port stylet
GJ tube must be placed by interventional radiology under fluoroscopy to ensure proper placement for both the initial placement and any subsequent tube replacement. GJ tubes are replaced every six months.
Complications/Emergencies
Tube Dislodgment
Tube dislodgment is a common emergency department chief complaint in both adults and children. This can occur because of coughing, gagging, pulling on the tubing, or getting the tubing caught around an object. In all cases, stop the feeding and inquire how long the patient can maintain his or her blood sugar without feeding. Hypoglycemia is a common complication for patients who are accustomed to receiving continuous feeds, and an infusion of dextrose‐containing IV fluids is commonly needed while awaiting feeding tube replacement. Replacement follows an algorithm based on the type of enteric feeding device and the duration since its initial placement (Figure 1.2). Unfortunately, tube replacement is not without risk, and the astute provider must be aware of clinical signs of an improperly positioned tube and how to best verify tube placement.
NG tube replacement is a simple procedure, and some patients may even replace their own NG tubes nightly; however, it is not without risk. Complication rates range from 1 to 2% in adults and up to 20–40% in pediatric patients, with higher rates seen in neonatal patients. Complications with improper NG tube placement include pneumonia if the tube is placed in the lungs and peritonitis if the tube perforates the bowel. Given this high complication rate, all NG tube replacements in the emergency department setting should be confirmed with a radiograph. Auscultation, enzyme testing, and pH testing are unreliable.
G‐tube placement is an equally common emergency department procedure, and complication rates range from 0.6 to 20%, with higher rates seen in immature tubes and tubes with traumatic dislodgement. The definition of an immature tube is debated in the literature. Most studies define immature tubes as those less than four to six weeks from placement; however, some studies define immature tubes as those less than six months from placement. There is an inverse relationship between the age of the tube, and, therefore, G‐tube tract healing, and the complication rate. In addition, patients who are symptomatic postreplacement are more likely to have a G‐tube complication. Complications include gastric outlet obstruction and intraperitoneal tube placement.
All G‐tube replacements can be completed at the bedside; however, the person performing the procedure and the method of checking placement are dependent on the age of the tube and the patient's presenting symptoms. The first tube change postoperatively is the most critical and should be completed by the subspecialty service responsible for the tube's placement. In addition, any stoma site with significant trauma or stoma that is difficult to identify should be evaluated by general surgery. Uncomplicated mature G‐tubes can be replaced at the bedside by the emergency department team, and placement should be confirmed with gastric aspirate and pH testing alone. For patients with immature tracts, trauma to the stoma site, or symptoms following G‐tube replacement, contrast‐enhanced radiograph is needed to confirm G‐tube placement prior to use. Extravasation of contrast dye on imaging and failure to fill the stomach indicates that the tube is improperly positioned.
Figure 1.2 Algorithm of the displaced enteric feeding device.
All transgastric jejunal tubes must be replaced by interventional radiology under fluoroscopic guidance.
Peristomal Skin Irritation
Patients can present with G‐tube erythema for a variety of reasons. While the presence of skin irritation can be highly distressing to patients and caregivers, the cause is commonly nonurgent. However, it is vital that providers have a healthy differential in order to distinguish severe causes of peristomal irritation from those that are less severe.
Peristomal Leakage
Peristomal leakage of gastric contents is seen with most G‐tubes. Diabetes, malnutrition, and poor wound healing can increase the likelihood and amount of leakage secondary to poor approximation of skin tissue around the tubing. In addition, a tightly secured retention device, noted by dimpling of the skin, can cause an inflammatory reaction and lead to increased leakage of gastric contents.
Skin irritation from peristomal leakage can be distinguished from infection by the color, which is a faint pink instead of the deep red color of cellulitis (Figure 1.3a). Likewise, the skin is not tender. Finally, crusting around the tube site, that is, dried formula and gastric juices, should easily wipe away.
Treatment options for peristomal leakage include skin barrier creams such as zinc oxide and antacid treatment to decrease the acidity of the gastric contents. If the stoma appears too large for the tubing, do not increase the size of the tube. A larger stoma site is not because the patient grew or gained weight. The stoma size increases secondary to repetitive trauma from the tube moving within the stoma. Increasing the tube size will only stretch the stoma further and lead to greater leakage of gastric contents. Do not make this common mistake. Instead, remove the tube and allow the stoma to shrink in size over the next several hours. A stoma can close within as little as 24 hours, so a smaller catheter should be left in place to maintain patency of the stoma. Once the stoma has decreased to the appropriate size, place the original sized G‐tube into the site.
Stomal Cellulitis
Stomal cellulitis is distinguished from skin irritation by the deeper red color and spreading erythema around a G‐tube site with significant pain to touch (Figure 1.3b). Patients with poor wound healing and an immunocompromised state are at increased risk for cellulitis. Pathogens are typically skin flora including beta‐hemolytic streptococci and Staphylococcus aureus. In a well‐appearing child with otherwise no systemic symptoms, a first‐generation cephalosporin is adequate to treat streptococcal infection. If a patient is a known methicillin‐resistant S. aureus carrier or appears ill, coverage should include agents that treat methicillin‐resistant Staphylococcus aureus (MRSA) based on local antibiograms. The tube does not need to be removed in the setting of stomal cellulitis. If there is fluctuance around the tube, an ultrasound should be obtained to evaluate for a peristomal abscess. Peristomal abscesses will require bedside incision and drainage and broad‐spectrum antibiotic coverage.