Percutaneous Endoscopic Gastrostomy (PEG), Patient Assessment The Nurses Role

Helen Holder Senior Lecturer Gastroenterology Pathway Leader

Learning Objectives
To critically discuss the specialist role of the nurse in PEG assessment, insertion and aftercare. To consider PEG insertion complications and strategies to prevent/manage these problems. To evaluate other endoscopic techniques for Enteral Tube Feeding (ETF)

Routes of ETF
Nasogastric Nasoduodenal/jejunal Gastrostomy PEG, Balloon-type, button, BalloonPEGJ Jejunostomy

Gastrostomy
PLACEMENT Endoscopically Surgically Radiologically Via existing stoma tract - balloon type retention gastrostomy

Gastrostomy
GENERAL INDICATIONS Longer term feeding (>4 weeks) NICE (2006) If upper GI tract inaccessible (surgical gastrostomy) gastrostomy)

Specific Indications - PEG

Dysphagia - e.g neurological disorders, head and neck cancer Supplemental feeding- e.g cystic fibrosis, severe burns, feedingshort bowel, HIV, Crohns Disease, Chronic renal failure Inability to tolerate an Ng tube if long-term feeding longindicated Patients on long-term Ng feeding who opt for a a PEG longfor convenience and/or cosmetic reasons. (Arrowsmith 1996, Reilly 1998, Pollard 2000, Mc Meekin 2000).

Patient Assessment
Multidisciplinary involvement: involvement: Nutritional screening / assessment nurse/dietitian Swallow assessment if appropriate SALT Referring medical team consider pt appropriate for PEG or may request second opinion Nutrition Nurse/Endoscopy Nurse /Gastroenterology doctor The decision to use a PEG feeding tube requires an in-depth inassessment of the potential benefits to the individual. All patients in whom PEG feeding is proposed should be reviewed by a multidisciplinary team. (NCEPOD 2004)

Review by Nutrition Nurse/Endoscopy Nurse /Gastroenterology doctor

Appropriateness of referral Any contraindications Explanation of procedure to pt and family/carers inc. demonstration with PEG tube, insertion procedure & risks/benefits, info. booklet, aftercare, clarify understanding Any other factors that may make PEG insertion difficult communication difficulties, dental/oral problems Ensure INR check, consent  Liaison and documentation crucial

Absolute Contraindications
Coagulation disorders INR>1.5 (>1.4 BSG 2006) Severe Ascites Peritonitis Interposed organs Anorexia Nervosa ? Severe psychosis Peritoneal carcinomatosis Severe erosive gastritis or ulcer (Loser et al 2005 - ESPEN)

Legal/Ethical Considerations Lennard-Jones (1998a&b) Lennard Decision to commence a tube feed made by consultant in conjunction with the health care team, patient and family/carers. Consent of a competent adult must be sought for any treatment I.e. hydration or feeding via a tube - refusal is binding. Incompetent adult Dr makes final decision in best interests of pt.

NCEPOD 2004 Consent Issues

16% of patients suffering from dementia or acute confusion but written consent obtained in 66% of these cases. Recommendation The ability of those with dementia or acute confusion to provide consent should be tested and clearly documented. Mental Capacity Act Code of Practice (2005) TwoTwo-stage test of capacity

Benefit vs Burden
Appropriate when therapeutic aim to improve or maintain physical condition - benefit outweighs burden. May be inappropriate when aim is palliative comfort and symptom relief. Tube feeding may be withheld if perceived burden outweighs probable benefit. Generally treatment should not be withheld on grounds of age, lifestyle, mental or physical disability. Decision difficult in many cases tightrope (Goodhall 1997)

Tube feeding started

Usually for a limited period in acute, reversible disease. If chronic underlying disorder and unlikely to improve - time trial of tube feeding.

Tube feeding enforced

Individual autonomy v`s clinical benefit, e.g in anorexia nervosa - Mental Health Act 1983 permits enforced treatment (in some cases) including Ng feeding.

Tube feeding withdrawn

No problem if feeding outcome successful but problem if considered of no benefit e.g Tony Bland case or Terri Schiavo (Breier-Mackie (Breier2005).

