokinetic such as metoclopramide,
domperidone or erythromycin (NICE
2006). Assess for decreased/absent
bowel sounds, abdominal distension,
nausea, vomiting.
Constipation
Inadequate fluid is the most
common cause of this
complication (Payne-James J,
Grimble G and Silk D 1995;
Bowling, 2004).
Other causes include drug
interaction, changes in gut
motility and type of feed.
Ensure that the patient is not
dehydrated and that the volume of
feed and fluid is being administered as
per feeding regimen.



Electrolyte
imbalance
Review current medication, the
following may cause constipation:
- Aluminium containing antacids
- Anticholinergics
- Antihistamines
- Calcium channel blockers
- Clonidine
- Diuretics
- Iron preparations
- Levodopa
- MAOI’s
- Opiates (Byron SE 1997)
Refer to dietitian to review of type
of feed and feeding regimen
Consider using laxatives or
enemas
Refer to CNSG 017 Guidelines for Assessment and Monitoring for
advice regarding recommended monitoring. Consult with doctor/dietitian.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 117 of 172
2. 0 GASTROSTOMY STOMA COMPLICATIONS AND MANAGEMENT – sore/infected stoma
back to index
PROBLEM
POSSIBLE CAUSES
INTERVENTION
Erythema/
inflammation
around
stoma
Gastric leakage around
stoma site.
Fixation device may be too
tight or too loose
Stoma site infection.
Stoma site
infection.
Silicone tube
Poor preparation of the
patient prior to insertion
Fixation device may be too loose. Reposition the
fixation device so that it sits lightly on the skin.
Clean regularly and protect the surrounding skin with a
barrier film e.g. Cavilon. Consider a Proton Pump
Inhibitor, if leakage is excessive and irresolvable; seek
advice from specialist (also see section 2.2 below for
further guidance for leakage from a gastrostomy
stoma).
Reposition the fixation device so that it sits lightly on
the skin.
See below
Source alternative tube


Poor asepsis at insertion
Insufficient and inadequate
cleaning.
Prep patient prior to insertion as per CNSG 009
Guidelines for Insertion and Management of
Gastrostomy Tubes. If the patient is MRSA
positive contact the IPCT/Microbiologist for advice
re Suppression therapy prior to insertion (As per
MRSA policy).
If antibiotics are required, they should be
prescribed as per Trust antibiotic policy. Or contact
the Consultant Microbiologist.
Adhere to strict aseptic technique during insertion
procedure.
Clean the PEG site daily using an Aseptic Non Touch
Technique (ANTT).
Cross contamination


Strict hand hygiene must be maintained
Where possible, train and encourage the patient to
clean their own PEG site, including information
regarding hand hygiene.
Excoriated skin due to
leakage allowing skin
commensals to take hold.

Apply a barrier film following cleaning. If leakage is
copious, increase cleaning as required and
consider using an absorbent dressing in addition to
the barrier film (see section 2.1.2 below for advice
regarding dressings).
Investigate the cause of the leakage and try to
resolve. See section 2.2 below for guidance.

Excessive handling by the
patient
Consider covering the PEG site if the patient is
confused and constantly touching the PEG site.
The fixation device is
positioned too close to the
skin.
Reposition the fixation device so that it sits lightly on
the skin (the device should be no more than 3-4mm
from the skin).
NB. If clinical signs of infection are detected i.e. pyrexia, pus, send a swab to Microbiology, clearly
labelling the site of the swab and detail clinical signs of infection.
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Created by Maggie Allen. October 2010. Updated July 2015.
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2.1.1 Recommended treatment for an infected stoma
back to index
Minimal exudate and erythema
Treatment with topical agents may be appropriate i.e. dressings (see section 2.1.3), or topical
creams e.g. Bactroban in the instance of colonisation of the PEG/PEJ site with MRSA. If known
sensitivity to Bactroban, consult with pharmacist for an alternative.
Moderate/excessive exudate, erythema, persistent unexplained pain
Treat systemically in addition to topical agents. The administration route i.e. Oral or IV will depend
on the severity of the infection. In severe cases, it may also be necessary to remove the PEG/PEJ
tube. Individual cases should be discussed with the Consultant Microbiologist.
MRSA – refer to East Cheshire NHS Trust antibiotic policy. All MRSA infections must be discussed
with a microbiologist.
2.1.2 Recommended cleaning and dressing technique for infected PEG stomas
index
Whilst the stoma is infected, it should be cleaned using ANTT as follows: -
back to
1. Undo the fixation device and remove dressing (if in situ).
NB. If within week of insertion, ideally leave the fixation device in place. The tube can be rotated to
allow cleaning under the device (Do not rotate completely if tube placed in jejunum). Refer to
CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes for further
guidance.
2. Clean around the stoma with Normasol and observe current condition.
3. Try to remove all dried secretions (leave a gauze soaked in saline resting on the area for a
couple of minutes to soften and aid removal).
4. Clean the fixation device.
5. Dry the skin and the fixation device.
6. If using, cut or wrap a topical dressing to form a keyhole dressing around the tube, ensuring
that it covers the stoma and reposition the fixation device so that it sits lightly on top of the
topical dressing.
7. If using a foam dressing as well (to manage excessive leakage), place on top of the fixation
device over the topical dressing and secure with tape.
Caution: If moving the fixation device within two weeks of insertion, it must be correctly
repositioned in order to minimise the risk of peritonitis. Refer to CNSG 009 Guidelines for
Insertion and Management of Gastrostomy Tubes for further guidance.
8. If the dressing is non adhesive, secure with tape.
9. When finished, dispose of clinical waste and wash hands as per Trust policy.
10. Document stoma condition and treatment in the patient’s medical/nursing notes.
Change the dressing every 48 hours, unless there is strike through, in which case, the dressing
should be replaced as above. Discontinue treatment as condition allows.
2.1.3 Which dressing
back to index
There is limited evidence for PEG site infections and best dressing. The literature supports use of
antimicrobial dressings such as silver impregnated, inadine or polyhexamethylene biguanide
(PHMB). The patient’s requirements should be assessed to ensure that the dressing used is
efficient and cost effective. Liaise with tissue viability and gastroenterology nurse specialist where
appropriate.
2.1.4 Use of topical and barrier products
 If an antibiotic cream has been prescribed, this should be applied after cleaning and drying.
 If a barrier film is also being used, the antibiotic cream should be applied around the stoma
first, then the film applied around the surrounding skin.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 119 of 172
2.2 GASTROSTOMY/JEJUNOSTOMY STOMA COMPLICATIONS AND MANAGEMENT –
leakage
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PROBLEM
POSSIBLE CAUSES
INTERVENTION
Leakage from
the stoma site.
Newly formed stoma – bloodied
serous fluid. The stoma may
take a while to settle down
around the PEG/JEJ tube. This
is a short-term problem and will
resolve.
Clean with Normasol until healed. A small dry
dressing can be used until healed.
Displaced tube – leakage ++ of
intestinal contents and leakage
++ during flushing –
accompanied by pain if a new
insertion.

Loose fixation device - leakage
of gastric contents.
Ensure that the external fixation device is
correctly positioned and if a low profile device
e.g. MicKey button, is the fit correct? Refer to
CNSG 009 Guidelines for Insertion and
Management of Gastrostomy Tubes.
Infection – pus, foul smelling
brown fluid. If the infection
occurs soon after insertion, it
may delay healing and settling
of the stoma. Once the infection
is treated, the situation should
resolve.
See recommended treatment for infection in
section 2 -2.1.1 above.
Deflated balloon - the balloon
should be fully inflated to
prevent leakage
If a balloon gastrostomy, check the water in
the balloon. The standard amount of water is
usually 5mls. If the balloon can take more
water, increase in 2ml increments until the
leakage is resolved, or the maximum amount
of water is reached. Refer to CNSG 009
Guidelines for Insertion and Management
of Gastrostomy Tubes, Section 10.
Incorrect shaft length of low
profile device. These come in a
variety of shaft lengths as well
as French sizes. Leakage
usually occurs when the shaft
length is too long. The exterior
part of the button should sit
lightly on the skin, without the
shaft being obviously visible.
Measure the stoma – Refer to CNSG 009
Guidelines for Insertion and Management
of Gastrostomy Tubes, section 10.11.
A small
amount of
sometimes
greenish
exudate is
normal and
should be
cleaned away
daily

If new insertion, stop feed/flush and seek
immediate senior medical/surgical advice.
Established PEG stoma, replace PEG
tube as soon as possible following CNSG
009 Guidelines for Insertion and
Management of Gastrostomy Tubes.
Refer to specialist.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 120 of 172
2.2 GASTROSTOMY/JEJUNOSTOMY STOMA COMPLICATIONS AND MANAGEMENT –
leakage continued
back to index
PROBLEM
POSSIBLE CAUSES
INTERVENTION
Leakage from
the stoma site.
Constipation – may cause
obstruction
Monitor bowels daily. Give aperients as
required.
NB. A small
amount of
mucous
discharge is
normal.
Large tube (20FR+) - Large
tubes are heavy and tend to
hang down, causing a gap on
one side of the stoma.
Try to tape the tube so that the weight is
supported.
Large tubes are associated with increased
leakage and associated skin problems. They
best replaced with a smaller tube as soon as
it is safe to do so. Avoid replacement until at
least 4 weeks post insertion. See CNSG 009
Guidelines for Insertion and Management
of Gastrostomy Tubes Section 10.8 for
further guidance.
Buried bumper
See section 4 below
Delayed gastric emptying/long
standing problems with
excessive flatulence. - Difficult
group to manage. Leakage is
persistent despite all attempts at
control.
Consider:  Drug therapy such as a PPI +/- a motility
drug.
 Venting the tube (insert a syringe and
draw air off prior to feeding).
 Remove the tube for a while and allow the
stoma to shrink.
 Decrease the size of the PEG tube.
NB. increasing the French size will only
exacerbate the problem.
 Increasing the water in the balloon to
maximum amount (if patient has a balloon
gastrostomy).
 An alternative PEG tube/site.
2.2.1 Recommended skin care for a leaking PEG/PEJ site
NB. Stomach contents are very acidic and contain digestive enzymes. Bile can irritate the
skin. Prolonged exposure will harm the surrounding skin.




