PEG J-Peg Tubes Gastrostomy drainage Jejunal feeding tubes

PEG-J Gastrostomy drainage/ jejunal feeding tubes are combined tubes with outer 24-28 Fr gastric drainage lumens and inner small long feeding tubes that go through the stomach into the jejunum (second part of small intestine). The small jejunal tube does not fit snugly into the gastric drainage tube, instead there is an open area around the jejunal tube to allow gastric drainage. A connector closes the end of the gastric tube and attaches feeding and drainage ports.

Many surgical patients develop gastric emptying problems and cannot eat.
The small bowel usually works soon after surgery, even in patients whose stomachs don't empty. Jejunal tube feedings will work in these patients.
Patients whose stomachs don't empty usually need gastric drainage. The combined gastrostomy drainage/ jejunal feeding tube allows gastric drainage without a separate gastrostomy tube or nasogastric tube useful.
The combined gastrostomy drainage jejunal feeding tube avoids a separate incision in the small bowel and a separate attachment of the small bowel to the abdominal wall—this avoids small bowel obstruction or leakage at a jejunostomy site.
 It is often possible to feed into the jejunum even above a colon anastomosis without endangering the anastomosis.
Jejunal feedings are safer than TPN (total parenteral nutrition) because they
Avoid central line bacteremia and sepsis
Avoid major metabolic problems that can be associated with TPN
Raise low serum albumins much faster (although still slowly)
Avoid non-use gut atrophy
Jejunal feedings are safer and often work better than gastric feedings
Less risk of aspiration with jejunal feedings; aspiration is most common complication of tube feedings and can even be fatal
The small intestine tends to work immediately after surgery; the stomach, in contrast, often empties poorly after surgery
Many patients prefer surgically placed abdominal tubes instead of nasogastric and nasojejunal tubes when feasible (because nasally placed tubes cause nose and throat pain)
Gastric drainage tube: The gastric drainage tube is the outer tube. It has firm wings which make it difficult but not impossible to pull out of the stomach. If this tube slides inward, it can block the duodenum (first part of small intestine), causing nausea, vomiting and leakage around the tube.
The gastric drainage tube can be used for stomach drainage or stomach residual checks
The gastric drainage tube can even be used for tube feedings in the undesirable situation where the jejunal tube becomes clogged and cannot become unclogged (but only if the patient's stomach empties properly and the patient does not aspirate gastric contents)

Jejunal feeding tube
Small about 18 inch long inner tube that is threaded through the drainage tube, through the stomach, through the duodenum and into the jejunum
Very easy to clog
Very hard to unclog
Difficult to replace-requires endoscopy
Care of the gastrostomy drainage / jejunal feeding tube
If gastric drainage ordered, connect drainage to Foley catheter bag.
Keeping the jejunal feeding limb unclogged
Do not aspirate from the jejunal feeding lumen
Do not check residuals from the jejunal feeding lumen
Flush jejunal feeding tube with 15-30 cc water
Every 4-6 hours during tube feedings
Before and after each administration of medication
Whenever feeding is interrupted
At least once daily if not used for feeding or medication
Use liquid forms of medication whenever possible
Already formulated liquid versions (children's syrups and elixirs) when possible
IV forms when available and no liquid form available
Crushed only when no other option available and only if pills can be crushed finely enough to not clog the tube
Do not mix medications-many precipitate into an unremovable clog
Flush with water after each medication when you administer multiple medications
Do not add medication to the tube feeding formula

 Unclogging the jejunal feeding limb
Flush tube with warm water in a piston syringe
Instill activated pancreatic enzyme solution in tube: 1 Cotazym or Viokase tablet in smallest possible volume of water; repeat as many times as needed, even hourly

Do not use:
Meat tenderizer
Carbonated beverages (tend to coagulate tube feedings forming clogs that cannot be removed)
Stylets or guidewires
When and how to irrigate the gastrostomy drainage lumen:
If used for drainage, irrigate only as needed to keep unclogged
If used for feeding, irrigate with 15-30 cc water:
Every 4-6 hours during tube feedings
Whenever feeding is interrupted
Before and after each administration of medication, irrigate with 15-30 cc water
At least once daily if not used for feeding or medication, irrigate with 15-30 cc water
Giving medications that cannot be crushed finely enough to go through the feeding lumen without clogging it:
Give these medications po if patient is eating or in the drainage lumen if patient cannot eat
Clamp drainage lumen for at least 1 hour after medications
Don't give medications into stomach (po or drainage lumen) if patient has gastric, duodenal or high jejunal fistula-the medications will just go out the fistula-in these cases, use IV, IM, sublingual or rectal medications 

