nov04.html

Nutrition Traineeship

e Journal Club

November 2004

 

This month we hosted four trainees from a variety of facility sizes (250 beds to 1000 beds) and from a variety of geographic areas (Iowa, Maryland, Ohio and Texas).  We had a great week, and the slightly bigger group lends itself to some nice discussions and sharing of case studies and experiences.

Our article this month was from the November 2004 Clinical Nutrition, and investigates the effects of delaying PEG placement on patient mortality.

Abuksis G, Mor M, Plaut S, Fraser G, Niv Y.  Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience.  Clin Nutr. 2004 Jun;23(3):341-6.

Summary:
This study used two consecutive cohorts of patients admitted with “malnutrition and terminal illness” who were referred for PEG placement.  The first group (January 1997 to December 1998) of 61 patients had PEG placement as soon as possible after the initial PEG request (7 days +/- 6.8). The second group (January 1999 to December 2000) of 66 patients were scheduled for PEG placement 30 days after discharge (16.6 days +/- 18.9). 

 The authors reported that delaying PEG placement for 30 days (or more) significantly decreased overall mortality.  The abstract states that 30-day mortality was 40% lower in the group who had the PEG delayed, and that mortality was 87.5% lower when it was calculated from the time of PEG insertion.

 Evaluation: 
One obvious limitation of this study is that it was NOT a randomized trial.  These groups were separated by time, and it is possible that some other factor, such as new techniques, new antibiotics, new endoscopists, or other unknown factor could have influenced mortality (History effect).  In addition, there was no attempt to control for severity of illness or underlying co-morbidities (diabetes, renal failure, etc.) that could have influenced mortality. 

  Ultimately, only 3 patients in the “delayed-PEG” group did not require their PEG because they were able to eat.  When one looks at the 90-day mortality of these two groups, the results are less impressive.  Based on the results in the figures it appears that 33 patients (50%) in the delayed-PEG group survived 90 days, while 18 patients (30%) in the early-PEG group survived for 90 days.  This difference would be worthy of notice if this were a randomized trial, but the concern for selection or a history bias diminishes the impact of this trial.

One factor that allowed this study to take place is the location.  This study was done in Israel, where the authors state that all nursing homes allow patients with a nasogastric feeding tube for a 30-day limit.  A policy of delayed PEG placement may be difficult in other parts of the world where the disposition of patients with nasogastric tubes is more complicated.  In addition, it is unclear if the morbidity and mortality of those patients with a nasogastric tube would be this low in all nursing homes.  Adequate staffing and supervision of patients are required to prevent adverse effects from partial dislodgement of nasogastric tubes while feeding in this population. 

 Take home message: Tube Placement

The results of this study are worthy of notice.  In this era of rapid discharge we should consider if there is a better timing of PEG placement in a population that is frequently debilitated and elderly.  However, the limitations of the study design are real, and therefore we would need to see a randomized study before we would consider any type of policy change regarding the timing of PEG placement.  In addition, the environment of the study (nursing homes in Israel) may limit the practicality of such a policy in other places.

Finally, despite its flaws this study does remind us that perhaps there should be better criteria for patient selection when it comes to PEG placement – just because we have the ability to keep patients hydrated and nourished, does not mean that we should always do so.  Perhaps there are some patients that we should not burden with this procedure.

“The greatest obstacle to discovery is not ignorance -- it is the illusion of knowledge.”

-Daniel Boorstin

  Other News:

Check out the latest article on our website:

Lynch CR, Fang JC.  Prevention and management of complications of percutaneous endoscopic gastrostomy (PEG) tubes.  Practical Gastroenterology 2004;XXVIII(11):66.

  Accessible at:
http://www.healthsystem.virginia.edu/pub/digestive-health/nutrition.html#ginutlinks

  Upcoming Articles;

¨      Refeeding Syndrome

¨      TPN-Induced Cholestasis

¨      Micronutrient Issues in Long term TPN

¨      Hitchhiker’s guide to Parenteral Nutrition

¨      The Zen of Formula Selection

¨      Bone marrow transplant - Nutrition considerations

¨      Nutrition Intervention in Cystic Fibrosis

¨      To PEG or not to PEG

¨      Short bowel syndrome – Adults

¨      Enterocutaneous fistulas and ostomies

 

Joe Krenitsky MS, RD

Carol Parrish RD, MS

 

PS – Please feel free to send this on to friends and colleagues.