Increase cleaning to 2-3 times daily to keep the surrounding area clean and dry.
Dry thoroughly after cleaning.
Apply a barrier film after drying. Use a foam applicator rather than spray as there is more
control during application. Avoid Sudacrem as it is thick and greasy and makes the tube very
slippery and may cause the fixation device to slip out of position).
Use an absorbent dressing if leakage is copious or distressing for the patient. The dressing
must be checked regularly and replaced if wet. A barrier film should be used underneath the
dressing, to protect the skin (see section 2.1.2 above for recommended dressing technique).
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 121 of 172
2.3 GASTROSTOMY/JEJUNOSTOMY STOMA COMPLICATIONS AND MANAGEMENT –
overgranulation
PROBLEM
POSSIBLE CAUSES
INTERVENTION
Granulation tissue around
the stoma – overgrowth of
dark pink moist tissue,
bleeds easily on contact.
Excessive friction at the site
Check that the tube is correctly
positioned.
See section 2.2 above for guidelines
in managing leakage.
See section 2.0
Leakage from the stoma
Infection
back to index
Granulation tissue occurs when there is an extended inflammatory response. Granulation tissue
grows proud of the wound and epithelial tissue is unable to migrate across it. Assess and start
treatment as soon as possible. The smaller the area, the more effective the treatment.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
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3.0 BLOCKED NASOGASTRIC, GASTROSTOMY AND JEJUNOSTOMY TUBES
PROBLEM
POSSIBLE CAUSES
INTERVENTION
Tube blockage
Not flushing or inadequate flushing
after feed and medication.
Flush as per guidelines. Refer to CNSG 013
Guidelines for Administration of Feed
and Fluid via Enteral Tubes for more
information regarding best practice for
flushing.
Administer medication as per CNSG 016
Guidelines for Administration of
Medications via an Enteral Feeding Tube.
Review medication and consider alternative
medication. If NG tube or gastrostomy
balloon tube, consider a larger bore tube.
Multiple medications being given
together without a flush in between
each drug.
Unsuitable medicine preparations
for giving via a tube, e.g. large
particles, viscous liquids.
Kinked tube/clamp left on (PEG
only).
Release clamp/straighten tube. NG tube
may be kinked in the stomach, pull back
slightly and retry.
Backflow/curdling of gastric
contents in the tube.
Clamp tube (if PEG) between use to prevent
gastric back-flow. Leave a column of water
in the tube after flushing.
This can be prevented by regularly pushing
the tube into the stomach a couple of
centimetres and rotating Refer CNSG 009
Guidelines for Insertion and Management
of Gastrostomy Tubes, section 7.6.5. The
patient will need to be referred the PEG
nurse specialist or gastroenterologist for
tube removal/replacement.
PEG bumper buried in the gastric
mucosa (‘buried bumper
syndrome’). Commonly presents
with the tube becoming
increasingly difficult to flush and
increased leakage around the
PEG site, particularly during
flushing.
3.1 Guidelines for unblocking the tube
back to index
Flushing with water can shift most blockages.
 Use a 60ml oral/enteral syringe with a plunger
 Prime with 20-30mls warm water
 Flush by using a pumping action
 Squeeze along the tube using thumb and forefinger, and then retry flushing.
 Once cleared, flush thoroughly.
(Colagiovanni 2000)
If unsuccessful:
Try using a smaller syringe, 20mls then 10mls then 5mls. Caution. This will exert greater pressure
and may split the tube. Check the tube for leakage after the blockage has been cleared.
If unsuccessful:
Try using Clog Zapper:
 Clog Zapper is available from NHS logistics. It costs approximately £16 and has a short shelf
life. It probably is more useful for NG tubes as a brush cannot be used.
 Clog Zapper consists of food enzymes. The powder in the syringe needs to be mixed with
water prior to use (see manufacturer’s instructions).
Clog Zapper will only work with food blockages. If medication is the cause of the blockage,
it will not work.
Using Coca cola/ pineapple juice: Anecdotal evidence suggests that this can be useful as a one
off, however long-term use may harm the tube.
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3.2 Using a brush - Gastrostomy tube only
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If unable to clear the tube as recommended above, consider using a single use endoscope
cleaning brush.
NB 1. There is a very small risk of the brush tip breaking off and being left in the tube. If this
occurs, the tube would need replacing. However the tube will need replacing if the blockage cannot
be cleared. An individual risk assessment is required for each case. Refer to specialist.
NB. 2. Do not use a brush with any tube that has been placed in the duodenum i.e. a Cook Tilma
RIG tube (used by Hope Hospital for patients with MND. Refer to CNSG 009 Guidelines for
Insertion and Management of Gastrostomy Tubes, section 12 for more information on this
tube).
Procedure (should only be carried out by individuals who have received training and are
assessed as competent)
Equipment:
50ml syringe, wipes, endoscope cleaning brush (must have a round smooth tip), water for flushing,
plastic cup with some water.
1. Place the brush against the length of the PEG tube and mark on the brush, where the tube
enters the abdomen.
2. Take off the end piece of the PEG and release the fixation device and clamp.
3. Insert the brush into the tube and advance until the blockage.
4. Gently advance through the blockage, if unable to advance, pull the brush back and clean
off the debris in water.
5. Repeat this action until the brush reaches the point where the tube enters the stomach (see
mark on brush).
6. Withdraw the brush.
 Once cleared, flush thoroughly.
7. Advise carers to flush immediately after feed and medication and to flush in between
different medication and in between medication and feed.
Never use excess force or introduce a sharp instrument.

If unsuccessful seek advice immediately – the longer a tube is blocked, the more difficult it is to
clear.
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3.3 Once the tube has been cleared, review practice - why did the tube block?
Suboptimal flushing:






Is the tube being flushed after bolus administrations of feed/medication?
Is the tube being flushed as soon as possible once the pump feed has finished?
Do the flushes need to be increased?
Is the plunger being used with the syringe?
Is the tube being flushed following aspirating to check pH or residuals?
Is the bumper buried? See above.
Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes for
more information regarding best practice for flushing.
Incorrect administration of medication


Are the medications being given separately and flushed after each one?
Are the medication preparations appropriate for the type/size of tube?
Refer to CNSG 016 Guidelines for Administration of Medication via Enteral Feeding Tubes.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 124 of 172
4.0 GASTROSTOMY/JEJUNOSTOMY TUBE RELATED PROBLEMS - tube displacement
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PROBLEM
POSSIBLE CAUSES
INTERVENTION
Closure of the gastrostomy stoma will occur from approximately 4 hours post tube removal. Aim to
insert a replacement balloon gastrostomy tube or, if unavailable, a suitable sized Foley catheter as
soon as possible. If the tube has been out for more than 4 hours, a smaller French sized tube may
be required than the patient originally had in situ. Stoma recovery may be still possible as late as
48 hours post removal by using a 6Fr tube. Refer to CNSG 009 Guidelines for Insertion and
Management of Gastrostomy Tubes, section 10 for further guidance.
Tube
displacement
Before 4
weeks
If the tube becomes displaced before the stoma is fully established (i.e. within the
first 4 weeks of insertion), there is a possibility of feed or gastric contents leaking
into the peritoneal cavity. This may result in peritonitis and is a life
threatening condition.
Do not put anything through the tube seek medical help immediately.
Community patients – contact A&E (Tel. 01625 661451/2).
Inpatients - contact on call registrar.
NB.
Inadvertent intraperitoneal insertion of replacement G-tube is a reported
risk in newly formed stomas Misplaced G-tubes can result in significant
morbidity and death. A radiological check of the tube’s position following
insertion is recommended if the tube is being replaced within 4 weeks of the
original placement of the tube. This applies to PEG, RIG, PEJ and surgically
placed tubes (gastrostomy and jejunostomy).
Link to management of suspected peritonitis
After 4 weeks
The stoma is usually fully established and displacement is unlikely to have
serious consequences, although there are case reports of inadvertent
intraperitoneal insertion of replacement G-tube in a mature stoma. Misplaced Gtubes can result in significant morbidity and death.
Do not use the tube until the position has been checked by aspiration of gastric
acid (less than pH5.5). Refer to CNSG 009 Guidelines for Insertion and
Management of Gastrostomy Tubes, section 10.
NB. A radiological check of the tube’s position following insertion is recommended
if the tube is difficult to insert and accompanied by pain.
Refer for specialist input.
Community patients: If there is not a health care professional/carer trained in
the procedure available to replace the PEG tube, the patient will need to come to
A&E. Try to contact the GI nurse specialist or enteral feeding dietitian prior to
bringing to A&E.
Do not attempt to pass a tube through the stoma unless you are sure that it is fully
established.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 125 of 172
4.0 GASTROSTOMY/JEJUNOSTOMY TUBE RELATED PROBLEMS - adaptor problems/split
tubes/discolouration/buried bumper
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PROBLEM
POSSIBLE CAUSES

INTERVENTION
Y connector
and giving set
stuck together
Residue of feed and medication in
the luer lock





Close the clamp
Cut the giving set close to the adaptor
Unscrew the adaptor from the PEG tube
Place in hot water and try to undo
If unsuccessful replace adaptor.
Broken
adaptor/
fixation device
Wear and tear
Replace – available from ETU and dietitians
Prevention
 Do not screw the giving set onto the PEG/PEJ adapter too tightly. A half turn is sufficient.
 Clean the adaptor regularly by closing the clamp then opening all the ports on the adaptor and
dangling the end in a bowl of warm soapy water, or taking off the adaptor and placing it under a
tap.
Inadequate flushing
Flush as per guidelines. Refer to CNSG
013 Guidelines for Administration of
Feed and Fluid via Enteral Tubes.
Stationary reflux clamp.

Long-term use of topical creams
e.g. Bactroban will weaken the
polyurethane.
Avoid long-term use. Refer to specialist.
Tube
discoloration
Medication e.g. Omeprazole turns
the tube black.
Unavoidable. It does not harm the tube.
Buried
bumper
Commonly presents with the tube
becoming increasingly difficult to
flush and increased leakage around
the PEG site, particularly during
flushing.
The patient will need to be referred the
PEG nurse specialist or gastroenterologist
for tube removal/replacement.
Split/cracked
tube
PEG bumper
buried in the
gastric
mucosa
(‘buried
bumper
syndrome’).
Move the reflux clamp daily - avoid
closing the reflux clamp near the base
of the tube.
The tube can be cut at the level of the split
and the adaptor re-attached. Refer to
specialist if the split is near to skin level.
Refer to CNSG 009 Guidelines for
Insertion and Management of
Gastrostomy Tubes to prevent and
manage buried bumper.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 126 of 172
APPENDIX 1 – REFERENCES AND BIBLIOGRAPHY
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Arrowsmith H. (1996) Nursing Management of Patients Receiving Gastrostomy Feeding. British
Journal of Nursing; 5: 268-273.
BAPEN (1996) Standards and Guidelines for Nutritional Support in Hospitals (ed. T. Sizer). British
Association for Parenteral and Enteral Nutrition, Maidenhead.
British Society of Gastroenterology (2006) Guidelines on Complications of Gastrointestinal
Endoscopy. London.
http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complications.pdf
Colagiovanni L. (2000) Preventing and clearing blocked feeding tubes. Nursing Times. 96(17): 3-4.
Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in
Partnership with Nutricia.
National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139
Infection Prevention and control of healthcare-associated infections in primary and community care
http://guidance.nice.org.uk/CG139
National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral
supplements, parenteral and enteral feeding. London.
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
National Patient Safety Agency (2010) Early detection of complications after gastrostomy
NPSA/2010/RRR010
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457
O’Toole P. (2006) Complications Associated with the Placement of Percutaneous Endoscopic
Gastrostomy. Guidelines in Gastroenterology. British Society of Gastroenterology (BSG). London.
Rollins, H. Hypergranulation tissue at gastrostomy sites. Journal of Wound Care 2000; 9(3): 127129
Spruce P, Warriner L, Keast D, Kennedy A. Exit site wounds Made Easy. Wounds International
2012; 3(2): Available from: http://www.woundsinternational.com
Stephen-Haynes, J. (2013) Managing overgranulation. Wound Care Today.
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 127 of 172
APPENDIX 2 SUPPORTING DOCUMENTS
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NPSA alerts relating to enteral feeding
National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation
of placement NPSA/2012/RRR001 22/03/12
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441
National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric
feeding tubes in adults, children and infants. NPSA/2011/PSA002
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640
National Patient Safety Agency (2010) Early detection of complications after gastrostomy
NPSA/2010/RRR010
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric
feeding tubes NPSA/2005/05
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798
Manufacturer’s websites
Abbott Nutrition home page – access to pump instruction manuals and training
Videos
http://www.abbottnutritionuk.com/
Corpak Medsystems – access to information about enteral tubes and company guidelines
http://corpakmedsystemsuk.com/
Medicina – information about enteral syringes and feeding devices
http://www.medicina.co.uk/
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Created by Maggie Allen. October 2010. Updated July 2015.
Page 128 of 172
APPENDIX 3 Flow chart for post PEG management of complications - Inform/doctor/PEG
nurse (as appropriate) of any complications
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






