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

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.

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

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

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.

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.

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.

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.

Record any problems or complications that occurred during the procedure.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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

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

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.

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

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.

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.

Alternative techniques to check for tube placement are:

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

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.