Nutrition management of enteral feeding - guidelines and procedures ect2353

CNSG Guidelines and Procedures for Management of Enteral Feeding Page 1 of 172 Created by Maggie Allen. October 2010. Updated July 2015. .

Guideline Title:

Clinical Nutrition Steering Group (CNSG)

Guidelines and Procedures for Management of Enteral Feeding

Executive Summary:

To optimise the care of adult in-patients receiving nutrition via an enteral feeding tube under the care of East Cheshire NHS Trust.

Supersedes: Version 1.2

Description of Amendment(s):

Guidelines reviewed and updated

This guideline will impact on: All staff caring for adult inpatients under the care of East Cheshire NHS Trust.

Financial Implications: Improvements in nutritional care should reduce costs and risks associated with sub-optimal patient nutrition.

Guideline Area: Nutrition Document Reference: CNSG guidelines

Version Number: 1.3 Effective Date: August 2012

Issued By: Departments of Dietetics and Gastroenterology

Review Date: June 2017

Author: Maggie Allen GI Nurse Specialist

Impact Assessment Date:

August 2014

APPROVAL RECORD

Committees / Group

Clinical Nutrition Steering Group

Date

August 2011

Consultation: Departments of Dietetics and Gastroenterology Clinical Nutrition Steering Group Infection prevention and control

June 2015

Approved by: Clinical Nutrition Steering Group July 2015

AMENDMENTS RECORD

August 2011 - Version 1.1 CNSG007 CNSG 008 and CNSG 012 guidelines updated for NPSA/2011/PSA002 alert compliance

August 2012 -Version 1.2 CNSG007 CNSG 008 and CNSG 012 guidelines updated for NPSA/2012/RRR001 alert compliance

June 2015 – Version 1.3 Guidelines reviewed and updated

CNSG Guidelines and Procedures for Management of Enteral Feeding Page 2 of 172 Created by Maggie Allen. October 2010. Updated July 2015. .

The following guidelines are to be used in association with CNSG 006 East Cheshire NHS Trust Enteral Feeding Policy for Adults MAIN INDEX

SECTION CONTENTS

PAGE

CNSG007 GUIDELINES FOR INSERTION AND MANAGEMENT OF NASOGASTRIC TUBES

3-26

CNSG 008

GUIDELINES FOR INSERTION AND MANAGEMENT OF NASAL BRIDLES

27-37

CNSG 009

GUIDELINES FOR INSERTION AND MANAGEMENT OF GASTROSTOMY TUBES

38-70

CNSG 010

PROTOCOL FOR FIRST ASSISTANT ROLE IN PEG INSERTION 71-79

CNSG 011

GUIDELINES FOR SUSPECTED PERITONEAL LEAK POST PEG INSERTION

80-81

CNSG 012

GUIDELINES FOR MANAGEMENT OF A JEJUNAL TUBE 82-98

CNSG 013

GUIDELINES FOR ADMINISTRATION OF FEED 99-111

CNSG 014

GUIDELINES FOR ENTERAL FEEDING COMPLICATIONS AND MANAGEMENT

112-130

CNSG 015

MICROBIOLOGICAL GUIDELINES FOR ENTERAL FEEDING

131-139

CNSG 016

GUIDELINES FOR ADMINISTRATION OF MEDICATION VIA ENTERAL TUBES

140-153

CNSG 017

GUIDELINES FOR ASSESSMENT AND MONITORING OF PATIENTS RECEIVING ENTERAL FEEDING

Available on Trust Intranet

CNSG 018

GUIDELINES FOR ENTERALLY FED PATIENTS ADMITTED TO HOSPITAL

154-156

PATIENT INFORMATION AND FORMS FOR PRINTING

CARE PATHWAY FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBES

158-165

ADVICE POST PEG REMOVAL

167

PRE-DISCHARGE TRAINING CHECKLIST- GASTROSTOMY FEEDING

167-168

NASOGASTRIC (NG) TUBE INSERTION AND MONITORING FORM

169-171

East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes Page 3 of 172 Created by Maggie Allen, October 2010. Updated March 2015.

Guideline Title:

Guidelines for Insertion and Management of Nasogastric Tubes

Executive Summary:

To optimise the care of adult in-patients receiving nutrition via a nasogastric tube under the care of East Cheshire NHS Trust.



Guidelines reviewed - no major changes



Guideline Area: Nutrition Document Reference: CNSG 007






August 2014

APPROVAL RECORD

Committees / Group


Date

August 2011

Consultation: Departments of Dietetics and Gastroenterology Clinical Nutrition Steering Group

October 2010- August 2011. June 2015

Approved by:


July 2015

AMENDMENT RECORDS

August 2011 - Version 1.1 Guidelines updated for NPSA/2011/PSA002 alert compliance.

May 2012 -Version 1.2 CNSG007 CNSG 008 and CNSG 012 guidelines updated for NPSA/2012/RRR001 alert compliance.

June 2015 – Version 1.3 Guidelines reviewed

April 2016 – Version 1.4 Addition to NG insertion and monitoring chart – to add ‘decision maker, name, date and time’.


GUIDELINES FOR INSERTION AND MANAGEMENT OF NASOGASTRIC TUBES

INDEX

Section Contents

Page

1.0 Definition 5

2.0 Indications 5

3.0 Contraindications 5

4.0 Assessment 6

5.0 Referral 6

6.0 Consent 6

7.0 Types of tubes and tube selection 7

8.0 Insertion of nasogastric tubes 8-10

8.1 Procedure 8-10

9.0 Confirmation of position 11-15

9.1 pH Testing 12

9.1.1 Obtaining and checking aspirate 12-13

9.1.2 Methods for successfully obtaining gastric aspirate 13

9.1.3 Recommended pH strips and usage 13

9.1.4 PH Values 13

9.1.5 Documentation of pH result 13

9.2 X-ray testing 13-14

9.2.1 When to X-ray 13

9.2.2 How to X-ray 14

9.2.3 Who should read the X-ray 14

9.2.4 Documentation of X-ray 14

9.3 Who should check the position of the tube 14

9.4 When to check the position of the tube 15

9.5 Unsafe methods for checking NG position 15

10.0 Management of a nasogastric tube 16

10.1 When to replace a should a nasogastric tube 16

10.2 Securing a nasogastric tube 16

10.3 Flushing 16

10.4 Blocked tube 16

11.0 Nasal care 16

12.0 Mouth care 17

13.0 Removal of a nasogastric tube 17

13.1 Planned 17

13.2 Accidental 17

13.3 Repeated unplanned removal 17

14.0 Escalation procedure for patient requiring NG tube insertion

18

15.0 Discharge of patients on NG feeding 19

Appendix 1 References and bibliography 20-21

Appendix 2 Links to supporting documents

Nasogastric insertion and monitoring form

NPSA alerts relating to NG use

Manufacturer’s information

Patient information

22

Appendix 3 Algorithm to check NG position 23-24

Appendix 4 Flow chart to guide decision making for tube feeding route 25

Back to main index


1.0 DEFINITION back to index A Nasogastric (NG) tube is a flexible tube that can be inserted transnasally into the stomach. It is commonly used for delivery of feed, fluids, medication, or drainage of gastric contents. Table 1

ADVANTAGES DISADVANTAGES COMMON COMPLICATIONS

RARER COMPLICATIONS

Readily available

Easily inserted

Easily reversed

Rapid start of enteral feeds

Few contraindications to placement

Easily dislodged

Uncomfortable

Aesthetically displeasing

Pulmonary intubation

Pulmonary aspiration

Reflux

Nasal and mucosal ulceration

Epistaxsis

Gastrointestinal bleeding

Oesophageal gastric and duodenal perforation

Pneumothorax

2.0 INDICATIONS back to index

Nutritional support and hydration.

Nasogastric feeding is the most common method of providing short-term artificial nutritional support in the acute setting. Decision to feed with a nasogastric tube should be a multidisciplinary approach.

NG tube feeding should be considered for patients who: -

are malnourished.

have a functioning gastrointestinal (GI) tract.

require short-term tube feeding (up to 4-6 weeks).

require long-term tube feeding (if an alternative route is inappropriate or not possible i.e. Percutaneous Endoscopic Gastrostomy (PEG) Radiologically Inserted Gastrostomy (RIG) or Parenteral Nutrition (PN).

are unable to fulfil their nutritional requirements with normal /modified diet nutritional supplements.

are not predicted to fulfil their nutritional requirements with normal / modified diet nutritional supplements.

have increased nutritional requirements e.g. sepsis, trauma, post-op stress & burns. See appendix 5 for flow chart to guide decision making for tube feeding route 3.0 CONTRAINDICATIONS back to index Table 2

Absolute

Relative

Non-functioning GI tract e.g. ileus.

Large gastric aspirate and/or high risk of aspiration.

Intractable vomiting not resolved by anti-emetics. Basal skull fracture, as the tube may enter the brain if incorrectly positioned (oro-gastric positioning may be appropriate).

Oesophageal varices

Mucositis

Vomiting responding to anti-emetics

Recent radiotherapy to head and neck

Advanced neurological impairment

Obstructive pathology in oropharynx or oesophagus preventing passage of the tube e.g. stricture, tumour, pharyngeal pouch. Procedure may need to be done under endoscopic or fluoroscopic control. Specialist input advised.


4.0 ASSESSMENT back to index Before a decision is made to insert a nasogastric tube, an assessment is undertaken to identify if nasogastric feeding is appropriate for the patient, and the rationale for any decision is recorded in the patient’s medical notes.

The decision to insert a nasogastric tube for the purpose of feeding must be made following careful assessment of the risks and benefits by at least two competent health care professionals including the senior doctor responsible for the patient’s care.

The decision to initiate enteral feeding should involve the patient, carer/family, and members of the multi-disciplinary team including speech and language therapists and dietitians as appropriate.

The patient must be assessed for the most suitable route of enteral feeding e.g. stomach or small bowel and most suitable type of tube.

The indication and rationale of the route and type of tube for enteral feeding will be clearly written in the patient’s medical notes. As a minimum, documentation should include signed, dated and timed entry, of the process of initial risk assessment that evaluates the benefits against the risks of introducing a nasogastric tube for the purpose of feeding. The following group of patients are at a high risk of incorrect tube positioning, dislodgement and aspiration. Appropriate specialist advice should be taken if the patient has:

Maxillo-facial disorders

Laryngectomy


Any disorder of the oesophagus/pharynx e.g. varices, stricture, pharyngeal pouch.

Nasal C.P.A.P. Oro-gastric positioning may be indicated following head injury or neuro surgery. High Risk also includes patients who: -

Are comatose/semi-comatose

Are ventilated/sedated

Have a swallow dysfunction

Have recurrent retching/vomiting

Need to be nursed prone 5.0 REFERRALS back to index

All patients requiring NG feeding should be referred to a dietitian. This may not be possible if the decision to feed is made out of hours. In this case the dietetic referral should be phoned through to the dietetic answer machine x1126.

Patients with the any of the above conditions or requirements as seen above in section 4 above will be referred a Trust employee with expert knowledge of insertion of NG tubes.

6.0 CONSENT back to index Informed consent must be obtained from the patient prior to the procedure as per Trust policy for consent. The consent must be recorded in the patient’s medical notes. If the patient lacks capacity for consent, the decision to treat must be made within the patient’s best interests. The goals of the treatment should be clearly identified in the patient’s medical notes. The procedure should also be discussed with the family where appropriate.


7.0 TYPES OF TUBES AND TUBE SELECTION back to index

Nasogastric tubes are manufactured in a range of sizes and materials (polyvinal chloride (PVC), polyurethane and silicone.

Feeding tubes must comply with: -

1. National Patient Safety Alert (NPSA) 19 (2007) Promoting safer measurement and

administration of liquid medicines via oral and other enteral routes.

Enteral feeding systems should not contain ports that can be connected to intravenous syringes, or that have end connectors that can be connected to intravenous or other parenteral lines.

Enteral feeding systems should be labelled to indicate the route of administration. 2. National Patient Safety Alert (NPSA 2011) Reducing the harm caused by misplaced

nasogastric feeding tubes in adults, children and infants.

The tubes should be fully radio-opaque with externally visible markings to enable accurate

measurement, identification and documentation of their position (NPSA 2011).

NB. PVC tubes (e.g. Ryles) are not recommended for feeding as they harden in contact with gastric acid and can cause internal ulceration (Payne-James et al 2001). In addition, they do not comply with NPSA guidance. Recommended tube size 8 Fr - recommended for standard use 10Fr - recommended if large volumes of medication are required via the tube (increased risk of blockage). Rationale for use of fine bore feeding tube

More comfortable

Less likely to interfere with eating and drinking

Less risk of reflux

Less likely to delay the return of swallowing mechanism Guidewires Fine bore tubes usually have a guidewire to aid insertion. The manufacturer’s guidance should be adhered to, primarily, to ensure the guidwire is firmly positioned prior to use and never reinsert the guidewire whilst the tube is within the patient.

back to index


8.0 INSERTION OF NASOGASTRIC TUBES back to index The procedure will be carried out by an appropriate healthcare professional who has received training in the procedure and has been assessed as competent. More advanced skills may be required if the patient is at a high risk of a tube being misplaced during insertion (see section 4) Additional training or expert input should be sought if required.

Placement should be delayed if there is insufficient experienced support available to accurately confirm nasogastric tube placement (e.g. at night), unless clinically urgent, and that the rationale for any decisions made is recorded in the patient’s medical notes.

8.1 Procedure back to index

Equipment Clinically clean surface, CE accredited pH indicator strips, tissues, 60ml enteral/oral syringe, gloves/apron, nasogastric tube. Freshly drawn tap water to flush the tube once position confirmed. Lubricating Jelly (may not be necessary if the tube has a water activated lubricant coating e.g.

Corpak Corflo tubes Nasal/cheek dressing to secure tube (included in some packs). Glass of water/coloured fluid and a straw (only if the patient has a safe swallow reflex)

Table 3

Action

Rational

Prior to the procedure, check the medical and nursing notes for complications, e.g. anatomical variations due to surgery or cancer.

These may affect the procedure and result in further complications. Patients with head injury or facial trauma may have the feeding tube passed through the mouth and down into the stomach to bypass nasal damage and cerebral oedema.

Assess the patient’s requirements. The appropriate tube is inserted to meet the patient’s needs and clinical condition and that the tube is acceptable and comfortable.

Explain the procedure to the patient (even if the patient appears not to understand).

To ensure that the patient understands and is able to give consent, also to co-operate with the procedure.

Arrange a signal so that the patient can communicate with the nurse during the procedure e.g. raise a hand.

Helps to alleviate fear as the patient has some control over the procedure.

Assist the patient in a semi-upright position. Support the head in a slightly forward position.

Assists swallowing and helps prevent tracheal placement if the swallow is compromised.

Check that the nostrils are patent by asking the patient to sniff with one nostril closed. Repeat with the other side. Alternate nostrils if replacing a tube.

Helps identify potential obstruction. Prevents nasal irritation and potential ulceration.

Wash hands and put on non-sterile gloves and an apron.

Minimises cross infection (Anderton 1995).

Unpack the tube, close the end connectors. If the tube has a guide wire, gently push it into the tube until it is fixed (see manufacturer’s guidelines in packet).

Check that the tube is not kinked.

Prevents the tube from coiling back on itself during insertion.


Table 3 continued

Action

Rational

Place the tip of the tube (the distal opening, if the tube is weighted) at the xiphisternum and measure up to the tip of the nose and then to an ear lobe (NEX measurement). Note the measurement on the tube.

Ensures that the correct length of tube is placed in the stomach.

Lubricate the tube. Use a thin coating of water based jelly. If the tube is hydrophilic

e.g. Corpak Corflo immerse the distal end of the tube in water to activate the lubricant. If re-passing a Corflo, use a lubricant.

Facilitates easy passage of the tube.

Insert the tip of the tube into the chosen nostril, advancing it, horizontally, gently along the floor of the nostril, parallel to the nasal septum, to the nasopharynx and then oropharynx. The patient may sneeze. Reassure. If resistance is met, withdraw slightly and alter the angle of insertion, otherwise try the other nostril.

Follow the natural anatomy of the nose.

If the patient is able to swallow small sips should be taken at this stage. An assistant may be required to help give thickened fluids to swallow.

The swallowing action places the epiglottis over the trachea so allowing the tube to enter the oesophagus. Also the patient has something else to focus on.

If liquids are contra-indicated, sometimes placing a cold spoon on the tongue may initiate a swallowing reflex.

Advance the tube down the oesophagus with successive swallows until the correct measurement or mark is seen at the nostril.

If the tip of the tube is in the oesophagus there is a high risk of aspiration. If too much tube is inserted it might kink in the stomach, or pass through the pylorus into the duodenum.

Check the position (see section 9.0 below)

To verify position in the stomach

NB

DO NOT FLUSH the tube before gastric placement has been confirmed.

Internal guidewires/ stylets should NOT be lubricated before gastric placement has been confirmed.

Water activation of the lubricant may give an inaccurate low pH result. NPSA/2012/RRR001

Fix the tube in position (See section 10.2) Helps prevent dislodgement.

NB. This should be done after successful verification of the tube’s position, as it may need to be moved to obtain aspirate. If X-ray is required, the tube should be secured to the nose/cheek.

back to index


Table 3 continued back to index

CAUTION

Never advance the tube against resistance, pull back slightly and retry.

If the patient shows signs of respiratory distress i.e. coughing gasping or cyanosis, the tube may have entered the trachea. Pull the tube back or remove to allow time to recover. If respiratory distress is prolonged or worsens, seek medical assistance.

Top tips (expert opinion): back to index

Hold the tube straight rather than coiled in your hand.

If the patient has a swallowing difficulty, altered consciousness or inability to cooperate: a) rotate the tube in your hand so that the tip points slightly upwards. This will position the

tip in the correct position on the nasopharyngeal wall. b) tip the patient’s chin towards the chest. c) advance the tube through the nostril and into the nasopharynx until resistance is felt

(usually 12-14cm marking on tube), there may be an involuntary swallow reflex stimulated by the tube. Advance the tube with the swallow. If no reflex, advance the tube slowly or the tube will back up into the mouth. Gentle pressure will allow the tube to pass into the oesophagus.

If after 3 attempts NG insertion has failed or pulled out by the patient on three consecutive occasions, escalate as soon as possible to an experienced practitioner (senior nurse/clinician/nurse specialist).

Action

Rational

Document

Type of tube, size and lot number

Name of person inserting the tube

The cm measurement on the tube at the exit point from the nostril.

The pH value (if gastric aspirate obtained)

Which nostril

The health care professional (HCP) reading the X-ray should record the result in the patient’s notes (See section 9.2.4 for

further guidance)

Ease of insertion

Tracking and traceability

For audit and training requirements

Allows the user to assess whether the tube has changed position.

Allows staff to compare with previous readings

Prevents the same nostril being used

To identify whether the tube is safe for use.

For tracking and accountability.

Useful information for other healthcare professionals inserting subsequent tubes.

Dispose of clinical waste as per Trust policy. The guide wire must be placed in the sharps bin.

Prevent contamination and sharps accident.

Wash hands as per Trust policy

Minimise risk of contamination


9.0 CONFIRMATION OF TUBE POSITION back to index

NOTHING should be introduced down the tube before gastric placement has been confirmed;

DO NOT FLUSH the tube before gastric placement has been confirmed;

Internal guidewires/ stylets should NOT be lubricated before gastric placement has been confirmed.

http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441

pH testing is used as the first line test method, with pH between 1 and 5.5 as the safe range, and that each test and test result is documented on a chart kept at the patient’s bedside.

An attempt at pH testing must be carried out following every nasogastric tube insertion even if the criteria for x-ray testing are met. This will allow for a baseline recording. Studies suggest a 90% + success rate in obtaining aspirate.

X-ray is used only as a second line test when no aspirate could be obtained or pH indicator paper has failed to confirm the position of the nasogastric tube.

NPSA/2011/PSA002 alert: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. 9.1 pH Testing back to index 9.1.1 Methods for successfully obtaining gastric aspirate Aspiration of gastric contents is sometimes difficult. The table below offers suggestions. A combination of these may be required. Refer to algorithms 1 and 2 in appendix 3 for further guidance. Patience is required. Table 4

ACTION

RATIONAL

Always use a large enteral syringe (50cc min).

Small syringes have insufficient draw.

Insert 20 – 30mls of air, then aspirate.

Repeat several times, aspirating after each injection of air.

If unable to aspirate air, move the tube in or out until air is returned. Usually a small amount of fluid will be returned with the air (0.5mls is sufficient to cover the pH strip).

The most common position for a return of aspirate is when the tube markings show between 52-60cm at the exit from the patient’s nose (expert opinion).

Pushes the tube away from the gastric mucosa, which may occlude the tube.

Allows the stomach to inflate and redistribute the position of fluid slightly (Colagiovanni 1999).

Lie the patient on their left side.

Gastric fluid will pool in a different position.

Alter the position of the tube and retry.

The tube may be positioned insufficiently, or too far into the stomach.

Flush the tube with water following aspiration Gastric acid causes the protein in the feed to coagulate and increases the risk of tube blockage.



9.1.2 Recommended pH strips and usage

Tube position must be checked using pH indicator strips that are CE marked, intended by the manufacturer to test human gastric aspirate and have a clear definition between pH 5-6 (NPSA 2005, 2011).

pH strips must be used and stored according to manufacturer’s instructions. The reagent section should not be contaminated before use through handling or inappropriate storage.

It is not accepted practice to put gastric aspirate onto the syringe wrapping/cover and then to run reagent strips through the aspirate. This may alter the pH reading (NPSA 2005).

NB.

The lids must be kept on the containers when not in use.

One box per patient – sharing has a high risk of cross contamination.

The box must be decontaminated once it is no longer required for a patient.

back to index 9.1.3 pH Values A pH of less than 5.5 is a reasonable indicator of gastric placement. (NPSA 2005) The pH of pulmonary fluid is normally above 6 The pH of intestinal fluid is normally above 6

Gastric pH levels may be elevated above 5.5 due to: - a) Medication i.e. H2 antagonists and proton pump inhibitors which inhibit or reduce acid production; antacids temporarily reduce gastric acidity by neutralising hydrochloric acid. b) Reflux of intestinal contents into the stomach (Metheny et al 1994b). c) Dilution of gastric acid due to:

recent feed/flush: wait half an hour and retry.

continuous feeds: consider stopping the feed for half an hour (Colagiovanni 1999). CAUTION: Stopping feed should be carried out with extreme caution for patients on insulin infusions for tight glycaemic control and only if other methods have failed. Stop insulin infusion whilst the feed is turned off (NPSA 2005).

If aspirate values are higher than normal, it can be hard to assess the position of the tube. Using algorithms 1 and 2 in appendix 3 will help individuals to assess and rationalise their decision making in order to make NG tube management as safe as possible. 9.1.4 Documentation of pH result Each pH test and result must be documented on the nasogastric monitoring form kept at the patient’s bedside.

back to index


9.2 X-Ray testing

Table 5

Method

Advantages Disadvantages

X-ray 2nd line testing method. See section 9.2 for indications

This is the most accurate method of confirming positioning.

No guarantee that the tube is still in position once the patient has returned to the ward and for the subsequent duration of NG feeding.

Risk of frequent exposure to X-rays.

Delay in commencing feeding via the tube.

Cost and resource implications.

Impractical for patients based in the community (Colagiovanni 1999).

9.2.1 When to X-ray back to index X-ray following insertion is only indicated if:

The patient is unconscious with no gag reflex (ICU protocol).

The patient has altered anatomy e.g. known large hiatus hernia, pharyngeal pouch, previous surgery on the upper GI tract.

There is absence of aspirate

pH testing is inconclusive.

Difficult tube insertion.

Fractured base of skull.

Recent radiotherapy to head and neck.

Recent surgery to head and neck. X-ray should not be used routinely to confirm tube position during subsequent use. If you are unable to confirm position using the above guidelines, refer to algorithms 1 and 2 in appendix 1 for further guidance for checking the tube position following failure to obtain aspirate or inconclusive pH values. An attempt at pH testing must be carried out following every nasogastric tube insertion even if the criteria for x-ray testing are met. This will allow for a baseline recording. Studies suggest a 90% plus success rate in obtaining aspirate. (NPSA 2011). 9.2.2 How to X-ray back to index

When ordering an X-ray check, the request form must clearly state that the purpose of the x-ray is to establish the position of the nasogastric tube for the purpose of feeding. The radiographer is responsible for: -

Ensuring that the nasogastric tube can be clearly seen on the x-ray to be used to confirm tube position.

Adjusting the exposure of the x-ray to allow the nasogastric tube to be visible to the bottom of the film.

Ensuring that the film is centred lower than would normally be appropriate for a chest x-ray so that it shows the abdomen as far as possible below the diaphragm.

Adjusting the x-ray film to show the bottom of both hemi-diaphragms in the midline.


X-rays that are not as described above will not allow accurate interpretation of nasogastric tube placement and should not be allowed out of the x-ray department. If there is any difficulty in interpretation the advice of a radiologist should be sought. Any nasogastric tubes identified to be in the lung should immediately be removed whether in the x-ray department or clinical area.

9.2.3 Who should read the X-ray? back to index

X-rays must be checked by an appropriately trained clinician/advanced nurse practitioner, with evidence to support this skill. 9.2.4 Documentation of X-ray Documentation following X-ray should include:

who authorised the x-ray

who confirmed the position of the nasogastric tube. This person must be evidenced as competent to do so

confirmation that any x-ray viewed was the most current x-ray for the correct patient

the rationale for the confirmation of position of the nasogastric tube, i.e. how placement was interpreted, and clear instructions as to required actions. For example:

19 January 2011, 10:30 – Dr A. Smith – core surgical trainee X-ray taken at 10:15 today NG tube passed down midline, past level of diaphragm and deviates to left Tip is seen in stomach Plan: NG tube safe to use for feeding Dr A. Smith 9.2.5 Cautions

There is no guarantee that the tube is still in position once the patient has returned to the ward and for the subsequent duration of NG feeding. The tube position i.e. centimetre marking at the tube’s exit from the nostril, should be checked and compared with the position post insertion, by the member of staff using the tube immediately prior to use.

Risk of frequent exposure to X-rays.

Delay in commencing feeding via the tube.

Cost and resource implications.

Impractical for patients based in the community 9.3 Who should check the position of the tube? back to index

Any health professional/carer/patient prior to using the tube.

In the majority of cases nurses pass the tube and manage subsequent feeding. A nurse may be involved in training a patient/carer to manage the tube.


9.4 When to check the position of the tube back to index After initial tube insertion

At least once per shift if continuous feeds are in progress

Before each bolus feed, fluid or drug administration.

If the patient complains of discomfort or feed reflux in the throat or mouth.

If the patient suddenly shows signs of respiratory distress, e.g. breathlessness, strider, cyanosis or wheezing.

Vomiting or violent retching.

Severe coughing bouts.

If the measurement marking the tube’s exit from the nose has changed.

If the tube length appears to have changed.

Following transfers from other clinical areas if feed in progress. 9.5 Unsafe methods for checking NG position back to index Table 6

METHOD

REASON WHY UNSAFE

Auscultation – the injection of 20 –30mls of air into the tube via a syringe whilst listening with a stethoscope over the left upper quadrant or epigastrium for a distinctive sound whooshing sound.

Auscultation cannot predict whether tube tip location is in the oesophagus, stomach or respiratory tract (Metheny et al 1990a and Neumann and Meyer 1995).

Unsuitable for obese patients, as no sound may be heard.

There are reported cases showing that NG tubes checked by air auscultation were later shown to have tracheopulmonary placement. (Rassias et al 1998).

Eleven deaths reported between 2002-2004 due to misplaced NG tubes following auscultation tests and using litmus paper (NPSA 2005, Colagiovanni 1999).

Checking ability to speak Fine bore tubes are small enough not to affect speech (Colagiovanni 1999).

Signs of respiratory distress Fine bore tubes might not cause respiratory distress.

Patients with a poor gag reflex, or altered consciousness might not demonstrate these signs.

Using Litmus paper to test aspirate Insufficiently accurate

Turns pink/red in contact with aspirate that has a pH value as high as 6.5 (NPSA 2005).

Placing the proximal end of the nasogastric tube in water and watching for bubbles to indicate placement in the lungs. If no bubbles, the tube is in the stomach.

Inaccurate and unsafe (Colagiovanni 1999).


10.0 MANAGEMENT OF A NASOGASTRIC TUBE back to index 10.1 When to replace a nasogastric tube Refer to manufacturer’s guidelines and individual patient assessment. Table 7

TUBE

TIME

Ryles tube Used for aspiration only

10 days, or sooner, if causing discomfort (Dougherty and Lister 2004)

Corpak Corflo tube

The manufacturers of Corflo tubes do not state a time limit for usage and suggest that they can be used as long as they are functional. (Merck communication). Decision to replace will depend on: -

Viability of the tube

Tolerance of the procedure by the patient

Difficulty in insertion

Other tubes Check with manufacturer/nurse specialist

10.2 Securing a nasogastric tube back to index

The tube should be fixed at the nose with a plaster.

If tube has already been accidentally removed on multiple occasions a nasal retention device (bridle) should be considered (NICE Clinical Guidelines (32)

2006) . .See Guidelines for Insertion and Management of Nasal Bridles for further information.

The external part of the tube should be brought to the same side of the face as the insertion nostril and allowed to rest over the ear.

- A dressing (preferably clear for aesthetic reasons) should be placed over the tube along the cheek. This is recommended for the following reasons: Less irritating for the patient as it secures the tube out of their line of sight.

- Does not interfere with the patient’s eating, by keeping the tube away from the mouth. - A confused patient is less likely to pull the tube out as they cannot see it or feel it when

they bring their hands up to the mouth area. - Patients receiving humidified oxygen (excess moisture makes the nasal tape slip).

The dressings should be checked regularly and replaced if dirty or peeling off.

The skin should be cleaned of any residual adhesive prior to replacing the tape/dressing. 10.3 Flushing back to index

Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes. 10.4 Blocked tube

See CNSG 014 Guidelines for Enteral Feeding Complications and Management. 11.0 NASAL CARE

The nose should be checked and cleaned daily.

If the nose appears sore or ulcerated, consider re-passing the tube via the other nostril. back to index


12.0 MOUTH CARE back to index Maintenance of oral hygiene is essential, particularly is a patient is unable to

have oral food and fluids

attend to their own oral care Table 8

PROBLEM REASON

ACTION

Dry sore mouth

Inadequate mouth care

Mouth breathing

Poor dental condition

Clean teeth/dentures with a soft toothbrush or a damp swab wrapped around a gloved finger (depending on patient). The frequency will depend on the condition of the patient, twice daily minimum).

Check the tongue and the hard palate for thickened secretions and remove.

Use lip salve to protect lips from chapping.

Consider use of artificial saliva if appropriate

Refer to dentist if necessary.

Saliva : - Tenacious Hyper-salivation

Dehydration

Neurological condition

Unable to swallow oral secretions

Ensure adequate fluids.

Consider drug therapy. Consult doctor.

Maintain good oral hygiene.

Refer to Guidelines for the Oral Healthcare of Stroke Survivors by the British Society of Gerodontology for comprehensive guidance as to management of oral hygiene. http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf 13.0 REMOVAL OF A NASOGASTRIC TUBE 13.1 Planned The patient must be referred to the dietitian prior to discontinuation of enteral feeding for review as to whether oral intake is sufficient and whether oral supplements may be required. 13.2 Accidental If the tube is still required for nutrition, fluids or medication, it should be reinserted as soon as possible – within a 6 hour period is recommended. See below for Escalation Procedure (section 14.0) for patient requiring NG tube insertion. In addition: -

Ensure that the tube is correctly positioned and secured, as above, when reinserted.

Arrange for alternative fluid support as necessary.

Arrange for an alternative route for medication as appropriate. 13.3 Repeated unplanned removal If unplanned removal is repeated, refer to CNSG 008 Nasal Bridle guidelines Appendix 1 flow chart to manage repeated unplanned removal of nasogastric tube.

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http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf


14.0 Escalation procedure for patients requiring NG tube insertion with or without introducer.

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Patient requires NG tube

Competent nurse unavailable

Competent Medical F1/F2 to insert

F1 /F2 unavailable or do not have skill to insert within two hours of request: Escalate

Competent Nurse identified and inserts as per Trust Guidelines for Insertion and Management of Nasogastric Tubes

Fully document procedure in medical and nursing notes

NG tube becomes

Blocked

Dislodged

Accidentally removed

Refer to competent nurse within area if unavailable escalate

Escalate to: In hours

Senior nurse /Matron for area.

MNP/PSP

Registrar

GI specialist nurse

Outreach team Out of hours

Senior nurse for area

Hospital senior nurse/Night sister

Registrar Competent in the procedure

Matrons Sam Leonard and Hayley Readiing August 2010


15.0 Discharge of patients on NG feeding Patients must have prior to discharge: -

A multidisciplinary risk assessment to assess needs (Appendix 5 Flow chart to guide decision making for tube feeding route)

Referral to a dietitian

Training and assessment of competency for them and/or their carers for tube care and feeding.

