. Nutritional Access Devices

Nutritional Access Devices


 

Lillian Sablan and Karen Sherry


 

ENTERAL ACCESS DEVICES


Nasogastric tubes (NG tubes) and nasojejunal tubes (NJ tubes) can be placed at the bedside or under fluoroscopy. These tubes are used as an initial or temporary feeding tube. Generally, the smallest size enteral tube should be chosen, and the tube should be replaced only when necessary. If long-term feedings are anticipated, tubes should be polyurethane or silicone to reduce the frequency of tube replacement and minimize trauma. Use of weighted tubes should be avoided to decrease the risk of bowel perforation.


Gastrostomy tubes (G tubes), transgastricjejunal tubes (GJ tube), and jejunal tubes are feeding tubes placed using endoscopic techniques, surgery, or interventional radiology. These types of tubes are used when long-term feeding is necessary. The commonly used enteral feeding devices are summarized in eTable 34.1. Image


Gastrostomy tubes are commonly used in patients who require prolonged enteral nutritional support. Some patients can tolerate prolonged use of nasogastric feedings and avoid a gastrostomy; however, patients who will require tube feedings for more than 2 to 3 months should be considered for gastrostomy tube placement to avoid complications and trauma with the replacement of nasogastric tubes.1 This is particularly important with infants and young children, who may develop a severe feeding aversion exacerbated by naso-gastric tube irritation of the nasal passages and oropharynx. Placement of a gastrostomy tube will facilitate progression of oromotor development in some of these children even though they still depend on tube feedings for their nutrition.


Gastrostomy tubes are frequently placed by percutaneous endoscopic gastrostomy (PEG), a fairly simple procedure typically performed under general anesthesia in children. The principal contraindications to placement of a PEG tube are overlying organs (eg, liver, colon), ascites, a coagulopathy, and failure to transilluminate the stomach, often resulting from a major portion of the stomach lying above the costal margin. PEG tubes have been successfully placed in patients who have undergone prior abdominal surgical procedures, including those with indwelling ventriculoperitoneal shunts, and in patients with various deformities, including intestinal malrotation or severe scoliosis. Complications of PEG tube placement include infection (which is decreased by prophylactic antibiotics before placement), pneumoperitoneum, transient fever, pain, bleeding, gastric ulceration from direct erosion of the gastric mucosa by the internal portion of the gastrostomy tube, ileus, gastric separation, gastric fistula, gastrocolic fistula, and tube extrusion. Removal of PEG devices for replacement with a standard gastrostomy tube usually is not performed for 2 to 3 months after placement to allow complete healing and maturation of the gastrostomy. Several tubes are available for use in a gastrostomy, ranging from skin-level, low-profile “buttons” to standard gastrostomy tubes (similar to Foley catheters). The choice of tube depends on the patient’s and caretaker’s preferences and tolerance of the tube by the patient. The skin-level, low-profile buttons are generally preferred in ambulatory, active children.


Awareness of the tube types, equipment, and resources (eg, nursing, nutritional, pharmaceutical, and home care companies) available in the local area is increasingly important for the pediatric practitioner because of the increased administration of outpatient nutritional support. Increased numbers of children with chronic disorders and efforts to decrease length of hospital stay have increased the use of nutritional support devices in the outpatient setting. In most settings, an ostomy nurse, pediatric surgeon or pediatric gastroenterologist manages the routine care of the variety of feeding tubes, as well as any complications that arise.


Care and management of enteral feeding tubes is summarized in Table 34-1.2 A detailed guide to troubleshooting and managing complications of enteral feeding is provided in eTable 34.2. Image These include local infections (Fig. 34-1), expansion of the size of the ostomy opening with leakage around the tube (Fig. 34-2), development of granulation tissue around the ostomy (Fig. 34-3), inadvertent removal of the tube, movement of the tube (eg, causing pyloric obstruction), and aspiration of gastric contents.


Table 34-1. Care and Management of Enteral Feeding Tubes



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Jan 7, 2017 | Posted by in PEDIATRICS | Comments Off on . Nutritional Access Devices

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