What is the management plan for an 81-year-old woman with chronic tracheal (tracheostomy) ventilator dependence, who is fed, hydrated, and medicated through a Jejunostomy (JEJ) tube that is now occluded, and can only use her Percutaneous Endoscopic Gastrostomy (PEG) tube for medications and flushing with water?

From the Guidelines

For an 81-year-old woman with chronic tracheostomy ventilator dependence and a blocked JEJ tube, I strongly recommend prioritizing medications based on clinical importance while using the PEG tube for medication administration and minimal water for flushing only, as per the ESPEN guideline on home enteral nutrition 1. The patient's situation requires immediate attention to prevent complications such as malnutrition, dehydration, and medication non-adherence.

• The PEG tube should be used for medication administration, with a focus on life-sustaining medications first, followed by symptom management medications, and lastly maintenance medications.
• Each medication should be administered separately through the PEG tube with minimal water (typically 15-30mL) before and after each medication to prevent clogging, as recommended by the ESPEN guideline 1.
• Liquid formulations are preferred when available, and tablets should be thoroughly crushed to a fine powder and mixed with 10-15mL of water.
• Extended-release, enteric-coated, or sublingual medications should not be crushed and may require alternative formulations or routes. The clinical team should urgently address the blocked JEJ tube situation, as this is the patient's primary nutrition and hydration route.
• While using the PEG for medications temporarily, arrangements should be made to either clear the blockage or replace the JEJ tube within 24-48 hours to prevent malnutrition and dehydration, as mechanical complications such as dislodgement and obstruction of the tubes are quite frequent in patients on home enteral nutrition (HEN) 1.
• Regular assessment of the patient's hydration status is essential during this period, as the limited water used for medication administration will not meet daily hydration requirements.
• If the JEJ tube cannot be restored quickly, alternative nutrition and hydration methods should be considered in consultation with the patient's healthcare team, taking into account the patient's underlying disease, drug treatment, and enteral formula, as well as the administration method 1.

From the Research

Management Plan for an 81-year-old Woman with Chronic Tracheal Ventilator Dependence and Occluded Jejunostomy Tube

The patient's situation involves managing an occluded Jejunostomy (JEJ) tube and relying on a Percutaneous Endoscopic Gastrostomy (PEG) tube for medications and flushing with water. The following points outline considerations for her care:

• PEG Tube Management: According to 2, PEG is an alternative to nasogastric tubes for enteral nutrition when required for four weeks or more. The European Society of Gastrointestinal Endoscopy (ESGE) recommends the "pull" technique as the standard method for PEG placement 3.
• Complications and Management: Awareness of potential complications such as endoscopic technical difficulties, PEG procedure-related complications, and late complications associated with PEG tube use and wound care is crucial 4. Strategies for managing these complications include proper aftercare of the catheter and understanding the indications and contraindications for PEG tube placement.
• Antibiotic Prophylaxis: The use of antibiotic prophylaxis in PEG placement has been studied, with results indicating that a single dose of a beta-lactam antibiotic can decrease the risk of post-procedural wound infection 3, 5.
• Safety in Patients Undergoing Corticosteroid Therapy: PEG tube placement has been shown to be safe in patients receiving corticosteroids, with complication rates comparable to those not receiving steroid medications 6.
• Enteral Nutrition: While the patient's JEJ tube is occluded, the PEG tube can be used for medications and flushing with water. However, for enteral nutrition, alternative methods or replacement of the JEJ tube may be necessary, considering the patient's reliance on ventilator support and her nutritional needs.

Considerations for the Patient's Care

Given the patient's complex medical situation, including chronic tracheal ventilator dependence and the current occlusion of her JEJ tube, a multidisciplinary approach to her care is essential. This includes:

• Monitoring her nutritional status and adjusting her feeding plan as necessary.
• Managing her PEG tube to prevent complications and ensure its continued functionality for medication administration and flushing.
• Considering replacement or alternative methods for her JEJ tube to meet her nutritional needs.
• Regular assessment of her overall health status, including her respiratory function and any potential complications related to her ventilator dependence.