Kimberly-Clark MIC-KEY* 
Low-Profile Gastrostomy Feeding Tube Kit

Nourishment and liquids are delivered through the tube and into the stomach or jejunum through the feeding and medication port. When not in use, the port should be capped off with the attached cover. An anti-reflux valve located inside and toward the top of the feeding port helps prevent stomach or jejunal contents from leaking out of the tube. The valve is opened with the extension set.

A 6 ml slip tip syringe is included with the feeding tube. It should be used to fill and empty the retention balloon when periodic volume checks are made and when the feeding tube is replaced. The 35 ml catheter tip syringe should be used when priming and flushing the extension sets and when checking for proper placement of the feeding tube.

1. Wash hands with soap and water then dry hands thoroughly before touching the tube.
2. Inspect the skin around the stoma before and after feeding. Make sure the skin is clean and dry, free of infection, and check for any gastric leakage.
3. If a dressing is used, change it when it becomes wet or soiled. Dressings are not recommended for long-term use and should be avoided unless absolutely necessary.
4. Gently clean the skin around the stoma using soap and warm water and cotton-tip applicators or a soft cloth, followed by a thorough rinsing and drying well.
5. Inspect the tube and rotate the bolster 360◦ plus a quarter turn to prevent tissue from adhering to the tube, to relieve pressure on the skin and to allow for air circulation. Do not rotate jejunal tubes as they extend into the jejunum and rotating may cause them to torque and retract into the stomach.
6. Gently clean the feeding port with a cotton-tip applicator or soft cloth.
7. Flush the feeding tube with water every 4-6 hours during continuous feeding, before and after every intermittent or bolus feeding, or at least every 8 hours if the tube is not being used.

The balloon should be filled with water at the time of insertion. We recommend the use of distilled or sterile water as saline may crystallize and clog the balloon valve or lumen and air may seep out and cause the balloon to collapse. Tap water may contain harmful contaminants that could shorten the life of the balloon. The balloon volume should be checked weekly and additional water added if the amount in the balloon is less than the amount prescribed by the physician. The balloon should never be filled with air as it may leak and the tube may fall out of the stomach.

The feeding tube balloon, which holds the tube in place, is located inside the stomach. It is filled and emptied with water by inserting a slip tip syringe into the balloon valve. The valve should only be used to check the balloon volume or to replace the tube. Never feed through the balloon valve.

Silicone balloons may last several months, but the life span of the balloon can be affected by various factors such as medication, gastric pH, infection and tube care. We recommend that you have a replacement feeding tube available in case of inadvertent tube removal or failure. If the tube fails and you have been properly trained, you may replace the tube. If you have not been properly trained or your clinician prefers to replace the tube, you should contact your clinician as soon as possible as the stoma may begin to close within 2-4 hours.

Proper tube flushing is the best way to avoid clogging the tube. Flush the tube with water every 4-6 hours during continuous feeding, before and after every intermittent or bolus feeding, or at least every 8 hours if the tube is not being used.

The feeding tube should also be flushed before and after administration of medications and after checking for stomach residuals. Medications should be given in liquid form. If a medication is only available in tablets or capsules, make sure it can be crushed and mixed with water. Medication should not be mixed with formula. Never crush enteric-coated medication. Before and after giving medication, the port should be flushed with water.

When flushing a tube, use water and a 30cc-60cc catheter tip syringe. Do not use smaller sizes as this can increase pressure on the tube and potentially rupture the tube. The amount of water used to flush the tube will depend on the individual's needs, clinical condition and type of tube, but the average volume ranges from 10-50 ml for adults, and 3-10 ml for children. Do not use excessive force to flush the tube as this can perforate the tube and can cause injury to the gastrointestinal tract.

Before feeding, check the MIC-KEY* tube to be sure it is not clogged or displaced outside the stomach. You may do this by drawing 5-10 ml of air into a syringe. Place a stethoscope on the left side of the abdomen just above the waist. Inject the air into the MIC-KEY* extension set feeding port and listen for the stomach to "growl." Try again if you do not hear the sound. If you still do not hear it, do not proceed to feed. Contact your specialist and report the problem.

