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Percutaneous endoscopic gastrostomy tube
insertion and referral guidelines (PEG)
Clinical Guideline
Developed in response to:
NCEPOD Scoping our Practice
Best Practice
Mental Capacity Act
Contributes to HCc Core Standard No
Professionally approved by
Professionally Approved on
5a
Glynis Wheeler, Nurse Endoscopist
Marjorie Roberts, Nurse Endoscopist.
Pauline Bird, Clinical Manager, Nutrition
& Dietetic Service
Siobhan Jordan, DDN.
April 2007
Version Number
Issuing Directorate
Approved by
Approved on
Next Review Date
Author/Contact for Information
1.0
Emergency Care & Clinical Sciences
Clinical Document Approval Group
8th May 2008
January 2009
Glynis Wheeler, Nurse Endoscopist
Policy to be followed by (target staff)
All clinical staff involved in the referral for,
and insertion of PEG Tubes.
Intranet and Website
04071 Infection Prevention
04080 Consent Policy Number:
Guidelines on Safety & Sedation for
Endoscopic Procedures, (British Society
of Gastroenterologists, 2003).
Distribution Method
Related Trust Policies (to be read in conjunction
with)
Document Review History
Review No
Reviewed by
Review Date
Registration Number
08035
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Index
1.
Purpose of Document
2.
Scope
3
Staff & Training
4.
Means of Referral
5.
Indications for PEG
6.
Contraindications for PEG
7.
Prior to Procedure
8.
Technique for Insertion
9.
Post Procedure Care
10.
Infection Control
11.
Audit
12
References
Appendix 1 - 1st Assistant Trainee Assessment Form (Insertion of PEG)
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1.
Purpose of Document
1.1
PEG has a procedure related mortality of around 1% and a 30-day mortality rate of
16%,) . It can also be a traumatic event for patients.
1.2
This document aims to ensure:

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that all referrals are appropriate
that a strict procedure is followed
that the task is carried out by apppriately trained staff
that post insertion care is optimised
that the correct infection prevention measures are followed
1.3
MEHT is committed to the provision of a service that is fair, accessible and meeting the
needs of alll individuals
2.
Scope
2.1
Patients are referred for insertion of PEG by Consultant Physicians, Surgeons and
General Practitioners.
2.2
Appropriateness of referral should be assessed by multi-disciplinary team of
Consultant Gastroenterologist/ Physicians, Associate Specialist, Nurse Endoscopist,
Dietitians, Speech & Language Therapist, Carers (including ward nurses).
2.3
A PEG tube should be considered for patients with a functional gastrointestinal tract
and meaningful longevity who are unable to consume enough calories to meet their
metabolic demands.
2.4
Feeding via a PEG tube is more reliable than nasogastic feeding in ensuring patients
receive their prescribed quantity of enteral feed.
2.5
Patients likely to require enteral feed for greater than 3 - 4 weeks should be considered
for PEG insertion.
3.
Staff & Training
PEG placement will be carried out by experienced clinical staff . e.g. Consultant
Gastroenterologists, Specialist Registrars, Associate Specialists, Nurse Endoscopists.
Nurse Endoscopists will have undergone observed and supervised practice (minimum
of 10 insertions) and competencies will be signed off. (See attached 1st assistant
compentency attainment form).
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4.
Means of Referral.
4.1
In - patients are referred to the endoscopy unit for consideration of PEG insertion by
means of ordercomm system.
4.2
Appropriate endoscopy staff will visit ward patients for consideration of PEG insertion
AFTER they have been recently assessed by Dietitians and Speech and Language
Therapists which has been documented in medical notes.
4.3
Ward staff caring for patient will give the patient a copy of the “Eido” patient information
leaflet (available on intranet).
4.4
Referrals for out-patients to attend as day cases should be assessed by MDT as above
and this should be the responsibility of the General Practitioner.
5.
Indications for PEG
5.1
Neurological dysphagia, including:



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
5.2
PEG insertion should also be considered in patients with neurological dysphagia if
they:


