Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging
American Journal of Emergency Medicine (2012) 30, 1501-1506
Original Contribution
Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging
Cory D. Showalter MD a,?, Benjamin Kerrey MD b,
Stephanie Spellman-Kennebeck MD b, Nathan Timm MD b
aDivision of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
bDivision of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, USA
Received 14 November 2011; revised 10 December 2011; accepted 11 December 2011
Abstract
Background: Gastrostomy tube (g-tube) dislodgement is a common problem in special needs children. There are no studies on the frequency of complications after g-tube replacement for children in a pediatric emergency department (ED).
Objectives: The objective of this study is to determine the frequency of misplacement and subsequent complications for children undergoing g-tube replacement in a pediatric ED and the impact of contrast- enhanced confirmatory imaging on ED length of stay .
Methods: This was a retrospective review of children presenting to a pediatric ED over 16 months. Subjects were included if they underwent g-tube replacement in the ED. Records were reviewed for historical and procedural data including patient age, g-tube age, ED LOS, documented difficulties replacing the tube, performance of confirmatory imaging (contrast-enhanced radiograph), and complications identified within 72 hours of ED visit.
Results: A total of 237 children met inclusion criteria. Three (1.2%) had evidence of g-tube misplacement, all of whom underwent confirmatory imaging. One complication from misplacement was identified (gastric outlet obstruction from overfilled balloon). Tract disruption was not identified for any subject. Eighty-four subjects (35%) had confirmatory imaging performed after replacement. Mean ED LOS in the imaged group was 265 vs 142 minutes for the nonimaged group (P b .001). No subjects with documentation of clinical confirmation had subsequent evidence of misplacement.
Conclusions: For children undergoing g-tube replacement in a pediatric ED, misplacement and associated complications were rare. Confirmatory imaging was associated with a considerably longer LOS. In the presence of clinical confirmation, confirmatory imaging may be judiciously used.
(C) 2012
Introduction
In the United States, gastrostomy tube (g-tube) placement in children is an increasingly common procedure [1,2].
* Corresponding author. Tel.: +317 414 6331.
E-mail address: [email protected] (C.D. Showalter).
Gastrostomy tube dislodgement is a frequent complication, occurring in nearly 65% of children within 5 years of placement [2-4]. Timely replacement is required to prevent stoma stenosis [5]. Caregivers can replace the tube at home [6], but a lack of proper equipment, difficulty in replacement, or discomfort with the procedure may prompt caregivers to come to an emergency department (ED) for assistance.
0735-6757/$ - see front matter (C) 2012 doi:10.1016/j.ajem.2011.12.014
The principal concern with any g-tube replacement is misplacement, with resultant tract disruption, obstruction, abdominal wall infection, and/or peritonitis. There are several published reports of improper g-tube positioning after replacement, with patients having associated morbidity and mortality [5,7-11]. Contrast-enhanced radiographs can be used to confirm correct g-tube positioning after replacement, but there is little evidence to justify the value of confirmatory imaging over clinical confirmation. In a retrospective review of pediatric patients presenting to an ED with feeding tube complications, Saavedra et al [4] noted that correct positioning after g-tube replacement by ED physicians was generally confirmed with clinical measures, such as aspiration of gastric contents. The frequency of misplacement and/or false tract creation after g-tube replacement for children in the ED has never been reported. In addition, there are no studies reporting the frequency of confirmatory imaging and the impact of imaging on ED length of stay .
The objective of this study was to determine the frequency of g-tube misplacement and subsequent compli- cations after replacement in a pediatric ED. Additional objectives were to determine the frequency of confirmatory imaging and to determine the impact of confirmatory imaging on ED LOS.
Methods
Study design and setting
We conducted a retrospective review of the medical records of patients presenting to the ED of a tertiary care pediatric institution, which is the primary referral center for children in its region and has approximately 125 000 ED visits a year. This study was conducted following institu- tional review board approval.
Study subjects
Eligible patients were those children with g-tube dislodg- ment undergoing replacement in the ED. We identified potentially eligible patients through an automated query of our electronic health record, using the International Classi- fication of Diseases, 9th Revision (ICD-9), codes related to g- tube replacement (53640, 53641, 56342, 53649, V441, V551, V5882, 97.0, 97.01, 97.02, V53.59, V53.50). The study
period was January 2010 through April 2011. Patients were excluded if they had a nasogastric or gastrostomy-jejunost- omy tube or if the g-tube was replaced outside the ED.
