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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