5.3
Are suffering from potentially harmful aspiration
Are progressively losing weight
Have intolerable difficulty with eating
Head and neck malignancy/obstructive dysphagia including:

5.4
Stroke
Head Injury
Motor Neurone Disease
Multiple Sclerosis
Hungtington’s Disease
Cerabral Palsy
Parkinsons Disease
Patients undergoing radiotherapy/surgery for head and neck malignancies whose
ability to take oral nutrition is impaired
Oropharyngeal cancer (especially pre operative)
Oesophageal cancer when other palliative endoscopic techniques are inappropriate
Supplementary feeding:



Cystic Fibrosis
Crohn’s Disease
Short Bowel Syndrome
Scleroderma
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
Nocturnal Hypoglycaemia
5.5
To supplement oral intake when non-gastrointestinal chronic disease causes
malnutrition, e.g. Renal Failure.
5.6
Access for gastrointestinal decompression in patients with benign or malignant
gastrointestinal obstruction.
6.
Contraindications for PEG.
6.1
Absolute
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6.2
The inability to pass the endoscope through the oesophagus
Severe respiratory compromise
Ascites
Diffuse peritonitis
Limited life expectancy
Most cases of small bowel obstruction
Disseminated intra-abdominal malignancy
Anorexia nervosa
Relative
These contraindications increase risk of complication following PEG insertion
and although PEG insertion could be undertaken decision to insert must be
made on an individual basis following constultation with patient, carers,
Consultant Gastroenterologist and other medical Consultants involved with
patients care.
Peritoneal dialysis
 Bleeding disorders/anticoagulation
 Gastric varices
 Portal hypertension
 Large hiatus hernia
 Hepatomegaly
 Morbid obesity
 Previous gastric surgery
 Severe gastro-oesophageal reflux with risk of aspiration
 Pregnancy
 Current chest infection
 Recent myocardial infarction
 dementia
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7.
Prior to procedure
7.1
A multi-disciplinary team assessment of patients referred for PEG insertion will be
undertaken, usually on a weekly basis
7.2
Procedure should preferably be performed in endoscopy unit. Procedure may
also be performed in intensive therapy unit and operating theatre depending on
patient’s needs.
7.3
Once a patient has been assessed and PEG insertion date agreed this will be
documented in patient’s medical records by endoscopy staff and it is the responsibility
of the ward ( Nursing) team caring for the patient to ensure that Dietitians are informed.
7.4 Informed consent from the patient must be obtained. If patient unable to
consent, referring clinician should complete consent form 4 and document this in
patient’s medical records.
7.5
Check MRSA status
7.6
24 hours prior to insertion prophylactic antibiotic measures should be commenced
7.7
Nasal application of Bactroban by ward staff in line with MEHT infection prevention
policy.
7.8
Intravenous access obtained prior to procedure for the administration of sedation.
7.9
Patients must be nil by mouth or nil by nasogastric tube for a minimum of 6 hours prior
to procedure.
7.10
Recent Liver Function Tests, Urea & Electrolyte, Full Blood Count, Phosphate,
Magnesium, Total Protein, C Reactive Protein and full clotting blood results must be
available.
8.
Technique for insertion
Before Insertion
8.1
The procedure is carried out with the patient sedated in the supine position.
8.2
Sedation is with the smallest effective dosage of intravenous midazolam, BSG
Guidelines on Safe Sedation.
8.3
Prophylactic intravenous antibiotics are administered before the procedure.
8.4
A complete oesophagogastroduodenoscopy (OGD) is performed before the stomach
is insufflated to maintain apposition with the anterior abdominal wall.
8.5
A transilluminated point is chosen on the epigastrium that allows clear visible
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indentation of the gastric lumen by a finger or blunt instrument.
8.6
The costal margins and deep folds within the abdominal wall should be avoided.
8.7
The abdominal wall is cleansed with Alcohol Chlorhexidine solution.
8.8
The skin and subcutaneous tissue at that point are infiltrated with local anaesthetic,
Lignocaine 2%.
Insertion
8.9
The direction required to pass local anaesthetic needle through into the stomach is
