From the Guidelines
When a patient pulls out a PEG tube in an urgent care setting, immediate action is required to prevent closure of the stoma tract, and the best course of action is to attempt to reinsert a replacement tube of the same size or a Foley catheter (16-18 Fr) as a temporary measure to maintain tract patency, as recommended by general medical guidelines and practices 1.
Key Considerations
- Stabilize the patient and assess for any complications such as bleeding or signs of peritonitis.
- If the tube has been out for less than 24 hours, attempt to reinsert a replacement tube of the same size or a Foley catheter (16-18 Fr) as a temporary measure to maintain tract patency.
- Apply water-soluble lubricant to the tube and gently insert it through the stoma to the same depth as the original tube.
- Confirm proper placement by aspirating gastric contents or instilling 10-20 mL of water and checking for coughing or respiratory distress.
Potential Complications
- Gastrostomy tracts can begin to close within 4-6 hours and may completely close within 24 hours, potentially requiring surgical intervention for new tube placement.
- Local wound infection, peristomal abdominal pain, fever, and transient leakage of stomach contents are possible complications that can be managed with proper aftercare and treatment.
Aftercare and Treatment
- Cover the stoma site with a clean dressing and arrange immediate transfer to an emergency department or gastroenterology service if unable to reinsert or if the tube has been out for more than 24 hours.
- Do not attempt to feed through a newly reinserted tube until proper placement is confirmed.
- Provide proper aftercare and treatment to prevent long-term complications such as occlusion of the tube, tube porosity, and fracture, and development of cellulitis, eczema, or hypergranulation tissue.
From the Research
Management of Inadvertent Removal of Peg Tube
When a patient pulls out a peg tube in an urgent care setting, the following steps can be taken:
- Replace the peg tube as soon as possible to prevent complications and ensure continued nutrition and hydration 2
- Provide pre-discharge instructions to the patient and their caregivers on how to manage the peg tube and prevent future removals 2
- Regular follow-up with the patient to monitor for any signs of infection, occlusion, or other complications related to the peg tube 2
Prevention of Complications
To prevent complications associated with peg tubes, the following strategies can be implemented:
- Regular follow-up with the patient to monitor for any signs of infection, occlusion, or other complications 2
- Provide pre-discharge instructions to the patient and their caregivers on how to manage the peg tube and prevent future removals 2
- Programmed tube changes to prevent occlusion and other complications 2
Nutrition and Hydration
It is essential to ensure that patients with peg tubes receive adequate nutrition and hydration:
- Predicting the nutritional and fluid requirements of enterally-fed patients can be challenging, and close monitoring is required to prevent malnutrition and dehydration 3
- Regular review by a dietitian is necessary to balance the delivery of adequate feed and fluids to meet each patient's individual needs 3
- Increasing awareness of the signs of malnutrition and dehydration among those involved in a patient's care can help detect deficiencies early on and rectify them before complications occur 3