Nasogastric Tube Management

General Recommendations

• The Centers for Disease Control and Prevention recommends removing the nasogastric tube as soon as clinically indicated to reduce infection risk, and elevating the head of the bed 30-45° for patients with nasogastric tubes can reduce aspiration risk 1, 2
• Routine verification of appropriate tube placement is necessary to prevent complications, and assessing intestinal motility (bowel sounds, residual gastric volume) and adjusting feeding rate/volume can help prevent regurgitation 1
• Patients with underlying conditions such as diabetes, obesity, poor nutritional status, chronic corticosteroid or immunosuppressive therapy, hyper-hydrated or inflamed skin, and excess moisture or friction from poorly secured tubes are at higher risk of developing PEG tube site infections, as recommended by Clinical Nutrition guidelines and the European Society for Clinical Nutrition and Metabolism (ESPEN) 3, 4

Infection Prevention and Management

• Signs of infection to look for at the PEG tube site include erythema, purulent or malodorous exudate, loss of skin integrity, pain at the site, and fever, and swabbing the area for fungal or bacterial culture is recommended if infection is suspected 4
• Common pathogens that may cause PEG tube site infections include Candida species, Staphylococcus aureus, and Pseudomonas aeruginosa 4
• Nystatin cream application is appropriate for confirmed or suspected fungal infections at the PEG tube site, and continued application until signs of infection resolve is recommended 4
• Topical antimicrobial agents are recommended as the first line of treatment for suspected bacterial infections at the PEG tube site, and use of antimicrobial dressings (such as silver, iodine, or polyhexamethylene biguanide) is recommended for bacterial infections 4
• Systemic antibiotics should be added if the infection is severe or does not respond to topical treatment, with recommended regimens including:

Tube Care and Maintenance

• The affected area should be cleaned at least once daily using an antimicrobial cleanser to prevent infection and promote healing, and antimicrobial ointment, dressing with sustained-release antimicrobial properties, or barrier film or cream should be applied to protect surrounding skin if there is exudate 3, 4
• Proper tube care, including daily cleaning and dressing changes, is essential to prevent infection, and patients at higher risk for infection should be closely monitored 3
• Cleanse the site daily during the first week after insertion using aseptic technique, and reduce dressings to once or twice weekly after stoma healing (usually 5-7 days) 3
• Cleanse with soap and water of drinking quality after initial healing, and flush the tube with 30-40ml of water before and after each feeding and medication administration 7, 3, 8
• Ensure proper positioning, with the external fixation plate retaining the tube but not exerting tension, and allowing free movement of at least 5mm 8

Patient-Centered Care

• Focus on comfort and quality of life rather than aggressive interventions, and prioritize symptom management over tube replacement for patients with limited life expectancy 4, 9
• Avoid overtightening the external bolster, using topical antibiotics, neglecting fungal infections, and delaying tube removal when indicated in refractory cases, as these can increase the risk of infection and promote resistance 4, 3
• Avoid unnecessary prophylactic systemic antibiotics, which are not indicated for routine care 10