2014 a tutorial on enteral access in adult patients in the hospitalized stting

Journal of Parenteral and EnteralNutritionVolume 38 Number 3 March 2014 282 295 2014 American Societyfor Parenteral and Enteral NutritionDOI: 10.1177/0148607114522487jpen.sagepub.comhosted at online.sagepub.com

Tutorial

Preface and Clinical Relevancy Statement

Nutrition support remains a mainstay in the management of disease regardless of diagnosis and preexisting conditions. Growing evidence has substantiated the role of nutrition sup-port in improving patient outcomes and reducing duration of hospitalization. When feasible, the gastrointestinal tract is the preferred route of delivery and superior to the parenteral route alone. As determined by nutrition assessment and evaluation, many patients will prove unable to tolerate sufficient nutrition support via the oral route. In these patients, alternative routes of delivery should be considered prior to the initiation of par-enteral support. A wide array of options are available to nutri-tion support teams, and a comprehensive understanding of the indications, contraindications, and complications inherent with each access route provides clinicians with the information needed to select the appropriate route in the individual patient. Just as with any other treatment plan, an individualized approach to the patient should be conducted prior to imple-mentation. Careful nutrition assessment provides information with regard to the likely duration of support.

Nutrition Support

Nutrition Assessment: Which Patients Should Be Considered?

The typical medical/surgical ward and the intensive care unit (ICU) often consist of heterogeneous populations, and it is clear that these populations often have different needs. Multiple nutrition screening tools are available to clinicians and include, among others, the Nutritional Risk Screening (NRS)2002,

Mini Nutritional Assessment (MNA), Simplified Nutritional Assessment Questionnaire (SNAQ), Subjective Global Assessment (SGA), and Malnutrition Universal Screening Tool.1 Recent evidence suggests that combining nutrition assessment with injury severity scores can help identify those patients most likely to benefit from nutrition support.2 Nutrition risk stratification is an important principle that must be consid-ered by all those involved in the care of the patient. Regardless of the assessment tool that is used, the goal in all at-risk patients is to initiate enteral support if possible in an early, safe, and efficacious manner. As in all facets of patient care, continuous reassessment and reevaluation are required in order for the cli-nician to adapt the nutrition support plan to the changing con-dition of the patient. During the assessment phase, a nutrition support plan is generated and the patient is prepared for imple-mentation through the establishment of appropriate enteral access. Early enteral support should be the goal, and this prac-tice has demonstrated improved patient outcomes in surgical, critically ill, and trauma patients.3-5

522487 PENXXX10.1177/0148607114522487Journal of Parenteral and Enteral NutritionMiller et alresearch-article2014

From the 1University of Louisville, Louisville, Kentucky, and 2Oregon Health Sciences University, Portland, USA.

Financial disclosure: None declared.

Received for publication October 24, 2013; accepted for publication January 13, 2014.

This article originally appeared online on February 5, 2014.

Corresponding Author:Keith R. Miller, MD, Department of Surgery, University of Louisville, ACB 2nd Floor, 550 South Jackson St, Louisville, KY 40202, USA. Email: [email protected]

A Tutorial on Enteral Access in Adult Patients in the Hospitalized Setting

Keith R. Miller, MD1; Stephen A. McClave, MD1; Laszlo N. Kiraly, MD2; Robert G. Martindale, MD2; and Matthew V. Benns, MD1

AbstractEnteral access is a cornerstone in the provision of nutrition support. Early and adequate enteral support has consistently demonstrated improved patient outcomes throughout a wide range of illness. In patients unable to tolerate oral intake, multiple options of delivery are available to the clinician. Access requires a multidisciplinary effort that involves nurses, dietitians, and physicians to be successful. These techniques and procedures are not without morbidity and even mortality. A comprehensive understanding of the appropriate management of these tubes and their inherent complications should be garnered by all those involved with nutrition support teams. This tutorial reviews available options for enteral access in addition to commonly encountered complications and their management. (JPEN J Parenter Enteral Nutr. 2014;38:282-295)

Keywordsenteral access; nutrition; nutrition support teams; nutrition support practice; adult; life cycle

at UNIV DE GUADALAJARA on February 18, 2015pen.sagepub.comDownloaded from

Miller et al 283

Initial Approach: Nasoenteric Access Options

Nasogastric access. The decision to attempt oral feeding or transition directly to tube feedings is empiric and based on clinical judgment with little guidance from the literature. Reas-sessment and reevaluation are necessary as the clinical course progresses and may result in a deviation from the original plan. Adequate access can be achieved in most patients with mini-mal intervention, with fewer patients requiring more complex approaches (Figure 1). Depending on the inpatient setting, there is a small subset of patients who will already have access in place. This is clearly the minority, but these patients should be recognized by the clinician early to avoid unnecessary inter-ventions. Multiple access options are available for patients determined to be at risk, who are unable to tolerate an early progression to oral intake, and who do not have prior enteral access in place.

