1. GI WORKSHOP

2. GASTRIC/GASTROINTESTINAL TUBES
Indications for use
Types of tubes
Tube feeding methods
Safety and Infection Control issues
Miscellaneous issues

3. INDICATIONS FOR GASTRIC/GASTROINTESTINAL TUBES
Decompression and gastric emptying
Enteral feeds - OG/NG/ND/GT
Diagnostic studies
Medication administration

4. DECOMPRESSION AND GASTRIC EMPTYING
What is it:
The removal of air and gastric contents from the stomach
A means of preventing intestinal distension by decreasing the amount of air & gastric secretions passing to intestines
Accomplished by placing a tube into the stomach and connecting this tube to a suction source

5. DECOMPRESSION AND GASTRIC EMPTYING
Why we do it:
Many surgical & medical procedures can cause a great decrease in intestinal motility. Air & secretions can accumulate and overwhelm a sluggish GI tract causing gastric and intestinal distension.

6. DECOMPRESSION AND GASTRIC EMPTYING
SURGICAL INDICATIONS :
-To protect a surgical suture line from the effects of over distension: i.e. TE fistula repair, diaphragmatic hernia repair
-To provide bowel rest after invasive abdominal procedures: ie. exploratory laparotomy, creation of an ostomy –any procedure where the abdominal cavity is invaded and there is “mechanical manipulation” of the bowel

7. DECOMPRESSION AND GASTRIC EMPTYING
SURGICAL INDICATIONS :
“Mechanical manipulation” causes peristalsis of the bowel to slow down significantly leading to distension
To provide bowel rest after abdominal trauma i.e. liver/splenic laceration which leads to decreased peristalsis and distension

8. DECOMPRESSION/GASTRIC EMPTYING
MEDICAL INDICATIONS :
To provide bowel rest for certain medical conditions: i.e. Crohn’s disease, ulcerative colitis
For patient’s with an ileus or bowel obstruction

9. DECOMPRESSION/GASTRIC EMPTYING
MEDICAL INDICATIONS :
For patients in shock and on high dose epinephrine/norepinephrine drips
These shunt blood flow away from the GI tract and therefore decrease motility and absorptive capability of the GI tract which can cause distension
Shock, arrest scenarios
The body automatically shunts blood from GI tract and redirects it to vital organs for organ preservation resulting in the same effect as above

10. TUBES USED FOR DECOMPRESSION AND GASTRIC EMPTYING

11. REPLOGLE/SUMP TUBE
Aspiration Port
Vent Port

12. REPLOGLE TUBE REPLOGLE TUBE—also called a “Salem Sump” tube Uses:
Prevention of gastric distension, vomiting and aspiration

13. REPLOGLE TUBE This is the only tube used for gastric decompression!!
Why?
It has both an aspiration port and a vent port (blue)
What do these do ?
As gastric contents are suctioned from the aspiration port, atmospheric air enters the blue vent port preventing a vacuum effect from occurring inside the stomach

14. REPLOGLE TUBE What does that do? Thereby:
Prevents the suction pressure that the stomach is exposed to from exceeding 25 mmHg
Thereby:
Preventing the replogle tube from adhering to the stomach wall & causing mucosal damage to stomach lining which can cause bleeding

15. REPLOGLE TUBE DO NOT FEED THROUGH THIS TUBE!!!
And with surgical repairs:
Protects esophageal and gastric suture lines from the trauma of excessive suction
DO NOT FEED THROUGH THIS TUBE!!!

16. REPLOGLE TUBE: USER GUIDE
Use LOW CONTINUOUS wall suction only
Replogle is working properly if you see a constant “MARCHING” of secretions up the tube
NEVER occlude blue vent port:
No syringes, clamps, claves - must be kept open to air

17. REPLOGLE TUBE: USER GUIDE
NEVER vent the blue port with a syringe. If secretions are coming up the blue vent port then the port needs to be cleared with air. If this occurs repeatedly, the replogle may need to be replaced. Check with MD.
Secretions can vary in color: clear, yellow, light green can be seen
Call MD immediately if secretions are coffee ground or red in color – this indicates bleeding

18. REPLOGLE TUBE: TROUBLESHOOTING
Problem #1: No “marching” of secretions up the tube
Solution: Clear both blue vent port and aspiration port with 3-10 ml of air
Still not working? Check with MD and see if they want the tube replaced
If so, clarify with the MD as to whether the RN or the physician is to replace
Be sure you get a physician order if RN is to replace tube