Another method is to connect the extension set to the feeding tube and attach a catheter tip syringe with 10 ml of water to the extension set feeding port. Pull back on the plunger. When stomach contents appear in the tube, flush the tube with water.

Check for leaking around the stoma. If at any time you suspect the feeding tube has become dislodged, discontinue feeding and contact your specialist to report the problem.

Decompression refers to releasing air or food from the stomach before or after feedings. To decompress the stomach, simply attach the MIC-KEY* extension set or MIC-KEY* bolus extension set to the feeding tube, and then drain any contents into a collection cup or bag.

If a MIC-KEY* tube does become clogged:

• Attach an MIC-KEY* extension set to the clogged port (gastric or jejunal) of the MIC-KEY* feeding tube. Place a catheter tip syringe filled with warm water into the MIC-KEY* extension set and gently pull back on then depress the plunger to dislodge the clog.

• If the clog remains, repeat the previous step. Gentle suction alternating with syringe pressure will relieve most obstructions.

• If this fails, consult your clinician and consider trying a solution of pancreatic enzymes and sodium bicarbonate instilled through a catheter tip syringe. Do not use cranberry juice, cola drinks, meat tenderizer or chymotrypsin, as these can actually cause clogs or create adverse reactions in some cases. Diet sodas (non-cola) and carbonated or seltzer water may prove successful in removing some clogs.

• If the clog is stubborn and cannot be removed, the tube will have to be replaced.

NOTE: The short length of the MIC-KEY* Gastric Feeding Tubes make them quite clog resistant. The MIC-KEY* Jejunal Feeding Tubes must be monitored carefully to prevent clogging.

The MIC-KEY* extension set connects the formula source to the MIC-KEY* feeding tube. The right angle Secur-Lok* extension set is convenient to use for continuous pump feedings because it lies flat against the abdomen and swivels with the patient's movements. This makes it comfortable for continuous feeding. Detach the MIC-KEY* extension set when not in use and wash it between feedings.

Medications should be given in liquid form. Thick medication can plug the feeding port.

If a medication is only available in tablets or capsules, make sure it can be crushed and mixed with water.

Medication should not be mixed with formula as they may harden together and cause the tube to become occluded.

Never crush enteric-coated medication.

Before and between each medication the port or tubing should be flushed with water.

The port and valve should be kept very clean. To prevent dried formula from lodging inside the recess and possibly holding the valve open, flush thoroughly with water and complete the cleaning with cotton-tipped applicators and water. Residual formula should not be left to pool and dry inside the valve opening.

Caution: Do not push cotton-tipped applicators or other foreign objects through the feeding port valve as this may cause the valve to tear and leak.

The MIC-KEY* kit includes a MIC-KEY* bolus extension set for feeding with a catheter tip syringe or feeding bag. Bolus feeding is comparable to a normal feeding pattern and normally takes 20 to 40 minutes. The MIC-KEY* bolus extension set is also attached by aligning the black line on the extension set with the black line on the feeding port and then rotating a quarter turn clockwise.

The MIC-KEY* bolus extension set is intended to be used for short term feeding when the person receives multiple feedings throughout the day. The straight connector and wide tubing facilitate quick feeds.

If you suspect gastric leakage:

• Gently clean and dry the site, then check the site after 30 minutes to see if there is any fresh leakage. This will indicate whether there is actual gastric leakage and not just spillage from a previous feeding or tube check. If there is actual gastric leakage and the skin is intact, you may ask your physician whether you should apply a skin protectant or moisture barrier such as zinc oxide ointment. Notify the physician if skin redness extends more than 1 cm from the stoma or is accompanied by pain, swelling or denuded skin.
• Check the amount of water in the balloon. The balloon may be leaking if it has lost the prescribed amount of fluid and the tube may need to be replaced. If the correct amount of water remains in the balloon, the device may be poorly sized or inadequately stabilized and you should have your clinician reevaluate the tube.
• Verify that the external bolster rests just above the abdomen by 2-3mm. Check for proper internal balloon placement by aspirating the stomach contents to assess for gastric residuals or by utilizing air auscultation.
• Verify that fluid will flow freely by flushing the tube with water.

