peg vs nasogastric tube feeding
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Early percutaneous endoscopic gastrostomy (PEG) versus nasogastric tube (NGT) for nutrition of severe
traumatic brain injury patients
By
Tarek Talaat Aly El-Sefi
The nutritional management of critically ill patients
has changed dramatically over the past 10 years
Changes in the areas of nutritional assessment,
guidelines for total energy provided, disease-
specific feeding, and immune-enhancing enteral
nutrition have been the most prominent
The rationale for nutritional support comes from
the knowledge that critically ill patients are prone
to develop malnutrition, which is known to be
associated with serious complications such as
sepsis and pneumonia, leading to a poor outcome
and even death
Why does malnutrition develop in critically ill
patients?
Negative nitrogen balance &
malnutritionin
the critically ill
Exogeneous steroids
Immobility
& prolonged bed rest
Hypermetabolism Poor intake with
protein loss and fat gain in muscles Surgery
Stress & organ failure
Acute phase response: TNF, IL-6, IL-1β with change in substrate utilization
Impaired gut
function
Weight loss1
Weakness and fatigue2
Impaired ventilatory drive3
Poor wound healing4
Impaired immune function, increase risk of infection5
Prolonged hospital stay6
Consequences of
malnutrition
(DEATH)
Provide nutritional substrates to meet protein and energy requirements1
Help protect vital organs and reduce break down of skeletal muscle2
To provide nutrients needed for repair and healing of wounds and injuries3
To maintain gut barrier function4
To modulate stress response and improve outcome5
Why we feed the
critically ill?
IN TRAUMATIC BRAIN INJURY)Nutrition…Is it important?(
The metabolic status and nutritional needs of
patients with TBI are of a less priority than
maintaining cerebral perfusion pressure )CPP(
However, TBI results in a hypermetabolic and
catabolic state that increases systemic and
cerebral energy requirements that can quickly lead
to malnutrition and its attendant complications
The Guidelines for the management of severe TBI
recommend that the patient’s feeding requirements
should be met by the end of the 1st week after TBI
Inadequate early nutrient intake in head-injured
patients has been associated with prolongation of
the acute-phase response and an increased
incidence of septic morbidity
Early EN in critically ill patients may be associated
with a significantly lower incidence of infections
and a reduced hospital stay
Is Early Feeding Beneficial in TBI?
Brain injuries can be classified according to
GCS score into:
Mild: a GCS 13 or above
Moderate: a GCS 9–12
Severe: a GCS 8 or below. This group has the
highest mortality and morbidity
Classification of TBI
Energy needs are calculated on the basis of basal energy expenditure
)BEE(
The BEE is the amount of energy required to perform metabolic
functions at rest, and is influenced by both body size and illness
BEE classically is estimated by the Harris-Benedict equation:
For men, BEE = 66.5 + )13.75 x kg( + )5.003 x cm( - )6.775 x age(
For women, B.E.E. = 655.1 + )9.563 x kg( + )1.850 x cm( - )4.676 x age(
Add stress factor - 1.2 to 2 times
Carbohydrate requirements: 55- 70% of total energy
Fat requirements: 15 – 30% of total energy
Protein requirements: range from1-2g/kg/day
electrolytes, micronutrients, and vitamins needs should not be missed
Nutritional requirements
30 – 35ml fluid/kg/24 hours baseline
Add 2-2.5ml/kg/day of fluid for each degree of
temperature
Highly individualized requirements according to
losses that occur through exudates, hemorrhage,
emesis, diuresis and diarrhea
Enteral nutrition1
Parenteral nutrition2
Nasogastric )NG(
Nasojejunal )NJ(
Percutaneous Endoscopic Gastrostomy )PEG(
Percutaneous Endoscopic Jejunostomy )PEJ(
Radiologically Inserted Gastrostomy )RIG(
Surgical Gastrostomy
Surgical Jejunostomy )JEJ(
WHY ENTERAL?
