Nursing Management of Percutaneous Endoscopic Gastrostomy and Jejunostomy (PEG/PEJ) in Adult Patients Summary Title

Publication Date: July 1, 2018
Last Updated: March 21, 2023

Rrecommendations

1: Patient Preparation for PEG/PEJ Procedures and Perioperative Monitoring

Guidelines suggest that the patient should have fasted for over 6 hours for solid food and 2 to 3 hours for fluids. Refer to your facility’s guidelines or protocols for recommendations regarding fasting prior to PEG/PEJ tube placement.

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Several interventions are recommended for prevention of infection at the tube placement site. The first is antibiotic prophylaxis administered 30 minutes before the procedure.

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Th e second is use of a mouthwash with an oral chlorhexidine solution to reduce bacterial burden.

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Preoperative hair clipping is also recommended if hair in the area of tube insertion, which is likely to interfere with the procedure. Use of an electric shaver is recommended.

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Application of standard measures for infection prevention is recommended including aseptic preparation of the surgical field and preoperative handwashing. In order to reduce the risk of colonic perforation, the patient should be positioned in a reverse or anti-Trendelenburg position during the procedure.

(D-GPP, )
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Checklists that serve as reminders of all steps prior to tube placement including identification of the patient, written informed consent, fasting, peripheral venous access, antibiotic prophylaxis, management of the antithrombotic/anticoagulant therapy, oral hygiene, hair removal, and patient positioning are recommended.

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During tube placement, routine monitoring of the patient’s heart rate, blood pressure, pulse oximetry, and body temperature is recommended in order to promptly recognize and reduce negative outcomes arising from hypoxemia and hypercapnia during sedation.

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Record any problems or complications that occurred during the procedure.

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Monitoring During the Initial 72 Hours After EN Tube Placement

We recommend monitoring heart rate, blood pressure, temperature, respiratory frequency, oxygen saturation, presence of pain, nausea, and grade of sedation every 15 minutes for the first 3 hours following EN tube placement. If the patient is stable, vitals may be monitored every 30 minutes for the next 3 hours. If the patient continues to be stable, monitor the vitals every 6 hours for the next 12 hours. Due to the expected difficulties in performing such intensive monitoring, we acknowledge that the level of monitoring may vary based on care setting and techniques used for EN tube insertion.

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We also recommended using the “red flag alerts” identified by the National Patient Safety Agency, a system used to report adverse events to the British National Health System. The red flag alerts are:

(1) severe pain not responding to routine analgesics or increasing when the tube is used for washing or infuse fluids;
(2) active bleeding (small bleeding is normal after the procedure and may require an adequate dressing), discharge of gastric fluid, or mixture nutrient from the stoma;
(3) a sudden change in the individual’s vital signs or clinical condition; and
(4) a sudden change in level of consciousness or behavior.

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We recommend that any type of administration through the tube should be discontinued and the physician notified promptly, should any of these signs occur during the first 72 hours following tube placement.
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We recommend using the length of the external tube at the skin level or indelible mark affixed as a reference point. This point should be compared to the length reported in the clinical documentation after its placement. The exit site should also be assessed for signs of inflammation, infection, hypergranulation tissue, pressure injury, or erosion. Document each mark detected and the treatment undertaken.

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Section 2: Management of the Stoma and Tube

Care should be taken to avoid creating too much distance between the external fixer and the skin to prevent fixation of the gastric wall to the abdominal wall and formation of a gastrocutaneous fistula. Proper placement also prevents/avoids excessive tube movement and unintended enlargement of the stoma.

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The clinician should mark the exit point of the tube from the abdominal wall with a permanent marker. This action allows identification of dislocation of the tube; daily checks of tube placement are recommended.

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Assess the stoma and peristomal skin daily for signs of inflammation, infection, pressure injury, bruises, and hypergranulation tissue. Document results of assessment and treatment used to manage stomal or peristomal complications.

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Several authors suggest placing the dressing above the external fixer to avoid excessive tension between the fixation device and the skin. This arrangement also enables the dressing to absorb any peristomal leakage. If the exterior fixer is placed 5 mm above the skin, the dressing can be placed under the bumper, if not too thick.