used as a guide for the insertion of the trochar/cannula from the PEG kit
8.10
A 0.5 cm to 1 cm incision is made through the skin and the trochar/cannula is the
inserted into the stomach under endoscopic visualisation
8.11
The Trochar is removed leaving the cannula in position
8.12
A guide wire is introduced through the cannula into the gastric lumen where it is
grasped with an endoscopic snare
8.13
The endoscope and guide wire are then withdrawn through the mouth.
8.14
The guidewire is attached to a gastrostomy tube that has an internal bumper at the
opposite end
8.15
By pulling the guide wire exiting the skin incision the tube is drawn through the
oesophagus and into the stomach, with the tapered end exiting through the abdominal
wall
8.16
Resistance may be felt as the tube passes through the skin if the initial incision was
inadequate and it is sometimes necessary to extend the skin incision at this stage.
8.17
The PEG is pulled into its final position with gentle tension. Markers on the PEG
indicate the distance from the retaining flange to the surface of the abdominal wall.
8.18
The PEG tube is fastened into position.
8.19
The PEG tube is then cut to the appropriate length and the securing external bumper is
fastened into position. Routine rescoping after the PEG is positioned is not necessary.
9.
Post Procedure Care
9.1
Patients should receive close observations for a minimum of 2 hours post PEG
insertion or until patient is fully recovered from effects of sedation.
9.2
Regular 4 hourly observations should then be maintained to observe for signs of
complications of PEG. Regular observations immediately after the procedure will
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increase the chances of identifying post-operative complications early and improve
their prognosis
9.3
This PEG protocol recommends that patients remain nil by PEG for 2 hours and that
checks are made for signs of complications before administering feed This is to allow
time for peristalsis to recover following the trauma of PEG insertion.
9.4
Day case patients will be monitored in endoscopy unit as per endoscopic policy for
sedated/therapeutic patients.
9.5
Day case patients will be discharged with endoscopy advice sheet containing on call
telephone number,24 hour access to trained, experienced endoscopy nurse.
10.
Infection Prevention
10.1
Staff will wash their hands before and after each procedure
10.2
Staff will use the Aseptic non touch Technique
11.
Audit
11.1
The service will be audited 6 monthly by Nurse Endoscopists. Audit will be performed
in line with MEHT Audit policy.
11.2
Audit will demonstrate clinical guidelines have been followed.
11.3
Audit will be quantitative and will include complication rates, outcomes and patient
satisfaction.
11.4
Audit will demonstrate those patients who were referred for PEG insertion but who
were not deemed appropriate, reasons for unsuitability and out come will be detailed.
11.5
Audit will be presented at relevant forums such as Endoscopy Users Meeting,
Consultant Gastroenterologists, and Deputy Director of Nursing and reviewed as part
of appraisal.
11.6
Dietetics audit will also be considered.
12.
References
Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a non operative technique
for feeding gastrostomy. Gastrointestinal Endoscopy, 1981; 27 (1): 9-11.
British Society of Gastroenterology, Clinical Guidelines. http://www.bsg.org.uk
Rabeneck L, McCullough LB, Wray NP. Ethically justified, clinically comprehensive guidelines
for percutaneous endoscopic gastrostomy tube placement. Lancet 1997; 349: 496-98.
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NCEPOD 2004. “Scoping our Practice” http://www.bsg.org.uk.
British Society of Gastroenterology, Guidelines on Safety and Sedation for Endoscopic
Procedures, 2003.
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Appendix 1
1st ASSISTANT TRAINEE ASSESSMENT FORM
(INSERTION OF PEG).
Date
Trainer
Case 1
Trainee
Case 2
Case 3
Checking of equipment
Administration of antibiotics
Identification of ANTT
Cleansing of skin
Infiltration of local anaesthetic
Surgical incision
Insertion of trochar
Insertion of guidewire
Applying fixation device
Application of opsite
Comments
Assessment of skill: Inadequate requires constant supervision=1, Adequate but needs focused
training=2, Competant=3
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