The Care and Feeding of PEG Tubes: Is Nursing Care EvidenceBased

1
The Care and Feeding of PEG Tubes Is Nursing
Care Evidence-Based?

• Cathy Carlson, PhD, RN
• clcarlson_at_niu.edu

2
Do you know?

• For a patient with aspiration pneumonia secondary
  to dysphagia, survival is improved following PEG
  placement.
• True
• False

3
Do you know?

• What is the average cost of a PEG tube, feedings,
  and charges for major complications (directly
  related to the PEG) for 1 year?
• 7, 488
• 31,832
• 52, 535
• 65,682

4
Do you know?

• For Medicare patients who have PEGs placed, the
  one year mortality rate is
• a. 10
• b. 20
• c. 40
• d. 60
• e. 80

5
Do you know?

• How many PEG tubes are placed in the U.S. each
  year?
• 510,000
• 230,000
• 760,000
• 100,000

6
The Problem

• Health care systems in the U.S. does not provide
  consistent, high-quality medical care to all
  patients (IOM, 2001).
• Patients entitled to receive quality care that is
  individualized and based on the best scientific
  evidence
• Delay between a scientific finding and its use at
  the bedside of approximately 17 years (Balas
  Boren, 2000)

7
Evidence-Based Practice

• Evidence-based practice is the integration of
  best research evidence with clinical expertise
  and patient values (IOM, 2001)
• When evidence-based knowledge is incorporated
  into nursing practice, patients experience better
  outcomes
• Use of evidence-based practice will lead to
  greater health, longer lives, less pain and
  suffering, reduced disability, reduced costs, and
  increased personal productivity (IOM, 2001)

8
Faced with the choice between changing one's
mind and proving that there is no need to do so,
almost everybody gets busy on the proof.

• J.K. Galbraith

9
Sacred Cows

• A traditional practice used by nurses which may
  be incongruent with the evidence-base
• Sacred cows may be difficult to slay!

10
The Problem

• Lack of protocol for PEG tube care
• Use of an enteral feeding policy that may not
  reflect current evidence
• Use of an electronic procedure manual provided by
  a publisher
• (The procedure manual also does not reflect
  current evidence)
• Variation in healthcare providers orders
  regarding PEG tube care and enteral feeding
• Lack of nurses knowledge regarding PEG tube care
  and enteral feeding.

11
Critical Incident Reports

• 2006 Sentinel Event Alert Tubing Misconnections
• 4 enteral feedings connected to IV catheter (4
  cases) and a peritoneal dialysis catheter (1
  case) (Joint Commission, 2006)
• UK findings- 11 deaths over a two year period,
  due to misplaced feeding tubes (Merrill
  Elixhauser, 2005)

12
The Project Development of an Evidence-Based
Guideline for PEG Tube Care and Enteral Feeding

• Healthcare provider orders vs. protocol
• Divided according to Illinois Nurse Practice Act
• What nurses can do without an order

13
Devices are Attached to Complex People

• Statistics are people
• with the tears wiped
• away.
• Professor Irving Selikoff

14
The Challenge for Evidence-Based Practice"What
we really want to get at is NOT how many reports
have been done, but how many people's lives are
being bettered by what has been accomplished. In
other words, is it the science being used, is
it being followed, is it actually being given to
patients?........What effect is it having on
people?

• Congressman John Porter, 1998, Chairman, House
  Appropriations Subcommittee on Labor, HHS, and
  Education

15
Challenge to Nursing Care

• Practice to reflect current best practice
  recommendations
• To standardize nursing practice and documentation
• To optimize patient outcomes through risk
  reduction
• Prevent complications
• Facilitate tolerance and timely advancement of
  enteral feedings
• Extend patency and functionality of PEG Tubes

16
The Review

• Systematic Review
• Search
• Databases
• Internet
• Citations within identified studies
• Inclusion Criteria
• Studies were reported in English
• Studies reported findings on Adults (gt18)

17
Outline

• Statement of Variable
• Recommended Practice
• Evidence-based practice
• Inconsistent or ineffective practices
• Based on review of the literature

18
Evidence-Based Interventions to Prevent
Complications from PEG Tubes and Enteral Feedings
19
Aspiration
20
Does the Presence of a PEG Prevent Aspiration?

