Speaker 1Okay, in this class, we're going to talk about percutaneous tube management. Now, as wound nurses and ostomy nurses, we're not routinely consulted about percutaneous tube management. We're usually consulted when there's a problem like leakage, like skin irritation, like hypergranulation tissue formation. So that's going to be our focus, but we're going to spend a few minutes talking about commonly used percutaneous tubes, purpose for their use, how they're inserted, how they're stabilized, because that will give you the background you need to manage these tubes more effectively. So we'll talk about that. Thank you. So we'll talk about common tubes. We'll talk about how to manage them. We will focus heavily on the importance of two-point stabilization, ideally, both internally and externally, and we'll talk about complications and complication management. G-tubes are almost always the most problematic of percutaneous tubes, so when I ask people, "How many percutaneous tubes do you use?" They say, "We use about 90% plus percutaneous tubes." So we'll talk about that. So we'll talk about the different types of percutaneous tubes. So you know why we use G-tubes, either to provide long-term continuous or intermittent decompression. So if a patient has a blockage distal to the stomach, then a lot of times we'll put in a G-tube because it's so much more comfortable than a nasogastric tube, and we can just keep the stomach decompressed. So we do this for some of our patients with late-stage malignancies, causing obstruction distal to the stomach. Some patients keep it open and draining all the time. Other patients close the tube unless they start feeling full or sick, and then they open it. More commonly, G-tubes are used for long-term access to the stomach for feeding. And a patient who can't. cannot take in enough nutrients orally, but who has a normal small bowel, so if we can get the nutrients to the stomach, they will pass normally into the small bowel, and they will get normal digestion and absorption of those nutrients. Now, there are two major types of G-tubes. The first is balloon-tipped silicone catheters. So you see a lot of those. If a patient's taken to surgery. and they have an open procedure, most of the time they're going to place a silicone tube. It's going to be a balloon-tipped catheter. The reason we use silicone tubes almost exclusively now is because they're much more resistant to incrustation, and they're much less likely to cause soft-tissue inflammation. They're a great choice for fairly long-term tube patients. placement and management. But more commonly, we're going to see patients who start out with PEG tubes. PEG tubes, percutaneous endoscopic gastrostomy tube. So it's a much less invasive approach to G-tube placement. So that's why we see many more PEG tubes, at least for initial insertion. And then many times down the road, we'll remove the PEG tube and place a silicone balloon tip tube in that tract. So let's go through how they place a PEG tube. Probably a lot of you know this. I didn't know it until I got involved with this and it was very helpful to me. So I'm going to explain to you how they do it. So it's a two-person team. It's an endoscopist and an assistant. So the endoscopist numbs the throat, puts down the endoscope, inspects the gastric wall, identifies a site along the gastric wall that is a great place for tube placement, and then uses the light on the scope to illuminate that site. Then the assistant infiltrates that site with lidocaine and makes a small incision. Once they make a small incision, they pass a heavy trocar in the throat and through that incision. And the trocar has either a silk suture or a wire. So now I've poked this needle or trocar through the abdominal wall into the stomach with the silk suture or the wire. The endoscopist then uses the snare on the scope to grab the wire or the silk thread. And then the endoscopist uses the snare on the scope to grab the wire or the silk thread and then the endoscopist then uses the snare on the scope to grab the wire or the silk thread and then the endoscopist then uses the snare on the scope to grab the wire or the silk thread and pulls that wire or silk thread all the way out and pulls that wire or silk thread all the way out through the mouth. So now I essentially all the way out through the mouth. So now I essentially have this very long piece of floss through the mouth. So now I essentially have this very long piece of floss that goes from outside my mouth, have this very long piece of floss that goes from outside my mouth, through my mouth, down the esophagus, that goes from outside my mouth, through my mouth, down the esophagus, out the stomach. through my mouth, down the esophagus, out the stomach. At that point, they can attach the tube, out the stomach. At that point, they can attach the tube, the peg tube, to that wire At that point, they can attach the tube, the peg tube, to that wire or that silk suture. the tube, the peg tube, to that wire or that silk suture. And then the assistant starts pulling the wire or the silk suture, so they pull the catheter all the way down through the esophagus out the stomach. And on the end of the catheter, there's a soft bumper that