Securing a leaking peg feeding tube
This case study looks at the use of eakin Wound Pouch to secure a leaking feeding tube.
By Delysia Tennant RN STN Hollywood Private Hospital Perth Western Australia
Ms B a 49yo single mother of 2 with supportive parents was admitted to hospital Nov 2015 with severe burning and leakage from her Jejunostomy feeding tube.
On review her past medical history consisted of
1. Multiple Myeloma with chemo treatment completed July 15
2. Gastric Banding 2001 (moderate wt. loss achieved)
3. Small bowel obstruction secondary to migrated gastric band May 15
4. Gastrocutaeneous fistula with Jejunostomy tube insertion June 15
The long term plan was to repair the fistula after she underwent
stem cell treatment and recovery for the Myeloma.
This would not be achieved for at least another 10 months.
Physically Ms B was in good health but the constant leaking and worry for her health had taken its toll and she was now extremely anxious as were her parents.
Community care had been unable to contain the leaking with either dressings or bags successfully with leaking occurring usually within only a few hours after being redressed.
The biggest problem was the need to keep the feeding tube free to allow for the necessary ongoing feeding regime as she was only allowed a small amount of water orally.
The second problem was that Ms B was still undergoing intensive treatment and her body was prone to swelling and her abdo distending as well as causing her to have severe thirst.
While drinking did not interfere with her health in any way it did cause an increase in leakage from the fistula. Due to her mental state I felt it was important that she was able to assuage this craving and drink whatever she felt she needed but I then needed to create a system that could deal with this excessive output.
1. Distended abdo with creasing at “3” and “9” with movement
2. Deep funnel shaped indent
3. Tubing was mobile with balloon often migrating out and needing to be replaced or reinserted.
4. Copious amounts of leaking viscous fluid
5. Tubing needed to be accessible for feeding
6. Only able to see patient once a week on a Friday (as pt. refused to
see anyone else and had treatment at the hospital every Friday).
At first I tried a two piece convex high output pouch using a belt and securing the tubing through the pouch. While this was successful it only lasted 2 to 3 days when not distended and only 24hrs with distention.
After sourcing an Eakin wound pouch I created the same system as the two piece with the tubing fed through the bag. This was wonderfully successful to the delight of both Ms B and myself.
With the exception of when the balloon for the tubing was dislodged we were able to keep the appliance in place for a full week and change it every Friday.
We used a large abdo eakin wound pouch with a drainage plug preferably to the side as this drained more easily and did not interfere with the peg.
First I snipped out the centre of the pouch to allow for stretching around the large peg fittings.
I then applied a layer of opsite/tegaderm and then a hydrocolloid ring followed by another opsite /tegaderm layer over this before I cut the centre of the ring out to allow for the peg tube to be placed through the pouch. ( by placing the opsite on before and after I increased the tensile strength of the pouch as well as waterproofing the seal
as moisture made the seal swell and often leak and was very tacky to remove from the tubing itself when it came to changing it. The added benefit was that I could stretch the seal to accommodate the large plugs and it would spring back to a smaller diameter for the tubing and so, less likely to leak through).
The prepared pouch was then placed under Ms B to warm up while we removed the old pouch and aired the skin for 10 minutes.
The skin was prepared after airing with powder, barrier spray and an eakin seal or stomahesive wafer around the exit site. (paste disintegrated too readily)
It was difficult to get the peg through the both holes with the backing removed so this was done in two halves.
First the tube was placed into the eakin and threaded through the seal.
We then removed half of the backing paper and ripped it off and placed it in position then ripped the rest of the backing off and applied into position.
The exit site was then moulded firmly with a finger until well sealed.
Once secure on the abdo it was then necessary to secure the tubing around the seal.
This took several layers but was very effective with never any leakages.
A second stoma seal was wrapped tightly around the tube followed by a piece of hydrocolloid wafer and then fixomull stretch tape
Despite the fact that it did not leak for the 7 days there was at times moderate erosion immediately around the exit site. This varied with how much she was drinking at the time. Ideally we would have changed the pouch every third day which I am sure would have kept the skin in excellent condition.
As it was, we successfully stopped the continuous leaking, allowed her to drink as needed and improved her mental state.
This allowed her to continue her treatments without the stress and worry of leakage with painfully eroded skin.
At the time of this report I am waiting to hear if she has successfully had the fistula reversed.