Early percutaneous endoscopic gastrostomy (PEG) versus nasogastric tube (NGT) for nutrition of severe traumatic brain injury

patients

By

Tarek Talaat Aly El-Sefi

Company

LOGO

The nutritional management of critically ill patients has changed dramatically over the past 10 years Changes in the areas of nutritional assessment, guidelines for total energy provided, diseasespecific feeding, and immune-enhancing enteral nutrition have been the most prominent

The rationale for nutritional support comes from the knowledge that critically ill patients are prone to develop malnutrition, which is known to be associated with serious complications such as sepsis and pneumonia, leading to a poor outcome and even death

Hypermetabolism

Poor intake with protein loss and fat gain in muscles

Surgery

Stress & organ failure

Negative nitrogen balance & malnutrition in the critically ill

Immobility & prolonged bed rest

Exogeneous steroids

Acute phase response: TNF, IL-6, IL-1 with change in substrate utilization

Impaired gut function

Consequences of
malnutrition

1 2 3 4

Weight loss
Weakness and fatigue Impaired ventilatory drive

(DEATH)
Poor wound healing
Impaired immune function, increase risk of infection

5 6

Prolonged hospital stay

Why we feed the

critically ill?

1
2 3

Provide nutritional substrates to meet protein and energy requirements Help protect vital organs and reduce break down of skeletal muscle To provide nutrients needed for repair and healing of wounds and injuries To maintain gut barrier function To modulate stress response and improve outcome

4
5

The metabolic status and nutritional needs of patients with TBI are of a less priority than maintaining cerebral perfusion pressure (CPP) However, TBI results in a hypermetabolic and catabolic state that increases systemic and cerebral energy requirements that can quickly lead to malnutrition and its attendant complications The Guidelines for the management of severe TBI recommend that the patients feeding requirements should be met by the end of the 1st week after TBI

Is Early Feeding Beneficial in TBI?

Inadequate early nutrient intake in head-injured patients has been associated with prolongation of the acute-phase response and an increased incidence of septic morbidity Early EN in critically ill patients may be associated with a significantly lower incidence of infections and a reduced hospital stay

Classification of TBI

a GCS 13 or above
a GCS 912 a GCS 8 or below. This group has the highest mortality and morbidity

Nutritional requirements
Energy needs are calculated on the basis of basal energy expenditure (BEE) The BEE is the amount of energy required to perform metabolic functions at rest, and is influenced by both body size and illness BEE classically is estimated by the Harris-Benedict equation: For men, BEE = 66.5 + (13.75 x kg) + (5.003 x cm) - (6.775 x age) For women, B.E.E. = 655.1 + (9.563 x kg) + (1.850 x cm) - (4.676 x age) Add stress factor - 1.2 to 2 times Carbohydrate requirements: 55- 70% of total energy Fat requirements: 15 30% of total energy Protein requirements: range from1-2g/kg/day electrolytes, micronutrients, and vitamins needs should not be missed

30 35ml fluid/kg/24 hours baseline Add 2-2.5ml/kg/day of fluid for each degree of temperature Highly individualized requirements according to losses that occur through exudates, hemorrhage, emesis, diuresis and diarrhea

Enteral nutrition

Parenteral nutrition

Nasogastric (NG) Nasojejunal (NJ) Percutaneous Endoscopic Gastrostomy (PEG) Percutaneous Endoscopic Jejunostomy (PEJ) Radiologically Inserted Gastrostomy (RIG) Surgical Gastrostomy Surgical Jejunostomy (JEJ)

Diminished ENTERAL feeding will cause:

Decrease in Peyers patch leukotrienes Decrease in T & B cells in Peyers patches, Lamina propria & epithelium Reduced secretory IgA and altered cytokines Mucosal atrophy Altered flora Decreased gastric acid

Bacterial translocation

So Enteral feeding

Is more physiological & relatively cheap promote gastrointestinal tract function and integrity prevent bacterial translocation

Nosocomial infections

Disadvantages of ENTERAL FEEDING

It requires adequate gastric emptying There is risk for aspiration which can be reduced by continuous feeds & checking for gastric residue Diarrhea- lactose intolerance,altered bowel flora, and malabsorption Tube dislodgment, malposition and blocked tubes can also occur

Contra-indications to Enteral feeding

Bowel obstruction

Ileus

Intestinal ischaemia

shock

Does not require gastric motility No risk of aspiration

Intestinal mucosal atrophy Catheter related sepsis Expensive in relation to EN Mechanical: pneumothorax, puncture Overfeeding syndrome

hydrothorax

and

arterial

Severe metabolic disorders Hyperglycemia Hypertriglyceridemia Azotemia. hepatic steatosis Fat overload syndrome

The nurition in critically ill patient could be either enteral or parentral. Enteral nutrition (EN) is recommended over parenteral nutrition (PN) in patients who are haemodynamically stable and have a functional GI tract Parenteral nutrition is required when the GI tract is not functioning

It is the classical, time-proven technique for EN but it has a lot of complications Risk of injury to nasal wing Chronic sinusitis Hypoxia, cyanosis, or respiratory arrest due to accidental tracheal intubation Risk of GER and aspiration Risk of displacement or blockage Reaching nutritional goals uncommon