Study protocol and data acquisitions
The 4 study authors (CS, BK, SK, and NT) abstracted all data. Data were entered directly into an electronic database
during review of the electronic health record. Each author collected data for the first 10 subjects, during which data collection methods were standardized and variable definitions refined. During data collection for the initial 10 subjects, there were few substantive disagreements among the 4 authors; a formal analysis of Interrater agreement was not performed. Discrepancies raised by the abstractors were clarified by the primary investigator (PI) during periodic meetings.
Outcomes
The primary outcome measured was the frequency of incorrect g-tube position after replacement in the ED. In- correct g-tube position was defined on confirmatory radiograph as extragastric termination of the g-tube or g- tube balloon, whether intraluminal or extraluminal. For subjects without confirmatory imaging, a chart review was conducted to evaluate return ED or clinic visits within 72 hours of the index visit. Incorrect g-tube position was broadly defined for these subjects as any clinical evidence of a misplaced g-tube, such as feeding intolerance.
The second outcome measured was the frequency of complications after g-tube misplacement in the ED. Com- plications were defined as g-tube tract disruption, obstruc- tion leading to vomiting, or any injury to an intra-abdominal organ. Complications were identified through chart review of any ED or clinic visits within 72 hours of the index visit. In addition, we asked our institution’s attending physicians from the divisions of Pediatric Critical Care and Pediatric Surgery, as well as leaders from Patient Safety and Risk Management, whether they could recall any cases during the study period in which patients had complications from g-tube replacement in the ED. No additional eligible patients were identified through this process.
The third outcome measured was the frequency of confirmatory imaging after replacement. Confirmatory imaging was defined as a contrast-enhanced radiograph performed explicitly to confirm g-tube positioning; for study purposes, only the final radiology interpretation was used. The final outcome measured was ED LOS, defined as the time from patient arrival to discharge from the ED.
Data collected and definitions
Data collected included age, sex, race (white, black, or other), payor status (private or nonprivate), and whether the patient was referred to the ED by an outside physician. Time since g-tube dislodgement was based on caregiver report. When time of dislodgment was unclear, the earliest time at which the caregiver noted the g-tube to be dislodged was used. Age of the g-tube tract was established through chart review to determine the date of initial surgical g-tube placement. If the date of initial placement was unclear from the record, further chart review of patient encounters preceding the index ED visit was performed to determine the tract age as mature (>=60 days)
Clinical evidence of
g-tube misplacement = 0
ICD-9 for gastrostomy tube = 910
No clinical evidence of
g-tube misplacement = 153
Confirmatory imaging
= 84 (35%)
No confirmatory imaging
= 153 (65%)
G-tube misplacement = 3
No g-tube misplacement = 81
Included: G-tube dislodgement and replacement in the ED = 237
Excluded: No g-tube dislodgement or not replaced in the ED = 673
Fig. 1 Study Subjects.
or immature (b60 days). The replacing physician’s level of training (resident, fellow, or attending) and specialty (pediatric emergency medicine, surgery, or other) were also recorded. Data collected on the replacement procedure included reported difficulty, evidence of stoma stenosis, and documented measures of clinical confirmation, including auscultation, aspiration of gastric contents, and observation of feeding tolerance after tube replacement.
Data analysis
We tabulated all data and generated descriptive statistics based on data type, including frequencies for categorical data elements and means and medians for continuous or discrete variables of sufficient range. We intended to compare patients with and without misplacement and complications, to identify those patients at greater risk for either outcome. In addition, we sought to explore the decision to perform confirmatory imaging by comparing the frequency of misplacement, complications, ED LOS, and other clinical characteristics between imaged and nonimaged groups. As appropriate, ?2 test and Student t test were used to test for differences between groups, with ? set a priori at 0.05.
Sample size
Because we anticipated that g-tube misplacement might be rare in study subjects, we used ED LOS and imaging status to estimate a study sample size. Assuming a 30-minute difference in LOS (SD, 60 minutes) between subjects with and without confirmatory imaging and standard ? and ? errors (5% and 20%, respectively), we estimated that 64 patients would be needed in each group (imaging and no imaging). The assumptions for ED LOS were based on data from published work [12].