An agreed plan if tube removed accidentally or blocked.

A discharge pack to include: - o Care of NG tube o Care of equipment o Contact numbers o Feeding regimen o Position monitoring form o CE accredited pH strips o Manufacturer’s guidelines for using pH strips o Spare NG tube o 7 days feed and equipment o How to maintain oral hygiene

Action plan if tube removed The plan will depend on the patient’s circumstances and the support available in the community

If tube comes out overnight wait until daytime for replacement

If the patient has had recent radiotherapy treatment at Christie, they will be at a high risk of procedure related complications. In the absence of specialist support, refer them back to Christie hospital.

If the patient has head and neck cancer and has had treatment at Leighton hospital, they have open access to ward 10 and should return there for tube placement.

Any other patients should come to come to A&E bringing their spare tube with them.

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APPENDIX 1 - REFERENCES AND BIBLIOGRAPHY back to index

Anderton A. (1995). Reducing bacterial contamination in enteral tube feeds. British Journal of Nursing 4(7); 368-376 BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners and Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead. BAPEN (1996) Standards and Guidelines for Nutritional Support in Hospitals (ed. T. Sizer). British Association for Parenteral and Enteral Nutrition, Maidenhead. Boyes, R.J., Kruse, J.A. (1992) Nasogastric and nasoenteric intubation. Critical Care Clinics 8(4): 865-867. British Society of Gerodontology (2010) Guidelines for the Oral Healthcare of Stroke Survivors. http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf Colagiovanni L. (1999) Taking the tube. Nursing Times 95:21 Supplement. Colagiovanni L. (2000) Preventing and clearing blocked feeding tubes. Nursing Times. 96(17): 3-4. Dougherty, L. & Lister S. (eds) (2004) The Royal Marsden Manual of Clinical Nursing Procedures, 6th edn. Blackwell Science Ltd, Oxford. Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in Partnership with Nutricia. Fater, K.H. (1995) Determining nasoenteral feeding tube placement. MedSurg Nursing, 4(1): 27-32. Human Rights Act 1998 Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical Devices: Implications and Consequences of Reuse. MDA DB2000(04) Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding Systems. MDA SN2000(27). Medicines and Healthcare products Regulatory Agency (MHRA2004) Enteral feeding tubes (nasogastric) MDA/2004/026 Mental Capacity Act 2005 Metheny N. et al. (1990a) Detection if inadvertent respiratory displacement of small bore feeding tubes: a report of 10 cases. Heart Lung 19(6): 631-638. Metheny N. et al. (1990b) Effectiveness of the ausculatory method in predicting feeding tube location. Nursing Research 39:262-7. Metheny N. et al. (1993) How to aspirate from small bore feeding tubes. American Journal of Nursing, May 86-89. Metheny N. et al. (1993) Effectiveness of pH measurements in predicting feeding tube placement: an update. Nursing Research 42(6): 324-331.

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Metheny N. et al. (1994a) Visual characteristics of aspirates from feeding tube as a method for predicting tube placement. Nursing Research 43(5): 282-287. Metheny N. et al. (1994b) pH testing of feeding tube aspirates to determine placement. Nutrition in Clinical Practice 9(5): 185-190. National Institute for Clinical Excellence (NICE) (2013) Nutrition support in adults Evidence Update August 2013. A summary of selected new evidence relevant to NICE clinical guideline 32 ‘Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition’ (2006) Evidence Update 46 National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation of placement NPSA/2012/RRR001 22/03/12 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441 National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA/2011/PSA002 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640 National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric feeding tubes NPSA/2005/05 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59794&p=4 National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139 Infection Prevention and control of healthcare-associated infections in primary and community care http://guidance.nice.org.uk/CG139 National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral supplements, parenteral and enteral feeding. London. http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf Neumann M.J., Meyer C.T. (1995) Hold that X-ray: aspirate pH and auscultation prove enteral tube placement. Journal of Clinical Gastroenterology 20(4): 293-295 Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London, NMC. Payne-James, J., Grimble, G. & Silk, D. (2001) Enteral nutrition: tubes and techniques of delivery. In: Artificial Nutritional Support in Clinical Practice, 2nd edn (eds J. Payne-James, G. Grimble & D. Silk). Greenwich Medical Media, London. Powell K.S. et al (1993) Aspirating gastric residuals causes occlusion of small bore feeding tubes. Journal of Parenteral and enteral Nutrition. 17(3): 243-246 Rassias A.J. et al (1998). A prospective study of tracheopulmonary complications associated with the placement of narrow bore feeding tubes. Critical Care 2: 25-28.

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http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640

http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808&p=3

http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59794&p=4

http://guidance.nice.org.uk/CG139

http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf


APPENDIX 2 LINKS TO SUPPORTING DOCUMENTS/NG CAREPLAN back to index NASOGASTRIC (NG) TUBE INSERTION AND MONITORING FORM – click on to access. Patient Information leaflets

Drug administration via enteral feeding tubes http://www.bapen.org.uk/pdfs/d_and_e/de_pat_guide.pdf

NPSA alerts relating to Nasogastric feeding National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation of placement NPSA/2012/RRR001 22/03/12 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441 National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA/2011/PSA002 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640 National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric feeding tubes NPSA/2005/05 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798 Manufacturer’s websites Abbott Nutrition home page – access to pump instruction manuals and training Videos

http://www.abbottnutritionuk.com/ Corpak Medsystems – access to information about enteral tubes and company guidelines

http://corpakmedsystemsuk.com/ Medicina – information about enteral syringes and feeding devices

http://www.medicina.co.uk/

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http://www.bapen.org.uk/pdfs/d_and_e/de_pat_guide.pdf





http://www.abbottnutritionuk.com/

http://corpakmedsystemsuk.com/



APPENDIX 3 ALGORITHM 1 - TO CONFIRM NG POSITION FOLLOWING INSERTION AND PRIOR TO USE No

Yes Yes

No Yes

Yes

No

NG TUBE ?

IN POSITION

ASPIRATE OBTAINED?

TRY A COMBINATION OF THE FOLLOWING

pH 6 OR

ABOVE?

TEST ON pH PAPER

See box A

pH 5.5 OR

LESS?

ASPIRATE OBTAINED?

FLUSH 20-30MLS AIR WITH A SYRINGE THEN ASPIRATE

REPEAT 2-3 TIMES

ALTER TUBE POSITION SLIGHTLY Aspirate is most commonly obtained when the tube is positioned between 52-60cm (mark at

exit from nose)

IF UNSUCCESSFUL REPEAT INSERTION OF AIR AS ABOVE

ALTER POSITION OF PATIENT - TURN ONTO LEFT SIDE AND REPEAT AS ABOVE

CONSIDER

COLOUR OF ASPIRATE

Yellow/green stained aspirate is suggestive

of bile (higher pH)

IF NEW INSERTION - X-RAY (see box C)

IF ROUTINE CHECK - REFER TO

ALGORITHM 2 FOR INCONCLUSIVE ASPIRATE -

ACTION B

X-RAY CHECK

See box C

IF NEW INSERTION - X-RAY (see box C)

REFER TO ALGORITHM 2 FOR

INCONCLUSIVE ASPIRATE - ACTION C

RECENT FEED

IF TUBE IS IN THE LUNG REMOVE AND START AGAIN IF IN GI TRACT BUT IN INCORRECT PLACE, REPOSITION AS PER EXPERT CLINCAL GUIDANCE.

Box C. X-RAY FOLLOWING INSERTION IS INDICATED FOR THE FOLLOWING HIGH RISK GROUPS: 1. Unconscious with no gag reflex (ICU protocol) 4. Difficult insertion 2. Altered anatomy e.g. known large hiatus hernia 5. Fractured base of skull 3. Testing of aspirate is inconclusive 6. Recent radiotherapy/surgery to head and neck.

X-ray should not be used routinely to confirm tube position during subsequent use. If you are unable to confirm position using the above guidelines, see algorithm 2 for checking tube position following no aspirate or inconclusive pH values.

When ordering X-rays, please specify ‘to check NG position’ on request form.

X-rays must be checked by an appropriately trained clinician/advanced nurse practitioner. The result must be recorded in the patient’s notes.

NB. High risk patients requiring X-ray following insertion should have a pH check of aspirate carried out as well, to provide a baseline for subsequent checks.

Box A. HOW TO USE pH STRIPS 1. Place a small amount of aspirate onto the pH strip-avoid touching the area to be

read. 2. Allow 10 seconds and compare the resulting colour with the colour chart on the pH

strip container.

Box B. VARIATIONS IN GASTRIC pH MAY BE CAUSED BY:

1. Medication i.e. H2 antagonists and proton pump inhibitors which inhibit or reduce acid production. PH value will be raised.

2. Bile/ Recent feed/Lung placement – less acidic, therefore will show a higher pH value.

GIVE FEED, FLUID AND MEDICATION AS

PRESCRIBED

See box C for whether X-ray is indicated

TUBE POSITION CORRECT ON X-RAY?

See box C.

MEDICATION See box B

IF NEW INSERTION WAIT ½ - 1 HOUR AND RETRY

IF NO CHANGE X-RAY (see box C)

IF ROUTINE CHECK - REFER TO ALGORITHM 2 FOR

INCONCLUSIVE ASPIRATE - ACTION D


ALGORITHM 2 - TO ASSIST IN CONFIRMING NG POSITION IF NO ASPIRATE OR PH VALUE INCONCLUSIVE

NO ASPIRATE INCONCLUSIVE ASPIRATE (Ph GREATER THAN 5.5) - COMBINE THE FOLLOWING WITH TUBE DISPLACEMENT CHECKS.

ACTION A. CHECK FOR TUBE DISPLACEMENT ACTION A.

ACTION B.

No

No Yes

No ACTION C.

No ACTION D.

No

ACTION B. ACTION C.

ACTION E.

Yes

HAS THE EXTERNAL LENGTH OF THE TUBE CHANGED? Check cm mark at exit from nose and compare with insertion data on monitoring charts/NG care plan.

HAS THE PATIENT VOMITED?

HAS THERE BEEN AN INCREASE IN THE PATIENT’S

RESPIRATORY DISTRESS e.g. breathlessness, strider, cyanosis

or wheezing.

IS THE NG TUBE VISIBLE IN THE MOUTH?

IF NO CHANGE, DOCUMENT RESULTS AND CONTINUE TO

USE THE TUBE - if unsure, consult a senior/more experienced member of staff. Document decision and rationale.

REPOSITION TUBE OR REMOVE AND

REPLACE – repeat confirmation checks as seen in algorithm1

FLUSH A SMALL AMOUNT OF AIR THROUGH THE TUBE TO CLEAR RESIDUAL FEED/FLUID THEN RETRY

MEDICATION: IF ON A PPI e.g. LANSOPRAZOLE/OMEPRAZOLE OR H2 ANTAGONIST e.g. RANITIDINE, Look at previous pH readings, if consistently high, treat as normal, if a one off, consider why. Request senior input.

CONSIDER DILUTION OF GASTRIC ACID.

1. RECENT FEED/FLUSH: WAIT HALF AN HOUR AND RETRY 2. CONTINUOUS FEEDS: CONSIDER STOPPING THE FEED FOR HALF AN HOUR. CAUTION: If the patient is having insulin infusions for tight glycaemic control . Consult with senior doctor/specialist before stopping the feed.

IF REMAIN UNSURE AFTER THE ABOVE, CONSIDER X-RAY. Consult a senior/more experienced member of staff prior to requesting an X-ray. Document decision and rationale.

HAS THE MARK AT THE EXIT FROM THE NOSE SLIPPED?

CONSIDER THE VOLUME OF ASPIRATE: LARGE VOLUMES SUGGEST GASTRIC PLACEMENT. CAUTION: There have been reported high volumes of aspirates from tubes that have been located in the lungs. Request senior input. CONSIDER THE COLOUR OF ASPIRATE: YELLOW/YELLOWY-GREEN/DARK GREEN ASPIRATE IS SUGGESTIVE OF BILE. CAUTION: Lung aspirates shave been described as the above colours. Look at previous pH readings, if consistently high, treat as normal, if a one off, consider why. Request senior input.


APPENDIX 4: FLOW CHART TO GUIDE DECISION MAKING FOR TUBE FEEDING ROUTE

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PEG/nasal bridle contraindicated or refused by patient

If for oral feeding, refer to SALT for safe feeding techniques and to dietetics for maximising calorific value of meals.

Consider referral for: -

PEG feeding (see Trust PEG guidelines)

Start NG feeding if appropriate whilst waiting for PEG insertion.

NG tube with nasal bridle (see Trust nasal bridle guidelines)

.

Enteral tube feeding support required (see indications section 2.0)

Confused and pulling out NGT (see flowchart to manage repeated unplanned removal of NG tubes)

If for NG feeding organise MDT assessment prior to discharge to plan:-

Care requirements in community

Who will provide care

Training required to minimise risks

Agree action plan if NGT comes out

Refer to section 15.0 above

Consider: -

Referral for radiologically inserted gastrostomy (RIG) (see section 12.0 of Trust PEG guidelines)

Continuing NG feeding +/- nasal bridle (unless contraindicated or refused by patient)

Limited oral feeding with palliative care Risk/benefit assessment required as to best modality for patient plus patient choice where possible

If for oral feeding repossible

Short term requirement Long term requirement – more than 6 weeks

Yes

If for palliative care, organise MDT to discuss plan of care and refer to relevant healthcare professionals.

Assess for risk and appropriateness of nasogastric tube (NGT)

No

Refer to specialist/expert practitioner for insertion and management advice

Insert NGT as per Trust guidelines

HIGH RISK of

complication

Yes


END OF EAST CHESHIRE NHS TRUST CNSG 007 GUIDELINES FOR INSERTION AND MANAGEMENT OF NASOGASTRIC

TUBES

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back to main index

East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles Page 27 of 172 Created by Maggie Allen, October 2010. Updated July 2015.

Guideline Title:

Guidelines for Insertion and Management of Nasal Bridles

Executive Summary:













August 2014

APPROVAL RECORD

Committees / Group

Date


October 2010-August 2011 June 2015

Approved by: Clinical Nutrition Steering Group

July 2015

AMENDMENT RECORDS

August 2011 Guidelines updated for NPSA/2011/PSA002 alert compliance


GUIDELINES FOR INSERTION AND MANAGEMENT OF NASAL BRIDLES INDEX

Back to main index

SECTION CONTENTS PAGE

1.0 Introduction 29

2.0 Definition 29

3.0 Indications 29


5.0 Assessment and referral 30

6.0 Consent 30

7.0 Equipment 30

8.0 Procedure 30

9.0 Potential complications 31

10.0 Aftercare 31

11.0 Discharge with a nasal bridle in situ 31

12.0 Displacement within the community 31

13.0 Planned Removal 31

14.0 Disposal 31

15.0 References 32

Appendix 1 Flow chart to manage repeated unplanned removal of a nasogastric tube

33

Appendix 2 Nasal Bridle Fixation device request form 34

Appendix 3 Flow chart to guide management if nasogastric tube or nasal bridle displaced

35

Appendix 4 Links to supporting documents/information

Patient information

NPSA alerts relating to NG use

Manufacturer’s websites

36


The following guidelines should be used in association CNSG 007 Guidelines for the Insertion and Management of Nasogastric Tubes.

1.0 Introduction back to index

Nasogastric feeding is the most common method of providing short-term artificial nutritional support in the acute setting. There is a high risk of accidental removal either by the patient or by staff caring for the patient. Unplanned removal impacts in the following ways: -

The patient does not meet their nutritional and fluid requirements

The patient requires another tube placing

Increased incidence of chest x-rays. 2.0 Definition back to index

A nasal bridle is the positioning of a tape around the nasal septum to secure a nasogastric tube where it exits the nostril. If required, the bridle can remain in place for the duration of nasogastric feeding. The use of a nasal bridle to secure a nasogastric feeding tube was first described in 1980 and has since been demonstrated to be safe and effective (Donaldson et al 2007).

The aim of a nasal bridle is to: -

Prevent unplanned removal by patients and staff caring for the patient.

Eliminate inappropriate gastrostomy insertion and associated risks.

Maintain nutritional intake.

Allow time for assessment as to the best method of nutritional support for a patient. 3.0 Indications back to index

Patients who require delivery of medication/feed/fluid via the enteral route with the following criteria: -

Poor tolerance of the nasogastric tube i.e. pulled out on at least 3 occasions in short succession.

Sub optimal nasal fixation tape as a result excessive moisture e.g. patient receiving humidified oxygen therapy (tube displaced on at least 3 occasions as a result of this).

Skin irritation caused by adhesive securing tape.

Long term nasogastric feeding required if gastrostomy insertion inappropriate.

Known difficult insertion procedure involving videofluroscopy or endoscopic insertion 4.0 Contraindications back to index

Patients excluded from nasal bridle placement include:

Severely agitated patients who are likely to cause damage to their nasal septum due to excessive pulling on the tube.

Facial or cranial trauma.

Basal skull fracture.

Severely deviated, structural deformity, or obstructed nasal septum or passage.

Nasotracheal tubes in situ.

Advanced dementia (as well as being highly likely to pull on the tube due to confusion, these individuals may not benefit from enteral nutrition support – see CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes for further guidance).

Thrombolytic therapy for acute stroke or MI in the last 5 days (relative - discuss with consultant)

Warfarin therapy (relative - discuss with consultant)

Recent radiotherapy to the nose


5.0 Assessment and Referral back to index

If the patient is pulling out a nasogastric tube, try to identify the cause

Rule out medical reasons for confusion such as infection, dehydration.

The decision to place a nasal bridle should be within an MDT setting

The patient should be referred to an appropriately trained doctor or nurse for assessment and insertion of the nasal bridle.

See appendix 1 for flowchart for recommended management plan. 6.0 Consent back to index Informed consent must be obtained from the patient prior to the procedure as per Trust policy. The consent must be recorded in the patient’s notes. If the patient lacks capacity for consent, the decision to treat must be made within the patient’s best interests. The goals of the treatment should be clearly identified in the patient’s medical notes. The procedure should also be discussed with the family where appropriate. 7.0 Equipment AMT nasal bridle - kept on ETU/Ward 3/Ward 11 Nasogastric tube insertion equipment (Refer to CNSG 007 Guidelines for the Management of Nasogastric Tubes). 8.0 Procedure back to index

The bridle must be inserted by an appropriately trained doctor or nurse.

The patient should be prepared as per CNSG 007 Guidelines for the Management of Nasogastric Tubes) and a nasogastric care plan completed.

The nasogastric tube must be inserted and the position checked prior to insertion of the bridle. National Patient Safety Agency Alert 19 guidance must be observed when assessing the tube’s position (www.npsa.nhs.uk) Also refer to CNSG 007 Guidelines for the Management of Nasogastric Tubes.

Insert bridle following manufacture’s guidelines. Follow link http://www.appliedmedical.net/amtbridle.htm for pictorial guidelines and link

http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm for a video of the procedure (click on the appropriate tube French size directions for use).

When finished, dispose of clinical waste and wash hands as per Trust policy.

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http://www.npsa.nhs.uk/

http://www.appliedmedical.net/amtbridle.htm

http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm


9.0 Potential complications back to index Anterior epistaxis Bleeding may occur during insertion of a nasal bridle device. Any bleeding lasting longer than 15 minutes or greater than 100mls should be discussed with the medical team. Pressure necrosis If the nasal bridle is fastened too tightly or becomes twisted, pressure sores may lead to necrosis of the nasal septum. If a pressure sore develops, the bridle tape should be cut and removed (see section 13.0 below). The area should be checked, cleaned daily and a dressing applied where indicated. The condition of the patient’s nostrils should be recorded daily in the patient’s care plan. Dislodged Nasogastric tubes It is still possible for a tube to become dislodged despite a bridle, either deliberately by the patient or accidentally during vomiting. The tube position must continue to be checked prior to each episode of use as per CNSG 007 Guidelines for the Management of Nasogastric Tubes. 10.0 Aftercare back to index The patient should be monitored as per CNSG 007 Guidelines for the Management of Nasogastric Tubes. In addition, the patient should be monitored closely for signs of nasal trauma as a result of the patient pulling on the tube, or irritation caused by the tape rubbing against the nasal passage. The nasal passage and tape should be cleaned daily. 11.0 Discharge with a nasal bridle in situ If the patient is to be discharged with a bridle in situ the following should be in place: -

A written care plan provided for carers.

Plan of action if the tube becomes displaced.

Support from dietetics to continue with nutritional monitoring.

12.0 Displacement within the community back to index District nurses or out of hours nurses should be contacted to assess whether the patient needs to attend the A&E department. 13.0 Planned removal Cut one side of the tape (usually the side exiting the nostril opposite the nasogastric tube) and pull the nasogastric tube out. The tape will follow with the tube. See video link for a demonstration. http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm 14.0 Disposal The tube and bridle should be disposed of as per East Cheshire NHS Trust policy for disposal of clinical waste.

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15.0 References back to index Donaldson, E., Early, T., Sheilds, P (2007) The Nasal Bridle – It’s place within an integrated nutrition service: a prospective audit of one year’s data. Gut (56) Suppl 56 A137 Johnston RD et al. (2008). Outcome of patients fed via a nasogastric tube retained with a bridle loop: do bridle loops reduce the requirement for percutaneous endoscopic gastrostomy insertion and 30-day mortality? Proceedings of the Nutrition Society 67, E116. Lancashire Teaching Hospitals NHS Trust (2006). Safe practice for insertion and management of a nasal bridle to secure nasogastric tubes. National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral supplements, parenteral and enteral feeding. London. http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf Russell KL et al. (2006). Bridle fixation of nasogastric tubes – the Addenbrooke’s experience. Proceedings of the Nutrition Society 65, 14A. Popovich MJ et al. (1996). Nasal bridle revisited: An improvement in the technique to prevent unintentional removal of small-bore nasoenteric feeding tubes. Critical Care Medicine 24, 429-431.

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APPENDIX 1. back to index

FLOW CHART TO MANAGE REPEATED UNPLANNED REMOVAL OF A NASOGASTRIC TUBE

back to index back to NG guidelines

Patient pulled out NG tube on more than three occasions

Is the patient confused? Yes No

Establish reason for confusion and treat accordingly

Reassess for a nasal bridle. MDT discussion to discuss appropriateness. To include Doctor/nurse/SALT/dietitian

Wait 24 hours

Identify why the patient is pulling the tube out. If the patient refuses the tube, they should have the risks and consequences explained to them so that they can make an informed choice.

Doctor/specialist nurse to discuss the procedure, pros and cons with the patient/relatives and obtain consent.

Document consent in medical notes

Insert NG tube and check tube position as per Trust guidelines prior to inserting the bridle as per manufacturer’s guidelines http://www.appliedmedical.net/bridleVideo/br

idleVideosWindow.htm

Monitor for complications. Refer to flow chart to guide management if displacement of nasal bridle/tube.

Refer to flow chart to guide decision making making for

tube feeding route

Nasal bridle to proceed

Yes No




APPENDIX 2 Nasal Bridle Fixation Device Request Form To be used alongside the NG care plan document. Please complete all the information requested on this form. Fax the form to x1904, Gastroenterology Department.

Patient Details:

Name: ……………………………………………………… Hospital No:........................... Date of Birth:…………………….. Ward................................. Consultant................................................................... Is the patient NBM On NG Feed Eating orally Date of last SALT review ............................ Date of last dietetic review....................... Number of NGs pulled out by the patient?................................. Can the patient consent to the bridle Yes/No Has the bridle been discussed with the patient relatives (if appropriate) Yes/No Is the patient receiving or has had recent anticoagulation therapy Yes/No If the patient has any of the following conditions nasal bridle is not appropriate Extreme confusion and likely to pull at the tube Yes/No Known basal skull fractures Yes/No Deviated or perforated nasal septum Yes/No Structural deformity of the nose or nasopharynx Yes/No Advanced dementia Yes/No Recent radiotherapy to the nose or nasopharynx Yes/No Bridle requested by (name/title).................................................................................. Doctor’s signature................................................ Contact number.............................


APPENDIX 3. FLOW CHART TO GUIDE MANAGEMENT IF NASAL BRIDLE AND / OR NASOGASTRIC TUBE DISPLACED *If there is a delay for specialist/trained intervention – continue with NG therapy and monitor carefully for unplanned tube removal. Bolus administration only recommended.

**Refer to flow chart to guide decision making making for tube feeding route. back to index

NG still in Bridle out

Review patient condition and reason for removal

Yes

Refer to specialist/HCP trained in the procedure for reinsertion of bridle* Check NG tube still in position prior to reinsert bridle as per Trust guidelines and secure to NG tube. If NGT also pulled out, reinsert NG tube and check position as per Trust guidelines, then secure to bridle.

No

Remove bridle and continue with oral diet.

Bridle and NG out

NG still required**

Bridle still required**

Reinsert NG tube as per Trust guidelines and consider whether bridle still required, if not, remove bridle.

Remove NGT and continue with oral diet.

NG still required**

Yes

No

Review patient condition and reason for removal. NB. There may be damage to nasal septum if bridle removed forcefully.

Bridle still required**

Yes

Reinsert NG tube and check position as per Trust guidelines, then secure to bridle.

Yes

No

NG out Bridle still in

No

No

Yes

No

East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles Page 36 of 172 Created by Maggie Allen. October 2010. Updated July 2015.

APPENDIX 4 SUPPORTING INFORMATION back to index

NPSA alerts relating to Nasogastric feeding National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation of placement NPSA/2012/RRR001 22/03/12 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441 National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA/2011/PSA002 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640 National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric feeding tubes NPSA/2005/05 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798 Manufacturer’s websites Applied Medical Technology (AMT ) nasal bridle

http://www.appliedmedical.net/amtbridle.htm http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm Abbott Nutrition home page – access to pump instruction manuals and training Videos http://www.abbottnutritionuk.com/ Corpak Medsystems – access to information about enteral tubes and company guidelines http://corpakmedsystemsuk.com/ Medicina – information about enteral syringes and feeding devices http://www.medicina.co.uk/

back to index





http://www.appliedmedical.net/amtbridle.htm





East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles Page 37 of 172 Created by Maggie Allen. October 2010. Updated July 2015.

END OF EAST CHESHIRE NHS TRUST CNSG 008 GUIDELINES FOR INSERTION AND MANAGEMENT OF NASAL BRIDLES

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back to main index

East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes Page 38 of 172 Created by Maggie Allen. October 2010. Updated July 2015

Guideline Title:

Guidelines for Insertion and Management of Gastrostomy Tubes.

Executive Summary:

To optimise the care of adult in-patients receiving nutrition via a gastrostomy tube under the care of East Cheshire NHS Trust.



Guidelines reviewed - New guidance: - Stop Clopidogrel 7 days prior to PEG insertion and to omit new anticoagulants dependent on specific anticoagulant and patient’s renal function. Updated advice on optimum positioning of gastrostomy tube.




Version Number: 1.1 Effective Date: November 2010





August 2014

APPROVAL RECORD

Committees / Group

Date

Consultation: Departments of Dietetics and Gastroenterology Clinical Nutrition Steering Group Infection prevention and control

October 2010

June 2015


July 2015

AMENDMENTS RECORD

East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes Page 39 of 172 Created by Maggie Allen October 2010. Updated July 2015.

GUIDELINES FOR INSERTION AND MANAGEMENT OF GASTROSTOMY TUBES INDEX

SECTION CONTENTS

PAGE

1.0 Definition 41

2.0 Indications 41


3.1 Advanced dementia 42

4.0 Referral 43

5.0 Information giving and informed consent 43

5.1 Capacity and consent 43-4

5.2 Multidisciplinary team 44

6.0 Preparation and Assessment 45-7

6.1 Type of tube 47

7.0 Patient care post gastrostomy insertion 48

7.1 Peri and postoperative complications of PEG insertion 48

7.2 Monitoring 48

7.3 Commencing feed/oral diet 49

7.4 Mouth care 49

7.5 Pain control 49

7.6 Gastrostomy site care 50

7.6.1 Procedure to clean a gastrostomy site 50

7.6.2 Bathing and showering 51

7.6.3 Gastrostomy site dressings 51

7.6.4 Positioning the fixation device 51

7.6.5 Prevention of buried bumper syndrome 51

7.6.6 Sutures 52

8.0 Maintenance of the gastrostomy tube 52

8.1 Flushing 52

8.2 Syringes 52

8.3 General maintenance of the tube 52

9.0 Removal of a gastrostomy tube 53

9.1 Accidental removal 53

9.2 Planned removal 53

9.3 Procedure for traction removal of a Merck Corflo gastrostomy tube 53-4

10.0 Management of balloon gastrostomy tubes 54

10.1 Definition 54

10.2 Low profile gastrostomy tubes – buttons 54

10.3 General management of balloon gastrostomy tubes, buttons and extension sets

54-5

10.3.1 Preparation of an extension set for administering fluids via a low profile device

55

10.3.2 Cleaning an extension set after use and replacement 55

10.4 Checking the balloon volume 56

10.5 Removal of a balloon gastrostomy tube 57

10.6 Discontinuing balloon gastrostomy feeding 58

10.7 Replacement of a balloon gastrostomy tube 58

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INDEX CONTINUED

SECTION CONTENTS

PAGE

10.8 Insertion procedure for a balloon gastrostomy tube 58-60

10.9 Insertion of a low profile device 60

10.10 Measurement of a gastrostomy stoma 60

10.11 Complications 60

10.12 Accidental removal of gastrostomy tube 61

10.13 Temporary gastrostomy tubes 62

10.14 Spare tubes 62

11.0 Management of an intestinal tube within a PEG tube for buried bumper

63

11.1 Insertion/replacement of an intestinal tube within a PEG tube 63-4

11.2 Care of an intestinal tube within a PEG tube 64

12.0 Radiologically inserted gastrostomy tubes (RIG) 65

12.1 Referrals 65

12.1 Sutures 65

13.0 Discontinuation of tube feeding 65

14.0 Discharge of patients on enteral feeding 65-6

14.1 Discharge within 72 hours of PEG insertion 65

14.2 Information required for discharge within 72 hours of insertion 66

14.3 Training required prior to discharge 66

14.4 Information and contact details required prior to discharge 66

14.5 Referrals required prior to discharge 66

14.6 Equipment required for discharge 66

Appendix 1 References and bibliography 67

Appendix 2 Linked supporting documents: -

Discharge check list

Patient information

NPSA alerts relating to PEG

Manufacturer’s information

Care Pathway for Percutaneous Endoscopic Gastrostomy (PEG) Tubes

68

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1.0 DEFINITION back to index

A gastrostomy tube is the generic term for a feeding tube that is inserted into the stomach either, surgically, endoscopically (PEG) or radiologically (RIG). The gastrostomy tube allows delivery of nutrients, fluid and medication directly into the stomach.

Percutaneous Endoscopic Gastrostomy (PEG) is the insertion of a small plastic tube through the abdomen and into the stomach under endoscopic vision. The following guidelines are biased towards this type of procedure as radiological insertion of a gastrostomy (RIG) is not currently undertaken at the Trust. 2.0 INDICATIONS back to index

When selecting patients for gastrostomy/PEG insertion the following should be considered:

Artificial nutrition is appropriate for the individual

Patients require enteral nutritional and hydration support (partial or complete) for more than 6 weeks.

The individual has a functional gastrointestinal tract.

Nasogastric (NG) tube feeding has not been tolerated or is thought to be unsafe.

- The patient has pulled out the NG tube on at least 3 occasions in short succession and use of a nasal bridle is contraindicated. Refer to CNSG 008 guidelines for management of nasal bridles for further information.

- The patient demonstrates significant distress during NG insertion. - The patient refuses nasogastric tube insertion. - Altered anatomy e.g. large hiatus hernia, increasing the risk of aspiration. - Basal skull fracture, as the tube may enter the brain if incorrectly positioned (oro-gastric

positioning may be appropriate). - Obstructive pathology in oropharynx or oesophagus preventing passage of the tube e.g.

stricture, tumour.

The patient is fit enough and will benefit from the procedure back to index

- Procedure related mortality 0.7-2%. - 30-day mortality rate 2-28% - Complications post PEG 15-70%

(NCEPOD 2004 and BSG Guidelines 2006)

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complications.pdf http://www.ncepod.org.uk/2004report/index.htm High risk groups include individuals with significant co-morbidity, in particular those with aspiration pneumonia prior to PEG insertion. See section 6 below for further information.