An early opportunity for initiation of nutrition support is afforded by using the hard plastic large-bore nasogastric tubes usually placed for gastric decompression. This tube can pro-vide decompression during the resuscitation and investigative phases of the patients presentation and then allow for early initiation of support as the patient stabilizes. Orogastric tubes are limited by patient discomfort but can be used for short-term access and are better tolerated in intubated and sedated patients. Once determined to be appropriate candidates for the initiation of enteral support, the naso- or orogastric tube provides tempo-rary conduits for delivery that can be used immediately follow-ing confirmation of appropriate placement.

Anecdotally, as the patient condition progresses, clinicians are better able to predict the duration that enteral access will be required (although these predictions remain empiric and largely based on clinical judgment). Large-bore nasogastric tubes should be replaced with smaller diameter and more pli-able nasoenteric access within 57 days to potentially reduce morbidity and improve patient discomfort. Nasoenteric feed-ing tubes are commonly composed of silicone or polyurethane and generally range from 812 French in size compared with standard large-bore sump nasogastric tubes, which are 1418 French.

Pliable nasoenteric tubes can be placed with endoscopic assistance or placed blindly with assistance of either promo-tility agents or various signaling devices. As a rule, all tubes should be confirmed to be in the appropriate location prior to the initiation of enteral support. Confirmation is usually pro-vided through imaging, which can add significant cost and time to tube placement. Recent adjuncts have been developed, including the use of carbon dioxide or pH sensors to confirm intubation of the stomach rather than the pulmonary tree. Sensitivity and specificity have been reported in 1 trial as high as 86% and 99%, respectively.6 Magnet devices to direct place-ment have also been used with high success rates, reported with regard to ensuring the tube is below the level of the dia-phragm.7 These options provide the clinician with multiple options in confirming tube location prior to the initiation of enteral feeding.

Postpyloric access. Patients intolerant of gastric feeding will often tolerate feeding more distally in the gastrointestinal (GI) tract. Self-propelling tubes that are placed blindly are designed to assist in this endeavor. The design of these tubes includes weights that theoretically facilitate peristaltic migration through the pylorus to the small bowel. The weighted tubes have failed to demonstrate any advantage with regard to place-ment in randomized clinical trials.8 Promotility agents (eg, erythromycin) are often utilized to assist with these maneuvers but are of questionable utility.9 Bedside placement of postpylo-ric tubes can be reasonably performed with success rates approaching 80% with well-trained personnel.10 In difficult patients, more directed guidance can be accomplished with the assistance of either endoscopy or fluoroscopy. Fluoroscopy has been demonstrated to be more successful with regard to post-pyloric placement and similar in cost compared with blindly placed tubes. In addition, a reduced incidence of complications and improved caloric delivery, particularly in the first 4 days following tube placement, have also been demonstrated.11,12 Disadvantages of this technique include delay in time until placement and the potential need for patient transport. Endo-scopically guided tubes allow for immediate assurance that the tube is in the GI tract and allow for more distal guidance under direct visualization. This can be accomplished using transnasal endoscopy13 (Figure 2) or with standard endoscopy using spe-cialized techniques to transfer the wire from the oropharynx to

Figure 1. Most patients are amenable to less complex enteral access strategies. However, as clinical complexity increases, a small subset of patients will require more invasive measures to achieve appropriate enteral access. PEG, percutaneous endoscopic gastrostomy; PEGJ, PEG with jejunal extension; PEJ, percutaneous endoscopic jejunostomy.


284 Journal of Parenteral and Enteral Nutrition 38(3)

the nasopharynx13 (Figure 3).14 Disadvantages include the complications associated with endoscopy and sedation as well as increased hospital costs.

Contraindications. Absolute contraindications to nasogas-tric tube placement include certain patterns of facial fracture (cribiform plate, nasal fractures), which can result in inadvertent

placement of the tube into the cranial vault. Proximal upper GI malignancies, head and neck cancers, and esophageal divertic-ula and strictures can preclude naso/orogastric tube placement or predispose patients to morbid complications such as GI per-foration. Although contraindications are rare, tube placement in these patients should be performed only with the involvement of appropriate clinicians, including those managing the primary malignancy or those with advanced technical skills in endos-copy or interventional radiology. Coagulopathies, either disease related or medication induced, should trigger heightened aware-ness for complication but generally do not preclude placement.

Complications and considerations. Risks associated with placement in all patients without the above risk factors include esophageal perforation, obstruction of normal sinus drainage resulting in an increased incidence of sinusitis, and uninten-tional placement into the bronchopulmonary tree. The rigidity and large diameter of the standardly placed nasogastric tube somewhat limits the duration that these tubes can be useful. One study examined the incidence of middle ear effusions and altered tympanometry in intubated patients with nasogastric tubes and demonstrated that there was no increased incidence with 12 F and 14 F tubes but there was with 18 F tubes.15 Larger diam-eter tubes are clearly more beneficial when decompression is the goal but should be avoided in patients who are unlikely to benefit from this feature. Sinusitis is often a difficult diagnosis to make in the critically ill patient but appears to be closely linked to the presence of nasogastric and nasoenteric tubes. Feeding through nasogastric tubes in the setting of sedation or a patient with a Glasgow Coma Score

Miller et al 285

consisted primarily of pain, stridor, dysphagia, and hoarseness.21 Treatment consisted of antibiotics, parenteral steroids, and often tracheostomy. This is mentioned only because it is a less well-recognized and devastating complication directly attributable to nasoenteric access and requires early and aggressive action to prevent decompensation.