Decrease in Peyer’s patch leukotrienes
Decrease in T & B cells in Peyer’s patches, Lamina
propria & epithelium
Reduced secretory IgA and altered cytokines
Mucosal atrophy
Altered flora
Decreased gastric acid
Diminished ENTERAL feeding will cause:
Bacterial translocation
Is more physiological & relatively cheap
promote gastrointestinal tract function and integrity
prevent bacterial translocation
So Enteral feeding
Nosocomial infections
It requires adequate gastric emptying
There is risk for aspiration which can be reduced by
continuous feeds & checking for gastric residue
Diarrhea- lactose intolerance,altered bowel flora, and
malabsorption
Tube dislodgment, malposition and blocked tubes
can also occur
Disadvantages of ENTERAL FEEDING
Contra-indications to Enteral feeding
Bowel
obstructionIleus
Intestinal
ischaemia shock
Advantages:Does not require gastric motility
No risk of aspiration
Disadvantages:Intestinal mucosal atrophy
Catheter related sepsis
Expensive in relation to EN
Mechanical: pneumothorax, hydrothorax and arterial
puncture
Overfeeding syndrome
Severe metabolic disorders
Hyperglycemia
Hypertriglyceridemia
Azotemia.
hepatic steatosis
Fat overload syndrome
The nurition in critically ill patient could be either
enteral or parentral.
Enteral nutrition )EN( is recommended over
parenteral nutrition )PN( in patients who are
haemodynamically stable and have a functional
GI tract
Parenteral nutrition is required when the GI tract
is not functioning
ROUTES FOR ENTERAL NUTRITION
It is the classical, time-proven technique for EN but it
has a lot of complications
Risk of injury to nasal wing
Chronic sinusitis
Hypoxia, cyanosis, or respiratory arrest due to
accidental tracheal intubation
Risk of GER and aspiration
Risk of displacement or blockage
Reaching nutritional goals uncommon
Gastrostomies are generally used for long-term
enteral feeding in patients with swallowing
limitations who require nutritional support provided
that the patient has a reasonable prospect of
survival and normal GIT function
Wider caliber:
less incidence of blockage
less interruption of feeding
Improve nutritional state
No risk for sinusitis
Minimize GER
Reduces Social and Psychological problems
Less incidence of dislodgment or malposition
Surgically )open or laparoscopic(1
Endoscopically )PEG(2
Radiologically )RIG(3
Gastrostomy can be inserted either:
PEG IS PREFERRED
It was first described in 1980 by Gauderer and colleagues
for use in children but has since gained wide acceptance
for use in patients of all ages
The PEG technique has largely replaced surgical
gastrostomy as the procedure of choice for patients who
require long-term enteral nutrition. The superiority has
been shown clearly in many clinical studies. Lower
complication rates, reduced hospital length of stay and
costs have been reported with PEG
PEG
Quick procedure
Shorter anaesthetic exposure than a surgical
placement
Fewer complications
Easily removed under general anaesthetic
Less likely to be displaced
Open gastrostomyApart from risk of general anaesthesia, postoperative ileus,
bleeding,wound infection and dehiscence
Laparoscopic gastrostomyCost
Use of OR Resources
Radiological:Requires patient transportation to radiology department
Requires CT and fluoroscopy in the same room which is not
available in many hospitals
General: life expectancy less than 3 months
Systemic: systemic sepsis
Rapidly deteriorating patients with multiorgan failure
Coagulopathy
Technical:Inability to perform upper endoscopy
Obstructing esophageal tumor
Stricture
Inability to oppose stomach to anterior abdominal wall
Previous subtotal gastric resection
Hepatomegaly, esp left lobe
Massive ascites
Abdominal:Intra-abdominal sepsis
Oesophogel or gastric varices
Large hiatal hernia
Pull tehcnique
Push technique
Introducer method No outcome difference between pull and
push methods
The pull-type technique is still the standard procedure for
endoscopic PEG placement
However, in several clinical situations the classical pull-type PEG
procedure is not possible or contraindicated. In case of high-grade
stenosis caused by an oesophageal tumor or a head and neck
tumor, a conventional upper GI endoscopy may not be possible or
the internal bumper of the PEG-tube may not pass. Also, the risk of
metastases at the site of the gastrostomy is high.
