G-Tube Troubleshooting by Doctor Lindsey Armstrong and Susan Hamilton.
Hi, I'm Lindsey Armstrong, a Surgical Critical Care Fellow at Boston Children's Hospital.
Today I'm going to be reviewing G-tube cases about things on which you might be called.
The objectives for this video are to examine case studies of children with leaking
and dislodged G-tubes, identify the causes of leaking or dislodged tubes,
and determine appropriate treatment and course of action for these two situations.
Case One: Leaking G-tube.
Probably one of the more common problems is that your G or GJ tube is leaking.
Usually the reason for this is that the water in the balloon is leaking
or has simply just decreased in quantity causing the tube to be loose on the skin.
Or that the tube has been pulled on for weeks, and weeks, and weeks,
and the surrounding stoma has enlarged. Thus, the gastric contents or formula are leaking around it.
When you are on the phone with the nurse or the provider, you should always ask what kind of tube
the child has, as in the brand, and the location, the size. And again, this can usually be found in
the patient's operative note or usually the parents will know this information as well.
What is most important is to know when the tube was placed. Greater than or less than
six to eight weeks is really the magic number. Because if it was placed less than two months ago,
then you're really going to immediately want to call your surgical colleagues so that they
can assist you. The tracks might not be mature at this point, so replacing it could honestly lead to
an inter-abdominal catastrophe, as the stomach might be pushed away from the abdominal wall.
If the tube's been in place and the track is well matured, usually greater than six to eight weeks,
then it is safe for you, or the nurse, or the family to replace this tube.
Once you come into the room to see the patient, the first thing you want to do
is to examine them. Note what kind of leaking you're having,
making sure it's not pus, purulence, making sure there's no redness or bleeding.
It's common to see some gastric juice which can be clear yellow or bilious. However, it's important
to note that this is acidic and can be irritating to the skin. If you notice excess bleeding or foul
smelling pus, this is atypical and concerning and you should call the general surgery team.
Once you have examined the patient and you note that their belly is soft, everything's OK,
it's probably OK to continue to assess the tube to troubleshoot it. However, if the patient is having
any new distention or new abdominal pain, this is another reason for which you should call the
general surgery team. Usually, these two problems, leaking, can be addressed without any labs or
imaging. However, it's not totally unreasonable to get a G-tube study if you're concerned. But again,
if you're that concerned about the tube you should probably call the surgical team to help you.
If the patient is more than one week from their initial surgical placement, you're allowed to
check to see how much water is in the balloon. To do this, have an assistant hold the G-tube
while you use a syringe to withdraw water from the port. You'll be able to withdraw all the
water and then you should test that amount with how much was supposed to be in the tube, into the
balloon. So if mom says five mLs are supposed to be in the balloon and there's only three,
then that's probably your problem. It's usually safe at that point
to get a new syringe, sterile water, and put in another five mLs of the water into the balloon.
This should re-secure the tube in place and help prevent any further leaking.
Case Two: Dislodged G-tube.
The next case, and also unfortunately a common problem with G-tubes, is if you're called that
a patient has had a G-tube that's been dislodged. So again, the first thing
you're going to want to ask him or her is when was the tube placed, what kind of tube it was,
and if they do know who placed it, that's helpful as well. These are all things that you can look
into the EMR to find in the op note if the tube was placed at your institution.
So if the tube is more than two months old, then it's safe for you and/or the
nurse to replace this tube. However, if it's less than two months old,
it's important to call the general surgery team to have them assist you. Another important thing,
before you even get off the phone with the nurse, is to have them hold the feeds.
So if your tube is more than two months old, and you were going to replace it,
it's safe to replace the G-tube that came out. It's not sterile, as it's in the stomach
and surrounded by bacteria and feeds anyway. However, if the tube looks like it's very old,
has signs of corrosion, or more importantly, if the balloon is leaking, which is something you
can test with a new syringe of water, then you should replace the tube. The OR or the STAT room
should have the same size and type of tube. In the interim, if you're worried about the gastrostomy
track closing, you could insert a Foley at this point. However, once you have the new tube that
you're going to use, you should again test the balloon to make sure there are no leaks.
Then it's important to lubricate the ballooned end of the tube and then carefully insert it
back into the tract. It should go easily, and the patient shouldn't be in pain, although
some children are scared when this is happening and some anxiety is expected.
Once it's inserted, re-inflate the balloon with the appropriate amount of water.
So again, it's important that you understand that if the tract is greater than 2 months old,
it's safe for you, or the nurse, or the parents to replace this tube. And they
will have been taught this and likely would be doing it at home if it were to happen there.
If you're using a Foley, in the interim, before you can replace the tube, then it's important to
use the same size Foley as was the G-tube, or even one that is 1 to 2 times smaller.
Again never forget to use lubrication, it'll make your life and the patient's life much better.
The process for inserting a Foley is the same as was for inserting the G-tube,
and you also will inflate the balloon at the end of that insertion. Once it's replaced,
you should see return of gastric contents with aspiration. If there are any new concerns then
you could get a contrast study, probably with the advice and assistance of your surgical team.
If the tube is less than two months old, it's much simpler because really all you need to do is call
the general surgery team, as the patient may require a return trip to the operating room
for replacement of this tube. Sometimes they are able to replace it at bedside, but it would most
definitely call for a contrast G-tube study to confirm placement. Again, important things to note
before you call them. What kind of tube it is, brand, is a G, GJ, just J. The size of the tube,
which is usually written on the outside of the tube. How many mL's of water were in the balloon
when you found it and how much were supposed to be in there. When it was placed and where,
if you're able to find this information. And also it's good to know if it's been replaced
recently or any problems that the parents or child may have been having with the tube.
At Boston Children's Hospital, we have a fairly set post-op G-tube protocol that you will get
informed of if any of your patients return to you with a newly placed G-tube. All patients will have
the G-tube vented to gravity for six hours, that just means the caps open and it's draining freely.
After six hours, you're allowed to cap the G-tube and start quarter volume enteral feeds
through the G-tube, advancing to goal over a 24 hour period or slower if your team would like.
The tube at this point is taped on all four sides. The balloon will be inflated
with a set amount of water and you should not check or deflate this balloon for one week.
After that point, it is safe to check the balloon. The surgery team will usually see the patient in
the morning and they or the nurse can perform a dressing change if necessary. And then they
will sign off, but are happy to come back and see the patient if there are any problems.
This is the set protocol. However, it's important to speak with your surgeons after every surgery,
as some patients are different and may have a different post-op plan.
So that's about it for G-tubes. They're fun, easy to use, but do have a few complications. So
don't be afraid to call your surgical colleagues if you have any questions.