Blindly placed nasoenteric tubes have the obvious advantage of generally avoiding conscious sedation and endoscopic inter-vention. However, there is significant risk with blindly placed nasoenteric tubes with regard to intubation of the tracheobron-chial tree. In an informative recent review analyzing 5 contribut-ing trials by Sparks et al,22 9931 nasoenteric tubes were reviewed with a malposition rate of 1.9%. Nearly 20% of the malposi-tioned tubes resulted in a pneumothorax with 5 deaths attributed to the complication. Also of interest, 60% of the malpositioned tubes were in ventilated patients. In an attempt to reduce the morbidity of nasoenteric tube placement, Marderstein et al23 implemented a protocolized approach involving specialized nasoenteric teams and limiting initial placement to 35 cm prior to radiographic confirmation of location, which resulted in reduced complications, particularly pneumothorax. Educational endeavors include web-based training modules and have dem-onstrated improvement in first-time success rates for the place-ment of postpyloric tubes.24 Serial films should clearly be considered in patients with decreased mental status and history of difficult tube placements. Mortality in these cases almost exclusively involves initiating feeding through a tube in the tra-cheobronchial tree. Blindly placed tubes must have confirma-tory imaging to avoid these potentially fatal complications.

Ultimately, long-term feeding with nasogastric tubes has been demonstrated to be less efficacious with regard to reduc-ing weight loss in patients with head and neck cancer when compared with gastrostomy.25 Some of the major limitations of long-term nasoenteric access are patient discomfort, tube occlusion, and increased aspiration events. To allow for improved patient tolerance, the tubes are generally smaller in size, predisposing them to occlusion. Pulmonary aspiration was 50% less with a percutaneous gastrostomy compared with a nasoenteric tube in 1 trial.26 In prospective trials in both stroke patients and geriatric patients receiving long-term enteral support, feeding through a gastrostomy resulted in fewer aspiration events and improved tolerance compared with nasoenteric feeding.27,28 In conclusion, due to their inferiority in nutrition delivery and inherent complication profile, stan-dard naso/orogastric tubes should be viewed as short-term access options for feeding less than 4 weeks duration as more definitive measures are implemented.

Percutaneous Tubes: Surgical, Endoscopic, and Radiologic Techniques

Should greater than 4 weeks of enteral access be thought nec-essary, percutaneous and long-term access options should be

considered such as percutaneous endoscopic gastrostomy (PEG), PEG with jejunal extension (PEGJ), direct percutane-ous endoscopic jejunostomy (DPEJ), and surgical gastros-tomy/jejunostomy. A small subset of complex surgical patients as well as patients with end-stage liver disease, ascites, neu-tropenia, and peritonitis will not be candidates for surgical tubes, and longer term nasoenteric tubes may be the only option. This is an important branch point in the treatment algorithm and requires some foresight by the nutrition support team (Figure 4).

The decision to pursue more permanent access can be facili-tated through endoscopic, radiologic, or conventional surgical approaches. Clinicians should be familiar with the options available as well as the advantages, disadvantages, and compli-cations associated with each approach (Table 1). Endoscopic approaches offer the advantages of avoiding laparotomy and general anesthesia, but there is no visualization of the other intra-abdominal organs during placement (primarily the colon and liver). An endoscope is inserted through the oropharynx, past the esophagus, and into the stomach to allow for direct needle access into the stomach. Transillumination and abdomi-nal palpation must be clearly associated with indentation into the stomach from the endoscopic viewpoint prior to catheter access. Using a wire placed through the catheter, a tube is either pushed or pulled through the dilated tract.29 The same principle is applied to percutaneous jejunal access, only the endoscope must be advanced more distally into the jejunum, which is then accessed with the finder needle (Figure 5).30

Surgical approaches offer the advantage of direct visualiza-tion of tube placement into the intended organ (stomach or jejunum) but require a laparotomy or laparoscopy with the potential for inherent complications (hernia, dehiscence, infec-tion). During the surgical approach, the stomach or jejunum is identified following a laparotomy incision, and the appropriate tube is secured within the lumen of the targeted organ and brought out through a separate stab incision. Variations in tech-nique are important to understand in the event of inadvertent removal and complication (Figure 6).31 The standard Stamm gastrostomy involves circumferential purse-string sutures sta-bilizing the tube within the lumen of the stomach and fixing the stomach to the posterior aspect of the anterior abdominal wall. The Witzel technique involves creating a serosal tunnel as well as an abdominal wall tunnel through which the tube passes and is generally used when the target organ cannot be fixed to the abdominal wall (eg, remnant stomach following Roux-en Y gastric bypass). Utilization of specific surgical techniques is largely surgeon and institution dependent. Witzel tubes, due to their tunneled nature, are more difficult to replace and often require radiologic assistance.32 Laparoscopy can reduce inci-sion size and potentially postoperative pain but can be difficult in patients who have undergone multiple prior abdominal oper-ations. The decision to use laparoscopic vs open techniques is largely dictated by surgeon preference and their individual



experience with laparoscopy. The risk of complications from general anesthesia and laparotomy varies widely and is some-what dependent on the overall condition of the patient.

