PEG tips

Who does Gastrostomy tubes at MCV?

- GI

- Interventional Radiology

- Surgery (General Surgery for floor patients, Trauma Surg for ICU patients)

• They can do the procedure endoscopically in the operating room or alternatively will do an open G-tube. In this instance, they make a midline incision, grab the stomach with a clip, make a hole for the peg tube and essentially suture the stomach/fascia to the abdominal wall.

Checklist when you get called for a PEG tube consult:

□ What is the indication for the PEG tube?

□ Are there any contraindications?

□ Is the patient unable to tolerate PO? (look for a DOCUMENTED note from speech path)

□ Are they stable for sedation?

□ Have they been afebrile X 24 hours?

□ Is there someone that can consent for family?

What are the relative contraindications/ considerations to GI placing a PEG tube?

- Ascites (relative)

- Cirrhosis

- LARGE ventral hernia- general surgery needs to do the PEG.

- Previous abdominal surgery (partial gastrectomy)

- Roux-en-y gastric bypass (cannot do endoscopically)

- Trismus (won’t be able to put the scope down)

- Fever in past 24 hours

- Too unstable to undergo sedation.

- Recent ulcer or bleed

- In general, if the risks of the procedure >> benefits.

- For oropharyngeal tumors, make sure the patient has good airway protection. (Also consider tumor load when evaluating these patients).

- Advanced Dementia

To Schedule Procedure:

- Get consent from the family or patient. This has to be on the chart BEFORE the patient is in the endoscopy suite.

- Make sure the patient has been off Plavix 5-7 days (attending discretion). Has to have normal INR.

- Place on list for the morning.

Instructions to put in the note

- Hold Plavix 5-7 days prior to procedure, 1 day post procedure if feasible.

- Heparin infusion: Hold 4-6 hours prior, 24 hours after procedure.

- Lovenox 10-12 hours prior, 24 hrs afterwards.

- Hold Heparin/ Lovenox prophylaxis the day of the procedure.

- 81 mg ASA OK to take on the day of procedure.

- Patient will be given antibiotics (Cefazolin 2-3 gm or Clindamycin 900 mg if PCN or cephalosporin allergy) during the procedure prior to incision time.

The day after the PEG has been placed, leave a note that includes the following:

- Examine site of insertion, look for signs/symptoms of infection or bleeding (both from around the site of insertion and from the stomach itself).

o If patient with evidence of bleeding from GI tract, might require re-scoping.

- Rotate the bumper and loosen (allow free rotation and about 1 cm total of in and out movement).

- The nurses should have a printed handout of post-peg recommendations.