Complex Care Curriculum Enteric Feeding Tubes ding Tubes

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Complex Care Curriculum Enteric Feeding Tubes ding Tubes Rebekah Conroy M. D. Priti Bhansali,

Complex Care Curriculum Enteric Feeding Tubes ding Tubes Rebekah Conroy M. D. Priti Bhansali, M. D. Neha Shah, M. D. Melanie Anspacher, M. D. Start Presentation

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Enteric Feeding Tubes Discuss

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Enteric Feeding Tubes Discuss the indications for placement of feeding tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Compare and contrast the different types of feeding tubes Complications Tube Dislodgement Summary References & Resources Evaluate and troubleshoot common problems and complications of feeding tubes including tube dislodgement

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric INDICATIONS Nasogastric Nasojejunal Gastrostomy Inability to orally consume caloric needs Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Prolonged feeding time Inadequate weight gain Weight loss

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Safety Concerns Indications Types of Feeding

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Safety Concerns Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Heart Failure Structural Anomalies Etiologies Complications Tube Dislodgement Summary References & Resources Need for unpalatable special formulas Neurologic Compromise

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Nasogastric Duration Nasojejunal Gastroesophageal Reflux Disease Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Integrated Aspiration Risk Anatomy

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Orogastric Tube (OGT) Nasogastric Tube (NGT) Nasojejunal Tube (NJT) Jejunostomy Complications Gastric Tube (GT) Tube Dislodgement Summary References & Resources Gastrojejunal Tube (GJT) Jejunal Tube (JT)

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Litwak Illustration Studio © Taina Litwak 2008

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Tubes Nasogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Inexpensive and easy to place, useful in obligate nose breathers Tube Dislodgement Summary References & Resources Easily dislodged, not useful when gag reflex is present

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Litwak Illustration Studio © Taina Litwak 2008

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Nasogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Nasogastric Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Inexpensive, easy to place Complications Tube Dislodgement Summary References & Resources Easy to dislodge, uncomfortable, aesthetically displeasing Consideration should be given to a more permanent enteral feeding tube if needed for more than 12 weeks.

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Nasojejunal

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Nasojejunal Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Confirmation of placement may be challenging in patients with acid blockade. NJ tubes must have radiographic confirmation prior to use. Tube Dislodgement Summary References & Resources Litwak Illustration Studio © Taina Litwak 2008

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Tubes Nasogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Bypasses the stomach Tube Dislodgement Summary References & Resources Easy to dislodge, uncomfortable, aesthetically displeasing, difficult to place in proper position

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes Gastrostomy Tubes

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Gastrostomy

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Gastrostomy Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy More secure, can be low profile Complications Tube Dislodgement Summary References & Resources More invasive, risk of sedation or anesthesia and surgery The GT can be removed when the patient no longer requires GT feeds for nutritional support

Complex Care Curriculum Learning Objectives Indications Enteric Feeding Tubes External Port Types of Feeding

Complex Care Curriculum Learning Objectives Indications Enteric Feeding Tubes External Port Types of Feeding Tubes Orogastric Nasogastric Tubing Nasojejunal Gastrostomy Gastrojejunal Jejunostomy COMPONENTS Complications Tube Dislodgement Summary Internal Bolster References & Resources External Bolster

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes Percutaneous Endoscopic Gastrostomy (PEG)

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Nasogastric Percutaneous Endoscopic Gastrostomy (PEG) Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications cost, minimally invasive, little discomfort, early use Tube Dislodgement Summary References & Resources Increased risk of peritonitis if dislodged early Upper GI series may be needed to evaluate for anatomic abnormalities prior to PEG placement

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes Surgical GT

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Surgical GT Nasogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Direct visualization and placement, can combine with Nissen fundoplication Tube Dislodgement Summary References & Resources Expensive, general anesthesia, > risk of inducing GER than PEG

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Enteric Feeding Tubes Low

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Enteric Feeding Tubes Low Profile Device (button) Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources The presence of a low profile device does NOT necessarily mean that the tract has fully healed.