The radiologic technique involves insufflation of the stom-ach through either an angiocatheter or nasogastric tube with air

and using a combination of ultrasound, computed tomography, and fluoroscopy to gain wire access into the lumen of the stom-ach (Figure 7).33 Wide variation in technique is used, with some deploying anchors to appose the stomach to the posterior abdominal wall.34

Can paent eat?Nutrion Support

Indicated Oral tolerant

Feed Supplement

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> 4 weeks

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feasible?

< 4 weeks

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emptying

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PEG

Figure 4. An algorithm details the multiple factors that contribute to individualizing access options to appropriate patients. DPEJ, direct percutaneous endoscopic jejunostomy; PEG, percutaneous endoscopic gastrostomy; PEGJ, PEG with jejunal extension.

Table 1. Comparison of the Various Enteral Access and Their Inherent Advantages and Disadvantages.

Tube Type Provider Absolute Contraindications Advantages Disadvantages

Large-bore nasogastric/orogastric Nurse Certain facial fractures/trauma

Avoids sedationAllows decompression

Blind placementPatient discomfort

Blind nasoenteric feeding tubes Nurse/dietitian Certain facial fractures/trauma

Avoids sedationCost

Blind placement

Endoscopic nasoenteric tubes Gastroenterologist surgeon

No endoscopic access Visual confirmation Endoscopy

Percutaneous endoscopic gastrostomy

Gastroenterologist surgeon

No endoscopic access Long-term access Endoscopy

Percutaneous endoscopic jejunostomy

Gastroenterologist surgeon

Endoscopic access Long-term accessDistal feeding

Endoscopy

Radiologic gastrostomy Radiologist None No endoscopic access required

Limited availability

Surgical gastrostomy/jejunostomy Surgeon None Direct visualization General anesthesiaLaparotomy


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Complications and Considerations

The various complications of percutaneous access placement are many. The reported major complication rate of PEG placement is between 1% and 3%. DPEJ placement, which involves endo-scopic placement of a tube within the jejunum as opposed to the stomach, can be performed by experienced endoscopists but car-ries a significantly higher major complication rate and has a lower success rate.35 This is due in part to the variability in loca-tion and mobility of the targeted access point. In addition, the risk of conscious sedation must be considered for both proce-dures but is generally low. Complications associated with percu-taneous endoscopic approaches include endoscopic trauma and perforation of the GI tract, bleeding, skin and soft tissue infec-tion, injury to intra-abdominal viscera such as the liver or colon, tube dislodgement, and fistula creation. These complications are discussed in further detail in subsequent sections.

Radiologic placement has many of the same risks as endoscop-ically placed tubes (soft tissue infection, bleeding, injury to intra-abdominal viscera, etc) with the exception of the absence of scope trauma/perforation of the upper aerodigestive tract. The reported major complication rate is below 8%, with minor complications in up to 10% of patients.36 Surgically placed tubes are associated most commonly with skin and soft tissue infection, incisional her-nia, bleeding, inadvertent removal, and complications associated with general anesthesia. Issues with inadvertent injury to sur-rounding intra-abdominal viscera should be exceedingly rare if not eliminated. The incidence of complication for surgical gas-trostomy has been reported as between 7% and 15%.32 When sur-gical enteral routes are deemed appropriate, multiple variants of operative access to the GI tract are available.

In a randomized controlled trial comparing endoscopic, laparoscopic-assisted, and open gastrostomy tube placement, the laparoscopic-assisted approaches had an increased compli-cation rate compared with the open and endoscopic techniques. The open technique took the longest to perform and had the greatest delay in the initiation of feeding.37 Decreased compli-cation rates are generally reported when endoscopic techniques are compared with surgical feeding tube placement. Overall, regardless of the technique employed, complication rates are generally low even given the high prevalence of malnutrition and chronic disease states in this patient population.38

One final point with regard to enteral access involves clini-cian awareness. Should a patient be taken to the operating room to undergo laparotomy for another reason, consideration should be given to placing enteral access at the time of opera-tion. This can result in the avoidance of unnecessary and tech-nically demanding procedures should the patient ultimately require access at a later time.

Contraindications

Percutaneous endoscopic approaches have become the preferred approach to obtaining longstanding enteral access primarily due

Figure 6. Surgical techniques for enteral access: (A) cross-sectional representation of a typical Stamm gastrostomy. (B) Witzel tunnels are an alternative technique generally used when apposition to the abdominal wall cannot be performed. (C) Laparoscopic approaches can be performed. Reprinted with permission from Elsevier: Allen JW, Spain DA. Open and laparoscopic surgical techniques for obtaining enteral access. Tech Gastrointest Endoscopy. 2001;3(1):50-54.

Figure 7. Computed tomography (CT)guided percutaneous gastrostomy (PG). (A) The left lobe of the liver wraps over the stomach, obviating a safe access route. There is also a small amount of ascites. (B) A CT-guided lateral approach into the stomach permits initial access. (C) The distended stomach now permits access into the stomach for PG. Reprinted with permission from Elsevier: vanSonnenberg E, Wittich GR, Goodacre BW. Radiologic percutaneous gastrostomy and related enterostomies. Tech Gastrointest Endoscopy. 2001;3(1):16-21.


