Enteral nutrition is often considered to be simpler than parenteral nutrition. Although nasogastric feeding is relatively common in hospital and gastrostomy feeding is the most common form of tube feeding in the community, in the past few decades more complex enteral access routes have become available and these may require specialist intervention by healthcare professionals, both for tube insertion and maintenance.

Despite the frequent use of nasogastric tubes for nutrition, an excellent standard of care is needed to avoid the hazard of feeding down an inappropriately placed nasogastric tube - this is a “never event” in NHS England (http://www.nrls.npsa.nhs.uk/resources/collections/never-events/core-list/misplaced-naso-or-orogastric-tube-not-detected-prior-to-use/). pH testing of aspirate is the recommended first-line method of checking tip position for nasogastric tubes and Chest X-ray second-line. X-rays must be interpreted by appropriately trained staff as misinterpretation has been the cause of a number of complications and deaths.

Some of the table below may not be visible at smaller screen sizes – Download the table as a PDF

Tube type Timeframe Common indications Common Insertion methods Hazards Key interventions Common issues

Naso-gastric

Fine bore feeding tubes ≤12fr

Short-term- generally less than 30 days

  • Early post stroke

  • Inadequate oral intake

  • Acute swallowing problem

  • Bedside

Ensuring tip in stomach

www.nnng.org.uk/download-guidelines/

naso-gastric-tube-insertion.pdf

www.nrls.npsa.nhs.uk

pH of aspirate on insertion then prior to every tube use/ daily if fed over 24 hours  to check tip position.

Also check if-

1) Any new or unexplained respiratory symptoms or if oxygen saturations decrease.

2) Episodes of vomiting, retching or coughing spasms.

Repeated displacement  

  • Retention devices may be useful

nnng.org.uk/download-guidelines/ 

Blockage 

  • 50ml enteral syringe + warm water

  • care with medications

nutrition-support/enteral-nutrition/medications

Naso-jejunal

Short-term - generally less than 90 days

  • Reduced gastric emptying

  • Pathology in oesophagus or stomach

  • Bedside magnetic imager

  • Endoscopy

  • Radiological screening

Insertion more complex

Xray after insertion to check tip position then if tube moves or symptoms.

Blockage  

  • may be kinked if too much tube inserted  - pull back to 80-100cm at nose

  • avoid drugs if at all possible

  • 50ml enteral syringe + warm water

Displacement
  • Retention devices may be useful

Gastrostomy

Long-term – generally more than 30 days

  • Longer term in neurological disease

  • Oesophageal pathology

  • Head and neck cancer

  • Brain injury

  • Endoscopy

  • Radiology –push or pull technique

  • Surgery

Inadequate  assessment before insertion

Complications of insertion – peritonitis/inadvertent puncture of colon/bleeding/infection, risk of aspiration

Displacement

Advance/Rotation 1-2weekly

pH check if tube replaced

appropriate 72 hour post procedure care

Displacement

  • If less than 4 weeks post-insertion, great care needed for replacement

  • If more than 4 weeks post-insertion, re-insertion spare tube or catheter as soon as possible to avoid closure of tract.  Closure of tract can occur within 4 hours!!

  • Foley catheters are not licensed  for feed/water/fluid administration and should only be used only be used on a temporary basis until appropriate g- tube available

Local leakage

  • Skin protection

  • Consider whether bumper too tight

Abscess

  • Antibiotics

  • May need removal of gastrostomy

Buried bumper

buried-bumper-diagnosis.pdf

buried-bumper-management.pdf

Damage to tube

  • Connections often replaceable

Jejunostomy

Long-term  - generally  over 30 days

  • Gastroparesis

  • As NJ  but longer term

  • Endoscopy (direct)

  • Endoscopy (extension via gastrostomy)

  • Radiology (transgastric)

  • Surgery

More difficult to insert than gastrostomy

Complications of insertion – peritonitis/inadvertent puncture of colon/bleeding/infection

Extensions liable to displacement

Small bowel volvulus

Displacement

  • If less than 4 weeks post-insertion, great care needed for replacement

  • If more than 4 weeks post-insertion, re-insertion spare tube or catheter as soon as possible to avoid closure of tract.

Blockage

  • 50ml enteral syringe + warm water

Local leakage

  • Skin protection

  • Consider whether bumper too tight

Abscess

  • Antibiotics

  • May need removal of jejunostomy

Damage to tube

  • Connections often replaceable

https://www.bsg.org.uk/resource/bsg-guidelines-for-enteral-feeding-in-adult-hospital-patients.html

https://www.bsg.org.uk/resource/bsg-guideline-on-the-provision-of-a-percutaneously-placed-enteral-tube-feeding-service.html