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PEG tube care: Care must be taken when deciding to use, locate and manage the percutaneous endoscopic gastrostomy tube (PEG tube) to avoid possible fatal errors or complications

Some adults and children cannot swallow or eat enough. Insertion of a percutaneous endoscopic gastrostomy (PEG) tube allows for long-term feeding, fluid and/or medication management. The procedure includes performing gastroscopy under sedation to determine the location of the catheter, placing the catheter, and checking that it is placed correctly. Serious complications include peritonitis and colon perforation. Frequent observations immediately after placement are essential. With good care, complications can be avoided or dealt with in time.

Citation: Haywood S (2012) PEG tube placement and aftercare. Nursing time [online]; 108:42, 20-22.

Author: Sharlene Haywood is a clinical nurse nutrition support specialist at the Royal Free London Foundation.

Many conditions impair the patient's ability to swallow or take sufficient food and drink. Some of them will require enteral feeding tubes to meet their nutritional needs. Percutaneous endoscopic gastrostomy (PEG) tube is a long-term artificial enteral feeding tube that requires an endoscope to be placed and allows direct access to the stomach from outside the abdominal wall. This approach is usually used to supplement nutrition, fluids and drug administration.

PEG tubes are usually made of flexible polyurethane, are about 35 cm long, and have a hollow lumen that allows liquid to pass through. The outer diameter is measured by regulations, and each unit represents 0.33mm. In the UK, 8-16 French gauges are commonly used-the exact gauge used is determined by the patient population and intended use.

Figure 1 shows the PEG tube in the fistula between the anterior and abdominal wall of the stomach. The tube is fixed in the stomach by a retention buffer against the anterior wall of the stomach. The bumper is usually a soft malleable silicone button or inflatable foam bladder (Best, 2004).

There is an adjustable fixed plate on the outside of the tube, usually made of soft silicone. There is no consensus on the exact location of this location from the abdominal wall in the literature or the manufacturer's guidance. The ideal situation is that the catheter cannot move freely in the fistula, nor is it too tight (Westaby et al., 2010; Best, 2004). In my experience, 1 cm from the abdominal wall usually meets these requirements, but local policies may vary.

There is an adapter at the outer end of the tube to install a specific enteral syringe and feeding device. Most tubes have a clamp to prevent fluid backflow when the adapter end is opened. When the PEG tube is not in use, the adapter end should be closed and the clamp should remain open to prevent damage to the tube (Löser et al., 2005).

The PEG tube can be placed on patients of all ages. The general indicators are symptoms of difficulty swallowing or the inability to eat or drink to meet nutritional requirements (Westaby et al., 2010). This is usually caused by neurological or anatomical diseases that affect swallowing, such as motor neuron disease or esophageal tumors (Kurien et al., 2010; Löser et al., 2005).

For endoscopic catheter placement, the patient should:

The patient’s medical history should be thoroughly reviewed to look for prominent risk factors or diagnoses that may make surgery difficult, impossible, or futile. For example, intestinal obstruction outside the duodenum can prevent

Liquids administered via PEG will not continue to be digested and there is a risk of inhalation. The multidisciplinary team should thoroughly discuss the risks and benefits of intubation, inform patients of these and alternative options, and proceed only according to the patient’s wishes and their best interests.

If the patient does not have any risk factors, PEG tube placement is still at risk of complications. Table 1 details the most frequently reported complications during catheterization (Fletcher, 2011; National Patient Safety Administration, 2010; Westaby et al., 2010).

In the UK, surgery-related morbidity is 9-17%, and mortality is 0.5% (NPSA, 2010); the 30-day postoperative mortality rate is 4-26% (Tanswell et al., 2007). From October 2003 to January 2010, NPSA reported 22 incidents of serious complications after gastrostomy insertion (5 of which occurred in children); these included endoscopic, radiological, and surgical placement Tube (NPSA, 2010). Among them, 11 cases of death and 11 cases of serious injury resulted in emergency surgery or admission to the high-dependency ward/intensive treatment ward. Therefore, patients should be carefully selected for PEG tube placement. Thorough multidisciplinary team discussions should be conducted, and patients and/or their close relatives should be involved in the decision-making process.

If you decide to continue PEG tube placement, you must closely monitor the patient's blood for signs of abnormal coagulation and infection before surgery, and monitor clinical observations. It is not recommended to place PEG tubes in infected patients and should be discussed by a multidisciplinary team.

Due to the invasive nature of the operation and the high risk of site infection (the PEG tube is placed through the patient’s mouth and may contain a lot of bacteria), it is recommended to use prophylactic antibiotics before the operation, such as intravenous co-amoxiclav or teicoplanin (Kurien and Sanders) , 2010; Westaby et al., 2010). Patients should fast for at least 6 hours before surgery and water for 2 hours to ensure that the stomach is empty; this may vary depending on local policies and patients.

