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G Tube ABC’s and some D’s about Enteral Feeding Indications for Enteral Feedings • Inability to consume an adequate amount of food to maintain health – Considerations • Appropriateness of enteral feeding route • Safety: Risk of aspiration • Duration of therapy • Need of enteral access for theraputic maneuvers – Medications for HIV, Refractory Constipation, Pancreatitis Methods of Enteral Feeding • Oral • “Temporary” devices – – – – Nasogastric (NG) Nasojejeunal (NJ) Orogastric (OG) Orojejeunal (OJ) • “Permanent” devices – Gastrostomy Tube (GT) – Gastrojejeunal Tube (GJT) – Jejeunal Tube (JT) Appropriate Evaluation Prior to GT • Upper GI – Evaluation for anatomic abnormalities • pH Probe – Evaluation of Reflux • Dysphagia Protocol/Swallowing Study – Assess ability to protect the airway • Trial of Nasogastric Feeding The Competition: Practitioners who place feeding devices • Surgeons – Open Gastrostomy, Gastrojejeunal or Jejeunal Tube – Fundoplication • Interventional Radiologists – Push Gastrostomy, Gastrojejeunal or Jejeunal Tube • Gastroenterologists – Percutaneous Endoscopic Gastrostomy or Gastrojejeunal Tube Decisions, Decisions: GT vs GJ Tube vs GT with Fundoplication • Gastrostomy Tube: – Device enters through the skin into the stomach with usually a single access port – Pros • Easy to place, can be done under conscious sedation • Reversable procedure – Cons • Provides no protection against aspiration Decisions, Decisions: GT vs GJ Tube vs GT with Fundoplication • GJ or J Tube – Feeding device placed through skin into stomach, a portion of the tube fed through pylorus into the jejunum. Feeding port in the jejunum, may have a second port in stomach (for medications, etc). – Pros • Easy to place, may be done with conscious sedation • Provides increased protection against aspiration – Cons • Requires continuous feeding method • Often more difficult to maintain Decisions, Decisions: GT vs GJ Tube vs GT with Fundoplication • G Tube with Fundoplication – Feeding device through skin with surgically created wrap of the stomach antrum around the lower esophagus – Pros • Provides greatest protection against aspiration • Provides remedy for reflux esophagitis – Cons • Requres general anesthesia • Irreversible procedure, feeding device removable The Brand Names • Standard or Non-skin level device (Tube) – Mic-Key Tube – Core-pac – One-step • Skin Level Devices (Button) – – – – Mic-Key Button Bard Ross Genie Yeah Baby…Let’s Accessorize • Bolus Feeding and Continuous Feeding adaptors • Venting Tubes • Extension Sets If this is an EMERGENCY, hang up and call 911 • Tube Falls Out – MUST be replaced within 1-4 HOURS – Need to know type size(French) and length (cm) – In a pinch, place a similar sized (French) foley catheter into gastrostomy tube site then call the practitioner that placed the device (you can always call the GI division if in doubt) – Important caveat: it takes 4-6 weeks for the device tract to mature. Get guidance from a practitioner familiar with feeding devices before replacing a newly created tube. – You can verify correct placement of a tube using xray contrast or by aspirating back stomach contents – Can reuse the same tube if no signs of breakage If this is an EMERGENCY, hang up and call 911 • Leaking Tube – With Mic-Key Button or Tube, can try to inflate balloon a little more (max inflation 6-8 cc) max inflation usually stamped on tube or in package insert – Reinforce with gauze for others – May need to change out tube and replace with correct size device Changing a Mic-Key button • Quick and easy, no anesthesia needed • Needed supplies – – – – – Lube Sterile water or saline (or not so sterile in a pinch) Gauze Cath tip syringe (Luer-lok works as well) Optional: stoma measuring device – – – – – – Test balloon on new tube and pre-lubricate Deflate balloon on old tube Pull out old tube Slide in new tube Inflate balloon Give patient a sticker or other prize • Steps: Some Cases: Case One • 14 yo trauma patient with a closed head injury • Tired patient, unable to sustain activity for more than ten minutes • Expected full recovery in 2 months • Normal intact gag Case 2 • 4 year patient with seizures • Oral aversion and chokes and gags with medications and feeds • No weight gain past 3 months • Normal dysphagia study, no history of aspiration pneumonia • Expected to remain in same clinical state Case 3 • • • • • 8 months old former 33 week premie infant Chronic lung disease GERD History of aspiration pneumonia No weight gain for two months despite fortified feeds • Abnormal dysphagia study