stabilizes the tube internally. So bottom line, this is a minimally invasive, very safe, very short procedure that establishes gastric access. And so PEG tubes have become pretty much the standard for G-tube placement in the vast majority of patients. In the pediatric population, the most commonly used device is a skin-level device like the MIC-KEY. And you can see exactly how these work. So in some settings, they do an analysis. And in some settings, they do an analysis. And in some settings, they do an initial PEG tube placement, and then they replace the PEG tube with the skin-level device. But in talking to nurses in pediatric settings, they're telling me that the trend is just to make this device the initial placement. So with the skin-level device, they're going to do a measurement of the depth between the abdominal surface and the gastric wall. And then they're going to select a device that is a good fit, because what you want is a snug fit. You want the balloon up against the gastric wall, and you want the top of the tube sitting right at skin level. You don't want any traction against the skin if the tube's too short, and you don't want the tube moving in and out because it's too long. So having an appropriately fitted tube is critical. So it needs to be secured at gastric wall and at the abdominal surface. It's maintained at the gastric level with a balloon. You have a one-way valve and a special adapter that you can attach at skin level to permit feeding, and then you can remove to prevent backflow of secretions. Now, this is a very common problem in the population, because children will grab tubes and pull them out. But with the skin-level device, it's hard for them to get hold of it. They don't really have anything to grab. And so skin-level device plus a onesie or a wrap usually gives you a pretty secure gastric access device. What about jejunostomy tubes? When we talked about anatomy of the GI tract, we talked about the GI tract, we said that your greatest absorptive capacity is at the level of the jejunum. And we pointed out that frequently, we place feeding tubes to the level of the jejunum, where we have very tall villi ready to absorb all those nutrients. So we can place tubes into the jejunum, and we can feed directly into the jejunum. It's the optimal site for absorption of most of your nutrients. The other good thing about placing a tube into the jejunum rather than the stomach is now we've bypassed the pylorus, and we really don't have to worry about reflux and aspiration pneumonia. So if that's an issue, many times they'll feed the tube past the stomach, past the duodenum, into the jejunum. So jejunostomy tubes are widely used for long-term from feeding. you'll have a GJ tube, and that is the gastrostomy tube with a jejunal extension, and that allows you to simultaneously drain and decompress the stomach while feeding into the jejunum. So that can be a great choice for patients who have a relatively healthy small bowel. They have the capacity to absorb nutrients. They have persistent problems with gastric acne, with gastric distension, with nausea and vomiting. So a GJ tube is designed to address gastric decompression, jejunal feeding with one device. One thing that's really important to know about jejunostomy tubes is they are almost always secured at skin level, with sutures. They are not typically secured at the intestinal level. They are not usually balloon-tipped tubes. So if you have a GJ tube, you'll have a gastric balloon. You will not have a jejunal balloon, because if you did have a balloon, you'd have to worry that it would be at least partially occluding the lumen of the bowel. So that also means that if we're managing a patient with a jejunostomy tube, we have to maintain skin-level stabilization. If the skin-level sutures fail, we have to come up with something else, or we lose the entire tube. It falls out. So let's talk about gastrostomy and PEG tube management. So site care is very simple. Clean the site daily with mild soap, warm water. That can help reduce the risk of gastric cancer. And if you're using a tube that keeps the skin clean and dry, so you get good stabilization at skin level. Peroxide use on a daily basis is discouraged. It can actually contribute to hypergranulation tissue formation. So just warm water and soap, and then rinse and dry. Critical to stabilize the tube at skin level. Use the bumper correctly. So I remember when these bumpers first started appearing, none of us knew what they were for. And we would frequently pull the bumper away from skin level so it didn't cause any compression. Clearly we didn't understand. And then we had all of the problems associated with in and out, back and forth migration. So the goal is to have the internal balloon stabilized at the gastric wall. Have the external bumper stabilized at skin level to stop tube migration. We don't want in and out. We don't want back and forth. We want that tube held in position. So the laxity between the tube and the abdominal surface should be no more than one centimeter. And usually we try to keep it at 0.5 centimeters so that we don't get damaged to the gastric mucosa, we don't get damaged to the abdominal skin, but we also don't get that back and forth