How to Replace a Dislodged or Malfunctioning G-tube

This post was authored by Ashley Endres, a senior pediatric resident at Cincinnati Children’s. It details how to replace a dislodged or malfunctioning G-tube.

Replace a G-tube

Gastrostomy tube dislodgment and malfunction are top causes for G-tube related ED visits in pediatric patients so it is important to understand how to replace a G-tube.

Gastrostomy tubes can be placed surgically or endoscopically. It is important to determine how the G-tube was placed and how long ago. It typically takes ~3 months for the tract between the skin and the stomach to mature. If the G-tube has been in for less than 3 months, it’s a good idea to talk with the department who placed it (i.e surgery or GI) before you mess with it.

First you need to determine some key facts about the G-tube

  • How was it placed (surgical vs endoscopic)
  • When was it placed – generally if it was placed within the last 30-60 days the tract is not mature and surgery should be contacted if the tube becomes dislodged
  • How long has it been dislodged
  • Did the family place a foley catheter in the stoma to keep it patent. It is important that families replace the G-tube or use a foley within 4 hours to help maintain patency of the stoma as the stoma can close quickly.
  • What is the size in diameter (French) and length of the G-tube.

Now, let’s walk through the steps of replacing a Mic-key or Mini ONE button G-tube and how to dilate the stoma using a foley catheter if the stoma has begun to close.

Supplies

  • Sterile water (~5mL)
  • Catheter tipped syringe
  • Water soluble gel
  • New G-tube with same French diameter and length (usually comes in a kit)
  • Gauze

Step 1: Test the new G-tube

  • Ensure the new g-tube is the correct diameter and length
  • Check how much water is needed to fill the balloon. This is in the instruction manual that comes with the tube
  • Fill the balloon with the correct volume (typically 2.5- 5mL) by attaching the catheter tipped syringe to the BAL port on the button
  • Inspect the balloon for leakage
  • Remove entire volume of water from the balloon
  • Place small amount of lubricant on the tip of the tube

Courtesy of Nationwide Childrens – nationwidechildrens.org/feeding-tube-changing

Step 2: Removing current G- tube

  • Remove water from the balloon using a catheter tipped syringe. Again typically 2.5-5mL
  • Gently pull G-tube out from stoma and use gauze to clean any drainage

Courtesy of Nationwide Childrens – nationwidechildrens.org/feeding-tube-changing

Step 3: Placing new G-tube

How to dilate the stoma if the G-tube has been dislodged for a prolonged period of time

Pro-Tip: You want to start small and work up to the patient’s typical size

Supplies

  • Foley catheters in a variety of sizes ( example 8, 10, 12, 14 french)
  • New G-tube with same french and length as patient’s original
  • Sterile water
  • Water soluble lubricant gel

Step 1

  • Apply water soluble gel to smallest foley. Typically start 2-3 sizes below the patient’s G- tube size.
    • Remember that French sizes are for internal diameter. A foley catheter is narrower than a g-tube. So, a 12-Fr holy has a smaller external diameter than a 12-French G-tube.
  • Gently insert foley catheter
  • Fill balloon with correct volume of water
  • Allow the foley to stay in place for 5-10 minutes
    • Depending on the maturity of the tract, and patient comfort you can decrease this time interval and insert the dilating Foley sequentially. Guage this based on ease of insertion and patient comfort.

Step 2

  • Remove water from foley balloon
  • Remove foley catheter and repeat step 1 with a foley that is the next size up. Ex 8 —>10
  • Continue to repeat these steps until you have reached the foley size that matches the patient’s G-tube. At that point you can follow the step of inserting new G-tube

 

Bonus Videos

These are 2 good videos on how to replace G-tubes. The first video is by NEJM. The second video is by Nemours Children’s Hospital. The steps on how to insert a new G-tube occurs at minute 11.