Results
The ICD-9, codes related to g-tubes were identified for 910 ED patients who presented during the period of interest (January 2010 through April 2011). Of these patients, 237 met inclusion criteria for the study; the remaining 673 were excluded because they did not have a g-tube replaced in the ED (Fig. 1).
The mean age of study subjects was 6.2 years. Most subjects had a mature g-tube tract. Most g-tubes were replaced by a resident; 77% were replaced without surgery involvement. The mean time from g-tube dislodgement to ED presentation was 4.1 hours (Table 1).
Of the 237 study subjects, 3 (1.2%) had incorrect g-tube position after replacement in the ED, all identified on confirmatory imaging. Of the 3 subjects with incorrect g-tube position, only 1 complication (0.4%) was identified-1 subject had subsequent gastric outlet obstruction. Tract disruption was not identified for any subject. Eighty-four patients (35%) had confirmatory imaging after dislodged g- tube replacement. Mean ED LOS in the imaged group was 265 vs 142 minutes for the nonimaged group (P b .001).
The first subject with misplacement was a 15-month-old girl with a mature g-tube tract whose tube was dislodged 1 hour before ED arrival. The 1.5-cm low-profile style g-tube was replaced by a resident. There was no documentation of clinical confirmation or retention balloon volume. Confir- matory imaging showed correct g-tube placement during the initial ED visit. The subject returned to the ED 2 weeks later with poor tolerance of g-tube feeds. Repeat fluoroscopy revealed gastric outlet obstruction caused by an overfilled retention balloon, which was rectified during that visit. The second subject was a 2-year-old girl with a mature g-tube tract, whose g-tube was dislodged less than 1 hour before presentation and was replaced by an attending physician. No
clinical confirmation of replacement was documented. The g-tube was repositioned by a radiologist after confirmatory fluoroscopy demonstrated the tube was postpyloric. The third subject was a 6-month-old boy whose g-tube dislodged 4 hours before ED arrival. His g-tube tract was 20 days old. The g-tube was replaced by a surgery resident in the ED. No clinical confirmation of g-tube placement was documented. A radiologist repositioned the g-tube after confirmatory fluoroscopy, performed immediately after replacement, demonstrated the retention balloon incorrectly located in the duodenum.
Table 1 Demographic and other characteristics
Of the 237 subjects, 160 (68%) had some documentation of proper tube position by clinical confirmation. Thirty-three subjects (14%) had neither documentation of clinical confirmation nor radiographic confirmation of proper Tube location (Table 2). No subjects with g-tube misplacement had documentation of clinical confirmation. No subjects with documentation of clinical confirmation had subsequent evidence of misplacement, whether or not confirmatory imaging was performed.
There were insufficient subjects with misplacement and complications to assess for group differences. Patient characteristics were compared between the imaged and nonimaged groups (Table 2). Confirmatory imaging was
more commonly performed for subjects with the following characteristics: white race, nonprivate insurance, g-tube tract age less than 60 days, replacement by a fellow in pediatric emergency medicine or surgery, and evidence of replace- ment difficulty or stoma stenosis. For the imaged group,
Table 2 Patient and replacement characteristics by imaging category
|
Mean (median, range) or no. of patients (%) shown, n = 237 |
|
Patient Imaged Not imaged P characteristics |
|
Age (y) 6.2 (4.0, 0-27) 6.2 (3.0, 0-29) .963 Sex Female 35 (33) 71 (67) .483 Male 49 (37) 82 (63) Race White 68 (43) 92 (58) .005 Black 12 (21) 45 (79) Other 4 (20) 16 (80) Payor status Nonprivate 64 (40) 97 (60) .044 Private 20 (26) 56 (74) Presentation Referral Yes 14 (35) 26 (65) .949 No 70 (35) 127 (65) Time since 5.0 (3.0, 0.5-72) 3.6 (2.0, 0.4-24) .073 dislodgment (h) a Age of g-tube tract b >=60 d 69 (31) 151 (69) b.001 b60 d 15 (88) 2 (12) Providers Training level of replacing provider c Fellow 14 (56) 11 (44) .023 Attending/ 67 (33) 136 (67) resident Replaced by surgery Yes 38 (70) 16 (30) b.001 No 46 (25) 137 (75) Replacement Difficulty with replacement Yes 32 (54) 27 (46) b.001 No 50 (29) 125 (71) Stoma stenosis Yes 58 (46) 68 (54) b.001 No 26 (23) 85 (77) Clinical confirmation Yes 40 (25) 120 (75) b.001 No 44 (57) 33 (43) ED LOS (min) 265 (246, 100-637) 141 (124, 39-437) b.001 |
|
a Documentation of dislodgement time was unclear for 7 subjects. b Date of initial g-tube placement was unclear for 17 subjects; chart review confirmed that tract age was greater than 60 days for all 17 subjects. c Attending physicians and residents were grouped together because resident imaging ordering characteristics were dependent on attending decision making. |
mean time from arrival to imaging order was similar to the total ED LOS for the nonimaged group (152 vs 142 minutes).