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Nasogastric Low Profile Device (button) Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Cosmetically appealing Tube Dislodgement Summary References & Resources More expensive than traditional GT, extension device

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes Gastrojejunal Tubes

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Gastrojejunal Tubes Nasogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy less invasive, decreases risk of aspiration, increases calories Complications Tube Dislodgement Summary References & Resources clogging, radiology to replace, continuous feeds, intussusception

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes Jejunostomy Tubes

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Jejunostomy Tubes Nasogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Anatomic abnormalities requiring jejunal feeds Complications Tube Dislodgement Summary References & Resources Leakage, increased risk of volvulus and intussusception

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Malfunction

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Malfunction Orogastric Nasojejunal Gastrostomy Cutaneous Malplacement Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Procedural Complications Dislodgment

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Pneumoperitoneum Indications Types of Feeding Tubes

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Pneumoperitoneum Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Fistula Paralytic Ileus Procedural Complications Tube Dislodgement Summary References & Resources Separation Skin Infections

Complex Care Curriculum Learning Objectives Indications Enteric Feeding Tubes Cutaneous Complications Types of Feeding

Complex Care Curriculum Learning Objectives Indications Enteric Feeding Tubes Cutaneous Complications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Granulation Tissue Irritant Dermatitis Prolapsed Mucosa Infection Jejunostomy Complications Tube Dislodgement Summary References & Resources

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Used with permission of HSC Pediatric Center, Washington, DC.

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes

Complex Care Curriculum Learning Objectives Indications Enteric Feeding Tubes Tube Malfunction Types of Feeding

Complex Care Curriculum Learning Objectives Indications Enteric Feeding Tubes Tube Malfunction Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Leakage Blockage

Complex Care Curriculum Learning Objectives Indications Enteric Feeding Tubes Tube Malplacement Types of Feeding

Complex Care Curriculum Learning Objectives Indications Enteric Feeding Tubes Tube Malplacement Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Buried Bumper Syndrome Tube Migration

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Tube migration Indications Types of Feeding

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Tube migration Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Vomiting GERD Overfeeding Jejunostomy Complications Tube Dislodgement Constipation Summary References & Resources Obstruction Intercurrent illness

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric

Complex Care Curriculum Enteric Feeding Tubes Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources GT Dislodgement

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Enteric

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Enteric Feeding Tubes Children’s National Medical Center Algorithms for feeding tube dislodgement View Algorithm for PEG tube dislodgement View Algorithm for Gastrostomy Tube dislodgement Gastrojejunal Jejunostomy Complications Tube Dislodgement Continue Presentation Summary References & Resources **Specific institutions and practitioners may follow different algorithms**

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Enteric Feeding Tubes Discuss

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Enteric Feeding Tubes Discuss the indications for placement of feeding tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Compare and contrast the different types of feeding tubes Complications Tube Dislodgement Summary References & Resources Evaluate and troubleshoot common problems and complications with feeding tubes

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal

Complex Care Curriculum Learning Objectives Indications Types of Feeding Tubes Orogastric Nasojejunal Gastrostomy Gastrojejunal Jejunostomy Complications Tube Dislodgement Summary References & Resources Enteric Feeding Tubes Axelrod D, Kazmerski K, Iyer K, Pediatric Enteral Nutrition. J Parenter Enteral Nutr 2006; 30: S 21 -6. Pedron-Giner, C, et al. , Consensus on paediatric enteral nutrition access: a document approved by SENPE / SEGHNP / ANECIPN / SECP, Nutr Hosp 2011; 26(1): 1 -15. Mahant S, Technical Trouble-Shooting: The role of the hospitalist in managing technological devises. Enterostomy Access: Gastrostomy and Gastrojejunostomy Tubes Marchand V. (2007) Enteral Nutrition Tube Feedings. In S. Baker, R. Baker, & A. Davis (Eds. ), Pediatric Nutrition Support (249 -60). Sudbury, MA: Jones and Bartlett. Ekvall S, & Ekvall V. (2007) Nutrition Support for Children with Develpmental Disabilities. In S. Baker, R. Baker, & A. Davis (Eds. ), Pediatric Nutrition Support (359 -68). Sudbury, MA: Jones and Bartlett. Marchand V, Canadian Paediatric Society, Nutrition and Gastroenterology Committee. Nutrition in neurologially impaired children. Paediatr Child Health 2009; 14(6): 395 -401. Marchand V, Motil K, NASPGHAN Committee on Nutrition Support for Neurologically Impaired Children: A Clinical Report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Journal of Pediatric Gastroenterology and Nutrition 2006; 43: 123 -135. CNMC Intervention Guidelines: Dislodgement of Surgical Gastrostomy and Percutaneous Endoscopic Gastrostomy (PEG) Process Flow Chart. CNMC Nursing Practice Guidelines: Gastrostomy Management.