19. REPLOGLE TUBE: TROUBLESHOOTING
Problem #2: Gastric secretions leaking out blue port
Trouble Shooting:
Flush blue port with 3-10 ml of air
Keep blue vent lumen above patient’s midline or it will act as a siphon and leak
Blue port still leaking? Check with MD to replace tube using previous guidelines
Never occlude blue port because of leakage of gastric secretions as this defeats the intended purpose of the vent port which is to prevent excessive suction. Troubleshoot and/or contact MD

20. REPLOGLE: MISCELLANEOUS INFORMATION
Document output every 4 hours on nurses notes
Check patency and aspirates every 4hrs
Be aware of patient’s fluid and electrolyte balance

21. REPLOGLE: MISCELLANEOUS INFORMATION
Notify MD of large amounts of output from replogle.
If deemed excessive, this volume may need to be replaced intravenously with appropriate IV fluids
NG charcoal can be administered via the replogle to counteract the effects of some types of ingestions if:
An ETT tube is in place to protect the airway in a patient with an altered LOC or
The patient’s own natural airway protective mechanisms are intact

22. USES FOR TUBES: ENTERAL FEEDING

23. WHY ENTERAL (TUBE) FEEDS?
Provide supplemental calories: i.e. patient’s with FTT (failure to thrive)
For patient’s with impaired intestinal digestion/absorption: i.e. Cystic Fibrosis
To bypass an anatomic abnormality: i.e. TE fistula
For patient’s who are unable to swallow/protect airway: i.e. neuromuscular disease

24. WHY ENTERAL (TUBE) FEEDS?
For patient’s experiencing cyanosis/apnea with feeds due to reflux
For patient’s on mechanical ventilation as they are unable to take nutrition orally
Promote wound healing
Speed recovery of patient—nutrition=strength

25. ENTERAL FEEDS: SHORT TERM VS. LONG TERM USE
Delivering feeds enterally (via tube) can be accomplished using an OG/NG/ND if the feeding problem is a temporary one
If long term feeds are required , special feeding devices that are introduced surgically will be used i.e. Mickey, Peg, Bard (GT feeds), and GJ tubes

26. TUBE PLACEMENT

27. TUBES FOR SHORT TERM ENTERAL FEED USE: OG/NG

28. OG/NG TUBE

29. OG/NG TUBE PLACEMENT: GENERAL SIZE GUIDELINES
< 2kg: use 5 French tube
3 - 9kg: use 8 French tube
kg: use 10 French tube
kg: use 12 French tube
kg:use 14 French tube
>50kg: use 16 French tube

30. OG/NG TUBE PLACEMENT METHOD
Nurse can insert with an MD order
Method:
NG:
Place distal end of tube from tip of nose to ear lobe and then down to a point midway between xiphoid and umbilicus
OG:
Place distal end of tube from corner of mouth to earlobe and then down to a point midway between xiphoid and umbilicus
Place a piece of ¼ inch tape here
Lubricate distal tip of tube

31. OG/NG TUBE PLACEMENT METHOD
Insert tube into nostril or mouth and pass into pharynx aiming down and back
Advance to premeasured mark (tape)
**Key point: If patient becomes dusky with tube placement - STOP IMMEDIATELY and remove tube -you may have entered the AIRWAY

32. OG/NG TUBE PLACEMENT METHOD
When the pre-determined depth is reached, check for proper placement of tube in stomach by BOTH:
Aspirating for stomach contents AND
Instilling 1-5 ml of air and listening for a whoosh of air over gastric region with stethoscope

33. OG/NG TUBE PLACEMENT METHOD
Finish by:
Taping NG in place in the space between the upper lip nose
Tape OG on chin
For NG/OG:
Use tube to vent/feed
Cap off if for prn use
*Note:
Replogle tube placed using same method but place tube to low continuous suction

34. TUBES FOR INTERMEDIATE TERM ENTERAL FEED USE: ND TUBES

35. NASODUODENAL (ND) TUBES
Guide Wire
Weight

36. ND TUBE: DESCRIPTION
ND tubes are placed nasally or orally and extend into the DUODENUM
ND tubes are made of a flexible polyurethane material that is yellow in color
The wire stylet inside the tube and the tungsten weight at the end of the tube are designed to assist with proper placement