Half hourly for 2 hours
Blood pressure
Pulse
Wound check
Temperature
Pain assessment
Oxygen saturation
Respiratory rate
PEG position
unchanged
Bleeding
Pain
Yes
Yes
Normal variants
Small volume
Monitor dressing for spread
Inform specialist if bleeding continues
Large volume
Inform gastroenterologist /surgeon
immediately
Assess pain, how much, where and when.
If localised to wound give appropriate
analgesia and monitor effectiveness.
If increasing abdominal pain, seek urgent
senior medical or surgical advice.
If pain or resistance when flushing, stop
immediately and seek urgent senior
medical or surgical advice.
Yes
Hourly for 2
hours
As per half hourly
assessments
Pyrexia
Low oxygen
saturation
Normal variants
Yes
Assess for cause
Consider Sepsis/peritonitis/chest
infection/UTI
Treat as appropriate
Yes
Consider effects of
sedation/aspiration/chest infection.
Treat as appropriate
Reverse sedation if necessary. Patient
position/antibiotic therapy.
Yes
Consider effects of sedation – reverse if
necessary.
Pre-existing condition. Correct with drug
therapy asap, continue to monitor.
Yes
Assess amount of leakage
Slight oozing of exudate is common post
insertion. Monitor amount.
Larger volumes particularly during
administration of fluids via the tube and
associated with pain are abnormal and
need urgent medical attention.
Larger volumes without pain may be
associated with constipation. Treat and
monitor bowel movements
Yes
No
2 Hourly for 2
hours
As per half hourly
assessments
Hyper/
hypotensive
Tachycardic
/bradycardic
Normal variants
Leakage
Yes
4 Hourly
As per half hourly
assessments
Normal variants
Yes
Aspiration
Reflux/
nausea/
vomiting
Yes
Monitor saturation levels
Position patient in upright position during
feeds/flushes
Consider prokinetics
Consider constipation
Consider secretion management
Discontinue
Assess cause of diarrhoea
Diarrhoea
Yes
observations as medical
Feed/infection/drugs
condition
allows.
Inform doctor/pharmacist/dietitian.
East
Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Page 129 of 172
Created by Maggie Allen. October 2010. Updated July 2015.
END OF EAST CHESHIRE NHS TRUST CNSG 014 GUIDELINES
FOR ENTERAL FEEDING COMPLICATIONS AND
MANAGEMENT
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East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management
Created by Maggie Allen. October 2010. Updated July 2015.
Page 130 of 172
Guideline Title:
Microbiological Guidelines for Enteral Feeding
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via an enteral
tube under the care of East Cheshire NHS Trust.
Supersedes:
Version 1.0
Description of
Guidelines reviewed - no major changes
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal care of enteral feeding lines.
Guideline Area:
Nutrition
Document Reference:
CNSG 015
Version Number:
1.1
Effective Date:
October 2010
Issued By:
Departments of Dietetics
and Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group
Date
Consultation:
Departments of Dietetics and
Gastroenterology
Clinical Nutrition Steering Group
Infection prevention and control
department
June 2015
Approved by:
Clinical Nutrition Steering Group
July 2015
AMENDMENTS RECORD
East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids
Created by Maggie Allen. October 2010. Updated July 2015.
Page 131 of 172
MICROBIOLOGICAL GUIDELINES FOR HANDLING OF ENTERAL FEED AND FLUIDS
INDEX
SECTION
CONTENTS
PAGE
1.0
2.0
2.1
2.2
3.0
3.1
3.2
3.3
4.0
5.0
6.0
6.1
6.2
6.2.1
Handling of enteral feeding systems
Storage of feed
Opened feeds
Unopened feed
Preparation of feed
Sterile ready to hang feeds
Sterile decanted feeds
Modular feeds (non-sterile)
Hanging times of feed
Water use for enteral tubes
Use of equipment for enteral feeding
Single use equipment
Single patient use equipment
Cleaning Gastrostomy button extension tubes e.g. MIC-Key
buttons
Syringes
Disposal of equipment
References
133
133
133
134
134
134
134
135
135
135
136
136
136
136
6.3
7.0
Appendix 1
137
137
138
Back to main index
East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids
Created by Maggie Allen. October 2010. Updated July 2015.
Page 132 of 172
MICROBIOLOGICAL GUIDELINES FOR HANDLING OF ENTERAL FEED AND FLUIDS
These guidelines should be used in conjunction with the following Infection Prevention and
Control Policies (Please note this is not an exclusive list and you may need to refer to other
Specific Infection Prevention and Control Policies via the Trust Intranet).
 Universal Precautions Policy
 Aseptic Non Touch Policy
 IV insertion and ongoing Care
 MRSA Policy
 Clostridium Difficile Policy.
For further advice around infection control issues please contact –
Infection Prevention Team on Ext 1597 Bleep 3034
Consultant Microbiologist Ext 1810, Bleep 3102
1.0 HANDLING OF ENTERAL FEEDING SYSTEMS
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Enterally fed patients are susceptible to infections of the gastro-intestinal tract, infections
around the tube insertion site, chest infections and septicaemia.
(Arrowsmith 1996, Pien et al. 1996).
The feeding tube does not have the natural defences against infection that the gastro-intestinal
tract has, for example peristalsis, lymph nodes or acidic secretions. The tube itself is at body
temperature, has a regular supply of nutrients and cannot be cleaned. It therefore provides an
ideal breeding ground for bacteria. For these reasons good food hygiene practices and further
infection control measures are necessary when handling and preparing enteral feeding
systems (Anderton 1990).



Full compliance with hand hygiene and personal protective equipment must be maintained
as per Trust Infection Prevention and Control Universal Precautions Policy.
Clean non-sterile disposable gloves and a clean disposable apron equipment must be worn
when handling any part of the enteral system.
Any staff who display symptoms of diarrhoea should not handle food products. They must
report to their line manager and remain absent from work until asymptomatic as per the
Infection Prevention and Control /Occupational Health requirements.
To help reduce the risk of contamination from human contact:



It is essential to use feeding systems that require a minimal amount of handling with a
minimum number of well designed connectors.
Systems with recessed connectors, additive ports and few connection points, for example
no extension tubes, are preferable.
Staff should use a Aseptic Non Touch technique (ANTT). This means avoiding touching
the connection parts of feeding systems or unnecessarily opening feeding systems.
2.0 STORAGE OF FEED
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2.1 Opened feeds
 Open cans/bottles of feed must be refrigerated.
 The temperature of fridge should be <5 and greater than 0.
 The feed bottle must be covered with a lid and labelled with the patient’s name, date and time
of opening.
 Opened feeds and modular feeds should be stored on the top shelf away from raw food.
 Discard after 24 hours.
East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids
Created by Maggie Allen. October 2010. Updated July 2015.
Page 133 of 172
2.2 Unopened feed


Store in a cool dry place away from direct sunlight or heat (minimum 8oC maximum 25oC).
Rotate the stock.
3.0 PREPARATION OF FEED










back to index
Hands must be decontaminated as per Trust Infection Prevention and Control Hand
Hygiene Policy prior to handling of any feed systems.
Clean non-sterile disposable gloves and a clean disposable apron equipment must be worn
as per the Universal Precautions policy.
Use minimal handling and an aseptic non touch technique to connect the administration system
to the enteral feeding tube.
Sterile Ready-to-Hang feeds should be used where possible.
Use the appropriate size of pre-packed feed for the patient's requirements. Feeds that require
decanting or mixing should be avoided wherever possible.
Giving sets and feed containers are ‘single use’ and must be discarded after use.
Feed must be used before its expiry date and within permissible hanging times (see section 4
below).
All equipment should be kept sealed in sterile packaging until immediately prior to assembly.
If opening a bottle/tetrapak/ring-pull tin to be decanted, it must be cleaned with a 70% alcohol
wipe prior to use and opened using a designated bottle opener where appropriate. Abbott
Nutrition supplies sterile foil cutters for the feed bottles. If opening a pack, sterile scissors
should be used. Do not use fingers, thumbs or non sterile scissors due to high risk of
contamination.
Label the feeding system/water reservoir with the date and the time of administration.
Never re-fill or ‘top-up’ nutrient containers, as this increases the risk of microbial
contamination.
3.1 Sterile ready to hang feeds



back to index
These are pre-filled nutrient containers, they attach to a giving set and are designed to
minimise the risk of microbial contamination.
System design eliminates the risk of bacteria being introduced during attachment of the giving
set to the nutrient container.
The giving set has a drip chamber incorporated, to reduce risk of retrograde growth of the
patient’s gut flora.
3.2 Sterile decanted feeds







Feeds that require decanting or mixing should be avoided wherever possible.
Sterile feeds that require decanting should be prepared using an Aseptic Non Touch
technique (ANTT).
Feed should be decanted into a sterile container (Abbott Flexitainer) or ‘single use’ enteral
syringe.
Prior to decanting, the aperture of a ring-pull can or tetrapak should be wiped with a 70%
alcohol wipe as contamination can occur during opening.
Re-sealable sterile feed containers that are open but not required immediately can be
stored on the top shelf of a patient’s food fridge. The feed should be sealed and have the
patient’s name, date and time of opening.
Non-re-sealable containers should be discarded immediately.
Never top up feeds, always prepare the required amount.
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East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids
Created by Maggie Allen. October 2010. Updated July 2015.
Page 134 of 172
3.3 Modular feeds (non-sterile)
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Many components used in modular formulas are not sterile and micro organisms have been
isolated from them. When reconstituting modular feeds the following must apply:  A clean working area must be used
 Only use equipment dedicated for enteral feed when decanting, reconstituting or diluting
feeds.
 Sterile water must be used for mixing and diluting.
 A set volume of feed should be prepared once; it must not be topped up.
4.0 HANGING TIMES FOR FEEDS



