G Tube ABC’s G Tube ABC’s

and some D’s aboutand some D’s about

Enteral FeedingEnteral 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

• Steps:– 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

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