37. ND TUBES: USES Used for:
Patients who will require feeds for an extended (not permanent) period of time
Patients with reflux/aspiration issues
Patients on ventilator support

38. ND TUBES Only a PHYSICIAN may place an ND
ND tubes may be placed by a physician at the bedside or in fluoroscopy
The ND tube’s internal guide wire must be removed by MD before tube can be used—DO NOT reinsert guide wire
Guide Wire

39. ND TUBES
The RN may ADVANCE an existing ND tube- (see policy and procedure PED_11 PCD for instructions)
When an ND tube is properly placed you will not be able to aspirate feeds
**DO NOT use ND until placement has been confirmed by MD with an abdominal X-ray

40. TUBES FOR LONG TERM ENTERAL FEED USE: MIC-KEY TUBE

41. ABOUT THE MIC-KEY The Mic-key is a type of “GT” feeding tube
The Mic-key device is inserted into stomach through the abdominal wall via a gastrostomy opening which has been previously surgically created
The Mic-key utilizes a feature whereby the feeding tube extension set locks into the Mic-key base “like a key in a lock”

42. MIC-KEY TUBE: FEATURES
The external base- which extends above the skin
The anti reflux valve inside the base - helps prevent stomach contents from leaking out of the Mic-Key
The silicone water filled balloon - sits inside the stomach - 5ml is usual volume-- do not fill with air!
Balloon
External Base

43. MIC-KEY TUBE: FEATURES
There are 2 types of feeding tube extension sets: one for continuous feeds and one for bolus feeds
Both can be used for venting (see picture-middle and left tube respectively)

44. MIC-KEY TUBE: USE Check for proper placement before each feed by:
Connecting the extension set to button and
Aspirating for stomach contents or
Instilling 5-10 ml of air into extension set and listen for air entry into stomach with stethoscope
Aspirate and check for residual feed amount:
Establish guidelines with MD as to whether residual is to be returned or discarded.
Remember, residuals contain important nutrients and electrolytes!

45. MIC-KEY TUBE: USE
Attach the appropriate extension set - continuous or bolus feeds
The bolus feed set is straight and has a larger diameter than the continuous feed extension set
Begin feeds
For continuous use kangaroo or medfusion pump
For bolus use a 60 ml syringe and gravity

46. MIC-KEY TUBE: USE
After feed, flush extension set with the amount of water specified by MD to prevent clogging of both extension set and Mic-key button
Both the continuous feed extension set and the bolus extension set can be used for venting
NEVER “hand-deliver” feeds by actively injecting them into any type of feeding device!

47. MIC-KEY TUBE: CARE
Inspect stoma site and surrounding skin after each feed - it should be dry and intact
Proper tube placement:
There should be no more than a dimes’ width of space between the base of the Mic-key and the skin
Stoma site care:
For a well healed stoma-soap and water
For a newer stoma see Policy PED_11_PTC

48. MIC-KEY TUBE: CARE
Rotate the Mic-key in a full circle when you do your daily tube care
A well healed Mic-key does not require a split 2x2 gauze placed between base and skin

49. MIC-KEY TUBE: TROUBLESHOOTING
Problem: Feeds leaking out around stoma site
Trouble Shooting:
Is the residual large?
Can you aspirate a lot of gas?
Are the feeds going in too fast?
Consider switching from bolus to continuous feeds
Does patient have a history of delayed gastric emptying?
Report findings to MD and await instructions

50. MIC-KEY TUBE: TROUBLESHOOTING
Problem: bleeding around stoma
Call MD immediately
Problem: Granulation tissue build up (results from body trying to repair the surgical incision)
May need to be treated by MD
Problem: Mic-key falls out:
Cover with gauze and call MD immediately. Nurses DO NOT replace Mic-key’s

51. OTHER LONG-TERM FEEDING DEVICES

52. BARD FEEDING TUBE

53. BARD TUBE Lower profile than Mic-key
Less chance of accidental dislodgement (see picture-top middle is actual device)
Has bolus or continuous extension set option (see picture - middle and far left respectively)
Has a SEPARATE extension set for venting
The feeding extension sets do not vent (see picture-far right)
Usually patient/ parent preference re: Mic-key or Bard tube

