Tell me more about g-tubes and J-tubes

[raindrop]

I know the difference as far as location, but does one look different than the other? Can placement be checked by air bolus for both of these?

Also, what is a peg tube? And what part og the GI tract is it inserted?

[AmericanChai]

My daughter is on a gtube. When she's really sick she's on 24 hour feeds. She does not have any residuals because her stomach empties faster than the feed comes. The strategy is to keep her from vomiting until she recovers. When she gets sicker or has a GI bug she will have residuals though, becuase she's not emptying well. At that point we switch her to clear fluids or watered down formula. She's on Neocate Jr.

[core0]

My daughter is on a gtube. When she's really sick she's on 24 hour feeds. She does not have any residuals because her stomach empties faster than the feed comes. The strategy is to keep her from vomiting until she recovers. When she gets sicker or has a GI bug she will have residuals though, becuase she's not emptying well. At that point we switch her to clear fluids or watered down formula. She's on Neocate Jr.

Mmm neocate or as we used to call it liquid gold. One question that I did not ask or answer for the OP is why someone with a G-tube would be on continuous feeds. Most people tolerate bolus feeds fairly well but there are some that do not. It is usually related to gastric emptying and in these people high residuals force you to do continuous feeds. For the most part the use of bolus feeds is easier on the caretakers and cheaper (no pump). Its not necessarily any better. The other group that does not tolerate bolus feeds in my experience is adults/kids with significant small bowel loss. In this case it is not a residual matter, it is that they cannot absorb enough food in the bolus so a drip works better. For kids they make a really neat pump called a Kangaroo pump. It lets them be very mobile, although as one of my former patients found out you probably should not Rollerblade with it.

David Carpenter, PA-C

[ebear, BSN, RN]

David, ah yes! I do remember the Kangaroo pumps!

ebear

[EmmaG, RN]

Another question:

How is it possible, with continuous infusion of feeding solution for shift, after shift of nurses document 0 for residual?

Shouldn't there be something there, at least sometimes?

Thanks,

Are you referring to continuous feeds via a G or J tube? Or one via an NG feeding tube? Dobbhoffs and the like are so flexible, it's nearly impossible to withdraw a residual.

[AmericanChai]

Mmm neocate or as we used to call it liquid gold. One question that I did not ask or answer for the OP is why someone with a G-tube would be on continuous feeds. Most people tolerate bolus feeds fairly well but there are some that do not. It is usually related to gastric emptying and in these people high residuals force you to do continuous feeds. For the most part the use of bolus feeds is easier on the caretakers and cheaper (no pump). Its not necessarily any better. The other group that does not tolerate bolus feeds in my experience is adults/kids with significant small bowel loss. In this case it is not a residual matter, it is that they cannot absorb enough food in the bolus so a drip works better. For kids they make a really neat pump called a Kangaroo pump. It lets them be very mobile, although as one of my former patients found out you probably should not Rollerblade with it.

David Carpenter, PA-C

Yeah tell me about it! That stuff is so expensive!

David, there are many great pumps now-- Zevex Infinity and Kangaroo Joey. Both can be worn by very small toddlers and they can do summersaults and the pumps still work. :) The Kangaroo Pets are portable but if they tip over, watch out.

Here's a photo of my daughter (age 3) and another little EE kid wearing their pumps in tiny backpacks. She started wearing her pump on her back at around 15 months old!

I actually know several children who are on continuous g-tubes through the EE community. My daughter can't tolerate gravity feeds and needs 2 hours to finish her feeds at least. She has slightly slow motility. The formula is so rich that she just can't handle very much at a time. She can hold 8 oz of water/pedialtye but only 4 oz of formula before she vomits. The gtubes are preferable for the continuous feed people if their stomachs work okay-- the J is too hard to place and keep in place. I can just change my daughter's gtube at home.

Speaking of tolerating formula-- many many people do much better on blenderized food vs. canned formula.

[aubie]

CoreO,

Would you explain more about the high G-tube with a large amount of dependent volume? Thanks.

Aubie

[core0]

CoreO,

Would you explain more about the high G-tube with a large amount of dependent volume? Thanks.

Aubie

G tubes are place in the stomach kind of wherever they fit. So if you put them up high in the stomach then there is much more volume in the dependent part of the stomach than if it was placed say in the mid body. This would apply more to patients where residuals are checked sitting up. Similarly if it was placed in the mid body then there would be more residual volume than if it was placed in the fundus or the lower body. This is why you will see some patients have very different residuals depending on what side they are laying on with bolus feeds. Here is a picture that may help visualize this:

You have to think about this in 3-D. The tubes are usually placed coming out of the picture. So if you placed one at the end of the fundus arrow everything below would be dependent volume if the patient was sitting up. Similarly if you placed one at the end of the circular muscular arrow then you would probably have the most dependent volume laying down.

David Carpenter, PA-C

[core0]

Yeah tell me about it! That stuff is so expensive!

David, there are many great pumps now-- Zevex Infinity and Kangaroo Joey. Both can be worn by very small toddlers and they can do summersaults and the pumps still work. :) The Kangaroo Pets are portable but if they tip over, watch out.

Here's a photo of my daughter (age 3) and another little EE kid wearing their pumps in tiny backpacks. She started wearing her pump on her back at around 15 months old!

I actually know several children who are on continuous g-tubes through the EE community. My daughter can't tolerate gravity feeds and needs 2 hours to finish her feeds at least. She has slightly slow motility. The formula is so rich that she just can't handle very much at a time. She can hold 8 oz of water/pedialtye but only 4 oz of formula before she vomits. The gtubes are preferable for the continuous feed people if their stomachs work okay-- the J is too hard to place and keep in place. I can just change my daughter's gtube at home.

Speaking of tolerating formula-- many many people do much better on blenderized food vs. canned formula.

I'm glad the pumps are smaller. In my case the patient fell directly backwards onto the pump while on roller blades. Not much that would have helped there. I have learned that anything man can build a young boy can destroy. This includes playing "touch" football with a $10,000 Ph monitor.

David Carpenter, PA-C

[aubie]

David,

Then how to best check residuals?

Suzanne

[core0]

David,

Then how to best check residuals?

Suzanne

Well as always I would follow your hospital policy. For me I don't check residuals on continuous feeds. There is no literature to show that there is any aspiration risk and if there is a problem the patients condition (ie distension, pain, vomiting etc...) will tell you that the problem is there. For bolus feeds one hour post residuals are a little helpful but I really don't get concerned unless the patient is symptomatic or they are greater than the feeds (for the reasons discussed above - anatomic variability and the potential for operator error).

David Carpenter, PA-C

[nservice]

Man, this is a great thread. I just thought I knew all about this subject. Thanks CoreO!

[aubie]

Thanks again CoreO,

I have tried to research this, and haven't come up with much as it relates to checking residuals. Also, talking with physicians hasn't been terribly helpful. These are geriatric clients with new PEG's and the hourly increase is predicated on the residual obtained.

So, do I understand correctly - it is really not a very accurate method?

Thanks again,

Suzanne