Percutaneous Endoscopic Gastrostomy ( PEG ) Placement

Publication: 01/10/2002  --
Last review: 16/10/2020  
Next review: 16/10/2023  
Clinical Guideline
CURRENT 
ID: 159 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Percutaneous Endoscopic Gastrostomy (PEG) Placement

Summary

These guidelines apply to all staff who are caring for adult patients who have difficulty in maintaining adequate nutritional intake orally and who are deemed to be at risk of malnutrition during their period in hospital and the community. These guidelines should be read in conjunction with the Trust Enteral Tube Feeding policy (LTHT 2017) and the Trust Methicillin Resistant Staphylococcus Aureus (MRSA) guideline (includes Panton-Valentine Leukocidin (PVL) positive S. aureus) (2017)
Variation from these guidelines applies in certain agreed clinical areas.
Patients with motor neurone disease will follow agreed clinical pathways.
These guidelines have been developed by a multi-disciplinary group within the Leeds Teaching Hospitals NHS Trust.

Aims

The aim of these guidelines is to ensure that patients who have a PEG insertion have been fully assessed as appropriate for PEG and prepared for the insertion procedure correctly.

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Background

Percutaneous Endoscopic Gastrostomy (PEG) tube placement is the feeding route of choice for those who are unable to establish or maintain adequate fluid and nutritional intake orally, coupled with the expectation that tube feeding will be needed for longer than 4 weeks. It is a relatively safe, reliable and comfortable means of providing nutrition (NICE 2006). Good nutrition has a positive influence on recovery from illness and injury (Enteral Tube Feeding Policy 2017).

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Patient Selection

Patients for whom a PEG insertion is being considered should be assessed regarding their nutritional needs, in accordance with the Trust Enteral Tube Feeding policy (LTHT 2017). A multidisciplinary team approach should be taken to ascertain the most appropriate route of feeding for the individual patient. This may include a Speech and Language Therapist or other appropriately trained professional assessing the patient's ability to swallow. Other feeding options should also be considered such as eating and drinking with an unsafe swallow, see Eating and Drinking with an unsafe swallow guidelines (LTH 2017) for further details.

Patients who have been assessed as requiring endoscopic PEG placement should be referred to the endoscopy unit for PEG via Order comms.

The patient's suitability for PEG post-referral will be undertaken by a designated member of the gastroenterology team to assess whether the PEG is clinically indicated, in the patient's best interests, acceptable to the patient and their family/carers and physically possible. The gastroenterology team will record the outcomes on PPM+.

All patients for consideration of PEG insertion will be discussed in the PEG Multi-disciplinary Meeting, led by Drs Helen Rafferty and Anita Sainsbury.

Contra Indications to PEG Placement

Absolute

  • Inability to perform endoscopy due to technical reasons
  • INR ≥ 1.5.

Relative

  • Ascites/peritoneal dialysis
  • Organomegaly
  • Other coagulopathy, e.g. platelets <80
  • Gastric varices/portal hypertension
  • Abdominal surgery/ previous partial gastrectomy
  • Ventriculoperitoneal shunt in PEG field
  • Infiltrative gastric disease
  • Recent Myocardial Infarction - within last month
  • Hypoxic 02 < 93% on 2 litres 02 per min.
  • Inability to safely tolerate conscious sedation - severe cardio respiratory disease or muscle weakness.

If PEG placement is possible a patient information leaflet explaining the procedure will be given to the patient and/or carer (see appendix documents LN00316).

This information leaflet is also available on the trust intranet on the endoscopy website and can be printed off here for inpatients. It is important that all interested parties involved in the welfare of the patients are informed of the risks, benefits and alternatives to the proposed procedure.

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Investigations and patient preparation

Prior to a PEG insertion the patient must undertake the preparation below. Failure to complete this preparation will result in the patients PEG insertion being delayed or cancelled.

Consent

If the patient has the mental capacity to do so, informed written consent for the PEG should be obtained using Consent form 1. A pre-printed consent form for PEG insertion is available (LTHT 2814) The patient should be given time to consider their decision and not sign the form immediately before the procedure, as this does not constitute informed consent (BSG 2008).

For patients who are unable to consent themselves, Consent form 4 should be used. Whilst not a legal requirement the patients family and others close to the patient should be involved in the process and sign the consent form accordingly.

A check should be made that the patient has not given a valid advance directive refusing this procedure. Advice can be sought from the Clinical Ethics Committee. It is essential that the form 4 is signed by a member of the gastroenterology team, indicating risks and benefits have been assessed. It is also essential that this is countersigned by the patient’s own team, to indicate PEG insertion is appropriate.

Specific Patient Preparation

1. MRSA screening and decolonisation:

Where it is intended to insert a PEG tube, the patient must have a current MRSA screen (including anterior nares, groin, axilla, and if practicable, any other site that is likely to be colonised). A current screen is one that has been taken within the three months prior to the date of procedure.

Patients must undertake a course of MRSA decolonisation, timed to finish on the day of the procedure. This is required even if the MRSA screen was negative. The appropriate date on which to commence decolonisation will be stipulated by the PEG MDT and be co-ordinated with the date of the planned PEG insertion.

