How do you perform a free water flush with a Percutaneous Endoscopic Gastrostomy (PEG) tube?

How to Perform a Free Water Flush with a PEG Tube

Flush the PEG tube with approximately 40 ml of drinking or still mineral water after each feed or medication administration to prevent tube occlusion and maintain patency. 1, 2

Step-by-Step Flushing Technique

When to Flush

• After every feed administration 1, 2
• After every medication administration 1, 2
• Before administering medications or feeds 1
• At least once daily even if not actively using the tube 1

Flushing Volume and Technique

• Use 40 ml of water as the standard flush volume 1, 2
• Use drinking water, still mineral water, fresh tap water, cooled boiled water, or sterile water 1, 3
• For initial tube assessment after placement, use 60 ml of sterile water to verify patency 4
• Ensure complete clearance of the tube with sufficient water volume 2

Proper Flushing Method

1. Draw up 40 ml of appropriate water into a syringe 1, 2
2. Connect the syringe to the PEG tube port
3. Flush the water through the tube using gentle, steady pressure 1
4. Disconnect the syringe and cap the tube appropriately

Critical Considerations for Medication Administration

Medication Preparation

• Use elixirs or suspensions rather than syrups when possible 1
• Establish medication compatibility with the tube before administration 1
• Avoid hyperosmolar drugs, crushed tablets, potassium, iron supplements, and sucralfate as these are particularly likely to cause tube blockage 1

Flushing Protocol with Medications

• Flush with water before giving medications 1
• Flush with water after giving medications 1
• This prevents medication residue from accumulating and causing occlusion 2

Managing Tube Occlusion

If the Tube Becomes Clogged

• First attempt: Flush with warm water 1
• Second attempt: Use an alkaline solution of pancreatic enzymes if warm water fails 1
• Expert intervention: A soft guidewire or commercially available tube declogger may be used by an experienced provider 2

What NOT to Use

• Never use carbonated drinks (including cola) as the sugar content enhances bacterial contamination risk 2, 3
• Never use pineapple juice or sodium bicarbonate solution as these may cause tube degradation 1
• Avoid acidic or sugary solutions that may damage the tube or promote bacterial growth 2

Prevention of Complications

Regular Maintenance

• Inspect the tube regularly for signs of degradation, breakage, or occlusion 2
• Loosen and rotate the gastrostomy tube every week to prevent mucosal overgrowth and blockage 1, 3
• Push the tube approximately 2-3 cm ventrally and carefully pull it back to the resistance of the internal fixation flange during dressing changes 1, 2

External Fixation Plate Management

• Ensure the external fixation plate allows at least 5 mm of free tube movement to prevent pressure necrosis and ischemia 1, 2, 3
• The plate should retain the tube but not exert tension on the stoma canal 1, 2

Common Pitfalls and How to Avoid Them

Insufficient Flushing Volume

• Always use the full 40 ml of water to ensure complete clearance 1, 2
• Insufficient water volume is a primary cause of tube occlusion 2

Using Inappropriate Solutions

• Stick to plain water only for routine flushing 1, 2
• Avoid the temptation to use carbonated beverages or juice-based solutions 1, 2

Neglecting Regular Maintenance

• Small-caliber tubes (like jejunostomies) are especially prone to occlusion and require diligent flushing 2
• Patients with neurological diseases have higher rates of tube occlusion, likely related to increased medication use 2

Monitoring for Problems

• Address tube blockage, leakage, or degradation promptly before issues become severe 2
• Water-soluble contrast can assess tube blockage or intraperitoneal leakage if problems arise 1