Percutaneous Endoscopic Gastrostomy tube placement in COVID‐19 patients: Multidisciplinary approach

Abstract

Percutaneous endoscopic gastrostomy (PEG-tube) placement is a relatively safe procedure for enteral nutrition in appropriately selected patients. Gastroenterologists are sought for PEG-tube placements in COVID-19 patients with vent-dependent respiratory failure. Although PEG-tube placement along with tracheostomy may expedite discharge planning, there are unique challenges for endoscopy staff because of the potential for viral transmission. 1 There is no gastroenterological society recommendation for a maximum duration of nasogastric (NG) or orogastric (OG) tube in critically ill patients. However, the general consensus is to wait about 4 weeks because of increased risk of complications beyond this duration. 2 If a PEG-tube is deemed necessary, a multidisciplinary discussion (patient's family, primary, procedural, and palliative care teams) should be held to discuss risks and benefits of the procedure, nutrition goals, and overall prognosis (Table 1). Guidelines from the COVID-19 tracheostomy task force recommend waiting for at least 21 days before performing a tracheostomy. 3 A similar window period of 3-4 weeks for PEG-tube placement can be considered to avoid transmission. Patients' transport should be minimized to reduce the transmission risk; however, barrier methods (plastic patient-isolation drapes) should be used if deemed necessary. A small size hole (about 6 inches) can be made in the drape to access expected site of PEG-tube placement. All patients should receive prophylactic antibiotics as per guidelines. The "pull-technique" should be used while minimizing suctioning in addition to practicing "cluster care" 4 while performing other procedures/imaging needed for the patient (PEG-tube placement immediately before or after tracheostomy to minimize transport and exposure risk) (Table 2). In short, devising institutional guidelines regarding appropriate patient selection, optimizing the timing of PEG-tube placement along with tracheostomy if needed, while observing a multidisciplinary team approach, and minimizing endoscopic personnel during the procedure can decrease the exposure risk and improve patient care as well as free-up intensive care unit (ICU) resources. Authors declare no conflicts of interest for this article.

Covid-19 Enfeksiyonunda Perkütan Endoskopik Gastrostomi Zamanlaması: Endoskopik Cerrahi Ünite Deneyimi

“…Meanwhile, current studies also suggest the optimal time for surgical intervention to be after an asymptomatic period of 7 weeks following virus infection [21]. Also, for PEG, a delay of 3-4 weeks with the pull technique is recommended [4].…”

“…At the same time, health authorities strive to establish the optimal approach [3]. Recommendations for invasive surgical procedures in patients infected with COVID-19 have also been reviewed, and a delay to surgery of 3-4 weeks is recommended in the case of patients who cannot be fed orally and so require feeding tube insertion [4].…”

Survival Following Percutaneous Endoscopic Gastrostomy in Neurology Intensive Care Unit Patients

“…As the criteria for PEG tube insertion, it was determined that oral intake would not be taken for at least 4 weeks or later, or that oral intake was not taken for 4 weeks or more and consent was obtained from the patients or their legal proxy decision makers (5). PEG tube was inserted in 29 patients who met these criteria.…”

“…For these reasons, EN is generally preferred over PN in patients with a functional gastrointestinal system (1,2). Nasoenteric nutrition is used as the first choice for EN in patients where oral intake is not possible; however, due to various adverse effects such as irritation, ulceration, bleeding, esophageal reflux and aspiration pneumonia with the use of nasoenteric nutrition, percutaneous endoscopic gastrostomy (PEG) is preferred, especially in patients who require EN for more than 2-4 weeks (2)(3)(4)(5). Briefly, PEG is defined as "the endoscopic placement of a flexible tube to create a temporary or permanent connection between the abdominal wall and the gastric cavity to allow direct passage of food into the patient's digestive tract" (6).…”

Interventional Pulmonology and the Esophagus: Tracheostomy and Percutaneous Endoscopic Gastrostomy Placement

“…Similar guidelines advocate “clustering care,” that is, performing gastrostomy immediately after tracheostomy, to minimize exposure risk. 61…”