• Oral or regurgitated gastric secretions can be
  aspirated. PEGs cannot prevent aspiration of
  oral secretions (Finucane Bynum, 1996)
• No improvement in aspiration incidence with PEGS
  (Finucane, Christmas, Travis, 1999 AGA, 1995)
• Case-controlled studies identified tube feeding
  as a risk factor for aspiration and demonstrated
  high rates of pneumonia and death in tube fed
  patients (Pick et al., 1996 Bourdel-Marchasson
  et al., 1997 Li, 2002 Opilla, 2003)

21
Risk Factors for Aspiration

• High gastric residual volumes
• Impaired gastric motility
• Drugs like opioids, dopamine, propofol,
  neuromuscular blocking agents
• Hyperglycemia
• Supine positioning
• Poor oral health
• Neurological deficits
• Decreased level of consciousness
• Endotracheal intubation
• Vomiting
• Tube malposition (more related to NGT)
• Metheny Titler, 2001 McClave et al., 2002
  Metheny, et al., 2004

22
Body Positioning

• Recommendations

• Inconsistency

• The recommendation from the American
  Gastroenterological Association (1995)
  areElevation of the head of bed to a minimum of
  30 degree to 45 degree to reduce the risk of
  microaspiration (AGA, 1995 McClave et al., 2002
  Drakulovic et al., 1999 Opilla, 2003)
• Maintain head elevation for at least 30 minutes
  after intermittent feeding (AGA, 1995)

• Placing the head to 45 degrees may increase the
  risk for shearing injuries to the shin in
  critically ill patients (CCN, 2007)

23
Gastric Residual Volumes

• Recommendations

• Inconsistency

• A single high volume of 200-250 ml should be
  rechecked within an hour (Heyland et al., 2004
  McClave Snider, 2002 Heyland et al., 2003)
• Feeding should not be stopped for an isolated
  high volume (AGA, 1995 )

• No difference in incidence of aspiration between
  200 and 400 cc residuals (Lukan, McClave,
  Stefater, et al., 2002)
• No studies that predict an actual safe amount
  of residual volume (McClave, Snidor, 2002)

24
Protocols to Follow for Gastric Residual Volume
Testing

• Not Recommended

• Recommendations

• Discard the gastric contents after aspiration to
  prevent frequent tube occlusions
• Do routine flushes with 30 ml of H2Oafter the
  checks of gastric residual volumes
• (Bourgault et al., 2007)

• Reinstill or return the gastric contents after
  check to avoid lower potassium levels (Booker et
  al., 2000)

25
Gastric Residual Volume

• Not Recommended/
• Inconsistency

• Recommendations

• Use of prokinetic agents to promote motility if
  residual volumes remain high (Booth, Heyland,
  Paterson, 2002)
• Metoclopromide
• Consistently recommended by experts (Booth,
  Heyland, Paterson, 2002)

• Erythromycin
• Not recommended because of potential
  complications such as bacterial resistance (CCN,
  2007, Spain, 2002, Berne et al., 2002)
• No difference in pneumonia rates if promotility
  agents are used (Yavagal, Karnad, Oak, 2000
  Booth, Heyland, Paterson, 2002)

26
Assessment of Risk of Aspiration

• Not Recommended/ Inconsistency

• Recommendations

• Combined use of gastric residual volumes and
  clinical assessment is recommended (DiSario,
  2002 McClave et al., 2002 Parrish, 2003)

• Use of blue food dye
• Increased risk of metabolic acidosis, refractory
  hypotension and also, death (FDA, 2003).
• Inconsistent results regarding feeding type
  (Opilla, 2003 Loeb, Becker, Eady,
  Walker-Dilks, 2003)

27
Mouth Care

• Recommendations

• Brush teeth every shift
• If intubated, every 2 hours
• Lubricate lips as needed
• Dental care as directed
• (Loeb, Becker, Eady, Walker-Dilks, 2003
  McClave, et al., 2002)

28
Infection

• Peritonitis

29
Confirmation of Feeding Tube Position

• Recommendations

• Not Recommended or Inconsistent

• Direct visualization via endoscope is the primary
  method for initial confirmation
• Use indelible ink marking on the tube at the exit
  site or noting the cm markings at skin exit for
  secondary method (Metheny et al., 1990
  Bourgault, Ipe, Weaver, Swartz, and ODea, 2007)

• Auscultatory method false assurance of correct
  placement (Used by many nurses) (Rassias, Ball,
  Corwin, 1998 Metheny et al., 1990)
• Clinical assessment methods unable to detect
  misplacement of feeding tubes into the
  respiratory system (Rassias et al., 1998)
• pH testing is not reliable (Ellett Beckstrand,
  1999)