Miller et al 289

to reduced costs, reduced complication rates, and the ability to avoid the morbidity (pain, complications) of laparotomy. PEG placement generally requires conscious sedation but has been successfully performed with no sedation.39 Fewer and fewer absolute contraindications to PEG placement persist as clini-cians continue to expand and refine the available techniques. Special considerations include patients with surgically altered gastric and upper GI anatomy, including gastric bypass, gastric resections, and gastrojejunostomy. Prior laparotomy, particu-larly those resulting in large ventral hernias requiring repair with mesh or resulting from intra-abdominal catastrophes, can make placement more technically difficult or prohibitive, but studies have demonstrated similar safety and efficacy results in these patients.40-42 In patients with esophageal cancer, there is some concern for inadvertent disruption of the gastroepiploic artery, which is the primary supply to the gastric conduit following esophagectomy, but this is reportedly a rare occurrence.43 Although morbidly obese patients can also present significant technical challenges, PEG placement has been demonstrated to be both safe and feasible.44 Patients with preexisting ventriculo-peritoneal (VP) shunts were once thought to be poor candidates, but retrospective data have not demonstrated an increased risk of shunt infections with PEG placement.45

Inability to pass the endoscope through the oropharynx or esophagus remains an absolute contraindication to PEG or PEJ placement for obvious reasons. Placing a PEG using the Russel introducer technique and a narrow caliber endoscope is pos-sible if a total obstruction is not present. In these patients, options include surgical placement of a gastrostomy/jejunos-tomy or placement using radiologic techniques. The availabil-ity of interventional radiologists who are trained and willing to use the radiographic techniques will largely dictate which approach is feasible in most institutions.

Preexisting medical comorbidities must be considered. Patients with advanced liver disease who undergo percutane-ous enteral access have a 30-day mortality as high as 40%, with the large majority of the mortalities observed in patients with ascites.46 Therefore, most would consider ascites to represent a relative contraindication to PEG placement. Finally, there are limited data with regard to PEG placement in adult patients with neutropenia. A small study examining bone marrow trans-plant patients in children found a 36% risk of infectious com-plications in patients with neutropenia.47 In general, individualized risk-benefit analysis should be considered and PEG placement should probably be avoided in neutropenic adult patients.47

Common Management Issues

Managing Newly Placed Tubes

Naso/orogastric tubes. The mainstays of management of naso/orogastric tubes include adequate securing of the tube to maintain the level of infusion as well as frequent flushing of

the tube to prevent occlusion. Tubes should be flushed regu-larly and following the administration of medications. Once the position of the tube has been confirmed, feeding can be initiated immediately.

PEG/PEGJ/ DPEJ tubes. Following placement of percutane-ous tubes, the external bolster should generally be left apposed to the skin for at least 4 days. After 4 days, there should be to 1 cm of laxity left between the entry point and the bumper of the tube to prevent buried bumper syndrome.48 In the long term, commercially available devices allow the tube to exit perpendicular to the abdominal wall. This avoids abnormal traction and potential erosion of the tract by the tube. Several randomized trials have demonstrated the safety of immediate feeding after PEG placement.49,50 After changes in patient posi-tioning and edema at the placement site, the original PEG posi-tion can change. Rechecking the tube position 2448 hours after placement can avoid overtightening of the PEG bolster.

Altering the Level of Infusion

Although gastric feeds are tolerated well by most patients, there are several appropriate clinical scenarios where more dis-tal access is appropriate. Changing the level of infusion more distally in the GI tract reduces reflux and aspiration but may not reduce the incidence of pneumonia or improve caloric delivery.51 Tubes most commonly placed are gastric, duodenal (postpyloric), and jejunal (distal to the ligament of Treitz). Reasons for considering distal access include severe acute pan-creatitis, true intolerance to gastric feeding, and diversion from a surgically altered proximal gastric or duodenal anatomy. Tubes placed at the bedside into the stomach will often migrate more distally regardless of intention to do so. Determining the appropriate level of infusion is often fluid, requires reassess-ment, and may need alteration with changes in patient condi-tion. Prior to PEG placement, it is often appropriate to trial the patient on gastric feeds to ensure tolerance. Combination gas-trojejunal feeding tubes are available for placement at the time of laparotomy. A jejunal extension tube can be placed through a preexisting PEG to facilitate more distal feeding while also providing an avenue for gastric decompression when necessary.

Who Should Put These Tubes In?

A multidisciplinary approach to placement of enteral access is preferred. Nasoenteric tubes are generally placed by dietitians and nurses, whereas percutaneous and surgically placed tubes are performed by a wide array of physicians, including gastro-enterologists, surgeons, radiologists, and medical intensivists. If prolonged access is warranted and the patient is able to undergo endoscopy, endoscopic gastrostomy or jejunostomy performed by surgeons or gastroenterologists is the likely choice. If the stomach is unable to be accessed endoscopically,



radiologic techniques (interventional radiologists) and open gastrostomy/jejunostomy (surgeons) are appropriate options.

