Download PEGS INS & OUTS

PEGS
INS & OUTS
Denni Arrup, BA, RN, CGRN, CFER
November 8, 2014
Learning Objectives
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History
Uses
Contraindications
Procedure
Complications
Equipment
What is a PEG?
• Definition: Percutaneous Endoscopic
Gastrostomy Tube
• Medical device used to provide nutrition and
medications
• Temporary or permanent
• Patients unable to obtain nutrition by mouth,
swallow safely or need supplementation
Composition
• Made of polyurethane or silicone
• Diameter is measured in French units (each
French unit = 0.33 millimeters). Most
common for adults is 20 Fr.
• Classified by site of insertion and intended
use
History of Feeding Tubes
• 3500 years ago to Greek and Egyptian
civilizations
• Papyrus writings: Egyptian physicians used
reed and animal bladders to rectally feed
patients things like milk, broth, wine, whey to
treat different complaints
• Rectal feeding – method of choice
for thousands of years
History – cont’d
• Difficulty accessing upper GI tract without killing
the patient. Some things remain important to
this day: not killing the patient
• 1598: Capivacceus used a hollow tube with a
bladder attached to one end, filled with nutrient
solution, down as far as patient’s esophagus
• 1617: Aquapendente (Italian professor of
anatomy and surgery) used silver tube as a
nasopharyngeal tube
History – cont’d
• 1646: Von Helmont devised flexible leather
tube for feeding into the top of esophagus
• 1710: Tubing might be used to reach all the
way to the stomach
• 1790: Oro-gastric feeding developed by John
Hunter, used a whale bone covered by eel
skin attached to a bladder pump.
History – cont’d
• 18th and 19th centuries: difficult and
uncomfortable to keep tube down a person’s
throat – rectal feeding was more accepted.
(you thought colonoscopies were messy)
• 1870: Tube was placed in mouth back toward
pharynx and mixtures of thick custards,
mashed mutton, warm milk, beef broth, eggs
and medications were given.
History – 1881
• US President James Garfield was shot and
kept alive 79 days by being rectally fed a
blend of beef broth and whisky.
• Rectal feeding (nutrient enemas) was popular
in the early 1900’s – gone out of fashion
(thankfully).
• Some medical students have re-discovered
that colonic absorption is a very fast way to
get drunk. Not a very clean method. . .
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PEG
• June 12, 1979 at the Rainbow Babies and
Children’s Hospital, University Hospitals of
Cleveland
• Performed by:
– Dr. Michael W.L. Gauderer, pediatric surgeon
– Dr. Jeffrey Ponsky, endoscopist
– Dr. James Bekeny, surgical resident
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PEG
• Patient: 4 ½ month old child with inadequate
oral intake
• Technique was first published in 1980 – gold
gold standard for PEG placement
Uses
Naso-pharyngeal feeding
• ‘Fasting girls and spoilt children who refused
food’
• Device that looked like a tea pot with a very
long spout were used to force-feed patients
in mental institutions – mixtures of egg, milk,
beef tea and wine thickened with arrowroot
Delivery of enteral nutrition
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Dysphagia due to stroke
Pre-op - for oral/esophageal cancer surgery
ALS
Anatomical: cleft lip and palate during the
process of correction
• Failure to thrive: premies to adults
• Persistent N/V during pregnancy
Decompression
• Gastric decompression – major trauma or
intestinal obstruction
• Provide gastric or post-surgical drainage
Delivery of Medication
• Liquid form of medication (elixir)
• Carafate slurry
• Administer medications as per guidelines
CONTRAINDICATIONS
Absolute contraindications
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Inability to perform an EGD
Peritonitis
Massive ascites (untreatable)
Uncorrected coagulopathy
Bowel obstruction (unless PEG is to be used
for drainage)
Relative Contraindications
• Gastric mucosal abnormalities: large gastric
varicies, portal hypertensive gastropathy
• Previous abdominal surgery
• Morbid obesity
• Gastric wall neoplasm
Procedure
Collects all supplies needed for PEG
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PEG kit
Sterile gloves for GI tech and MD
Sterile bowl for collecting sharps
Sterile 4x4’s
Marking Pen
Gowns
Consents for procedure and sedation
Antibiotics and tubing, if required
Pre-op patient for procedure
• Consent
• Advance directives
• Obtain current set of vital signs, weight (kg),
height (cm)
Pre-op
• Patient assessment
• Medications
• Labs
• NPO
Procedure Room
• Explain procedure to patient
• Take patient to room
• Insert bite block
• Drape patient
In the Room
• Perform time out
• Sedation
• Endoscopy performed
Procedure - 1
• Open PEG Kit
• Scrub
• Mark
• Medicate
• Trocar
Procedure - 2
• Stylet
• Snare
• Retrieve
• Insert guidewire
Procedure - 3
• Grab guidewire
• Scope withdrawn
• Guidewire threaded into insertion tube
Procedure - 4
• MD will pull guidewire – insertion tube
comes through skin
• MD pulls insertion tube
• MD positions PEG in place
Procedure - 5
• GI tech places external bumper and clamp on
tube
• MD confirms placement of PEG
• GI tech inserts adapter on tube
• Measurement of tube given to RN for record
Procedure - 6
• Assess patient – abdominal binder?
