Dehydration and PEG tubes

whoo-ee. if you can't get this resolved immediately, it's time to call the state and make an anonymous report.

I've found that when pegg tubes clog it usually means someone hasn't being doing the water flushes...but that being said I don't take care of pts longer term with g-tubes.

I was told that there is no excuse for someone with a PEG tube to be dehydrated. Most of our residents have q 2-3 hr 200 cc flushes, but I wonder when EVERY tube is clogged, with old coagulated formula in the port, no matter if they are a pump or bolus...

I just hate making assumptions about what other people have or haven't done. It's really hard to tell if the tube has been flushed properly or not. I know for all our feeds except for bolus feeds, we hang the water with the formula and use a kangaroo pump and the pump is programmed to flush automatically. As far as bolus feeds, I have no idea why someone would administer the feed and not flush with water before and after.

Haven't you also seen stomach contents come back up the tube when the person coughs or belches?

As far as no excuse for dehydration, what about severe diarrhea or aggressive diuresis?

I just hate making assumptions about what other people have or haven't done. It's really hard to tell if the tube has been flushed properly or not. I know for all our feeds except for bolus feeds, we hang the water with the formula and use a kangaroo pump and the pump is programmed to flush automatically. As far as bolus feeds, I have no idea why someone would administer the feed and not flush with water before and after.

Haven't you also seen stomach contents come back up the tube when the person coughs or belches?

As far as no excuse for dehydration, what about severe diarrhea or aggressive diuresis?

We don't have pumps that automatically flush(those would be heaven!) And I'm pretty sure they flush with feedings, but the majority of people have for example a 2300 feeding then just flushes at 0100,0300,0500 etc.

In my experience, it's been poorly crushed meds that gum up the tube rather than formula. All the meds given thru a 60ml syringe, then water to clear the syringe but not enough to clear the tube as well. I've been a J-tuber myself for 6 years. Clogged tubes at home? Once. Clogged tubes inpatient? Can't count!

mm

As someone already posted, you can get dehydrated as a result of various means....not just lack of intake. When I worked in a nursing home, we always did I/O on those with feeding tubes. The problem is, if the pt/resident is incontinent that makes exact I/O very difficult. In addition, the liquid stools that can result from tube feeds also can skew I/O numbers. At this point, physical assessment can point to dehydration as can lab values (if the doctor finds the latter necessary).

The problem with maintaining I/O sheets is that one blank can cause a nurse to lose a license. Also, water and solutions have to be given per clear order, you can't just give more water. So if the formula and water is actually being given (happens maybe half of the time, in my experience), then the doc needs to check labs, consult with dietician, and change the orders.

As someone already posted, you can get dehydrated as a result of various means...

I've had a lot of experience with PEG tubes over the past few years, and here is a general rule of thumb: Dehydration isn't usually the concern, its OVER-hydration that you have to be careful with. With the continuous fluid going in and flushes between (as well as meds), there is a lot of fluid going in. Couple that with Co-morbidity and high-protein infusions (which strain the kidneys, especially with someone who is bed-bound), its easy to send someone into fluid overload. This is why everything is strict and spelled out (i.e., how much to flush and how often).

If they are become dehydrated, something else is going on. With a PEG tube, you have much greater control of hydration than a PO diet; you know EXACTLY what is going in, and people don't generally refuse fluid via PEG tube as they might offering them a glass of water to drink. If they are dehydrated, think diarrhea as mentioned above. Also think about kidney function and third spacing - just because the fluid is inside the body doesn't mean its where it needs to be within the body.

I'm concerned about the clogging of the PEG tubes. Granted, with infusions (particularly continuous) its easy for th e feedings to cake up and clog. But if you're flushing every 2 hours with 200 cc, this isn't going to be very likely. This seems aggressive to me, but I don't know the circumstances. Not be by the cynical jerk, but it sounds like some people are skipping flushes (especially if you're concerned about dehydration - 200 cc x 12 a day = 2400 cc a day in flushes alone, let alone bolus/meds/jevity).

Hope this helps

I've yet to see formula clog a g-tube. I've yet to see formula clog a j-tube. And I do peds, so my tubes are teeny tiny. Meds on the other hand, I've seen those clog a LOT of tubes.

I agree that people not following protocol and doing proper flushes before and after is a problem and not crushing meds fine is another. The free water flushes are very important. I get Peg tubes every once and awhile and when these people come from a nursing home you can tell the ones that have been properly maintained. That first flush you do on the tube tells you what has been going on. Most of the people who come in with the peg tubes are dehydrated but it depends on what they are there for, be it diarrhea, emesis, or patient is on a diuretic and hasn't had labs checked for ever.

Ask your pharmacy for liquid meds for TF. Ask company to get self-flushing pumps (will still have to do 2 water bolus as pumps currently only deliver 500 cc water flush, 25 cc per hour). Ask central supply for those great de-clogger tubes