54. ENTERAL FEEDS
CONTINUOUS VS BOLUS

55. ENTERAL FEEDS: CONTINUOUS
Delivered via feed pump at a set rate using kangaroo pump and bag (see below)
Can be delivered OG, NG, ND, GT
Check residuals every hr
Define parameters for residuals with House Officer re: return, discard, hold feeds

56. ENTERAL FEEDS: BOLUS Can be delivered NG, OG, GT only -NOT ND
Cannot gravity flow into ND tube - (ND needs continuous method of delivery)
Check residuals before giving feed by aspirating feeding tube prior to feed
Check MD order for instructions for residuals: ie. discard/give back/ hold feed
Delivered via “CHIMNEY”
That is, connect a 60 ml syringe (WITHOUT the barrel inside) to the feeding tube. Attach syringe to bed above level of patient’s head but no more than 18 inches above stomach

57. ENTERAL FEEDS: BOLUS
***Remember, the HEIGHT OF THE CHIMNEY dictates how fast the feeds will be delivered. The higher the chimney, the faster the feeds are delivered and visa versa
Deliver bolus feed over minutes by adjusting the height of the chimney &/or putting small amounts of feed in at a time
Flush and clamp when feed complete or vent to allow excess gas to escape

58. ENTERAL FEEDING: GENERAL GUIDELINES
Always confirm feed rate, method and type
Check Kardex to confirm depth at which tube placement documented
Number visible on tube at nare for NG/ND and at the corner of the mouth for OG/OD
Charted on Kardex
Confirm tube placement via auscultation and aspiration for stomach contents (auscultation and X- ray confirmation for ND)

59. ENTERAL FEEDING: GENERAL GUIDELINES
Check tape on tube is secure to both face and tube
Be aware tube can slide through tape out of stomach and into upper esophagus or posterior pharynx resulting in a high risk of ASPIRATION!
HOB up ° during feed
After bolus feeds
Instill 1-2 ml sterile H20 for small tubes
ml for larger tubes
Prevents clogging

60. DISCONTINUING OG/NG TUBES
Wait a minimum of 30 minutes after a feed before discontinuing to prevent emesis
Position patient HOB up °
Drape patient (chux)
Flush tube with 1-3 ml H20

61. DISCONTINUING OG/NG TUBES
Clamp
Remove tape from face
Withdraw tube and discard
Provide oral/nare care

62. ENTERAL FEEDS: SAFTEY & INFECTION CONTROL

63. SAFTEY/INFECTION CONTROL
Always check tube placement before use
HOB up ° during and after feeding
Stop feeds ½ hour before and after CPT
Kangaroo pump
Change bag every 24, only 4 hours of feed in bag

64. SAFTEY/INFECTION CONTROL
No microwaving of formula or breast milk
Breast milk - 2RN’s check and document
**DO NOT modify the feed tubing in any way
Prevents inadvertent IV delivery of enteral feeds
Use special orange-striped “safety” tubing if using Medfusion pump to deliver feeds

65. WHAT TO DOCUMENT WITH EACH FEED
Size and type of tube/device
Confirmation of placement, patency of tube/device
Amount, color, consistency of residuals

66. WHAT TO DOCUMENT WITH EACH FEED
Type of feed, amount, rate, method used to deliver (continuous/bolus)
Tolerance of feed
Complications/adverse side effects

67. REPORTABLE EVENTS Stop feeds and call MD for:
Abdominal distension or pain
Signs/symptoms of respiratory distress: gasping, coughing, cyanosis, excessive drooling
Decreased or absent bowel sounds
Altered skin integrity around tube site
Accidental removal or slippage of tube
Increased residuals
Diarrhea or cramping

68. GASTRIC TUBES AND DIAGNOSTIC STUDIES

69. DIAGNOSTIC STUDIES OG/NG Tubes can be used for :
Administration of barium for upper GI studies
Administration of contrast medium (i.e. radioisotope) for special CT studies
To withdraw gastric contents for specimen collection and examination

70. TUBES AND MEDICATION ADMINISTRATION

71. MEDICATION ADMINISTRATION
OG/NG/ND/GT TUBES CAN BE USED TO:
Give scheduled OG/NG/ND/GT medications
NOTE: If patient is on bolus feeds or is NPO except for medications, keep tube clamped x minutes after medication administration to ensure absorption
OG /NG/GT tubes can be used to deliver medications which:
Counteract the effects of overdose or ingestion (charcoal and mucomyst for example)

72. THE END!!!!!!!