Insertion Method / Tube

Generally Gauderer/Ponsky Pull through method (Gauderer et al 1980) Tubes usually polyurethane, life 2-3yrs 2 Size range 9-14fg (uk), up to 20fg 9 Retention in stomach by small disc/flange External fixation vary, should be easy to use/replace Clamp desirable

Insertion Method / Tube

End adaptor compatible with enteral feeding systems /syringes (incompatible with IV) & replaceable Endoscopic or traction removal (some cut!) (Stroud, Duncan & Nightingale 2003). Also Russell Procedure- more difficult (Lin et al Procedure2001)

Prophylactic Antibiotics
All patients having a PEG should receive prophylactic antibiotics e.g a single dose of cocoamoxiclav 30 mins pre insertion to prevent wound infections & post procedural pneumonia (Grade B evidence). Grade A evidence to support use of PA in malignant disease. (BSG 2001)

Insertion Complications
Reported mortality - < 1% Minor complications 5-15% inc. cellulitis, wound infection, ileus, peristomal leakage, aspiration PEG site infection 3-3.7% (Leak 2002)

Insertion Complications
Major complications 3% inc. sepsis, peritonitis, haemorrhage, visceral perf (partic obstructive cancers), PEG site metastasis, gastrocolic fistula. (Lin et al 2001) Their own study demonstrated 10.7% minor comps and 1% major (PEG site metastasis). Majority of pts head & neck ca

PEG stoma site Post insertion

Problem Post insertion pain Potential haemorrhage Intervention Assessment of pain and analgesia (soluble) Pulse & BP post insertion,  hrly 2hrs  hrly-2hrs hrly 4hrly Inspect site for bleeding

PEG Stoma Site

Problem Peritonitis Intervention Observe pt for signs of abdominal pain, temp, nausea and vomiting report Clean site daily with n/saline leave exposed if clean & dry Soap and water when healed If site inflamed, exudes pus, tender swab microbiology. Monitor temp.

Local Infection/abscess formation

PEG stoma site long term complications

Problem Granulation tissue / Leakage/skin excoriation Intervention Exclude/treat infection Ensure tube anchorage barrier cream leakage Proton pump inhibitor (BSG 2006) Use of polyurethane foam dressing (Rollins 2000) Actisorb Silver 220 improvement in Granulation & infection (Leak 2002) Tube change last resort

PEG stoma site long term complications

Buried bumper syndrome Rotate tube 3600 daily and c/o fixation device (Grant 1993) Weekly (BSG 2006)

Commencement of feed
(NICE 2006) It is safe to start feeding through a PEG 4 hours after insertion in uncomplicated cases. However, should seek medical advice before starting a feed if the patient is in discomfort or the abdomen is tense.

Follow up
Nurse Advisor from enteral feeding company Nutrition Nurse Specialist SALT Dietitian OP clinic (medical/surgical condition) LIAISON CRUCIAL MDT PEG clinic (Gibson et al 2001) monthly clinic involving MDT. Inc. Endoscopy/PEG nurse.

New Innovations for Nurses

Pollard (2000) Development of a nurse-led nurseservice for PEG placement. Involving a Nurse Endoscopist and GI Clinical Nurse Specialist. Reduced waiting times BSG 2006. Greater continuity of care for pts from assessment to post PEG follow up

New Innovations for Nurses

White (2002) Nurse-led multidisciplinary PEG clinic Nurse 2/3rd pts attend clinic, other 1/3rd off site visits. (1999) 75 PEGs placements and 104 replacement tubes PEG liaison nurse full-time post. Leads to Continuity fullof care, support & education & point of contact.

Other endoscopic techniques for EF

Nasojejunal tube placement Drag & pull technique Over-the-wire method Over-the Push technique Via biopsy channel Transnasal endoscopy

Other endoscopic techniques

Percutaneous endoscopic Gastrojejunostomy (PEGJ) Drag and Pull a/a Over the wire kits for passage via PEG e.g 9fg tube via 18fg tube Direct PEJ Modification of PEG placement more difficult. Comps in 2% pts, bleeding, abdo wall abcess, colonic perf (DiSario et al 2002)

Conclusion
Nurses have a major role within the MDT in relation to PEG assessment, placement, aftercare & follow up. This can have a positive impact on the patient (and family/carers) experience and outcomes.