Reducing Accidental Dislodgement of the Percutaneous Endoscopic Gastrostomy: A Prospective Trial of the "SafetyBreak" Device

Preventing inadvertent drain removal using a novel catheter securement device

Percutaneous drains have provided a minimally invasive way to treat a wide range of disorders from abscess drainage to enteral feeding solutions to treating hydronephrosis. These drains suffer from a high rate of dislodgement of up to 30% resulting in emergency room visits, repeat hospitalizations, and catheter repositioning/replacement procedures, which incur significant morbidity and mortality. Using ex vivo and in vivo models, a force body diagram was utilized to determine the forces experienced by a drainage catheter during dislodgement events, and the individual components which contribute to drainage catheter securement were empirically collected. Prototypes of a skin level catheter securement and valved quick release system were then developed. The system was inspired by capstans used in boating for increasing friction of a line around a central spool and quick release mechanisms used in electronics such as the Apple MagSafe computer charger. The device was tested in a porcine suprapubic model, which demonstrated the effectiveness of the device to prevent drain dislodgement. The prototype demonstrated that the miniaturized versions of technologies used in boating and electronics industries were able to meet the needs of preventing dislodgement of patient drainage catheters.

Home Parenteral and Enteral Nutrition

While the history of nutrition support dates to the ancient world, modern home parenteral and enteral nutrition (HPEN) has been available since the 1960s. Home enteral nutrition is primarily for patients in whom there is a reduction in oral intake below the amount needed to maintain nutrition or hydration (i.e., oral failure), whereas home parenteral nutrition is used for patients when oral-enteral nutrition is temporarily or permanently impossible or absorption insufficient to maintain nutrition or hydration (i.e., intestinal failure). The development of home delivery of these therapies has revolutionized the field of clinical nutrition. The use of HPEN appears to be increasing on a global scale, and because of this, it is important for healthcare providers to understand all that HPEN entails to provide safe, efficacious, and cost-effective support to the HPEN patient. In this article, we provide a comprehensive review of the indications, patient requirements, monitoring, complications, and overall process of managing these therapies at home. Whereas some of the information in this article may be applicable to the pediatric patient, the focus is on the adult population.

An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit

Critically ill patients are at increased risk for malnutrition as they often have underlying acute and chronic illness, stress related catabolism, decreased appetite, trauma and ongoing inflammation. Malnutrition is recognized as a leading cause of adverse outcomes, higher mortality, and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes provide a safe and effective route to provide supplemental enteral nutrition to these patients. PEG placement has essentially replaced surgical gastrostomy as the modality of choice for longer term feeding in patients. This is a highly prevalent procedure with 160,000 to 200,000 PEG procedures performed each year in the United States. The purpose of this review is to provide an overview of current knowledge and practice standards with regards to placement of PEG tube in the Intensive Care Unit (ICU). When a patient is considered for a PEG tube, it is important to evaluate the treatment alternatives and identify the best option for each patient. In this review, we provide the advantages and disadvantages of various feeding modalities and devices. We review the indications and contraindications for PEG tube placement as well as the risks of this procedure. We then describe in detail the per-oral pull, per-oral push, and direct percutaneous techniques for PEG tube placement. Additionally, we review the feasibility of having interventional pulmonologists place PEG tubes in the ICU.

Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

'Re-PEGing': an endoscopic approach to inadvertent early removal of PEG tube

Inadvertent removal of percutaneous endoscopic gastrostomy (PEG) tube shortly after placement creates the potential for gastric perforation and requires immediate attention. This problem has been addressed in the past with either observation or surgery. We describe our experience with the alternative approach of semi-urgent ‘re-PEGing’. Our results in seven patients were favorable.