Leaks can also be caused by improper patient positioning, by infusing the feeding formula too rapidly, or by feeding too large a volume. Keep the head of the patient elevated at least 30 degrees during, and 1 hour after feeding. This will also help to prevent aspiration. If the feeding volume is too large, consult your clinician as to whether you should change to smaller, more frequent, or continuous volume feedings.

The MIC* (Bolus) Gastrostomy Feeding Tube is used to provide a means of accessing the stomach to provide nourishment, liquids and medication. It may also be used as a means to release excess air or contents from the stomach.

The MIC* (Bolus) Gastrostomy Feeding Tube is made of silicone and is kept in place by an internal balloon that keeps the tube from falling out of the stomach and a SECUR-LOK* external retention ring or bolster that keeps the tube from migrating into the stomach.

The specialist will decide when to replace the gastrostomy feeding tube. You may change the gastrostomy feeding tube yourself provided you have been properly trained and have been given permission to do so. Note: Do not try and replace a jejunal or transgastric-jejunal tube yourself, this should only be done by your doctor.

Steps for replacing your gastrostomy tube:

1. Cleanse the skin around the stoma site and allow to air dry.
2. Remove the new tube from the package. Using a slip tip syringe, fill the balloon with 5 ml of sterile or distilled water.
3. Remove the syringe and check the balloon for leaks. It should be symmetrical. Reinsert the syringe and remove the water from the balloon by pulling back on the plunger.
4. Attach the luer slip syringe to the balloon valve that is in the patient's stomach. Pull back on the plunger until all of the water is out of the balloon.
5. Gently remove the tube from the patient. It may help to use a small amount of water-soluble lubricant around the stoma site and tube.
6. Lubricate the tip of the replacement feeding tube with a water-soluble lubricant. Do not use oil or petroleum jelly as these can damage the tube.
7. Gently guide the new tube into the stoma until it is flat against the skin.
8. Hold the tube in place and fill the balloon with amount of sterile or distilled water recommended by your physician. Do not use air or exceed the recommended volume.
9. Wipe away any fluid or lubricant from the tube and the stoma site.
10. Check the tube for correct placement by inserting an extension set into the  gastrostomy feeding tube and listening for air or aspirating any residual stomach contents. If you cannot verify the tube placement, contact your clinician.
11. Flush the tube to confirm that fluid will flow freely and to also clean the tube.

If water cannot be extracted from the balloon with the syringe, make sure the recess in the balloon valve is clean and that the valve is not blocked by food. Clean inside the recess, then firmly seat the syringe into the valve, push and twist a quarter turn. Try pulling back on the plunger again. If the balloon will not deflate, use the end of a large paper clip to depress the valve and release the water. Make sure to have a replacement tube to insert into the stoma.

If the feeding administration set becomes disconnected from the MIC-KEY* extension set tubing, stop the pump and estimate the amount of formula lost. Thoroughly wipe the tube connections with soap and water or alcohol. Clean inside the MIC-KEY* extension set feeding port with a cotton-tipped applicator and alcohol. Irrigate the tube with warm water. Dry the connections and firmly reconnect the tubes with a quarter turn. Resume feeding.

Correct feeding position is essential to avoid aspiration of stomach contents through the esophagus and potentially into the lungs. The end user/patient should be placed in an upright position or at least at a 30-degree angle during, and one hour after feeding.

To attach the right angle MIC-KEY* extension set, align the black line on the set with the black line on the feeding port. Insert the "nose" of the Secur-Lok* connector into the MIC-KEY* feeding port, then rotate it a quarter turn clockwise. Next, open the MIC-KEY* extension set feeding port and attach the feeding bag connector to the extension set by firmly pushing and twisting. The MIC-KEY* extension set will swivel with movement, which allows the user to change position during feeding.

The MIC-KEY* extension set should be washed after every feeding with warm, soapy water, then rinsed thoroughly and allowed to air dry. Prompt flushing and rinsing prevent the formula from drying and collecting.

Be on the alert for the following signs and symptoms of stoma problems:

1. Persistently red and sore stoma with a red area larger than 2.5 cm in diameter
2. An odor coming from the stoma
3. Swollen skin around the stoma
4. Pus around the stoma
5. Fever
6. Granulation, which is the body's attempt to repair the surgical incision

If any of these conditions occurs, contact your clinician for advice on how to treat the problem.