Abbott Healthcare - Information on Duodopa

Permanent Treatment

Introduction

When it has been decided that the patient will continue Duodopa treatment, a tube is inserted into the stomach (PEG) with the help of a gastroscope. An 'inner tube' is put through the tube (PEG) and pushed through the pylorus into the small intestine.

This chapter describes actions to take before operation, the tube system, how to dress the stoma, and the daily care of the tube wound.

PEG tube

Before PEG surgery

Follow hospital routines during insertion of PEG. Example: fasting, premedication, Venflon™.

Send the PEG and inner tube with the patient to the endoscopy unit.

PEG operation

Due to the nature of the patient’s disease, it is important that no longer than 2 hours elapse after the patient takes their PD medication as the muscles become rigid, making surgery significantly more difficult and increasing the risk of complications. If there are delays, the patient will need to continue with oral rescue medication until surgery is possible.

The PEG tube is inserted as usual and the inner tube is fed down into the small intestine with the help of the gastroscope.

Post-operative care and maintenance of the PEG

The dressed wound should be inspected to make sure that there is no bleeding or leakage. If there is, the dressing should be replaced.

Tension

Mild tension should be applied to the PEG some time after the operation to prevent the PEG from moving around in the wound, and to prevent leakage that may cause peritonitis.

Check the tension as follows:

Pull the PEG until you feel a mild resistance. If the tension is too tight there is a risk of tissue damage.
Move the outer stop plate 2 mm clear of the skin and lock it.

Dressing the wound

Daily dressing of the tube wound is necessary for the first three weeks after surgery.

Cleaning

One or two weeks after the operation, the stop plate may be fixed 2 cm from the skin when the wound has healed. The tube orifice should be cleaned with soap and water during showers/baths. Make sure the skin is dried afterwards.

Measures in case of complications

Complication	Action
The tube wound is inflamed.	Rub on water-repellent barrier cream.
The tube wound is infected.	Use NaCl (normal saline 0.9%) and cotton wool/gauze swab to clean it, once or twice daily. In complicated cases, a bacteria culture may be taken. Treat with antibiotics if there is no improvement.

Components

The tube system consists of a PEG and an inner tube fixed to the outer connections and leading through the PEG into the stomach and into the small intestine.

The connections are attached to the PEG and inner tube.

To connect:

Undo the white cap of the PEG tube.
Remove the RED cap from the cassette tubing.
Connect the cassette tubing to the PEG. Do this by holding the PEG tube with one hand securely whilst gently rotating clockwise the cassette tube onto the PEG with the other hand. DO NOT twist the PEG tube, as this may dislodge the tubing internally. Do all the twisting with the cassette tubing not the PEG tubing

To disconnect:

Hold the PEG tube with one hand securely whilst gently rotating the cassette tube anti-clockwise. Then remove the cassette tube from the PEG with the other hand.

Placement of the intestinal tube

During the PEG operation it is recommended that the surgeon places the inner tube in the small bowel with the help of the gastroscope.

Note: It may be difficult to pull back the gastroscope without also removing the tube. If this happens the most important thing is to place the tip of the tube well past the pylorus.

Optimal tube position

Optimal tube position is when:

No loop is present in the stomach.
The tip of the tube is well down the duodenum. It is recommended to place the tip in the distal part of the duodenum near the Treitz ligament to reduce the risk of dislocation to the stomach.
Experience has shown that the tip can also be placed just beyond the ligament of Treitz, in the proximal jejunum, so that the tube will stay in place correctly. Available knowledge indicates that the absorption of levodopa does not differ at any site in the upper small intestine, including duodenum and the upper part of jejunum.

The inner tube should be cut off when the tip of the tube is in upper part of the small intestine and with the smallest amount possible in the stomach.

The outer tube should be kept as long as is required to give maximum comfort to the patient.

The connections must always be firmly tightened, or the inner tube may lose its position in the small bowel or move back into the stomach.

Starting permanent treatment

Extra Dose Button On the day of operation, EXTRA DOSE is used to fill the tube.

Do not use the morning dose as this function has a time lock of 20 hours.

Connect the medicine cassette to the PEG tube.

