A 23-year-old male with developmental delay and seizure disorder with G-tube dependence is being evaluated in the ED for ankle swelling. He has been waiting for a while before getting into his room and now his seizure medications are due. His caretakers brought his seizure medications but realized he forgot the tubing for his Mickey button. The patient has a tendency to seize when his seizure medications are delayed even for a small amount of time. What are you going to do?
Take Away #1 - What is a Mickey Button?
A Mickey button is a type of G-tube that does not have any external tubing. When viewed on the abdominal wall, there is a small button visible in the left upper quadrant. Mickey buttons are excellent for chronic G-tubes as they are difficult to pull out and they have less tube clogging. However, without the tubing set they are very difficult to access. These tubing sets vary from model to model. Sometimes hospitals may not stock any meaningful amount of them.
The Mickey button has a one-way valve and that prevents reflux of medications and feeds back through the button. This makes it difficult to overcome. You can overcome a Mickey button with a little bit of effort and a 50 cc syringe. The Mickey button one-way valve will accept a Luer-lock if applied with significant pressure to overcome the one-way valve. Once you have the 50 cc syringe attached, you can push in medications and flush with water.
Take Away #2 - Enzymatic G-tube or J-tube declogger
Enzymatic G-tube or J-tube declogger
Obtain 2 tabs of pancrelipase/creon 4200u tablets and 1 tab 325mg sodium bicarbonate from the pharmacy. It may help to call the pharmacy and tell them that you are using it to declog G-tube so they will not decline it.
Tell the nurse to give the tablets to you when she/he receives them, not to administer to the patient. You will need a pill crusher, preferably the silent knight variety with a little baggies. Ask a nurse for help if you’re not familiar with it.
Open the 2 Creon tablets and dump the little pellets inside the capsule into the bag. Crush finely with the silent knight.
Dump into a sterile specimen cup.
Repeat with the sodium bicarbonate.
Add 5 to 10 cc of warm water and shake to combine. This mixture is difficult to get into solution so shake shake shake.
Instill as much of the solution as you can get into the feeding tube and leave for 1 hour. Attempt to flush with water. I
f tube does not flush, add more of the pancrelipase solution and wait another hour before attempting to flush.
This can be repeated indefinitely until tube is open.
Take Away #3 - What if patient has a G J-tube and you can't unclog it despite using enzymatic declogging?
In patients that are J-tube dependent for feeds, you cannot just replace it in the emergency department. J-tubes require placement by IR or GI. This means patient may be admitted to the hospital for 1 to 2 days just waiting for tube exchange.
This tip is more likely to be useful in the ICU, but there is a type of feeding tube that can be advanced to the jejunum easily and without any additional guidance needed.
This type of tube is called a Tiger tube or self advancing jejunal tube. This is like a regular feeding tube except it has little fins on the bottom.
These fins use peristalsis to advance the tube into the jejunum without any additional guidance. Just follow the instructions in the packet on how often to repeat the x-ray and how often to push the tube a few centimeters.
Now you do not have to convert all your patient's medications to IV while waiting for their J tube to be exchanged and you can feed them. Yay!
Laura Saltzman, MD is a current third year resident at Stony Brook Emergency Medicine.
References
https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-March-14.pdf
Edited by Bassam Zahid, MD