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Dilation

1. Use a #11 scalpel blade to create a skin incision that extends alongside the guidewire, downward through the

subcutaneous tissue and fascia of the abdominal musculature. After the incision is made, dispose of the scalpel according

to facility protocol.

2. Advance a dilator over the guidewire and dilate the stoma tract at least four French sizes larger than the enteral feeding

tube being placed.

3. Remove the dilator over the guidewire, leaving the guidewire in place.

Note.

After dilation, a peel-away sheath may be used to facilitate advancement of the tube through the stoma tract.

Tube Placement under Fluoroscopic (Radiologic) Visualization

1. Advance the distal end of the tube over the guidewire, through the stoma tract and into the stomach.
2. Rotate the MIC* GJ Feeding Tube while advancing to facilitate passage of the tube through the pylorus and in the

jejunum.

3. Advance the tube until the tip of the tube is 10–15 cm beyond the Ligament of Treitz and the balloon is in the stomach.
4. Using the male Luer syringe, inflate the balloon with 7–10 ml of sterile or distilled water.

Caution.

Do not exceed 20 ml total balloon. Do not use air. Do not inject contrast into the balloon.

5.  Gently pull the tube up and away from the abdomen until the balloon contacts the inner stomach wall.
6.  Clean the residual fluid or lubricant from the tube and stoma.
7.  Gently slide the external retention bolster to approximately 2–3 mm above the skin. Do not suture the bolster to the skin.
8.  Remove the guidewire.

Tube Placement under Endoscopic Visualization

1.  Advance the distal end of the tube over the guidewire, through the stoma tract and into the stomach.
2.  Grasp the suture loop or the tip of the tube with atraumatic forceps.
3.  Advance the MIC* GJ Feeding Tube through the pylorus and upper duodenum. Continue to advance the tube using the

forceps until the tip is positioned 10-15 cm beyond the Ligament of Treitz and the balloon is in the stomach.

4. Release the tube and withdraw the endoscope and forceps in tandem, leaving the tube in place.
5. Using the male Luer syringe, inflate the balloon with 7–10 ml of sterile or distilled water.

Caution.

Do not exceed 20 ml total balloon. Do not use air. Do not inject contrast into the balloon.

6.  Gently pull the tube up and away from the abdomen until the balloon contacts the inner stomach wall.
7.  Clean the residual fluid or lubricant from the tube and stoma.
8.  Gently slide the external retention bolster to approximately 2–3 mm above the skin. Do not suture the bolster to the skin.
9.  Remove the guidewire.

Verify Tube Position and Patency

1. Verify proper tube placement radiologically to avoid potential complication (e.g. bowel irritation or perforation) and

ensure the tube is not looped within the stomach or small bowel.

Caution:

The jejunal portion of the tube contains tungsten, which is radiopaque and can be used to radiographically

confirm position. Do not inject contrast into the balloon.

2. Flush both the jejunal and gastric lumens with water to verify patency.
3. Check for moisture around the stoma. If there are signs of gastric leakage, check the tube position and placement of the

external retention bolster. Add sterile or distilled water as needed in 1–2 ml increments. Do not exceed balloon capacity

as indicated previously.

4. Check to ensure that the external retention bolster is not placed too tightly against the skin and rests 2–3 mm above the

abdomen for initial placement and 1–2 mm above the abdomen for a replacement tube.

5. Begin feeding only after confirmation of proper patency, placement and according to physician instructions.

Replacement Procedure through an Established Gastrostomy Tract

1. Cleanse the skin around the stoma site and allow the area to air dry.
2. Select the appropriate size MIC* GJ Feeding Tube and prepare according to the instructions in the Tube Preparation

section above.

3. If using endoscopic visualization perform routine esophagogastroduodenoscopy (EGD). Once the procedure is complete

and no abnormalities are identified that could pose a contraindication to placement of the tube, place the patient in the

supine position and insufflate the stomach with air. Manipulate the endoscope until the indwelling gastrostomy tube is

in the visual field.

4. Under either fluoroscopic guidance or endoscopic guidance, insert a floppy-tipped guidewire, up to .038”, through the

indwelling gastrostomy tube.

5. Remove the gastrostomy tube over the guidewire.
6. Place the MIC* GJ Feeding Tube according to the Tube Placement section above.

Caution:

For a replacement feeding tube, gently slide the external retention bolster to approximately 1–2 mm above

the skin. Do not suture the bolster to the skin.

7. Verify tube position and patency using the Verify Tube Position and Patency section above.

Tube Patency Guidelines

Proper tube flushing is the best way to avoid clogging and maintain tube patency. The following are guidelines to avoid

clogging and maintain tube patency.
• Flush the feeding tube with water every 4–6 hours during continuous feeding, anytime the feeding is interrupted, or at

least every 8 hours if the tube is not being used.

• Flush the feeding tube after checking gastric residuals.
• Flush the feeding tube before and after medication administration and between medications. This will prevent the

medication from interacting with formula and potentially causing the tube to clog.

• Flush the feeding tube after checking gastric residuals.
• Use liquid medication when possible and consult the pharmacist to determine if it is safe to crush solid medication and

to mix with water. If safe, pulverize the solid medication into a fine powder form and dissolve the powder in warm water

before administering through the feeding tube. Never crush enteric-coated medication or mix medication with formula.

• Avoid using acidic fluids such as cranberry juice and cola beverages to flush feeding tubes as the acidic quality when

combined with formula proteins may actually contribute to tube clogging.