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Rotate the position of the gastrostomy tube 360° after the first 24 hours to prevent adhesion, and repeat this maneuver at least once weekly, but no more than once daily, to prevent BBS.

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We recommend against rotating jejunal tubes in order to avoid perforation. If the external fixation device of a PEGJ is not stitched in place, it is anchored by an internal fixation device. The external fixation device can be released, and the stoma cleaned. We also recommend avoiding rotation of a PEGJ because the jejunal extension lacks a retaining disc and rotation could displace the tube.

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In addition to rotation of the PEG tube described earlier, the risk of BBS may be reduced by gently pushing the EN tube into the stomach 2 to 3 cm after loosening the exterior fixer, and then gently pulling it back until it reaches the area of minimal resistance (the internal gastric wall). The maneuver should be repeated at least once weekly, and no more than once daily. This push/pull maneuver should not be initiated until 7 to 10 days after initial insertion of a PEG tube, when the gastrocutaneous tract has healed.

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A gastric tube with a retention balloon should be inflated with distilled water to prevent precipitation of salt or encrustations with subsequent failure of balloon deflation. Clinicians should follow manufacturer’s recommendations concerning inflation and deflation of retention balloons.

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Check the volume of fluid in the balloon (to prevent accidental dislocations of the tube), and the clarity of the solution (to highlight possible losses) once weekly. If precipitate is noted, the tube should be replaced and the retention balloon filled with distilled water.

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Administering Nutrition and Drugs

Enteral nutrition can be initiated as soon as 4 hours after PEG/ PEJ placement.

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Start with 50 mL of pure water and assess the patient for any red flag alerts during the first hour following administration.

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Before administering EN, verify the correct placement of the tube by assessing the length of exposed tubing as described previously.

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Use disposable gloves when administering nutrition and replace the nutritional set every 24 hours.

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Irrigate the EN tube with 15 to 30 mL of pure water every 4 to 6 hours (when continuous nutrition is administered), or after each bolus injection of EN or administration of drugs to prevent tube obstruction. Jejunal tubes tend to have smaller calibers than gastric tubes, and particular attention should be paid to strategies to avoid obstruction.

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Use sterile water in immunocompromised or critical patients if there are concerns about the safety of the pure water.

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Implement a protocol to maintain the patency of the PEG/PEJ tube in people with restricted fluid intake.

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Monitor gastric residual volume and emptying time every 4 hours during the fi rst 48 hours of continuous EN or before every bolus when administering intermittent EN in patients with PEG to prevent nausea, reflux, abdominal distension, and aspiration pneumonia. Do not stop EN if the residual volume is less than 500 mL. Rather, monitor these individuals every 6 to 8 hours.

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Preventing Reflux or Aspiration of Gastric Contents

In the absence of contraindications, elevate the head of the bed 30° to 45° to prevent reflux or aspiration of gastric contents and maintain this position for at least 1 hour after the end of the administration.

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This recommendation is also strongly supported by a 2011 Spanish Society of Parenteral and Enteral Nutrition consensus document and 2009 American Society of parenteral and Enteral Nutrition guidelines for prevention of the gastric reflux and aspiration pneumonia together with the postpyloric EN, the use of prokinetic drugs and oral hygiene with chlorhexidine gluconate.

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We recommend placing the patient who cannot tolerate a semi-Fowler position in a reverse- or anti-Trendelenburg position.

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Monitor gastric residual volume and emptying time every 4 hours during the first 48 hours of continuous EN or before every bolus when administering intermittent EN in patients with PEG to prevent nausea, reflux, abdominal distension, and aspiration pneumonia. Do not stop EN if the residual volume is less than 500 mL. Rather, monitor these individuals every 6 to 8 hours.

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Modality of Drug Administration

Administer drugs given via EN separately from nutritional preparations to avoid interactions, obstruction of the tube, or altered absorption and onset of action of drugs. Administer drugs labeled as “for oral use only” whenever possible.

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Whenever possible, select a liquid formulation of a particular drug or crush and dissolve tablets in pure water.