The referring ward must check MRSA screening swabs to determine if there is any resistance to mupirocin or neomycin to ensure correct decolonisation therapy is given.

In the event that PEG placement is delayed, decolonisation should only be repeated if there is a delay of 14 days or more.

2. Antibiotic prophylaxis
A single dose of Teicoplanin 400 mg is given intravenously, just prior to PEG insertion (detail.aspx?id=1744). This will be given in the endoscopy unit.

3. A clotting screen MUST be completed by the referring ward. The patient’s medication will be reviewed and the discontinuation of Clopidogrel/NOAC drug, or bridging warfarin with heparin may be required in the week prior to PEG insertion. See LTHT guidelines for management of anticoagulation in patients undergoing endoscopy for further information.

4. An endoscopy checklist should be completed

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Patient management post PEG insertion

Post-PEG insertion patient care should be provided according to the “Integrated Care Pathway For the Aftercare of A Newly Inserted Percutaneous Endoscopic Gastrostomy PEG”(see appendix document LTH 3237).Feeding can commence as per the dietetic assessment for the individual patient once appropriate steps have been undertaken as per the above care pathway.

If problems with the PEG occur, advice is available on Leeds Health Pathways (see: Gastrostomy Feeding Tubes- Guidelines For The Management Of Problems). Alternatively you can contact the Enteral Feeding Nurse Specialist (0113 2068690 Bleep 80- 4727) or the gastroenterology registrar on call on 80- 4770.

Patient Education:

Instructions for the care of the PEG will be given to the patient post procedure. Individual programmes of education should be developed for patients and/or their carers. Patients and/or their carers should be referred by the Dietitian for formal training to care for the PEG to be organised.

10. Discharge Planning

In addition to the principles in the LTHT enteral feeding policy (2017) all patients should:

  • Have PEG feeding established as determined by the multidisciplinary team. If the patient is being transferred prior to establishment of PEG feeding, there should be appropriate services available to support the establishment of feeding as agreed with the multidisciplinary team.
  • The stoma site should be infection free. However if infection is present they should be discharged with appropriate topical or systemic therapy and advice on who to contact if symptoms persist
  • All medications should be reviewed with the ward pharmacist. If to be administered via the PEG all medication should be in liquid form or altered, where possible, to alternative routes where liquid forms are unavailable. Crushed tablets are a major cause of PEG blockage.
  • Prior to discharge handover should be arranged to community dietitians and where necessary community nurses providing details of the feeding regimen, equipment used and other care and support required. 72 hours notice of discharge is usually required.
  • Patients and, where appropriate carers, should be informed and educated in all aspects of the care and maintenance of the PEG tube. The referring ward has responsibility for ensuring the patient and/or carers are competent in care and maintenance of the PEG tube prior to discharge. See Enteral Feeding: Discharge Planning (LTH2333) for further details, which should be placed in the notes.
  • Contact numbers MUST be available to the patient, outlining who to contact should problems occur.
  • If the patient is discharged within 14 days, they should go home with a photocopy of all the pages of the Integrated Care Pathway booklet as this is a handheld document. The original should be placed in the notes.

Provenance

Record: 159
Objective:

The objective of this guideline is to provide a clear pathway for the multidisciplinary team to follow when referring a patient for a PEG insertion.

Clear instructions will be given on how each element of the pathway can be achieved.

Patients presenting to the endoscopy department for a PEG insertion will be expected to have completed the preparation stages of the pathway.

Clinical condition:
Target patient group: Adult patients who have difficulty in maintaining adequate nutritional intake orally and who are deemed to be at risk of malnutrition during their period in hospital and the community.
Target professional group(s): Secondary Care Doctors
Allied Health Professionals
Adapted from: www.bapen.org.uk
www.espen.org European Society of Parental and Enteral Nutrition
www.bda.uk.com British Dietetic Association

Evidence base

British Society of Gastroenterology (2009) Antibiotic Prophylaxis in Gastrointestinal Endoscopy

British Society of Gastroenterology (2008) Guidelines For Obtaining Valid Consent For Elective Endoscopic Procedures.

Hull M., Beane A., Bowen J., Settle C. (2001) Methicillin- Resistant Staphylococcus Aureus Infection Of Percutaneous Endoscopic Gastrostomy Sites

Leeds Health Pathways (2007) “Gastrostomy Feeding Tubes- Guidelines For The Management Of Problems”

Leeds Teaching Hospitals NHS Trust (2014) Enteral Tube Feeding Policy.

Leeds Teaching Hospitals NHS Trust (2017) Meticillin Resistant Staphylococcus aureus (MRSA) guideline (includes Panton-Valentine Leukocidin (PVL) positive S. aureus)

Leeds Teaching Hospitals Trust (2009) Gastrointestinal Endoscopy and Gastroenterology in Adults

Leeds Teaching Hospitals NHS Trust (2008) Oral Nutritional Support Of Adults

NICE (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding And Parental Nutrition.

LTHT Documents:
Having A PEG: A Guide To The Procedure WRU 097
Integrated Care Pathway For the Aftercare of A Newly Inserted Percutaneous Endoscopic Gastrostomy PEG”(see appendix document WUN 1153)
Enteral Feeding: Discharge Planning LTH2333

Document history

LHP version 2.0

Related information

Not supplied

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