Filling the PEG tube

$On\Off Button$ Press the ON/OFF button, keep pressed for 3 seconds. The pump runs the programme and displays the set values. This takes approx. 30 seconds and STOPPED will be displayed.
Press the NEXT button several times until 'Extra dose X.X ml' is displayed (3 ml to fill the tube + any extra dose).
Change the dosage using the arrow buttons until the desired dose is reached.
Confirm the change of dosage by pressing the ENTER/CLEAR button.

Press the STOP/START button and keep pressed until (---- ---- ----) disappears. The pump runs through the set values again. This takes approx. 15 seconds.
Press the EXTRA DOSE button.
Reset the pump to the normal extra dosage according to steps 1-4.

During the test treatment period and after insertion of the PEG, a Duodopa Support Nurse will be on hand to offer advice and guidance on operating the pump and adjusting the dosage.

Daily routines

After PEG operation, the Morning dose is increased by 3 ml due to flushing of tube.

Morning

Take the Duodopa cassette out of the fridge at least 20 minutes before starting the pump.
Attach the cassette to the pump:

Fit the hooks of the cassette onto the pivot pins at the pump's base.
Place the pump on a level surface.
Steady the cassette and put a coin in the slot of the lock knob.
Lock the cassette by pushing the coin or the Duodopa key and turning it 90 degrees counter-clockwise until it stops.

Remove stopper from the pump tube.
Remove the RED cap from the cassette tubing.

5. Connect the cassette tubing to the PEG. Do this by holding the PEG tube with one hand securely whilst gently rotating clockwise the cassette tube onto the PEG with the other hand. DO NOT twist the PEG tube, as this may dislodge the tubing internally. Do all the twisting with the cassette tubing not the PEG tubing.

6. Turn the pump on:

Press and hold down the [ON/OFF] button for 3 seconds.

Press and hold down the [STOP/START] button for 3 seconds.

7. Give the Morning Dose:

Press the [MORNING DOSE] button. The set morning dose is shown in the display. Press the button again and the pump will administer the morning dose.

8. Continuous Dose:

The pump will automatically deliver the continuous dose after the morning dose has been administered.

9. Extra Dose:

(This is to be used if you find you need an extra dose. It should only be required up to 4 times a day. If you find that you require this more often, you should contact your Nurse or Duodopa Support Nurse as you may need your continuous dose increased. The extra dose can only be given again once an hour has passed.)

Secure the pump safely, e.g. in a bag or with a harness.

Night

1. Press the [STOP/START] button for 3 seconds followed by the ON/OFFbutton to turn the pump off.
2. Disconnect the pump from the PEG tube by gently rotating the green luer lock connector anti-clockwise.
3. Slowly flush the PEG tube with 10-30ml drinking water until the tube is clean and clear.
4. Detach the cassette from the pump: Place the pump with the cassette upright on a level hard surface. Put a coin or the Duodopa key in the slot of the lock knob and turn 90 degrees clockwise. The lock knob will pop out slightly when the cassette is unlocked. Remove the hooks of the cassette from the pivot pins of the pump. Discard the used cassette if it is not to be used later the same day.

Guide to Daily Routine

Click here to view and download a guide to the use of Duodopa following PEG surgery.

Post-PEG Diary

Click here to view and download the Post-PEG diary.

Stoma dressing instructions

Daily care of the stoma

The stoma should be cleaned with soap and water during showers/baths. Make sure the skin is dried afterwards.

If the stoma gets inflamed you can rub on a water-repellent ointment. If it gets infected it should be cleaned thoroughly with salt solution (normal saline 0.9%) and cotton wool/gauze swab, once or twice daily. You can also ask to try antiseptic ointment.

In complicated cases, a bacterial culture may be taken in case antibiotics will be necessary.

Dressing Stoma:

Wash hands thoroughly with soap and water.
Clean the external plate as advised by your Healthcare Professional.
Open the fixation catch (see Fig 1).
Detach tube from groove in fixation plate (see Fig 2).
Move plate away from skin (see Fig 3).
Clean tube and stoma area and the underside of the plate and dry. Push 2-3cm of the tube into the stomach and gently pull back the tube to feel resistance.
Place the fixation plate back to its original position (approx 1cm away from the skin). Re-insert tube in the groove (see Fig 4) and close the fixation catch (see Fig 5).
Your fixation plate should not be too tight or too loose. If you feel that it is, your Healthcare Professional will be able to advise you.