motion that causes all kinds of complications. Common question from staff, is it okay for me to use a split gall stressing underneath the bumper, between the bumper and the abdominal surface? I don't think so. I don't think it's okay to use a bumper in the skin? Yes. Can I use a foam dressing? Yes. You just want to maintain your two-point stabilization. So you can put your dressing down, but then you need to fit your bumper down so that the tube is held securely against the abdominal wall. Now most of the time gastrostomy tubes are not sutured into place. As long as they're not sutured into place, it's helpful to rotate the tube every day when you're doing site care so you break up any adhesions that are forming around the tube. That allows a sleeve of granulation tissue to form around the tube without getting wrapped around the balloon. So if the tube is not sutured in place, just rotate it very gently every day when you're doing site care. Obviously you can't do that if the tube is sutured in place. So we like to see situations where it's not sutured. Also if you have a balloon tip tube, you're going to deflate and re-inflate once a week. Remember your balloon tip tubes are typically your silicone tubes. Studies have shown that silicone balloons gradually leak down. So at the time of insertion, you filled that balloon with the recommended 20 milliliters of water. What you don't realize is every week you have less water in the balloon and less effective stabilization at the gastric wall. So very helpful to set up a protocol where every Wednesday or whatever day you pick, anyone caring for a patient with a balloon-tipped gastrostomy tube takes a syringe, attaches it to the inflation port, allows the balloon to deflate. You don't do it actively, you allow it to deflate. Fills the syringe with the recommended volume and re-inflates the balloon. That's recommended standard of care. Now let's talk about biliary tubes. When would we use a biliary tube? Where does it go exactly? Well, these are very small, narrow caliber tubes. These are very small, narrow caliber tubes polyurethane that are inserted under fluoroscopic guidance into the biliary tree. So that is the common bile duct. And what we're trying to do is we're trying to decompress the biliary tree. If you have blockage and the biliary trees become distended with bile, what we want to do is provide ongoing drainage and decompression. So that's appropriate for any patient who has denotation of the biliary duct. So that's appropriate for any patient who has denotation of the biliary tree. Obstruction of the common bile duct. So they can put in this tube to keep the biliary tree drained. Now as you can see here, it's usually secured internally via T-tube construction. So I'll talk about a T-tube and you can see the crossbar of the T. So the T fits within the common bile duct and allows bile to either flow through that T into the duodenum, if it's patent, or if you still have blockage, it flows out the long arm of the T into the drainage bag. So that's what a T-shaped biliary tube does. It supports the common bile duct, ideally allows bile to flow through, but when there's blockage, it provides for biliary drainage. And you can monitor the amount of biliary drainage to determine, is the edema, is the obstruction resolving? Do we have more bile going through and less bile coming out into the drainage bag? And typically these are stabilized at skin level again with a little disc, which is what you see there. Now managing biliary tubes, you may or may not be involved in managing these tubes. We've already said they're going to be secured at skin level, usually with a disc, sometimes with sutures, to prevent dislodgement, to prevent kinking. We usually do dressing changes once a week, no more frequently. Sometimes the surgeon orders sterile irrigation. And what they really mean, they say irrigation, but they really want you to flush the tube. When you're flushing the tube, the volume should be limited to 10 milliliters of sterile saline because the biliary tree cannot accommodate much fluid. You very gradually instill the fluid. You do not aspirate. It's very painful when you aspirate. And you're likely to pull small bowel contents into the biliary tree, causing contamination and infection, specifically cholangitis. So you just instill 10 milliliters sterile saline, sterile technique, very slowly. You would notify the surgeon who ordered the procedure if you could not flush the tube or if flushing caused pain or leakage. If we're sending patients home with biliary tubes, we want to educate them about routine care. What does the surgeon want done on a routine basis? What are the signs of infection? Pain, fever. Notify your surgeon. And what are the signs of blockage? Increased drainage through the tube into the bag. Inability to flush if that has been ordered. What about percutaneous tubes? We see more of those than we see biliary tubes. so those the nephrostomy tubes are placed directly into the renal pelvis and they're indicated for anyone who has blockage at the level of ureteral insertion into the bladder. So these are small polyurethane tubes inserted by the interventional radiology team through the skin into the renal pelvis to drain