Emergency Presentations for Gastrostomy Complications Are Similar in Adults and Children

Troubleshooting the pediatric gastrostomy

Gastrostomy tubes benefit patients but also introduce hazards and costs. Most of these costs tend to be administratively invisible, but clinically expensive. Nurses, residents, emergency physicians, surgeons, and others routinely manage complaints about gastrostomy tubes or sites, and the time and effort costs are enormous. Despite widespread use of gastrostomy tubes and the large "cost of ownership," scant instruction guides practitioners on troubleshooting the panoply of tube-related problems. Instead, clinical folk-wisdom leaves staff disarmed, resorting to lore or maladaptive work-arounds that are futile or even harmful. But tubes and gastrostomies fail in predictable ways. This guide reviews commonly used gastrostomy tubes and how they are placed. Routine care of these tubes both in the immediate postoperative period and long-term is detailed. Then, specific gastrostomy tube complications and their principle-based countermeasures are described, organized by presenting complaint. Throughout, specific clinical pitfalls are called out along with their remedies. The aim is to demystify these devices and dispel myths that lead to error.

Ultrasound is safe and highly specific for confirmation of proper gastrostomy tube replacement in pediatric patients

BACKGROUND

Gastrostomy tube (GT) dislodgement is a common cause of Pediatric Emergency Department (PED) visits. Postoperative patients and those who require stoma dilation are more likely to have complications during emergent replacement. Although incorrect replacement can cause significant morbidity overall, the occurrence is infrequent. Contrast injection of the GT is considered the standard for confirming proper placement. Case reports in both pediatric and adult patients suggest that ultrasound can be used to confirm proper replacement. The objective of the present study was to assess the utility of ultrasound to confirm GT placement in pediatric patients most at risk for complications from incorrect replacement.

METHODS

This is a non-randomized cohort pilot trial to determine the sensitivity and specificity of ultrasound to confirm proper replacement of a GT in a Pediatric Emergency Department.

RESULTS

We enrolled 55 pediatric subjects, of which 50 had ultrasound imaging after GT replacement in the PED prior to contrast injection. Ultrasound was found to have 96% sensitivity and 100% specificity for confirming GT placement.

CONCLUSIONS

Ultrasound is a safe and reliable confirmatory study to confirm GT placement in pediatric patients, especially those at highest risk of complications from incorrect placement.

LEVEL OF EVIDENCE

II.

Assessment of the effect of colored beverage on gastric returns after gastric tube replacement to enhance placement verification

BACKGROUND

Verification of appropriate placement of newly replaced gastrostomy tubes is essential prior to use to avoid potentially serious adverse events.

PROBLEM

A lack of standardized guidance regarding effective and practical means to verify placement exists. Aspiration or drainage of gastric-like contents is one mean suggested to help determine placement, yet when returns are minimal, this becomes challenging.

MATERIALS, METHOD, INTERVENTION

Oral ingestion or the instillation of a colored beverage prior to tube replacement was used in a midwestern healthcare clinical setting to enhance returns in both volume and color via the newly replaced gastrostomy tube. A retrospective review of this practice was conducted, which included 176 gastric tube replacements over 4 years.

RESULTS

A significant increase in volume of returns via the newly replaced tube was noted (P < .001) and a strong correlation of color to the ingested or consumed beverage was found with 95% of returns reflecting color tinting of the beverage or in many cases, strong color change to that of the beverage color.

CONCLUSION

Presented is a simple, cost-effective method that has shown to be clinically useful in assessing placement of newly replaced gastrostomy tubes that may be useful in other practices and settings.