General Flushing Guidelines

Flush the feeding tube with water using an ENFit® syringe every 4–6 hours during continuous feeding, anytime the feeding

is interrupted, at least every 8 hours if the tube is not being used, or per clinician’s instructions. Flush the feeding tube after

checking gastric residuals. Flush the feeding tube before, after, and in between medication administration. Avoid using acidic

irrigants such as cranberry juice and cola beverages to flush feeding tubes.

• Use a 30 to 60 ml ENFit® syringe. Do not use smaller size syringes as this can increase pressure on the tube and potentially

rupture smaller tubes.

• Use room temperature water for tube flushing. Sterile water may be appropriate where the quality of municipal water

supplies is of concern. The amount of water will depend on the patient’s needs, clinical condition, and type of tube,

but the average volume ranges from 10 to 50 ml for adults, and 3 to 10 ml for infants. Hydration status also influences

the volume used for flushing feeding tubes. In many cases, increasing the flushing volume can avoid the need for

supplemental intravenous fluid. However, individuals with renal failure and other fluid restrictions should receive the

minimum flushing volume necessary to maintain patency.

• Do not use excessive force to flush the tube. Excessive force can perforate the tube and can cause injury to the

gastrointestinal tract.

• Document the time and amount of water used in the patient’s record. This will enable all caregivers to monitor the

patient’s needs more accurately.

Nutrition Administration

1. Open the cap to the Jejunal access port of the MIC* GJ Feeding Tube.
2. Use an ENFit® syringe to flush the tube with the prescribed amount of water as described in the General Flushing

Guidelines.

3. Remove the flushing syringe from the Jejunal access port.
4. Securely connect an ENFit® feed set to the Jejunal access port.

Caution:

Do not over-tighten the feed set connector or the syringe to the access port.

5. Complete feeding per the clinician’s instructions.

Warning: If formula is present in the gastric drainage, stop feeding and notify the physician or health

care provider.

6. Remove the feed set or syringe from the Jejunal access port.
7. Use an ENFit® syringe to flush the tube with the prescribed amount of water as described in the General Flushing

Guidelines.

8. Remove the flushing syringe from the Jejunal access port.
9. Close the cap to the Jejunal access port.

Medication Administration

Use liquid medication when possible and consult the pharmacist to determine if it is safe to crush solid medication and mix

with water. If safe, pulverize the solid medication into a fine powder form and dissolve the powder in warm water before

administering through the feeding tube. Never crush enteric coated medication or mix medication with formula.
1. Open the cap to the prescribed access port of the MIC* GJ Tube.
2. Use an ENFit® syringe to flush the tube with the prescribed amount of water as described in the General Flushing

Guidelines.

3. Remove the flushing syringe from the access port.
4. Securely connect an ENFit® syringe containing the medication to the access port.

Caution:

Do not over-tighten the syringe to the access port.

5.  Deliver the medication by depressing the ENFit® syringe plunger.
6.  Remove the syringe from the access port.
7.  Use an ENFit® syringe to flush the tube with the prescribed amount of water as described in the General Flushing

Guidelines.

8. Remove the flushing syringe from the access port.
9. Close the cap to the access port.

Gastric Decompression

Gastric decompression may be performed via either gravity drainage or low intermittent suction.

Caution:

Never connect the Jejunal access port to suction. Do not measure residuals from the Jejunal access port.

1. Open the cap to the Gastric access port of the MIC* GJ Feeding Tube.
2. For gravity drainage, place the opened Gastric access port of the MIC* GJ Feeding Tube directly over the opening of an

appropriate container.

Note:

Ensure the open access port is positioned below the stoma.

3. For low intermittent suction, connect an ENFit® syringe to the Gastric access port.
4. Apply low intermittent suction by slowly retracting the plunger of the syringe in short intervals.

Warning: Do not use continuous or high pressure suction. High pressure could collapse the tube or injure

the stomach tissue and cause bleeding.

5. Disconnect the decompression syringe from the Gastric access port.
6. Use an ENFit® syringe to flush the tube with the prescribed amount of water as described In the General Flushing

Guidelines.

7. Remove the flushing syringe from the Gastric access port.
8. Close the cap to the Gastric access port.

Balloon Maintenance

Precise balloon life cannot be predicted. Silicone balloons generally last 1–8 months, but the life span of the balloon varies

according to several factors. These factors may include medications, volume of water used to inflate the balloon, gastric pH,

and tube care.
Check the water volume in the balloon once a week.
• Insert a male Luer syringe into the Balloon Inflation Port (BAL.) and withdraw the fluid while holding the tube in place.

Compare the amount of water in the syringe to the amount recommended or the amount initially prescribed and

documented in the patient record. If the amount is less than recommended or prescribed, refill the balloon with the

water initially removed, then draw up and add the amount needed to bring the balloon volume up to the recommended

and prescribed amount of water. Be aware as you deflate the balloon there may be some gastric contents that can leak

from around the tube. Document the fluid volume, the amount of volume to be replaced (if any), the date and time.

• Wait 10–20 minutes and repeat the procedure. The balloon is leaking if it has lost fluid, and the tube should be replaced.

A deflated or ruptured balloon could cause the tube to dislodge or be displaced. If the balloon is ruptured, it will need

to be replaced. Secure the tube into position using tape, then follow facility protocol and/or call the physician for

instructions.

Caution:

Refill the balloon using sterile or distilled water, not air or saline. Saline can crystallize and clog the balloon

valve or lumen, and air may seep out and cause the balloon to collapse. Be sure to use the recommended amount of water