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The hanging time is the total time that the opened feed is kept at room temperature.
Storage time in a refrigerator below 5ºC is not included in the hanging time.
There should be individual risk assessment and the hanging times reduced if necessary.
FEED TYPE
MAXIMUM HANGING TIME
Sterile, ready-to-use feeds if
not decanted.
24 hours
MAXIMUM STORAGE TIME
IN REFRIGERATOR
Not applicable
Sterile feeds decanted into a
sterile reservoir using
aseptic/non-touch technique
(ANTT).
24 hours
24 hours
Non sterile (modular)
feeds e.g. reconstituted
powders and mixed feeds
decanted into a sterile
reservoir.
4 hours
24 hours
5.0 USE OF WATER
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In the hospital setting tap water is suitable for flushing, providing that it is:  kept in a lidded container
 changed twice a day
 not contaminated by dipping the syringe into the jug to draw up water (pour the water into a
clean container first).
Use sterile water if:  the patient is immuno-compromised
 the feeding tube is positioned in the small intestine
 large volumes of water are required to be given via a reservoir i.e. an Abbott Flexitainer.
 It is the first flush following initial PEG insertion
The sterile water bottle must be labelled with the patient’s name, date and time of opening. It
must be discarded after 24 hours.
East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids
Created by Maggie Allen. October 2010. Updated July 2015.
Page 135 of 172
6.0 USE OF EQUIPMENT FOR ENTERAL FEEDING
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6.1 Single use equipment
Most enteral feeding devices are ‘single use’ meaning that they cannot be re-used. It is
identified by this symbol.
The Trust’s Single Use of Medical Devices Policy must be followed at all times.
1. Devices designated for ‘single use’ must not be reused under any circumstances.
2. The reuse of ‘single use’ devices can affect their safety, performance and effectiveness,
exposing patients and staff to unnecessary risk.
3. The reuse of ‘single use’ devices has legal implications.
a) Anyone who reprocesses or reuses a device intended by the manufacturer for use on a single
occasion, bears full responsibility for its safety and effectiveness.
b) Anyone who reprocesses a ‘single use’ device and passes it on to a separate legal entity for
use, has the same legal obligations under the Medical Devices Regulations as the original
manufacturer of the device.
Medical Devices Agency Safety Notice. Single-use Medical Devices: Implications and
Consequences of Reuse. MDA DB2000 (04) August 2000
6.2 Single patient use equipment
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Definition
A medical device that may be used for more than one episode on one patient only and the device
may undergo some form of reprocessing between each use.
DB2006(04) states that reprocessing is: ‘To make good a device for re-use by any or a
combination of the following processes: cleaning, disinfection / decontamination, sterilisation,
refurbishment and repackaging’.



Devices marked for single patient use must not be used for more than one patient.
Equipment that is designated single patient use must be reprocessed and stored as per
manufacturer’s and Trust policy and guidelines.
Enteral equipment requiring reprocessing is very limited and is likely to be an adaptor or
extension set for a low profile gastrostomy e.g. MIC-Key button.
6.2.1 Cleaning gastrostomy button extension tubes e.g. MIC-Key buttons








Open the reflux/roller clamp on the tube.
Immerse in hot soapy water and flush through several times using a syringe.
Rinse through thoroughly with cold water
Flush the tube through with air to remove excess fluid
Store in a lidded container in the fridge
The container must be labelled with the patient’s name
Replace weekly
Do not store in Milton
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East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids
Created by Maggie Allen. October 2010. Updated July 2015.
Page 136 of 172
6.3 Syringes
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Some companies e.g. Medicina, provide ‘single use’ enteral syringes for hospital use and reusable
syringes for community use. Caution is required, as they are the same colour. The ‘single use’
syringes are labelled with the ‘single use’ logo as seen above in section 6.1, both on the packet
and the syringe. All syringes are to be ‘single use’ only in the hospital setting even if they specify
that they are reusable. The syringe must be discarded after the episode of use i.e. flushing
followed by administration of fluid/ medication, followed by flush, then dispose of the syringe.
Wards should order the ‘single use’ only enteral syringes.
Community use
Reusable syringes are suitable for community. They should be cleaned in between use as follows:
In between each use,
 Separate the syringe and plunger and clean the syringe in warm soapy water.
 Rinse with cold tap water and dry with paper towel.
 Store in dry container
 Replace as advised by manufacturers guidelines (Medicina state maximum use of 7 days).
 Do not store in Milton
http://www.medicina.co.uk/uploads/fck/hospital-syringe-booklet.pdf
7.0 DISPOSAL OF EQUIPMENT
Clinical waste should be disposed of as per Trust policy
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East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids
Created by Maggie Allen. October 2010. Updated July 2015.
Page 137 of 172
APPENDIX 1
REFERENCES AND BIBLIOGRAPHY
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Anderton A. (1990) Microbial aspects of Home Enteral Nutrition – a discussion. Journal of Human
Nutrition and Dietetics; 3: 403-412.
Anderton A. (1995) Reducing bacterial contamination in enteral tube feeds. British Journal of
Nursing: 4, 7 : 368-376.
Arrowsmith H. (1996) Nursing Management of Patients Receiving Gastrostomy Feeding. British
Journal of Nursing; 5: 268-273.
Food safety Act 1990
Food Standard Agency (2007) Guidance on Temperature Control Legislation in the United
Kingdom EC Regulation 852/2004
Food Hygiene Regulations (2006)
Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in
Partnership with Nutricia.
The Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical
Devices: Implications and Consequences of Reuse. MDA DB2000(04)
The Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding
Systems. MDA SN2000(27).
National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139
Infection Prevention and control of healthcare-associated infections in primary and community care
http://guidance.nice.org.uk/CG139
Pien, Hume & Pien. (1996) Gastrostomy Tube Infections In A Community Hospital. American
Journal of Infection Control; 24: 5: 353-358
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East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids
Created by Maggie Allen. October 2010. Updated July 2015.
Page 138 of 172
END OF EAST CHESHIRE NHS TRUST CNSG 015
MICROBIOLOGICAL GUIDELINES FOR HANDLING OF
ENTERAL FEED AND FLUIDS
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Back to main index
East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids
Created by Maggie Allen. October 2010. Updated July 2015.
Page 139 of 172
Guideline Title:
Executive
Summary:
Supersedes:
Clinical Nutrition Steering Group (CNSG)
Guidelines for Administration of Medication via Enteral Tubes
(CNSG 016)
This document aims to support health care professionals in their practice
to ensure that the administration of medication via an enteral feeding tube
is carried out safely and effectively, so minimising risk of complications.
Version 1.0
Description of
Guidelines reviewed - no major changes
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients, carrying out administration of medication via an enteral feeding
tube.
Financial Implications: Correctly administered medication via an enteral tube should reduce
costs and risks associated with unsafe practice.
Guideline Area:
Pharmacy/Enteral tubes
Document Reference:
CNSG 016
Version Number:
1.1
Effective Date:
August 2012
Issued By:
Departments of Pharmacy
and Gastroenterology
Review Date:
June 2017
Author:
Maggie Allen, GI Nurse
Specialist/Sarah Element,
Lead Pharmacist for
Medicine.
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group
Date
Clinical Nutrition Steering Group
August 2012
Consultation:
Dane Bradwell, Clinical Pharmacist
April 2015
Approved by:
Clinical Nutrition Steering Group
July 2015
AMENDMENTS RECORD
East Cheshire NHS Trust CNSG 016 Guidelines for Administration of Medication via Enteral Tubes
Page 140 of 174
Created by GI Nurse Specialist Maggie Allen and Pharmacist Sarah Element. August 2012. Updated July 2015.
The following guidelines should be used in accordance with the following policies:  East Cheshire NHS Trust Medicines Policy for the Safe and Secure Handling of Medicines
within East Cheshire NHS Trust.
 East Cheshire NHS Trust Policy for medication administration in patients with
oropharyngeal dysphagia.
INDEX
SECTION
CONTENTS
PAGE
1.0
Introduction
142
2.0
Legal implications
142
3.0
Referrals
142
4.0
Route of administration – gastric or jejunal tube
142-3
5.0
Drug formulations
143-4
5.1
Medicines not to be given via an enteral feeding tube
143
5.2
Preferred formulations
144
5.2.1
Liquids
144
5.2.2
Tablets
144
5.2.3
Capsules
144
6.0
Equipment
144-5
6.1
Tubes
144
6.2
Syringes
145
6.3
Adaptors
145
6.3
Non standard equipment
145
8.0
Complications
146-8
APPENDICES
Appendix 1
References and bibliography
149
Appendix 2
Preparation and administration of medication
150-152
Appendix 3
Linked documents/information
154




Patient information
Training aids
NPSA alerts relating to medication and enteral tubes
Manufacturer’s websites
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1.0 INTRODUCTION
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Incorrect intravenous administration of oral liquid medicines resulted in three reported deaths
between 2001 and 2004 and there are reports of four incidents of harm or near misses between
1997 and 2004.
NPSA (2007)
This document aims to support health care professionals in their practice to ensure that the
administration of medication via an enteral feeding tube is carried out safely and effectively, so
minimising risk of complications.
These guidelines should be used in accordance with the following policies:  East Cheshire NHS Trust Medicines Policy for the Safe and Secure Handling of Medicines
within East Cheshire NHS Trust.
 East Cheshire NHS Trust Policy for medication administration in patients with
oropharyngeal dysphagia.
 East Cheshire NHS Trust Policy and Guidelines for Enteral Feeding (CNSG006)
Further guidelines and documents linked to these guidelines can be found in appendix 3
2.0 LEGAL IMPLICATIONS
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Most drug administration via feeding tubes falls outside the product license for that drug, as does
crushing tablets and opening capsules not specifically designed for this purpose. In these
circumstances the prescriber and practitioner may be liable for any adverse effects resulting from
the administration of that drug.
Staff prescribing and administering drugs via the enteral route should be covered by the Trust’s
vicarious liability providing that they can demonstrate that they acted in accordance with Trust
policy and guidelines.
3.0 REFERRALS
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All patients must be referred to a dietitian and pharmacist once an enteral feeding tube has been
inserted, or a patient is admitted with one in situ. The patient’s medication should be reviewed by
pharmacists and the medical team prior to commencing enteral feeding, in addition, the pharmacist
and prescriber must be aware of the administration route.
4.0 ROUTE OF ADMINISTRATION – gastric or jejunal tube
back to index
The best way to take most medication is via the mouth, however if this is not possible it may be
given via the enteral feeding tube. The metabolism of different drugs varies, each drug is designed
to be absorbed in a particular area of the gut. If administered in the wrong part of the gut, the drug
may be ineffective. Examples of this include:  Sublingual or buccal preparations which are formulated for absorption across the oral mucosa
and are ineffective if administered through feeding tubes.
 Drugs meant for absorption in the stomach, may be ineffective if administered via a tube that is
placed in the jejunum.
The intended area of absorption for a particular drug should be considered prior to prescribing and
administering through an enteral tube. The pharmacist and clinician must be aware of the position
of the tube in the gut. If the patient has jejunal tube, administration of certain medications may be
contraindicated for the following reasons:

The risk of blockage is high
Most drugs are not licensed to be given via the jejunum or duodenum, as the mode of action
and absorption in the small bowel is not known.
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
Some drugs may not be absorbed as effectively in the duodenum as the stomach, resulting in
sub-therapeutic doses.
The patient must have their medication reviewed by a pharmacist and the prescribing clinician
must be aware that the tube is placed in the jejunum. If the patient has jejunal tube, it may be
necessary to consider passing a second tube into the stomach, or use a double lumen tube so that
drugs can be administered into the stomach.
5.0 DRUG FORMULATIONS
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Drugs are available in a variety of preparations. A pharmacist should assess the prescribed drugs
and recommend the best formulation. Some drugs may require a change of dosage and frequency
of administration when given via enteral feeding tubes.
5.1 Medicines not to be given via an enteral feeding tube unless advised by a pharmacist
Table 1
TYPE OF DRUG
RATIONALE
Injections
Must not be given through feeding tubes unless specifically
advised by a pharmacist. An example of an acceptable
injection preparation is glycopyrronium bromide, an
anticholinergic used to control excess salivation.
Chewable tablets
Form a sticky clump when crushed
‘Melt’ tablets
Designed to dissolve in the saliva, be swallowed and then
absorbed in the gastrointestinal tract.
Enteric coated tablets (e/c).
These have a protective coating either to prevent inactivation
by stomach acid or to prevent the stomach from damage by
the drug.
Crushing enteric-coated tablets or the enteric coated pellets
from a capsule destroys this coating. In addition the coating
will block the tube.
Slow or modified release
formulas e.g. EC, SR, MR, LA,
XL or CR
These are formulated to release the drug slowly in the GI tract.
Crushing or breaking tablets, or opening capsules can destroy
their slow release properties increasing the risk of side effects,
toxicity and reducing their duration of action.
Sublingual or buccal
preparations.
Formulated for absorption across the oral mucosa and are
ineffective if administered through feeding tubes.
Hormone and Cytotoxic drugs
Must not be given through feeding tubes unless specifically
advised by a pharmacist. The powder will potentially harm
others if inhaled.
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5.2 Preferred Formulations
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Liquids or soluble tablets are the preferred formulation for administration via feeding tubes,
however they are not without pitfalls as seen in table 2 below.
5.2.1 Liquids
Liquid medications are available in the following preparations: Table 2
PREPARATIONS
CAUTION
Solution
Expensive
Syrup


Suspension
May be viscous and require diluting prior to administration, in order
to minimise risk of blocking the tube.
May have a high sorbitol content which will cause diarrhoea and/or
stomach cramps. In some circumstances it may be preferable to
crush an insoluble tablet and mix with water.
Large particles block the feeding tubes e.g.
 antibiotics such as Clarithromycin suspension
 Lansoprazole – the suspension contains granules which must not
be crushed.
5.2.2 Tablets
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Ideally tablets being administered via an enteral tube should be soluble or dispersible. Some
insoluble tablets not commercially marketed as dispersible may disperse in water especially when
crushed. The preparation must be fully dissolved prior to administration via the tube, particularly
fine bore tubes, in order to prevent blockage.
5.2.3 Capsules
Some capsules can be opened and mixed with water.
Caution:
 Some may be potentially harmful if opened.
 Some capsules contain pellets these should be administered intact. Do not give these via a
fine bore tube as they will block the tube (10 Fr minimum).
Always consult a pharmacist before altering preparations.
6.0 EQUIPMENT
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All equipment used in enteral feeding systems must comply with:  National Patient Safety Alert (NPSA) 19 (2007) Promoting safer measurement and
administration of liquid medicines via oral and other enteral routes.
 The Medicines Policy for the Safe and Secure Handling of Medicines within East Cheshire
NHS Trust, section 4.4.
6.1 Tubes


back to index
Enteral feeding systems should not contain ports that can be connected to intravenous
syringes, or that have end connectors that can be connected to intravenous or other
parenteral lines.
Enteral feeding systems should be labelled to indicate the route of administration.
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6.2 Syringes


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Only use labelled oral/enteral syringes that cannot be connected to intravenous catheters
or ports to measure and administer oral liquid medicines.
Do not use intravenous syringes to measure and administer oral liquid medicines.
The exception may be if a drug is only available in a glass ampoule, in which case it will need to be
drawn up with an IV syringe and filter needle, then transferred to an oral/enteral syringe. This
procedure may result in loss of volume and reduced dose. Consult with the pharmacist for advice.
A risk assessment should be completed to allow the drug to be given using an IV syringe and
adaptor to fit the enteral tube.



Stocks of oral/enteral syringes should be available in all clinical areas that may need to
measure and administer oral liquid medicines though an enteral feeding tube.
Enteral syringes are available in a range of sizes, which should be available on the wards.
Small doses of medicine should always be measured and drawn up in a small syringe (the
size should be appropriate for the dose prescribed). An inaccurate dose may be
administered if an inappropriate sized syringe is used.
Patients being discharged with an enteral tube in situ should be given enteral syringes to
take home with them.
Refer to CNSG 013 Guidelines for Administration of Feed and Fluids via an Enteral Tube, for
further information regarding use of enteral syringes.
6.3 Adaptors
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Three-way taps and syringe tip adaptors should not be used in enteral feeding systems because
connection design safeguards can be bypassed.
6.3 Non standard equipment
Periodically a patient may need a specialist device fitting which does not comply with NPSA
guidelines. The risk to the patient should be assessed and clear guidance for using the device
written in the patient’s care plan. The patient should be referred to a specialist in enteral devices to
assess the patients requirements and advise staff. Non standard devices should be labelled and
stored in an area with restricted access. At Macclesfield hospital, nonstandard enteral devices are
kept on the endoscopy unit.
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7.0 COMPLICATIONS
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Most complications associated with enteral feeding are drug interactions, incompatibility with the
feed and incorrect administration resulting in tube blockage.
Table 3
TYPE
Blockage
Causes:
 Inappropriate drug formula
 too fine a tube
 Sub optimal preparation of the drug
 Poor flushing technique
 Insufficient flushing
Sub therapeutic dose – interaction with
feed
Interaction with the enteral feed may reduce
bioavailability resulting in suboptimal dosage.
More common with drugs that have a narrow
therapeutic range or that interact with food,
vitamins and electrolytes, e.g. phenytoin,
theophylline, digoxin, warfarin and some
antibiotics. Reasons include:
 Binding to the protein source in the feed
 Poor solubility due to incompatible
chemical makeup of the drug and the
feed.
PREVENTION


Choose correct drug formula see tables 1 and 2.
If crushing drugs, crush to a fine powder and mix
with water.
 During administration agitate or rotate the syringe
to prevent the sediment being administered as a
solid lump (see appendix 2).
 Flush the tube before, in between and after each
medication.
 Use the plunger with the syringe.
Refer to CNSG 013 Guidelines for Administration
of Feed and Fluids via an Enteral Tube for further
guidance.
 Insert a larger bore tube if large volumes of
medication need to be given. Tubes of 10Fr or
less are at greater risk of blocking.




Sub therapeutic dose – reduced
absorption due to position of tube
Reduced absorption due the exit position of
the tube in the gut i.e. if the tube is placed in
the duodenum (See section 4.0 above)
Sub therapeutic dose – reduced
absorption
Decreased transit time, particularly if
individual has enteral associated diarrhoea or
receiving a hyperosmolar feed.


Suspend administration of feed to allow for a
clear period between administration of the drug
and feed. The optimum clear period will depend
on the drug and the patient’s gastric motility.
Check with the pharmacist/clinician.
The dose of the drug may need to be adjusted
upwards due to lack of therapeutic response as a
result of interaction with the feed. This is
particularly relevant for drugs with a narrow
therapeutic index.
The patient should be monitored for altered
response and plasma levels.
Liaison between the pharmacist and dietitian is
essential to ensure that the feeding and
medication regimen are compatible.
The prescriber and pharmacist should be aware
of the tube’s position within the gut.
Alteration to dose, a double lumen tube or an
additional gastric tube may need to be
considered.
The dose or frequency of administration may need to
be altered. Liaise with the pharmacist.
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Table 3 continued
TYPE
Sub therapeutic dose – dose variation
between formulations
Altered dosage due to change of prescribed
formulation e.g. some liquids/suppositories
have a different bioavailability from tablets
e.g. digoxin and carbamazepine
back to index
PREVENTION


The dose or frequency of administration may
need to be altered if changing between
formulations and from controlled to ordinary
release tablets.
Liaise with the pharmacist.
Sub therapeutic dose – loss during
preparation

Accidental loss during crushing, mixing with
water and administration.
Sub therapeutic dose - Interaction with
other drugs
Ensure all the powder in the table crusher is
mixed with water and given.
 Check that any sediment in the bottom of the
mixer cup or syringe is drawn up and
administered.
 Use an appropriate sized syringe for measuring.
Some drugs may interact resulting in a reduction in
effectiveness if mixed together, always administer
individually flushing in between each drug (see
appendix 2
Sub therapeutic dose – crushing modified
release tablets
Crushing (particularly modified release
e.g. SR, MR, LA, XL or CR)
Slow or modified release formulas are
designed to release the drug over a period of
time. Crushing or breaking tablets, or opening
capsules can destroy their slow release
properties increasing the risk of side effects,
toxicity and reducing their duration of action.
One side effect of this, is that the patient will
receive an ineffective dose over a period of
time.
Sub therapeutic dose – inaccuracy during
preparation
Using inappropriate sized syringes to
measure medication
Over dose
The same applies as for sub therapeutic
doses


Do not crush modified release tablets
Liaise with the pharmacist for an alternative.
The syringe size should be tailored to the dose
required. Small doses should be measured in small
syringes for accuracy.
Apply the same principles as for sub therapeutic
dosing as seen above. Particular attention should be
paid when:
 Feed prescription is changed (dose/type/method
of administration
 Drug formulations are changed (e.g. liquid to
tablet to controlled to ordinary release
 The position of the tube in the gut is altered
Liaise with the pharmacist.
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Table 3 continued
back to index
TYPE
PREVENTION
Contamination



The feeding tube does not have the
natural defences against infection that the
gastro-intestinal tract has, for example
peristalsis, lymph nodes or acidic
secretions. The tube itself is at body
temperature, has a regular supply of
nutrients and cannot be cleaned. It
therefore provides an ideal breeding
ground for bacteria. For these reasons
good food hygiene practices and further
infection control measures are necessary
when handling and preparing enteral
feeding systems (Anderton 1990).


