G-tubes/J-tubes falling out

[bumble12]

i'm a new intern and would appreciate some help. I had a patient in the ED whose G tube fell out. We replaced it with a foley and sent him home to continue his feeds. Can you do the same with a J-tube or do those need to be immediately replaced rather than temporized with a foley? What if it's a freshly placed tube? Can i still put in a foley? thanks for the help

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[Venko]

Assuming its not a fresh G-tube and it hasn't been out for too long, you can simply just replace the G Tube. in fact, if you are able to put the foley in you can just put the G tube back in.

As for J tubes, they are more difficult and really I haven't seen one fall out. I have seen them coming partially out, but you can just slide it back in...

TL

 

[deleted109597]

Old G tubes you can slip right in, as above.
Usually if the G tube fell out, it is because the bladder was damaged in some way, so putting it back in isn't as helpful. You can put a foley in, or put a new G tube.

J tubes that come out get surgery if they need a new one.

 

[KYTNOH]

As long as they're establish (2 months or so old) then you'll have a good track and can simply put a new one in. If they are fresh then I would get surgery to place a new one because of the risk of creating a false track.

The one caveat with J-tubes is to not use a foley. If you, or anyone else, inflates the balloon on a foley while it's in the jejunum then you can cause an obstruction. For J-tube I put a red rubber in and stitch it in place. For both G-tubes and J-tubes I give a little contrast through the tube and shoot a KUB to confirm placement in the GI tract more for my comfort. You probably don't have to do that on on established tubes, but it makes me feel better.

 

[bumble12]

Can I send someone home with a foley in the J-tube stoma? or does that just hold the tract open until IR or surgery can replace it?

 

[EM_Rebuilder]

I like how these tubes just "fall out" all the time. We should do a study.... I bet they tend to fall out more on weekends, holidays, and evenings.

 

[SLUser11]

i'm a new intern and would appreciate some help. I had a patient in the ED whose G tube fell out. We replaced it with a foley and sent him home to continue his feeds. Can you do the same with a J-tube or do those need to be immediately replaced rather than temporized with a foley? What if it's a freshly placed tube? Can i still put in a foley? thanks for the help

J tubes can be replaced at the bedside as well, but remember that it's a small lumen, so there's much less room for error. If you inflate a balloon, then you will create an obstruction. If you push it in too far, you can more easily perforate the bowel. I think the safe move is to call surgery for most J-tubes. As for G-tubes, I think calling surgery every time is overkill.

Regardless of the tube, the main issue is how long ago it was placed and what exactly was done. I think if it's a fresh tube of any kind (PEG, surgical g-tube, j-tube), then surgery should be called. They can decide what the best course of action is, be it bedside procedures or a trip to the OR. J tubes and open G-tubes usually involve stitching the stomach or small bowel to the abdominal wall, so leakage and sepsis are less common. If it's a PEG, and it's new, then the stomach now has a big anterior hole in it, and the patient might need surgery.

If the tube has been in for 3-4 weeks, then usually a tract has developed, and you can try to replace the tube at bedside. People always place foleys because they are ubiquitous (therefore readily available), but if you have a bunch of g-tubes sitting in your ER storage, then it's silly to use a foley.

Look at the size of the tube that was removed, and go 2-4 french smaller with your first attempt. (e.g. most PEGs and Open Gs are 20-24 french. Much J tubes are much smaller). If it goes easily, and flushes/aspirates okay, then you're probably done. You can always get a gastrografin contrast study through the tube to confirm placement if necessary.

It's important to act relatively fast. As much as you can in your busy ER schedule, I'd try to triage these to the front of the non-critical activities. Even over the course of 1-2 hours, these holes can close up, and you'll lose your opportunity.

Sometimes I get creative, and use guidewires, stylets from ET tubes, etc, but I don't recommend any of this, as the risks are higher. If it doesn't go easily on the first few attempts, I'd call surgery.


I hope that helps.

 

[WilcoWorld]

J tubes can be replaced at the bedside as well, but remember that it's a small lumen, so there's much less room for error. If you inflate a balloon, then you will create an obstruction. If you push it in too far, you can more easily perforate the bowel. I think the safe move is to call surgery for most J-tubes. As for G-tubes, I think calling surgery every time is overkill.

Regardless of the tube, the main issue is how long ago it was placed and what exactly was done. I think if it's a fresh tube of any kind (PEG, surgical g-tube, j-tube), then surgery should be called. They can decide what the best course of action is, be it bedside procedures or a trip to the OR. J tubes and open G-tubes usually involve stitching the stomach or small bowel to the abdominal wall, so leakage and sepsis are less common. If it's a PEG, and it's new, then the stomach now has a big anterior hole in it, and the patient might need surgery.

If the tube has been in for 3-4 weeks, then usually a tract has developed, and you can try to replace the tube at bedside. People always place foleys because they are ubiquitous (therefore readily available), but if you have a bunch of g-tubes sitting in your ER storage, then it's silly to use a foley.

Look at the size of the tube that was removed, and go 2-4 french smaller with your first attempt. (e.g. most PEGs and Open Gs are 20-24 french. Much J tubes are much smaller). If it goes easily, and flushes/aspirates okay, then you're probably done. You can always get a gastrografin contrast study through the tube to confirm placement if necessary.

It's important to act relatively fast. As much as you can in your busy ER schedule, I'd try to triage these to the front of the non-critical activities. Even over the course of 1-2 hours, these holes can close up, and you'll lose your opportunity.

Sometimes I get creative, and use guidewires, stylets from ET tubes, etc, but I don't recommend any of this, as the risks are higher. If it doesn't go easily on the first few attempts, I'd call surgery.


I hope that helps.