Enteral Access and Liver Failure

As mentioned previously, patients with advanced liver disease experience significant mortality when undergoing percutane-ous enteral access procedures. This is particularly true in those with ascites.46 Nasoenteric access is the preferred route in these patients for this reason. Ascites can preclude adequate seal and lead to continued ascites leak and predispose the patient to bacterial peritonitis. PEG placement is potentially feasible if ascites is adequately drained through paracentesis prior to placement and the patient is kept dry until an appro-priate seal is formed. A seal can be facilitated through gastro-pexy using T-fasteners at the time of placement and has been described.52 Esophageal varices are another potential compli-cation associated with advanced liver disease. Management decisions in these patients can prove quite difficult and should generally be managed on an individualized basis. Patients with nonbleeding esophageal varices should be fed through nasoenteric access. However, in patients with actively bleed-ing varices, nasoenteric tube placement should likely be avoided.53

Anticoagulation and Enteral Access

According to guidelines published by the American Society of Gastrointestinal Endoscopy (ASGE), percutaneous enteral access is considered a high-risk endoscopic procedure.54 As such, patients receiving therapeutic anticoagulation should have their anticoagulants held for an appropriate period to ensure normalization of coagulation parameters (57 days for warfarin). For patients with high-risk conditions (heart valves, etc), bridge therapy with heparin or low-molecular-weight heparin can be considered. Anticoagulation can generally be safely resumed within 1 day of uncomplicated percutaneous enteral access.

Decisions regarding withholding antiplatelet therapy depend highly on the underlying indications for which they are prescribed. Any decision to hold therapy should be discussed with the patients appropriate managing physician. In general, patients on single-agent therapy with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) may continue these medi-cations during the periprocedural period. Consideration should be given to holding thienopyridines (eg, clopidigrel) for 5 days prior to percutaneous enteral access if possible. Patients on dual therapy should continue aspirin, and consideration should be given to starting aspirin for patients on thienopyridine monotherapy if it is to be held during the periprocedural period. One recent study did not show a significant increase in bleed-ing events with antiplatelet therapy held for shorter durations and suggested 3 days prior to the procedure as a safe waiting time.55

Patients undergoing percutaneous enteral access will com-monly be on prophylactic dosages of anticoagulants such as low-molecular-weight heparin to prevent venous thromboem-bolism. The bleeding risk for procedures on these agents is not well studied, but it appears reasonable and safe to hold them the day of the procedure and resume them the following day.56

How Do You Address the Combative Patient?

Combative and agitated patients present additional hurdles to maintaining adequate enteral access as tubes can become dis-lodged or entirely removed. ICU psychosis and recreational drug or alcohol withdrawal are common situations resulting in both airway and enteral access issues. Tube dislodgement is a major contributor to reduced caloric provision in the ICU in addition to requiring significant cost and resources for repeated replacement.18

Nasoenteric tubes can be secured with a nasal bridle. Commercially available magnetized devices are available for use as opposed to the standard adhesive tape that is tradition-ally applied. Magnetized kits offer the advantage of bedside placement with minimal sedation and instrumentation of the oropharynx. These are best placed at the time of tube place-ment, taking advantage of conscious sedation or general anes-thesia. A recent randomized controlled trial in 80 surgical intensive care patients compared the bridling technique with standard adhesive tape application. Only 18% of the bridled tubes became dislodged vs 63% of the nonbridled tubes, result-ing in significantly improved caloric provision (78% vs 62% goal) in the bridled group.19 Complications of the bridling technique included nasal ulceration and epistaxis. This tech-nique provides a practical and safe approach for securing the access device.

Managing Complications

Wound Infection

Peristomal infections are a common concern but probably occur in less than 1%2% of cases. Most cases consist of mild superficial cellulitis that can be treated with antibiotics cover-ing normal skin flora, although methicillin-resistant Staphylococcus aureus (MRSA) is becoming increasingly common.57 Rarely cases will involve an abscess within the soft tissue surrounding the tube and are best treated with local drainage and subsequent wound care. Even more rarely, abscesses develop in the deeper tissue planes and are not read-ily apparent on visual inspection. Patients usually report exces-sive pain around the tube and may exhibit signs of systemic infection such as leukocytosis or fever. Computed tomography (CT) scan can be helpful in the diagnosis of these abscesses. They can usually be drained by extending the tube site skin incision. Patients with percutaneous enteral access can also


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develop necrotizing soft tissue infections at the tract site.58,59 The treatment involves systemic antibiotics and prompt surgi-cal debridement of affected tissues. Tube removal is usually necessary. Fortunately, these cases are rare. Signs of infection or leakage should also prompt consideration for the buried bumper syndrome as described below.

