Rosen & Barkin's 5-Minute Emergency Medicine Consult (267 page)

Increased risk of aspiration:

• Delayed gastric emptying
  
• Immaturity of lower esophageal sphincter
  

DIAGNOSIS

• Extubation:
  
  • Tube removed from source
    
• Occlusion:
  
  • Unable to pass liquid through tube
    
• Tube migration:
  
  • Distal displacement of PEG tube
    
  • Obstruction at or distal to pylorus
    
  • Dumping syndrome
    
  • Ischemia
    
  • Intussusception
    
  • Evidence of distal prolapse on external tube (if marked)
    
• Peristomal wound infections:
  
  • Cellulitis
    
  • Abscess formation
    
  • Necrotizing fasciitis
    
• Stoma leak:
  
  • Leakage of feedings/GI tract contents around stoma
    
• Aspiration pneumonia:
  
  • Cough
    
  • Dyspnea
    
  • Hypoxia
    
  • Food particulate in pulmonary secretions
    
  • Fever
    
• Misplacement of nasoenteric tube in pulmonary tree:
  
  • Pneumothorax
    
  • Hydrothorax
    
  • Pleural effusion
    
  • Bronchopleural fistula
    
  • Pneumonia
    
• Diarrhea:
  
  • Frequent loose stools
    
  • Dehydration
    
• Intolerance to enteral nutrition:
  
  • High residuals
    
  • Associated with increased risk of aspiration
    

• Carefully examine the tube site and position of feeding tube within wound
  
• For suspected tube migration, obtain a water-soluble contrast radiography of the tube to establish the tube position within the abdomen/stomach/intestine
  

• Peristomal wound infections:
  
  • CBC for significant infections
    
  • Blood culture if systemically ill
    
• Aspiration pneumonia:
  
  • Pulse oximetry or arterial blood gas
    
  • CBC
    
  • Electrolytes, BUN/creatinine, glucose
    
  • Blood and sputum culture
    
• Diarrhea:
  
  • Stool for white blood cells/culture/
    C. difficile
    toxin
    
• GI bleeding
  
  • Serial CBC
    

• CXR:
  
  • Nasoenteric tube position
    
  • Aspiration pneumonia
    
• Water-soluble contrast radiography for suspected tube migration
  

Endoscopy to evaluate for tube migration

TREATMENT

• ABCs
  
• IV fluid resuscitation for dehydration/sepsis
  

• Nasoenteric tube:
  
  • Replace in emergency department
    
  • Confirm position by radiograph before use
    
• PEG tube and gastrojejunal (G-J) tube:
  
  • Takes 4–6 wk for gastrocutaneous tract/fistula to mature
    
  • Improper or aggressive attempt at tube replacement could lead to disruption of gastrocutaneous tract and subsequent peritonitis
    
  • PEG tube in place >4 wk:
    
    • Replace in emergency department (may use a Foley catheter of equivalent size)
      
    • Confirm by water-soluble radiographic study
      
    • Secure catheter to abdominal wall to prevent distal migration
      
  • PEG tube in place <4 wk:
    
    • Do not replace in ED
      
    • Risk of intraperitoneal placement
      
    • May need hospital admission and endoscopic tube replacement
      
  • Surgical G tube or J tube:
    
    • Management similar to that for PEG tube
      
    • Early dislodgment within 1st 3 days requires emergency surgical consult and antibiotic coverage for peritonitis
      
    • May need endoscopic replacement if <4 wk old
      

• Attempt gentle irrigation with NS, water, carbonated soda, pancreatic enzymes
  
• If irrigation fails, replace tube
  
• Do not use meat tenderizer
  

• If retraction of tube is possible and well tolerated:
  
  • Secure tube externally
    
  • Discharge home after brief trial of tube feeding
    
• If feeding is not tolerated, or if there are signs of persistent obstruction or peritonitis:
  
  • Admit with consult to appropriate service (surgical/GI).
    
