How to know if air is the problem in a g tube?

gtoko · Apr 20, 2010

How long has she had the gtube? Maybe the end is dilated so much ,from use, that the connections will not hold snugly.

Please post the solution, as this sounds like something that could happen frequently.

Kitty Hawk, ADN, RN · Apr 20, 2010

How long has she had the gtube? Maybe the end is dilated so much ,from use, that the connections will not hold snugly.
Please post the solution, as this sounds like something that could happen frequently.

Well she's been with us since the beginning of the year. However she's ripped out several tubes 2 of which were just foley tubes, (issues of us handling it rather than transport to hospital) so when the balloon didn't hold anymore those were easy to get out for her. The first one was stitched in so well she ended up just snapping it as it didn't come out whole!

This last one I'd say has been in place for about a month. I see what you're saying but then why a few days later will it hold snug and stay that way for awhile?

She gets disconnected from the feed for about 2 hours a day, plus when she goes to therapy. I'm not sure if that "off" time contributes to things settling and holding better? I hope someone has experienced this too, it does seem like an air problem beings it just pops right back out with no pressure.

CaLLaCoDe, BSN, RN · Apr 20, 2010

Just curious to know the average amount of residual you get every four hours while she's on feeding? And I wonder if the feeding rate may be too high, thus putting too much pressure on the cone and catheter? Has the physician ever considered an xray to find out if the catheter is not being blocked somehow internally, could the catheter be kinked? Thanks for posting your query. Hope someone, a nursing genius, comes up with "the answer."

Ivanna_Nurse, BSN, RN · Apr 20, 2010

How about a Lopez valve?? That would seal the g tube side, and provide a snug seal for the feed side. ~Ivanna

Kitty Hawk, ADN, RN · Apr 21, 2010

Well that's just wonderful regarding the comment about residual amount. I was told when I questioned this when we first got her, that there's no need to do that, as it's a continuous feed set by the doctor and of course there will be residual! Basically one of those "this is what they taught in school, but this is real world".

I was also taught that aspirating contents wasn't necessary (let alone testing PH) that auscultation was enough! I even observed this is how 2 different charge nurses handle it w/only auscultation b/c we've had to put in foley's in place of g tubes.

It's set at 75hr w/30cc auto flushes. So should I be concerned if the residual is greater than 100cc? (or less for the 20pct over hourly volume?)

Can I just check for residual when I come onto shift? What if she's been disconnected for a while, then do I wait 4 hours from that point? She's supposed to have 4 hours off from 8a to 12n but that sometimes varies. I work 3-11.

Ivanna-lovely thought about the connector. We don't have access to cool gadgets as it's a SNF. One time she came back with this really nice stopcock that eliminated the need for us to use a stopper (which half the time we use makeshift ones using the plastic part of vial access cannulas) but someone who worked that particular weekend, didn't know how to operate it and took it off AND apparantly tossed it! :madface: I was rather upset when I came on and it was gone, nowhere to be found. I even asked why, if someone didn't know how to use something they wouldn't ask instead of just taking it off. (I was told the person probably didn't know how to use it when I asked why someone would take it off in the first place) I'm not the most mechanical but c'mon the stopcock was wonderful...as you can tell you hit a nerve with that one!

So it's possible it's set too high at 75? This will take some investigation. BTW last night I changed the feeding and now it holds fine. Just 3 hours prior when the previous nurse hooked her back up it wasn't holding again and she had to tape it.

sunnycalifRN · Apr 21, 2010

a few thoughts for you:

1) residual checks: we check residuals Q4, I don't know why your charge RN would say otherwise . . how else will you know if you might be feeding too fast?

2) disconnection problem: a simple check to see if air or too much residual is causing your problem; just get an emesis basis or other container, disconnect the feeding tube and let the PEG drain by gravity. If little or nothing comes out, then your problem isn't pressure, but if a liter drains out fast, you may be feeding too fast (the patient may have gastroparesis)

3) disconnection problem, part 2: the cone connector disconnecting from the PEG. often with PEG's that have been in for a long time, the PEG end is just dilated and you need a new PEG inserted. But, sometimes, the PEG end and the feeding cone get all slimey and won't hold . . . clean both the PEG tube end and the feeding tube cone with alcohol swabs, get them both dry with 2x2's and reconnect. Usually, the clean, dry surfaces will hold much better.

Kitty Hawk, ADN, RN · Apr 21, 2010

a few thoughts for you:
1) residual checks: we check residuals Q4, I don't know why your charge RN would say otherwise . . how else will you know if you might be feeding too fast?
2) disconnection problem: a simple check to see if air or too much residual is causing your problem; just get an emesis basis or other container, disconnect the feeding tube and let the PEG drain by gravity. If little or nothing comes out, then your problem isn't pressure, but if a liter drains out fast, you may be feeding too fast (the patient may have gastroparesis)
3) disconnection problem, part 2: the cone connector disconnecting from the PEG. often with PEG's that have been in for a long time, the PEG end is just dilated and you need a new PEG inserted. But, sometimes, the PEG end and the feeding cone get all slimey and won't hold . . . clean both the PEG tube end and the feeding tube cone with alcohol swabs, get them both dry with 2x2's and reconnect. Usually, the clean, dry surfaces will hold much better.