The overall incidence of infections at PEG sites can be decreased by the use of periprocedural antibiotics.60,61 A single intravenous (IV) dose of a first-generation cephalosporin 30 minutes prior to the procedure is acceptable. Recent studies have also shown equivalence with a single oral dose of Bactrim instilled into the PEG tube after placement.62

Bleeding

Significant bleeding during percutaneous enteral access is uncommon. Most bleeding represents disruption of superficial blood vessels arising from the tube tract, which can be con-trolled by tightening the bumper to apply direct pressure. An excellent retrospective study examining more than 1500 PEG insertions determined a GI bleeding incidence of around 3% and bleeding directly attributable to PEG placement as 0.4%. Heparin and length of hospitalization were 2 independent risk factors identified. Alternative antiplatelet and anticoagulants were not identified as independent risk factors despite being held between 1 and 2 days prior to intervention. Nearly 10% of the patients undergoing PEG placement were on clopidrogrel in this study.63 If excessive pressure is required, it should be released within 2448 hours to avoid injury to the skin. Ulceration with subsequent bleeding may also occur in the stomach on the posterior wall opposite the PEG or underneath the internal bolster. Abdominal wall and rectus sheath hemato-mas can occur,64 but these are usually self-limited and gener-ally do not require intervention. There are case reports of aortic perforation, gastric artery injury, and retroperitoneal hemor-rhage during PEG placement.65,66 Adherence to good technique should limit risk to significant blood vessels, as they can gener-ally be visualized endoscopically and with transillumination. As previously discussed, coagulopathy should be corrected and anticoagulants should be held during access procedures to decrease the risk of bleeding complications. In addition, there is recent evidence that the bleeding risk during PEG is increased with the use of serotonin reuptake inhibitors.67

Leakage

Peristomal leakage of gastric contents due to enlarging diameter of the PEG tract is a common complication and reported in some studies as high as 10%.68 Most common causes are side torsion on the tract wall causing ulceration at the skin and enlargement of the hole. This can be corrected by using a commercial clamp-ing device to secure the tube and prevent side pressure against the walls of the tract. The second most common cause is lack of

an external bolster allowing the tube to migrate in and out, thereby causing enlargement of the PEG tract (Figure 8).69 Creating an external bolster or replacing the PEG usually cor-rects this problem. A common pitfall, however, is excessive tightening of the bolster to stop leakage (Figure 9).69 This will only lead to further skin breakdown and delay further wound healing. Another common pitfall is replacing a leaking tube with a larger diameter tube in the hopes of obtaining a better seal. This only serves to further enlarge and distort the leaking tube tract. In rare cases of persistent leakage, the site must be sacri-ficed, and the tube may have to be replaced to a different skin site, allowing the original site to close and heal.

Pneumoperitoneum

Pneumoperitoneum is relatively common after PEG place-ment.70,71 PEG placement represents a controlled perforation of a hollow viscus, so some degree of pneumoperitoneum is expected. It is caused by the distention of the stomach with escape of air into the peritoneal space during endoscopy with subsequent needle puncture. It is a benign condition but can lead to diagnostic confusion for clinicians. If there are no asso-ciated signs of peritonitis, it can simply be observed. Most cases will resolve within 72 hours. If there is uncertainty, a contrasted study through the tube or a CT scan can be obtained to confirm position. Pneumoperitoneum should only be con-sidered benign for newly placed enteral access. Patients with mature tubes who present with free air should undergo the same diagnostic considerations as any other patient.

Figure 8. Excessive torsion can enlarge the tube tract, resulting in leakage and superficial excoriation. Reprinted with permission from Elsevier: McClave SA, Chang WK. Complications of enteral access. Gastrointest Endoscopy. 2003;58(5):745.



Clogging/Tube Dysfunction

Tube clogging is a common and frustrating issue and can occur with both medication administration as well as enteral formula. The best management strategy is prevention. All medications should be appropriately dissolved in liquid prior to administra-tion. Certain medications such as bulking agents or resins should never be placed through enteral access tubes. Tubes should also be flushed with warm water after every use. If clog-ging does occur, the tube can usually be irrigated using a syringe to create pressure. Pancreatic enzymes dissolved in bicarbonate and allowed to dwell in the tube prior to flushing may be also be effective.72 If clogging is persistent, guidewires or specially designed tube brushes may be used. Occasionally, tubes will have to be replaced for clogging, cracks, or general deteriora-tion. This appears to be more common with silicone tubes (due to fungal colonization) compared with polyurethane.73

Persistent Fistula Following Removal

Following removal, most tube sites will close spontaneously within 72 hours. The development of a persistent gastric fistula is more common in children and may correlate with the dura-tion of tube use.74 Treatment often requires formal surgical closure of the fistula. Minimally invasive techniques, includ-ing gastric mucosa endoclipping, fibrin glue, and fistula tract lining disruption using a curette or electrocautery device, have

also been described and may be attempted prior to proceeding with surgery.75-78 Anecdotally, placing a purse-string suture beneath the skin in the subcutaneous tissue may be added to the endoclipping of the mucosal defect to promote closure.

Buried Bumper Syndrome

Buried bumper syndrome occurs when the internal bolster of the PEG erodes into the gastric wall as a long-term conse-quence of excessive tightening of the bolsters.79 The syndrome is associated with pain, increased drainage, PEG site infection/inflammation, and eventually an inability to feed through the tube. Diagnosis is usually made by endoscopy or CT scan. Treatment involves removal and replacement of the tube and can be done through the same site, adding a commercial clamp-ing device to hold the tube in place, prevent migration into the mucosa, and allow for healing of the ulceration to take place.

