Care must be taken when deciding to use, siting and managing percutaneous endoscopic gastrostomy tubes to avoid errors or complications that could prove fatal.
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In this article
- Why patients must be carefully selected for tube insertion
- Observations to be done after insertion
- The nurse’s role in preventing serious complications
Sharlene Haywood is clinical nurse specialist nutrition support, Royal Free London Foundation Trust.
Haywood S (2012) PEG feeding tube placement and aftercare. Nursing Times; 108: 42, 20-22.
Some adults and children are unable to swallow or eat and drink enough. Insertion of a percutaneous endoscopic gastrostomy (PEG) tube may enable long-term feeding, fluid and/or medication administration. The procedure involves gastroscopy under sedation to identify tube placement site, place the tube and check it has been placed correctly. Serious complications include peritonitis and perforation of the colon. Frequent observations immediately after placement are essential. With good nursing care, complications can be avoided or dealt with promptly.
Keywords: PEG feeding/Enteral nutrition/Patient safety
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section ofthis page
5 key points
- Percutaneous endoscopic gastronomy (PEG) tubes are suitable for adults and children
- They allow direct access to the stomach from outside the abdomen
- An endoscope is used to place the PEG tube
- Careful monitoring is essential after placement
- Nurses need to watch out for “red-flag” signs
A number of conditions can compromise patients’ ability to swallow, or take in sufficient food and drink orally. A proportion of these will require an enteral feeding tube to meet their nutrition requirements. Percutaneous endoscopic gastrostomy (PEG) tubes are long-term, artificial enteral feeding tubes that require endoscopic placement and allow direct access to the stomach from outside the abdominal wall. This route is generally used for supplementation of nutrition, fluids and medication administration.
The PEG tube
PEG tubes are usually made from flexible polyurethane and approximately 35cm in length, with a hollow lumen that allows for the passage of liquids. The external diameter is measured in French gauge, with each unit representing 0.33mm. In the UK 8-16 French-gauge tubes are commonly used - the exact gauge used is determined by the patient group and intended use.
Fig 1 shows the PEG tube in the fistula tract between the anterior gastric wall and abdominal wall. The tube is held within the stomach by a retention bumper that lies against the anterior gastric wall. The bumper is commonly a button of soft malleable silicone or an air-filled foam sac (Best, 2004).
The external part of the tube has an adjustable fixation plate commonly made from soft silicone. There is no consensus in the literature or manufacturers’ guidance on exactly how far from the abdominal wall this should be positioned. The ideal is that the tube cannot move freely in the fistula tract nor fit too tightly (Westaby et al, 2010; Best, 2004). In my experience, 1cm from the abdominal wall usually meets these requirements but local policies may differ.
There is an adaptor at the external end of the tube to fit specific enteral syringes and feed-giving sets. The majority of tubes have a clamp to prevent backflow of fluid when the adaptor end is open. When the PEG tube is not in use, the adaptor end should be closed and the clamp left open to prevent damage to the tubing (Löser et al, 2005).
Box 1. “Red-flag” alerts
- Severe pain that is not relieved by simple analgesia, or is made worse by using the tube
- Fresh bleeding* or gastric fluid or feed leaking from wound site
- Sudden change in clinical observations
- Change in level of responsiveness or behaviour
- *A small amount of bleeding from the site is expected and may need a small dressing. Large, thick dressings should be avoided as they prevent thorough observation of the site
PEG tubes can be placed in patients of all ages. The general indicators are symptoms of dysphagia or an inability to eat or drink enough to meet nutritional requirements (Westaby et al, 2010). This is usually caused by neurological or anatomical disorders that affect swallowing, for example, motor neurone disease or an oesophageal tumour (Kurien et al, 2010; Löser et al, 2005).
For endoscopic tube placement, patients should:
- Be able to open their mouth to at least 3cm to allow mouthguard placement;
- Be able to lie flat for approximately 20 minutes for the duration of the procedure;
- Be on no more than minimal oxygen therapy;
- Have blood coagulation within the normal range.