Measuring residuals
Not really necessary with gastrostomy drainage jejunal feeding tubes
Do not measure residuals from the feeding lumen
Measure residual checks only if ordered, and then, from gastrostomy drainage lumen
When to clamp and unclamp the gastrostomy drainage lumen without a specific physician order
Clamp gastrostomy drainage lumen for at least one hour after medications
Clamp gastrostomy drainage lumen for at least one hour after patient eats, unless patient complains of nausea or complains of left upper abdominal pain or vomits
Open gastrostomy drainage lumen if patient
Becomes nauseated
Develops left upper abdominal pain
Develops significant drainage around tube insertion site
When to stop feedings:
If the output from the drainage lumen is the same color and consistency as the tube feedings
If the patient vomits tube feedings.
If the patient vomits and aspirates. Call physician, who may have you restart tube feedings with gastrostomy drainage lumen to dependent drainage

Other don'ts:
Do not disconnect the tube connector hubs from the feeding tube, because this would pull the jejunal feeding tube outward.
If you then try to put the tube connector hubs back into the outer gastrostomy drainage lumen, you will push the jejunal tube inward. This will kink the bendable jejunal feeding tube tip and block it. You will then not be able to unblock the jejunal feeding tube tip without surgery or endoscopic manipulation.
If you do not push the tube connector hubs back into the outer gastrostomy drainage lumen, you will have leakage from the end of the gastrostomy tube. There is no good way other than the manufacturer's connector hubs to seal the opening between the gastrostomy drainage tube and jejunal feeding tube.       
 Don't put medications that have a direct effect on the stomach (sucralfate or Carafate, antacids) down the jejunal feeding tube:
They clog the feeding tube
They have no medication effect on the jejunum
They cannot effect the stomach unless they contact it directly
Don't crush and instill controlled release medications into drainage or feeding tubes, this speeds their release-instead get an order for a comparable non-control release medication (which will have to be given more often than the controlled release medication you are replacing)

 Anchoring tubes that do not come with retention rings:
Newly placed tubes are usually sutured in place
Don't apply tape-the sutures should hold them in place
Dress only if leaking-change dressings often enough to keep gastric contents off the skin-gastric contents rapidly break down skin
Anchoring tubes after suture removed
Apply Duoderm around tube--slit to apply and cut out circle for tube to go through
If necessary, level skin before applying Duoderm with Stomadhesive or Hollihesive paste
Place baby nipple around tube on top of Duoderm near insertion site
Slit baby nipple
Enlarge one nipple hole just enough so it fits around tube snugly--if snug enough won't need to tape
Pull outward gently on tube to bring wings up against stomach wall which is sutured to inside abdominal wall--don't pull hard enough to pull tube out--tube may already be at correct position, but if not should slide easily without force
Tape or tie nipple slit back together
If nipple doesn't fit snugly enough around tube to keep it from moving, tape nipple to tube
Use 4x4's as necessary to catch drainage between Duoderm and nipple--change 4x4's as needed to keep any drainage off skin

Major drainage around tube
Gastric drainage is highly irritating to skin and will break it down rapidly so keep the drainage off the skin
Try putting gastrostomy drainage lumen to dependent drainage (Foley bag)
Try Duoderm and Stomadhesive or Hollihesive paste as described above in section
If above fail:
Place zinc oxide ointment around tube opening as widely and thickly as necessary to keep drainage off skin--reapply as often as needed
Collect drainage with 4x4's, ABD's, Kotex type pads cut to fit or other dressings and change as often as needed to keep drainage off skin
Tube feeding labs for patients new to tube feedings (first 4 weeks or patients who are having frequent tube feeding adjustments)
Glucometers at least once daily until tube feeding formula remains at a stable rate and patient's blood sugars remain within a reasonable range (80-150) for at least 3 days
Electrolytes, BUN, Cr weekly
Hgb weekly
Magnesium, Phosphorus, Calcium, Albumin weekly