Use a sterile enteral syringe
Use a fresh medicine cup
Use fresh tap water or water that has been
stored in a lidded container and replaced twice a
day
Use sterile water if the patient is immunocompromised or the tube is post pylorus.
Tablet crushers are single patient use only and
should be washed with hot soapy water in
between use.
Refer to CNSG 015 Microbiological
Guidelines for Enteral Feeding for further
information.
Diarrhoea

Antibiotics


Contamination


High doses of preparations containing
sorbitol

Some antibiotics may cause diarrhoea. Discuss
with pharmacist for antibiotic choice.
Review practice. See above. Refer also to CNSG
015 Microbiological Guidelines for Enteral
Feeding for further information.
Cumulative sorbitol doses of 7.5 to 30g may
cause adverse effects, with symptoms being
particularly severe above 20g. Sorbitol content
varies with manufacturer and drug concentration.
Liaise with the pharmacist.
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APPENDIX 1 REFERENCES AND BIBLIOGRAPY
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BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners and
Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead.
http://www.bapen.org.uk/
BeIknap, D, Seifert, C. F, Peterman. M. et al. Administration of Medications Through Enteral
Feeding Catheters. American Journal of Critical Care. 1997; 6(5): 382-392.
Colagiovanni, L. Preventing and clearing blocked feeding tubes. Nursing Times. 2000; 96(17): 34.
Lourenco, R. Enteral Feeding: Drug/nutrient interaction. Clinical Nutrition. 2001; 20(2): 187-193.
Medicines Act 1968
Misuse of Drugs Act 1971
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and enteral routes. NPSA/2007/19
Reilly, H. Enteral Feeding: an overview of indications and techniques. British Journal of Nursing.
1998; 7(9): 510-520.
Thomson F.C. et al (2000). Managing drug therapy in patients receiving enteral and parenteral
nutrition. Hospital Pharmacist 7(6) 155-164
Woolfrey, S, Geddes. A, Cox. J. et al. Percutaneous Endoscopic Gastrostomy. The
Pharmaceutical Journal. 1996; 257: 181-184.
.
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APPENDIX 2 PREPARATION AND ADMINISTRATION OF MEDICATION
Recommended preparation of medication prior to administration
Table 4
TYPE OF MEDICATION
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METHOD OF PREPARATION
Soluble/dispersible tablets
Place the tablet in the barrel of the syringe and replace the
plunger. Draw up approximately 10-15mls of water into the
syringe and allow to disperse. Administer as per table 5
Effervescent tablets
Dissolve in the amount of dilutent as recommended by the
manufacturer. Administer as per table 5
Insoluble Tablets
Crush the tablets or open capsules and mix in 10-15mls
water. Administer as per table 5
NB. See table 1 for which tablets should not be crushed.
Liquids
Shake liquid formulations in the bottle thoroughly to mix the
contents in order to minimise dose variation.
Viscous liquids
Some preparations are too thick to syringe down the tube
and will cause blockage. Dilute viscous preparations with
water (up to 1:3) prior to administration. Administer as per
table 5
Capsules
The capsule can be pulled open or snipped at the end and
the powdered contents mixed with water.
NB. Some capsules contain pellets these should be
administered intact. Do not give these via a fine bore tube
as they will block the tube (10 Fr minimum). Liaise with
pharmacist for alternative.
Method of administration
Table 5
back to index
ACTION
RATIONAL
Wash hands and wear gloves as per the
Infection Prevention and Control Good
Practices Policy prior to handling of any
feed systems.
Minimises risk of infection
Assemble equipment and medication required
Efficient practice and minimises risk of errors
Explain the procedure to the patient and
position them correctly in a semi-raised (at least
3 pillows) or upright position depending on risk
of reflux. If the patient has a large hiatus hernia
or a history of reflux and have a swallowing
disorder, they should be positioned in an
upright position.
Minimise risk of aspiration
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Table 5 continued - Method of administration
back to index
ACTION
RATIONAL
Assess patient to check for contraindications
prior to administration of medication
Minimise risk of complications
Stop feed if in progress
Minimises drug/feed interaction
If the tube has a Y connector and the feed is in
progress, use the port that is not attached to the
giving set.
Minimises handling and disconnection of the
feed system and reduces risk of infection
Check position of tube, if NG or NJ
(See CNSG 007 Guidelines for Insertion and
Management of Nasogastric Tubes and CNSG
012 Guidelines for Insertion and Management
of Jejunal Tubes for further guidance).
Minimises risk of accidental administration of
fluids into the lungs and reflux if tube positioned
in oesophagus
Flush the tube with a minimum of 30mls water
prior to drug administration (or volume as
advised by the dietitian).


Rinse the tablet crusher and flush washings
down the tube.
Ensures that the whole dose is given
Draw up the medication into an enteral syringe.
The size should be appropriate for the
dosage/volume to be given.

Administer each drug separately, flushing the
tube with 10mls of water in between each
medication.
Prevents drug/drug interaction
Ensures that the tube is patent
Prevents feed/drug interaction
Prevents administration of a drug meant for
the enteral route being given intravenously,
resulting in serious harm.
Using the correct sized syringe prevents
incorrect dosing.
Ideally drugs should be given separately to avoid drug interaction. Extenuating circumstances may
be:  Fluid restrictions
 Practicality – patients with limited dexterity, on multiple medications and in the home setting.
If in doubt contact your pharmacist
If the solution contains sediment e.g.
Lansoprazole, agitate or rotate the syringe
during administration to ensure that the
sediment is evenly distributed.
Prevents a clump of sediment being given,
which will block the tube.
Flush the tube with water after administration is
complete.



Ensures that the full dose is given and not
still sitting in the tube.
Prevents tube blockage
Prevents drug/feed interaction
Flushing post medication is crucial. Tube blockages due to medication cannot be cleared using
food enzymes. A new tube would be required. Refer to CNSG 013 Guidelines for Administration of
Feed and Fluids via an Enteral Tube for further guidance for flushing.
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Table 5 continued- Method of administration
back to index
ACTION
RATIONAL
Document the amount of water used
Important in multiple drug therapy as the daily
fluid intake can be monitored
Consultation with a pharmacist is advised if the patient is on multiple drug therapy and fluid
restricted.
Always take medication as prescribed.


The absorption of certain drugs may be
affected by the feed and a delay between
the drug is required e.g. phenytoin
Others drugs need to be taken with the feed
Never introduce medication into the enteral
feed.




Risk of contamination
Risk of drug/feed interaction
Risk of the tube blocking
Risk of suboptimal dosage
Restart feed if appropriate
Minimise delay to feeding regimen
Lock up medication as per East Cheshire NHS
Trust Medicines Policy
Prevents misuse of medication
Clean up any spills and dispose of equipment
as per East Cheshire NHS Trust policy.
Syringes must be discarded after use.
Minimise risk of contamination and harm to
others
Wash hands
Minimise risk of cross contamination
Monitor patient
To check for complications
Document medication given and any variances
as per East Cheshire NHS Trust Medicines
Policy
Provides evidence of medication given and any
complications
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APPENDIX 3 LINKED SUPPORTING DOCUMENTS/INFORMATION
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The following documents regarding enteral tube feeding are available on the Trust intranet:
Patient Information
Drug administration via enteral feeding tubes
http://www.bapen.org.uk/pdfs/d_and_e/de_pat_guide.pdf
Training aids
East Cheshire NHS Trust Pharmacy Training modules - Administration Of Medicines via
Enteral Feeding Tubes
http://trustnet/Pharmacy/Presentation.pps
NPSA alerts
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National Patient Safety Agency (NPSA) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808
Manufacturer’s websites
Abbott Nutrition home page – access to pump instruction manuals and training
Videos
http://www.abbottnutritionuk.com/
Corpak Medsystems – access to information about enteral tubes and company guidelines
http://corpakmedsystemsuk.com/
Medicina – information about enteral syringes and feeding devices
http://www.medicina.co.uk/
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East Cheshire NHS Trust CNSG 016 Guidelines for Administration of Medication via Enteral Tubes
Page 153 of 174
Created by GI Nurse Specialist Maggie Allen and Pharmacist Sarah Element. August 2012. Updated July 2015.
Guideline Title:
Guidelines for management of patients admitted to hospital with an enteral
feeding tube
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via a
nasogastric tube under the care of East Cheshire NHS Trust.
Supersedes:
Version 1.0
Description of
Guidelines reviewed - no major changes
Amendment(s):
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal patient nutrition.
Guideline Area:
Nutrition
Document Reference:
CNSG 018
Version Number:
1.1
Effective Date:
August 2011
Issued By:
Departments of Dietetics
and Gastroenterology
Review Date:
June 2017
Author:
Dietetics Department
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group
Date
Clinical Nutrition Steering Group
July 2015
Consultation:
Departments of Dietetics and
Gastroenterology
Clinical Nutrition Steering Group
June 2015
Approved by:
Clinical Nutrition Steering Group
July 2015
AMENDMENT RECORDS
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 154 of 172
1.0 Flowchart to guide management of patients admitted on enteral feeding
Monday to Friday 8.30-16.30
No
Yes
Medical condition assessed as
safe for enteral feeding
Yes
Yes
What is their usual method of
administration?
Bolus feeding
Continue with
this method of
administration
If no, refer to
dietitian when
clinically stable
Pump feeding
If the patient is stable and
unlikely to pull out the
tube, consider pump
administration.
If not give as bolus admin.
Dietitian to:
1. Write correct feed on
drug chart
2. Write out feed and fluid
regimen on feeding chart
Administer feed and fluids
as per dietetic
recommendation.
Has the patient come in with feed?
No
Yes
Abbott feed
Contact dietetics dept
Yes
No
Pt may need feed
changing to Abbott
feed depending on
clinical circumstances
*
Give Abbott feed as per
emergency feed regimen as
per documented medical
advice.*
Dr must write feed on
prescription chart and sign
regimen form
Refer to dietetics dept
* The emergency regime gives a reduced amount of feed. If a patient’s clinical condition and
medical advice allows, they can continue with a full dose feed as per their normal regimen. If
Abbott feed, use Trust pump. If non Abbott feed, give with bolus admin as community pumps
cannot be used within the hospital.
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 155 of 174
2.0 Management of Enteral device
The management will depend on the device in situ.
If a nasogastric tube manage as per CNSG 007 Guidelines for the Insertion and Management
of Nasogastric Tubes.
If gastrostomy, manage as per CNSG 009 Guidelines for Insertion and Management of
Gastrostomy Tubes
Refer to specialist if further information required.
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East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 156 of 174
PATIENT INFORMATION AND FORMS TO DOWNLOAD OR PRINT
CARE PATHWAY FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY
(PEG) TUBES
158-165
ADVICE POST PEG REMOVAL
166
PRE-DISCHARGE TRAINING CHECKLIST- GASTROSTOMY FEEDING
167-168
NASOGASTRIC (NG) TUBE INSERTION AND MONITORING FORM
169-171
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East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 157 of 172
CARE PATHWAY FOR PERCUTANEOUS
ENDOSCOPIC GASTROSTOMY (PEG) TUBES
Mark boxes with X as appropriate or circle NA
Patient Details: Fix label if available
Name: ……………………………………………………. Date of Birth:……………..……….. Hospital No:……………..……
Address:……………………………………………………………………………………………. Ward …………………………..
Consultant: …………………………….. Admission date: ………………………..
Outpatient/Inpatient
REFERRAL
If the patient has the following conditions PEG is not appropriate (tick appropriate boxes).
Total gastric outflow obstruction
Tense ascites
Peritoneal dialysis
If the patient has the following conditions PEG may not appropriate (tick appropriate boxes).
Gastro-oesophageal reflux with risk of aspiration
Partial gastric outflow obstruction
Previous upper GI surgery
Dementia
Recurrent aspiration pneumonia due to severe dysphagia, following a CVA.
Indication for PEG: (tick appropriate boxes)
Dysphagia
Supplementary Nutrition
Previous NG tube feeding Yes/No
Other
Long term feeding likely >2 months
Start date…………………… No. of times tube pulled out by patient ……………
Please fax PEG referrals through to the gastroenterology department: Fax 01625 661904
Consultant Gastroenterologists: Dr R Saravanan and Dr K Koss. GI Specialist Nurse: Maggie Allen
PEG referral date…………………………..
PEG booked for:…………………………..
Accepted for PEG
Outcome if not accepted: Continue NG feeding
Continue oral feeding
Name and signature of PEG nurse or referring doctor………………………………………………………………………….
ASSESSMENT
Clinical assessment
Diagnosis: …………………………………………………………
Conscious level: Alert/fluctuating/unresponsive (circle)
Relevant co-morbidity……………………………………………………………………………………………………………………
CPR form
Tracheostomy
Cervical/Neck problems
Obese
UTI
Raised WCC
Recent or current chest infection/aspiration
MRSA
Current O2 therapy
Antibiotic therapy
If patient is MRSA positive treat prior to PEG (See Trust policy for MRSA).
Previous abdominal surgery
Type……………………………………………………………………………………………………………………………………
PEG Nurse assessment
Dietetic assessment
Swallow assessment (SALT)
All dysphagic patients should have had a recent swallowing assessment prior to PEG.
MDT discussion
Complex cases i.e. Multiple co-morbidity, should be discussed in an MDT forum
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 158 of 172
PREPARATION PRIOR TO PEG
Mark boxes with X  as appropriate
BLOODS
Day before procedure:
FBC
INR
If the patient is malnourished, check the prothrombin time 48 hours before the procedure.
If INR > 1.3: Correct to within normal limits.
MEDICATION – is the patient on anticoagulant therapy?
Yes/No
Low molecular weight heparin e.g.
Tinzaparin/Clexane/Enoxaparin
Omit 24 hours prior to PEG.
Warfarin
Omit 5 days prior to PEG (arrange for heparin if appropriate).
Restart Warfarin the following day.
Stop 4-6 hours prior to procedure. Restart 6 hours post
procedure if no complications.
Heparin
Drugs to be prescribed:

Re-feeding drugs required
Re-feeding drugs prescribed

Prophylactic antibiotics: intravenous Co-amoxiclav 1.2g, just before the procedure (1hour max).
If penicillin allergic, give a single dose of Gentamicin 3mg/kg (max 300mg), just before
the procedure. If MRSA positive discuss with microbiologist.
 Corsodyl (chlorhexidine gluconate 0.2%) mouthwash to start 48 hours prior to procedure
 Analgesia PRN, IM and soluble
Ward pharmacist Informed re PEG
The patient’s drug formulations may need to be changed. Timing and dosage of drug administration may need to be altered due to
altered drug formulation and/or potential interaction with feed.
NUTRITIONAL ASSESSMENT
Last fed/ate…………………………………
Weight
Weight Kg……..
Risk of re-feeding
Date…………………………
PEG regimen
Pump, feed and equipment required for feeding available
Feed prescribed
Before start feeding: U& Es
(including calcium group, phosphate and magnesium and levels)
Correct any electrolyte disturbances before commencing nutritional support.
CONSENT
Patient (Consent form1)
Consultant (consent form 4)
Written information (EIDO E09 PEG sheet) given to patient /relative/carer
Relatives aware of planned PEG insertion
NB. Informed consent, written/verbal/signage, must be obtained from patients where possible, in compliance with Trust Policy.
This may require repeated discussions and the use of visual aids to help the process. If a patient is unable to give informed
consent, the lead clinician and the healthcare professional undertaking the PEG insertion must sign the consent form. Evidence of
discussion with appropriate family is required.
SUBCUTANEOUS FLUIDS:
Avoid siting the butterfly cannula in the upper central abdomen as this can result in skin infections or abscesses that may affect PEG insertion.
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 159 of 174
Mark boxes with X as appropriate
PRE PEG CHECKLIST
X
Variance/Notes
Fasting (mouth and tube)
Morning list (9am) - No diet/feed and fluid after 3am.
Afternoon list (13.00pm) - No diet/feed and fluid after 7am.
Hygiene
Full wash – do not use talcum powder
Clean theatre gown
Clean sheets.
Working cannula in situ
Venous access should be established before the patient
arrives on the Endoscopy Unit (except for outpatients).
Antibiotic prophylaxis prescribed
Patients should have a single dose of intravenous Coamoxiclav 1.2g just before the procedure (1hour max). If
penicillin allergic, give a single dose of Gentamicin 3mg/kg
(max 300mg), just before the procedure. If MRSA discuss with
microbiologist.
Analgesia prescribed
Immediate PRN use (intramuscular and dispersible
preparations of oral analgesia).
Take home analgesia for out patients (where required).
Mouth Care with Corsodyl mouthwash
Mouth Assessment
Own teeth
Loose or decayed teeth
Dentures
Able to open mouth Advise endoscopy staff of loose/broken
teeth (document of endoscopy care plan).
Consent form completed
INR
Date
PLT
Date
PEG is contra-indicated if INR >1.3 or platelet count <100
Recheck
INR
Date
PLT Date
Baseline observations – within 2 hours of procedure
Pulse…………
BP………………
Temperature……………. SaO2……………
Resps…………
Allergies ………………………………………………
DATE:…………………………
CHECKLIST COMPLETED BY:……………………………………………………………
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 160 of 174
Post PEG management of complications - Inform/doctor/PEG nurse (as appropriate) of any complications.
Refer to East Cheshire NHS Trust CNSG 014: Guidelines for Enteral Feeding Complications and
Management.







Half hourly for 2 hours
Blood pressure
Pulse
Wound check
Temperature
Pain assessment
Oxygen saturation
Respiratory rate
PEG position
unchanged
Bleeding
Pain
Yes
Yes
Normal variants
Yes
Hourly for 2
hours
As per half hourly
assessments
Yes
Low oxygen
saturation
Yes
Consider effects of
sedation/aspiration/chest infection.
Treat as appropriate
Reverse sedation if necessary. Patient
position/antibiotic therapy.
Hyper/
hypotensive
Yes
Consider effects of sedation – reverse if
necessary.
Pre-existing condition. Correct with drug
therapy asap, continue to monitor.
Yes
No
2 Hourly for 2
hours
As per half hourly
assessments
Tachycardic
/bradycardic
Normal variants
Leakage
Yes
Yes
4 Hourly
As per half hourly
assessments
Normal variants
Assess pain, how much, where and when.
If localised to wound give appropriate
analgesia and monitor effectiveness.
If increasing abdominal pain, seek urgent
senior medical or surgical advice.
If pain or resistance when flushing, stop
immediately and seek urgent senior
medical or surgical advice.
Assess for cause
Consider Sepsis/peritonitis/chest
infection/UTI
Treat as appropriate
Pyrexia
Normal variants
Small volume
Monitor dressing for spread
Inform specialist if bleeding continues
Large volume
Inform gastroenterologist /surgeon
immediately
Aspiration
Reflux/
nausea/
vomiting
Yes
Yes
Discontinue
Diarrhoea
observations as medical
East Cheshire NHS Trust. Patient Information
condition
allows.
Created
by GI Nurse
Specialist Maggie Allen. August 2012. Updated July 2015.
Yes
Assess amount of leakage
Slight oozing of exudate is common post
insertion. Monitor amount.
Larger volumes particularly during
administration of fluids via the tube and
associated with pain are abnormal and
need urgent medical attention.
Larger volumes without pain may be
associated with constipation. Treat and
monitor bowel movements
Monitor saturation levels
Position patient in upright position during
feeds/flushes
Consider prokinetics
Consider constipation
Consider secretion management
Assess cause of diarrhoea
Feed/infection/drugs
Page 161 of 174
Inform doctor/pharmacist/dietitian.
POST PEG
ACTIVITY
Up to 24 hours post PEG
DATE………………………………
NAME
SIGN
MONITORING
Half hourly for a minimum of 2 hours.
Hourly for a minimum of 2 hours.
 Blood pressure, pulse and temperature
As per half hourly assessments
 Oxygen saturation and respiratory rate
 Wound check
 Pain assessment (see below)
 PEG position unchanged.
Measurement at the exit from the skin ...............cm
2 - 4 hourly (depending on clinical status).
Discontinue as clinical condition allows.
As per half hourly assessments
PAIN ASSESSMENT
 Does the patient have any pain
 Ask where the pain is
 Assess the degree of pain using the pain scale below
 Assess whether the pain is worse
 Give analgesia appropriate to degree of pain
 Assess whether the analgesia is effective
 Refer for urgent medical attention if increasing severity of abdominal pain despite analgesia
 Record pain score on observation chart
 Record location of pain in patient’s notes
 If the patient is unable to communicate observe for signs of increased restlessness and abnormal
observations
COMMENCING FEED /ORAL DIET
NBM or tube until 4 hours post insertion. Give first flush at: ..............................