Management of early PEG tube dislodgement: simultaneous endoscopic closure of gastric wall defect and PEG replacement

A 53-year-old man with dysphagia underwent uneventful placement of a percutaneous endoscopic gastrostomy (PEG) tube for long-term enteral feeding access. 11 hours after the procedure, it was discovered that he had accidentally dislodged the feeding tube. On physical examination, he was found to have a benign abdomen without evidence of peritonitis or sepsis. He was observed overnight with serial abdominal examinations and nasogastric decompression. In the morning, he was taken back to the endoscopy suite where endoscopic clips were employed to close the gastric wall defect and a PEG tube was replaced at an adjacent site. The patient was fed 24 hours thereafter and discharged from the hospital 48 hours after the procedure. Early accidental removal of a PEG tube in patients without sepsis or peritonitis can be safely treated with simultaneous endoscopic closure of the gastrotomy and PEG tube replacement, resulting in earlier enteral feeding and shorter hospital stay.

Reducing the Unintended Dislodgement of Gastrostomy Tubes in a Long-Term Acute Care Hospital: A QA/QI Pilot Study

Background

Since their introduction in 1980, gastrostomy tubes have become effective means of providing both short-term and long-term enteral access and nutritional support. These feeding tubes are ubiquitous in many health care facilities that care for the elderly, but carry high rates of unintended dislodgement - a complication that, if not detected promptly, is associated with substantial morbidity and health care costs. This study determined the dislodgment rate of gastrostomy tubes at 90 days in a cohort of 221 patients and tested the hypothesis that the implementation of a concise protocol to care for patients’ gastrostomy tubes would reduce these unintended dislodgements.

Methods

The dislodgment rate of gastrostomy tubes at 90 days in a cohort of 221 patients was determined. In addition, a randomized controlled trial was conducted in a long-term acute care hospital in which patients were alternately allocated to either of two geographically separate units: 1) a selected unit where a concise protocol to care for patients’ gastrostomy tubes was implemented, and 2) a separate unit where standard care was provided. Enrollment included patients diagnosed with dysphagia - who were receiving mechanical ventilatory support for chronic respiratory failure - who were being administered feedings, fluids and medications via a balloon gastrostomy tube. The primary endpoint was the number of unintended dislodgements of gastrostomy tubes during a 90-day study period.

Results

In a cohort of 221 patients with balloon gastrostomy tubes placed that was observed for a period of 90 days, 64 (29.0%) had unintended gastrostomy tube dislodgement (P < 0.028). A total of 34 patients were enrolled in the randomized controlled trial with 17 in the treatment group and 17 in the control group. All subjects were followed for a maximum of 90 days. During the study period, there was one episode of unintended gastrostomy tube dislodgement (5.9%) in the treatment group, compared with six episodes (35.3%) in the control group (P < 0.047) and the previous cohort of 221 patients (P < 0.028).

Conclusion

This study showed a significant reduction in dislodgements after implementation of a protocol that is an innovative, straightforward and economical solution to the problem of the unintended dislodgement of gastrostomy tubes.

Endoscopic suturing for the management of recurrent dislodgment of percutaneous endoscopic gastrostomy-jejunostomy tube

OBJECTIVE

To describe a novel technique for the prevention of recurrent percutaneous endoscopic gastrostomy-jejunostomy (PEG-J) tube dislodgements and assess its feasibility and efficacy. This technique utilizes endoscopic suturing to secure the PEG-J tube to the gastric wall.

METHODS

This was a retrospective analysis of consecutive cases of recurrent PEG-J tube dislodgements referred to a single endoscopist between June 2016 and June 2017, using an endoscopic suturing system to secure the PEG-J tube directly to the gastric wall. Technical success rates, the procedure time and related adverse events were analyzed.

RESULTS

There were five patients in total (three females). The procedure was technically successful in all patients. There were no procedure-related adverse events. The mean duration of follow-up was 7.8 ± 5.1 months. Two patients had accidental dislodgement at 8.5 and 12 months, respectively. There were no other unintended dislodgements.

CONCLUSION

Endoscopic suturing with internal fixation of PEG-J tube is a safe and feasible approach to manage recurrent unintended dislodgements.