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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 1 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) 2 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: 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). 3 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: 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 4 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 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 5 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 6 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 7 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. 8 NCEPOD 2004. “Scoping our Practice” http://www.bsg.org.uk. British Society of Gastroenterology, Guidelines on Safety and Sedation for Endoscopic Procedures, 2003. 9 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 10 11