30
Malpositions Specific to PEGs
31
Preventing PEG Tube Migration
32
Frequency of Checking Placement

• Following insertion
• Prior to each bolus feeding
• Following a break in continuous feeding
• Prior to medication administration

• Alteration of external length of tube
• Interdepartmental transfer

33
External Bumper Position
34
Buried Bumper
35
External Bumper Position

• Recommendations

• Inconsistency

• Avoid direct contact with external bolster
  against the skin (DeLegge, DeLegge, Brady, 2006)

• Allow 1.5 cm between the esternal bumper of the
  PEG tube and the skin (Gencosmanoglu, Demet,
  Tozun, 2003)

36
Rotation of Tube

• Recommendations

• Rotate tube 180-360 degrees each day (Guenter,
  1999)
• Do not rotate the tube during the first 2 weeks
  following insertion (Guenter, 1999b)

37
Infection

• Insertion Site

38
Prevention of Infection

• Recommendations

• New PEGs Cleaned with gauze and sterile NS or
  H2O. Dry thoroughly. Cover with a light gauze
  dressing. (North West Melbourne Division of
  General Practice, 2006)
• Mature gastrostomy tube sites should be cleaned
  daily with soap and warm water, then dried
  thoroughly (National Collaborating Center for
  Nursing and Supportive Care, 2003)
• Unless drainage is excessive, no dressing is
  necessary (Guenter, 1999b)

39
Hypergranulation (Proud Flesh)

• Over growth of tissue around the stoma
• Causes
• Nonspecific
• Tube too loose or too tight
• Treatment may include
• Cauterization with silver nitrate
• Steroid-based creams

40
Excess Drainage

• Severity Varies
• Excess Drainage
• Enlargement of site
• Breakdown of site

41
Prevention and Treatment of Leakage

• Recommendations

• Inconsistency

• Assess the PEG site daily for erythema and
  drainage (Guenter, 1999b)
• Place skin barrier around insertion site (Davis,
  1989)
• For minor leakage, apply liquid antacids around
  the stoma 2X/day (Roche, 2003)
• Stabilize tube with an anchoring device (Guenter,
  1999b)

• Do not replace the original PEG with a larger one
  (Schapiro Edmundowicz, 1996)

42
Tube Occlusion
43
Causes of Tube Occlusions

• Inadequate tube flushing
• Medications
• Fungus
• Thick formulas
• Adherence of formula to the tube
• Reflux of gastric contents into tube

44
Prevention of Tube Occlusion

• Recommendations

• Routinely flush tube with water (Metheny,
  Eisenberg, McSweeney, 1988 Reising Neal,
  2005)
• Flush tube with 30 ml of water every 4 hours,
  before and after intermittent feedings, before
  and after medication, before and after gastric
  aspiration (Bourgault, 2007 Guenter, 1999a,
  1999b National Collaborating Centre for Nursing
  and Supportive Care, 2003)
• Use sterile water if immunocompromised

45
Treatment of Tube Occlusion

• Not Recommended/ Inconsistency

• Recommendations

• Use a syringe gt 30 ml and gently pull back on
  plunger (Guenter, 1999a, 1999b)
• Instill 20-50 ml of warm water (Guenter, 1999a)
• Using a syringe, alternate pressure and suction
  (Guenter, 1999a)

• Cranberry juice, soft drinks, and meat
  tenderizers have not been consistently effective
  (Marcuard et al., 1988 Bourgault et al., 2003)

46
Treatment of Tube Occlusion

• Not Recommended/ Inconsistency

• Recommended

• Milk the tube (Guenter, 1999a)
• If flushing with warm water water doesnt clear
  the obstruction, use a pancreatic enzyme solution
  (Marcuard, 1988 Bourgault, 2007)

• Use commercial decloggers with caution as they
  may perforate a compromised/ deteriorating tube

47
Treatment of Tube Occlusion

• Risk factors (incidence 9-20)
• ? Tube length Infrequent flushes Instilling
  meds? Tube caliber Continuous infusion
• Declogging agents (0none to 3dissolution) (p lt
  0.01)
• Agent Viokase (bicarb) Coke
  Papain Viokase (plain)
• Score 2.9 1.4
  0.8 0.8
• (Marcuard, Stegall, Trogdon, 1989)
  

48
The Magic Recipe

• Pancrelipase-8 tablet mixed with 325 mg sodium
  bicarbonate (crushed) and 5 ml of warm water
• Clamp tube for 5 minutes after administration
• Then flush with water