Thank you! I agree, about the residual checks. I'm going to bring this up again, if I get nowhere I'll just start to do it. That's why I was asking if I can check upon arrival or if I need to wait 4 hours from when I know it was reconnected. Sometimes when I come on it's been running normal since 12n...other times it's been off and reconnected at 2p or so b/c she's off to therapy or the salon (we have a beauty salon)

Thank you for points 2 and 3. I didn't think of something as simple as a basin to use. The slime may be an issue as well. That very well may be why when I hooked up a new feeding it held fine.

Really, thank you very much for taking the time to give me these tips. It may seem like I should have been taught the correct way, but I'm learning there are no hard and fast rules for anything and the way things are done. Once I questioned a blatant mistake that I and another nurse caught and I was told flat out that the majority of nurses don't care and don't take pride in what they do and if I saw some things...that I would be shocked and the mistake we caught was nothing :eek: It definately sucks sometimes trying to navigate being a new nurse.

Pediatric Critical Care Columnist · Apr 21, 2010

I blanched when I read that you're putting Foleys in when patients pull out their PEGs. That's a REALLY dangerous practice. There's nothing to stop peristalsis from pulling that Foley balloon into the proximal duodenum and causing duodenal rupture. PEG tubes are designed with a flange that snugs the balloon up to the gastric wall and prevents much movement of the balloon. The cost to your facility of having a handful of PEGs on hand for this sort of situation is far lower than a wrongful death suit if a patient's bowel ruptures and they die... as happened on our unit recently.

Kitty Hawk, ADN, RN · Apr 21, 2010

I blanched when I read that you're putting Foleys in when patients pull out their PEGs. That's a REALLY dangerous practice. There's nothing to stop peristalsis from pulling that Foley balloon into the proximal duodenum and causing duodenal rupture. PEG tubes are designed with a flange that snugs the balloon up to the gastric wall and prevents much movement of the balloon. The cost to your facility of having a handful of PEGs on hand for this sort of situation is far lower than a wrongful death suit if a patient's bowel ruptures and they die... as happened on our unit recently.

WOW! I did not know that. I'm sure it'll fall on deaf ears if I inform them of this. I was put off by and I questioned the idea of a foley in the first place, as it doesn't seem right in many ways let alone you can't even see if anything is clogged etc...and my concerns were immediately dismissed as they've done it a million times before, they've been nurses a long time, it's perfectly normal etc...

I'm working on getting out of there. For many reasons, mostly it's just not a fit for me, but I'm trying to do the best job I can w/ the circumstances while I'm there. However we sometimes can't get our normal supplies let alone an item like a PEG. The resident has orders though that she can be sent out to the hospital if we can't get a foley in. That'll take care of that on my shift anyway.

Thank you! I do love to learn as much as I can.

Kitty Hawk, ADN, RN · Apr 22, 2010

Mystery may be getting solved.

After coming on shift, nurse going off duty just reconnected her. Connex held fine. About an hour later, the tube connex was apart (she may have pulled it apart she does this) and it was leaking bile again. (same problem at the beginning of the week, she was sent out to the hosp, evaluated and sent back w/no changes, hospital said they couldn't find anything wrong)

I was told to let the bile drain, flush and proceed with meds, b/c nothing was done before at the hospital, it was pointless to send her again. A little more drained out, I was able to give the meds and reconnect feeding but would only hold with tape.

Still bugged about this whole thing and feeling like no answer is also not a solution, I ran into one of the nurses that isn't there freq. I asked for her thoughts, and she mentioned that maybe it's a gas buildup :idea: suddenly I remember that she used to be on omeprazole and zantac and ever since she returned from the hospital about a month ago (sent out for a breathing issue and developed sepsis), they've never restarted these, even though I originally questioned it. I was told the doctor didn't see the need :rolleyes:

So hopefully if he restarts her on these or at least the omeprazole the problem may resolve. However this doctor is known to do his own thing and not listen to us, so it's anybody's guess. It took 2 weeks of us reporting high blood sugars before he finally readjusted her insulin. Thanks again, I appreciated all the tips.

CaLLaCoDe, BSN, RN · Apr 22, 2010

still bugged about this whole thing and feeling like no answer is also not a solution, i ran into one of the nurses that isn't there freq. i asked for her thoughts, and she mentioned that maybe it's a gas buildup suddenly i remember that she used to be on omeprazole and zantac and ever since she returned from the hospital about a month ago (sent out for a breathing issue and developed sepsis), they've never restarted these, even though i originally questioned it. i was told the doctor didn't see the need
so hopefully if he restarts her on these or at least the omeprazole the problem may resolve. however this doctor is known to do his own thing and not listen to us, so it's anybody's guess. it took 2 weeks of us reporting high blood sugars before he finally readjusted her insulin. thanks again, i appreciated all the tips.

i so dislike power tripping mds who don't see us as part of the "team." i wish i could petition to have them fired, but they are the bread and butter of the system, aren't they?!

follow up question: what does this patient's stools look like? is she having stools regularly?