Tolerance of the gastrostomy tube by patient/partner. - Physical implications – changes to body image, foreign object in body, feel unable

undertake activities such as swimming. Psychological implications - changes to body image which may affect the individual and their partner, unable to engage in normal social activity such as eating, regular interference with the body by others accessing the gastrostomy tube to deliver feed and fluids.

back to index

http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complications.pdf


http://www.ncepod.org.uk/2004report/index.htm


3.0 CONTRAINDICATIONS back to index

Table 1

Absolute

Relative

Tense ascites

Peritoneal dialysis

Total gastric outflow obstruction

Morbid obesity

Treatment with high dose steroids

Previous upper GI surgery

Partial gastric outflow obstruction

Advanced dementia (see below)

Coagulopathy disease/drugs

Gastro-oesophageal reflux with risk of aspiration

Recurrent aspiration pneumonia due to severe dysphagia following a stoke

3.1 Advanced dementia back to index The following summary illustrates the problems faced in deciding whether a gastrostomy tube is appropriate for an individual with advanced dementia.

There is insufficient evidence to suggest that enteral tube feeding is beneficial in patients with advanced dementia. Data are lacking on the adverse effects of this intervention

Patients with advanced dementia often develop dysphagia (difficulties swallowing). They also experience changes in appetite and apraxia (difficulty co-coordinating movements) and may have difficulties feeding themselves. Two methods of enteral tube feeding are commonly used: the administration of food and fluids via a nasogastric tube (a tube that is passed through the nose and into the stomach) or via a percutaneous endoscopic gastrostomy (PEG) where a feeding tube is inserted into the stomach and is accessed through a permanent incision in the abdominal wall. The decision to use artificial hydration and nutrition in someone with dementia is often emotive and complex. Relatives and carers may request the intervention because they are concerned that the patient may starve; clinicians may be aware of the risks but feel pressurised by institutional, societal or even legal directives to intervene. We found no conclusive evidence that enteral tube nutrition is effective in terms of prolonging survival, improving quality of life, or leading to better nourishment or decreasing the risk of pressure sores. It may actually increase the risk of developing pneumonia due to inhaling small quantities of the feed and even death. This area is difficult to research but better designed studies are required to provide more robust evidence

Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007209. DOI: 10.1002/14651858.CD007209.pub2 Further information and guidance regarding the difficulties in providing nutrition support can be found in:

Oral feeding difficulties and dilemmas. A guide to practical care, particularly towards the end of life. Report of a joint RCP/BSG Working Party - January 2010. https://www.rcplondon.ac.uk/sites/default/files/documents/oral-feeding-difficulties-and-dilemmas.pdf

back to index

https://www.rcplondon.ac.uk/sites/default/files/documents/oral-feeding-difficulties-and-dilemmas.pdf

https://www.rcplondon.ac.uk/sites/default/files/documents/oral-feeding-difficulties-and-dilemmas.pdf


4.0 REFERRAL back to index The patient should be referred to: -

Gastroenterologist/Specialist nurse

Dietitian

Speech and language therapists (where appropriate)

Independent mental capacity advocate (IMCA)(If the patient lacks capacity to make an informed decision and does not have any family or friends with whom it is ‘appropriate to consult’ about the decision – see section 5 below for further information)

5.0 INFORMATION GIVING AND INFORMED CONSENT back to index

Decision-making and consent may be affected by previous experiences and/or by fear. Time should be spent explaining about gastrostomy feeding to the individual and family. They may find it useful to meet someone else with a gastrostomy tube. Information about support groups should also be offered.

Key information to be discussed includes: -

Full explanation of the procedure and associated complications (see section 7.1 below). Written information should also be offered (EIDO E09 PEG leaflet, accessible from the Trust front page. Click on Patient information, then EIDO link and log in following instructions. Once logged in, scroll down to Endoscopy and click on PEG, print off as required.

Benefits and disadvantages of gastrostomy feeding

Aftercare

Major impact on lifestyle, for instance if alternative accommodation needs to be considered if the patient needs specialist care post gastrostomy.

The patient’s consent should be written where possible on the Trust consent form (Form 1). If this is not possible, verbal consent should be witnessed on the Trust consent form (Form 1). Refer to East Cheshire NHS Trust consent policy for further information regarding the validity of consent. If communication is impaired, every effort should be made to communicate with the individual, including the use of drawings/props where necessary. In some cases repeated sessions to impart information may be necessary. Evidence of these conversations should be documented in the patient’s notes. Liaison with other healthcare professional e.g. speech and language therapists (SALT) may be indicated to maximise communication techniques. 5.1 Capacity and consent back to index Assessment of capacity to make informed decisions should be made prior to PEG insertion. If the individual is thought not to have capacity for informed consent, it is important to have early, sensitive discussions with relatives or individuals close to the patient, to try to determine whether the individual has previously expressed any views on the subject, or if they have a legitimate advanced decision, or have appointed a lasting power of attorney to make decisions for them, as legislated for within the Mental Capacity Act (MCA) 2005. In absence of a valid advanced decision or lasting power of attorney (welfare), the family should be reassured that the decision making is not their responsibility, but that of the clinician (Decision Maker) in charge of their relatives care, to make the decision regarding PEG based on the individual’s best interests. Under these circumstances an additional safeguard has been implemented by the Act which requires clinicians to involve an independent mental capacity advocate (IMCA) for serious medical treatment decisions when: -

a best interests decision is required because the doctor has assessed the person as not having the capacity to make the decision themselves.

the person does not have family or friends with whom it is ‘appropriate to consult’ about the decision.


Serious medical treatment is defined in the Mental Capacity Act 2005 (Independent Mental Capacity Advocates) (General) Regulations 2006 as treatment which involves providing, withdrawing or withholding treatment in circumstances where one or more of the following apply:

in a case where a single treatment is being proposed, there is a fine balance between its benefits to the patient and the burdens and risks it is likely to entail for them

in a case where there is a choice of treatments, a decision as to which one to use is finely balanced

what is proposed would be likely to involve serious consequences for the patient. The MCA Code of Practice states that ‘serious consequences’ may include treatment options which:

cause serious and prolonged pain, distress or side effects

have potentially major consequences for the patient (for example, major surgery or stopping life-sustaining treatment)

have a serious impact on the patient’s future life choices. back to index

Patients who have been referred for PEG and lack capacity for decision making and do not have any family or friends with whom it is ‘appropriate to consult’ about the decision, should be referred to an IMCA as they fall within several of the above criteria. The IMCA ensures that the Decision Maker (clinician) considers what the wishes and beliefs of that person would be when deciding what course of action to take. This is done by questioning all the people involved with that person, investigating the medical condition and treatment options and making recommendations based on these findings. This statutory IMCA service is provided by qualified Independent Mental Capacity Advocates.

For further information please contact East Cheshire Advocacy on: Tel. 01625 534889 Online. www.ecadvocacy.co.uk Email: [email protected] East Cheshire Advocacy, 81 Park Lane, Macclesfield, SK11 6TX. If an individual is assessed as lacking capacity to give informed consent, the ‘Form for adults who are unable to consent to investigation or treatment’ (Consent Form Four) should be completed. The form should be signed by the clinician in charge of care, the clinician undertaking the procedure and the patient’s family/carers to indicate that they have been involved in the discussion process. If the family are unable to sign the form, there should be documented evidence in the patient’s medical notes regarding the discussion process. 5.2 Multidisciplinary team (MDT) approach back to index For patients who lack capacity to make an informed choice, there are potentially difficult ethical decisions to be made. Each patient considered for PEG feeding should be assessed on his or her own merits. They may not fall within the above criteria. The decision should be made within an MDT approach and based on the patient’s best interests. The team should consist of healthcare professionals involved with the patient, e.g. speech and language therapist, dietitian, doctor (including GP if appropriate), nurse (ward level and specialist), physiotherapist, occupational therapist, social worker, community carers. Where the situation is particularly complex, or the MDT decision is equivocal, consider referral to the palliative care consultant.

http://www.opsi.gov.uk/si/si2006/20061832.htm


http://www.ecadvocacy.co.uk/

mailto:[email protected]


6.0 PREPARATION AND ASSESSMENT PRIOR TO PEG back to index Clinical assessment In addition to assessing for contraindications, the following should be considered: - Table 2

CONDITION RATIONALE

Relevant co-morbidity Increases risk of complications during or post PEG insertion.

Infection prior to PEG

Increases risk of complications during or post PEG insertion. If patient is MRSA positive –follow MRSA Trust policy. In relation to antibiotics/treatment refer to Trust antibiotic policy, contact the IPCT and/or the Microbiologist.

Cervical/Neck problems May affect positioning during PEG insertion.

Tracheostomy Requires specialist support and suctioning during the procedure.

Previous abdominal surgery

Altered anatomy and adhesion increases the risk of bowel perforation.

Respiratory condition

Known aspiration pneumonia or respiratory problems prior to the procedure carries an increased risk of fatality post procedure. Local audit 2001-2004 indicated that 66% of patients diagnosed with aspiration pneumonia prior to PEG insertion, died within 30 days of the procedure.

Allergies

Ensure the patient is prepared safely for the procedure.

Unable to open mouth/ poor dentition

Increased risk of damage to teeth during endoscopy. Poor dentition will increase the amount of bacteria in the mouth which if aspirated will result in an increased risk of respiratory infection. Referral to a dentist may be required.

Coagulopathy PEG is contra-indicated if INR >1.3

Severely malnourished patients may have a vitamin K deficiency which will need correcting prior to PEG.

Anticoagulant therapy PEG is contra-indicated if INR >1.3

Anticoagulants need to be stopped prior to PEG See below.

Severely malnourished - risk of re-feeding syndrome

Increased risk of electrolyte imbalance once feeding starts.

Thrombocytopenia PEG is contra-indicated if platelet count <100

Low platelet count causes increased risk of peri-procedural bleeding.

back to index


6.0 PREPARATION continued back to index

Preparation Action

Bloods

FBC

If platelet count <100 consider correcting with 1 -2 units of platelets within 4 hours of the procedure.

INR

If INR > 1.3: Correct and recheck

U& Es inc calcium group, phosphate and magnesium and levels

Correct any electrolyte disturbances before commencing nutritional support. Re-feeding drugs, if required, should be prescribed according to CNSG Guidelines for Re-feeding management.

Review medication

Anticoagulants

PEG is classified as a high risk procedure with regards to risk of bleeding and anticoagulation therapy.

NB. Some anticoagulants need stopping up to 7 days prior to PEG e.g Clopidogrel 7 days, Warfarin 5 days.

New anticoagulants - the stoppage time will depend on the particular anticoagulant and the patient’s renal function. Alternative anticoagulation therapy may be required depending on the patient’s medical condition. Check with gastroenterology/haematology team for further advice.

Current drug therapy Refer to pharmacist as the patient’s drug formulations may need to be changed. Timing and dosage of drug administration may need to be altered due to altered drug formulation and/or potential interaction with feed, particularly in the drug has a narrow therapeutic index. Refer to CNSG 016 Guidelines for Administration of Medication via Enteral Feeding Tubes.

Medication required

Prophylactic antibiotics

Patients should have a single dose of intravenous Co-amoxiclav 1.2g, just before the procedure. British Society of Gastroenterology (BSG) 2009. Antibiotic prophylaxis in gastrointestinal endoscopy.

If penicillin allergic, give a single dose of Gentamicin 3mg/kg (max 300mg), just before the procedure (maximum of 1 hour). If MRSA discuss with microbiologist.

MRSA eradication therapy (if known MRSA colonisation or infection)

If the patient is MRSA positive contact the IPCT/Microbiologist for advice regarding suppression therapy prior to insertion (as per Trust MRSA policy).

If antibiotics are required, they should be prescribed as per Trust antibiotic policy.

Analgesia Prescribe prn soluble oral and IM analgesia for pain post PEG insertion (arrange for a take home prescription if for discharge post PEG).

Feed Doctor/dietitian to write up feed on prescription chart and feeding regimen.

Corsodyl mouthwash

(chlorhexidine gluconate 0.2%)

To start 48 hours prior to procedure. Aim to reduce bacterial load in mouth, as the tube is pulled though the mouth and into the newly formed stoma.

back to index


6.0 PREPARATION continued back to index

Preparation Action

Weight A baseline and regular weight is required in order to: -

accurately assess nutritional and fluid requirements

assess weight following PEG insertion (barometer of the patient’s nutritional requirements and monitors for potential fluid overload).

Fasting

Fasting (mouth and tube) 6 hours prior to procedure.

Hygiene

Full wash

Clean theatre gown

Clean sheets.

Venous access Must be established before the patient arrives on the Endoscopy Unit (except for outpatients).

Mouth Care

Regular mouth care required with Corsodyl mouthwash - to reduce risk of stoma infection. The mouth must be clear of dried secretions prior to PEG insertion. There is an increased risk of stoma infection if the mouth is not clean at the time of PEG insertion. If mouth care is difficult, inform specialist nurse.

Advise endoscopy staff of loose/broken teeth.

Equipment required

Pump, giving sets, oral/enteral syringes, recommended feed, sterile water for first flush, tap water for subsequent flushes.

Subcutaneous fluids

Avoid siting the butterfly cannula in the upper central abdomen as this can result in skin infections or abscesses that may affect PEG insertion. (Insertion of sub cut cannula must be done using aseptic technique).

Documentation required The following documents must be sent with the patient to the endoscopy unit at the time of the procedure:

Signed consent form

Patient notes

Nursing Kardex

Drug charts

Completed PEG pathway (Click for link)

6.1 Type of tube back to index The tube of choice at East Cheshire NHS Trust is a Merck Corflo traction removable tube. It is available in 12Fr, 16Fr and 20Fr sizes. Most patients have a 16Fr tube inserted. Other sizes may be used depending on the patient’s requirements. The most appropriate type of tube and size will be decided at the time of assessment. Greater than 16Fr tubes should be avoided due to increased risk of stoma leakage.


7.0 PATIENT CARE POST PEG INSERTION back to index 7.1 PERI AND POST PROCEDURAL COMPLICATIONS ASSOCIATED WITH PEG

Perforation

Haemorrhage

Sepsis

Peritonitis

Respiratory depression due to sedation

Pulmonary aspiration

Peristomal site infection

Ischaemic pressure necrosis

Gastrocolic fistulae

Tube blockage

Accidental displacement of the PEG Monitor patient post PEG for development of complications and report promptly. Link to management of suspected peritonitis Link to flow chart for complications post PEG and management 7.2 MONITORING back to index Observations

Half hourly for a minimum of 2 hours. o Blood pressure, pulse and temperature o Oxygen saturation and respiratory rate o Wound check o Pain assessment o PEG position unchanged

Hourly for a minimum of 2 hours. o As per half hourly assessments

2 - 4 hourly (depending on clinical status). o As per half hourly assessments

Discontinue as clinical condition allows Bloods

Repeat full profile if at risk of re-feeding syndrome. See CNSG re-feeding guidelines or contact the dietitian.

Repeat U& Es. Refer to CNSG Guidelines for Assessment and Monitoring for further guidance. Contact dietitian for information.

back to index Bowels

Document and monitor bowel movements

Consider aperients if constipated NB. Constipation presents serious hazard for a patient following PEG insertion. A build up of pressure within the abdomen may increase the risk of leakage from the stomach into the peritoneal cavity with subsequent peritonitis. There is also an increased risk of vomiting which places the patient at greater risk of aspiration, particularly if they have an unsafe swallow. Weight

As requested by dietitian. back to index


7.3 COMMENCING FEED/ORAL DIET back to index

NBM or tube until 4 hours post insertion then flush tube with 50mls sterile water.

NB. If pain or difficulty flushing, stop and seek immediate senior medical or surgical advice. Refer to: -

CNSG 014 Guidelines for Enteral Feeding Complications and Management for further information.

Rapid response Report NPSA/2010/RRR010: Early detection of complications after gastrostomy


Administer medication for re-feeding if applicable.

Commence feed/fluids as per dietetic regimen.

The patient should be positioned in semi-raised position during feed - upright if known history of reflux and vomiting (the patient may require day time feeding in this instance).

Oral diet/fluids (if applicable) can restart as the individual wishes, after the first flush of water has been given without complications.

The patient should have regular reassessment of swallowing ability, where applicable. 7.4 MOUTH CARE back to index

Maintenance of oral hygiene is essential, particularly is a patient is unable to: -


attend to their own oral care Table 3 PROBLEM REASON

ACTION

Dry sore mouth


Mouth breathing


Clean teeth/dentures with a soft toothbrush or a damp swab wrapped around a gloved finger (depending on the patient). The frequency will depend on the condition of the patient, twice daily minimum.






Dehydration






Refer to Guidelines for the Oral Healthcare of Stroke Survivors by the British Society of Gerodontology for comprehensive guidance as to management of oral hygiene. http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf 7.5 PAIN CONTROL back to index Administer analgesia as required. Intravenous or intramuscular analgesia is sometimes required within the first 24 hours of insertion. Increasingly severe pain should be reported and investigated (see Guidelines for Management of Suspected Peritonitis Post Percutaneous Endoscopic Gastrostomy (PEG) Insertion). Oral/via PEG analgesia may be required for a few days post PEG and should be offered regularly. If the patient is unable to communicate and is showing signs of discomfort or restlessness, give analgesia regularly for a few days post PEG. Use the pain score on the PEG care pathway to assess the level of pain.




7.6 PEG SITE CARE back to index

The gastrostomy stoma must be cleaned daily in order to maintain comfort and minimise risk of infection. Management should be as per the PEG care plan.

For the 72 hours, the PEG stoma should be cleaned with a saline or antiseptic solution using an aseptic non touch technique (ANTT).

7.6.1 Procedure to clean a PEG site

Use aseptic technique for 72 hours post PEG insertion.

Assemble equipment required onto a clean trolley

Explain the procedure to the patient and obtain consent

Wash hands and put on sterile gloves as per Trust policy.

Remove the dressing (if in situ) and discard into the yellow clinical waste bag

Clean the stoma site and fixation device with Normasol and gauze swabs, removing any exudate.

Slide a swab under the fixation to remove any dried blood.

Dry the skin and fixation device thoroughly.


Do not undo the fixation device until 2 weeks post insertion, unless too tight. See below for further information regarding the position of the fixation device.

A small dressing can be applied until the site dries up. (NB. Gastric leakage is extremely acidic. The dressing must be observed regularly and changed if wet).

After 72 hours back to index



Wash hands as per Trust protocol and wear gloves. Non-sterile gloves are adequate once the stoma has dried up.

Use mild soap with a clean cloth and clean water.

Remove secretions as above.

Dry thoroughly.

Do not apply talcum powder as this increases the risk of infection.

Observe for infection/leakage/granulation tissue – document any variances in the patient’s nursing and/or medical notes.


After 2 weeks the tube should be pushed into the stomach and rotated, in order to prevent buried bumper syndrome (see section 7.6.5). Ideally, this should be done prior to cleaning. NB. Exceptions include balloon tubes and tubes with the distal tip placed in the small intestine i.e. jejunal tubes.)

Where possible, teach the patient to clean his or her own PEG site using a socially clean technique. If the stoma is infected, continue with aseptic technique until infection resolved. Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management for further guidance. Document any variances in the patient’s nursing and/or medical notes.

back to index


7.6.2 Bathing and showering back to index

Do not immerse in water i.e. bath, or swimming, for 3 weeks post insertion. If showering, for the first few days a large waterproof dressing can be used to cover the stoma and removed afterwards. The stoma will still need cleaning if covered with a waterproof dressing. 7.6.3 Dressings

Dressings are not recommended unless the leakage is profuse or distressing to the patient.

If a dressing is used, it should be absorbent (foam), checked regularly and changed if wet. A barrier cream, applied under the dressing, is also advised in order to protect the skin against the harmful effects of gastric aspirate.

Do not place a foam dressing under the fixation device without changing the position of the fixator as it will increase the pressure on the internal retention bumper/balloon, resulting in localised ischaemia (see section 7.6.4 below)

Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management for further advice on management of leakage and dressings. 7.6.4 Positioning of external fixation device back to index The positioning of the fixation device is crucial especially post insertion. Too tight and localised ischaemia may occur, increasing the risk of infection and buried bumper (O’Toole 2006, Wong and Ladabaum 2013), Too loose and the stoma layers will not adhere together, increasing the risk of peritonitis. Following endoscopy, the external fixator will be fixed at approximately 1cm from the abdominal wall. It should be left in position for 1-2 weeks post PEG insertion to allow healing and reduce the risk of peritonitis. However, the fixation device may become too tight post PEG insertion as a result of inflammation and/or re-hydration. If repositioning of the fixation device is required, release the fixation device and slide it backwards up the tube to the optimum position (approximately 1cm) then secure the tube within the device. Recheck the position after closing the device whilst gently pulling back on the tube. Document the adjusted measurement in the patient’s care pathway/notes. If there is any doubt about the correct position of the fixation device, expert advice should be sought.

Within 1-2 weeks of insertion, the PEG tube can be turned to allow cleaning under the fixation device, after this period, the fixation device can be undone and moved away from the skin to allow thorough cleaning. After cleaning, pull back gently on the tube until slight resistance is felt and reposition the fixation device so that it sits 1cm away from the skin, unless recommended otherwise by specialist.

7.6.5 Prevention of buried bumper back to index

If the gastrostomy tube is left in the same position permanently, or pulled too tight, there may be internal ulceration and subsequent migration of the internal bumper through the gastric wall. This can result in in potential occlusion of the tube, pain and difficulties in removal or replacement. In order to prevent this, from within one to two weeks post insertion, the external fixator should be released and the gastrostomy tube pushed into the stomach a couple of centimetres and rotated in a full circle. The external fixator should then be refixed as above. This procedure should be carried out on a regular basis i.e. prior to daily cleaning. NB. Does not apply to balloon gastrostomy tubes or PEG-J tubes.

Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management for further guidance.

Document any variances in the patient’s nursing and/or medical notes.


7.6.6 Sutures back to index

The use of sutures to secure a gastrostomy tube is not recommended. Exceptions to this rule are radiologically inserted gastrostomy tubes. Refer to section 12.1 below for further guidance. Do not remove the sutures until the method of tube insertion is known. Refer to specialist nurse/gastroenterologist. 8.0 MAINTENANCE OF THE GASTROSTOMY TUBE 8.1 Flushing

Correct flushing is essential in order to keep the tube patent. Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes for more information regarding best practice for flushing and type of water. 8.2 Syringes back to index

Enteral syringes for oral / enteral use should have a purple barrel, and be labelled ‘oral / enteral’ use only.

Enteral syringes should only connect to tubes for enteral use, and not to tubes for IV use. The syringes are available with different connectors to fit the various enteral feeding tube ports. The recommended syringes should have either: -

a female luer connector to fit male luer ports on enteral feeding tubes (reverse luer connector combination)

a catheter tip connector to fit catheter tip ports on enteral feeding tubes

non-luer (non-standard connector that does not fit any non-flexible port)

Where the guidance above cannot be followed for an individual patient (e.g. if the patient has a non standard tube), a risk assessment for the equipment to be used should be undertaken prior to use. Non standard equipment should be stored separately, clearly labelled, with restricted access. Only staff with specialist knowledge and skills should have access to these devices. http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808&p=3

NB. All syringes are to be single use only in the hospital setting even if they specify that they are reusable. The syringe must be discarded after the episode of use. 8.3 General care of the tube back to index

Always wash hands before and after handling the tube, or preparing the feed (MHRA 2000).

Regularly change the position of the reflux clamp to prevent wearing a hole in the tube.

Avoid handling the tube unnecessarily.

The long-term use of steroid creams/ointments around the stoma is not advised as they weaken the tube.

If the accessories break, replacement parts are available.

If the accessories are soiled, they should be cleaned or replaced.

The tube should be positioned where it is comfortable and convenient for the patient.

Do not tuck the tube into under garments or incontinence pads, as it is unhygienic – consider the gastrostomy tube port as a knife and fork.



9.0 REMOVAL OF A GASTROSTOMY TUBE back to index

9.1 Accidental Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management for further guidance.

9.2 Planned Gastrostomy tubes can be taken out by either, endoscopic removal, or by pulling, depending on the type of tube. All non balloon tubes should be referred to a specialist for removal. Patients should have a dietetic review prior to removal. They should have maintained their weight on oral diet and be able to drink sufficient fluids. 9.3 Procedure for traction removal of a Merck Corflo gastrostomy tube back to index Preparation Pull tubes - no preparation necessary Endoscopic removal – NBM 6 hours prior to procedure.

Equipment Dressing pack Inco sheet Normasol Instillagel Adhesive dressing Jelonet Apron Gloves Procedure

1. Explain the procedure to the patient and obtain consent as per East Cheshire NHS Trust policy.

2. Wash hands, wear gloves and apron as per East Cheshire NHS Trust policy. 3. Protect the patient’s clothes with an inco sheet. 4. Release the fixation device and move away from the skin. Insert some Instillagel around the

tube and manoeuvre the tube in and out in order to coat the stoma in instillagel. 5. Whilst waiting for the instillagel to take effect, remove the end connector. 6. When ready, remove the clamp and fixation device. NB. Be prepared for air and gastric

contents refluxing up the tube. 7. Hold the tube firmly in your hand – do not wrap the tube around your hand or the air line will

be occluded. Use a gauze swab to help grip the tube if necessary. 8. Apply continuous traction to the tube (if the patient is able to co-operate, ask them to cough

on a count of three, as they cough, pull the tube out. 9. The stoma may bleed slightly after removal, especially if the patient has granulation tissue

around the stoma. Apply pressure with a gauze swab until settled. 10. Clean the stoma. 11. Place a folded square of Jelonet over the stoma, then some gauze dressing and secure. 12. When finished, dispose of clinical waste and wash hands as per Trust policy. 13. Give the patient some spare dressings for replacement as necessary. 14. Give the patient an East Cheshire NHS Trust gastrostomy tube removal advice sheet (See

Patient Information and forms to download or print) 15. Document the procedure in the patient’s medical notes.

East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes Page 54 of 172 Created by Maggie Allen, October 2010. Updated July 2015

Aftercare back to index The patient may eat and drink normally immediately after gastrostomy tube removal (expert opinion).

Place a dressing over the stoma site until healed over (should heal over within 24-48hrs).

Check the dressing regularly for leakage.

Change the dressing if leakage is evident (gastric leakage is acidic and will harm the skin).

A barrier cream may need to be applied under the dressing in order to protect the skin.

The stoma may take longer to close if the patient has an infection in the stoma site or overgranulation. A course of antibiotics may be required if the stoma does not close. Seek expert advice if unsure.

10.0 MANAGEMENT OF BALLOON GASTROSTOMY TUBES back to index 10.1 Definition Balloon gastrostomy tubes are made of silicone and are available as catheter type tubes (G-tubes) or as low profile devices (buttons). They are generally used as a replacement device and can be inserted without endoscopy or X-ray (mature stomas only. See section 10.8 below for further information). Balloon gastrostomy tubes can also be inserted surgically or radiologically (RIG). RIG procedures are not undertaken at MDGH; if a patient has been referred for a RIG, always follow the inserting hospital’s postoperative guidelines following initial radiological placement (these will have been sent with the patient/carer). Balloon tubes are available in a range of sizes and are kept in position by a fluid inflated balloon. The balloon volume varies depending on the make/size of tube. Check the manufacturer’s guidelines prior to use. In general, the minimum amount of fluid specified by the manufacturer should be inserted and increased only if leakage evident.

10.2 Low profile gastrostomy tubes back to index

Low profile tubes are designed to sit close to the skin. They are available in different French (Fr) sizes and shaft lengths. The gastrostomy stoma will need to be measured in order to select the correct sized tube. They require an extension set to enable administration of feed, fluid and medication. There is an anti-reflux valve built in, to prevent leakage following removal of the extension set. 10.3 General management of balloon gastrostomy tubes, buttons and extension sets

Table 4

ACTION

REASON

Always close the cap when not in use.

Balloon gastrostomy tubes may not have a reflux clamp. Spillage will occur especially after a feed.

Ensure the external fixation device is placed in the correct position. It should sit lightly on the skin.

Prevents the tube from sliding in and out of the stomach.

Too loose – increases the risk of leakage.

Too tight – causes tissue necrosis.

Check and change the fluid content in the balloon weekly. Balloons are inflated with sterile or cooled, boiled

Manufacturers recommend that the balloon is checked on a regular basis to prevent accidental removal of the tube caused by


water. Check manufacturer’s guidelines.

deflation of the balloon.

Replace the tube 3-4 monthly To prevent accidental displacement due to balloon failure.

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10.3.1 Preparation of an extension set for administering fluids via a low profile device

1. Prime the extension set with water prior to attachment. 2. Close the clamp to prevent the water escaping. 3. Align the black line on the extension set with the black line on the button device. 4. Push the extension set into the button and rotate it a three-quarters turn clockwise until

resistance is felt. Do not turn beyond this point. Each manufacturer has a slightly different system. Refer to manufacturers guidelines.

5. Attach the syringe/giving set to the extension set, open the clamp and commence administration of feed/fluids.

6. When finished, flush the extension set thoroughly and remove it following point 4 in reverse. 7. Wipe up any drops of fluid that escape from anti-reflux valve, prior to replacing the cap. 8. When finished, dispose of clinical waste and wash hands as per Trust policy.

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10.3.2 Cleaning an extension set after use and replacement The extension set should be cleaned after each use following manufacturer’s instructions.

1. Remove and open the reflux/roller clamp on the tube. 2. Immerse in hot soapy water and flush through several times using a syringe. 3. Rinse through with clear water. 4. Using a syringe, plunge air through the tube and leave to air dry. 5. If conditions do not allow air-drying, store in a lidded container in the fridge. 6. Do not store in Milton 7. When finished, dispose of clinical waste and wash hands as per Trust policy. 8. Replace fortnightly.

Refer to CNSG 015 Microbiological Guidelines for Handling of Enteral Feeds and Fluids.

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10.4 Checking the balloon volume back to index Table 5

ACTION

REASON

Step 1

Explain the procedure to the patient and obtain consent. (The procedure should be explained even if the patient appears not to understand). Position the patient so that the tube is in an accessible position.


Step 2

Wash hands and put on non-sterile gloves.


Guidelines from MHRA SN 2000 (27) Enteral Feeding Systems.

Step 3

Observe the cm measurement on the tube where it exits from the abdomen.

Helps identify correct positioning post-fluid change.

Step 4

Push the tube into the stomach a couple of centimetres.

Helps prevent the tube falling out accidentally whilst changing the fluid.

Helps prevent inflation of the balloon whilst in the stoma tract.

Step 5

Place a luer slip syringe into the balloon port and pull back on the syringe until all the fluid has been removed. Discard the fluid and repeat.

Ensures that all fluid is removed. Failure to completely empty the balloon may result in: -

the balloon rupturing due to over-inflation.

discomfort and/or damage to the stoma.

Step 6

Record the amount of fluid aspirated.

A small amount of loss is normal (0.5-1.5ml/fortnight). Increased loss may indicate balloon failure.

Step 7

Draw up the required amount of replacement fluid (water/saline depending on manufacturer’s guidelines) into the syringe, then insert it into the balloon port and inflate the balloon. Check the amount of fluid required on the balloon port. Different tubes and sizes have varying balloon volumes.

Under filling a balloon may result in the tube falling out accidentally. Overfilling will split the balloon.

Step 8

Pull back gently on the tube, check that the cm measurement at the abdomen is correct and reposition the fixation device.

Ensures the tube is correctly positioned in order to reduce leakage.

Step 9



Step 10

Document the total amount of water used in the patient’s medical/nursing notes

Information for the next individual who changes the water, or in the event or complications.

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10.5 Removal of a balloon gastrostomy tube back to index Table 6

ACTION REASON

Step 1

Explain the procedure to the patient and obtain consent. (The procedure should be explained even if the patient appears not to understand). Position the patient so that the tube is in an accessible position.


Step 2

Wash hands and wear gloves.


Guidelines from MHRA SN 2000 (27) Enteral Feeding Systems.

Step 3

Before removal, check that the tube is definitely a balloon tube. Seek advice if unsure.

To ensure that the tube is safe to be removed by traction. The port will be marked with ‘5cc or 20cc inflation’.

Step 4

Flush 30 - 50mls fluid down the tube prior to removal (replacement only).

Ensures that there is fluid in the stomach to check the position of the new tube.

Step 5

Record the cm measurement where the tube exits from the abdomen.

Helps to correctly position the new tube.

Step 6

Place a Luer tipped syringe into the balloon port and withdraw all the fluid. Check that the amount of fluid withdrawn corresponds with the amount on the written on the balloon port. Discard the fluid and repeat.

Ensures that all fluid is removed. Pulling a partly deflated tube out of the patient may cause discomfort and/or harm the stoma.

Step 7

If the balloon does not deflate, cut the tubing below the balloon port. If the tube is a low profile device/button, push the tip of a pen into the valve to release the fluid.

Helps to deflate the balloon completely.

Step 8

With gentle traction pull the tube out of the stomach.

There may be slight resistance caused by the deflated tube cuff.

Step 9

Expect a small amount of gastric leakage. Wipe away immediately.

Gastric contents are very acidic and will harm the skin. See below for discontinuation of tube feeding.

If replacing a balloon tube, continue to section 10. 9, step 3.

Step 10



Step 11

Document procedure in the patient’s medical/nursing notes

Evidence of procedure. Information as to when next tube change due.