Discussion
Our study is the first to report the outcomes of g-tube replacement for children in an ED. In this study, misplace- ment was rare, and we identified no cases of tract disruption. The 1 complication noted after g-tube misplacement was minor and easily addressed. Importantly, among patients with documentation of clinical confirmation, none were identified with g-tube misplacement. Confirmatory imaging was performed in one third of study subjects, and these patients were in the ED an average of 2 hours longer than those who did not undergo imaging.
Prior studies on g-tube misplacement are limited to case reports of complications associated with initial placement [13,14], initial change from a catheter-style tube to a low- profile tube [7,11,15], or replacement through an immature g-tube tract [13]. Saavedra et al [4] is the only study to describe children presenting to a pediatric ED with g-tube dislodgement. This study did not report the frequency of misplacement, complications, or confirmatory imaging after g-tube replacement in the ED, nor did it address the impact on ED LOS associated with confirmatory imaging. Our study directly addresses each of these issues.
If the low frequency of misplacement in our study is representative, there are several reasons to support limited use of confirmatory imaging. First, in our study, there was limited to no clinical benefit to confirmatory imaging. Second, although the radiation from a single plain radiograph is low (reported at 150-500 mrad or 1.5-5 mGy) [16], patients with a g-tube typically receive frequent imaging studies with higher cumulative radiation exposure. Third, our results suggest that LOS may be considerably greater for patients with confir- matory imaging, which has potentially negative implications for patient/family experience and ED flow.
We were surprised that one third of subjects had no documentation of clinical confirmation of g-tube position, particularly in light of the high success rate of g-tube replacement in our study. Moreover, a notable percentage of subjects had neither clinical confirmation documented nor confirmatory imaging. This finding is consistent with a previous study showing a deficiency in documentation for the majority of g-tubes replaced in the ED [4]. These deficiencies have clear medicolegal and quality assurance implications. Poor documentation of confirmation, particu- larly for patients without confirmatory imaging, creates a potential liability for the providers in the unlikely case of g- tube misplacement and associated morbidity [17]. An institutional policy statement regarding g-tube placement confirmation would be helpful in standardizing documenta- tion of the procedure.
Our study demonstrated that patients undergoing confir- matory imaging had significantly higher rates of immature
tracts, difficult g-tube replacement, and stoma stenosis. We surmise that practitioners perceived these children as higher risk for misplacement, prompting radiographic confirmation. That perception was not supported by our study results.
This study has several limitations. First, the validity of our estimates may be limited by the quality of documentation in the written record. The study was designed and conducted to maximize the quality of the data collection based on published standards [18]. Second, g-tube misplacement and tract disruption are rare events, and our sample size was not large enough to perform any analysis for factors associated with misplacement or complications. The subset of patients in our study who did not undergo imaging did well after replacement; however, because of our study’s sample size, we are unable to make specific recommendations on the safe omission of confirmatory imaging. Third, although we reviewed the medical record of each patient to identify return visits, it is possible, but unlikely, that a patient with tract disruption could have presented to another hospital for treatment. Our setting is the primary referral center for the entire region, and most children would return to our institution for complications of care, particularly those with chronic medical conditions. Finally, we performed this study at a single academic pediatric ED; our results may not generalize to the general or community ED setting.
Conclusions
Gastrostomy tube replacement was highly successful and safe for children in a pediatric ED. Clinical confirmation of g-tube positioning was documented inconsistently, and confirmatory imaging was associated with considerably longer LOS, without clear benefit to the patient. For children undergoing g-tube replacement in the ED, our study supports the more judicious use of confirmatory imaging.
Acknowledgments
We would like to acknowledge Terri Byczkowski, PhD, and Wendy Pomerantz, MD, of the Division of Emergency Medicine of Cincinnati Children’s Hospital Medical Center for their statistical and editorial support.
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