Critically ill patients are at increased risk for malnutrition as they often have underlying acute and chronic illness, stress related catabolism, decreased appetite, trauma and ongoing inflammation. Malnutrition is recognized as a leading cause of adverse outcomes, higher mortality, and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes provide a safe and effective route to provide supplemental enteral nutrition to these patients. PEG placement has essentially replaced surgical gastrostomy as the modality of choice for longer term feeding in patients. This is a highly prevalent procedure with 160,000 to 200,000 PEG procedures performed each year in the United States. The purpose of this review is to provide an overview of current knowledge and practice standards with regards to placement of PEG tube in the Intensive Care Unit (ICU). When a patient is considered for a PEG tube, it is important to evaluate the treatment alternatives and identify the best option for each patient. In this review, we provide the advantages and disadvantages of various feeding modalities and devices. We review the indications and contraindications for PEG tube placement as well as the risks of this procedure. We then describe in detail the per-oral pull, per-oral push, and direct percutaneous techniques for PEG tube placement. Additionally, we review the feasibility of having interventional pulmonologists place PEG tubes in the ICU.

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A man in his 30s with a history of hypertension and occasional tobacco use presented to the emergency department (ED) with several hours of chest pain and nausea. The pain started after eating breakfast and was variably described as constant, sharp, pressurelike, and burning, but was nonexertional, nonpleuritic, and nonreproducible. An electrocardiogram (ECG) was obtained in triage (Figure 1). The first troponin I value was more than 3 times the upper limit of normal at 0.1 ng/mL (normal, Յ0.028 ng/mL [to convert to μg/L, multiply by 1.0]) but still fell within the assay indeterminate range (Յ0.3 ng/mL).Three weeks prior the patient had presented to the same ED with similar-quality pain and was diagnosed with gastroesophageal reflux disease. An ECG was obtained during this prior encounter, providing a baseline for comparison (Figure 2).Question: Is this patient presenting with an ST elevation myocardial infarction (STEMI)?

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