• Patient moved to recovery
• Call report to floor or nursing home
COMPLICATIONS
Complications of procedure
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Hemorrhage
Cellulitis
Gastric ulcer
Perforation of bowel
Puncture of left lobe of liver
Gastrocolic fistula
Diarrhea
Clogged tube
• Flush PEG tube
• Use brush to create opening in clogged tube
• Instill grapefruit juice or lemon-lime soda and
let sit 10 minutes
• Much easier to keep the lumen flushed
Infection
• SKIP
• Wash PEG site with soap and water as part of
daily cleansing routine
• Check VS – temperature
• Check labs - WBC
Infection, cont’d
• Turn the PEG tube – 360 with feedings/flush
• Check for PEG tube measurement
“Buried Bumper Syndrome”
• Occurs
– when the gastric bumper migrates into the
gastric wall
– when the external bumper is too tight on the
outside, causing pressure on the gastric bumper,
eroding into the stomach wall at site of stoma
• Abdominal pain, crepitus around stoma,
purulent drainage
REMOVAL OF PEG
Indications
• PEG tube no longer needed
• Persistent infection at the PEG site
• “Buried Bumper Syndrome”
• Failure, breakage or deterioration of PEG
tube
Procedure – removal of PEG: 1
• PEG tubes with rigid, fixed internal bumpers
are to be removed endoscopically.
• Bumper removed
• Cut tube pushed into stoma
• Insert snare
Procedure – Removal of PEG: 2
• Pull snare with scope
• Place endoclip
• Dress skin
NEW USES
ASPIRE
• Low risk method of weight loss
• Developed by 3 physicians:
– Dr. Sam Klein – Director of the Center for Human
Nutrition at Washington University School of
Medicine in St. Louis, Missouri
- Dr. Moshe Shike – Attending Physician and
Director of Clinical Nutrition at Memorial Sloan
Kettering Cancer Center in New York
- Dr. Stephen Solomon – Attending Physician and
Chief of IR at Memorial Sloan Kettering
Aspire Bariatrics founded in 2005 by
Drs. Klein, Shike and Solomon
• These 3 physicians combined their expertise
in the areas of nutrition, obesity,
gastroenterology, interventional radiology,
percutaneous endoscopic gastrostomy (PEG)
tubes and medical device discovery
• Modified and adapted the PEG tube to help
patients lose weight
New Approach to Weight Loss
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Minimally invasive
Reversible
‘AspireAssist’ available in Europe
Clinical trials in the United States
Dramatic results – patients have lost an
average of 46 pounds during the first year
Procedure
• During an outpatient procedure in an
endoscopy center or surgi-center, the patient
would meet all the requirements for an
endoscopy: NPO for 8 hours, labs and EKG,
sleep study if needed, heart and blood
pressure medications taken with a sip of
water prior to arrival, ride home verified
before procedure
Procedure – cont’d
• Consent obtained by anesthesia and
endoscopist
• Procedure explained to patient with possible
complications
• Discharge instructions reviewed with patient
so he/she able to care for the fresh PEG
• Diet – normal food, drink and amounts
• Follow up visit scheduled for 10 days
Procedure – cont’d
• No diet change needed to begin
• Patient to learn healthier eating habits over
time
• Relatively inexpensive – cost of AspireAssist
device, PEG tube insertion with anesthesia
• Bariatric surgery very expensive
Aspire Assist
• After a meal, the patient can attach the
Aspire Assist device to the skin port on the
outside of the abdomen. The valve on the
skin port is opened to remove 30% of
stomach contents into the toilet
Aspire Assist - 2
• This ‘aspiration’ takes place 20 minutes after
consumption of a meal.
• Time needed to perform procedure – 5 to 10
minutes
• Weight loss is attained because 30% of
stomach contents removed 3 times/day (with
each meal), resulting in less caloric intake in
small intestines
ASPIRE
• New way to reduce portion size
• Vitamins will be prescribed to keep healthy
• Counseling sessions
• Important to drink plenty of fluids to assist
with aspiration
Caring for skin-port
• Care is similar to PEG care –
• Activity is encouraged, no deep-water diving
Removal of Skin-Port
• Reversible if not needed or wanted
Weight loss achieved
Changed mind
 Removal is same as for PEG removal
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Procedure under sedation to remove device
Clip the opening on the inside of the stomach
Steristrips on the outside of the opening
Closes within 2-3 days.
Equipment
By Vendors
Boston Scientific
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20 Fr PUSH PEG
20 Fr PULL PEG
24 Fr PUSH PEG
24 Fr PULL PEG
Cook Medical
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Flow 20 Pull Method
Flow 20 Push Method
Peg 20 Jejunal tube
Peg 24 Jejunal tube
Corpak
• CORFLO feeding tubes
Today’s Overview
1
• Familiarize yourself with
PEG procedure
2
• Explore the equipment
3
• Review the steps for a
smooth placement
Today’s Overview
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• Review contraindications
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• Review complications
6
• Review removal
procedure
Summary
• INS
– History
– Procedure
– Contraindications
– Uses
Summary – cont’d
• OUTS
– Removal
– Procedure
References
 Aadhaar (2012, March 14). You start with a tube…: Tubefeeding –
a brief history [Web log post]. Retrieved from http://
youstartwithatube.blogspot.com/2012/03/tubefeeding-briefhistory.html
 Phillips, N. (2006). Nasogastric tubes: An historical context. Medsurg
Nursing, 15(2), 84-88.
 Ponsky, J. (2011). The development of PEG: How it was. J Interv
Gastroenterology, 1(2), 88-89
References (cont’d)
 Ponsky, J. & Gauderer, M. (1981). Percutaneous
endoscopic gastrostomy: a nonoperative technique
for feeding gastrostomy. Gastrointestinal Endoscopy,
27(1), 9-11.
 Sullivan, S., Stein, R., Jonnalagadda, S., Mullady, D., & Edmundowicz, S.
(2013). Aspiration therapy leads to weight loss in obese subjects: A
pilot study. Gastroenterology, 145(6), 1245-1252.
QUESTIONS?