49
Medication Administration
50
Administering Medications

• Recommendations

• Consult with a pharmacist! (Guenter, 1999)
• Verify the position of the gastrostomy before
  administering medications (Guenter, 1999)
• Liquid forms of medications should be used if
  possible (Guenter, 1999 Phillips Nay, 2008)
• Dilute all medications with at least 30 ml of
  water (Guenter, 1999)
• Give medications individually with 30 ml
  before/after and 15 ml of water between each
  (Guenter, 1999)

51
Administering Medications

• Recommendations

• Use a syringe size greater than 30 ml as smaller
  syringes create too much pressure on the
  gastrostomy tubes (Guenter, 1999)
• Do NOT add medications to feeding formula
  (Guenter, 1999)

52
Diarrhea
53
Diarrhea

• Recommendations

• Evaluate etiology of diarrhea (AGA, 1995)
• Avoid stopping feeding but may reduce the flow
  rate (AGA, 1995)

54
Avoidance of Contamination

• Recommendations

• Wash hands carefully to minimize contamination
  (NICE, 2003)
• Use closed enteral feeding systems to reduce
  bacterial contamination (Jackson, 2002 NICE,
  2003)
• Routinely change formula container every 24 hours
  (Jackson, 2002)

55
Nutrition
56
Enteral Feedings

• Recommendations

• Inconsistency

• Give formula full strength, undiluted (Greenwood,
  2003)
• Begin feeding at 25 ml/hr increase rate by 25
  ml/hour every 4 hours if tolerated (Bourgalt, et
  al, 2007)
• Daily PEG tube requirements (Roche, 2003)
• Caloric and/or protein replacement 25 kcal/kg 1
  gm protein/kg
• Water replacement Free water 30cc/kg or 1cc/kcal

• No significant improvement in BMI, weight,
  albumin, cholesterol, triceps skin fold
  (Callahan, 2000) may not prevent weight loss or
  depletion of lean and fat body mass (Henderson et
  al, 1992)
• Significant improvement in albumin and weight
  gain (Norton, Homer-Ward, Donnelly, Long,
  Holmes, 1996 Park, Allison, Lang, et al., 1992)
• No published studies that demonstrate better
  tolerance in one-half strength feedings.

57
Feeding Assessment

• Recommendations

• Measure weight and assess weight change
• Check caloric and free water intake including
  formula and rate of 24 hour PEG regimen
• Assess PEG tube site
• Check albumin, electrolytes, BUN, and creatinine
• Assessment needed at 6 weeks, then every 4 weeks
  until stable for 2 consecutive visits, then 3-4
  month interval visits (Roche, 2003)

58
Interruptions in Feeding

• Recommendations

• Minimize interruptions
• Maintain feeding until start of minor procedures
  and restart within 1 hour following
• Stop feedings for 4 hours before anesthesia or
  major procedures
• (Greenwood, 2003)

59
Tube Dislodgement
60
Prevention of Tube Dislodgement

• Recommendations

• Check the security of the external disc every
  shift (Guenter, 1999b)
• Use a gastrostomy anchoring device to secure the
  tube (Guenter, 1999b)

61
Replacement Tubes

• Recommendations

• Inconsistency

• Do not replace a recently placed gastrostomy tube
  (lt 4 wks)with a replacement feeding tube or foley
  catheter (Bumpers, Collure, Best, et al., 2003)

• Balloon and non-balloon type replacement PEGs are
  equivilent (Heiser Malaty, 2001)
• May replace if tract is gt 2 weeks old (Hong Kong
  Geriatrics Society, 2003)

62
What Next?

• Evaluate the strength of the evidence
• Educate staff nurses
• Incorporate into electronic charting
• Develop a role for a PEG Tube nurse(s)
• Develop standardized orders for PEGs
• Develop follow-up methodology

63
Rating Scheme for the Strength Of The Evidence

• Evidence Categories
• Ia Evidence from meta-analysis of randomized
  controlled trials
• Ib Evidence from at least one randomized
  controlled trial
• IIa Evidence from at least one controlled study
  without randomization
• IIb Evidence from at least one other type of
  quasi-experimental study
• III Evidence from non-experimental descriptive
  studies, such as comparative studies, correlation
  studies, and case-control studies
• IV Evidence from expert committee reports or
  opinions and/or clinical experience of respected
  authorities.

64
Summary

• What should I remember from this talk?
• Do NOT carry out auscultation or whoosh test to
  assess position of tube
• Give each medication separately
• Who follows up patients after PEG tube insertion?
• Use evidence-based practice to provide better
  care
• Evidence-based practice is fun!

65
Questions?????