We Can't Use Tap Water for G-tube Meds? Only Sterile Water?

[Plagueis]

The following is a link to a recent article from the October 2009 issue of AJN about tube feeding, and how it should be performed. I know that we aren't supposed to mix meds or combine meds with feeding. Plus, we should flush between each med. However, I was surprised to see that it states sterile water should be used for flushing and diluting through a G-tube, not tap water:

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=935429

A few questions: do any of you use sterile water for tube feeding medications? If tap water is bad for tube feeding meds, then shouldn't it also be bad for oral medications? Or to have patients/residents drinking it, in general? (Or us, for that matter?!) I was never taught to use sterile water in school for tube medications.

[Midwest4me]

How odd!! Never heard of such a thing. Seems it would quite expensive to use sterile water and where's the logic in that when the MEDS aren't sterile? I've always used tap water to dilute meds in g-tube feedings.

[Simba&NalasMom, LPN]

I've never used sterile water in the hundreds of GT med administrations I've done. However, article presents an interesting rationale for doing so:

Sterile water meets United States Pharmacopeia standards. Tap water should not be used; it can and often does contain contaminants, including pathogenic microorganisms, pesticides, pharmaceuticals, and heavy metals that might interact with a drug and reduce its bioavailability.

Of course, one could argue the same for drinking tap water. There are several hair-splitting and tedious scientific arguments that could follow.

Though I see the logic in this rationale, I, for one, am pretty skeptical. I think drugs pushed through a GT and flushed with tap water, as long as it's deemed potable, probably absorb just fine and I see no real danger in it. There is also a huge additional expense in using sterile water.

JMHO, but I'm curious as to if and or when JCAHO will get ahold of this and make it regulation...

[mamamerlee, LPN]

I read the article and the instruction sheet. A few things come to mind - I think sterile water is one step too many, although in places where there may be well water, or poor water quality, I would use commercially distilled water.

Although I understand in theory the rationale if giving each med seperately - assuming they are all crushable in the first place - if you have more than 2 or 3 meds, this would be very labor- and supply-intensive. Don't they all mix in the stomach anyway? I take 9 different AM meds - should I take them one at a time? I swallow 7 of them in one swallow, and then the other 2 (Size matters !).

If the patient is in a facility, is the pharmacist aware that the pt has a feeding tube, and is receiving meds thru it? Why would a reputable pharmacist dispense an inappropriate drug type, such as enteric-coated, or other non-crushable med? And what about the MD? ( Hi, Doc! Pt X has a feeding tube, and gets all meds thru it. Policy dictates that we may not crush med Y. What would like instead?) ( and why do WE have to do make that call ?!!)

I am saddened by the fact that many nurses seem to disregard these simple rules. I have taught many family members how to give meds at home thru a variety of feeding devices, and they follow the handouts, like the one in the article. And I remind them to tell any prescriber that the pt receives meds thru a tube, and to ask for liquids whenever possible.

[rachelgeorgina]

We feed and flush with tap water through g-tubes. The stomach isn't sterile and that's where it's going...

[morte, LPN, LVN]

the word "overreaching" comes to mind.......sounds like some one trying to be important.

and distilled water should meet their requirements...and cheaper, though even that seems excessive.

[wooh, BSN, RN]

Well gee, if tap water doesn't meet pharmacological standards, then we better give patients a bottle of sterile water to swig from for their oral meds.

Ridiculous.

[rngolfer53]

the word "overreaching" comes to mind.......sounds like some one trying to be important.

and distilled water should meet their requirements...and cheaper, though even that seems excessive.

I admit to skimming the article, but it mentions that tap water "can" contain the imperfections complained about. I wonder how widespread that problem is, and what concentrations of each substance would be a problem. Is the effect even measurable, given that each Pt will already experience a slightly different bioavailability of any med?

One of the drawbacks of specialized expertise is that the possessors and purveyors of that expertise tend to view the world only from their position. (We as nurses share this trait, too.)

Yes, it's certainly possible to use only sterile water for giving tube meds. But, since resources are limited, the potential harm of using tap water must be balanced against the potential harm of taking money from another part of Pt care to buy sterile water.

[LTACRN]

I work in a long term care setting and about 90% of my patients have a PEG tube and the others usually have duotubes or NGT. These patients get a multitude of medications some of which HAVE to be mixed with warm water to somewhat dissolve them before administration or they would certainly clog a tube. I routinely dilute my medications before administration using tap water unless it is contraindicated in such cases as an electrolyte imbalance. Administering medications using only sterile water is absurd. We as individuals have multiple bacteria in our digestive tracks and by using sterile water you are doing nothing more than creating an extra expense for a patient. It is great that the research is being performed, but there are far more serious issues that need to be researched.

[Flare, ASN, BSN]

it comes to mind that in places with a municipal water system, the water is subjected several times a year to routine tests and screenings for everything from bacteria to lead to chemicals. These tests are mandatory should the water systems experience an issue such as a main break or power failure to the pumphouses. This is another example of needless watse in the medical field.

[llg, PhD, RN]

I've worked in 2 neonatal ICU's in which the plumbing sytem had been contaminated with harmful microorganisms. In one case, it was Serratia. I can't remember what the other bug was.

[catshowlady]

I, too, was taught that the stomach wasn't sterile, so sterile water to dilute G-tube meds was unnecessary. That being said, my facility's policy is to use sterile water, so that is what I use. I also think it overkill to mix and give each med separately. These folks often have at least ten meds per am med pass alone, so passing them this way would be very time-consuming.

I confess to not having read the article, but I was curious that they weren't supposed to be given with feedings? Are they recommending to hold the TF for a particular period of time for all meds? Our facility times meds for 1 hour after meals on purpose (unless contraindicated for a particular med). I have only ever held TF when giving Dilantin per GT.

Interesting...

:paw: