The digest on enteral access devices
Enteral access placement is considered a routine procedure but requires insightful direction from nutrition clinicians to help guide decision-making for each individual patient. Enteral access devices (EAD) can be used for various reasons, including nutrition therapy, hydration, medication administration, or for decompression/drainage.
Enteral access device considerations
Prior to EAD selection, the following considerations should be assessed:
- Physical ability: How active is the patient? Do they go out frequently or prefer to stay home? Do they play sports or engage in regular physical activity? What about rehab or therapy schedules?
- Mental capacity and/or age: Will the patient pull on or disturb the tube? Will the patient need help with enteral nutrition (EN) administration, medication dosing, water flushes, or skincare?
- Socioeconomic factors: Does the patient have a secure living arrangement? Will insurance cover the expense of EN formula and supplies? If not, how will these costs be covered?
- Ethical considerations: Does the patient consent to having an EAD placed? Are advanced directives known? Does EN align with the patient’s goals of care?
- Religious and cultural preferences: Some religions may or may not believe in extraordinary means of preserving life. Some cultures prefer that the medical team make decisions independent of the family/patient. And some cultures prefer more family-centered decision making. Each individual may make different decisions than what is common to their religion or culture.
Types of enteral access devices
Types: Nasogastric tube (NGT), orogastric tube (OGT), nasoduodenal (NDT), nasojejunal (NJT) and small bore Dobhoff tubes (DHT)
Placement: EAD is inserted through the nasal or oral passage down the esophagus with the tip placed into the stomach or distal to the pylorus. These are commonly placed blindly at the bedside by a trained clinician. X-ray confirmation is the gold standard to verify placement. Post-pyloric tubes are often placed via fluoroscopy, ultrasound, magnetic guided, or camera guided.
Potential complications: Risk of clogging, bleeding during placement, sinusitis, rhinorrhea, nasal wounds, otitis media, vocal cord paralysis, ulcers/perforations, fistulae and obstruction of upper GI tract. NDT/NJT tips can migrate up into the stomach.
Contraindications: Nasal surgery, nasal fractures, severe head/neck trauma, coagulation disorders, severe esophageal strictures/varices, alkaline ingestion, prior esophageal banding, upper GI head/neck cancers.
Specifications: French sizes 3.5 to 12; length 15 to 107 cm. Irrigate every 4 hours with 20 mL of water before/after medication administration or when feeding formula is interrupted. Tubes should be in place for no longer than 4 to 6 weeks.
Types: Gastrostomy tube (G-tube), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrojejunostomy (PEG-J), low-profile gastrostomy tube, jejunostomy tube (J-tube).
Placement: EAD inserted via endoscopic, fluoroscopic or surgical procedure. PEGs can be placed at bedside by a trained clinician. Placement can occur in interventional radiology, endoscopy suites, or during surgery as inpatient or outpatient status.
Potential complications: Pulmonary aspiration due to reflux, stomal prolapse, tube migration, obstruction of lumen, wound infection, pneumoperitoneum, perforation, gastrocolonic fistula, ileus, hypergranulation tissue around the stoma, liver laceration/perforation with misplaced PEG, persistent leaking, enterocutaneous fistula, peritonitis, or dislodgement/malposition of jejunal limb.
Contraindications: Ascites, hiatal hernia, severe obesity, pharyngeal/esophageal obstruction that precludes endoscope, peritoneal dialysis, previous abdominal surgery, mechanical or functional gastric outlet obstruction (for gastrostomy tubes), intestinal wall edema, distal intestinal obstruction, post-radiation enteritis, chronic inflammatory diseases, coagulopathies, inability to visualize stomach or intestines. Clinicians consulted to assess patients for EAD placement may decline due to unfavorable GI anatomy, high risk for sedation, and/or if EN therapy will not change long-term outcomes.
Specifications: French sizes 12 to 24 for G-tubes and 14 to 18 for J-tubes; length of PEG/PEJ depends on where the end of the tube is cut by the clinician at time of placement. If cut too short, the patient will need extension tubing; if cut too long, it will add additional weight and bulkiness to the tube and can pull or snag with daily movement. A low-profile G-tube’s length is 0.6 to 0.8 cm and is flush with patient’s skin.
Long-term EADs can last one to eight months. PEG replacement is recommended every three months. To clean, assess the stoma site and wash with warm water and mild soap. Keep the stoma clean and dry at all times. Turn the low-profile button daily, stopping at a different point each time to allow for air circulation.
Occasionally non-enteral tubes, such as catheters, are used as EADs as a temporary solution when replacement is indicated, and an EAD is out of stock. Patients need to have a mature stoma tract. Research supports this temporary solution.
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Reddick, Cynthia A., et al. “Choosing Wisely: Enteral Feeding Tube Selection, Placement, and Considerations before and beyond the Procedure Room.” Nutrition in Clinical Practice, no. 2, Wiley, Mar. 2023, pp. 216–39. Crossref, doi:10.1002/ncp.10959.
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