NB. Some gastrostomy tubes including low profile devices have a plastic flexible retention device to hold the device within the stomach rather than a balloon. These are easily identified by the lack of balloon port. Specialist advice should be sought prior to removal.

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10.6 Discontinuing balloon gastrostomy feeding back to index

If tube feeding is to be discontinued, refer to section 9.3 from procedure point No. 10 for guidelines regarding skin care management and aftercare. 10.7 Replacement of a balloon tube (G–tube)

This is normally a straightforward procedure; however, the practitioner should be aware that inadvertent intraperitoneal insertion of replacement G-tube is a reported risk in newly formed stomas and less commonly in a mature stoma. Misplaced G-tubes can result in significant morbidity and death.

Available literature suggests 2 to 4 weeks for a stoma to reach maturity. The time for maturity will depend on the patient’s condition and drug therapy, for instance if a patient is malnourished or on steroid therapy the stoma will take longer to establish. Elective replacements should be avoided until the stoma has reached the expected maturity for the patient in question.

A radiological check of the tube’s position following insertion is recommended: -

If a tube is being replaced within 4 weeks of a new gastrostomy (PEG, RIG, surgical) insertion,

The tube is difficult to insert and accompanied by pain (new and mature stomas).

Refer for specialist input. 10.8 Insertion of gastrostomy balloon tube back to index

Equipment required Dressing pack Normasol Lubricant and/or Instillagel* Apron

Gloves Luer slip syringe 5 or 10ml 60 ml catheter tipped enteral syringe Merck pH strips

Water for flushing (sterile or recently drawn tap water or cooled, boiled water if at home) Water/saline for injection, if not included in the gastrostomy tube pack.

* Some tubes have lubricant within the pack. Instillagel may be required if the patient has inflammation at the site and is experiencing discomfort. Procedure Table 7

ACTION REASON

Step 1 Explain the procedure to the patient and obtain consent. (The procedure should be explained even if the patient appears not to understand). Position the patient so that the tube is in an accessible position.


Step 2 Wash hands and put on non-sterile gloves.

Minimises cross infection (Anderton 1995). Guidelines from MHRA SN 2000 (27) Enteral Feeding Systems.

Step 3 Open the dressing pack and the equipment required on to a clean trolley. Remove the new tube from the packaging, slide the fixation device up the tube, nearer to the cap end and close the cap.

Allows adequate tube to be inserted into the stomach before inflating the balloon.


Procedure continued back to index Table 7

ACTION REASON

Step 4 Prepare the new tube by checking that the balloon is intact.

Prevents insertion of a faulty device.

Step 5 Draw up the correct amount of fluid as specified by the manufacturers. The recommended amount is written on the balloon port.

Under-filling a balloon may result in the tube falling out accidentally. Overfilling may cause the balloon to split.

Step 6 Place the syringe in the balloon port and inflate the balloon.

Observe for leaks and correct inflation.

Step 7 If the balloon sticks to the tube, roll it between your fingers and re-inflate. Deflate once checked.

Incorrect inflation may result in increased leakage.

Step 8 If the tube has introducer e.g. Fresenius tubes, assemble as per manufacturer’s guidelines.

Helps insertion.

Step 9 Lubricate the tip of the new tube with a fluid-soluble agent. Use a topical anaesthetic gel e.g. Instillagel, if the patient is in discomfort.

Helps insertion.

Step 10 Place one hand on the abdomen to pull the skin around the stoma reasonably taut. Hold the tube just above the balloon, then insert the tip of the tube into the stoma and push gently.

Slight resistance may be felt; a slight twist of the tube may aid insertion. There is usually a feeling of sudden give when the tube enters the stomach.

The tube may need to be angled slightly so that the tip points towards the diaphragm.

Holding the tube near to the tip will increase the stability during insertion. Radiologically inserted gastrostomy stomas are usually always angled.

NB. If insertion is difficult due to the stoma tract being angled or very long, a Seldinger technique may be required. This involves passing a wire into the stomach via the existing tube and inserting a new tube over the wire. Refer to a specialist. In the interim, if possible, insert a fine bore tube e.g. 6-10 Fr Ryles (with Spigot) and secure on the abdomen. This will keep the stoma patent until expert help available. Do not use the tube until the tube has been established as being correctly placed in the stomach. A radiological check of the tube’s position following insertion is recommended if the tube is being replaced within 4 weeks of the original placement of the tube and if the stoma is mature and the insertion procedure difficult. This applies to PEG, RIG and surgically placed tubes. See section 10.8 above.

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ACTION REASON

Step 11

Insert the tube a couple of inches into the stomach then inflate the balloon.

Inflating the balloon whilst within the stoma tract may force the stomal layers apart, resulting in potential development of fistulas and subsequent peritonitis.

NB.

Do not push the tube too far into the stomach, as it is possible to inflate the balloon beyond the pylorus. This will prevent gastric emptying, resulting in excessive vomiting and leakage.

Ensure that the balloon is positioned in the stomach and not the stoma tract. If you feel any resistance whilst inflating the balloon stop and check the position of the tube. Inflating the balloon whilst within the stoma tract may force the stomal layers apart, resulting in potential development of fistulas and subsequent peritonitis.

Step 12

Insert a 60cc syringe in the tube and draw back to obtain aspirate. Test with pH paper. If unable to obtain aspirate move the tube in or out whilst withdrawing on the syringe. If still unsuccessful flush 20-30mls air down the tube and retry. If this causes pain, stop and seek expert advice.

Ensures that the tube is in the stomach. Gastric pH should be less than pH 5.5. It may be higher following recent feed, fluid or certain medications e.g. Proton pump inhibitors and H2 antagonists. Seek expert advice if unsure.

NB. A radiological check of the tube’s position following insertion is recommended if the tube is being replaced within 4 weeks of the original placement of the tube. This applies to PEG, RIG and surgical insertion procedures. See section 10.8 above.

Step 12

Wipe away any fluid or lubricant from the skin and dry thoroughly.

Gastric leakage is acidic and harmful to skin.

Step 13

Pull back gently on the tube, check that the cm measurement at the abdomen is correct and reposition the fixation device so that it sits lightly on the skin. Pull back gently again to recheck the position.

Prevents the tube from sliding in and out of the stomach.

Prevents leakage.

Prevents tissue necrosis.

Step 14

Flush the tube with fluid if there is gastric aspirate in the lumen.

Prevents tube blockage.

Step 15



Step 16

Record type, size and Lot number of the tube in the patient's notes.

Required for tracking and is a useful reference for subsequent replacement and audit.

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10.9 Insertion of a low profile device e.g. MIC-KEY button back to index The same principles for removal, replacement and checking the fluid apply as for a balloon gastrostomy tube. The tube may need to be replaced if it becomes too tight or too loose (due to weight loss/gain or growth). The stoma should be measured in order to select the correct sized tube. 10.10 Measuring a gastrostomy stoma (based on Vygon measuring device)

1. Explain the procedure to the patient and obtain consent as per Trust policy. 2. Wash hands, wear gloves and apron. 3. Remove the current tube as per guidelines 4. Lubricate the end of the measuring device 5. Gently insert approx 5-6cm of the measuring device into the stoma 6. Inflate the balloon with 3-4mls of air 7. Pull back on the tube until slight resistance is felt 8. Push down the disc on the device so that it sits lightly on the skin 9. Read the measurement above the disc to give the correct shaft length 10. The French size of the button should correspond with the current gastrostomy tube unless

there is a plan to reduce the stoma size. 11. Record the measurements in the patient's notes.

Alternative measuring devices are available. Follow the manufacturer’s instructions as measuring instructions vary.

10.11 Complications back to index Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management for a comprehensive guide to managing complications. 10.12 Accidental removal of a balloon gastrostomy A replacement tube should be inserted as per section 10.8, as soon as possible, to prevent the stoma from closing over. A gastrostomy stoma will start to close from the inside within a few hours. There may still be access up to 24-48 hours post removal, however a smaller tube will be required. The stoma can then be dilated up to its original size by a specialist. Insert a fine bore tube e.g. 6 Fr, if possible, and refer the patient to the gastroenterologist/specialist nurse for further management. NB. If the tube becomes displaced before the stoma is fully established (i.e. within the first 4 weeks of insertion), there is a possibility of feed or gastric contents leaking into the peritoneal cavity. This may result in peritonitis and is a life threatening condition.

Do not put anything through the tube seek medical help immediately.

A radiological check of the tube’s position following insertion is recommended if the tube is being replaced within 4 weeks of the original placement of the tube. This applies to PEG, RIG and surgical insertion procedures.

A radiological check is also advised for a mature stoma if the insertion procedure is difficult, as there are case reports of inadvertent intraperitoneal insertion of replacement G-tube resulting in significant morbidity and death. For further information, please refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management and section 10.14 below on temporary gastrostomy tubes.

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10.14 Temporary gastrostomy tubes back to index Patients usually have a spare tube and are asked to bring it with them if they need to come to A&E/ETU for replacement. If not and it is not possible to source a new balloon gastrostomy tube, a catheter can be inserted for short-term use. If using a catheter: -

1. Check when the initial gastrostomy was inserted, if less than 4 weeks see section 10.12 above.

2. Insert as per guidelines in section 10.8 3. Fix the catheter in position at the exit from the stomach. This will prevent migration into the

stomach and subsequent leakage at the stoma site. Fixation with tape is required as a catheter does not have an external fixation device.

4. Use a spigot to seal the tube. 5. When finished, dispose of clinical waste and wash hands as per Trust policy. 6. The catheter can be used for feed, fluid and medication, providing the aspirate has been

checked as per guidelines in section 10.8. 7. Inform GI nurse specialist, dietician or ETU, so that the catheter can be replaced as soon

as a suitable tube is available. 8. Record the procedure in the patient’s notes

NB. MHRA one liners caution against the use of a Foley catheter as a gastrostomy tube, however in emergency situations it more acceptable to use a Foley catheter for temporary use than to allow a gastrostomy stoma to close over. A Foley catheter can be used within the remit of these guidelines providing the above conditions are met.

10.15 Spare tubes back to index Balloon gastrostomy tubes are available from: - Endoscopy Unit Dietitians.


11.0 MANAGEMENT OF AN INTESTINAL TUBE WITHIN A PEG TUBE FOR BURIED BUMPER A known complication of gastrostomy tubes is when the gastric mucosa migrates across the internal bumper, eventually completely occluding it. Increased resistance during flushing and more leakage around the stoma site may be an indicator of a buried bumper. Prior to referring for endoscopy, an initial assessment should be made to determine buried bumper.


2. Wash hands, wear gloves and apron. 3. Undo the fixation device move it up the tube away from the skin. 4. Take hold of the tube and push it into the stomach. The tube should slide easily into the

stomach without bending or kinking. 5. If the tube does kink, or the patient experiences pain, refer for specialist advice. 6. When finished, dispose of clinical waste and wash hands as per Trust policy. 7. Record procedure in the patient’s notes.

If the tube is a Fresenius Freka tube, it cannot be pulled out and may need surgical removal. If the patient is unsuitable for surgery, it may be possible to insert a smaller bore tube via the PEG and into the stomach through the remaining fistulae. Refer to specialist.

back to index 11.1 Inserting/replacing an intestinal tube within a Fresenius 15Fr PEG tube The initial procedure may need an endoscopic view to assess whether there is still a patent tract. The tract can be established endoscopically by syringing water through the PEG tube and watching for the entry point in the stomach. Equipment Dressing pack Scissors Fresenius 9Fr intestinal tube pack Lubricant 60ml enteral syringe Water for flushing (sterile or recently drawn tap water or cooled, boiled water if at home) Merck pH strips

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Procedure – with or without endoscopy back to index


2. Wash hands, wear gloves and apron. 3. Remove the end connecters from the PEG tube. 4. Release the external fixation device 5. Remove the 9Fr tube from the packet and advance the guide wire to the end of the tube. 6. Release the clamp on the PEG tube 7. Insert the 9Fr tube into the PEG tube and advance until approx 4-5” of the tube is in the

stomach. Avoid inserting too much tubing as it may form a knot. 8. If it is difficult to advance the internal tube it may be trapped in the mucosal pouch. Try to

change the angle of insertion by manipulating the PEG tube. 9. Once successfully in the stomach, withdraw the guide wire. 10. Cut the internal tube so that it sits 2-3” proud of the PEG tube. 11. Put on the adapters as shown in the booklet provided with the intestinal tube (inside front

leaf). 12. Reposition the external fixation device. 13. When finished, dispose of clinical waste and wash hands as per Trust policy. 14. Give care instructions to the patient/carer. 15. Document procedure in the patient’s medical/nursing notes.

If the tube has not been replaced under endoscopic vision, the internal tube should be aspirated and the contents tested on pH paper to indicate correct gastric placement. The pH value should be less than 5.5. Refer to CNSG 007 Guidelines for Insertion and Management of Nasogastric tubes for more information on pH values. 11.2 Care of the PEG and intestinal tube back to index

The Y connector at the top of the tube has two ports; ‘I’ for the intestinal tube and ‘g’ for the gastric tube (markings on Y connector). Only use the port marked ‘I’ (The ‘g’ port is for the PEG tube and must not be used as this is the part that is buried within the gastric mucosa). Do not rotate the PEG tube as the internal tube may become twisted and knotted. Feed and water can still be given as normal, however the system is at a much greater risk of blocking, as the intestinal tube within the PEG tube is only 9Fr. Correct flushing is very important! Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes for more information regarding best practice for flushing and type of water.

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12.0 RADIOLOGICALLY INSERTED GASTROSTOMY (RIG) TUBES. Gastrostomy tubes are inserted radiologically when endoscopic placement of a gastrostomy tube is contraindicated, or has been unsuccessful. They are not inserted at Macclesfield hospital. The majority of patients with these in situ will come from Salford Royal or Wythenshawe Hospital. The tubes used at these centres may vary. 12.1 Sutures back to index The tube may be sutured in position post insertion. The sutures will depend on the insertion method, the type of tube and the practitioner’s preference. Some sutures are inserted as a failsafe to prevent the tube from falling out (more typical if the tube has been inserted surgically) and are non essential. Others however are essential to hold the stomach adjacent to the abdominal wall until healed. The sutures must be removed as per the inserting hospital guidelines. If unsure, refer to specialist for advice. General care is as per a PEG.

13.0 Discontinuation of tube feeding back to index The patient may eat and drink normally immediately after gastrostomy tube removal (expert opinion).

Place a dressing over the stoma site until healed over (should heal over within 24-48hrs).

Check the dressing regularly for leakage.

Change the dressing if leakage is evident (gastric leakage is acidic and will harm the skin).

A barrier cream may need to be applied under the dressing in order to protect the skin. The stoma may take longer to close if the patient has an infection in the stoma site or overgranulation. A course of antibiotics may be required if the stoma does not close. Seek expert help if unsure. Give the patient an East Cheshire NHS Trust gastrostomy tube removal advice sheet (available from ETU Ext 1044). 14.0 DISCHARGE PLANS back to index 14.1 Discharge within 72 hours of PEG insertion The patient must have a senior review prior to discharge to check that there are no serious complications following PEG insertion (NPSA 2010). The review should be carried out by:-

the clinician/practitioner inserting the PEG - if unavailable,

the SpR for gastroenterology - if unavailable

the on call medical registrar


14.2 Information required for discharge within 72 hours of insertion

• Verbal and written warning given to patient/carer • 24 hour telephone contact number given to patient for urgent aftercare advice • NPSA alert stickers will be on the patient discharge documentation regarding PEG feeding.

back to index 14.3 Training required prior to discharge back to index Prior to discharge the patient and/or carers will be taught how to: -

Care for the PEG site

Care for the tube

Set up and administer feed

Store and dispose of equipment See pre-discharge training proforma

14.4 Information and contact details required prior to discharge back to index The patient will be given contact details for

Dietitian

Specialist nurse

Company providing the feed and equipment The patient will be given written information for the following: -

Pump manual

Gastrostomy care booklet

Syringe reprocessing leaflet

Information Booklet for ordering replacement equipment 14.5 Referrals required prior to discharge back to index

Dietitian

District nurses

Pharmacist (if medication needs modifying) 14.6 Equipment required for discharge The patient will be discharged with sufficient feed and equipment to last until the first home delivery. To include: -

Feed

Syringes

Giving sets

Pump (not ward stock - contact dietitians)

IF THERE IS PAIN ON FEEDING,

OR EXTERNAL LEAKAGE

OF GASTRIC CONTENTS,

OR FRESH BLEEDING,

ADVISE CARERS TO STOP

FEED IMMEDIATELY AND

URGENTLY REFER TO A&E 01625 661451/2


APPENDIX 1 - REFERENCES AND BIBLIOGRAPHY back to index Arrowsmith, H. Nursing Management of patients receiving gastrostomy feeding. British Journal of Nursing 1996; 5(5): 268-273. BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners and Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead. BAPEN (1996) Standards and Guidelines for Nutritional Support in Hospitals (ed. T. Sizer). British Association for Parenteral and Enteral Nutrition, Maidenhead. British Society of Gastroenterology (2006) Guidelines on Complications of Gastrointestinal Endoscopy. London. http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complications.pdf British Society of Gerodontology (2010) Guidelines for the Oral Healthcare of Stroke Survivors. http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf Colagiovanni L. (2000) Preventing and clearing blocked feeding tubes. Nursing Times. 96(17): 3-4. Curzio, J, McGowan, M. Getting research into practice: developing oral hygiene standards. British Journal of Nursing. 2000; 9(7): 434-438. Dougherty, L. & Lister S. (eds) (2004) The Royal Marsden Manual of Clinical Nursing Procedures, 7th edn. Blackwell Science Ltd, Oxford. General Medical Council (GMC) Management for Doctors (2006) Human Rights Act 1998 Hussain A, et al. (1995). The team approach to percutaneous endoscopic gastrostomy feeding. British Journal of Hospital Medicine: 54(7) 308-312 Hussain A et al (1996). Percutaneous Endoscopic Gastrostomy. Postgrad Med J 72:581-585 Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in Partnership with Nutricia Jones, C. The importance of oral hygiene in nutritional support. British Journal of Nursing 1998; 7(2): 74-83 Joint Advisory Group for Gastrointestinal Endoscopy (JAG 2004). Guidelines for the training, appraisal and assessment of trainees in GI endoscopy. Lennard-Jones JE. Ethical and Legal Aspects of Clinical Hydration and Nutritional Support. British Association for Parenteral and Enteral Nutrition 1998. Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical Devices: Implications and Consequences of Reuse. MDA DB2000(04) Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding Systems. MDA SN2000(27).

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back to index Mental Capacity Act 2005 the Mental Capacity Act 2005 (Independent Mental Capacity Advocates) (General) Regulations 2006 National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139 Infection Prevention and control of healthcare-associated infections in primary and community care http://guidance.nice.org.uk/CG139

National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral supplements, parenteral and enteral feeding. London. http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf National Patient Safety Agency (2010). Early detection of complications after gastrostomy NPSA/2010/RRR010 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457 National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808NCEPOD (2004) Scoping our practice.

The 2004 Report of the National Confidential Enquiry into Patient Outcome and Death. London http://www.ncepod.org.uk/2004report/index.htm Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London, NMC.

Oral feeding difficulties and dilemmas. A guide to practical care, particularly towards the end of life. Report of a joint RCP/BSG Working Party - January 2010. http://bookshop.rcplondon.ac.uk/contents/pub295-ca2ff0c8-85f7-48ee-b857-8fed6ccb2ad7.pdf

O’Toole P. (2006) Complications Associated with the Placement of Percutaneous Endoscopic Gastrostomy. Guidelines in Gastroenterology. British Society of Gastroenterology (BSG). London. Payne-James, J., Grimble, G. & Silk, D. (2001) Enteral nutrition: tubes and techniques of delivery. In: Artificial Nutritional Support in Clinical Practice, 2nd edn (eds J. Payne-James, G. Grimble & D. Silk). Greenwich Medical Media, London.

Rollins, H. Hypergranulation tissue at gastrostomy sites. Journal of Wound Care 2000; 9(3): 127-129

Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007209. DOI: 10.1002/14651858.CD007209.pub2

Smedley F, Bowling T, James M, Stokes E, Goodger C, O’Connor O et al. Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. British Journal of Surgery 2004, 91(8): 983-90.

Stroud M, Duncan H, Nightingale J. (2003) Guidelines for enteral feeding in adult hospital patients. British Society of Gastroenterology (BSG). London. Wong, Robert, and Uri Ladabaum. "An uncommon complication of percutaneous endoscopic gastrostomy tubes." Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 11.2 (2013): A25. DeLegge, MH Gastrostomy tubes: Complications and their management. In UpToDate. Saltzman, J, Lipman T (Eds). UpToDate, Waltham, MA, 2015. DeLegge, MH Gastrostomy tubes: Gastrostomy tubes: Placement and routine care. In UpToDate. Saltzman, J, Lipman T (Eds). UpToDate, Waltham, MA, 2013.

back to index







http://bookshop.rcplondon.ac.uk/contents/pub295-ca2ff0c8-85f7-48ee-b857-8fed6ccb2ad7.pdf

East Cheshire NHS Trust CNSG 10 Protocol For First Assistant Role In PEG Insertion Page 69 of 172 Created by Maggie Allen. October 2010. Updated July 2015.

APPENDIX 2 LINKED SUPPORTING DOCUMENTS back to index Care Pathway for Percutaneous Endoscopic Gastrostomy (PEG) Tubes Patient Information leaflets

Patient information for consent - EIDO healthcare.com. E09 PEG. Available from Trust Intranet front page, click on Patient information, then EIDO link and log in following instructions. Once logged in, scroll down to Endoscopy and click on PEG, print off as required.

Information post PEG removal


NPSA alerts relating to PEG National Patient Safety Agency (2010) Early detection of complications after gastrostomy NPSA/2010/RRR010 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457 National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 Manufacturer’s websites Abbott Nutrition home page – access to pump instruction manuals and training Videos http://www.abbottnutritionuk.com/ Corpak Medsystems – access to information about enteral tubes and company guidelines http://corpakmedsystemsuk.com/ Medicina – information about enteral syringes and feeding devices http://www.medicina.co.uk/ back to index








END OF EAST CHESHIRE NHS TRUST CNSG 009 GUIDELINES FOR INSERTION AND MANAGEMENT OF GASTROSTOMY

TUBES

back to index back to main index


Protocol Title:

Protocol For First Assistant Role In Percutaneous Endoscopic Gastrostomy ( PEG) Insertion

Executive Summary:

To ensure that the insertion of a PEG tube is safe, effective and comfortable for the patient.

To provide authorisation and guidance for approved qualified nursing staff to act as first assistant in the endoscopic placement of gastrostomy tubes.




This guideline will impact on: Staff undertaking insertion Percutaneous Endoscopic Gastrostomy ( PEG) Insertion for adult inpatients under the care of East Cheshire NHS Trust.

Financial Implications: Improvements in standards of care should reduce costs and risks associated with sub-optimal patient care and procedures.



Issued By: Department of Gastroenterology




August 2014

APPROVAL RECORD

Committees / Group

Date

Consultation: Department of Gastroenterology Clinical Nutrition Steering Group

October 2010

June 2015


July 2015

AMENDMENTS RECORD


PROTOCOL FOR FIRST ASSISTANT ROLE IN PEG INSERTION INDEX SECTION CONTENTS

PAGE

1.0 Introduction 73

2.0 Aim of protocol 73

3.0 Roles and responsibilities 73

4.0 Standards 73

5.0 Assessment 74

6.0 Equipment 74

7.0 Preparation 74

8.0 Procedure 75-7

9.0 Documentation 78

10.0 Special conditions 78

11.0 References 78

Back to main index


PROTOCOL FOR FIRST ASSISTANT ROLE IN PEG INSERTION 1.0 Introduction back to index

This protocol is for a competent qualified nurse to act as ‘first assistant’ to the endoscopist during the insertion of a Percutaneous Endoscopic Gastrostomy (PEG) tube.

The protocol is to be used in conjunction with CNSG 006 Policy for Enteral Feeding and CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes.

2.0 Aim of protocol

To ensure that the insertion of a PEG tube is safe, effective and comfortable for the patient.

To provide authorisation and guidance for approved qualified nursing staff who have been assessed as competent by a Consultant Gastroenterologist or approved Nurse Specialist to act as first assistant in the endoscopic placement of gastrostomy tubes.

To clarify the tasks that can be undertaken by the first assistant

To identify training requirements 3.0 Roles and responsibilities back to index

East Cheshire Trust acknowledges that changes in medical and nursing roles within many areas of clinical practice are necessary to meet governmental and professional targets.

East Cheshire Trust has therefore identified the need for nurses to develop their scope of professional practice.

The first assistant must acknowledge any limitations of personal knowledge and skills (Code of Conduct, NMC 2015), and will refer any patient back to medical staff if necessary.

The first assistant is professionally and legally accountable for his/her own actions and omissions (Code of Conduct, NMC 2015).

The first assistant must maintain updated personal and professional training, by ongoing education and regular clinical updates.

The Trust will provide vicarious liability whilst the first assistant is working within the parameters of this protocol.

4.0 Standards back to index

Level 1 or level 2 registered general nurse.

2 years post basic experience in endoscopy.

ENB 906 or equivalent course preferred.

Sound knowledge of the anatomy of the abdomen

Knowledge of the PEG equipment

Compliance with British Society of Gastroenterology (BSG) and Joint Advisory Group (JAG) standards for endoscopic procedures and training.


5.0 Assessment back to index The following skills and knowledge will be formally assessed by a consultant gastroenterologist or approved nurse specialist, prior to a nurse acting as a first assistant: -

1. Demonstrate knowledge of the: - a. criteria for PEG insertion b. contraindications for PEG insertion c. complications associated with PEG insertion d. anatomy of the stomach and abdomen e. aftercare post insertion

2. Sterile technique 3. Preparation of a patient's abdomen 4. Digital indentation of the stomach 5. Infiltration of the patient's abdomen with local anesthetic 6. Make a small incision in the abdominal wall with a scalpel 7. Insert a trocar though the abdominal wall into the stomach cavity 8. Insert a guide wire through the trocar and into the stomach cavity 9. Pulling the PEG tube into the correct position. 10. Correct positioning of the fixation device

The first assistant will be required to successfully complete the East Cheshire NHS Trust PEG insertion competency work book prior to being recognised as competent. 6.0 Equipment back to index Trolley Dressing pack Extra gauze 9x10cm Mepore dressing 2% Chlorhexidine (ChloraPrep) 1% Lidocaine (10mls) Scissors PEG kit Sterile gloves 10ml syringe Green and orange needle Filter needle Endoscope – preferably 9mm Small mouth guard Snare Lubricant 7.0 Preparation back to index Check that the PEG care pathway has been completed. Confirm the following with the endoscopist: -

patient’s name

allergies

anticoagulants withheld

INR not greater than 1.3

Platelet count above 100

observations including oxygen saturation are within normal limits

prophylactic antibiotics given

indication for PEG

previous abdominal surgery


8.0 Procedure back to index PEG insertion should be undertaken following East Cheshire NHS Trust aseptic policy.

Step

Action Rational

1. Wash hands thoroughly and wear sterile gloves as per East Cheshire NHS Trust aseptic policy Apply strict aseptic technique throughout the procedure.

Reduce the risk of surgical site infection and sepsis

2. Prepare the equipment and draw up the Lidocaine whilst the endoscopist is examining the upper GI tract and inflating the stomach with air.

Full inflation ensures maximum views of the stomach and raises it towards the abdomen.

3. The endoscopist will locate the appropriate place on the abdomen by pressing a finger into the upper left epigastrium (the indentation should be clearly seen on the monitor) the position will then be clarified by boosting the endoscopic light and observing the red glow from the endoscope light on the abdominal wall (trans-illumination) (O’Toole 2006).

To clarify the position of the stomach on the abdomen and reduce the risk of the puncturing the colon and causing a gastro-colic fistulae.

4. Clean the insertion site and surrounding area with 2% Chlorhexidine (ChloraPrep). Wait until dried.

Reduces skin microorganisms so minimising the risk of surgical site infection and sepsis.

Drying kills the bacteria

5. Place the sterile drape over the abdomen, ensuring that the hole is over the planned insertion area.

Reduces the risk of contamination of the surgical site.

6. Using an orange needle, insert the Lidocaine primed syringe subcutaneously at the planned site and draw back the plunger. If no blood is returned, inject 1-2mls.

Anaesthetise the insertion site. Checking for blood within the syringe minimises the risk of injection of Lidocaine into the blood stream.

7. Remove the syringe and connect the green needle. Longer length needle allows optimum local anaesthesia and visibility in the stomach when inserted through the abdomen.

8. Place the syringe perpendicular to the abdomen at the previously injected site.

Optimum position for entry into the stomach.

9. Advance the syringe into the abdomen whilst drawing back on the plunger – continue to watch the monitor during insertion.

Allows the monitoring of air back into the syringe. If air is seen without the needle being visible in the stomach then the needle may be in the colon.

10. When the needle is visible in the stomach pull back slightly and inject a further 3-4mls.

Ensures that insertion site is adequately anaesthetised.

NB. If unsuccessful, tilt the bed to lower the feet and retry.

back to index


8.0 Procedure continued back to index

Step

Action Rational

11. Test that the Lidocaine has worked by pricking the skin with the scalpel.

Checks that insertion site is adequately anaesthetised.

12. Make a small incision of approx 3-4mm.

Avoid too large an incision as there is a greater risk of skin infection.

13. Place the tip trocar (with introducer) into the small incision site. The angle of the trocar should be perpendicular to the abdomen.

Optimum position for entry into the stomach.

14. Place the other hand on the abdomen so that the fingers are positioned on either side of the insertion site. Keep the site relatively taut and gently advance the trocar into the stomach cavity – observe the monitor whilst advancing the trocar.

Aids insertion.

NB. If the trocar is not visible in the stomach despite full insertion, pull back the trocar and alter the angle so that the tip of the trocar is slightly angled towards the diaphragm, then reinsert the trocar. If still unsuccessful, remove the trocar and start again with finger palpation, followed by the green needle.

15. Once in the stomach remove the introducer immediately.

To reduce the risk of puncturing the gastric wall and blood vessels if the patient suddenly expels air from the stomach.

16. Continue to hold the trocar until it has been secured with a snare by the endoscopist.

Violent expelling of air can dislodge the trocar if not secured. Re-inflation of the stomach may be impaired due to the puncture, resulting in a failed procedure.

17. Pass the guide wire (in the PEG pack) through the trocar and advance approx 10cms so that it is visible in the stomach.

Optimal position for endoscopist.

18. The endoscopist will release the snare slightly and grasp hold of the guide wire.

To allow the guide wire to be pulled back with the endoscope.

19. Allow the guide wire to run freely whilst the endoscopist withdraws the endoscope and guide wire, until the wire is seen coming out of the mouth.

Prevents garrotting whilst the endoscope is removed.

20. Once the endoscopist has secured the PEG tube to the guide wire exiting the mouth, pull gently on the guide wire exiting the stomach and pull the tube though until slight resistance is felt. The measurement on the exterior of the PEG tube at the exit point will depend on the size of the patient (normally between approximately 3-5 cms).

Pull gently to avoid garrotting the patient with the wire.

back to index


8.0 Procedure continued back to index

Step

Action Rational

21. The endoscopist should verify the correct position by reinserting the endoscope and checking that the internal PEG bumper is close to the abdominal wall. If this is not possible i.e. intubation is difficult and presents a risk of serious complication e.g. perforation or aspiration, careful assessment of the exit position and measurement should be made to determine correct positioning of the PEG and agreed by the endoscopist and first assistant.

Incorrect positioning of the internal bumper can increase the risk of peritonitis.

22. Cut the PEG tube at the required length (usually at the end of the markings on the tube, the tube can be shortened at a later date if required) and attach the fixation device to the tube as per manufacturer’s guidelines.

Allows the PEG to be secured properly.

23. Position the fixation device so that it sits lightly on the skin. Pull back gently on the tube to ensure that there is not too large a gap between the abdomen and the device. There should be no more than 3-4mm gap between the device and the skin.

Incorrect positioning of the internal bumper can increase the risk of peritonitis.

If the fixation device is too tight, there is an increased risk of necrosis and stoma infection.

24. Inform the endoscopist of the cm measurement at the point where the tube exits the abdomen.

The exit cm marking will be documented on the endoscopy report and PEG care pathway. This facilitates checks for tube displacement post insertion and ensures that the tube is repositioned correctly following daily cleaning.

25. Place the clamp and the ‘Y’ connector on the tube. To allow connection of syringes and the giving set for administration of feed and fluids.

26. Clean around the site with 2% Chlorhexidine and allow to dry.

Reduce risk of surgical site infection.

27. Position the tube to either side of the abdomen and place a dressing over the PEG tube and site. The PEG tube should not be positioned down towards the pelvic area.

To prevent contamination of the PEG site and the PEG end.