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Stop EN before the administration of drugs and irrigate the tube with 15mL of lukewarm water. At the end of the administration, irrigate the tube with the same quantity of water. Wait 30 to 60 minutes before restarting EN.

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Use medical devices specifi cally designed for enteral and avoid devices designed for parenteral administration.

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Refer to national, regional, or facility policies for prevention of errors in enteral administration. In the United States, the Joint Commission on Accreditation of Healthcare Organizations and the National Patient Safety Agency provide guidelines concerning prevention of errors when administering enteral versus parenteral nutrition. In Italy, the Minister of Health has recommended use of enteral devices consistent with European standards.

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3. Nursing Management of Common Complications

Because of the risk for bleeding associated with PEG/PEJ procedures, the patient should be screened preoperatively for bleeding disorders and for use of anticoagulant/ antiaggregant therapy.

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Leakage from around the EN tube may result from enlargement of the stoma due to traction on the tube, weight loss, underinflation or rupture of the internal bumper, increased abdominal pressure, higher residual gastric volume, and BBS. Prevention of leakage includes securing the tube in a manner that avoids excessive traction, regular adjustment of the internal bumper, replacement of the tube before degeneration, prevention of constipation, treatment of coughing, and control of residual gastric volume. Do not replace an EN but with a larger tube, since this may cause enlargement of the tract, resulting in exacerbation of the leakage.

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Peristomal moisture-associated skin damage may be caused by poor placement of the tube, excessive traction or laxity of the fixers, and contact of the gastric fluid with the skin. Protect the skin with a nonocclusive dressings, keeping it clean and dry, and change the dressing frequently.

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Hyperhydrated and infl amed skin promotes growth of coliform microorganisms. Regular cleansing of the skin and antibiotic prophylaxis are fi rst-line interventions preventing cutaneous infections. Secondary prevention is based on early detection of signs and symptoms of infection such as loss of skin integrity, erythema, purulent and/or malodorous exudate, fever, and pain. Routine skin care and antimicrobials are also used to treat peristomal cutaneous infections.

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Medical device-related pressure injuries may occur. Regularly assess the position of the external disc of the fixation device and readjust it to 5 mm from the abdomen when indicated. Rotate EN tubes regularly and regularly assess tube placement to reduce the risk for pressure injuries. Consider the effects of changes in body weight on pressure injury risk.

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Peristomal hypergranulation tissue may form in response to excessive humidity and friction. Prevent its formation by cleansing the peristomal skin at least once daily and minimize friction from the EN tube on the stoma by stabilizing the tube and its extensions. Local treatment includes application of nonocclusive dressings such as polyurethane foam under the external fixer or use of antimicrobial agents like polyhexanide. If these treatments do not lead to satisfactory results, refer to physician to consider alternative treatments such as topical corticosteroids or silver nitrate.

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Occlusion of the EN tube causes slowing or interruption of delivery of nutritional or other agents through the tube. Obstruction also may be attributable to viscosity of infused solutions, caliber of the tube, formation of biofilm or encrustation within the lumen of the tube, or insufficient irrigation following administration of nutritional preparations or drugs. Preventive interventions include regular irrigation with water as described previously and following the manufacturer’s recommendations when constituting and administering nutritional or pharmacologic agents. If occlusion occurs, implement the following recommendations in this order:

(1) irrigate the EN tube with lukewarm water using a gentle “push and pull” technique;
(2) if this strategy fails to reverse occlusion, use an 8.4% NaHCO 3 solution; and
(3) if strategies 1 and 2 fail, irrigate with pancreatic enzymes diluted in water plus NaHCO3 solution closing the tube for 5 to 10 minutes.

If all these strategies fail, use a brush to mechanically dislodge obstructing materials. Do not use sodas or cranberry juice, since they can worsen the occlusion.

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If the occlusion is due to fungal infection, the tube must be replaced.

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Tube dislocation, defined as unintended movement out of the stoma, toward the esophagus or toward the pylorus/duodenum, may occur, resulting in obstruction. Prevent dislocation by regular assessment of the external fixation disc. Assess its mechanical seal, length of the exposed tube, and volume of fluid in the retention balloon. All must be consistent with parameters documented after tube placement.