Risks and potential complications
The patient’s medical history should be thoroughly reviewed for outstanding risk factors or diagnoses that could make the procedure difficult, impossible or futile. For example, an intestinal obstruction beyond the duodenum could prevent
liquids administered via the PEG from continuing to be digested, and risk aspiration. A multidisciplinary team should discuss the risks and benefits of tube placement thoroughly, informing the patient of these and alternative options, and only proceed in accordance with the patient’s wishes and in their best interests.
If a patient does not have any risk factors, PEG tube placement still has a risk of complications. Table 1 details the most commonly reported complications at the time of insertion (Fletcher, 2011; National Patient Safety Agency, 2010;Westaby et al, 2010).
In the UK, procedure-related morbidity is thought to be 9-17% and mortality 0.5% (NPSA, 2010); 30 days post-procedure mortality rates are 4-26% (Tanswell et al, 2007). The NPSA reported 22 incidents of serious complications after gastrostomy insertion (five of these in children) from October 2003 until January 2010; these included endoscopically, radiologically and surgically placed tubes (NPSA, 2010). Of these, there were 11 deaths and 11 incidences of severe harm resulting in emergency surgery or high dependency unit/intensive therapy unit admission. Patients should therefore be carefully selected for PEG tube placement. There should be thorough multidisciplinary team discussion, and patients and/or their next of kin should be included in the decision-making process.
If the decision is made to proceed with PEG tube placement, prior to the procedure the patient’s bloods must be closely monitored for signs of abnormal coagulation and infection, and clinical observations monitored. PEG tube placement in patients with an infection is not advised and should be discussed by the multidisciplinary team.
Due to the invasive nature of the procedure and high risk of site infection (the PEG tube is sited via the patient’s mouth, which can be highly loaded with bacteria), a prophylactic antibiotic such as intravenous co-amoxiclav or teicoplanin is recommended before the procedure (Kurien and Sanders, 2010; Westaby et al, 2010). Patients should be fasted of food for at least six hours and of water two hours before the procedure to ensure the stomach is empty; this may vary according to local policy and patient.
Box 2. Observation type and frequency
- Blood pressure
- respiratory rate
- Oxygen saturation
- Pain score
- Monitoring for nausea
- Sedation score
- Every 15 minutes for first 3 hours
- If stable, every 30 minutes for further 3 hours
- If stable, every 6 hours for a further 12 hours
- If stable, continue for further 72 hours and then as required
Just before the procedure patients are given mild sedation, usually midazolam, intravenously. A mouthguard is put in their mouth to prevent them biting the endoscope and to protect their teeth.
There are a variety of techniques for PEG tube placement; this article describes the Gauderer-Ponsky pull-through technique (Gauderer et al, 1980) - there may be local variations on this procedure.
First, a gastroscopy is performed to evaluate the anatomy of the stomach; this is done by passing the endoscope through the mouthguard into the patient’s mouth, down the oesophagus and into the stomach. Gases are used to inflate the stomach; the camera on the end of the endoscope allows the endoscopist to see and assess the inside of the stomach.
The patient’s abdomen is exposed and the room is darkened, then a powerful light is emitted from the end of the endoscope within the stomach. This can be seen on the outside of the abdomen, indicating the most direct route from the stomach to abdominal wall; this process is called trans-illumination.
The endoscopist applies digital pressure to the abdomen, which is checked against the view from the endoscope inside the stomach in order to see the smooth stomach wall indent as the finger presses down on the abdomen. This identifies the safest point at which the fistula tract can be made, avoiding any interposed organs between the abdominal wall and anterior gastric wall. The subcutaneous tissue in this area is anaesthetised with a local anaesthetic, such as lignocaine, using a needle and syringe.
The same needle and syringe (filled with more anaesthetic) is pushed into the abdomen with negative pressure once air is aspirated; the tip of the needle in the stomach is located using the endoscope. This allows the endoscopist to visualise exactly where the tract will be, in order to ensure the PEG tube retention bumper will lie in a desirable position. As the needle is retracted, anaesthetic is injected to anaesthetise the layers of the abdominal wall (Fig 2).