Flush tube with 50mls of sterile water. If pain or difficulty flushing, stop immediately and seek
urgent senior medical or expert advice.
Administer medication for re-feeding if applicable
Commence feed/fluids as per dietetic regimen
Oral diet/fluids (if applicable) can restart as the individual wishes after the first successful flush of water
Position the patient in a semi-raised (at least 30°) position during feed. Upright if known history of reflux
and vomiting.
MOUTHCARE
2 hourly if no oral diet or fluids. Document care given on mouth care chart
STOMA CARE
 Do not change the dressing for 24 hours
 Monitor for bleeding
 Monitor for leakage
If excessive leakage or bleeding, refer for urgent senior medical/surgical review. Document complications.
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 162 of 174
POST PEG
24 – 48 hours post PEG
DATE…………………...........
ACTIVITY
NAME
SIGN
MONITORING
4 hourly observations (more frequently if necessary depending on medical condition)
 Blood pressure, pulse and temperature
 Oxygen saturation and respiratory rate
 Wound check
 Pain assessment
 PEG position unchanged.
Measurement at the exit from the skin ...............cm
Discontinue as clinical condition allows
Bowel movements
Monitor. If no bowel movement assess for constipation. If constipated treat. Record bowel movements on
observation chart
Bloods - repeat full profile if at risk of re-feeding syndrome, or previous abnormal results.
PAIN ASSESSMENT
 Does the patient have any pain
 Ask where the pain is
 Assess the degree of pain using the pain scale below
 Assess whether the pain is worse
 Give analgesia appropriate to degree of pain
 Assess whether the analgesia is effective
 Refer for urgent medical attention if increasing severity of abdominal pain despite analgesia
 Record pain score on observation chart
 Record location of pain in patient’s notes
 If the patient is unable to communicate observe for signs of increased restlessness and abnormal
observations
ADMINISTRATION FEED /ORAL DIET
 Administer feed/fluids as per dietetic regimen
 If pain during administration of fluids, stop immediately and seek urgent senior medical or
expert advice.
 Continue oral diet/fluids (if safe)
 Position the patient in a semi-raised (at least 30°) position during feed. Upright if known history of
reflux and vomiting.
MOUTH CARE
2 hourly if no oral diet or fluids. Document care given on mouth care chart
STOMA CARE
See overleaf (page 7)
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 163 of 174
POST PEG
ACTIVITY
24 – 48 hours post PEG
DATE………………………
STOMA CARE
Use aseptic technique when cleaning the stoma site for the first 72 hours post insertion.
 Assemble equipment required onto a clean trolley
 Explain the procedure to the patient and obtain consent
 Wash hands and put on sterile gloves as per Trust policy
 Remove the dressing, clean the stoma site and fixation device using Normasol and gauze swabs,
removing any exudate.
 Rotate the PEG tube to clean under the fixation device
 Dry the skin and fixation device thoroughly
 Observe the stoma for inflammation/redness/swelling
 Check that the position of the PEG is unchanged (check that the cm marking at the exit point from the
stomach corresponds with the measurement recorded in the patient's notes)
 When finished, dispose of clinical waste and wash hands as per Trust policy.
 Do not undo the fixation device until 2 weeks post insertion, unless too tight. See below for further
information regarding the position of the fixation device.
 A small dressing can be applied until the site dries up (see below for advice regarding dressings).
 Position the distal part of the tube away from the groin region as it is unhygienic
 Inform doctor/specialist nurse of complications (see page 4 of PEG care plan for complication flow
chart)
 Document condition of the stoma in the nursing care plan
NAME
SIGN
Fixation Device Position
The fixation device should be left in position for two weeks post PEG insertion to allow healing and reduce the risk of
peritonitis. The positioning of the fixation device is crucial especially post insertion. Too tight and pressure necrosis will
If
excessive
bleeding,
refer for
senior
medical/surgical
review.
4 of PEG
develop.
Too leakage
loose andorthe
stoma layers
will urgent
not adhere
together,
increasing the
risk ofPage
peritonitis.
The fixation device
care plan
should
be no more than 3-4mm from the skin.
The fixation device may become too tight post PEG insertion as a result of inflammation and/or re-hydration
If repositioning of the fixation device is required, release the fixation device and slide it backwards up the tube to the
optimum position then secure the tube within the device. Recheck the position after closing the device whilst gently pulling
back on the tube. Seek specialist advice if unsure or further guidance required. Document the adjusted measurement in
the patient’s care plan/notes.
Dressings
Avoid bulky dressings under the fixation device as it may increase the pressure on the internal fixation device, resulting in
localised ischaemia. If using a thick dressing, lay it on top of the fixation device. Any thinner topical dressings e.g. silver
impregnated dressings can placed keyhole style around the tube.
Seek specialist advice if unsure or further guidance required.
Bathing and showering
The PEG stoma must not be immersed in water for 3 weeks following insertion. If using a shower, for first few days, a
large waterproof dressing can be used to cover the stoma and removed after showering. The stoma will still need cleaning
if covered with a waterproof dressing.
Further Guidance
Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes and CNSG 014 Guidelines for
Enteral Feeding Complications and Management for further information.
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 164 of 174
POST PEG
ACTIVITY
48 – 72 hours post PEG
DATE……………………
MONITORING
4 hourly observations (more frequently if necessary depending on medical condition)
 Blood pressure, pulse and temperature
 Oxygen saturation and respiratory rate
 Wound check
 Pain assessment
 PEG position unchanged.
Measurement at the exit from the skin ...............cm
Discontinue as clinical condition allows
Bowel movements
Monitor. If no bowel movement assess for constipation. If constipated treat. Record bowel movements on
observation chart.
Bloods - repeat full profile if at risk of re-feeding syndrome, or previous abnormal results.
NAME
SIGN
PAIN ASSESSMENT
 Does the patient have any pain
 Ask where the pain is
 Assess the degree of pain using the pain scale below
 Assess whether the pain is worse
 Give analgesia appropriate to degree of pain
 Assess whether the analgesia is effective
 Refer for urgent medical attention if increasing severity of abdominal pain despite analgesia
 Record pain score on observation chart
 Record location of pain in patient’s notes
 If the patient is unable to communicate observe for signs of increased restlessness and abnormal
observations
ADMINISTRATION FEED /ORAL DIET
 Administer feed/fluids as per dietetic regimen
 If pain during administration of fluids, stop immediately and seek urgent senior medical or
expert advice.
 Continue oral diet/fluids (if safe)
 Position the patient in a semi-raised (at least 30°) position during feed. Upright if known history of reflux
and vomiting.
MOUTH CARE
2 hourly if no oral diet or fluids. Document care given on mouth care chart
STOMA CARE
As per 24-48 hours (page 7)
72 HOURS ONWARDS
Continue care as per CNSG009 Guidelines for Insertion and Management of Gastrostomy Tubes (Trust infonet).
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 165 of 174
ADVICE POST PEG REMOVAL
Following PEG tube removal, food and drink can be taken as normal.
 A dressing has been placed over the stoma to absorb any leakage.
 The dressing should be checked regularly and replaced if wet (stomach
contents are very acidic and may burn the skin).
 The skin around the stoma should be regularly cleaned and dried to prevent
soreness.
 A barrier cream can help to protect the skin if there is a lot of leakage.
The hole should start to close over in 24-48 hours. The dressing is no longer
needed when the stoma has dried up.
Occasionally the stoma can take longer to close, particularly if there have been
problems with leakage around the tube in the past. Healing may also be delayed if
the patient has an infection in the stoma site, or overgranulation. A course of
antibiotics may be required.
If the problem persists contact the specialist nurse or doctor/GP.
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 166 of 174
Department of Nutrition & Dietetics
Macclesfield District General Hospital
Tel: 01625 661126
HOME ENTERAL FEEDING
PRE-DISCHARGE TRAINING CHECKLIST
GASTROSTOMY FEEDING
NAME
WARD
Please date and sign for each entry. Practice column indicated practice under supervision
and should be signed and dated on each occasion.
When discharged from hospital, the patient and/ or carer will know/ know how to:-
GOAL
Why tube feeding is required
Discuss
Demo
Practice
Competent
Feeding route and type of tube
When and how to wash hands
Care of Tube
Check tube position
Clean gastrostomy site
Rotate tube
Care of tube and connectors
How and when to flush tube
Administer medication
Feed
How to obtain feed supplies
How to store feed
Name of feed and volume
required daily
Timing of feeds
Timing of extra water
East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles
Created by Maggie Allen, October 2010. Updated July 2015.
Page 167 of 172
GOAL
Discuss
Demo
Practice
Competent
Setting Up Feeding System
Prepare feed for administration
Connect giving set to feed
Connect giving set to pump
Prime giving set
Programme pump and/ or
deliver a bolus feed
Pump features
Pump Alarms
Connect giving set to
gastrostomy
Disconnect the giving set from
tube
Care of Equipment
How to store equipment
Clean Handling Procedures
How to dispose of equipment
Problem Solving e.g.
Feeding tube is blocked
Pump not working
Feeding tube dislodged
Who to contact for help
Follow up Appointment arranged with Dietitian
Date ________________________________ Time _________________________
Signed_________________________Date ________________( Patient/carer)
Signed_________________________Date________________ (Dietitian)
Signed_________________________Date ________________ (Nurse)
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 168 of 174
NASOGASTRIC (NG) TUBE INSERTION AND MONITORING FORM
Patient Details: Fix label if available
Name: ……………………………………………Date of Birth:……………...
Hospital No:…………………….. NHS No…………………………………
Assessment and Preparation:
Assess for risk,
indication and
appropriateness of NG
tube feeding/gastric
decompression and
document rationale in
the patient’s medical
notes.
Decision maker………………………………………………. Signature…………………………….
Date……………………………Time……………………..
VERY HIGH RISK OF INSERTION COMPLICATION
 Fractured base of skull
 Upper GI obstruction
 Recent surgery / radiotherapy to upper GI tract /
larynx?

No
HIGH RISK OF: incorrect positioning,
dislodgement and aspiration
 Altered state of consciousness / ventilated
 Swallow dysfunction / nursed prone
 Recurrent retching vomiting?
No
Yes
Yes
PPI therapy
Consider referral to specialist / expert practitioner /
nutrition support team for:
 Insertion and management advice
 Alternative feeding methods
Refer to specialist or expert
practitioner prior to insertion.
astric Insertion Chart
Date/time of
Type of
Nostril Cm mark at
pH
X-ray
Reason for
Consent,
insertion
tube/
exit
from
nose
value
insertion
and
L/R
PH testing: Is the patient on a PPI e.g. Lansoprazole or H2 antagonist e.g. Ranitidine
Yes procedure
/No
Lot
(after correct
A.Decompression positional check
Number
tube position
B.Enteral feeding
documented in
confirmed)
Yes/No
patient’s notes
Yes/No
Reason for failed insertion
A. Unable to pass through nostril
B. Unable to pass into the
oesophagus
C. Patient unable to tolerate
D. Respiratory distress
Yes / No
Refer to
algorithms 1 & 2
Inserted by:
A maximum of 3 attempts at NG insertion is recommended prior to seeking more expert help/advice. If out of hours, wait until more expert help is available.
Do not use the tube before the position is verified. pH testing is the first line test. Refer to algorithms 1 & 2 in Trust NG guidelines for insertion and confirmation of position.
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 169 of 174
Insert tube as
per Trust
guidelines and
complete core
care plan.
Nasogastric Tube Monitoring Chart
Patient Name:
Mark: Yes, No, A, B, C, D, or E (mark as many as appropriate).
DATE
TIME
PH
VALUE
CM
MARKING
at exit
from nose
Hospital Number:
NO ASPIRATE
INCONCLUSIVE ASPIRATE
ACTION TAKEN – see algorithm 2
A – Tube position checked
B – Use tube
C – Reposition/replace tube
ACTION TAKEN – see algorithm
2
A – Inject air
B – Check volume/colour
C – Compare previous
readings
D – Stop/delay feed
E – X-ray
X-RAY
RESULT –
TUBE IN
STOMACH
YES/NO
NASAL/
CHEEK TAPE
SECUREYES/NO
TUBE
PULLED
OUT
YES/NO
COMPLICATION
INITIALS
A. Nausea/
vomiting
B. Diarrhoea
C. Constipation
D. Tube blocked
E. Reflux
F. Feed stopped
Refer to East Cheshire NHS Trust clinical nutrition steering group guidelines for insertion and management of nasogastric tubes (CNSG007) and guidelines for enteral feeding complications and
management for advice about clearing a blocked tube (CNSG 014).
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 170 of 174
SENIOR
CHECK
INITIALS –
where
appropriate
Nasogastric Tube Monitoring Chart
Patient Name:
Mark: Yes, No, A, B, C, D, or E (mark as many as appropriate).
DATE
TIME
PH
VALUE
CM
MARKING
at exit
from nose
NO ASPIRATE
Hospital Number:
INCONCLUSIVE ASPIRATE
ACTION TAKEN – see algorithm
ACTION TAKEN – see
algorithm 2
A – Tube position checked
B – Use tube
C – Reposition/replace tube
A – Inject air
B – Check volume/colour
C – Compare previous
readings
D – Stop/delay feed
E – X-ray
2
X-RAY
RESULT –
TUBE IN
STOMACH
YES/NO
NASAL/
CHEEK TAPE
SECUREYES/NO
TUBE
PULLED
OUT
YES/NO
COMPLICATION
INITIALS
A. Nausea/
vomiting
B. Diarrhoea
C. Constipation
D. Tube blocked
E. Reflux
F. Feed stopped
Refer to East Cheshire NHS Trust clinical nutrition steering group guidelines for insertion and management of nasogastric tubes (CNSG007) and guidelines for enteral feeding complications and
management for advice about clearing a blocked tube (CNSG 014).
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 171 of 174
SENIOR
CHECK
INITIALS –
where
appropriate
Back to main index
East Cheshire NHS Trust. Patient Information
Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.
Page 172 of 174