the kidney. They're typically secured within the renal pelvis as you see by pigtail configuration so they're straightened out inserted into the renal pelvis then the little guide is removed and that allows the pigtail configuration to reestablish itself which holds it within the renal pelvis. When the urologist is ready to remove the tube they can use steady pressure and it will straighten out the pigtail and permit removal of the tube. At skin level these tubes are almost always secured by some kind of commercial device and there are a number of commercial devices out there so here's one. So you can see that the tube would be secured it has a little block the tube fits into the block and then you cover it with the adhesive dressing. Site care, we start out cleaning and doing a dry sterile dressing change daily. Eventually we typically progress to dry gauze and a transparent adhesive dressing that will keep bacteria out and we usually change twice a week every three to four days. Critical to assure adequate fluid intake so that the renal pelvis is flushed the entire system is flushed we're flushing bacteria out. So how many times have you heard that during this course? Keep these patients hydrated is the best protection against infection. What about irrigation? We don't routinely irrigate these tubes. Anything that we instill through this tube is going straight to the renal pelvis. So we irrigate only if we have a specific order to do so but if the patient has a history of obstruction then the surgeon may very well order routine irrigations. If we do have an order for routine irrigations it's going to be low volume five to ten milliliters that's all the renal pelvis can hold. It's going to be instilled very slowly under sterile technique. We never force it. We do not aspirate because it's painful so we instill the fluid sterile technique and then allow it to drain by gravity. Long-term these tubes are typically changed every three months unless they become blocked and then they're changed sooner. Now looking at percutaneous tubes as a whole these are the most common complications. Dislodgement, they slide out of place. Skin irritation typically associated with leakage. Occasionally patients will develop cellulitis. It does go through the skin. There is the potential for soft tissue infection. Hypergranulation tissue and leakage and skin irritation. Those three skin irritation, hypergranulation tissue and leakage are almost always due to failure to maintain two-point stabilization. Allowing the tube to move back and forth in and out that enlarges the tract which permits leakage which causes skin irritation and that back and forth also causes hypergranulation tissue development. And finally obstruction or blockage which is why we sometimes have orders to instill or to flush routinely. So we want to prevent dislodgement. We never want the tube to fall out so the internal stabilization component is designed to prevent that. If you're talking specifically about gastrostomy tubes and about PEG tubes, they have the bumper or the balloon. Biliary tubes have the T-tube configuration. They don't tend to fall out. I don't think I've ever seen a biliary tube fall out. Nephrostomy tubes have the pigtail configuration. So when I think of dislodgement, I think primarily of PEG tubes and balloon tipped gastrostomy tubes. And most commonly is your balloon tipped gastrostomy tubes because if those balloons are not reinflated they do gradually deflate over time and then the tube can slide out of position. So again we've talked about deflating, reinflating weekly to help prevent that. For J-tubes, skin level stabilization is critical to prevent dislodgement. Remember J-tubes are typically not secured internally. So skin level stabilization is the only stabilization you have. Most of the time surgeons prefer sutures, but as you know sutures can pull loose. You can get a lot of irritation at the level of the sutures. So if the sutures are pulling loose, if they have acute inflammation, the suture needs to be removed. We have other options. We can use commercial stabilization devices. We can take a wafer for a two-piece ostomy system, put sutures through the flange and tie the sutures around the tube to hold it in place. We can come up with some way to stabilize that tube at skin level without causing all the pain associated with recurrence. We can come up with some ways to stabilize that tube at skin level without causing all the pain associated with recurrence. And then for all tubes, we need to be careful when we're repositioning patients so that we don't cause traction and we don't pull the tube out. You don't want to call the surgeon and report that event. Okay, so now let's talk specifically about complications for which we might be consulted, for which we might be rescheduled, for which we might be rescheduled, for which we might be responsible for management. So skin irritation, one of the most common complications associated with percutaneous tubes. And most of the time, skin irritation is associated with leakage. So it usually means that the tube is not effectively stabilized at both the internal and the external level, that you've got a tube moving back and forth, causing tract erosion, and