Great summary. Thanks

 

[glorfindel]

The only thing I can add is: be more careful when you're dealing with a thin, floppy tube.

For instance, I know of a case where a guy came in with a mic-key feeding tube ("MIC-KEY* Enteral Feeding Tubes go hand-in-hand with an active lifestyle, freeing children and adults alike to be more mobile and enjoy life to the fullest while ensuring their nutritional health and well-being") that had fallen out.

Tract was old. It got replaced in the ER, sent home without a confirmatory abd xray. Guy came back a couple days later with schmutz (i.e., tube feeding material) in his rectus sheath.

As far as I can tell, the floppiness of the tube vs. a foley probably contributed to the misplacement.

I can't prove it, but I can suspect it.

 

[Apollyon]

J tubes can be replaced at the bedside as well, but remember that it's a small lumen, so there's much less room for error. If you inflate a balloon, then you will create an obstruction. If you push it in too far, you can more easily perforate the bowel. I think the safe move is to call surgery for most J-tubes.

You can always get a gastrografin contrast study through the tube to confirm placement if necessary.

I appended this for a few reasons.

First is I've only seen a j-tube replaced in the ED by a CT surgery fellow (on whom he'd done the CABG) over a wire. For me, that was enough - from what I saw, and what he told me, I did not have the confidence that I had sufficient training to do that.

Second, to replace a tube and not do a confirmatory study (in this case) is foolhardy. I mean, you might say that we don't confirm Foleys, as you could have created a false lumen, but, without blood and well-tolerated by the patient and good urine flow and return, that is indirectly confirmatory enough without doing a cystogram. However, we tug on sutured wounds, get chest x-rays and follow patient condition and vital signs after ET tubes, and check x-rays and objective signs after relocating most joints (maybe not on a distal phalanx). To put a tube in and not shoot 30mL of contrast through it is courting disaster.

Now, you may say, "But I know this person! It falls out all of the time!" How do you know that you've not bored out a tract that is too large (might as well as used a router) over repetitive reinsertions, and the same-size tube tube is now functionally too small? And if it's a patient that ISN'T a frequent flyer, then you don't know what is going on.

And if you have to call in IR to do it, then you have supreme hospital system problems.

Alternately, if you don't do a tube check, you have more guts than I do. (And I know you're out there - you can make a case as to why you don't do a tube check, but I don't believe you can make a credible case that I am wrong.)

 

[SLUser11]

Alternately, if you don't do a tube check, you have more guts than I do. (And I know you're out there - you can make a case as to why you don't do a tube check, but I don't believe you can make a credible case that I am wrong.)

I think you have to do whatever is necessary to feel safe dismissing the patient from the ER, so nobody would fault you for getting a contrast study.

In patients will well-defined tracts, it's probably not always necessary, but it's not wrong, either.

Someone mentioned a mickey button. We usually placed those in the office later on, i.e. we'd use a regular tube initially, then replace it with the low profile tube after a month or so. So, to me that means that most patients with a mickey button have a well-defined tract.

 

[DocVirk]

Regarding confirmatory xrays- I will typically get them but sometimes in patients with an old, well-defined tract and a tube that goes in easily, I will simply aspirate some fluid. If I get gastric contents and didn't have to manipulate at all, I'm done and send them home. Most other people get some contrast.

Another trick I've used in people who have had their tube out for a while is cervical dilators. Use a little lidocaine jelly and progressively dilate the stoma. It can be a little scary, and I will always order a confirmative xray in these people.

 

[docB]

I see this silliness several times per week. It gets so painful that I once met a patient at the ambi door with foley and gastrograffin in hand and xray in tow. Placed the foley, squirted the contrast and shot the xray within 2 minutes of arrival. I sent the patient back to the SNF on the same ambulance. This had the effect of pissing off EMS (they wanted to drop and run, not transport back to the SNF) and the SNF (they wanted that patient gone until the next nursing shift at least).

Recently the SNFs have been demanding that the patient get a "real G-tube" and not a foley before they will accept the patients back. This is for two reasons. #1 they feel entitled to have the patient gone for at least one complete nursing shift. #2 if it's replaced with a foley they will need to call the PMD and arrange the appropriate, non-emergent change back to a G-tube as an out patient. That is not as convenient as just dumping the patient into the ED and getting them back with no follow up requirement... after at least one nursing shift .

 

[SLUser11]

I see this silliness several times per week. It gets so painful that I once met a patient at the ambi door with foley and gastrograffin in hand and xray in tow. Placed the foley, squirted the contrast and shot the xray within 2 minutes of arrival. I sent the patient back to the SNF on the same ambulance. This had the effect of pissing off EMS (they wanted to drop and run, not transport back to the SNF) and the SNF (they wanted that patient gone until the next nursing shift at least).

Recently the SNFs have been demanding that the patient get a "real G-tube" and not a foley before they will accept the patients back. This is for two reasons. #1 they feel entitled to have the patient gone for at least one complete nursing shift. #2 if it's replaced with a foley they will need to call the PMD and arrange the appropriate, non-emergent change back to a G-tube as an out patient. That is not as convenient as just dumping the patient into the ED and getting them back with no follow up requirement... after at least one nursing shift .

So why not just stock g-tubes in your ER and use those instead? Then the NH nurses have less to work with. Honestly, most ERs I've worked in had a stack of g-tubes in their storage area.

A foley is a great idea when you're in a bind and there's nothing else available, but it will ultimately have to be replaced by a G-tube in the near future. Why not just skip the extra step?

I feel for you with the BS ambulance transfers, and the desire to pin the EMS crew down so they can't take off without the patient. I used to do locums in small town ERs, and if you lost that ambulance crew, there may not be another one available for quite some time...