Gastrostomies are generally used for long-term enteral feeding in patients with swallowing limitations who require nutritional support provided that the patient has a reasonable prospect of survival and normal GIT function

Wider caliber: less incidence of blockage less interruption of feeding Improve nutritional state No risk for sinusitis Minimize GER Reduces Social and Psychological problems Less incidence of dislodgment or malposition

Gastrostomy can be inserted either:

1 2 3

Surgically (open or laparoscopic)

Endoscopically (PEG) Radiologically (RIG)

PEG

It was first described in 1980 by Gauderer and colleagues for use in children but has since gained wide acceptance for use in patients of all ages The PEG technique has largely replaced surgical gastrostomy as the procedure of choice for patients who require long-term enteral nutrition. The superiority has been shown clearly in many clinical studies. Lower complication rates, reduced hospital length of stay and costs have been reported with PEG

Quick procedure Shorter anaesthetic exposure than a surgical placement Fewer complications Easily removed under general anaesthetic Less likely to be displaced

Apart from risk of general anaesthesia, postoperative ileus, bleeding,wound infection and dehiscence
Cost Use of OR Resources Requires patient transportation to radiology department Requires CT and fluoroscopy in the same room which is not available in many hospitals

life expectancy less than 3 months

systemic sepsis Rapidly deteriorating patients with multiorgan failure Coagulopathy Inability to perform upper endoscopy Obstructing esophageal tumor Stricture

Inability to oppose stomach to anterior abdominal wall Previous subtotal gastric resection Hepatomegaly, esp left lobe Massive ascites Intra-abdominal sepsis Oesophogel or gastric varices Large hiatal hernia

Pull tehcnique Push technique Introducer method No outcome difference between pull and push methods

The pull-type technique is still the standard procedure for endoscopic PEG placement However, in several clinical situations the classical pull-type PEG procedure is not possible or contraindicated. In case of high-grade stenosis caused by an oesophageal tumor or a head and neck tumor, a conventional upper GI endoscopy may not be possible or the internal bumper of the PEG-tube may not pass. Also, the risk of metastases at the site of the gastrostomy is high. This has led to the development of push technique and then the introducer technique

Wound infection Peristomal leakage Pneumoperitoneum Tube clogging

Necrotizing fascitis Esophogeal and gastric perforation Buried bumper syndrome Colocutaneous fistula Aspiration Peritonitis

The study was carried out on 30 adult patients of both sex. They were selected from those admitted to the Critical Care

Medicine Department at the Alexandria Main University

Hospital with the diagnosis of severe traumatic brain injury (GCS 8 or less) was given nutritional support via nasogastric tube was given nutritional support via PEG after hemodynamic stabilization (>3days)

The following patients were Excluded

Patients with multiple traumatic injuries including abdominal trauma Patients with massive or untreatable loculated ascites Patients with uncorrected coagulapathy Gastric mucosal abnormalities: large gastric varices, portal hypertensive gastropathy Previous abdominal surgery, including previous partial gastrectomy: increased risk of organs interposed between gastric wall and abdominal wall Morbid obesity: difficulties in locating stomach position by digital indentation of stomach and transillumination Gastric wall neoplasm Abdominal wall infection: increased risk of infection of PEG site

In the first group, NG tube was inserted and position was confirmed by auscultation method and by aspiration of gastric contents In the second group, PEG was inserted in the fourth day using pull technique

Both groups of patients received conventional enteral feeding All the studied patients were assessed for: Anthropometric parameters(MAC and TSFT) on admission and weekly for 28days Serum albumin on admission and on discharge Nitrogen balance every 2 weeks for 28 days Duration of ICU stay(days) Duration of hospital stay(days) Complications of both techniques were recorded

www.themegallery.com

Comparison between the two studied groups according to age

45
40 35 Mean of age 30 25 20 15 10

5
0 Control group PEG group

Comparison between the two studied groups according to sex

80 70 Percentage 60 50 40 30 20 10

Control group PEG group

0
Male Female

Comparison between the 2 studied groups as regards MAC

Comparison between the 2 studied groups as regards TSFT

Comparison between the 2 studied groups as regards Nitrogen balance

3
2 1
Control group

PEG group

Mean

-1 -2

-3
-4 -5 -6 -7
On starting feeding Week 2 Week 4

Comparison between the 2 studied groups as regards serum albumin

Control group PEG group

3.5 Mean serum albumin

3.0
2.5 2.0 1.5 1.0

0.5
0.0
On starting feeding Week 4

Time

Comparison between the 2 studied groups as regards ICU and hospital stay

50 45

Control group PEG group

40

Mean

35 30 25 20

15
10 5 0

Icu stay

Hospital stay

Comparison between the 2 studied groups as regards incidence of complications

80 70 60 50
Control group PEG group

Percentage

40 30 20

10
Intervention failure pneumoperitoneum Epistaxis Sinusitis Pneumonia Wound infection

PEG tube feeding is more effective than NGT feeding in improving nutritional status (in terms of serum albumin and nitrogen balance) of patients with severe traumatic brain injury

PEG should be inserted within the first 24hrs of intubation to decrease the incidence of VAP Measurements of anthropometric parameters can be of value after long period follow up Simultaneous measurements of acute phase reactants together with serum albumin to help determine whether low albumin levels are related to inflammatory process or result of poor nutrition status