This has led to the development of push technique and then the
introducer technique
MINOR:Wound infectionPeristomal leakagePneumoperitoneumTube clogging
Major:Necrotizing fascitisEsophogeal and gastric perforationBuried bumper syndromeColocutaneous fistulaAspirationPeritonitis
AIM OF THE WORK
Is to Compare early
percutaneous endoscopic
gastrostomy)PEG( versus
nasogastric tube for
nutrition of severe
traumatic brain injury
patients
Pateints & Methods
The study was carried out on 30 adult patients of both sex.
They were selected from those admitted to the Critical Care
Medicine Department at the Alexandria Main University
Hospital with the diagnosis of severe traumatic brain injury
)GCS 8 or less(
These patients were divided randomly into 2
groups:
Group A: was given nutritional support via nasogastric
tube
Group B: was given nutritional support via PEG after
hemodynamic stabilization )>3days(
Patients with multiple traumatic injuries including abdominal traumaPatients with massive or untreatable loculated ascitesPatients with uncorrected coagulapathyGastric mucosal abnormalities: large gastric varices, portal hypertensive gastropathyPrevious abdominal surgery, including previous partial gastrectomy: increased risk of organs interposed between gastric wall and abdominal wallMorbid obesity: difficulties in locating stomach position by digital indentation of stomach and transilluminationGastric wall neoplasmAbdominal wall infection: increased risk of infection of PEG site
The following patients were Excluded
In the first group, NG tube was inserted and position was confirmed by auscultation method and by aspiration of gastric contentsIn the second group, PEG was inserted in the fourth day using pull technique
Both groups of patients received conventional enteral feedingAll the studied patients were assessed for:
A(Nutritional status:Anthropometric parameters)MAC and TSFT( on admission and weekly for 28daysSerum albumin on admission and on dischargeNitrogen balance every 2 weeks for 28 days
B(OUTCOMEDuration of ICU stay)days(Duration of hospital stay)days(Complications of both techniques were recorded
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Comparison between the two studied
groups according to age
Control group PEG group0
5
10
15
20
25
30
35
40
45
Mea
n o
f ag
e
Comparison between the two studied
groups according to sex
Male Female 0
10
20
30
40
50
60
70
80Control group
PEG group
Per
cen
tag
e
Comparison between the 2 studied groups
as regards MAC
0
5
10
15
20
25
30
35
40
45
50
On starting feeding Week 1 Week 2 Week 3 Week 4
Mea
n
Control group
PEG group
Comparison between the 2 studied groups
as regards TSFT
0
2
4
6
8
10
12
14
On starting feeding Week 1 Week 2 Week 3 Week 4
Mea
n
Control group
PEG group
Comparison between the 2 studied groups
as regards Nitrogen balance
On starting feed-ing
Week 2 Week 4-7
-6
-5
-4
-3
-2
-1
0
1
2
3
Control group
PEG group
Mea
n
Signifi
cant
Comparison between the 2 studied groups
as regards serum albumin
On starting feeding Week 40.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5Control groupPEG group
Time
Mea
n s
eru
m a
lbu
min Sig
nifican
t
Comparison between the 2 studied groups
as regards ICU and hospital stay
Icu stay Hospital stay0
5
10
15
20
25
30
35
40
45
50Control group
PEG group
Mea
n
Comparison between the 2 studied groups
as regards incidence of complicationsS
inu
sit
is
Pn
eu
mo
nia
Inte
rve
nti
on
fa
ilure
Ep
ista
xis
Wo
un
d in
fec
tio
n
pn
eu
mo
-p
eri
ton
eu
m
0
10
20
30
40
50
60
70
80
Control groupPEG group
Per
cen
tag
e
PEG tube feeding is more effective than NGT feeding
in improving nutritional status )in terms of serum
albumin and nitrogen balance( of patients with
severe traumatic brain injury
PEG should be inserted within the first 24hrs of intubation to
decrease the incidence of VAP
Measurements of anthropometric parameters can be of value
after long period follow up
Simultaneous measurements of acute phase reactants together
with serum albumin to help determine whether low albumin
levels are related to inflammatory process or result of poor
nutrition status
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