When a patients with a PEG/PEJ/RIG that has come out attends the ED its important that we can either replace it or insert an EN-Plug OR NG tube into the tract to maintain patentcy while being admitted (how to guide is below)

NG/Foley catheters must not be used to administer fluid or feed nor should the patient be sent home with it in-situ.

Equipment

• Dressing pack
• Replacement BGT – 12 or 14Fr
• Optilube®
• 5ml luer slip syringe
• 2 x 10mls sterile water ampule
• pH strip
• 60ml ENfit enteral syringe
• 1 pack of ENplugs

Method

1. Remove any old dressings and clean the entrance of the tract.
2. Replacement tube
   • Patient/Carer may have one – use this.
   • ED Grab Box
   • Endoscopy, MAU and theatre (Also have stock).
3. Unable to insert BGT
   • Attempt placement of an EN-Plug, available in 10 -16fr packs.
   • Alternatively insert a smaller bore NG tube. These will maintain the tract allowing the placement of an appropriate device by the admitting team during routine working hours.
4. Check the expiry date of the replacement tube.
5. Using a sterile technique, check that the balloon inflates evenly by instilling 5ml sterile water (remove water prior to placement).
6. Lubricate the tube with OptiLube®
7. Gently pass it into the tract. (Tip: It sometimes passes more easily if a gentle rotational motion is applied to the tube by rolling it between your fingers and thumb as it is advanced.)
8. Advance it until the balloon is completely within the stomach or bowel (approx. 6 – 8 cm).
9. Gently inflate the Ballon (watching the patient for any signs of discomfort. If inflation of the balloon is painful, it is likely that the balloon is still within the tract. If so, deflate and advance the tube further along the tract then attempt to re-inflate it. )
   • 5mls of sterile water for gastric placement
   • 3-5mls for jejunal placement
10. Once inflated, pull back on the tube until the balloon snugs against the bowel wall
11. Slide the fixation disc up to 5mm from the skin.
12. Aspirate some contents using a 60ml enteral (purple) syringe – test on pH indicator paper. pH 5.5 or less indicates presence of stomach acid, confirming placement in the stomach (NB some medications may alter pH, if >5.5 recheck in 30 – 60 minutes).
13. Slowly flush with 10mls of sterile water – to ensure there is no resistance to flow or discomfort to patient.
14. Clean off excess lubricant or any enteric contents and apply a protective foam dressing with some absorptive capacity – often there is some leakage around replacement tubes. Reassure the patient about this and that it can be addressed when they are reviewed.

Follow up

• If you have managed to reinsert a BGT:
  • Discharge patient and advise Nutrition Specialist Nurses 01484 342096 or via switchboard, and Nutricia Nurse 0345 2501068, 0345 2501069, to arrange follow up at home. Patient will require visit within a week to provide training and equipment if did not have previous balloon device.
• However, arrange for the patient to be admitted under the care of physicians if:
  • There are concerns following BGT placement.
  • EN-Plug or NG tube have been used to maintain the tract.

DO NOT transfer across sites from CRH to the HRI surgical team unless there is some other acute surgical issue. Patients presenting at CRH can be handed to the gastroenterology team at CRH the next morning by the acute medical team.