28. Dispose of sharps in the sharps bin and clinical waste in a yellow bag.

Comply with Trust policy

29. Wash hands as per Trust policy Minimise risk of contamination

back to index


9.0 Documentation back to index

Record the type and size of tube on the endoscopy report.

Place the manufacturer’s lot number label on the endoscopy report.

Record the centimetre measurement on the tube at the exit point from the abdomen on the endoscopy report and PEG care pathway.

Place the correct NPSA alert sticker (inpatient/outpatient) on the endoscopy report.

Ensure that PEG care pathway and endoscopy report are sent back to the ward with the patient.

Ensure that the staff/carers are aware of the importance of regular observations post gastrostomy insertion and why.

Record any complications related to the procedure on the endoscopy report.

10.0 Special Conditions

The first assistant will practice within the scope of this protocol.

At no time will the first assistant take over the role of endoscopist unless recognised by the Trust as a competent endoscopist.

Any amendments to the procedure should be documented.

The protocol will be reviewed annually by the consultant gastroenterologist and/or approved advanced nurse practitioner.

11.0 References back to index British Society of Gastroenterology (2006) Guidelines on Complications of Gastrointestinal Endoscopy. London. http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complications.pdf Joint Advisory Group for Gastrointestinal Endoscopy (JAG 2004). Guidelines for the training, appraisal and assessment of trainees in GI endoscopy. O’Toole P. (2006) Complications Associated with the Placement of Percutaneous Endoscopic Gastrostomy. Guidelines in Gastroenterology. British Society of Gastroenterology (BSG). London. National Patient Safety Agency (2010) Early detection of complications after gastrostomy NPSA/2010/RRR010 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457 NCEPOD (2004) Scoping our practice. The 2004 Report of the National Confidential Enquiry into Patient Outcome and Death. London http://www.ncepod.org.uk/2004report/index.htm Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London, NMC.

back to index





END OF EAST CHESHIRE NHS TRUST CNSG 10 PROTOCOL FOR FIRST ASSISTANT ROLE IN PEG INSERTION


East Cheshire NHS Trust CNSG 011 Guidelines for management of suspected peritonitis post PEG insertion Page 80 of 172 Created by mallen Allen. October 2010. Updated July 2015.

Guidelines Title:

Guidelines for Management of Suspected Peritonitis Post Percutaneous Endoscopic Gastrostomy (PEG) Insertion

Executive Summary:

To provide guidance for Trust staff to enable early recognition of complications following PEG insertion and recommended action required. Guidance complies with National Patient Safety Alert (NPSA) Early detection of complications after gastrostomy. NPSA/2010/RRR010:




This guideline will impact on: All staff caring for adult inpatients post insertion of Percutaneous Endoscopic Gastrostomy (PEG) tubes under the care of East Cheshire NHS Trust.

Financial Implications: Improvements in standards of care should reduce costs and risks associated with sub-optimal patient care and procedures.



Issued By: Department of Gastroenterology




August 2014

APPROVAL RECORD

Committees / Group

Date

Consultation: Department of Gastroenterology Endoscopy Users Group Clinical Nutrition Steering Group

October 2010

June 2015


July 2015

AMENDMENTS RECORD

Back to main index

East Cheshire NHS Trust CNSG 011 Guidelines for management of suspected peritonitis post PEG insertion Page 81 of 172 Created by mallen Allen. October 2010. Updated July 2015.

GUIDELINES FOR SUSPECTED PERITONEAL LEAK POST PEG INSERTION

Back to main index

Symptoms within 72 hours of PEG insertion

Increasing severity of pain

Tachycardia

Nausea and vomiting

Pyrexia

Pain during administration of fluids via the PEG tube

Leakage during administration of fluids via the PEG tube

Leakage of gastric contents

Fresh bleeding

Yes

STOP FEED/FLUSH IMMEDIATELY

Refer urgently to on call surgical registrar

Recommended monitoring includes: -

Blood pressure

Pulse

Oxygen saturation

Respiratory rate

Temperature

Pain assessment

Wound check

PEG tube position

Bloods +blood cultures if temperature >37.5

Also Consider

IV fluids

IV antibiotics

Urgent X-ray/CT scan (with gastrografin contrast)

Keep NBM

Once the cause of the patient's symptoms has been identified and treated, recommence feed as per doctor/dietitians instructions. Monitor for complications.

Increase feed as clinical condition allows.

East Cheshire NHS Trust CNSG 012 Guidelines for Management of Jejunal Feeding Page 82 of 172 Created by Maggie Allen. October 2010. Updated July 2015.

Guideline Title:

Guidelines for Management of Jejunal Feeding

Executive Summary:

To optimise the care of adult in-patients receiving nutrition via a jejunal tube under the care of East Cheshire NHS Trust.












August 2014

APPROVAL RECORD

Committees / Group

Date

Consultation: Departments of Dietetics and Gastroenterology Clinical Nutrition Steering Group Matrons

October 2010 – August

2013

June 2015


July 2015

AMENDMENTS RECORD

August 2011 Guidelines updated for NPSA/2011/PSA002 alert compliance


GUIDELINES FOR MANAGEMENT OF JEJUNAL FEEDING INDEX


1.0 Introduction 84

1.1 Definition 84

1.2 Types of tubes 84-5

1.3 Indications for jejunal feeding 85

1.4 Contraindications for jejunal feeding 85-6

1.5 Contraindications relative to specific tube categories 86

2.0 Referrals 87

3.0 Consent 87

4.0 Preparation and assessment prior to insertion of a endoscopic insertion of a jejunal tube

87

4.1 Preparation and assessment prior to endoscopic insertion of a jejunal tube (PEJ)

87

4.2 Preparation and assessment prior to endoscopic insertion of a nasojejunal tube

88

4.3 Preparation and assessment prior to surgical insertion of a nasojejunal tube

88

4.4 Preparation and assessment prior to bedside insertion of a nasojejunal tube

88

5.0 Patient care post endoscopic and surgical insertion of jejunostomy tubes

89

6.0 Management of a jejunal tube 89

6.1 Confirmation of placement of jejunal tubes prior to commencing feed

89

6.1.1 Use of X-ray to confirm tube position 89

6.2 Routine checking of the tube position prior to use 89

6.3 Flushing 90

7.0 Administration of feed via a jejunal tube 91

7.1 Position of the patient during administration of feed 91

8.0 Individual care related to tube type 91-2

8.1 Nasojejunal tube and nasal care 92

8.2 Management of a jejunal extension tube via a PEG (PEG - J) 92

8.3 Management of Endoscopically and surgically placed tubes 92

9.0 Complications of jejunal feeding 93

10.0 Administration of medication via jejunal tubes 93

11.0 Monitoring of patients on jejunal feeds 94

12.0 Mouth care 94

13.0 Removal of jejunal feeding tubes 94

14.0 Discharge planning of patients on jejunal feeds 95



Patient information

Training aids

NPSA alerts


97

Back to main index


1.0 INTRODUCTION back to index 1.1 DEFINITION Jejunal feeding is administration of enteral feed via a tube that has been placed into the proximal jejunum distal to the ligament of trietz*. This can be achieved using the following methods: -

Naso-jejunal (NJ) tube – insertion of a flexible, hollow tube through the pyloric sphincter into the jejunum via the nasal passage. This can be placed under direct vision endoscopy or by bedside tube manipulation technique.

Surgical jejunostomy (Surgical JEJ) - insertion of a polyurethane tube through the abdominal wall into the jejunum during laparotomy.

Percutaneous Endoscopic Jejunostomy (PEJ) – insertion of a polyurethane tube through the abdominal wall into the jejunum under endoscopic vision.

Percutaneous Endoscopic Gastrostomy conversion (PEG-J) tube - a polyurethane tube is passed through the existing gastrostomy tube and pulled through to the jejunum with an endoscope.

* Some tubes may be placed into the duodenum only, depending on the indication. Refer to the patient’s medical notes for information regarding the insertion procedure. Table 1

1.2 TYPES OF TUBES back to index The choice of jejunal tube placed is dependent upon several factors including indication, condition of patient, duration of nutritional support required and access to endoscopy/ theatre. Table 2

Type of tube Advantages Disadvantages

Naso-jejunal tube Low risk insertion procedure

Suitable for short term use

Difficulty of insertion

X-ray confirmation of position required

Risk of perforation

Naso-pharynx discomfort

Risk of displacement

Aesthetically displeasing

Advantages Disadvantages

Limits the need for parenteral nutrition with its associated risks, complications and costs.

Reduced risk of aspiration

Feed delivery is improved with small bowel feeding versus gastric (Glencourse 1998).

Risk of bile reflux

Risk of aspiration

Risk of ‘dumping syndrome’

Risk of blocked tube

Increased risk of infection due to post pyloric feeding

Complications associated with insertion and tube management (see table 2)



Type of tube Advantages Disadvantages

Surgical jejunostomy Can be placed adjunctly with GI surgery


Suitable for long term feeding

Cosmetically more acceptable to patient

Low risk of displacement

Surgical / radiological procedure

Risk of perforation

Risk of infection

Increased risk bacterial overgrowth

Risk of bleeding

Percutaneous Endoscopic Jejunostomy (PEJ)


Suitable for long term feeding


Low risk of displacement

Endoscopic procedure required

Risk of perforation

Risk of jejuno-colonic fistula

Risk of infection

Risk of bleeding

Risk of respiratory depression due to sedation

Risk of aspiration during procedure

Percutaneous Endoscopic Gastrostomy conversion (PEG-J)


Suitable for short to medium term feeding


Endoscopic procedure required with associated risks

Risk of displacement

1.3 INDICATIONS back to index Jejunal feeding (e.g. Naso-Jejunal tube or Jejunostomy) should be considered for patients with: -

documented gastroparesis

gastric stasis secondary to paralysing agents required for ventilation

delayed gastric emptying despite treatment with prokinetics

severe acute pancreatitis

pancreatic or duodenal injury

carcinoma of oesophagus or stomach (where NG or gastrostomy feeding is inappropriate)

upper gastro-intestinal fistulae

recent upper GI surgery

recent hepatobilliary surgery 1.4 CONTRAINDICATIONS FOR JEJUNAL FEEDING back to index

Gastric stasis not treated with gastric motility agents

Gastric stasis secondary to constipation

Advanced dementia (Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes.

Malabsorption

Intestinal obstruction


Relative contraindications include the following: back to index

Patients with severe immuno-suppression during chemotherapy

Diabetics with neuropathy

Hypothyroidism

Neuromotor deglutition disorders

Neuro-surgical patients

Impaired gastrointestinal motility

Neuromuscular blocking agents

Post abdominal surgery See below for contraindications specific to type of jejunal tube 1.5 Contraindications relative to specific tube categories back to index Absolute contraindications Table 3

Nasojejunal feeding Surgical Jejunostomy Percutaneous Endoscopic Jejunostomy

Obstructive pathology in oropharynx or oesophagus preventing passage of the tube e.g. stricture, tumour.

Basal skull fracture, as the tube may enter the brain if incorrectly positioned (oro-gastric positioning or endoscopic insertion may be appropriate).

Crohn's disease

Radiation enteritis

Ascites

General peritonitis

Patient unfit for surgery

Ascites

General peritonitis

Patient unfit for endoscopy

Relative contraindications Table 4

Nasojejunal feeding Surgical Jejunostomy Percutaneous Endoscopic Jejunostomy

Agitated patient who is unlikely to tolerate a nasal tube (consider use of a nasal bridle to secure the tube. Refer to CNSG 008 guidelines for management of nasal bridles)

Oesophageal varices

Mucositis


Morbid obesity



Morbid obesity


Previous upper GI surgery


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2.0 REFERRALS back to index The patient should be referred to: -

Consultant gastroenterologist/surgeon

Specialist nurse

Dietitian

Independent mental capacity advocate (IMCA) (If the patient lacks capacity to make an informed decision and does not have any family or friends with whom it is ‘appropriate to consult’ about the decision. Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes for further guidance for information giving and informed consent.

3.0 CONSENT back to index

Prior to insertion of an enteral tube, the procedure and any risks should be explained to the patient so that informed consent, written/verbal/signage, can be obtained from the patient. The patient’s consent must be recorded in the patient’s notes, in compliance with Trust Policy.

Written information regarding the procedure should be given to the patient where available.

Written consent is required for procedures that carry a greater degree of risk to the patient e.g. endoscopic insertion of an enteral tube. If the patient is unable to sign, the patient’s verbal consent must be witnessed and the witness sign the consent form.

If the patient is unable to give informed consent and in the absence of a patient’s advanced decision regarding treatment, or a registered individual who has lasting power of attorney (Mental Capacity Act 2005), the lead clinician is responsible for any decision to withhold, give, or withdraw, a medical treatment, which includes provision of food and fluid via a feeding tube.

Where possible a multidisciplinary approach should be taken when deciding on jejunal tube insertion for a patient. For severely debilitated patients, ethical, medical and legal implications of long term tube feeding needs to be considered. For patients in the terminal phase of their illness, consideration should be given to the effect of undergoing an invasive procedure which carries significant morbidity and mortality risks.

The goals of the treatment should be clearly identified in the patient’s medical notes.

Evidence of discussion with family members, where appropriate, is required.

Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes for further guidance for information giving and informed consent.

4.0 PREPARATION AND ASSESSMENT PRIOR TO INSERTION OF AN ENDOSCOPIC INSERTION OF A JEJUNAL TUBE The preparation required will depend on the type of tube being inserted. 4.1 Preparation and assessment prior to endoscopic insertion of a jejunal tube (PEJ) The patient should be assessed and prepared as per CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes.

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4.2 Preparation and assessment prior to endoscopic insertion of a nasojejunal tube Patients requiring nasojejunal tubes should be assessed for contraindications, see tables 3 and 4 above and any other medical conditions that will place them at high risk of developing complications related to Nasojejunal feeding. Refer to section 4 in CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes above for information regarding decision making as to whether tube feeding is appropriate. The following group of patients are at a high risk of incorrect tube positioning, dislodgement and aspiration.

Maxillo-facial disorders back to index

Laryngectomy


Any disorder of the oesophagus e.g. varices, stricture.

Nasal C.P.A.P. Oro-gastric positioning may be indicated following head injury or neuro surgery. High Risk also includes patients who: -

Are comatose/semi-comatose

Are ventilated/sedated

Have a swallow dysfunction

Have recurrent retching/vomiting

Need to be nursed prone The patient will require: - back to index

A venflon for sedation, if required

Baseline observations – to check that the patient is fit enough for the procedure

Recent U&Es – for accurate assessment of nutritional and fluid requirements. The following documents must be sent with the patient to the endoscopy unit at the time of the procedure:

Signed consent form

Patient notes

Nursing notes

Drug charts

Procedure checklist/care plan.

4.3 Preparation and assessment prior to surgical insertion of a nasojejunal tube The patient will be assessed and prepared for surgery as per East Cheshire NHS Trust policy and guidelines. 4.4 Preparation and assessment prior to bedside insertion of a nasojejunal tube The patient will be assessed and prepared as per CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes.

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5.0 PATIENT CARE POST ENDOSCOPIC AND SURGICAL INSERTION OF JEJUNOSTOMY TUBES Endoscopic insertion – as per CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes. Surgical insertion back to index Follow surgical plan as recommended by individual consultant surgeons and Trust guidelines. 6.0 MANAGEMENT OF A JEJUNAL TUBE 6.1 Confirmation of placement of jejunal tubes prior to commencing feed

If a jejunal tube has been placed ‘blind’ at the bedside, the position of the tube should be confirmed by abdominal X-ray prior to using the tube.

Endoscopically placed tubes may not need to be x-rayed prior to use. The endoscopist should state whether x-ray is required on the endoscopy report.

The external length of all jejunal tubes should be measured, marked and documented. 6.1.1 Use of X-ray to confirm tube position

Refer to section 9.2 in CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes for further guidance 6.2 Routine checking of the tube position prior to use back to index Aspiration Aspirate is not normally obtainable from the jejunum. Therefore the absence of aspirate is not a contra-indication to feeding. Routine aspiration is, therefore, not required. If the patient is nauseated or vomiting, the NJ tube should be aspirated. If an aspirate is obtained, this may indicate that the tip of the tube has migrated to the stomach. Any feed or medication being administered through the tube at this time should be stopped and advice sought from medical staff/specialist nurse. Assessment for tube displacement Check the length and position of the marking on the tube and compare with the position documented following initial placement. If position of the tube is in doubt consider abdominal X-ray. NB. Jejunal tubes can be more complex to insert and may involve procedures that carry a degree of risk of complications to the patient. Therefore every effort must be made to minimise the need for replacement in the instance of blocked or displaced tube.

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6.3 Flushing back to index Jejunal tubes are mainly fine bore and have a higher potential to block. Regular and effective flushing is essential. Prior to flushing Full compliance with hand hygiene and personal protective equipment must be maintained as per Trust Infection Prevention and Control Good Practices Policy. When to flush Using a 60ml enteral feeding syringe, flush the tube with a minimum of 30-50mls water:

Before and after administration of feed

Before and after administration of each type of medication (if the patient is on a strict fluid restriction – liaise with the pharmacist and dietitian for advice)

If the patient is disconnected from the feed for a short period of time.

4 hourly if the tube is at high risk of blocking e.g. a nasojejunal tube

Leave a column of water in the tube during the rest period. What to flush with

Sterile water – hospital use. Cooled boiled water – community use (should be prepared fresh daily, dated, named (if in a

care setting) and stored at room temperature.

Enteral syringes only. They should have a purple barrel, and be labelled ‘oral / enteral’ use only. Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes for further guidance.

How to flush back to index

Moderate pressure should be applied with the plunger when flushing feeding tubes.


7.0 ADMINISTRATION OF FEED VIA A JEJUNAL TUBE back to index Patients should be referred to the Department of Nutrition and Dietetics for assessment of nutritional requirements and recommendation of an appropriate feed. Whereas the stomach can tolerate administration of intermittent boluses of feed, the duodenum and jejunum are not designed to receive food in this way. In the normal gut a gradual continuous flow of diluted and partially digested is slowly released from the stomach. To simulate this when feeding directly into the duodenum or jejunum, the feed should be administered by slow continuous infusion.

A slow rate of administration must be used initially and the volume and rate increased gradually.

The rate of infusion should be carefully controlled using an enteral feeding pump.

Too rapid an infusion is likely to cause diarrhoea and other gastrointestinal side effects as the reservoir of the stomach is bypassed.

Feed can be administered over 24 hours as a rest period is not essential. Once a patient is established on jejunal feeding (i.e. tolerating the feed and meeting nutritional requirements) the rate of infusion can be increased to enable the hours of feeding to be reduced.

Feed administered should be documented on a fluid balance chart.

The enteral feed should be labelled with patient's name, date and time the feed was opened.

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Post-pyloric feeding by-passes the anti-microbial effects of gastric acid. In order to prevent contamination and infection:-

Full compliance with hand hygiene and personal protective equipment must be maintained as per Trust Infection Prevention and Control Good Practices Policy.

Staff should use a Non-Touch Aseptic Technique. This means avoiding touching the connection parts of feeding systems or unnecessarily opening feeding systems.

Follow the procedure for administration of feed as recommended in CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.

Store, prepare and dispose of feed and equipment as per CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids.

7.1 Position of the patient during administration of feed Although there is less risk of reflux with jejunal feeding, patients at risk of aspiration due to a swallow disorder, should be in a sitting or elevated position (at least 30 o), during feeding and for an hour afterwards, to help to reduce the risk of reflux and aspiration. 8.0 INDIVIDUAL CARE RELATED TO TUBE TYPE back to index 8.1 Nasojejunal tube

Securing the Tube Once the tube has been confirmed as being correctly placed, it must be secured to the side of the face by a hypoallergenic adherent dressing and looped over the ear. This is recommended for the following reasons: -

Less irritating for the patient as it secures the tube out of their line of sight.

Does not interfere with the patient’s eating, by keeping the tube away from the mouth.

A confused patient is less likely to pull the tube out as they cannot see it or feel it when they bring their hands up to the mouth area.

Patients receiving humidified oxygen (excess moisture makes the nasal tape slip).

The external part of the tube should be brought to the same side of the face as the insertion nostril and allowed to rest over the ear.


An addition narrow piece of tape can be placed to secure the tube at the exit from the nostril.

Avoid pulling the tube too tight so that it causes pressure on the nostril; localised cyanosis and necrosis can occur if blood flow is impaired.

The securing dressing should be checked regularly and replaced if dirty or peeling off.

A nasal bridle may be appropriate.See Guidelines for Insertion and Management of Nasal

Bridles for further guidance.

Nasal care back to index

Monitor the patient’s nose daily for signs of friction abrasions and clear away dried secretions.

If the nose appears sore or ulcerated refer to specialist 8.2 Management of a jejunal extension tube via a PEG (PEG - J) An intestinal tube can be passed through an existing PEG tube and pulled through into the small intestine with an endoscope. A ‘Y’ adapter placed on the end of the PEG tube allows administration of liquid via the intestinal tube, or the PEG tube. The indication for this procedure is to feed into the small intestine rather than the stomach to help reduce reflux and vomiting. The Y connector on the PEG tube has two ports, ‘I’ for the intestinal tube and ‘g’ for the gastric tube (markings on Y connector).

Use the ‘I’ port for administration of feed and water

Use the ‘g’ port for administration of medication into the stomach Both lumens are narrow so there is a high risk of blockage. Correct flushing is essential. See section 6.3 above. Rotation of the tube back to index Normally a gastrostomy tube is rotated in order to prevent the internal bumper form becoming buried in the gastric mucosa. Do not rotate the gastrostomy tube in this instance as it will displace the jejunal tube – the gastrostomy tube can be pushed into the stomach a couple of centimetres then pulled back (reduces the risk of buried bumper). Refer to specialist for advice. 8.3 Management of Endoscopically and surgically placed tubes Tube management will depend on the type of tube. Refer to specialist. back to index


9.0 COMPLICATIONS OF JEJUNAL FEEDING back to index For advice regarding management of enteral feeding complications refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tube. Specific advice relating to jejunal tubes is seen below.

PROBLEM

POSSIBLE CAUSES INTERVENTION

NJ tube partially pulled out

Accidental removal by staff or patient

Request abdominal X-ray to confirm exact position.

If still in small intestine continue feeding.

If in the stomach will need to be replaced

Contact gastroenterologist if endoscopic placement required.

NJ tube completely pulled out

Accidental removal by staff or patient

Contact gastroenterologist if endoscopic placement required.

PEJ pulled out Accidental removal by staff or patients

Contact gastroenterologist/specialist nurse for advice immediately

Surgical Jejunostomy pulled out

Accidental removal by staff or patients

Contact Medical / Surgical team for advice immediately

Infected PEJ or Jejunostomy site

Refer to CNSG 014 Guidelines For Enteral Feeding Complications and Management for causes and recommended management.

Leaking Jejunostomy stoma

Refer to CNSG 014 Guidelines For Enteral Feeding Complications and Management for causes and recommended management.

10.0 ADMINISTRATION OF MEDICATION VIA JEJUNAL TUBES back to index Administration of some medications via a jejunal tube may be contraindicated for the following reasons:-

The risk of blockage is high

Most drugs are not licensed to be given via the jejunum or duodenum, as the mode of action and absorption in the small bowel is not known.

Some drugs may not be absorbed as effectively in the duodenum as the stomach, resulting in sub-therapeutic doses.

The patient must have their medication reviewed by a pharmacist and the prescribing clinician must be aware that the tube is placed in the jejunum. If the patient has jejunal tube, it may be necessary to consider passing a second tube into the stomach or use a double lumen tube so that drugs can be administered into the stomach. Refer to CNSG 016 Guidelines for Administration of Medicines via Enteral Feeding Tubes for further information.

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11.0 MONITORING OF PATIENTS ON JEJUNAL FEEDS back to index Refer to CNSG Guidelines for Assessment and Monitoring for further guidance. Contact dietitian for information. 12.0 MOUTH CARE

Maintenance of oral hygiene is essential, particularly is a patient is unable to


attend to their own oral care

PROBLEM REASON

ACTION

Dry sore mouth


Mouth breathing


Clean teeth/dentures with a soft toothbrush or a damp swab wrapped around a gloved finger (depending on the patient. The frequency will depend on the condition of the patient, twice daily minimum).






Dehydration






Refer to Guidelines for the Oral Healthcare of Stroke Survivors by the British Society of Gerodontology for comprehensive guidance as to management of oral hygiene. http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf 13.0 REMOVAL OF JEJUNAL FEEDING TUBES back to index Jejunal tubes should only be removed if patients are meeting their nutritional requirements via an alternative route. The method of removal will depend on the type of tube.

Naso-jejunal tubes can be removed by pulling.

Surgical Jejunostomy tubes may need further surgical intervention for removal, particularly if the tube has an internal retaining cuff. Refer to surgeon. If the tube is a balloon tube, the balloon should be deflated and the tube removed by traction. If the type of tube is unknown, refer to specialist for advice.

PEJ tubes can be removed by traction. The procedure should be undertaken by a trained practitioner.

For further guidance about tube removal, including skin care, refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes.

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14.0 DISCHARGE PLANNING OF PATIENTS ON JEJUNAL FEEDS back to index Patients must have prior to discharge: -

A multidisciplinary risk assessment to assess needs (Appendix 5 Flow chart to guide decision making for tube feeding)

Referral to a dietitian

Training and assessment of competency for them and/or their carers for tube care and feeding.

An agreed plan if tube removed accidentally or blocked.

A discharge pack to include: - o Care of NJ tube o Care of equipment o Contact numbers o Feeding regimen o Position monitoring form o CE accredited pH strips o Manufacturer’s guidelines for using pH strips o Spare NG tube o 7 days feed and equipment o How to maintain oral hygiene


APPENDIX 1 REFERENCES AND BIBLIOGRAPHY back to index BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners and Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead. British Society of Gerodontology (2010) Guidelines for the Oral Healthcare of Stroke Survivors. http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf Human Rights Act 1998 Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in Partnership with Nutricia. Mental Capacity Act 2005 National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139 Infection Prevention and control of healthcare-associated infections in primary and community care http://guidance.nice.org.uk/CG139 National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral supplements, parenteral and enteral feeding. London. http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation of placement NPSA/2012/RRR001 22/03/12 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441 National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA/2011/PSA002 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640 National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London, NMC. Payne-James, J., Grimble, G. & Silk, D. (2001) Enteral nutrition: tubes and techniques of delivery. In: Artificial Nutritional Support in Clinical Practice, 2nd edn (eds J. Payne-James, G. Grimble & D. Silk). Greenwich Medical Media, London. The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7th edition. Available from the Trust Intranet.








APPENDIX 2 LINKS TO SUPPORTING DOCUMENTS back to index NPSA alerts relating to Nasogastric feeding

National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation of placement NPSA/2012/RRR001 22/03/12 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441 National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA/2011/PSA002 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640 National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric feeding tubes NPSA/2005/05 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798 Manufacturer’s websites Abbott Nutrition home page – access to pump instruction manuals and training Videos http://www.abbottnutritionuk.com/ Corpak Medsystems – access to information about enteral tubes and company guidelines http://corpakmedsystemsuk.com/ Medicina – information about enteral syringes and feeding devices http://www.medicina.co.uk/

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END OF EAST CHESHIRE NHS TRUST CNSG 012 GUIDELINES FOR

MANAGEMENT OF JEJUNAL FEEDING

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East Cheshire NHS Trust CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes. Page 99 of 172 Created by Maggie Allen. October 2010. Updated July 2015.

Guideline Title:

Guidelines for Administration of Feed and Fluid via Enteral Tubes

Executive Summary:

To optimise the care of adult in-patients receiving nutrition via an enteral tube under the care of East Cheshire NHS Trust.







Version Number: 1.1 Effective Date: October 2010





August 2014

APPROVAL RECORD

Committees / Group

Date

Consultation: Departments of Dietetics and Gastroenterology Clinical Nutrition Steering Group Matrons Infection prevention and control department

October 2010

June 2015

Approved by:


July 2015

AMENDMENTS RECORD


GUIDELINES FOR ADMINISTRATION OF FEED and FLUID VIA ENTERAL TUBES INDEX

SECTION CONTENTS

PAGE

1.0 Method of feeding 101

1.1 Continuous feeding 101

1.2 Cyclic feeding 101

1.3 Bolus feeding 101

1.4 Preparation of feed 101

2.0 Administration of bolus feeding 102-2

3.0 Administration of feed via a pump 104-5

3.1 Split feeding 105

4.0 Feeding position 105

5.0 Hanging times for feeds 105

6.0 Enteral feeding equipment 106

6.1 Single use and single patient use equipment 106

6.2 Syringes 106

6.3 Tubes 107

6.4 Adaptors 107

6.5 Feeding pumps 107

7.0 Administration of water 108

7.1 Type of water 107

7.2 Flushing enteral feeding tubes 108

8.0 Disposal of equipment 109

Appendix 1 References 109


Patient information

Training aids

NPSA alerts


110

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GUIDELINES FOR ADMINISTRATION OF FEED and FLUID VIA ENTERAL TUBES Enterally fed patients are susceptible to infections of the gastro-intestinal tract, infections around the tube insertion site, chest infections and septicaemia. (Arrowsmith 1996, Pien et al. 1996). The following guidelines must be used in association with CNSG 015 Microbiological Guidelines for Enteral Feeding. 1.0 METHOD OF FEEDING back to index A dietitian will tailor the feeding regimen to suit individual needs. This will take into account the clinical condition, lifestyle, mobility and the route of administration. The feed can be given continuously, intermittently, overnight or as bolus feeds. Enteral feeds may provide all the nutritional requirements or may be used to supplement an inadequate oral intake. 1.1 Continuous feeding This is normally used for patients who are critically ill, requiring tight glucose control, or for patients requiring the lowest possible feeding rate due to slow gastric emptying or gastro-oesophageal reflux. 1.2 Cyclic Feeding Allows the patient to be fed continuously via a pump over only part of the day. A higher rate of feeding is required compared to someone on continuous feeding. Cyclic feeding is generally given overnight to free up the daytime for normal activities. It also allows for the patients to eat at mealtimes, if an oral diet is still being taken. Discontinue the feed at least 1 hour prior to strenuous activity e.g. physiotherapy. 1.3 Bolus Feeding back to index This involves the administration of a specific volume of feed, via a syringe or a Paediatric Feeding Set, at intervals throughout the day. This method of feeding may be preferable to continuous feeding for some patients. This method can: -

release mobile patients from long periods attached to feeding equipment

allow individuals to have "normal mealtimes"

help regulate appetite and help transition to oral feeding

be a safe method of feeding for agitated and restless patients who would have a tendency to pull at and displace tubing if fed via a pump .

Not all patients can tolerate bolus feeds. The dietician will discuss the choice of bolus versus pump feeding. Some patients use a combination of both methods. 1.4 Preparation of feed Refer to sections 2 and 3 in CNSG 015 Microbiological Guidelines for Enteral Feeding for best practice for storage and preparation of feed.

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2.0 ADMINISTRATION OF BOLUS FEEDING back to index Equipment

Feed as stated on feeding regimen

Water (fresh tap water in hospital/ cooled boiled water in community, sterile water if the patient is immuno-compromised or if the tube is placed in the duodenum/jejunum)

60ml enteral syringe (purple)

Alcohol wipe

Gloves

Always use the designated bottle opener. Abbott Nutrition supply foil cutters for the feed bottles.

Procedure for bolus feeding

ACTION RATIONALE

Wash hands and assemble equipment required. Minimise cross infection.

Check feed and volume on prescription chart and dietetic feeding regimen.

To reduce risk of incorrect feed being given.

Explain procedure to patient. To ensure patients co-operation and promote confidence.

Position the patient in a semi-upright or upright position, 30-45o angle.

To reduce risk of reflux and aspiration and ensure patient is comfortable.

Wash hands thoroughly and put on gloves (non-sterile) as per East Cheshire NHS Trust policy.

To minimise risk of cross-infection.

Check expiry date of feed and check for damage.

To ensure contents are sterile and within use-by date.

Shake feed container well.

To ensure contents are thoroughly mixed.

Wipe container with alcohol wipe and open using a sterile foil cutter (Abbott bottles) or sterile scissors.

Reduce risk of contamination.

If using a nasogastric tube, check position prior to use. Refer to CNSG 007 Guidelines for the Management of Nasogastric Tubes.

Prevents feeding into the lungs.

Flush tube with 50mls of water (or as volume recommended on dietetic regimen). Use the plunger for flushing. See section 7.2 below for further guidance.

To check patency of tube and clear gastric juices. Using the plunger achieves optimum flushing of the tube.

Close the clamp on the gastrostomy tube prior to disconnecting the syringe from the tube.

Prevents leakage of gastric contents.