• If external tube is cut (accidental or intentional) and the inner tube is within the abdomen:
  
  • Inner bumper usually passes through GI tract
    
  • Cases of obstruction, subsequent perforation, and peritonitis have been reported, especially in children
    

• Local wound care
  
• Antibiotics:
  
  • 1st-generation cephalosporin (cefazolin or cephalexin)
    
  • Ampicillin/sulbactam
    
  • Amoxicillin/clavulanic acid
    
  • Clindamycin (penicillin allergic)
    
• Outpatient management for milder cases
  
• More severe cases require surgical consult for possible drainage/debridement and inpatient care
  
• Prophylactic use of antibiotic (cefazolin) before tube placement decreases wound infection (3% vs. 18%)
  

• Change from intermittent to continuous delivery
  
• Decrease rate of infusion
  
• Optimize nutritional status
  
• Relieve excess tension on tube
  
• Administer prokinetic agents (e.g., metoclopramide)
  
• Do NOT place larger tube
  
• Local care:
  
  • Keep site clean and dry
    
  • Barrier creams
    

• Stop enteral feeding
  
• Administer oxygen and broad-spectrum antibiotics
  
• Endotracheal intubation with mechanical ventilation for respiratory failure and airway protection when indicated
  
• Prevent by:
  
  • Elevation of head of bed
    
  • Monitoring gastric residual
    
  • Use of continuous infusion at graduated rate
    
  • Use of prokinetic agent
    

• Manage cause
  
• Correct fluid and electrolyte imbalance
  
• Try isotonic, hypotonic, or fat- or lactose-free formulas
  
• High-fiber formula if above measures fail
  
• Antimotility agents:
  
  • Loperamide
    
  • Kaopectate
    
  • Cholestyramine
    

Prokinetic agents promote gastric emptying

• Amoxicillin/clavulanic acid (Augmentin): 500–875 mg (peds: 25–45 mg/kg/24 h) PO q12h
  
• Ampicillin/sulbactam: 1.5–3 g (peds: 100–200 mg/kg/24 h) IV q6h
  
• Cefazolin (Ancef, Kefzol): 500 mg–1 g (peds: 25–100 mg/kg/24 h) IV q6h
  
• Cephalexin (Keflex): 250–500 mg (peds: 25–50 mg/kg/24 h) PO q6h
  
• Cholestyramine: 2–4 g (peds: >6 yr 80 mg/kg q8h) PO q6–12h
  
• Clindamycin: 150–300 mg (peds: 5–10 mg/kg) IV q6h
  
• Kaopectate: 30 mL (peds: 3–6 yr old, 7.5 mL; 6–12 yr old, 15 mL) PO after each loose bowel movement up to 7 times per day
  
• Loperamide (Imodium): 4 mg initially, then 2 mg (peds: 1 mg q8h if 13–20 kg; 2 mg q12h if 20–30 kg; 2 mg q8h, if >30 kg not to exceed 9 mg/d) PO up to 16 mg/d
  
• Metoclopramide: 5–10 mg (peds: 0.1–0.2 mg/kg to max. 0.8 mg/kg/d) PO/IV/IM q6h (30 min before feeds and every night)
  

FOLLOW-UP

• PEG tube extubation within 1 wk of placement
  
• Surgical G tube or J tube extubation within 3 days of placement
  
• Significant peristomal wound infection
  
• Aspiration pneumonia
  
• Diarrhea associated with dehydration
  
• Active GI bleeding
  
• Peritonitis
  

Successful replacement of extubated feeding tube

GI consult or surgical consult for feeding tube replacement when cannot be placed successfully in the emergency department

Primary care or GI follow-up for recurrent feeding tube complications

• Radiography should be used to confirm placement of all feeding tubes
  
• Do not attempt replacement of a newly placed PEG tube, G tube, or J tube in the ED
  

• Metheny NA, Meert KL, Clouse RE. Complications related to feeding tube placement.
  Curr Opin Gastroenterol
  . 2007;23:178–182.
  
• Niv E, Fireman Z, Vaisman N. Post-pyloric feeding.
  World J Gastroenterol
  . 2009;15(11):1281–1288.
  
• Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review.
  J Gastrointestin Liver Dis
  . 2007;16(4):407–418.
  
• Stayner JL, Bhatnagar A, McGinn AN, et al. Feeding tube placement: Errors and complications.
  Nutr Clin Pract.
  2012;27(6):738–748.
  

CODES