I am a pediatric surgery NP with 30+ years of experience. My hope is that this article will precipitate dialogue regarding gastrostomy issues. The gastrostomy tube placement is my favorite surgery (odd comment, right?) as it allows kids to reach their greatest potential. Please send your questions and thoughts.
Pediatric Gastrostomy Tube Changes
Routine gastrostomy tube (gtube) changes occur every 4-6 months or as needed for low profile balloon devices. As the device can break within a day, it is always good practice to have a correct size spare with the child at all times. This spare should accompany the patient to school, on vacation, or anywhere the child is transported. Prior to the patient’s discharge from the hospital, a prescription should be faxed to a DME company with the correct size and type of device. Parents should be instructed to notify their DME company when the spare has been used.
As many of our special needs children receive Medicaid benefits, it is important to know that Medicare allows for payment of one gtube (or three nasogastric tubes) every 90 days. In the case of an inadvertent dislodgement or device breakage, the supplier must provide documentation to support the medical necessity of the need for a spare device.
For children with a mature laparoscopic or open surgically placed gastrostomy tract (not a first postoperative replacement) confirmation of gastric placement is by aspiration of gastric contents or via a water-soluble contrast study through the tube. At my institution, a mature tract is typically six weeks postoperatively, although gastric confirmation is demonstrated (and documented) after every gtube change. Should an inadvertent dislodgement of the gtube be discovered with an intact balloon, our hospital nurses teach caregivers to remove the water from the balloon and replace the same device using a water soluble lubricant. The nurses consult our pediatric surgery service if the gastrostomy tube has been recently placed and do not feed the child until the team verifies gastric placement. Gastric confirmation is verified by either confirmation of gastric placement by aspiration of gastric contents or via a water-soluble contrast study through the gtube. Feeding outside of the stomach can result in peritonitis and death, and the most significant teaching point that must be stressed to each family.
Our nurses also teach families how to unclog gtubes to restore patency. This can be done with warm water or an enzyme solution to dissolve protein clogs. All caregivers have a contact number (nurse practitioner voicemail) in order to trouble shoot minor problems after discharge from the hospital. It is also very important for all gastrostomy tubes to be properly secured when the attachment device is in place.
Non balloon devices are usually changed annually by an NP or MD, or as needed if broken. These replacements are either scheduled in the NP clinic with a local anesthetic, or our sedation suite.
It’s important to understand that gastrostomy tubes may be surgically placed by different clinicians, using different techniques. Within a ten-mile radius of my institution, a child’s gastrostomy may have been placed by endoscopy, laparoscopy, or an open surgery. Before a gtube is changed, it is important to note the date of placement as well as the operative technique. This is important as there are different morbidities involved with the type of placement. If a child presents to my clinic or hospital requiring a change, a surgical history including an operative note is necessary before removing the tube. This operative note will verify the actual date of placement, and technique employed by the physician. If there is ever a question of gastric placement, a tube study is done prior to introduction of feeds. In the case of accidental dislodgement, we ask our caregivers to replace the tube as soon as possible. The tract will begin closing within 24 hours (in some cases within an hour), so placement of a replacement tube should not be delayed.