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Procedure for bolus feeding continued back to index

ACTION RATIONALE

Method of administrating feed: gravity versus pushing with the plunger

Feed can be given by gravity i.e. removing the plunger from the syringe and pouring the feed directly into the syringe casing and allowing it to drain into the stomach. The speed can be controlled by the height of the syringe in relation to the body (the higher the syringe the quicker it will empty). The alternative method is to draw up the feed in the syringe by pulling back on the plunger then attach the syringe to the enteral tube and push using a slow steady action. NB. Using the plunger will not harm the patient or the tube. Some individuals may be hypersensitive and feel slightly nauseous with ‘push’ feeding in which case, gravity feeding will be better for them. With either method, continue until the recommended dose has been given, unless the patient cannot tolerate the amount in which case rest and then recommence after reviewing the patient. If the patient has pain during administration of feed/fluid, stop immediately and assess for complications. Refer to CNSG 014 Guidelines for Enteral Feeding Complications and Management for further guidance.

On completion of feed, flush the tube with at least 50mls of water (or volume as recommended on dietetic regimen). The plunger must be used for flushing.

Using the plunger achieves optimum flushing of the tube and prevents blockage. See section 7.2 below for further guidance.

On completion of the flush, close the clamp on the gastrostomy tube then disconnect the syringe and recap the feeding port.


Opened feed must be stored in a refrigerator. Discard after 24 hours. Refer to CNSG 015 Microbiological Guidelines for Enteral Feeding for further information.

To minimise risk of bacterial contamination.

To minimise risk of feed contamination.

Dispose of used equipment in accordance with East Cheshire NHS Trust policy.

To minimise risk of cross infection.

Wash and dry hands thoroughly as per Trust policy.

To minimise risk of cross infection.

Complete appropriate documentation: - 1. Sign prescription chart for feed given. 2. Enter water and feed volume on fluid

balance chart. 3. Record pH value on the nasogastric

monitoring form if NG feeding. 4. Record any complications.

To ensure accurate records are maintained.

Wash hands and assemble equipment.


Check feed and volume on prescription chart and dietetic regimen.

To reduce risk of incorrect feed being given.

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3.0 ADMINISTRATION OF FEED VIA A PUMP back to index

ACTION RATIONALE

Wash hands as per East Cheshire NHS Trust policy and put on gloves (non-sterile).


Check expiry date of feed and check for damage.

To ensure contents are sterile and within use-by date.

Shake feed container well.

To ensure contents are thoroughly mixed.

Set up feed and pump following the manufacturer’s instructions and using an Aseptic Non Touch technique (ANTT) i.e. do not allow any part of the equipment that comes in contact with feed, to touch hands, skin or clothing.

See section 6.5 below for further information on pumps.


Set the pump rate and feed volume (as recommended by the dietitian).

If using a nasogastric tube, check position prior to use and record the pH value on the

Nasogastric Tube Insertion and Monitoring Form. Refer to CNSG 007 Guidelines for the Management of Nasogastric Tubes.

Prevents feeding into the lungs.

Flush tube with 50mls (or as volume recommended on dietetic regimen) of water. Use the plunger for flushing.

To check patency of tube and clear gastric juices. Using the plunger achieves optimum flushing of the tube.

Close the clamp on the gastrostomy tube prior to disconnecting the syringe from the tube.


Attach the giving set to the feeding tube.

Undo the reflux clamp (gastrostomy tubes).

Turn pump dial to run.

On completion of feed, close clamp on gastrostomy tube then disconnect the giving set and flush the tube as volume recommended on dietetic regimen.

To prevent blockage

On completion of the flush, close the clamp on the gastrostomy tube then disconnect the syringe and recap the feeding port.


Dispose of used equipment in accordance with East Cheshire NHS Trust policy.

Act in accordance with "Waste Disposal Policy" to be found in the East Cheshire NHS Trust Health and Safety Policy.

Wash and dry hands thoroughly.

To minimise risk of cross infection

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ADMINISTRATION OF FEED VIA A PUMP – continued back to index

ACTION RATIONALE

Complete appropriate documentation. 1. Sign prescription chart for feed given

2. Enter water and feed volume on fluid

balance chart

3. Record pH value on Nasogastric Tube

Insertion and Monitoring Form if NG

feeding

4. Document any complications.

To ensure accurate records are maintained.

3.1 Split feeding If the patient has a break in the feeding regime i.e. a few hours in the morning, followed by a few hours in the evening, during the rest period: -

Disconnect the giving set from the feeding tube

Place the purple connector and dust cover on the end of the giving set and store in the slot at the back of the pump.

Flush and close the cap on the feeding tube.

Discard the feed after 24 hours 4.0 FEEDING POSITION back to index The individual receiving enteral feed must be in a sitting or elevated position (at least 30o), during feeding and for an hour afterwards. This helps to reduce the risk of reflux and aspiration. When feeding overnight, ensure that the upper body is propped up with pillows, or the bed head elevated. If the individual has a history of reflux or a known large hiatus hernia, daytime feeding should be considered so that the patient can be fed sitting upright in a chair. 5.0 HANGING TIMES FOR FEEDS

The hanging time is the total time the opened feed is kept at room temperature.

Storage time in a refrigerator below 5ºC is not included in the hanging time.

There should be individual risk assessment and the hanging times reduced if necessary.

FEED TYPE MAXIMUM HANGING TIME

MAXIMUM STORAGE TIME IN REFRIGERATOR

Sterile, ready-to-use feeds if not decanted.

24 hours Not applicable

Sterile feeds decanted into a sterile reservoir using aseptic/non-touch technique (ANTT).

24 hours 24 hours

Non sterile feeds e.g. reconstituted powders and mixed feeds decanted into a sterile reservoir.

4 hours 24 hours

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6.0 ENTERAL FEEDING EQUIPMENT back to index Devices used for enteral feeding, must not compromise the health and safety of the patient, user, or any other person. Any risks associated with the device must be compatible with patient health and protection. Medical Devices Regulations 2002. The principles governing the use of enteral feeding equipment are outlined in National Patient Safety Alert (NPSA) Alert 19 (2007): Promoting safer measurement and administration of liquid medicines via oral and other enteral routes.

6.1 Single use and single patient use equipment

Single use equipment is recommended in the hospital setting. An exception to this rule is extension sets or specialist adapters for gastrostomy tubes. Refer to CNSG 015 Microbiological Guidelines for Handling of Enteral Feeds and Fluids, for further information regarding cleaning and storage.

6.2 Syringes back to index Enteral syringes for oral / enteral use should have a purple barrel and be labelled ‘oral / enteral’ use only. Enteral syringes should only connect to tubes for enteral use and not to tubes for IV use. The syringes are available with different connectors to fit the various enteral feeding tube ports. The recommended syringes should have either: -

a female luer connector to fit male luer ports on enteral feeding tubes (reverse luer connector combination)

a catheter tip connector to fit catheter tip ports on enteral feeding tubes

non-luer (non-standard connector that does not fit any non-flexible port) Where the guidance above cannot be followed for an individual patient (e.g. if the patient has a non standard tube), a risk assessment for the equipment to be used should be undertaken prior to use. Non standard equipment should be stored separately, clearly labelled, with restricted access. Only staff with specialist knowledge and skills should have access to these devices. National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808&p=3 NB. Some companies e.g. Medicina, provide single use enteral syringes for hospital use and reusable syringes for community use. Caution is required, as they are the same colour. The single use syringes are labelled with the single use logo, both on the packet and the syringe. All syringes are to be single use only in the hospital setting even if they specify that they are reusable. The syringe must be discarded after the episode of use i.e. flushing followed by administration of fluid/ medication, followed by flush, then dispose of the syringe. Wards should order the single use only enteral syringes. Refer to CNSG 015 Microbiological Guidelines for Enteral Feeding for information regarding use of ‘single use’ and ‘single patient use’ devices.

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6.3 Tubes back to index

All tubes for enteral use must be labelled ‘for enteral use only’.

All tubes for enteral use should only connect to syringes for enteral use, and not to syringes for IV use.

The patient should be assessed for the correct enteral tube. Refer to CNSG Guidelines for Assessment and Monitoring for Patients receiving Enteral Nutrition.

6.4 Adaptors Three way taps and syringe tip adaptors should not be used as routine. The correct enteral syringe should be ordered to fit the tube. 6.5 Feeding pump back to index Pumps are on loan from Abbott Nutrition as part of a contract. Each ward is allocated a supply of pumps and is responsible for their use decontamination and retention. Type FreeGo pump Available from: Wards Before using the pump, always check that: back to index

Staff are trained to use the equipment.

The pump and cable are clean and undamaged. General care

ACTION

RATIONALE

Keep plugged in Battery lasts 6 – 8 hours. The pump needs to be fully charged in case of electrical failure.

Clean spilt feed off the pump immediately with a disposable damp cloth.

Source of bacterial contamination and may prevent the pump from functioning accurately.

Report faults to medical electronics ext 1930.

To allow prompt repair/replacement.

When no longer required, clean the pump thoroughly and return to designated storage area. Refer to manufacturer’s pump manual for correct decontamination procedure.

Pump should be decontaminated prior to being used for the next patient in order to prevent cross infection.

The pump comes with a comprehensive manual with step by step pictures for setting up a feed and a useful troubleshooting section in the event of problems. There is also a free phone number in the front of the manual if you are unable to solve the problem. The following link is the home page of Abbott Nutrition for access to the pump manual and training videos. https://www.abbottnutrition.co.uk/media/70612/freego_operating_manual.pdf

https://www.abbottnutrition.co.uk/media/70612/freego_operating_manual.pdf


7.0 ADMINISTRATION OF WATER back to index

7.1 Type of Water

In the hospital setting tap water is suitable for flushing, providing that it is: -

Kept in a lidded container

Changed twice a day

Not contaminated by dipping the syringe into the jug to draw up water (pour the water into a cup first).

Use sterile water if: -

The patient is immuno-compromised.

The feeding tube is positioned in the duodenum or jejunum.

Large volumes of water are required to be given via a reservoir i.e. an Abbott Flexitainer.

It is the first flush following PEG insertion The sterile water bottle must be labelled with the patient’s name, date and time of opening. It must be discarded after 24 hours. Refer to CNSG 015 Guidelines for Handling of Enteral Feeds and Fluids, for further information. 7.2 Flushing enteral feeding tubes back to index

When to flush

Using a 60ml enteral feeding syringe, flush the tube with a minimum of 30-50mls water:

Before and after administration of feed

Before and after administration of each type of medication (if the patient is on a strict fluid restriction – liaise with the pharmacist and dietitian for advice)

If the patient is disconnected from the feed for a short period of time.

Following aspiration to check tube position

Leave a column of water in the tube during the rest period. Omitting to flush after halting the feed or after giving a medication is a common cause of tube blockage How to flush

Moderate pressure should be applied with the plunger when flushing feeding tubes.


8.0 DISPOSAL OF EQUIPMENT back to index Clinical waste should be disposed of as per Trust policy. APPENDIX 1 REFERENCES AND RELATED READING back to index Arrowsmith, H. Nursing Management of patients receiving gastrostomy feeding. British Journal of Nursing 1996; 5(5): 268-273. Food safety Act 1990 Food Standard Agency (2007) Guidance on Temperature Control Legislation in the United Kingdom EC Regulation 852/2004 Food Hygiene Regulations (2006) Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in Partnership with Nutricia Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical Devices: Implications and Consequences of Reuse. MDA DB2000(04) Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding Systems. MDA SN2000(27). National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139 Infection Prevention and control of healthcare-associated infections in primary and community care http://guidance.nice.org.uk/CG139 National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral supplements, parenteral and enteral feeding. London. http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric feeding tubes NPSA/2005/05 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798

Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London, NMC. Pien, Hume & Pien. (1996) Gastrostomy Tube Infections In A Community Hospital. American Journal of Infection Control; 24: 5: 353-358

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APPENDIX 2 SUPPORTING DOCUMENTS back to index

Patient Information leaflets


NPSA alerts relating to enteral feeding back to index National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation of placement NPSA/2012/RRR001 22/03/12 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441

National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA/2011/PSA002 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640 National Patient Safety Agency (2010) Early detection of complications after gastrostomy NPSA/2010/RRR010 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457

National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric feeding tubes NPSA/2005/05 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798 Manufacturer’s websites Abbott Nutrition home page – access to pump instruction manuals and training Videos https://www.abbottnutrition.co.uk/media/70612/freego_operating_manual.pdf Corpak Medsystems – access to information about enteral tubes and company guidelines http://corpakmedsystemsuk.com/ Medicina – information about enteral syringes and feeding devices http://www.medicina.co.uk/

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No







https://www.abbottnutrition.co.uk/media/70612/freego_operating_manual.pdf




END OF EAST CHESHIRE NHS TRUST CNSG 013 GUIDELINES FOR

ADMINISTRATION OF FEED AND FLUID VIA ENTERAL TUBES


East Cheshire NHS Trust CNSG 014 Guidelines For Enteral Feeding Complications and Management Page 112 of 172 Created by Maggie Allen. October 2010. Updated July 2015.

Guideline Title:

Guidelines For Enteral Feeding Complications and Management

Executive Summary:




Guidelines reviewed – updated advice for managing infected PEG sites.









August 2014

APPROVAL RECORD

Committees / Group

Date

Consultation: Departments of Dietetics and Gastroenterology Clinical Nutrition Steering Group Infection prevention and control department

October 2010, June 2015


July 2015

AMENDMENTS RECORD


nGUIDELINES FOR ENTERAL FEEDING COMPLICATIONS AND MANAGEMENT INDEX

SECTION CONTENTS

PAGE

1.0 Systemic problems – causes and intervention 114-17

Abdominal pain and distension 114

Diarrhoea 115

Nausea & vomiting 116

Dehydration 116

Weight change 116

Reflux and aspiration. 117

Constipation 117

Electrolyte imbalance 117

2.0 Gastrostomy stoma complications and management – causes and intervention

118-122

2.1.1 Recommended treatment for an infected stoma 119

2.1.2 Cleaning and dressing an infected stoma 119

2.1.3 Dressings 119

2.1.4 Use of topical treatments and barrier products 119

2.2 Leakage – causes and intervention 120-22

2.1.1 Recommended skin care for a leaking PEG/PEJ site 121

2.3 Overgranulation – causes, intervention and treatment 122

3.0 Blocked nasogastric and gastrostomy tubes – causes and intervention

123-4

3.1 Guidelines for unblocking the tube 123

3.2 Unblocking a PEG tube with a brush 124

3.3 Review of why the tube blocked 125

4.0 Gastrostomy tube related problems – causes and intervention

125-6

Accidental tube displacement 125

Adaptor problems 126

Split tubes 126

Discolouration of the tube 126

Buried bumper 126



Patient information

NPSA alerts


128

Appendix 3 Flow chart for post PEG management of complications 129

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GUIDELINES FOR ENTERAL FEEDING COMPLICATIONS AND MANAGEMENT

Complications should be dealt with as soon as possible. If you are unsure about how to resolve a complication, seek specialist advice. Any intervention and outcome should be recorded in the patient’s medical/nursing notes. Link to flow chart for post PEG management of complications

1.0 SYSTEMIC PROBLEMS – Abdominal pain and distension back to index

PROBLEM


Abdominal Pain

New insertion – surgical trauma

If pain is localised to wound area, give appropriate analgesia and monitor effectiveness. If the pain increases, seek medical review and consider stronger analgesia.

Peritoneal leak (normally within 72 hours of the PEG/PEJ insertion)

Observe for increasing severity of abdominal pain, pyrexia, tachycardia, nausea and vomiting. If suspected, seek urgent senior medical or surgical advice.

If pain or resistance when flushing, stop immediately and seek urgent senior medical or surgical advice.

Rapid response Report NPSA/2010/RRR010: Early detection of complications after gastrostomy

Infection

Check and clean the PEG/PEJ site daily, monitor for erythema and exudate. Inform doctor if infection suspected and manage as per guidelines in section 2 below.

Constipation

Monitor bowel movements. Give aperients if constipated.

Feed intolerance If no other obvious cause for pain and associated with diarrhoea. Refer to dietitian for review of feed regimen.

Abdominal distension

Delayed gastric emptying

Reconsider choice of feeding route/regime. Consider drugs to alter gut motility. Over rapid infusion rate

Reduce rate

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1.0 SYSTEMIC PROBLEMS – Diarrhoea back to index

PROBLEM


Diarrhoea Diarrhoea in enteral feeding is common, affecting 10-20% of patients on general wards (Bowling 2004).It can be linked to a number of causes such as malabsorption, infection, drug interaction and faecal impaction.

Contaminated feed/equipment Refer to East Cheshire NHS Trust Infection Prevention and Control Policies and CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids.

Over rapid infusion of feed Reduce rate. Do not dilute feed. Once the diarrhoea settles, aim to increase the rate until the recommended rate is reached. Infection e.g.: Clostridium

Difficile, Enteropathic E coli

Send a stool specimen and treat as per Trust guidelines if positive.

Pharmaceutical e.g. antibiotics, laxatives, antacids, multiple elixirs. Some elixirs have a high sorbitol content. Cumulative sorbitol doses of 7.5 to 30mg may cause adverse effects, with symptoms being severe above 20g.

Review medication. Consult pharmacist/doctor.

Malabsorption e.g. IBD, short bowel syndrome, pancreatic insufficiency.

Consider elemental/semi-elemental feeding. Consult dietitian. If there is a history of pancreatic disease, consider sending a sample for faecal elastase test for pancreatic exocrine insufficiency.

Intestinal mucosal atrophy e.g. radiation enteritis or after NBM.

Consider elemental/semi-elemental feeding. Consult dietitian.

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1.0 SYSTEMIC PROBLEMS – Nausea & vomiting, dehydration weight change

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PROBLEM


Nausea/vomiting Delayed gastric emptying

Reconsider choice of feeding route/regime. Consult dietitian. Consider drugs to alter gut motility.

Constipation

Treat constipation

Drug therapy

Check drug/nutrient interactions

Over rapid infusion rate

Reduce rate

Electrolyte imbalance

Review blood profile and correct levels. Consult dietitian/doctor

Contaminated feed Refer to East Cheshire NHS Trust Infection Prevention and Control Policies and CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids.

NB. In severe cases, stop the feed and give water/hydration solution for 24 hours. Gradually reintroduce feed. Consult dietitian/doctor.

Excessive vomiting and site leakage with no other sign of gastroenteritis

If the patient has a balloon gastrostomy in situ and the majority of the shaft of the tube is inserted into the stomach, the balloon may have been inflated beyond the pyloric sphincter. This can cause gastric outlet obstruction.

Deflate balloon

Pull back on tube to approximately the 5cm mark

Re-inflate the balloon and reposition the tube (Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes for correct positioning)

Seek expert advice if unsure.

Dehydration

Inadequate water flushes.

Always give the recommended amount of water through the tube.

Vomiting/diarrhoea/pyrexia.

Contact doctor/dietitian Record fluid balance.

Hot weather Increase fluid as medical condition allows.

Weight above/below ideal/target weight.

If unintentional loss/gain is >1kg(2lb) in a week. Contact dietitian. Sharp fluctuation in weight may be due to fluid balance.

Weigh patient if possible.

Record volume of feed administered, and if applicable oral intake.


1.0 SYSTEMIC PROBLEMS – reflux and aspiration, constipation, electrolyte imbalance. back to index

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PROBLEM


Reflux and aspiration

Over rapid infusion rate Reduce rate

Volume too large

Decrease volume of feed; consider changing to a more energy dense feed. Consult dietitian.

Poor positioning/poor swallow/unconscious patient

Feed in an elevated position at least 30-

45 whilst feeding and for 30 minutes post feed.

Hiatus hernia

May need elevating to 90 during feeding, if evidence of reflux.

Delayed gastric emptying

Reconsider choice of feeding route/regimen.

Decreased GI function Consult doctor/dietitian.

Consider drugs to alter gut motility i.e. a prokinetic such as metoclopramide, domperidone or erythromycin (NICE 2006). Assess for decreased/absent bowel sounds, abdominal distension, nausea, vomiting.

Constipation

Inadequate fluid is the most common cause of this complication (Payne-James J, Grimble G and Silk D 1995; Bowling, 2004).

Ensure that the patient is not dehydrated and that the volume of feed and fluid is being administered as per feeding regimen.

Other causes include drug interaction, changes in gut motility and type of feed.

Review current medication, the following may cause constipation: - Aluminium containing antacids - Anticholinergics - Antihistamines - Calcium channel blockers - Clonidine - Diuretics - Iron preparations - Levodopa - MAOI’s - Opiates (Byron SE 1997)

Refer to dietitian to review of type of feed and feeding regimen

Consider using laxatives or enemas

Electrolyte imbalance

Refer to CNSG 017 Guidelines for Assessment and Monitoring for advice regarding recommended monitoring. Consult with doctor/dietitian.


2. 0 GASTROSTOMY STOMA COMPLICATIONS AND MANAGEMENT – sore/infected stoma back to index

PROBLEM


Erythema/ inflammation around stoma

Gastric leakage around stoma site.

Fixation device may be too loose. Reposition the fixation device so that it sits lightly on the skin.

Clean regularly and protect the surrounding skin with a barrier film e.g. Cavilon. Consider a Proton Pump Inhibitor, if leakage is excessive and irresolvable; seek advice from specialist (also see section 2.2 below for further guidance for leakage from a gastrostomy stoma).

Fixation device may be too tight or too loose

Reposition the fixation device so that it sits lightly on the skin.

Stoma site infection. See below

Silicone tube Source alternative tube

Stoma site infection.

Poor preparation of the patient prior to insertion

Prep patient prior to insertion as per CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes. If the patient is MRSA positive contact the IPCT/Microbiologist for advice re Suppression therapy prior to insertion (As per MRSA policy).

If antibiotics are required, they should be prescribed as per Trust antibiotic policy. Or contact the Consultant Microbiologist.

Poor asepsis at insertion

Adhere to strict aseptic technique during insertion procedure.

Insufficient and inadequate cleaning.

Clean the PEG site daily using an Aseptic Non Touch Technique (ANTT).

Cross contamination

Strict hand hygiene must be maintained

Where possible, train and encourage the patient to clean their own PEG site, including information regarding hand hygiene.

Excoriated skin due to leakage allowing skin commensals to take hold.

Apply a barrier film following cleaning. If leakage is copious, increase cleaning as required and consider using an absorbent dressing in addition to the barrier film (see section 2.1.2 below for advice regarding dressings).

Investigate the cause of the leakage and try to resolve. See section 2.2 below for guidance.

Excessive handling by the patient

Consider covering the PEG site if the patient is confused and constantly touching the PEG site.

The fixation device is positioned too close to the skin.

Reposition the fixation device so that it sits lightly on the skin (the device should be no more than 3-4mm from the skin).

NB. If clinical signs of infection are detected i.e. pyrexia, pus, send a swab to Microbiology, clearly labelling the site of the swab and detail clinical signs of infection.

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2.1.1 Recommended treatment for an infected stoma back to index Minimal exudate and erythema Treatment with topical agents may be appropriate i.e. dressings (see section 2.1.3), or topical creams e.g. Bactroban in the instance of colonisation of the PEG/PEJ site with MRSA. If known sensitivity to Bactroban, consult with pharmacist for an alternative.

Moderate/excessive exudate, erythema, persistent unexplained pain Treat systemically in addition to topical agents. The administration route i.e. Oral or IV will depend on the severity of the infection. In severe cases, it may also be necessary to remove the PEG/PEJ tube. Individual cases should be discussed with the Consultant Microbiologist.

MRSA – refer to East Cheshire NHS Trust antibiotic policy. All MRSA infections must be discussed with a microbiologist. 2.1.2 Recommended cleaning and dressing technique for infected PEG stomas back to index Whilst the stoma is infected, it should be cleaned using ANTT as follows: -

1. Undo the fixation device and remove dressing (if in situ). NB. If within week of insertion, ideally leave the fixation device in place. The tube can be rotated to allow cleaning under the device (Do not rotate completely if tube placed in jejunum). Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes for further guidance. 2. Clean around the stoma with Normasol and observe current condition. 3. Try to remove all dried secretions (leave a gauze soaked in saline resting on the area for a couple of minutes to soften and aid removal). 4. Clean the fixation device. 5. Dry the skin and the fixation device. 6. If using, cut or wrap a topical dressing to form a keyhole dressing around the tube, ensuring

that it covers the stoma and reposition the fixation device so that it sits lightly on top of the topical dressing.

7. If using a foam dressing as well (to manage excessive leakage), place on top of the fixation device over the topical dressing and secure with tape.

Caution: If moving the fixation device within two weeks of insertion, it must be correctly repositioned in order to minimise the risk of peritonitis. Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes for further guidance. 8. If the dressing is non adhesive, secure with tape. 9. When finished, dispose of clinical waste and wash hands as per Trust policy. 10. Document stoma condition and treatment in the patient’s medical/nursing notes.

Change the dressing every 48 hours, unless there is strike through, in which case, the dressing should be replaced as above. Discontinue treatment as condition allows. 2.1.3 Which dressing back to index

There is limited evidence for PEG site infections and best dressing. The literature supports use of antimicrobial dressings such as silver impregnated, inadine or polyhexamethylene biguanide (PHMB). The patient’s requirements should be assessed to ensure that the dressing used is efficient and cost effective. Liaise with tissue viability and gastroenterology nurse specialist where appropriate. 2.1.4 Use of topical and barrier products

If an antibiotic cream has been prescribed, this should be applied after cleaning and drying.

If a barrier film is also being used, the antibiotic cream should be applied around the stoma first, then the film applied around the surrounding skin.

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2.2 GASTROSTOMY/JEJUNOSTOMY STOMA COMPLICATIONS AND MANAGEMENT – leakage back to index

PROBLEM


Leakage from the stoma site. A small amount of sometimes greenish exudate is normal and should be cleaned away daily

Newly formed stoma – bloodied serous fluid. The stoma may take a while to settle down around the PEG/JEJ tube. This is a short-term problem and will resolve.

Clean with Normasol until healed. A small dry dressing can be used until healed.

Displaced tube – leakage ++ of intestinal contents and leakage ++ during flushing – accompanied by pain if a new insertion.

If new insertion, stop feed/flush and seek immediate senior medical/surgical advice.

Established PEG stoma, replace PEG tube as soon as possible following CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes.

Refer to specialist.

Loose fixation device - leakage of gastric contents.

Ensure that the external fixation device is correctly positioned and if a low profile device e.g. MicKey button, is the fit correct? Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes.

Infection – pus, foul smelling brown fluid. If the infection occurs soon after insertion, it may delay healing and settling of the stoma. Once the infection is treated, the situation should resolve.

See recommended treatment for infection in section 2 -2.1.1 above.

Deflated balloon - the balloon should be fully inflated to prevent leakage

If a balloon gastrostomy, check the water in the balloon. The standard amount of water is usually 5mls. If the balloon can take more water, increase in 2ml increments until the leakage is resolved, or the maximum amount of water is reached. Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes, Section 10.

Incorrect shaft length of low profile device. These come in a variety of shaft lengths as well as French sizes. Leakage usually occurs when the shaft length is too long. The exterior part of the button should sit lightly on the skin, without the shaft being obviously visible.

Measure the stoma – Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes, section 10.11.

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2.2 GASTROSTOMY/JEJUNOSTOMY STOMA COMPLICATIONS AND MANAGEMENT – leakage continued back to index

PROBLEM


Leakage from the stoma site. NB. A small amount of mucous discharge is normal.

Constipation – may cause obstruction

Monitor bowels daily. Give aperients as required.

Large tube (20FR+) - Large tubes are heavy and tend to hang down, causing a gap on one side of the stoma.

Try to tape the tube so that the weight is supported. Large tubes are associated with increased leakage and associated skin problems. They best replaced with a smaller tube as soon as it is safe to do so. Avoid replacement until at least 4 weeks post insertion. See CNSG 009

Guidelines for Insertion and Management of Gastrostomy Tubes Section 10.8 for further guidance.

Buried bumper See section 4 below

Delayed gastric emptying/long standing problems with excessive flatulence. - Difficult group to manage. Leakage is persistent despite all attempts at control.

Consider: -

Drug therapy such as a PPI +/- a motility drug.

Venting the tube (insert a syringe and draw air off prior to feeding).

Remove the tube for a while and allow the stoma to shrink.

Decrease the size of the PEG tube. NB. increasing the French size will only exacerbate the problem.

Increasing the water in the balloon to maximum amount (if patient has a balloon gastrostomy).

An alternative PEG tube/site.

2.2.1 Recommended skin care for a leaking PEG/PEJ site NB. Stomach contents are very acidic and contain digestive enzymes. Bile can irritate the skin. Prolonged exposure will harm the surrounding skin. Increase cleaning to 2-3 times daily to keep the surrounding area clean and dry. Dry thoroughly after cleaning. Apply a barrier film after drying. Use a foam applicator rather than spray as there is more

control during application. Avoid Sudacrem as it is thick and greasy and makes the tube very slippery and may cause the fixation device to slip out of position).

Use an absorbent dressing if leakage is copious or distressing for the patient. The dressing must be checked regularly and replaced if wet. A barrier film should be used underneath the dressing, to protect the skin (see section 2.1.2 above for recommended dressing technique).

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2.3 GASTROSTOMY/JEJUNOSTOMY STOMA COMPLICATIONS AND MANAGEMENT –overgranulation

PROBLEM


Granulation tissue around the stoma – overgrowth of dark pink moist tissue, bleeds easily on contact.

Excessive friction at the site

Check that the tube is correctly positioned.

Leakage from the stoma

See section 2.2 above for guidelines in managing leakage.

Infection See section 2.0

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Granulation tissue occurs when there is an extended inflammatory response. Granulation tissue grows proud of the wound and epithelial tissue is unable to migrate across it. Assess and start treatment as soon as possible. The smaller the area, the more effective the treatment.

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3.0 BLOCKED NASOGASTRIC, GASTROSTOMY AND JEJUNOSTOMY TUBES

PROBLEM POSSIBLE CAUSES INTERVENTION

Tube blockage

Not flushing or inadequate flushing after feed and medication.

Flush as per guidelines. Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes for more information regarding best practice for flushing. Multiple medications being given

together without a flush in between each drug.

Administer medication as per CNSG 016 Guidelines for Administration of Medications via an Enteral Feeding Tube.

Unsuitable medicine preparations for giving via a tube, e.g. large particles, viscous liquids.

Review medication and consider alternative medication. If NG tube or gastrostomy balloon tube, consider a larger bore tube.

Kinked tube/clamp left on (PEG only).

Release clamp/straighten tube. NG tube may be kinked in the stomach, pull back slightly and retry.

Backflow/curdling of gastric contents in the tube.

Clamp tube (if PEG) between use to prevent gastric back-flow. Leave a column of water in the tube after flushing.

PEG bumper buried in the gastric mucosa (‘buried bumper syndrome’). Commonly presents with the tube becoming increasingly difficult to flush and increased leakage around the PEG site, particularly during flushing.

This can be prevented by regularly pushing the tube into the stomach a couple of centimetres and rotating Refer CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes, section 7.6.5. The patient will need to be referred the PEG nurse specialist or gastroenterologist for tube removal/replacement.

3.1 Guidelines for unblocking the tube back to index

Flushing with water can shift most blockages. Use a 60ml oral/enteral syringe with a plunger Prime with 20-30mls warm water Flush by using a pumping action Squeeze along the tube using thumb and forefinger, and then retry flushing. Once cleared, flush thoroughly.

(Colagiovanni 2000)

If unsuccessful: Try using a smaller syringe, 20mls then 10mls then 5mls. Caution. This will exert greater pressure and may split the tube. Check the tube for leakage after the blockage has been cleared.

If unsuccessful: Try using Clog Zapper:

Clog Zapper is available from NHS logistics. It costs approximately £16 and has a short shelf life. It probably is more useful for NG tubes as a brush cannot be used.

Clog Zapper consists of food enzymes. The powder in the syringe needs to be mixed with water prior to use (see manufacturer’s instructions).

Clog Zapper will only work with food blockages. If medication is the cause of the blockage, it will not work.

Using Coca cola/ pineapple juice: Anecdotal evidence suggests that this can be useful as a one off, however long-term use may harm the tube.

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3.2 Using a brush - Gastrostomy tube only back to index

If unable to clear the tube as recommended above, consider using a single use endoscope cleaning brush.

NB 1. There is a very small risk of the brush tip breaking off and being left in the tube. If this occurs, the tube would need replacing. However the tube will need replacing if the blockage cannot be cleared. An individual risk assessment is required for each case. Refer to specialist. NB. 2. Do not use a brush with any tube that has been placed in the duodenum i.e. a Cook Tilma RIG tube (used by Hope Hospital for patients with MND. Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes, section 12 for more information on this tube).

Procedure (should only be carried out by individuals who have received training and are assessed as competent) Equipment:

50ml syringe, wipes, endoscope cleaning brush (must have a round smooth tip), water for flushing, plastic cup with some water. 1. Place the brush against the length of the PEG tube and mark on the brush, where the tube

enters the abdomen. 2. Take off the end piece of the PEG and release the fixation device and clamp. 3. Insert the brush into the tube and advance until the blockage. 4. Gently advance through the blockage, if unable to advance, pull the brush back and clean off the debris in water. 5. Repeat this action until the brush reaches the point where the tube enters the stomach (see

mark on brush). 6. Withdraw the brush. Once cleared, flush thoroughly. 7. Advise carers to flush immediately after feed and medication and to flush in between

different medication and in between medication and feed.

Never use excess force or introduce a sharp instrument.

If unsuccessful seek advice immediately – the longer a tube is blocked, the more difficult it is to clear.

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3.3 Once the tube has been cleared, review practice - why did the tube block?

Suboptimal flushing:

Is the tube being flushed after bolus administrations of feed/medication?

Is the tube being flushed as soon as possible once the pump feed has finished?

Do the flushes need to be increased?

Is the plunger being used with the syringe?

Is the tube being flushed following aspirating to check pH or residuals?

Is the bumper buried? See above.

Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes for more information regarding best practice for flushing.

Incorrect administration of medication

Are the medications being given separately and flushed after each one?

Are the medication preparations appropriate for the type/size of tube?

Refer to CNSG 016 Guidelines for Administration of Medication via Enteral Feeding Tubes.

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4.0 GASTROSTOMY/JEJUNOSTOMY TUBE RELATED PROBLEMS - tube displacement

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PROBLEM


Closure of the gastrostomy stoma will occur from approximately 4 hours post tube removal. Aim to insert a replacement balloon gastrostomy tube or, if unavailable, a suitable sized Foley catheter as soon as possible. If the tube has been out for more than 4 hours, a smaller French sized tube may be required than the patient originally had in situ. Stoma recovery may be still possible as late as 48 hours post removal by using a 6Fr tube. Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes, section 10 for further guidance.

Tube displacement Before 4 weeks

If the tube becomes displaced before the stoma is fully established (i.e. within the first 4 weeks of insertion), there is a possibility of feed or gastric contents leaking into the peritoneal cavity. This may result in peritonitis and is a life threatening condition. Do not put anything through the tube seek medical help immediately. Community patients – contact A&E (Tel. 01625 661451/2). Inpatients - contact on call registrar. NB. Inadvertent intraperitoneal insertion of replacement G-tube is a reported risk in newly formed stomas Misplaced G-tubes can result in significant morbidity and death. A radiological check of the tube’s position following insertion is recommended if the tube is being replaced within 4 weeks of the original placement of the tube. This applies to PEG, RIG, PEJ and surgically placed tubes (gastrostomy and jejunostomy). Link to management of suspected peritonitis

After 4 weeks The stoma is usually fully established and displacement is unlikely to have serious consequences, although there are case reports of inadvertent intraperitoneal insertion of replacement G-tube in a mature stoma. Misplaced G-tubes can result in significant morbidity and death.

Do not use the tube until the position has been checked by aspiration of gastric acid (less than pH5.5). Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes, section 10.

NB. A radiological check of the tube’s position following insertion is recommended if the tube is difficult to insert and accompanied by pain. Refer for specialist input.

Community patients: If there is not a health care professional/carer trained in the procedure available to replace the PEG tube, the patient will need to come to A&E. Try to contact the GI nurse specialist or enteral feeding dietitian prior to bringing to A&E. Do not attempt to pass a tube through the stoma unless you are sure that it is fully established.

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4.0 GASTROSTOMY/JEJUNOSTOMY TUBE RELATED PROBLEMS - adaptor problems/split tubes/discolouration/buried bumper back to index

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PROBLEM


Y connector and giving set stuck together

Residue of feed and medication in the luer lock

Close the clamp

Cut the giving set close to the adaptor

Unscrew the adaptor from the PEG tube

Place in hot water and try to undo

If unsuccessful replace adaptor.

Broken adaptor/ fixation device

Wear and tear

Replace – available from ETU and dietitians

Prevention

Do not screw the giving set onto the PEG/PEJ adapter too tightly. A half turn is sufficient.

Clean the adaptor regularly by closing the clamp then opening all the ports on the adaptor and dangling the end in a bowl of warm soapy water, or taking off the adaptor and placing it under a tap.

Split/cracked tube

Inadequate flushing

Flush as per guidelines. Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.

Stationary reflux clamp.

Move the reflux clamp daily - avoid closing the reflux clamp near the base of the tube.

The tube can be cut at the level of the split and the adaptor re-attached. Refer to specialist if the split is near to skin level.

Long-term use of topical creams e.g. Bactroban will weaken the polyurethane.

Avoid long-term use. Refer to specialist.

Tube discoloration

Medication e.g. Omeprazole turns the tube black.

Unavoidable. It does not harm the tube.

Buried bumper PEG bumper buried in the gastric mucosa (‘buried bumper syndrome’).

Commonly presents with the tube becoming increasingly difficult to flush and increased leakage around the PEG site, particularly during flushing.

The patient will need to be referred the PEG nurse specialist or gastroenterologist for tube removal/replacement. Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes to prevent and manage buried bumper.


APPENDIX 1 – REFERENCES AND BIBLIOGRAPHY back to index Arrowsmith H. (1996) Nursing Management of Patients Receiving Gastrostomy Feeding. British Journal of Nursing; 5: 268-273. BAPEN (1996) Standards and Guidelines for Nutritional Support in Hospitals (ed. T. Sizer). British Association for Parenteral and Enteral Nutrition, Maidenhead. British Society of Gastroenterology (2006) Guidelines on Complications of Gastrointestinal Endoscopy. London. http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complications.pdf Colagiovanni L. (2000) Preventing and clearing blocked feeding tubes. Nursing Times. 96(17): 3-4. Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in Partnership with Nutricia. National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139 Infection Prevention and control of healthcare-associated infections in primary and community care http://guidance.nice.org.uk/CG139 National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral supplements, parenteral and enteral feeding. London. http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf National Patient Safety Agency (2010) Early detection of complications after gastrostomy NPSA/2010/RRR010 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457 O’Toole P. (2006) Complications Associated with the Placement of Percutaneous Endoscopic Gastrostomy. Guidelines in Gastroenterology. British Society of Gastroenterology (BSG). London. Rollins, H. Hypergranulation tissue at gastrostomy sites. Journal of Wound Care 2000; 9(3): 127-129 Spruce P, Warriner L, Keast D, Kennedy A. Exit site wounds Made Easy. Wounds International 2012; 3(2): Available from: http://www.woundsinternational.com Stephen-Haynes, J. (2013) Managing overgranulation. Wound Care Today.

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http://www.woundsinternational.com/


APPENDIX 2 SUPPORTING DOCUMENTS back to index NPSA alerts relating to enteral feeding National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation of placement NPSA/2012/RRR001 22/03/12 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441

National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA/2011/PSA002 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640 National Patient Safety Agency (2010) Early detection of complications after gastrostomy NPSA/2010/RRR010 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=73457 National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric feeding tubes NPSA/2005/05 http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59798 Manufacturer’s websites Abbott Nutrition home page – access to pump instruction manuals and training Videos http://www.abbottnutritionuk.com/ Corpak Medsystems – access to information about enteral tubes and company guidelines http://corpakmedsystemsuk.com/ Medicina – information about enteral syringes and feeding devices http://www.medicina.co.uk/

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APPENDIX 3 Flow chart for post PEG management of complications - Inform/doctor/PEG nurse (as appropriate) of any complications back to index

Half hourly for 2 hours Blood pressure Pulse Wound check Temperature Pain assessment Oxygen saturation

Respiratory rate PEG position

unchanged

Normal variants

Hourly for 2 hours As per half hourly

assessments

No

Yes

2 Hourly for 2 hours As per half hourly assessments

Leakage

Bleeding

Aspiration Reflux/ nausea/ vomiting

Pain

Diarrhoea

Yes

Normal variants

Normal variants

Yes

Discontinue observations as medical condition allows.

Normal variants

Yes

Small volume Monitor dressing for spread Inform specialist if bleeding continues Large volume Inform gastroenterologist /surgeon immediately

Assess pain, how much, where and when. If localised to wound give appropriate analgesia and monitor effectiveness. If increasing abdominal pain, seek urgent senior medical or surgical advice. If pain or resistance when flushing, stop immediately and seek urgent senior

medical or surgical advice.

Pyrexia

Yes

Low oxygen

saturation

Hyper/ hypotensive Tachycardic /bradycardic

Assess for cause Consider Sepsis/peritonitis/chest infection/UTI Treat as appropriate

Consider effects of sedation/aspiration/chest infection. Treat as appropriate Reverse sedation if necessary. Patient position/antibiotic therapy.

Consider effects of sedation – reverse if necessary. Pre-existing condition. Correct with drug therapy asap, continue to monitor.

Assess amount of leakage Slight oozing of exudate is common post insertion. Monitor amount. Larger volumes particularly during administration of fluids via the tube and associated with pain are abnormal and need urgent medical attention. Larger volumes without pain may be associated with constipation. Treat and monitor bowel movements

Assess cause of diarrhoea Feed/infection/drugs Inform doctor/pharmacist/dietitian.

4 Hourly As per half hourly assessments Monitor saturation levels

Position patient in upright position during feeds/flushes Consider prokinetics Consider constipation Consider secretion management

Yes

Yes

Yes

Yes

Yes

Yes

Yes


END OF EAST CHESHIRE NHS TRUST CNSG 014 GUIDELINES FOR ENTERAL FEEDING COMPLICATIONS AND

MANAGEMENT

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East Cheshire NHS Trust CNSG 015 Microbiological Guidelines for Handling of Enteral Feed and Fluids Page 131 of 172 Created by Maggie Allen. October 2010. Updated July 2015.

Guideline Title:

Microbiological Guidelines for Enteral Feeding

Executive Summary:






Financial Implications: Improvements in nutritional care should reduce costs and risks associated with sub-optimal care of enteral feeding lines.


Version Number: 1.1 Effective Date: October 2010





August 2014

APPROVAL RECORD

Committees / Group

Date

Consultation: Departments of Dietetics and Gastroenterology Clinical Nutrition Steering Group Infection prevention and control department

June 2015


July 2015

AMENDMENTS RECORD


MICROBIOLOGICAL GUIDELINES FOR HANDLING OF ENTERAL FEED AND FLUIDS INDEX


1.0 Handling of enteral feeding systems 133

2.0 Storage of feed 133

2.1 Opened feeds 133

2.2 Unopened feed 134

3.0 Preparation of feed 134

3.1 Sterile ready to hang feeds 134

3.2 Sterile decanted feeds 134

3.3 Modular feeds (non-sterile) 135

4.0 Hanging times of feed 135

5.0 Water use for enteral tubes 135

6.0 Use of equipment for enteral feeding 136

6.1 Single use equipment 136

6.2 Single patient use equipment 136

6.2.1 Cleaning Gastrostomy button extension tubes e.g. MIC-Key buttons

136

6.3 Syringes 137

7.0 Disposal of equipment 137

Appendix 1 References

138

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MICROBIOLOGICAL GUIDELINES FOR HANDLING OF ENTERAL FEED AND FLUIDS These guidelines should be used in conjunction with the following Infection Prevention and Control Policies (Please note this is not an exclusive list and you may need to refer to other Specific Infection Prevention and Control Policies via the Trust Intranet).

Universal Precautions Policy

Aseptic Non Touch Policy

IV insertion and ongoing Care

MRSA Policy

Clostridium Difficile Policy. For further advice around infection control issues please contact – Infection Prevention Team on Ext 1597 Bleep 3034 Consultant Microbiologist Ext 1810, Bleep 3102 1.0 HANDLING OF ENTERAL FEEDING SYSTEMS back to index Enterally fed patients are susceptible to infections of the gastro-intestinal tract, infections around the tube insertion site, chest infections and septicaemia. (Arrowsmith 1996, Pien et al. 1996). The feeding tube does not have the natural defences against infection that the gastro-intestinal tract has, for example peristalsis, lymph nodes or acidic secretions. The tube itself is at body temperature, has a regular supply of nutrients and cannot be cleaned. It therefore provides an ideal breeding ground for bacteria. For these reasons good food hygiene practices and further infection control measures are necessary when handling and preparing enteral feeding systems (Anderton 1990).

Full compliance with hand hygiene and personal protective equipment must be maintained as per Trust Infection Prevention and Control Universal Precautions Policy.

Clean non-sterile disposable gloves and a clean disposable apron equipment must be worn when handling any part of the enteral system.

Any staff who display symptoms of diarrhoea should not handle food products. They must report to their line manager and remain absent from work until asymptomatic as per the Infection Prevention and Control /Occupational Health requirements.

To help reduce the risk of contamination from human contact:

It is essential to use feeding systems that require a minimal amount of handling with a minimum number of well designed connectors.

Systems with recessed connectors, additive ports and few connection points, for example no extension tubes, are preferable.

Staff should use a Aseptic Non Touch technique (ANTT). This means avoiding touching the connection parts of feeding systems or unnecessarily opening feeding systems.

2.0 STORAGE OF FEED back to index 2.1 Opened feeds

Open cans/bottles of feed must be refrigerated.

The temperature of fridge should be <5 and greater than 0.

The feed bottle must be covered with a lid and labelled with the patient’s name, date and time of opening.

Opened feeds and modular feeds should be stored on the top shelf away from raw food.

Discard after 24 hours.


2.2 Unopened feed

Store in a cool dry place away from direct sunlight or heat (minimum 8oC maximum 25oC).

Rotate the stock. 3.0 PREPARATION OF FEED back to index

Hands must be decontaminated as per Trust Infection Prevention and Control Hand Hygiene Policy prior to handling of any feed systems.

Clean non-sterile disposable gloves and a clean disposable apron equipment must be worn as per the Universal Precautions policy.

Use minimal handling and an aseptic non touch technique to connect the administration system to the enteral feeding tube.

Sterile Ready-to-Hang feeds should be used where possible.

Use the appropriate size of pre-packed feed for the patient's requirements. Feeds that require decanting or mixing should be avoided wherever possible.

Giving sets and feed containers are ‘single use’ and must be discarded after use.

Feed must be used before its expiry date and within permissible hanging times (see section 4 below).

All equipment should be kept sealed in sterile packaging until immediately prior to assembly.

If opening a bottle/tetrapak/ring-pull tin to be decanted, it must be cleaned with a 70% alcohol wipe prior to use and opened using a designated bottle opener where appropriate. Abbott Nutrition supplies sterile foil cutters for the feed bottles. If opening a pack, sterile scissors should be used. Do not use fingers, thumbs or non sterile scissors due to high risk of contamination.

Label the feeding system/water reservoir with the date and the time of administration. Never re-fill or ‘top-up’ nutrient containers, as this increases the risk of microbial contamination. 3.1 Sterile ready to hang feeds back to index

These are pre-filled nutrient containers, they attach to a giving set and are designed to minimise the risk of microbial contamination.

System design eliminates the risk of bacteria being introduced during attachment of the giving set to the nutrient container.

The giving set has a drip chamber incorporated, to reduce risk of retrograde growth of the patient’s gut flora.

3.2 Sterile decanted feeds

Feeds that require decanting or mixing should be avoided wherever possible.

Sterile feeds that require decanting should be prepared using an Aseptic Non Touch technique (ANTT).

Feed should be decanted into a sterile container (Abbott Flexitainer) or ‘single use’ enteral syringe.

Prior to decanting, the aperture of a ring-pull can or tetrapak should be wiped with a 70% alcohol wipe as contamination can occur during opening.

Re-sealable sterile feed containers that are open but not required immediately can be stored on the top shelf of a patient’s food fridge. The feed should be sealed and have the patient’s name, date and time of opening.

Non-re-sealable containers should be discarded immediately.

Never top up feeds, always prepare the required amount.

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3.3 Modular feeds (non-sterile) back to index

Many components used in modular formulas are not sterile and micro organisms have been isolated from them. When reconstituting modular feeds the following must apply: -

A clean working area must be used

Only use equipment dedicated for enteral feed when decanting, reconstituting or diluting feeds.

Sterile water must be used for mixing and diluting.

A set volume of feed should be prepared once; it must not be topped up. 4.0 HANGING TIMES FOR FEEDS back to index

The hanging time is the total time that the opened feed is kept at room temperature.

Storage time in a refrigerator below 5ºC is not included in the hanging time.

There should be individual risk assessment and the hanging times reduced if necessary.

FEED TYPE MAXIMUM HANGING TIME MAXIMUM STORAGE TIME IN REFRIGERATOR

Sterile, ready-to-use feeds if not decanted.

24 hours Not applicable

Sterile feeds decanted into a sterile reservoir using aseptic/non-touch technique (ANTT).

24 hours 24 hours

Non sterile (modular) feeds e.g. reconstituted powders and mixed feeds decanted into a sterile reservoir.

4 hours 24 hours

5.0 USE OF WATER back to index In the hospital setting tap water is suitable for flushing, providing that it is: -

kept in a lidded container

changed twice a day

not contaminated by dipping the syringe into the jug to draw up water (pour the water into a clean container first).

Use sterile water if: -

the patient is immuno-compromised

the feeding tube is positioned in the small intestine

large volumes of water are required to be given via a reservoir i.e. an Abbott Flexitainer.

It is the first flush following initial PEG insertion The sterile water bottle must be labelled with the patient’s name, date and time of opening. It must be discarded after 24 hours.


6.0 USE OF EQUIPMENT FOR ENTERAL FEEDING back to index 6.1 Single use equipment Most enteral feeding devices are ‘single use’ meaning that they cannot be re-used. It is identified by this symbol.

The Trust’s Single Use of Medical Devices Policy must be followed at all times. 1. Devices designated for ‘single use’ must not be reused under any circumstances. 2. The reuse of ‘single use’ devices can affect their safety, performance and effectiveness, exposing patients and staff to unnecessary risk. 3. The reuse of ‘single use’ devices has legal implications. a) Anyone who reprocesses or reuses a device intended by the manufacturer for use on a single

occasion, bears full responsibility for its safety and effectiveness. b) Anyone who reprocesses a ‘single use’ device and passes it on to a separate legal entity for

use, has the same legal obligations under the Medical Devices Regulations as the original manufacturer of the device.

Medical Devices Agency Safety Notice. Single-use Medical Devices: Implications and Consequences of Reuse. MDA DB2000 (04) August 2000 6.2 Single patient use equipment back to index Definition A medical device that may be used for more than one episode on one patient only and the device may undergo some form of reprocessing between each use. DB2006(04) states that reprocessing is: ‘To make good a device for re-use by any or a combination of the following processes: cleaning, disinfection / decontamination, sterilisation, refurbishment and repackaging’.

Devices marked for single patient use must not be used for more than one patient.

Equipment that is designated single patient use must be reprocessed and stored as per manufacturer’s and Trust policy and guidelines.

Enteral equipment requiring reprocessing is very limited and is likely to be an adaptor or extension set for a low profile gastrostomy e.g. MIC-Key button.

6.2.1 Cleaning gastrostomy button extension tubes e.g. MIC-Key buttons

Open the reflux/roller clamp on the tube.

Immerse in hot soapy water and flush through several times using a syringe.

Rinse through thoroughly with cold water

Flush the tube through with air to remove excess fluid

Store in a lidded container in the fridge

The container must be labelled with the patient’s name

Replace weekly

Do not store in Milton back to index


6.3 Syringes back to index Some companies e.g. Medicina, provide ‘single use’ enteral syringes for hospital use and reusable syringes for community use. Caution is required, as they are the same colour. The ‘single use’ syringes are labelled with the ‘single use’ logo as seen above in section 6.1, both on the packet and the syringe. All syringes are to be ‘single use’ only in the hospital setting even if they specify that they are reusable. The syringe must be discarded after the episode of use i.e. flushing followed by administration of fluid/ medication, followed by flush, then dispose of the syringe. Wards should order the ‘single use’ only enteral syringes. Community use Reusable syringes are suitable for community. They should be cleaned in between use as follows: In between each use,

Separate the syringe and plunger and clean the syringe in warm soapy water.

Rinse with cold tap water and dry with paper towel.

Store in dry container

Replace as advised by manufacturers guidelines (Medicina state maximum use of 7 days).

Do not store in Milton http://www.medicina.co.uk/uploads/fck/hospital-syringe-booklet.pdf 7.0 DISPOSAL OF EQUIPMENT Clinical waste should be disposed of as per Trust policy

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http://www.medicina.co.uk/uploads/fck/hospital-syringe-booklet.pdf


APPENDIX 1 REFERENCES AND BIBLIOGRAPHY back to index

Anderton A. (1990) Microbial aspects of Home Enteral Nutrition – a discussion. Journal of Human Nutrition and Dietetics; 3: 403-412. Anderton A. (1995) Reducing bacterial contamination in enteral tube feeds. British Journal of Nursing: 4, 7 : 368-376. Arrowsmith H. (1996) Nursing Management of Patients Receiving Gastrostomy Feeding. British Journal of Nursing; 5: 268-273. Food safety Act 1990 Food Standard Agency (2007) Guidance on Temperature Control Legislation in the United Kingdom EC Regulation 852/2004 Food Hygiene Regulations (2006) Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in Partnership with Nutricia. The Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical Devices: Implications and Consequences of Reuse. MDA DB2000(04) The Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding Systems. MDA SN2000(27). National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139 Infection Prevention and control of healthcare-associated infections in primary and community care http://guidance.nice.org.uk/CG139 Pien, Hume & Pien. (1996) Gastrostomy Tube Infections In A Community Hospital. American Journal of Infection Control; 24: 5: 353-358

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END OF EAST CHESHIRE NHS TRUST CNSG 015 MICROBIOLOGICAL GUIDELINES FOR HANDLING OF

ENTERAL FEED AND FLUIDS

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East Cheshire NHS Trust CNSG 016 Guidelines for Administration of Medication via Enteral Tubes Page 140 of 174 Created by GI Nurse Specialist Maggie Allen and Pharmacist Sarah Element. August 2012. Updated July 2015.

Guideline Title:

Clinical Nutrition Steering Group (CNSG) Guidelines for Administration of Medication via Enteral Tubes (CNSG 016)

Executive Summary:

This document aims to support health care professionals in their practice to ensure that the administration of medication via an enteral feeding tube is carried out safely and effectively, so minimising risk of complications.




This guideline will impact on: All staff caring for adult inpatients, carrying out administration of medication via an enteral feeding tube.

Financial Implications: Correctly administered medication via an enteral tube should reduce costs and risks associated with unsafe practice.

Guideline Area: Pharmacy/Enteral tubes Document Reference: CNSG 016


Issued By: Departments of Pharmacy and Gastroenterology


Author: Maggie Allen, GI Nurse Specialist/Sarah Element, Lead Pharmacist for Medicine.


August 2014

APPROVAL RECORD

Committees / Group


Date

August 2012

Consultation: Dane Bradwell, Clinical Pharmacist April 2015

Approved by: Clinical Nutrition Steering Group July 2015

AMENDMENTS RECORD


The following guidelines should be used in accordance with the following policies: -

East Cheshire NHS Trust Medicines Policy for the Safe and Secure Handling of Medicines within East Cheshire NHS Trust.

East Cheshire NHS Trust Policy for medication administration in patients with oropharyngeal dysphagia.

INDEX


1.0 Introduction 142

2.0 Legal implications 142

3.0 Referrals 142

4.0 Route of administration – gastric or jejunal tube 142-3

5.0 Drug formulations 143-4

5.1 Medicines not to be given via an enteral feeding tube 143

5.2 Preferred formulations 144

5.2.1 Liquids 144

5.2.2 Tablets 144

5.2.3 Capsules 144

6.0 Equipment 144-5

6.1 Tubes 144

6.2 Syringes 145

6.3 Adaptors 145

6.3 Non standard equipment 145

8.0 Complications 146-8

APPENDICES


Appendix 2 Preparation and administration of medication 150-152

Appendix 3 Linked documents/information

Patient information

Training aids

NPSA alerts relating to medication and enteral tubes


154

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1.0 INTRODUCTION back to index

Incorrect intravenous administration of oral liquid medicines resulted in three reported deaths between 2001 and 2004 and there are reports of four incidents of harm or near misses between 1997 and 2004.

NPSA (2007) This document aims to support health care professionals in their practice to ensure that the administration of medication via an enteral feeding tube is carried out safely and effectively, so minimising risk of complications. These guidelines should be used in accordance with the following policies: -

East Cheshire NHS Trust Medicines Policy for the Safe and Secure Handling of Medicines within East Cheshire NHS Trust.

East Cheshire NHS Trust Policy for medication administration in patients with oropharyngeal dysphagia.

East Cheshire NHS Trust Policy and Guidelines for Enteral Feeding (CNSG006)

Further guidelines and documents linked to these guidelines can be found in appendix 3 2.0 LEGAL IMPLICATIONS back to index

Most drug administration via feeding tubes falls outside the product license for that drug, as does crushing tablets and opening capsules not specifically designed for this purpose. In these circumstances the prescriber and practitioner may be liable for any adverse effects resulting from the administration of that drug.

Staff prescribing and administering drugs via the enteral route should be covered by the Trust’s vicarious liability providing that they can demonstrate that they acted in accordance with Trust policy and guidelines. 3.0 REFERRALS back to index

All patients must be referred to a dietitian and pharmacist once an enteral feeding tube has been inserted, or a patient is admitted with one in situ. The patient’s medication should be reviewed by pharmacists and the medical team prior to commencing enteral feeding, in addition, the pharmacist and prescriber must be aware of the administration route. 4.0 ROUTE OF ADMINISTRATION – gastric or jejunal tube back to index

The best way to take most medication is via the mouth, however if this is not possible it may be given via the enteral feeding tube. The metabolism of different drugs varies, each drug is designed to be absorbed in a particular area of the gut. If administered in the wrong part of the gut, the drug may be ineffective. Examples of this include: -

Sublingual or buccal preparations which are formulated for absorption across the oral mucosa and are ineffective if administered through feeding tubes.

Drugs meant for absorption in the stomach, may be ineffective if administered via a tube that is placed in the jejunum.

The intended area of absorption for a particular drug should be considered prior to prescribing and administering through an enteral tube. The pharmacist and clinician must be aware of the position of the tube in the gut. If the patient has jejunal tube, administration of certain medications may be contraindicated for the following reasons:-

The risk of blockage is high

Most drugs are not licensed to be given via the jejunum or duodenum, as the mode of action and absorption in the small bowel is not known.


Some drugs may not be absorbed as effectively in the duodenum as the stomach, resulting in sub-therapeutic doses.

The patient must have their medication reviewed by a pharmacist and the prescribing clinician must be aware that the tube is placed in the jejunum. If the patient has jejunal tube, it may be necessary to consider passing a second tube into the stomach, or use a double lumen tube so that drugs can be administered into the stomach. 5.0 DRUG FORMULATIONS back to index

Drugs are available in a variety of preparations. A pharmacist should assess the prescribed drugs and recommend the best formulation. Some drugs may require a change of dosage and frequency of administration when given via enteral feeding tubes. 5.1 Medicines not to be given via an enteral feeding tube unless advised by a pharmacist Table 1

TYPE OF DRUG

RATIONALE

Injections Must not be given through feeding tubes unless specifically advised by a pharmacist. An example of an acceptable injection preparation is glycopyrronium bromide, an anticholinergic used to control excess salivation.

Chewable tablets

Form a sticky clump when crushed

‘Melt’ tablets Designed to dissolve in the saliva, be swallowed and then absorbed in the gastrointestinal tract.

Enteric coated tablets (e/c). These have a protective coating either to prevent inactivation by stomach acid or to prevent the stomach from damage by the drug. Crushing enteric-coated tablets or the enteric coated pellets from a capsule destroys this coating. In addition the coating will block the tube.

Slow or modified release formulas e.g. EC, SR, MR, LA, XL or CR

These are formulated to release the drug slowly in the GI tract. Crushing or breaking tablets, or opening capsules can destroy their slow release properties increasing the risk of side effects, toxicity and reducing their duration of action.

Sublingual or buccal preparations.

Formulated for absorption across the oral mucosa and are ineffective if administered through feeding tubes.

Hormone and Cytotoxic drugs

Must not be given through feeding tubes unless specifically advised by a pharmacist. The powder will potentially harm others if inhaled.

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5.2 Preferred Formulations back to index Liquids or soluble tablets are the preferred formulation for administration via feeding tubes, however they are not without pitfalls as seen in table 2 below. 5.2.1 Liquids Liquid medications are available in the following preparations: - Table 2

PREPARATIONS CAUTION

Solution Expensive

Syrup

May be viscous and require diluting prior to administration, in order to minimise risk of blocking the tube.

May have a high sorbitol content which will cause diarrhoea and/or stomach cramps. In some circumstances it may be preferable to crush an insoluble tablet and mix with water.

Suspension

Large particles block the feeding tubes e.g.

antibiotics such as Clarithromycin suspension

Lansoprazole – the suspension contains granules which must not be crushed.

5.2.2 Tablets back to index

Ideally tablets being administered via an enteral tube should be soluble or dispersible. Some insoluble tablets not commercially marketed as dispersible may disperse in water especially when crushed. The preparation must be fully dissolved prior to administration via the tube, particularly fine bore tubes, in order to prevent blockage. 5.2.3 Capsules Some capsules can be opened and mixed with water. Caution:

Some may be potentially harmful if opened.

Some capsules contain pellets these should be administered intact. Do not give these via a fine bore tube as they will block the tube (10 Fr minimum).

Always consult a pharmacist before altering preparations. 6.0 EQUIPMENT back to index

All equipment used in enteral feeding systems must comply with: -

National Patient Safety Alert (NPSA) 19 (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes.

The Medicines Policy for the Safe and Secure Handling of Medicines within East Cheshire NHS Trust, section 4.4.

6.1 Tubes back to index

Enteral feeding systems should not contain ports that can be connected to intravenous syringes, or that have end connectors that can be connected to intravenous or other parenteral lines.

Enteral feeding systems should be labelled to indicate the route of administration.


6.2 Syringes back to index

Only use labelled oral/enteral syringes that cannot be connected to intravenous catheters or ports to measure and administer oral liquid medicines.

Do not use intravenous syringes to measure and administer oral liquid medicines. The exception may be if a drug is only available in a glass ampoule, in which case it will need to be drawn up with an IV syringe and filter needle, then transferred to an oral/enteral syringe. This procedure may result in loss of volume and reduced dose. Consult with the pharmacist for advice. A risk assessment should be completed to allow the drug to be given using an IV syringe and adaptor to fit the enteral tube.

Stocks of oral/enteral syringes should be available in all clinical areas that may need to measure and administer oral liquid medicines though an enteral feeding tube.

Enteral syringes are available in a range of sizes, which should be available on the wards. Small doses of medicine should always be measured and drawn up in a small syringe (the size should be appropriate for the dose prescribed). An inaccurate dose may be administered if an inappropriate sized syringe is used.

Patients being discharged with an enteral tube in situ should be given enteral syringes to take home with them.

Refer to CNSG 013 Guidelines for Administration of Feed and Fluids via an Enteral Tube, for further information regarding use of enteral syringes. 6.3 Adaptors back to index

Three-way taps and syringe tip adaptors should not be used in enteral feeding systems because connection design safeguards can be bypassed. 6.3 Non standard equipment Periodically a patient may need a specialist device fitting which does not comply with NPSA guidelines. The risk to the patient should be assessed and clear guidance for using the device written in the patient’s care plan. The patient should be referred to a specialist in enteral devices to assess the patients requirements and advise staff. Non standard devices should be labelled and stored in an area with restricted access. At Macclesfield hospital, nonstandard enteral devices are kept on the endoscopy unit. back to index


7.0 COMPLICATIONS back to index

Most complications associated with enteral feeding are drug interactions, incompatibility with the feed and incorrect administration resulting in tube blockage. Table 3

TYPE

PREVENTION

Blockage Causes:

Inappropriate drug formula

too fine a tube

Sub optimal preparation of the drug

Poor flushing technique

Insufficient flushing

Choose correct drug formula see tables 1 and 2.

If crushing drugs, crush to a fine powder and mix with water.

During administration agitate or rotate the syringe to prevent the sediment being administered as a solid lump (see appendix 2).

Flush the tube before, in between and after each medication.

Use the plunger with the syringe. Refer to CNSG 013 Guidelines for Administration of Feed and Fluids via an Enteral Tube for further guidance.

Insert a larger bore tube if large volumes of medication need to be given. Tubes of 10Fr or less are at greater risk of blocking.

Sub therapeutic dose – interaction with feed

Interaction with the enteral feed may reduce bioavailability resulting in suboptimal dosage. More common with drugs that have a narrow therapeutic range or that interact with food, vitamins and electrolytes, e.g. phenytoin, theophylline, digoxin, warfarin and some antibiotics. Reasons include:

Binding to the protein source in the feed

Poor solubility due to incompatible chemical makeup of the drug and the feed.

Suspend administration of feed to allow for a clear period between administration of the drug and feed. The optimum clear period will depend on the drug and the patient’s gastric motility. Check with the pharmacist/clinician.

The dose of the drug may need to be adjusted upwards due to lack of therapeutic response as a result of interaction with the feed. This is particularly relevant for drugs with a narrow therapeutic index.

The patient should be monitored for altered response and plasma levels.

Liaison between the pharmacist and dietitian is essential to ensure that the feeding and medication regimen are compatible.

Sub therapeutic dose – reduced absorption due to position of tube

Reduced absorption due the exit position of the tube in the gut i.e. if the tube is placed in the duodenum (See section 4.0 above)

The prescriber and pharmacist should be aware of the tube’s position within the gut.

Alteration to dose, a double lumen tube or an additional gastric tube may need to be considered.

Sub therapeutic dose – reduced absorption

Decreased transit time, particularly if individual has enteral associated diarrhoea or receiving a hyperosmolar feed.

The dose or frequency of administration may need to be altered. Liaise with the pharmacist.



TYPE

PREVENTION

Sub therapeutic dose – dose variation between formulations

Altered dosage due to change of prescribed formulation e.g. some liquids/suppositories have a different bioavailability from tablets e.g. digoxin and carbamazepine

The dose or frequency of administration may need to be altered if changing between formulations and from controlled to ordinary release tablets.

Liaise with the pharmacist.

Sub therapeutic dose – loss during preparation Accidental loss during crushing, mixing with water and administration.

Ensure all the powder in the table crusher is mixed with water and given.

Check that any sediment in the bottom of the mixer cup or syringe is drawn up and administered.

Use an appropriate sized syringe for measuring.

Sub therapeutic dose - Interaction with other drugs

Some drugs may interact resulting in a reduction in effectiveness if mixed together, always administer individually flushing in between each drug (see appendix 2

Sub therapeutic dose – crushing modified release tablets Crushing (particularly modified release e.g. SR, MR, LA, XL or CR) Slow or modified release formulas are designed to release the drug over a period of time. Crushing or breaking tablets, or opening capsules can destroy their slow release properties increasing the risk of side effects, toxicity and reducing their duration of action. One side effect of this, is that the patient will receive an ineffective dose over a period of time.

Do not crush modified release tablets

Liaise with the pharmacist for an alternative.

Sub therapeutic dose – inaccuracy during preparation Using inappropriate sized syringes to measure medication

The syringe size should be tailored to the dose required. Small doses should be measured in small syringes for accuracy.

Over dose The same applies as for sub therapeutic doses

Apply the same principles as for sub therapeutic dosing as seen above. Particular attention should be paid when:

Feed prescription is changed (dose/type/method of administration

Drug formulations are changed (e.g. liquid to tablet to controlled to ordinary release

The position of the tube in the gut is altered Liaise with the pharmacist.

back to index



TYPE

PREVENTION

Contamination The feeding tube does not have the natural defences against infection that the gastro-intestinal tract has, for example peristalsis, lymph nodes or acidic secretions. The tube itself is at body temperature, has a regular supply of nutrients and cannot be cleaned. It therefore provides an ideal breeding ground for bacteria. For these reasons good food hygiene practices and further infection control measures are necessary when handling and preparing enteral feeding systems (Anderton 1990). Refer to CNSG 015 Microbiological Guidelines for Enteral Feeding for further information.

Use a sterile enteral syringe

Use a fresh medicine cup

Use fresh tap water or water that has been stored in a lidded container and replaced twice a day

Use sterile water if the patient is immuno-compromised or the tube is post pylorus.

Tablet crushers are single patient use only and should be washed with hot soapy water in between use.

Diarrhoea

Antibiotics

Contamination

High doses of preparations containing sorbitol

Some antibiotics may cause diarrhoea. Discuss with pharmacist for antibiotic choice.

Review practice. See above. Refer also to CNSG 015 Microbiological Guidelines for Enteral Feeding for further information.

Cumulative sorbitol doses of 7.5 to 30g may cause adverse effects, with symptoms being particularly severe above 20g. Sorbitol content varies with manufacturer and drug concentration. Liaise with the pharmacist.

back to index


APPENDIX 1 REFERENCES AND BIBLIOGRAPY back to index

BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners and Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead.

http://www.bapen.org.uk/ BeIknap, D, Seifert, C. F, Peterman. M. et al. Administration of Medications Through Enteral Feeding Catheters. American Journal of Critical Care. 1997; 6(5): 382-392. Colagiovanni, L. Preventing and clearing blocked feeding tubes. Nursing Times. 2000; 96(17): 34. Lourenco, R. Enteral Feeding: Drug/nutrient interaction. Clinical Nutrition. 2001; 20(2): 187-193. Medicines Act 1968 Misuse of Drugs Act 1971 National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and enteral routes. NPSA/2007/19 Reilly, H. Enteral Feeding: an overview of indications and techniques. British Journal of Nursing. 1998; 7(9): 510-520. Thomson F.C. et al (2000). Managing drug therapy in patients receiving enteral and parenteral nutrition. Hospital Pharmacist 7(6) 155-164 Woolfrey, S, Geddes. A, Cox. J. et al. Percutaneous Endoscopic Gastrostomy. The Pharmaceutical Journal. 1996; 257: 181-184. . back to index

http://www.bapen.org.uk/


APPENDIX 2 PREPARATION AND ADMINISTRATION OF MEDICATION Recommended preparation of medication prior to administration back to index Table 4

TYPE OF MEDICATION METHOD OF PREPARATION

Soluble/dispersible tablets Effervescent tablets Insoluble Tablets

Place the tablet in the barrel of the syringe and replace the plunger. Draw up approximately 10-15mls of water into the syringe and allow to disperse. Administer as per table 5 Dissolve in the amount of dilutent as recommended by the manufacturer. Administer as per table 5 Crush the tablets or open capsules and mix in 10-15mls water. Administer as per table 5 NB. See table 1 for which tablets should not be crushed.

Liquids Viscous liquids

Shake liquid formulations in the bottle thoroughly to mix the contents in order to minimise dose variation. Some preparations are too thick to syringe down the tube and will cause blockage. Dilute viscous preparations with water (up to 1:3) prior to administration. Administer as per table 5

Capsules The capsule can be pulled open or snipped at the end and the powdered contents mixed with water. NB. Some capsules contain pellets these should be administered intact. Do not give these via a fine bore tube as they will block the tube (10 Fr minimum). Liaise with pharmacist for alternative.

Method of administration back to index Table 5

ACTION

RATIONAL

Wash hands and wear gloves as per the Infection Prevention and Control Good Practices Policy prior to handling of any feed systems.

Minimises risk of infection

Assemble equipment and medication required Efficient practice and minimises risk of errors

Explain the procedure to the patient and position them correctly in a semi-raised (at least 3 pillows) or upright position depending on risk of reflux. If the patient has a large hiatus hernia or a history of reflux and have a swallowing disorder, they should be positioned in an upright position.

Minimise risk of aspiration


Table 5 continued - Method of administration back to index

ACTION

RATIONAL

Assess patient to check for contraindications prior to administration of medication

Minimise risk of complications

Stop feed if in progress Minimises drug/feed interaction

If the tube has a Y connector and the feed is in progress, use the port that is not attached to the giving set.

Minimises handling and disconnection of the feed system and reduces risk of infection

Check position of tube, if NG or NJ (See CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes and CNSG 012 Guidelines for Insertion and Management of Jejunal Tubes for further guidance).

Minimises risk of accidental administration of fluids into the lungs and reflux if tube positioned in oesophagus

Flush the tube with a minimum of 30mls water prior to drug administration (or volume as advised by the dietitian).

Ensures that the tube is patent

Prevents feed/drug interaction

Rinse the tablet crusher and flush washings down the tube.

Ensures that the whole dose is given

Draw up the medication into an enteral syringe. The size should be appropriate for the dosage/volume to be given.

Prevents administration of a drug meant for the enteral route being given intravenously, resulting in serious harm.

Using the correct sized syringe prevents incorrect dosing.

Administer each drug separately, flushing the tube with 10mls of water in between each medication.

Prevents drug/drug interaction

Ideally drugs should be given separately to avoid drug interaction. Extenuating circumstances may be: -

Fluid restrictions

Practicality – patients with limited dexterity, on multiple medications and in the home setting.

If in doubt contact your pharmacist

If the solution contains sediment e.g. Lansoprazole, agitate or rotate the syringe during administration to ensure that the sediment is evenly distributed.

Prevents a clump of sediment being given, which will block the tube.

Flush the tube with water after administration is complete.

Ensures that the full dose is given and not still sitting in the tube.

Prevents tube blockage

Prevents drug/feed interaction

Flushing post medication is crucial. Tube blockages due to medication cannot be cleared using food enzymes. A new tube would be required. Refer to CNSG 013 Guidelines for Administration of Feed and Fluids via an Enteral Tube for further guidance for flushing.


Table 5 continued- Method of administration back to index

back to index

ACTION

RATIONAL

Document the amount of water used Important in multiple drug therapy as the daily fluid intake can be monitored

Consultation with a pharmacist is advised if the patient is on multiple drug therapy and fluid restricted.

Always take medication as prescribed.

The absorption of certain drugs may be affected by the feed and a delay between the drug is required e.g. phenytoin

Others drugs need to be taken with the feed

Never introduce medication into the enteral feed.

Risk of contamination

Risk of drug/feed interaction

Risk of the tube blocking

Risk of suboptimal dosage

Restart feed if appropriate

Minimise delay to feeding regimen

Lock up medication as per East Cheshire NHS Trust Medicines Policy

Prevents misuse of medication

Clean up any spills and dispose of equipment as per East Cheshire NHS Trust policy. Syringes must be discarded after use.

Minimise risk of contamination and harm to others

Wash hands

Minimise risk of cross contamination

Monitor patient

To check for complications

Document medication given and any variances as per East Cheshire NHS Trust Medicines Policy

Provides evidence of medication given and any complications


APPENDIX 3 LINKED SUPPORTING DOCUMENTS/INFORMATION back to index The following documents regarding enteral tube feeding are available on the Trust intranet: Patient Information Drug administration via enteral feeding tubes http://www.bapen.org.uk/pdfs/d_and_e/de_pat_guide.pdf Training aids

East Cheshire NHS Trust Pharmacy Training modules - Administration Of Medicines via Enteral Feeding Tubes http://trustnet/Pharmacy/Presentation.pps

NPSA alerts back to index National Patient Safety Agency (NPSA) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes NPSA/2007/19 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=59808 Manufacturer’s websites Abbott Nutrition home page – access to pump instruction manuals and training Videos http://www.abbottnutritionuk.com/ Corpak Medsystems – access to information about enteral tubes and company guidelines http://corpakmedsystemsuk.com/ Medicina – information about enteral syringes and feeding devices http://www.medicina.co.uk/ back to index


http://trustnet/Pharmacy/Presentation.pps






Guideline Title:

Guidelines for management of patients admitted to hospital with an enteral feeding tube

Executive Summary:











Author: Dietetics Department Impact Assessment Date:

August 2014

APPROVAL RECORD

Committees / Group


Date

July 2015


June 2015

Approved by:


July 2015

AMENDMENT RECORDS

East Cheshire NHS Trust. Patient Information Page 155 of 174 Created by GI Nurse Specialist Maggie Allen. August 2012. Updated July 2015.

1.0 Flowchart to guide management of patients admitted on enteral feeding

Monday to Friday 8.30-16.30

Medical condition assessed as

safe for enteral feeding

Contact dietetics dept

Dietitian to: 1. Write correct feed on drug chart 2. Write out feed and fluid regimen on feeding chart

Refer to dietetics dept

Yes

Yes

No

Has the patient come in with feed?

Bolus feeding Continue with this method of administration

Pt may need feed changing to Abbott feed depending on clinical circumstances *

Pump feeding If the patient is stable and unlikely to pull out the tube, consider pump administration. If not give as bolus admin.

Administer feed and fluids as per dietetic recommendation.

No

Abbott feed

Yes

Give Abbott feed as per emergency feed regimen as per documented medical advice.* Dr must write feed on prescription chart and sign regimen form

What is their usual method of administration?

If no, refer to dietitian when clinically stable

Yes

Yes

* The emergency regime gives a reduced amount of feed. If a patient’s clinical condition and medical advice allows, they can continue with a full dose feed as per their normal regimen. If Abbott feed, use Trust pump. If non Abbott feed, give with bolus admin as community pumps cannot be used within the hospital.

Yes No


2.0 Management of Enteral device

The management will depend on the device in situ. If a nasogastric tube manage as per CNSG 007 Guidelines for the Insertion and Management of Nasogastric Tubes. If gastrostomy, manage as per CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes Refer to specialist if further information required.

Back to index Back to main index


PATIENT INFORMATION AND FORMS TO DOWNLOAD OR PRINT

CARE PATHWAY FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBES

158-165


166

PRE-DISCHARGE TRAINING CHECKLIST- GASTROSTOMY FEEDING

167-168


169-171

Back to main index


CARE PATHWAY FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBES Mark boxes with X as appropriate or circle NA

REFERRAL ASSESSMENT

Patient Details: Fix label if available Name: ……………………………………………………. Date of Birth:……………..……….. Hospital No:……………..…… Address:……………………………………………………………………………………………. Ward ………………………….. Consultant: …………………………….. Admission date: ……………………….. Outpatient/Inpatient

If the patient has the following conditions PEG is not appropriate (tick appropriate boxes). Total gastric outflow obstruction Tense ascites Peritoneal dialysis

If the patient has the following conditions PEG may not appropriate (tick appropriate boxes).

Gastro-oesophageal reflux with risk of aspiration Previous upper GI surgery Dementia

Partial gastric outflow obstruction Recurrent aspiration pneumonia due to severe dysphagia, following a CVA.

Indication for PEG: (tick appropriate boxes)

Dysphagia Supplementary Nutrition Other Long term feeding likely >2 months

Previous NG tube feeding Yes/No Start date…………………… No. of times tube pulled out by patient ……………

Please fax PEG referrals through to the gastroenterology department: Fax 01625 661904 Consultant Gastroenterologists: Dr R Saravanan and Dr K Koss. GI Specialist Nurse: Maggie Allen

PEG referral date………………………….. PEG booked for:…………………………..

Accepted for PEG Outcome if not accepted: Continue NG feeding Continue oral feeding

Name and signature of PEG nurse or referring doctor………………………………………………………………………….

Clinical assessment

Diagnosis: ………………………………………………………… Conscious level: Alert/fluctuating/unresponsive (circle)

Relevant co-morbidity……………………………………………………………………………………………………………………

CPR form Tracheostomy Cervical/Neck problems Obese

UTI Raised WCC

Recent or current chest infection/aspiration Current O2 therapy Antibiotic therapy

MRSA If patient is MRSA positive treat prior to PEG (See Trust policy for MRSA).

Previous abdominal surgery

Type……………………………………………………………………………………………………………………………………

PEG Nurse assessment Dietetic assessment Swallow assessment (SALT)

All dysphagic patients should have had a recent swallowing assessment prior to PEG.

MDT discussion Complex cases i.e. Multiple co-morbidity, should be discussed in an MDT forum


PREPARATION PRIOR TO PEG

Mark boxes with X as appropriate

MEDICATION – is the patient on anticoagulant therapy? Yes/No

Low molecular weight heparin e.g. Omit 24 hours prior to PEG. Tinzaparin/Clexane/Enoxaparin

Warfarin Omit 5 days prior to PEG (arrange for heparin if appropriate). Restart Warfarin the following day.

Heparin Stop 4-6 hours prior to procedure. Restart 6 hours post procedure if no complications.

Drugs to be prescribed:

Re-feeding drugs required Re-feeding drugs prescribed

Prophylactic antibiotics: intravenous Co-amoxiclav 1.2g, just before the procedure (1hour max). If penicillin allergic, give a single dose of Gentamicin 3mg/kg (max 300mg), just before the procedure. If MRSA positive discuss with microbiologist.

Corsodyl (chlorhexidine gluconate 0.2%) mouthwash to start 48 hours prior to procedure

Analgesia PRN, IM and soluble

Ward pharmacist Informed re PEG

The patient’s drug formulations may need to be changed. Timing and dosage of drug administration may need to be altered due to altered drug formulation and/or potential interaction with feed.

BLOODS Day before procedure: FBC INR

If the patient is malnourished, check the prothrombin time 48 hours before the procedure. If INR > 1.3: Correct to within normal limits.

NUTRITIONAL ASSESSMENT

Last fed/ate………………………………… Risk of re-feeding

Weight Weight Kg…….. Date…………………………

PEG regimen Feed prescribed Pump, feed and equipment required for feeding available

Before start feeding: U& Es (including calcium group, phosphate and magnesium and levels)

Correct any electrolyte disturbances before commencing nutritional support.

CONSENT

Patient (Consent form1) Consultant (consent form 4)

Written information (EIDO E09 PEG sheet) given to patient /relative/carer

Relatives aware of planned PEG insertion

NB. Informed consent, written/verbal/signage, must be obtained from patients where possible, in compliance with Trust Policy. This may require repeated discussions and the use of visual aids to help the process. If a patient is unable to give informed consent, the lead clinician and the healthcare professional undertaking the PEG insertion must sign the consent form. Evidence of discussion with appropriate family is required.

SUBCUTANEOUS FLUIDS:

Avoid siting the butterfly cannula in the upper central abdomen as this can result in skin infections or abscesses that may affect PEG insertion.


Mark boxes with X as appropriate

PRE PEG CHECKLIST X Variance/Notes

Fasting (mouth and tube) Morning list (9am) - No diet/feed and fluid after 3am.

Afternoon list (13.00pm) - No diet/feed and fluid after 7am.

Hygiene

Full wash – do not use talcum powder

Clean theatre gown

Clean sheets.

Working cannula in situ Venous access should be established before the patient arrives on the Endoscopy Unit (except for outpatients).

Antibiotic prophylaxis prescribed Patients should have a single dose of intravenous Co-amoxiclav 1.2g just before the procedure (1hour max). If penicillin allergic, give a single dose of Gentamicin 3mg/kg (max 300mg), just before the procedure. If MRSA discuss with microbiologist.

Analgesia prescribed Immediate PRN use (intramuscular and dispersible preparations of oral analgesia). Take home analgesia for out patients (where required).

Mouth Care with Corsodyl mouthwash

Mouth Assessment

Own teeth

Loose or decayed teeth

Dentures

Able to open mouth Advise endoscopy staff of loose/broken teeth (document of endoscopy care plan).

Consent form completed

INR Date PLT Date

PEG is contra-indicated if INR >1.3 or platelet count <100

Recheck INR Date PLT Date

Baseline observations – within 2 hours of procedure

Pulse………… BP………………

Temperature……………. SaO2……………

Resps…………

Allergies ………………………………………………

DATE:………………………… CHECKLIST COMPLETED BY:……………………………………………………………


Post PEG management of complications - Inform/doctor/PEG nurse (as appropriate) of any complications. Refer to East Cheshire NHS Trust CNSG 014: Guidelines for Enteral Feeding Complications and Management.

Half hourly for 2 hours Blood pressure Pulse Wound check Temperature Pain assessment Oxygen saturation

Respiratory rate PEG position

unchanged

Normal variants

Hourly for 2 hours As per half hourly

assessments

No

Yes

2 Hourly for 2 hours As per half hourly assessments

Leakage

Bleeding

Aspiration Reflux/ nausea/ vomiting

Pain

Diarrhoea

Yes

Normal variants

Normal variants

Yes

Discontinue observations as medical condition allows.

Normal variants

Yes

Small volume Monitor dressing for spread Inform specialist if bleeding continues Large volume Inform gastroenterologist /surgeon immediately

Assess pain, how much, where and when. If localised to wound give appropriate analgesia and monitor effectiveness. If increasing abdominal pain, seek urgent senior medical or surgical advice. If pain or resistance when flushing, stop immediately and seek urgent senior medical or surgical advice.

Pyrexia

Yes

Low oxygen saturation

Hyper/ hypotensive Tachycardic /bradycardic

Assess for cause Consider Sepsis/peritonitis/chest infection/UTI Treat as appropriate

Consider effects of sedation/aspiration/chest infection. Treat as appropriate Reverse sedation if necessary. Patient position/antibiotic therapy.

Consider effects of sedation – reverse if necessary. Pre-existing condition. Correct with drug therapy asap, continue to monitor.

Assess amount of leakage Slight oozing of exudate is common post insertion. Monitor amount. Larger volumes particularly during administration of fluids via the tube and associated with pain are abnormal and need urgent medical attention. Larger volumes without pain may be associated with constipation. Treat and monitor bowel movements

Assess cause of diarrhoea Feed/infection/drugs

Inform doctor/pharmacist/dietitian.

4 Hourly As per half hourly assessments Monitor saturation levels

Position patient in upright position during feeds/flushes Consider prokinetics Consider constipation

Consider secretion management

Yes

Yes

Yes

Yes

Yes

Yes

Yes


POST PEG Up to 24 hours post PEG DATE………………………………

ACTIVITY

NAME SIGN

MONITORING

Half hourly for a minimum of 2 hours. Hourly for a minimum of 2 hours.

Blood pressure, pulse and temperature As per half hourly assessments Oxygen saturation and respiratory rate Wound check Pain assessment (see below) PEG position unchanged. Measurement at the exit from the skin ...............cm

2 - 4 hourly (depending on clinical status). Discontinue as clinical condition allows.

As per half hourly assessments

PAIN ASSESSMENT

Does the patient have any pain

Ask where the pain is

Assess the degree of pain using the pain scale below

Assess whether the pain is worse

Give analgesia appropriate to degree of pain

Assess whether the analgesia is effective

Refer for urgent medical attention if increasing severity of abdominal pain despite analgesia

Record pain score on observation chart

Record location of pain in patient’s notes

If the patient is unable to communicate observe for signs of increased restlessness and abnormal observations

COMMENCING FEED /ORAL DIET

NBM or tube until 4 hours post insertion. Give first flush at: ..............................

Flush tube with 50mls of sterile water. If pain or difficulty flushing, stop immediately and seek urgent senior medical or expert advice.

Administer medication for re-feeding if applicable

Commence feed/fluids as per dietetic regimen

Oral diet/fluids (if applicable) can restart as the individual wishes after the first successful flush of water

Position the patient in a semi-raised (at least 30°) position during feed. Upright if known history of reflux and vomiting.

MOUTHCARE 2 hourly if no oral diet or fluids. Document care given on mouth care chart

STOMA CARE

Do not change the dressing for 24 hours

Monitor for bleeding

Monitor for leakage If excessive leakage or bleeding, refer for urgent senior medical/surgical review. Document complications.


POST PEG 24 – 48 hours post PEG DATE…………………...........

ACTIVITY NAME SIGN

MONITORING 4 hourly observations (more frequently if necessary depending on medical condition)

Blood pressure, pulse and temperature

Oxygen saturation and respiratory rate

Wound check

Pain assessment

PEG position unchanged. Measurement at the exit from the skin ...............cm

Discontinue as clinical condition allows

Bowel movements Monitor. If no bowel movement assess for constipation. If constipated treat. Record bowel movements on observation chart

Bloods - repeat full profile if at risk of re-feeding syndrome, or previous abnormal results.

PAIN ASSESSMENT











ADMINISTRATION FEED /ORAL DIET

Administer feed/fluids as per dietetic regimen

If pain during administration of fluids, stop immediately and seek urgent senior medical or expert advice.

Continue oral diet/fluids (if safe)


MOUTH CARE 2 hourly if no oral diet or fluids. Document care given on mouth care chart

STOMA CARE See overleaf (page 7)


POST PEG 24 – 48 hours post PEG DATE………………………

ACTIVITY NAME SIGN

STOMA CARE Use aseptic technique when cleaning the stoma site for the first 72 hours post insertion.



Wash hands and put on sterile gloves as per Trust policy

Remove the dressing, clean the stoma site and fixation device using Normasol and gauze swabs, removing any exudate.

Rotate the PEG tube to clean under the fixation device

Dry the skin and fixation device thoroughly

Observe the stoma for inflammation/redness/swelling

Check that the position of the PEG is unchanged (check that the cm marking at the exit point from the stomach corresponds with the measurement recorded in the patient's notes)


Do not undo the fixation device until 2 weeks post insertion, unless too tight. See below for further information regarding the position of the fixation device.

A small dressing can be applied until the site dries up (see below for advice regarding dressings).

Position the distal part of the tube away from the groin region as it is unhygienic

Inform doctor/specialist nurse of complications (see page 4 of PEG care plan for complication flow chart)

Document condition of the stoma in the nursing care plan

If excessive leakage or bleeding, refer for urgent senior medical/surgical review. Page 4 of PEG care plan

Fixation Device Position

The fixation device should be left in position for two weeks post PEG insertion to allow healing and reduce the risk of peritonitis. The positioning of the fixation device is crucial especially post insertion. Too tight and pressure necrosis will develop. Too loose and the stoma layers will not adhere together, increasing the risk of peritonitis. The fixation device should be no more than 3-4mm from the skin. The fixation device may become too tight post PEG insertion as a result of inflammation and/or re-hydration If repositioning of the fixation device is required, release the fixation device and slide it backwards up the tube to the optimum position then secure the tube within the device. Recheck the position after closing the device whilst gently pulling back on the tube. Seek specialist advice if unsure or further guidance required. Document the adjusted measurement in the patient’s care plan/notes.

Dressings Avoid bulky dressings under the fixation device as it may increase the pressure on the internal fixation device, resulting in localised ischaemia. If using a thick dressing, lay it on top of the fixation device. Any thinner topical dressings e.g. silver impregnated dressings can placed keyhole style around the tube. Seek specialist advice if unsure or further guidance required.

Bathing and showering

The PEG stoma must not be immersed in water for 3 weeks following insertion. If using a shower, for first few days, a large waterproof dressing can be used to cover the stoma and removed after showering. The stoma will still need cleaning if covered with a waterproof dressing. Further Guidance Refer to CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes and CNSG 014 Guidelines for Enteral Feeding Complications and Management for further information.


POST PEG 48 – 72 hours post PEG DATE……………………

ACTIVITY

NAME SIGN

MONITORING 4 hourly observations (more frequently if necessary depending on medical condition)

Blood pressure, pulse and temperature

Oxygen saturation and respiratory rate

Wound check

Pain assessment

PEG position unchanged. Measurement at the exit from the skin ...............cm

Discontinue as clinical condition allows

Bowel movements Monitor. If no bowel movement assess for constipation. If constipated treat. Record bowel movements on observation chart.

Bloods - repeat full profile if at risk of re-feeding syndrome, or previous abnormal results.

PAIN ASSESSMENT











ADMINISTRATION FEED /ORAL DIET

Administer feed/fluids as per dietetic regimen

If pain during administration of fluids, stop immediately and seek urgent senior medical or expert advice.

Continue oral diet/fluids (if safe)


MOUTH CARE 2 hourly if no oral diet or fluids. Document care given on mouth care chart

STOMA CARE As per 24-48 hours (page 7)

72 HOURS ONWARDS Continue care as per CNSG009 Guidelines for Insertion and Management of Gastrostomy Tubes (Trust infonet).



Following PEG tube removal, food and drink can be taken as normal.

A dressing has been placed over the stoma to absorb any leakage.

The dressing should be checked regularly and replaced if wet (stomach contents are very acidic and may burn the skin).

The skin around the stoma should be regularly cleaned and dried to prevent soreness.

A barrier cream can help to protect the skin if there is a lot of leakage. The hole should start to close over in 24-48 hours. The dressing is no longer needed when the stoma has dried up. Occasionally the stoma can take longer to close, particularly if there have been problems with leakage around the tube in the past. Healing may also be delayed if the patient has an infection in the stoma site, or overgranulation. A course of antibiotics may be required. If the problem persists contact the specialist nurse or doctor/GP.


Department of Nutrition & Dietetics Macclesfield District General Hospital

Tel: 01625 661126

HOME ENTERAL FEEDING

PRE-DISCHARGE TRAINING CHECKLIST GASTROSTOMY FEEDING

NAME

WARD

Please date and sign for each entry. Practice column indicated practice under supervision and should be signed and dated on each occasion. When discharged from hospital, the patient and/ or carer will know/ know how to:-

GOAL

Discuss

Demo

Practice

Competent

Why tube feeding is required

Feeding route and type of tube

When and how to wash hands

Care of Tube

Check tube position

Clean gastrostomy site

Rotate tube

Care of tube and connectors

How and when to flush tube

Administer medication

Feed

How to obtain feed supplies

How to store feed

Name of feed and volume required daily

Timing of feeds

Timing of extra water


GOAL

Discuss

Demo

Practice

Competent

Setting Up Feeding System

Prepare feed for administration

Connect giving set to feed

Connect giving set to pump

Prime giving set

Programme pump and/ or deliver a bolus feed

Pump features

Pump Alarms

Connect giving set to gastrostomy

Disconnect the giving set from tube

Care of Equipment

How to store equipment

Clean Handling Procedures

How to dispose of equipment

Problem Solving e.g.

Feeding tube is blocked

Pump not working

Feeding tube dislodged

Who to contact for help

Follow up Appointment arranged with Dietitian Date ________________________________ Time _________________________ Signed_________________________Date ________________( Patient/carer)

Signed_________________________Date________________ (Dietitian)

Signed_________________________Date ________________ (Nurse)



astric Insertion Chart

A maximum of 3 attempts at NG insertion is recommended prior to seeking more expert help/advice. If out of hours, wait until more expert help is available. Do not use the tube before the position is verified. pH testing is the first line test. Refer to algorithms 1 & 2 in Trust NG guidelines for insertion and confirmation of position.

Date/time of insertion

Type of tube/ Lot Number

Nostril

L/R Cm mark at exit from nose (after correct tube position confirmed)

pH value

X-ray Yes/No

Reason for insertion A.Decompression B.Enteral feeding

Consent, procedure and positional check documented in patient’s notes Yes/No

Reason for failed insertion A. Unable to pass through nostril B. Unable to pass into the

oesophagus C. Patient unable to tolerate D. Respiratory distress

Inserted by:

Assessment and Preparation:

PH testing: Is the patient on a PPI e.g. Lansoprazole or H2 antagonist e.g. Ranitidine Yes /No

Decision maker………………………………………………. Signature……………………………. Date……………………………Time……………………..

Patient Details: Fix label if available

Name: ……………………………………………Date of Birth:……………... Hospital No:…………………….. NHS No…………………………………

VERY HIGH RISK OF INSERTION COMPLICATION

Fractured base of skull

Upper GI obstruction

Recent surgery / radiotherapy to upper GI tract / larynx?

Yes

Insert tube as per Trust guidelines and complete core

care plan.

Assess for risk, indication and appropriateness of NG tube feeding/gastric decompression and document rationale in the patient’s medical notes.

No No

Yes

Consider referral to specialist / expert practitioner / nutrition support team for:

Insertion and management advice

Alternative feeding methods

Refer to specialist or expert practitioner prior to insertion.

PPI therapy Yes / No Refer to algorithms 1 & 2

HIGH RISK OF: incorrect positioning, dislodgement and aspiration

Altered state of consciousness / ventilated

Swallow dysfunction / nursed prone

Recurrent retching vomiting?


Nasogastric Tube Monitoring Chart

Patient Name: Hospital Number:

Mark: Yes, No, A, B, C, D, or E (mark as many as appropriate).

Refer to East Cheshire NHS Trust clinical nutrition steering group guidelines for insertion and management of nasogastric tubes (CNSG007) and guidelines for enteral feeding complications and management for advice about clearing a blocked tube (CNSG 014).

DATE TIME PH VALUE

CM MARKING

at exit from nose

NO ASPIRATE

ACTION TAKEN – see algorithm 2

A – Tube position checked B – Use tube C – Reposition/replace tube

INCONCLUSIVE ASPIRATE


A – Inject air B – Check volume/colour C – Compare previous readings D – Stop/delay feed E – X-ray

X-RAY RESULT – TUBE IN

STOMACH

YES/NO

NASAL/ CHEEK TAPE

SECUREYES/NO

TUBE PULLED

OUT

YES/NO

COMPLICATION A. Nausea/ vomiting B. Diarrhoea

C. Constipation D. Tube blocked E. Reflux F. Feed stopped

INITIALS SENIOR CHECK

INITIALS – where

appropriate


Nasogastric Tube Monitoring Chart

Patient Name: Hospital Number:

Mark: Yes, No, A, B, C, D, or E (mark as many as appropriate).

Refer to East Cheshire NHS Trust clinical nutrition steering group guidelines for insertion and management of nasogastric tubes (CNSG007) and guidelines for enteral feeding complications and management for advice about clearing a blocked tube (CNSG 014).

DATE TIME PH VALUE

CM MARKING

at exit from nose

NO ASPIRATE


A – Tube position checked B – Use tube C – Reposition/replace tube

INCONCLUSIVE ASPIRATE


A – Inject air B – Check volume/colour C – Compare previous readings D – Stop/delay feed E – X-ray

X-RAY RESULT – TUBE IN

STOMACH

YES/NO

NASAL/ CHEEK TAPE

SECUREYES/NO

TUBE PULLED

OUT

YES/NO

COMPLICATION A. Nausea/ vomiting B. Diarrhoea

C. Constipation D. Tube blocked E. Reflux F. Feed stopped

INITIALS SENIOR CHECK

INITIALS – where

appropriate


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