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Gastrostomy tubes for EN should be regularly replaced every 4 to 6 weeks. If the tube is unintentionally dislodged, attempt reintroduction. If a replacement gastrostomy tube is not available, an indwelling urinary catheter may be gently inserted until a new gastrostomy tube can be placed.

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Consult the physician immediately if a jejunal or gastrostomy tube is dislocated within 4 weeks of placement. Under these circumstances, replacement should occur under endoscopic or radiological guidance.

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In the case of pyloric or duodenal migration (indicated by a diff erent length of the tube at skin level to that reported after its placement), gently manipulate the tube back into its original position.

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Buried bumper syndrome is caused by excessive traction of the tube and/or fixers resulting in ischemia and necrosis of the gastric epithelium and migration of the internal fixer into the gastric wall. Prevent BBS by maintaining a minimum distance between the internal and external fixation devices in such a way that the external one should be separated from the skin of at least 0.5 cm, daily to weekly rotation of the tube, and retraction of the tube.

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In the case of BBS, the tube must be removed and may require endoscopic guidance when replaced.

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Rare complications associated with EN include necrotizing fasciitis, gastrocolic fistula, and peritonitis. Necrotizing fasciitis is a rare but serious complication of EN tubes characterized by erythema and edema, high fever, cellulitis, septic shock, and death. Preventive strategies include avoidance of excessive traction between the internal and external fixer and maintaining the external fixer at 0.5 cm from the skin plane.

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Section 4: Education for Patients and Caregivers

Provide written instructions about care of the EN tube. Ensure educational materials are clear and written at an appropriate level for patients and lay care providers. Incorporate photographs and diagrams into educational materials whenever indicated. Provide a replacement EN in case of dislocation and key telephone contacts.

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Advise patients and caregivers to stop the EN infusion immediately and seek professional advice if the patient experiences pain during nutritional infusion, prolonged pain after the procedure, passage of nutritional fluids or drugs through the stoma, or bleeding.

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Patients and caregivers should be taught all pertinent procedures regarding the administration of EN or drugs along with techniques for connecting and disconnecting all tubes and connectors.

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Counsel patients about oral hygiene and care. The teeth and gums should be brushed twice daily with a toothbrush and toothpaste.

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Document scheduled and unplanned tube replacements along with characteristics of the tube and aspirated materials.

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Section 5: Tube Replacement and Methods to Assess Tube Position

All tubes should be replaced according to the manufacturer’s directions.

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Prior to routine (anticipated) tube replacement, the patient should refrain from fluid intake for 2 hours and nutritional intake for 4 hours. Administer only essential drugs during this period.

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We recommend performing the first planned tube change in a clinic or hospital environment.

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After initial healing of the stoma (at least 1 month from the first tube placement), replacement may be completed in the home care setting by patients themselves or by a nurse if patients are not able to perform it.

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Gently insert the new tube in the fistula, verifying the correct positioning in the gastric cavity. Radiographic or endoscopic imaging is considered the gold standard for confi rming placement of EN tubes.

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Alternative techniques to check for tube placement are:

(1) aspiration of gastric contents and confirmation that the pH is 5 or less.

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(2) irrigation of the tube with 3 to 50 mL of sterile water without resistance or leakage from around the stoma.

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(3) assessment of the external length of the tube and.

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(4) manipulation of the tube via rotation and in-out movement.

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Do not introduce air through the tube while listening to peristalsis. This technique has proved unreliable for confirmation of tube placement. Specifically, it was failed to distinguish whether peristalsis originated from the stomach or intestine.

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Recommendation Grading

Disclaimer

Overview

Title

Nursing Management of Percutaneous Endoscopic Gastrostomy and Jejunostomy (PEG/PEJ) in Adult Patients

Authoring Organization

Publication Month/Year

July 1, 2018

Last Updated Month/Year

January 10, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospice, Long term care, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D007582 - Jejunostomy, D005774 - Gastrostomy

Keywords

enteral nutrition, Feeding tube, gastroenterology, Percutaneous Endoscopic, Gastrostomy, Jejunostomy, (PEG/PEJ), nasogastric tubes, nursing management