Just before the operation, the patient is lightly sedated, usually with intravenous midazolam. A mouthguard was put in their mouths to prevent them from biting the endoscope and protect their teeth.

There are many techniques for PEG tube placement; this article describes the Gauderer-Ponsky penetration technique (Gauderer et al., 1980)-there may be local differences in this process.

First, a gastroscopy is performed to assess the anatomy of the stomach; this is done by passing the endoscope through the mouthguard into the patient’s mouth and down the esophagus into the stomach. The gas is used to inflate the stomach; the camera at the end of the endoscope allows the endoscopist to view and evaluate the inside of the stomach.

The patient's abdomen is exposed, the room darkens, and then a strong light is emitted from the end of the endoscope in the stomach. This can be seen on the outside of the abdomen and represents the most direct route from the stomach to the abdominal wall; this process is called transmitted illumination.

The endoscopist applies digital pressure to the abdomen and checks against the view of the gastric endoscopy to see a smooth depression of the stomach wall when the finger presses down on the abdomen. This determines the safest point at which a fistula can be made, avoiding any inserted organs between the abdominal wall and the front wall of the stomach. Using a needle and syringe, anesthetize the subcutaneous tissue in the area with a local anesthetic (such as lidocaine).

After inhaling the air, push the same needle and syringe (filled with more anesthetic) into the abdomen under negative pressure; use an endoscope to locate the tip of the needle in the stomach. This allows the endoscopist to accurately see the position of the tube to ensure that the PEG tube fixation buffer is in the ideal position. When the needle is retracted, anesthetic is injected to anesthetize all layers of the abdominal wall (Figure 2).

Make a small incision in the anesthetized abdomen. A trocar (a metal needle wrapped in a plastic sheath) is inserted into the incision to form a fistula from the abdominal wall to the front wall of the stomach. Once the endoscopist can see the trocar in the stomach, the metal needle is removed, leaving the open sheath in the fistula (Figure 3).

A soft guide wire is inserted into the stomach through the trocar sheath. The endoscopist grasps the wire using endoscopic forceps that pass through the endoscope and pull it out of the mouth. The trocar sheath is removed (Figure 4).

The PEG tube is connected to the guide wire at the end that leaves the patient's mouth and is lubricated. Pull the stomach end of the guide wire, and pass the PEG tube through the mouth through the esophagus into the stomach and exit through the fistula (Figure 5).

The patient is usually endoscopically examined again to check the position of the retention buffer. Then install the adjustable fixing plate, clamp and adapter end to the outside of the tube (Figure 6). The adjustable fixed plate is located 1 cm from the skin, the mouthguard is removed, and the patient wakes up from sedation.

The monitoring of clinical observation is very important within 72 hours after the placement of the PEG tube. NPSA (2010) recommends certain observations at specific times; these are summarized in Box 2.

When observing the patient, observe the PEG tube and position and check the fixing plate to ensure that it is about 1 cm away from the abdomen.

If the tube is secured too tightly, there is a risk of pressure damage, which can lead to necrosis, bleeding, ambushed bumper syndrome, and/or leakage of stomach contents. If the grip is loose and the catheter moves freely, the catheter may not form properly; this may cause leakage of stomach contents, peritonitis, infection, or excessive granulation in the area (Conroy, 2009). Once the fixed plate is in the correct position, it should not be moved for the first 7 days unless it is clinically necessary.

NPSA (2010) developed a "red flag" alert to immediately respond to serious complications after PEG tube insertion. If the patient develops any of the symptoms in box 1, the medical team must be notified immediately; these symptoms may be signs of complications.

After the first 72 hours, it is important to monitor the PEG tube and site at least daily, if you are concerned, you can monitor it more frequently. The patient’s doctor must be notified of any problems as soon as possible so that the management plan can be initiated and referred to the relevant members of the multidisciplinary team.

Patients usually do not use the oral cavity and PEG tube for 4 hours after insertion to make the sedation disappear. Then rinse the tube with 50 ml of sterile water. If flushing causes pain, stop immediately and notify the medical team immediately, as this is a red flag and requires urgent attention. If the flushing does not cause pain, it is safe to start using the tube.

PEG tube placement has many advantages. It can enter the gastrointestinal tract bypassing the oral cavity and esophagus for a long time. However, the patient must be carefully selected for PEG tube placement. With good care, many related complications can be avoided or highlighted in time for investigation and management.

Thanks to Fresenius Kabi for the diagrams and pictures

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