Vent! PEG tube replacement

chrisrn24 · Aug 12, 2013

Stomas close very quickly. I believe with a provider order it is okay to insert a Foley to keep the stoma open.

However he should've returned with either a new PEG or it fixed. I would've called the ER to see what happened. Why did they send him back with the Foley in and no new PEG tube?

Advanced Practice Columnist / Guide · Aug 12, 2013

A few points to bear in mind in these situations as PEG tubes do get dislodged quite frequently usually from the patient being confused and pulling it.

1. Your nursing home should have a policy and procedure regarding PEG tube care including what nurses should do in case of dislodgement.

2. As a rule, the age of the PEG tube or the time when the PEG was initially placed by a physician and the time of the PEG's dislodgement, determines whether you should stick a replacement PEG tube in or not. Feshly-placed PEG tubes and those that were placed 1-2 weeks has not formed a mature tract yet. This tract is a patent tunnel that communicates from the outer skin stoma to the opening in the stomach itself. Never replace or stick anything into a PEG that has not formed a mature track! You don't know where the tip of that tube will go. The right thing to do is to send to the ED and have a surgeon reinsert the tube under Fluoroscopy or Endoscopy.

3. If the PEG has a mature track. It is perfectly acceptable to place a similar French Foley Catheter through the stoma temporarily while a replacement PEG tube is not available. However, Foley catheters do not have anchoring devices on the external stoma, only a balloon on the tip that could prevent the Foley from sliding out. You also can not trust auscultation or aspiration of gastric contents as confirmation of placement. The patient should be checked in the ED where radiographic tests can be done.

4. No matter how old the PEG tube is, the right thing to do is to have it replaced right away because the tract will close within hours if a tube is not placed.

I did some web searches on this issue. Some places actually allow Foley catheters as a replacement PEG tube. A small research study compared PEG tube replacement with another PEG tube vs a Foley catheter: Comparison of Foley catheter as ... [Gastrointest Endosc. 1994 Mar-Apr] - PubMed - NCBI

Regarding what happened in the OP's case. Be careful with PEG's. There is a case in California where a nurse replaced a freshly placed PEG on a patient who accidentally pulled it. The nurse thought she was doing the right thing, checked placement by auscultation alone, and the patient became sick and was taken to the ED later and died. The PEG tip was inadvertently reinserted to the peritoneal space. The case is found here if you want to read it: http://rn.ca.gov/public/rn533139.pdf

Anna Flaxis, BSN, RN · Aug 12, 2013

It's totally fine to replace a PEG tube with a Foley catheter. They even use red rubber catheters for J-Tubes sometimes (in this case it's important to tape it down because there is nothing holding it in and it can be pulled out very easily). Urinary catheters can be very cost effective substitutes for more expensive commercially made enteral tubes.

Probably what happened at the ED was that they saw that he had an enteral tube in place, they checked it for patency, and left well enough alone, knowing that you would have to follow up with his primary and report the dislodged tube. The primary would then decide the next steps, but in the meantime, the patient had a means to receive feedings.

Also keep in mind that in many instances, the ED does not have access to the type of enteral feeding device that the patient normally takes, and may insert a Foley in the meantime until the patient can be evaluated by their primary.

chrisrn24 · Aug 12, 2013

It's totally fine to replace a PEG tube with a Foley catheter. They even use red rubber catheters for J-Tubes sometimes (in this case it's important to tape it down because there is nothing holding it in and it can be pulled out very easily). Urinary catheters can be very cost effective substitutes for more expensive commercially made enteral tubes.
Probably what happened at the ED was that they saw that he had an enteral tube in place, they checked it for patency, and left well enough alone, knowing that you would have to follow up with his primary and report the dislodged tube. The primary would then decide the next steps, but in the meantime, the patient had a means to receive feedings.
Also keep in mind that in many instances, the ED does not have access to the type of enteral feeding device that the patient normally takes, and may insert a Foley in the meantime until the patient can be evaluated by their primary.

Or can be seen by the right provider to insert... I've heard before that on call radiology teams have to be called in for emergency PEGs.

Anna Flaxis, BSN, RN · Aug 12, 2013

@ chrisrn24,

It depends upon the situation. If the person has an established PEG tube, it can often just be replaced by the MD and then confirmed radiographically.

chrisrn24 · Aug 12, 2013

@ chrisrn24,
It depends upon the situation. If the person has an established PEG tube, it can often just be replaced by the MD and then confirmed radiographically.

Ah yes thank you! You just mean like in a clinic setting right? As opposed to going to a hospital?

Anna Flaxis, BSN, RN · Aug 12, 2013

Not necessarily. We would do this in the ED.

RN&mom · Aug 12, 2013

This is a huge pet peeve of mine, (but I do follow regulations and never replace them)! I just think its rediculous that a parent with no medical knowledge can change a feeding tube (I know I did it on my son every month, or whenever he pulled it out)... Yet RN's can not be trained to do it? It is really easy and you can check for placement with a stethoscope. If its safe for thousands of children to have parents changing them at home I really don't see why we as nurses can't do it?

Anyway, yes at my facity the policy is to put a foley in the hole so it doesn't close. Though if someone has had a tube for years it probably won't close on its own anyway, my son only had his tube for 1 yr and it had to be surgically closed because it wouldn't close completely on its own and I've heard of this happening a lot... So you probably have time but better safe than sorry. I'm very confused as to them sending him back with the foley still in, not trying to put the ER down but what's the point of sending them out then? Obviously they confirmed placement but it seriously is easier to put a g-tube in than a foley or supra pubic, it takes like 5 seconds once your field is set up... Maybe they didn't have that tube though? I personally would have called an on call or my DON before giving a feed through a catheter. But I know it's hard when your supervisor is telling you to do something (I'm charge but if my girls ever felt uncomfortable I would gladly let them call the DON) its still your license...

Anna Flaxis, BSN, RN · Aug 12, 2013

I'm very confused as to them sending him back with the foley still in, not trying to put the ER down but what's the point of sending them out then? Obviously they confirmed placement but it seriously is easier to put a g-tube in than a foley or supra pubic, it takes like 5 seconds once your field is set up... Maybe they didn't have that tube though?

Most likely the ED does not stock G-Tubes.

MunoRN, RN · Aug 12, 2013

At least at my facility we don't replace PEG's after hours, it's not emergent. We typically put a foley in until it gets replaced the next day.

chrisrn24 · Aug 12, 2013

At least at my facility we don't replace PEG's after hours it's not emergent. We typically put a foley in until it gets replaced the next day.[/quote']
And give the feeding through that?