allowing leakage. How do we prevent skin irritation? We do routine cleansing. We protect the skin right around the tube, and we maintain two-point stabilization. If they have irritation, we have to determine the cause. Is it leakage? If it is leakage, we probably need to pouch around the tube. And we'll come back to that. We will practice, pouching around a tube when you come onsite for bridge weight. When we have skin irritation around a tube, we can always do our crusting. So sprinkle on our ostomy powder, dust off the excess. Optional to use alcohol-free liquid skin barrier. You could also use a hydrocolloid dressing or a foam dressing right around the tube to help manage skin irritation. Cellulitis. Usually, we're not consulted on that. Occasionally, we are, and you'll see all of the classic signs of cellulitis. So acute erythema, induration, possibly purulent drainage, or a pustular lesion. They might have fever. They might have an elevated white count. This does not routinely occur, but what if you have a patient who's immunosuppressed, and now you've placed a tube, and you've created a pathway for bacterial migration. So yes, immunosuppressed patients sometimes do develop cellulitis. Occasionally, those with poorly controlled diabetes. Most likely to see this following initial placement or when the tube's been replaced. Signs and symptoms we just covered, and how are you going to manage? The physician has to be notified. They're going to need to drain any purulent collections, and they'll need an order for antibiotic therapy. So mainly, we come in, we say, "This isn't anything we can handle. This is cellulitis." I'm going to call the physician. We'll get the patient on antibiotics. About all we would have to offer is, after they drain any purulent fluid collections, we can recommend an antimicrobial foam, right? around the base of the tube. Hyper granulation tissue. Again a failure of two-point stabilization. We see a lot of this. Hyper granulation tissue leaks clear fluid. Sometimes you have bleeding. It's frequently very painful. I don't really understand why it's painful, but I know that it is. I've heard that from so many patients. So we have two approaches to management. If we're dealing with teens and adults, we can use silver nitrate sticks to cauterize the hypergranular tissue, and then we can put a silver foam dressing right around the base. We can repeat the silver nitrate as needed. Now if it's infants and children, we don't like to use silver nitrate because it's very hard to hold them still. We don't want to get it onto the intact skin. If they're outpatients, their parents are not going to want to use silver nitrate, and we're not going to want to teach them to do that. So instead we recommend a mid-potency steroid daily like triamcinolone. And of course critically important to initiate two-point stabilization so we interrupt the adiologic cycle. Keep that tube from moving back and forth. Leakage. We are the ones typically consulted for leakage. We are the appropriate people to consult for leakage. Again, it's almost always due to enlargement of the tract because the tube moved in and out and back and forth. You will need to pouch around the tube if there's any significant leakage. I'm going to go through the pouching procedure, but I will tell you you're going to practice this when you're here for Bridge Week. So you're going to select an ostomy pouch. You're going to size the opening in the pouch to clear the opening in the skin by at least an eighth to a quarter of an inch. You're going to take a piece of hydrocolloid wafer and you're going to put it on the front of the pouch because what we want to do is cut a hole in the front of the pouch so that we can feed the tube through the hole. And this will make great sense to you after you've done it. So I have my pouch. I'm going to put a piece of hydrocolloid right over the front of the pouch. Then I'm going to cut an X through the hydrocolloid and the pouch material. Now the reason we're applying the hydrocolloid is to reinforce the pouch material so it won't split when we cut that X. The size of the X is determined by the size of the tube and specifically by whether it's single lumen, double lumen, triple lumen. If it's a triple lumen, there's a lot more tube to pull through that X, so I have to have a bigger X. If it's single lumen, no, I can do a very small X. So once I have my pouch ready, I've cut out the opening so that it's big enough to fit around the opening in the skin. I've attached my hydrocolloid to the front of the pouch and I've cut my X. Now I'm going to clean the skin. I'm going to treat any skin damage. I'm going to peel the backing off. I'm going to take my tube. I'm going to feed it through the back of the pouch and through the front of the pouch, through my X. Then I will press my pouch into place and I will seal the defect in the front of the pouch with paste, paste strips, chevrons of hydrocolloid, waterproof tape, whatever. Every one of you will end up doing that at some point. Obstruction and blockage, that occurs most commonly with G-tubes and J-tubes. It usually occurs because we inadvertently allowed the formula to come in contact with the medication and we've got coagulation of the