A patient is sent from nursing home at 10pm for a non-functioning PEG tube. He has a prior history of stroke with L sided weakness and is now bedbound at baseline. He has stable vitals, no abdominal tenderness, and is otherwise well appearing. What do you do next? You could call GI to help, but there is no G-tube nurse* overnight so the patient would have to wait until morning. Here are some steps you can try:
First, you need to make sure that the visible part of the PEG is intact. Tubes can deteriorate over a period of time, and a cracked or leaking tube will need to be exchanged by GI. If the tube appears intact, it is likely just clogged.
Gather your supplies:
- 60mL catheter-tip syringe
- basin with warm water
- chux
- face shield
Attach the syringe and attempt to apply suction. If that fails (which is likely, since the nursing home has hopefully tried this before declaring the tube nonfunctioning), attempt to instill approximately 10mL of warm water into the PEG tube. If this does not go in easily, move the plunger back and forth for a few minutes to try to break up the clog. If you can palpate or see material in the tube you can also attempt to break this up by pinching or massaging the tube between your fingers. Here is a demonstration video.
If after a few minutes you are still not succeeding, instill as much warm water into the tube as you can, clamp the tube, and walk away for 20 minutes. This gives the clog some time to soak and hopefully loosen up. When you come back, again try to agitate the contents of the tube using the syringe. This has generally worked well for me.
Warm water is still not doing the trick? Theoretically you can mix crushed pancrelipase with a sodium bicarb tablet and dissolve in water, then instill and soak in that solution. I have not needed to get this far down the pathway so I can’t speak to how to operationalize it, but GI may be able to guide you over the phone. Carbonated sodas have also been tried but studies have generally found that to be less effective than just warm water.
And if all of the above have not worked, you can call GI and have your patient wait until morning knowing you have put in a valiant effort to unclog their tube.
*The G-tube nurse is an actual nurse at Sinai that can bring down specialized thin brushes to clean out clogged tubes.
References:
- J Soscia, JN Friedman. A guide to the management of common gastrostomy and gastrojejunostomy tube problems. Paediatr child Health 2011;16(5):281-287.
- LM Dandeles, AE Lodolce. Efficacy of agents to prevent and treat enteral feeding tube clogs. Ann Pharmacother. 2011 May;45(5):676-80. doi: 10.1345/aph.1P487. Epub 2011 Apr 26.
