PEG dressing options

[jessieh13]

Hi all

I work with home health, and this is in regards to a colleague's patient who has had a PEG for a LONG time (can't swallow d/t cancer and the treatments), and is having a lot of issues with the skin surrounding the PEG.

There is an ostomy nurse at the nearby hospital that works with the patient and passes down orders, however they often don't make sense (I recently got my WCC training, but no ostomy training...) and the most recent set is at a new level of crazy.

The issue is that this patient has a lot of oozing around the tube, usually made up of stomach contents (yeah, that's its own issue, we won't even go there). So the challenge has been to absorb all of that and protect the skin. From what I can tell they have been doing things like layer ostomy powder with aloe vesta etc which mostly just makes this abrasive paste, and then laying down a split gauze sponge. After the last visit to the ostomy nurse the pt was told "cotton kills" and the split sponges were d/c'd. The new orders are for 2-3x daily dsg changes on this thing, using mepilex foam (yep, the stuff that's like $7 each and supposed to stay on for 2-5 days) and antifungal powder.

I've tried suggesting doing crusting, but I guess that suggestion was brushed off.

I can't think what else could be put around the tube that would be absorbent and NOT a mepilex foam (which, unsurprisingly, isn't absorbing the drng well because it's basically stomach acid and tube feedings).

Any ideas from ostomy nurses or nurses who work with PEG tubes a lot? The poor pt is constantly uncomfortable, and has high levels of anxiety anyway so this really isn't helping...

[karen4164]

Jessiah,

I am a CWOCN and have come across this issue many times. What most WOC nurses do when a tube constantly leaks and dressings cannot manage the drainage and there is subsequent skin breakdown we will pouch around it. This can be done with a number of appliances, even fecal incontinence pouches. What you have to do however, is pull the tube out of the pouch near the top of the pouch so you have access to it. When you do this you will need to tape around the tube has it comes out of the pouch so there is no leaking or little leaking. Then the drainage goes into the pouch and it is contained until emptied. Hollister has a specific product that helps with securing the tube but right now I do not have access to the number or what it is called.

You may wan to call the Hollister rep in your area. If you need further detail let me know. If you need consultation by another WOC in the area go to Wound, Ostomy and Continence Nurses Society™ (WOCN®) and you can do a search for a local WOC nurse. Good luck!

Karen

[BeenThere2012, ASN, RN]

I am not an ostomy nurse, but have seen a few things done successfully over the years for this problem. However, it does involve some gauze and so I am wondering what is meant by "cotton kills"? Was it explained why a Cotton gauze is not recommended any longer?

[ProBeeRN, BSN, RN]

I agree with karen4164 about pouching the peg. Is the tube stabilized? Sometimes if the tube is stabilized properly the tract will shrink and stop the leakage. Try a commercial stabilizer, Hollister has one.

[jessieh13]

Thank you all!

Karen and ProBee I will have to look into those pouches and stabilizers...very good to know!

BeenThere...I don't know what she meant by that. "Cotton kills" is something said by campers/hikers etc, because of how it can cause hypothermia when it's the only thing worn as clothing...not exactly a medical statement about dressings. There's no reason I can think of that cotton couldn't be used.

Fortunately, this patient's nutritionist suddenly noticed that she has lactose intolerance, and has been getting tons of milk based products in her tube. They changed her feeding formula, and almost all of the leaking has stopped (I've been saying for a while that I will try to find a solution for the skin, but that really we need to be asking why she's leaking).

Also, after discussion with people who are NOT the ostomy nurse the patient decided to begin refusing the mepilex foam, and demanding a silver alginate...her skin healed up within a week.

[TammyG]

With a leaky PEG, I always like to do a crusting and then use a wound pouch to keep the discharge off of the skin. If done correctly, this almost always works. I can only think that the "cotton kills" comment refers to the fact that the sponge will absorb the acidic contents that are leaking and hold them against the healthy skin, further damaging the skin. Good idea to figure out why the PEG is leaking, frankly I don't give that enough attention. I honestly did not think that it is usually related to diet but maybe it is . . .