NG/OG tube placement can be verified by the aspiration of gastric contents with a pH < 4.0. However, be aware that medications can change the gastric pH, and in a patient with reflux, an esophageal aspirate may have the same pH as a gastric aspirate. Likewise, the aspiration of “gastric fluid” does not confirm gastric placement alone because there is fluid within the bronchial tree and distal esophagus that resembles gastric fluid. In addition, lack of fluid aspirate can lead to falsely believing the tube is not in the stomach when the tube collapses or is above the fluid level. Finally, auscultation is an unreliable method of determining NG/OG tube placement because the sound of an NG tube in the thorax may transmit to the upper abdomen. X‐ray confirmation remains the gold standard for NG/OG tube placement in both adult and pediatric patients.
Bedside placement of ND and NJ feeding tubes is still controversial; however, there are increasingly more studies supporting this practice. Most research has focused on the placement of ND tubes. ND tube placement is similar to NG tube placement; however, the patient is kept in the right‐lateral decubitus position. Several adjunctive measures have been described including the use of promotility agents and gas insufflation to promote tube position past the pylorus. Of note, these techniques are better described in the adult patients and less so in pediatric patients. All post‐pyloric feeding tubes should be confirmed with an X‐ray prior to use.
G‐tubes and GJ tubes
G‐tubes may be replaced by a caregiver following the first tube change and at least four weeks from initial tube placement (Table 1.4). Typically, a gastrostomy tube is changed every three to four months. G‐tube replacement should be confirmed with the aspiration of gastric contents and/or pH testing. The gold standard for G‐tube confirmation is a fluoroscopic dye study whereby dye is injected through the G‐tube port and a radiograph is taken to verify dye positioning in the stomach. If there is any trauma to the G‐tube site or if the tube is considered an immature tube (<4 weeks from placement), aspiration of gastric contents and pH testing are inadequate, and the tube site should be verified with a fluoroscopic dye study.
Table 1.4 Gastrostomy‐tube replacement.
| Supplies |
| G‐tube low profile button with extension tubingOrTraditional G‐tubeLuer slip tip syringe to inflate balloonLarger catheter tip syringe to prime and flush tubingOptional:G‐tube port stylet |
| Stepwise procedure |
| Deflate the G‐tube gastric balloon with a 10 ml syringe.Gently remove the G‐tube by holding the port site and steadily pulling it back.Keep stoma patent with a Foley catheter (do not exceed the G‐tube size).Remove the G‐tube from packaging and check balloon by filling it with tap water (do not fill with normal saline as this will degrade balloon and do not use air as it will not provide adequate tension on the balloon).Deflate balloon prior to tube insertion.Insert the G‐tube stylet, if one is provided.Lubricate the tube with sterile jelly (do not use petroleum jelly as it will degrade tubing).Direct the G‐tube into the stoma and apply steady pressure.Stop and reposition if you meet resistance.Once the G‐tube external base is resting on the skin surface, inflate the balloon.Confirm positioning by pulling gently on the port site. |
GJ tube must be placed by interventional radiology under fluoroscopy to ensure proper placement for both the initial placement and any subsequent tube replacement. GJ tubes are replaced every six months.
Complications/Emergencies
Tube Dislodgment
Tube dislodgment is a common emergency department chief complaint in both adults and children. This can occur because of coughing, gagging, pulling on the tubing, or getting the tubing caught around an object. In all cases, stop the feeding and inquire how long the patient can maintain his or her blood sugar without feeding. Hypoglycemia is a common complication for patients who are accustomed to receiving continuous feeds, and an infusion of dextrose‐containing IV fluids is commonly needed while awaiting feeding tube replacement. Replacement follows an algorithm based on the type of enteric feeding device and the duration since its initial placement (Figure 1.2). Unfortunately, tube replacement is not without risk, and the astute provider must be aware of clinical signs of an improperly positioned tube and how to best verify tube placement.
NG tube replacement is a simple procedure, and some patients may even replace their own NG tubes nightly; however, it is not without risk. Complication rates range from 1 to 2% in adults and up to 20–40% in pediatric patients, with higher rates seen in neonatal patients. Complications with improper NG tube placement include pneumonia if the tube is placed in the lungs and peritonitis if the tube perforates the bowel. Given this high complication rate, all NG tube replacements in the emergency department setting should be confirmed with a radiograph. Auscultation, enzyme testing, and pH testing are unreliable.
G‐tube placement is an equally common emergency department procedure, and complication rates range from 0.6 to 20%, with higher rates seen in immature tubes and tubes with traumatic dislodgement. The definition of an immature tube is debated in the literature. Most studies define immature tubes as those less than four to six weeks from placement; however, some studies define immature tubes as those less than six months from placement. There is an inverse relationship between the age of the tube, and, therefore, G‐tube tract healing, and the complication rate. In addition, patients who are symptomatic postreplacement are more likely to have a G‐tube complication. Complications include gastric outlet obstruction and intraperitoneal tube placement.
All G‐tube replacements can be completed at the bedside; however, the person performing the procedure and the method of checking placement are dependent on the age of the tube and the patient's presenting symptoms. The first tube change postoperatively is the most critical and should be completed by the subspecialty service responsible for the tube's placement. In addition, any stoma site with significant trauma or stoma that is difficult to identify should be evaluated by general surgery. Uncomplicated mature G‐tubes can be replaced at the bedside by the emergency department team, and placement should be confirmed with gastric aspirate and pH testing alone. For patients with immature tracts, trauma to the stoma site, or symptoms following G‐tube replacement, contrast‐enhanced radiograph is needed to confirm G‐tube placement prior to use. Extravasation of contrast dye on imaging and failure to fill the stomach indicates that the tube is improperly positioned.
Figure 1.2 Algorithm of the displaced enteric feeding device.
All transgastric jejunal tubes must be replaced