medication or we allowed the formula to come in contact with gastric contents in the tube and we got clotting of the formula within the tube. So the best way to prevent blockage, we want to flush the tube with water before and after each medication, and before and after each tube feeding. So we prevent those chemical reactions in the tube system. But once we have a blockage, how can we get rid of it? Well first we'll try mechanically milking the tube to see if we can break it up. We'll aspirate any fluid we can get to, then we'll take a 60 milliliter syringe with 10 milliliters of warm water and instill it. And then pull back and forth, back and forth, back and forth to see if we can use that little bit of warm water to break up the blockage. But many times we have a pretty well established clot of formula. It's clotted formula. It's in the process of being digested. So then we have to work with the pharmacist, we have to get pancreatic enzyme tablet, a sodium bicarb tablet, crush both of them, mix them with 5 to 10 milliliters of warm water, or use whatever formula your agency has on hand in the pharmacy, whatever they have established in protocol. Then instill it into the tube, clamp the tube for 20 to 30 minutes to allow the enzymes to start to break up that clotted formula. And then you're going to take your 60 milliliter syringe and you're going to do the back and forth, back and forth, back and forth to see if you can break it up. If you can't break it up, you have to notify the physician because the tube will have to be replaced. Prevention is better than management. What about bedside replacement of a G-tube? By you or by another R.O.? Yes, once it's a well-established tract, we can typically do this. So it's indicated only when you have a well-heeled tract. That means the tube's been in place for four to six weeks. The tube is secured internally either with a deflatable balloon or a very soft bumper that can safely be pulled through the abdominal wall. So you want two things. You want a well-established, stable tract so that you don't have to worry about everything closing up on you mid-procedure. And you want to make sure that either you have a balloon-tipped catheter where you can deflate the balloon and it just falls right out, or you have a very soft, a very soft bumper that you can pull through the abdominal wall without causing trauma. If you're not sure, you've got to verify that. You might have to call the people who put it in or go back in the medical record. You would never try to change a tube at the bedside if you had a rigid internal stabilizing device, if you had a tube where you didn't know how it was stabilized internally, or if the patient was very prone to bleeding. In that case, they have to go back to the GI lab to have this done. If you are going to change the tube at the bedside, you have to go back to the GI lab to have this done. If you are going to change the tube at the bedside, you should have a well-established policy and procedure that says you can do this. And once you change the tube out, you have to verify placement before you resume feedings. Okay, so in summary, sometimes you will be consulted to see a patient because of issues related to a percutaneous tube. The three most common types are gastrostomy or jejunostomy, biliary, and nephrostomy. The common complications: Dislodgement is one. We can help prevent that by assuring that the tube is appropriately stabilized. If it's a balloon-tipped G-tube, you want to deflate/reinflate the balloon every week. Whenever we're turning patients, we want to be careful that we don't apply traction to a tube that causes inadvertent dislodgement. The common complications are: Loss of oxygen, poor oxygen levels, and poor oxygen levels. The common complications are: Loss of oxygen levels, poor oxygen levels, and poor oxygen levels. of leakage. If they develop cellulitis, you've just got to identify it. So they might ask you to assess the patient. You would verify, yes, this looks like cellulitis. We need to get the surgeon involved. The patient's going to need antibiotics. They might need drainage of any purulent fluid collections. And then we could place an antimicrobial foam at the base around the tube. Hypergranulation tissue, first we're going to stop the in and out migration. If it's an older child or an adult, we're going to treat with silver nitrate and silver foam. If it's an infant or a young child, we're going to treat with a mid-potency steroid like triamcinolone. Leakage, again, we're going to go back to stabilizing the pouch to stop that back and forth. But once leakage is an issue, we need to pouch around the tube and we'll practice that. And then finally, we encourage the staff, prevent obstruction by routinely irrigating the tube before and after each medication, before and after each feeding. If they develop an obstruction, we try to break it up with warm water. If that doesn't work, we get pancreatic enzymes, soda bicarb, and water, create a slurry, instill it, let it sit there, then do back and forth, back and forth, to try to break it up. If that doesn't work, the tube will have to be replaced. And that's it for percutaneous tubes.
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