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PEG (PERCUTANEOUS ENDOSCOPIC GASTROSTOMY) CARE AND MANAGEMENT
1. PURPOSE
The content of this material is to provide instructions on the care and management of adult patients pre and post Percutaneous Endoscopic Gastrostomy (PEG) tube insertion.
2. DEFINITION AND ABBREVIATIONS
PEG (Percutaneous Endoscopic Gastrostomy) – a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus.
GASTROSTOMY – a surgical opening into the stomach, is made through the skin using a flexible, lighted instrument (endoscope) passed orally into the stomach to assist with the placement of the tube and secure it in place. PEG tube provides nutrition for patients who are having trouble swallowing. The internal bumper rests in the stomach, and the adapter comes out through the skin of the abdomen.
3. STATEMENT
The Armed Forces Medical Services Intensive Care Unit is committed in providing safe, quality and effective care to all patients. All members of the health care team must be aware and knowledgeable of the protocols that serve as a guideline in critical care practices in order to achieve optimal patient outcomes
4. SCOPE
This document defines the actions and responsibilities of Registered/Staff Nurses in the care and management of adult patients pre and post PEG tube insertion.
5. TARGET AUDIENCE
Anesthetists/Intensivists, Registered/Staff Nurses, Dietician in Intensive Care Unit
6. RESPONSIBILITY
Anesthetists/Intensivists- initiates order for insertion of PEG tube.
Nurses- prepares patient pre and post PEG tube insertion.
Dietician- evaluates and monitors patient's nutritional status; calculates needed energy, proteins and fluid requirements.
7. PROCEDURE
7.1. INDICATIONS AND CONTRA-INDICATIONS
7.1.1 PEG is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Indications include difficulties with oral intake often where obstruction to the upper airway or gastrointestinal tract makes passing a nasogastric tube difficult.
7.1.2. Absolute contra-indications for use of PEG in adults are active coagulopathies and thrombocytopenia (platelet count less than 50 x 109/L) must be corrected before tube insertion and anything that precludes endoscopy (such as haemodynamic compromise, sepsis or a perforated viscous).
7.2. DAY BEFORE PEG INSERTION
7.2.1 Inform patient to brush teeth properly the day prior to procedure.
PLEASE NOTE: Oral toilet to be done with antiseptic mouth wash (Chlorhexidine mouthwash) for patient with activity of daily living (ADL) dependent.
7.2.2. Instruct patient to observe Nil By Mouth (NBM) from 12 midnight.
7.2.3. Take Informed consent.
7.2.4. STOP Aspirin at least 72 hours, Clexane to hold for 1day and Clopidogrel for 5 days prior to procedure.
7.2.5. Check FBCD, UEG, LFT, Coagulation profile.
7.2.6. Do skin care (shaving of area of insertion).
7.3. DAY OF PEG INSERTION
7.3.1. PRE-PEG INSERTION
7.3.1.1. Maintain NBM status. Give Ceftriaxone 2gm IV 1hr before the procedure as ordered by the physician.
7.3.1.2. Ensure patient has a patent intravenous access (IV line)
7.3.1.3. Ensure hand restraints accompany patient to Endoscopy centre if needed
7.3.2 POST-PEG INSERTION
7.3.2.1. Maintain NBM status for at least 24 hours. IVF to be started peripherally.
7.3.2.2. Monitor hourly parameters (Temp, BP, HR, RR) for 4 hours and abdominal girth 2 hourly for 6 hours then every shift for 24 hours
7.3.2.3. Observe for active bleeding and do not remove the pressure dressing on the PEG stoma. The stoma site should not be touched for 12-24 hours. Small amount of blood and serous fluid will be present at the stoma, this is normal.
7.4. DAY AFTER PEG INSERTION (after 24 hours)
7.4.1. Keep pressure dressing intact till wound inspection is done by Doctors
7.4.2. Cleanse stoma with Normal Saline 0.9% and cover with sterile gauze after wound inspection. The area around the tube must be dried gently but thoroughly after the wash. No dressing should ever be placed below the external bolster.
7.4.3. If there is no fever, abnormal bowel sounds and gross pneumoperitonium (disappearance of liver dullness), Dextrose 5% 500ml is administered for 24 hours via PEG at a rate of 20ml/hr. If tolerated after 24 hours, commence PEG tube feeding as per feeding protocol. Refer patient to Dietician as per Doctor's order.
7.5. SUBSEQUENT DAYS AFTER PEG INSERTION (after 72 hours)
7.5.1. PEG tube should be rotated in a complete circle during daily cleaning (on 3rd day post insertion). This enables thorough cleaning of the tube and prevents the build up of scar tissue which could adhere to the tube.
7.5.2. Position patient in semi-Fowler's position to prevent reflux and aspiration during feeding. Maintain this position for at least 45 minutes to 1 hour after feeds.
7.5.3. The tube is flushed before and after feeding with 30ml of water.
7.5.4. Document appropriately in Intake/Output Chart.
7.5.5. Cleanse stoma site once daily and when necessary with Normal Saline 0.9% and cover it with sterile gauze till 14th day of PEG insertion.
7.5.6. Cleanse PEG site with mild soap and water after 14 days. Dap dry and cover with gauze.
7.5.7. Notify Doctor when any of the following signs are present:
7.5.7.1. Infected PEG site
7.5.7. 2. Leakage of feeds through the stoma site
7.5.7.3. Skin excoriation or redness
7.5.7.4. Persistent PEG tube blockage
7.6. MANAGEMENT OF PEG TUBE BLOCKAGE
7.6.1. Assess PEG site for cause of blockage
7.6.2. Use 3cc or 5cc syringe to inject 5ml of warm water into the tube and clamp for 5 minutes. Unclamp tube, apply gentle pressure and attempt suction.
PLEASE NOTE: 2-way PEG tube (with only feeding and balloon port), use a connector to connect 3cc or 5cc syringe before injecting 5mls of warm water into the tube.
7.6.3. Flush tube with 30ml warm water after tube is unblocked.
7.6.4. If PEG tube falls out, insert a Foley's catheter of the same size into the stoma immediately and inform the doctor.
8. CROSS REFERENCES/ FORMS/MAI/DOCUMENT
https://www.asge.org/home/for-patients/patient-information/understanding-peg
http://www.medicinenet.com/percutaneous_endoscopic_gastrostomy/article.htm
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