A small incision is made on the anaesthetised abdomen. A trocar (metal needle encased by a plastic sheath) is inserted into the incision to create the fistula tract from the abdominal wall to anterior gastric wall. Once the endoscopist can see the trocar in the stomach, the metal needle is removed leaving the open-ended sheath in the fistula tract (Fig 3).
A soft guide wire is inserted through the trocar sheath into the stomach. The endoscopist grasps the wire using endoscopic forceps that are passed through the endoscope, and pulled out through the mouth. The trocar sheath is removed (Fig 4).
The PEG tube is attached to the guide wire at the end that is exiting the patient’s mouth and lubricated. The stomach end of the wire is pulled, bringing the PEG tube through the mouth via the oesophagus into the stomach and out through the fistula tract (Fig 5).
The patient is usually endoscoped again to check the position of the retention bumper. The adjustable fixation plate, clamp and adaptor ends are then fitted to the external part of the tube (Fig 6). The adjustable fixation plate is positioned 1cm from skin, the mouthguard is removed and the patient roused from sedation.
During the 72 hours after PEG tube placement, monitoring of clinical observations is important. The NPSA (2010) recommends that certain observations are conducted at certain time; these are outlined in Box 2.
During patient observation, the PEG tube and site should be observed and the fixation plate checked, ensuring it is approximately 1cm from the abdomen.
If the tube is held in place too tightly there is a risk of pressure damage, which can result in necrosis, haemorrhaging, buried bumper syndrome and/or leakage of gastric content. If it is held loosely and the tube moves freely, the tract may not form properly; this can give rise to leakage of gastric content, peritonitis, infection or overgranulation at the site (Conroy, 2009). Once the fixation plate is in the correct position it should not be moved for the first seven days, unless clinically necessary.
The NPSA (2010) developed “red-flag” alerts to initiate immediate reaction to serious complications post PEG tube insertion. If the patient develops any of the symptoms in Box 1, the medical team must be informed immediately; these symptoms could be signs of complications.
After the first 72 hours it is important to monitor the PEG tube and site at least daily and more often if concerned. The patient’s doctor must be informed of any concerns as soon as possible so management plans can be initiated, and referral made to relevant members of the multidisciplinary team.
Using the PEG tube
Patients are usually kept nil by mouth and PEG tube for four hours after insertion to allow sedation to wear off. The tube should then be flushed with 50ml of sterile water. If flushing causes pain it should be stopped and the medical team informed immediately as this is a red-flag alert and needs urgent attention. If flushing does not cause pain it is safe to start using the tube.
There are many advantages to PEG tube placement for long-term access to the gastrointestinal tract that bypasses the mouth and oesophagus. However, patients must be carefully selected for PEG tube placement. With good nursing care many of the associated complications can be avoided or highlighted promptly for investigation and management.
With thanks to Fresenius Kabi for diagrams and pictures
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Best C (2004) The correct positioning and role of an external fixation device on a PEG. Nursing Times; 100: 18, 50-51.
Conroy T (2009) The Prevention and Management of Complications Associated with Established PerCutaneous Gastrostomy Tubes in adults: A Systematic Review. London: Joanna Briggs Institute.
Fletcher J (2011) Nutrition: safe practice in adult enteral tube feeding. British Journal of Nursing; 20: 19, 1234-1239.
Gauderer M et al (1980) Gastrostomy without laparotomy: a percutaneous endoscopic technique. Journal of Paediatric Surgery; 15: 6, 872-875.
Kurien M, Sanders D (2010) Antibiotic prophylaxis after percutaneous endoscopic gastrostomy. British Medical Journal; 341: 55-56.
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National Patient Safety Agency (2010) Early Detection of Complications after Gastrostomy. London: NPSA.
Tanswell I et al (2007) Assessment by a multi-disciplinary clinical nutrition team before percutaneous endoscopic gastrostomy placement reduces early post-procedure mortality. Journal of Parental and Enteral Nutrition; 31: 205.
Westaby D et al (2010) The provision of a percutaneously placed enteral tube feeding service. Gut; 59: 1592-1605.