How to secure a percutaneous endoscopic gastrostomy (PEG) tube on a confused patient who pulls tubes

Securing PEG Tubes in Confused Patients Who Pull Tubes

Use hand mittens to prevent grasping and replace standard PEG tubes with low-profile button gastrostomy devices, which simply disconnect when pulled rather than dislodging the entire tube. 1

Primary Prevention Strategies

Most Effective: Low-Profile Button Gastrostomy

• Replace the standard PEG tube with a low-profile button gastrostomy device - when the connector tubing is accidentally pulled, it simply disengages while leaving the button securely in place 1
• This is the most definitive solution for patients with delirium, dementia, or altered mental status who are at high risk for inadvertent tube removal 1

Hand Mittens

• Place mittens on the patient's hands to reduce their ability to grasp and pull the gastrostomy tubing 1
• This is a simple, non-invasive first-line intervention that should be implemented immediately 1

Gastropexy Devices at Initial Placement

• Request gastropexy device placement at the time of initial tube insertion - these devices prevent the stomach from falling away from the abdominal wall if premature removal occurs, facilitating safer replacement 1
• This is particularly important in high-risk patients with a history of pulling tubes or IV lines 2

What NOT to Do

• Do not use abdominal binders - they increase side torsion at the gastrostomy site and raise the risk of stoma enlargement 1
• This is a common pitfall that worsens outcomes rather than preventing tube removal 1

Proper External Bumper Positioning

• Maintain approximately 1 cm of free space between the external bumper and the abdominal wall with at least 5 mm of free movement along the tube shaft 3, 4
• Excessive tension between internal and external bumpers increases infection risk (15% of cases) and can cause buried bumper syndrome, local ischemia, and tissue necrosis 4
• Use a Y-compress or sterile dressing placed under the external disc plate to cushion movements 3

Understanding the Risk Timeline

• Accidental gastrostomy tube removal occurs in 1.6%-4.4% of cases, with delirium and dementia being major risk factors 1
• The gastrostomy tract typically matures within 7-10 days but may take up to 4 weeks in malnourished patients, those with ascites, or on corticosteroids 1
• If the tube is removed within the first 14 days, do not attempt blind reinsertion - the tract is immature and blind replacement risks free perforation with separation of the stomach from the abdominal wall 1, 2

Emergency Management if Tube is Pulled

• If recognized immediately: A new gastrostomy tube may be placed through or near the original site using endoscopy or image guidance to seal the stomach against the anterior abdominal wall 1
• If recognition is delayed: Initiate NG suction, broad-spectrum antibiotics, and plan repeat gastrostomy placement in 7-10 days 1
• Reserve surgical exploration for patients with signs of decompensation or peritonitis 1

Patient Selection Considerations

• Patients with a documented history of pulling tubes and IV lines should be identified preoperatively as high-risk candidates requiring enhanced securing strategies from the outset 2
• Consider whether the patient is an appropriate candidate for PEG placement at all, as inadvertent removal by confused patients is a preventable serious complication 2