What volume of water is needed to flush a Percutaneous Endoscopic Gastrostomy (PEG) tube with a device?

PEG Tube Flushing Volume

A PEG tube should be flushed with 30 mL of water before, between, and after each medication administration to maintain patency and prevent tube occlusion. 1

Proper PEG Tube Flushing Protocol

The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines provide clear recommendations for PEG tube flushing:

1. Flush volume: Use 30 mL of water for each flush 1
2. Flushing frequency:
   • Before medication administration
   • Between each medication (when administering multiple medications)
   • After medication administration
   • Before and after enteral feeding

Rationale for 30 mL Volume

This specific volume recommendation is based on evidence that:

• Using at least 30 mL of water for irrigation when giving medicines or when flushing small diameter tubes reduces the number of tube occlusions 1
• Adequate flushing between feed and/or medications is necessary to prevent drug-drug interactions and maintain tube patency 1

Important Considerations for PEG Tube Management

Medication Administration

• Administer drugs individually through the feeding tube 1
• Never mix medications before administration due to risk of drug-drug interactions 1
• Use liquid medication formulations when possible to reduce clogging risk 2
• Avoid hyperosmolar drugs, potassium supplements, iron supplements, and sucralfate as they are more likely to cause clogs 2

Preventing Tube Occlusion

• Tube occlusion is often caused by:
  • Inadequate flushing
  • Medication residue
  • Coagulated protein from formula 3
  • Dried-out protein appears to be a significant factor in difficult-to-clear clogs 3

Type of Water for Flushing

• Recent evidence supports using tap water (of drinking quality) for enteral tube flushes as a safe, cost-effective alternative to sterile water 4
• After initial stoma healing (typically 5-7 days post-procedure), the entry site can be cleansed using soap and water of drinking quality 1

Management of Clogged Tubes

If a tube becomes clogged despite proper flushing:

1. Try warm water flushes first
2. Consider enzyme treatments if water is unsuccessful
3. Mechanical occlusion clearing devices have shown higher success rates (93%) compared to warm water flushes (20%) or enzyme treatments (33%) 3

Common Pitfalls to Avoid

• Insufficient flush volume (less than 30 mL)
• Mixing medications before administration
• Failing to flush between medications
• Not maintaining proper head elevation during and after feeding (minimum 30° elevation) 2
• Inadequate monitoring of tube placement and function

Following these evidence-based guidelines for PEG tube flushing will help maintain tube patency, prevent complications, and ensure proper medication delivery.