 

 

 

References

Juern, Jeremy, and Amy Verhaalen. “Gastrostomy-Tube Exchange.” New England Journal of Medicine, vol. 370, no. 18, 2014, doi:10.1056/nejmvcm1207131.

http://www.nationwidechildrens.org/feeding-tube-changing

Saavedra, Heather, et al. “Gastrostomy Tube-Related Complaints in the Pediatric Emergency Department.” Pediatric Emergency Care, vol. 25, no. 11, 2009, pp. 728–732., doi:10.1097/pec. 0b013e3181bec847.

Showalter, Cory D., et al. “Gastrostomy Tube Replacement in a Pediatric ED: Frequency of Complications and Impact of Confirmatory Imaging.” The American Journal of Emergency Medicine, vol. 30, no. 8, 2012, pp. 1501–1506., doi:10.1016/j.ajem.2011.12.014.

Goldin, Adam B., et al. “Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement.” The Journal of Pediatrics, vol. 174, 2016, doi:10.1016/ j.jpeds.2016.03.032.

Bhambani, Shiloni, et al. “Replacement of Dislodged Gastrostomy Tubes After Stoma Dilation in the Pediatric Emergency Department.” Western Journal of Emergency Medicine, vol. 18, no. 4, Jan. 2017, pp. 770–774., doi:10.5811/westjem.2017.3.31796.

A great blog post about the “utility” of CBC in febrile children

Sean Fox over at the always informative Pediatric EM Morsels just posted a great, brief review of the “usefulness” of CBC – especially WBC in febrile children. It is entitled “Poor Utility of WBC Count for the Evaluation of Fever.”

You should all go read it – here’s the link.

Pediatric EM Morsels / Poor Utility of WBC Count for the Evaluation of Fever

 

My main point about CBC and WBC is that it is most useful when you have a defined reason to get it and it is supported by your clinical assessment and a validated schema that utilizes other tests in concert. Don’t just get a CBC to see if a patient has an infection. Also, have a reassuring discussion ready to go for the family and patient that has had a previous CBC that was sent, got them worried, but the kid looks great.

You can follow Sean on Twitter @PedEMMorsels

50 Words – January 2018

This is a new feature on PEMBlog. I will be summarizing recent articles in 50 words (or less). I know that all of you are busy, so I wanted to give a quick synopsis of current literature, and offer you a chance to see what’s out there. I highly encourage you to look at the individual studies to see what conclusions you’ll draw on your own of course.

HSV study group of the PEMCRC and Cruz et al.

Pediatrics, 2018

This multi center retrospective cross-sectional study of infants <60 days old who had CSF studies sent. 112 of 26,533 had HSV identified with >80%  in weeks 1 to 4; median age 14 days. HSV was more common in 0-28 days vs 29-60 days (OR 3.9; 95% CI: 2.4-6.2).

Barrick et al.

Pediatric Emergency Care, 2018

A review of nearly 5,000 encounters for urolithiasis in children saw a 14% decrease in CT as the first imaging modality and subsequent imaging modality. Concordantly, ultrasound use increased by 15%.

Wendt et al.

Academic Emergency Medicine, 2018

Unprovoked seizures are more likely to see recurrent seizures than febrile seizures (which are approximately 33%). The risk is estimated at 29%, 37%, 43%, and 46% at 1, 2, 5, and 10 years, respectively.

Verbal et al.

Arch Dis Child, 2017

This prospective Belgian study incorporated CRP + assessment and vitals into an algorithm for febrile children. CRP >75mg/L had a 26.8% risk of serious infection requiring admission. Well appearing kids had lower CRPs. It’s not validated in a multi-center manner yet; don’t use CRP alone to determine sick vs not.

Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections

Gerber et al.

JAMA, 2017

A retrospective cohort study of 6 months – 12 years with acute respiratory tract infection prescribed an oral antibiotic showed that broad-spectrum treatment (augmenting, cefdinir vs amox) was not associated with a lower rate of treatment failure but was more likely to have adverse events.

Kwak et al.

Seizure, 2017

Interestingly, a meta analysis showed that iron deficiency anemia is significantly associated with febrile seizures (OR, 1.98; 95% CI, 1.26-3.13; P=0.003). You still don’t need to send ion levels/ferritin in the ED at this point though. Treatment doesn’t necessarily reduce the risk of recurrence.