Inadvertent Removal

Percutaneously and surgically placed tubes also can be dis-lodged or removed during episodes of agitation and present additional problems. An interesting recent retrospective review of 563 PEGs over a 3-year period demonstrated an early (within 7 days) dislodgement rate of 4.1% and total lifetime dislodgement rate of almost 13%, with most occurring after discharge from inpatient hospitalization. The average cost of replacement was $1200.80 Abdominal binders and clinical restraints can be useful adjuncts following PEG placement and prevent patient access to the majority of the tube. Tailoring the tube at a length that allows adequate care but also restricts access is advisable. Inadvertent removal is a relatively com-mon and expensive problem. Management of tube removal depends on the length of time the tube has been present and the overall maturity of the tract. For tubes in place >4 weeks, blind bedside tube replacement through the tube tract is generally safe and easy. It should be attempted as soon as possible to prevent the tube tract from closing. A similarly sized Foley catheter is commonly available and makes for a great tempo-rary replacement PEG. If enteric contents can be aspirated and the tube flushes easily, a confirmatory radiographic study is not necessary. For tubes in place

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the PEG immediately, the patient can be managed by nasogas-tric aspiration, broad-spectrum antibiotics, and parenteral nutrition. Surgical exploration is warranted if the patient dem-onstrates signs of peritoneal leakage and early peritonitis.69,81

Liver Injury

The left lateral segment of the liver lies in close proximity to the stomach and may be quite large in some patients or low lying in other patient populations (eg, chronic obstructive pul-monary disease). Liver injuries commonly occur with the tube tract passing through the liver parenchyma prior to entering the stomach and can lead to fistula formation.82 Liver injuries are most commonly associated with bleeding, either during place-ment or at the time of removal. In many cases, injury may be completely asymptomatic and diagnosed in delayed fashion. When identified, tubes passing through the liver can be removed surgically or endoscopically.83,84 If surgical hemosta-sis is not obtained, a period of observation for signs of bleeding after removal is warranted. This complication may be pre-vented by routinely percussing and marking the lower edge of the liver prior to choosing the PEG site.

Colon Injury

The splenic flexure of the colon lies in close proximity to the stomach and may overly portions of it in some patients. Injuries to the colon usually involve the tube passing through the colon prior to entering the stomach. Although possible, most injuries do not lead to early onset peritonitis and are diagnosed in delayed fashion. Patients may develop colocutaneous or gas-trocolic fistulas that become evident only at the time of tube removal.85,86 Conservative measures are often successful in obtaining closure (pulling the PEG tube and simply applying a dressing over the tract site), but occasionally surgery is required for definitive treatment.

Conclusion

The provision of adequate nutrition support in the hospital set-ting is the standard of care. Enteral access in patients unable to sustain volitional oral intake is a fundamental concept, allow-ing the facilitation of appropriate support. As in any interven-tion, forethought and consideration should be given to successfully use the appropriate access option in a given patient. Clinicians across disciplines should have a working knowledge with regard to technique as well as the advantages and disadvantages of the various enteral access options to opti-mize outcomes and minimize unnecessary and higher risk interventions. Finally, in the event that complications arise from attempted access, clinicians should be aware of appropri-ate management strategies to prevent further clinical deteriora-tion and salvage attempts at ongoing support.

Further Reading

Allen JW, Spain DA. Open and laparoscopic surgical techniques for obtaining enteral access. Tech Gastrointest Endosc. 2001;3(1):50-54.

DeLegge MH. Enteral accessthe foundation of feeding: endoscopic nasoen-teric tube placement. Tech Gastrointest Endosc. 2001;3(1):22-29.

Ginsberg GG, Kochman M, Norton I, Gostout C. Clinical Gastrointestinal Endoscopy. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005.

McClave SA, Chang WK. Complications of enteral access. Gastrointest Endosc. 2003;58(5):739-751.

Glossary

APACHEAcute Physiology and Chronic Health Evaluation. A severity of illness score used in the ICU that takes into account acute and chronic illness to predict mortality.

Dobhoff tubea subtype of tube placed through the mouth or nose into the GI tract.

DPEJdirect percutaneous endoscopic jejunostomy. Endoscopically placed tube into the jejunum through the abdominal wall.

Fluoroscopyreal-time imaging modality using x-ray.Frenchunit of measurement used in tube diameters equal to 1/3 mm.GCSGlasgow Coma Score. A severity of derangement score used to

assess neurologic score in the ICU and in trauma patients.ISSInjury Severity Score. A severity of illness score in trauma patients

used to predict mortality, morbidity, and length of hospitalization.Nasoenteric accessbroad term to describe tubes placed through the

nose into the GI tract; includes nasogastric as well as nasojejunal tubes.

Nasogastricplaced through the nose into the stomach.Orogastricplaced through the mouth into the stomach.PEGpercutaneous endoscopic gastrostomy. Endoscopically placed tube

into the stomach through the abdominal wall.PEGJpercutaneous endoscopic gastrojejunostomy. An extension tube

placed through an existing PEG down into the jejunum.Polyurethaneless compliant material used in tubes commonly utilized

for gastric decompression and replacement pegs.Siliconemost common material used in feeding tubes, prone to fungal

colonization.SOFASequential Organ Failure Assessment. A severity of illness score

assessing organ function used in the ICU to predict mortality.

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