Surgical Nutrition Access
Inpatient PEG consultations:
1.
The acute Care Surgery Chief can decide who to see the
consult: chief, junior, intern, PA/NP
3.
If unable to contact trauma chief, call Blue
Floor or ICU attending through UKMDs.
4.
Staffing:
a.
Floor PEG consults will be staffed with the EGS Floor Attending of the week.
b.
ICU PEG consults will be staffed with the EGS ICU Attending of the week.
5.
The PEG will be posted by resident per attending
discretion with Endo scheduler: 323-6450
6.
Timeline: Consults will be seen the same day and
performed the same or following day when possible.
Pre-clinic:
1.
Patient should know that they won’t get PEG’d at
the clinic visit.
2.
UK Blue Surgery PEG patient education to be provided by referring clinic AND by the General Surgery Clinic (Rhonda or Krista) AND in the Endo Suite again by someone from the EGS Service.
Preoperative
considerations:
1. Is a G-tube indicated (See Guideline below)?
History and Physical documented in SCM under
document entitled “Blue Surgery History and Physical in Epic.
a.
NOTE: This can be a FOCUSED H&P to include
all routine H&P COMPONENTS with emphasis on:
i. The
full name of the consulting
attending
ii. Brief
HPI to include tolerance of gastric
feeds (patients with known emptying problems will not tolerate a G tube)
iii. PMHx
with attention to coagulopathy,
malignancy, liver disease, renal failure
iv. Meds
to include: anti-platelets and
anticoagulants
v. SurgHx
to include the abdomen
vi. ROS:
resp symptoms (dyspnea, wheezing,
hypoxia)
vii. Physical
exam to include:
1.
ability
to open the mouth
2.
abdominal
contour and scars
3.
resp
status
2.
Sedation/Anesthesia
a.
If the patient’s medical comorbidity would
normally warrant preop clinic (eg, ALS cases), send the patient to preop and
post the case as ‘Endo with Anesthesia’ or in operating room.
3.
Consent done (after procedure is confirmed to be
a ‘go’).
4.
Evaluate Home/Inpatient medicines list,
especially any blood thinners (ASA, Plavix, Coumadin, heparin drip, lovenox,
pradaxa, etc).
a.
If on novel oral anti-coagulants, hold for at
least 2 half-lives (24-36 hours in most patients unless renal dysfunction).
b.
Hold AM therapeutic lovenox dose if on TLov on
day of PEG.
c.
Hold heparin infusion 4 hrs before procedure.
d.
Do not hold prophylactic heparin/lovenox.
e.
If no
history of bleeding diathesis, liver disease or recent IV heparin or warfarin
use: NO coagulation panel is needed.
f.
Obtain PLT
count (if not done in recent days) in patients with: chemo, liver disease,
hypersplenism or known thrombocytopenia.
5.
NPO
a.
2 hours prior for clears
b.
4 hours prior for full liquids
c.
8 hours prior if gastric tube feeds, oral diet
or with anesthesia
d.
On call
to endo (or pre-med if ICU) if post-pyloric feeds.
Special
Considerations in Outpatients
1.
Rhonda will have screened the patient prior to
clinic visit.
2.
Identify payer status and decide what type of
admission accordingly:
a.
Across all payers, there is a significant
financial advantage to performing PEGs as outpatient, particularly with bed
availability constraints. This should be the default visit type for elective
PEG’s assuming preop arrangements and teaching are completed.
b.
Specifics about Medicare and Medicaid patients: Medicare/Medicaid
patients should be ‘outpatient surgery’. You are not to use ‘Observation’
prospectively. If the patient needs care afterward that requires an overnight
stay, document accordingly and change to ‘observation’ if minor or ‘inpatient’
if major needs with input from Utilization Review (859-323-5316). Short stay is
used if there are no significant needs of the patient but they just need a
bed for overnight. UR will decide this.
c.
Commercial insurance will fund observation more
readily.
3.
Confirm that referring service (MCC, Neurology,
etc) dietitian has seen or is scheduled to see the patient.
4.
Referring service will have ordered tube feeds
and DME. Rhonda will confirm.
5.
PEG teaching in clinic by Rhonda.
6.
Post the case with Scheduler as usual (whether Endo
or OR)
7.
Consent and antibiotic order to be completed in
clinic and sent to Surgery Scheduler.
Endoscopy
considerations:
1.
Consent checked/confirmed
2.
H&P on chart
3.
Labs/Meds reviewed
4.
Pre-operative abx given: Kefzol 1-2g IV x 1
dose. If PCN allergy, clindamycin 600mg
IV x 1.
5.
PEG placed to Foley bag drainage immediately
post-procedure.
6.
The PEG booklet provided in PEG procedure kit is
given to patient, family, or placed on the patient chart
7.
A Blue Surgery service or attending card is
included in the booklet
8.
If present, talk to family in Endo or ICU
waiting room post-procedure
9.
Procedure note completed in Provation
10. Patient/Family
PEG tube education provided by Endo RN prior to Endo discharge is variable and
limited. Do not count on this.
11. Inpatients:
PEG teaching will be performed by the Ward or ICU RN if staying overnight.
12. If
outpatient, reiterate to patient the date/time to start feeding. Rhonda will
have performed preop teaching at clinic visit.
Postoperative
considerations:
1.
Standard PEG order set, specifically:
a.
Bolster height and how to monitor
b.
Residual checks at least every 8
c.
Who to call if dislodged
2.
Feed at 2 hrs post-procedure. OK for meds per PEG right away.
3.
Add patient to SGB census if staying overnight
on SGB.
4.
Patient will be seen on following am rounds and
sign-off with following criteria
a.
PEG tube at same skin marking at procedure
b.
Bolster loosened and tube advanced into stomach
and re-tightened to procedure skin-level.
Tube spins freely.
c.
Patient and family questions answered.
5.
Displaced PEG’s:
a.
Unlikely to achieve reinsertion if early after
insertion (first few days).
b.
If attempting reinsertion, do so ASAP.
c.
Confirm placement radiographically unless tract
is clearly mature.
d.
Tube choice:
i. Replacement
G tube is ideal but can be hard to locate. Tube diameter should be close to the
one that was displaced-to prevent leakage or difficulty inserting.
ii. Alternatively,
use a Foley. However, take the bolster from the displaced PEG and slide it onto
the Foley so that the Foley balloon can be pulled snugly against the gastrotomy
to prevent leaking.
6.
Buried bumpers:
a.
What is it? PEG bumpers (internal mushrooms) on
the Ponsky-type, ‘traction removable’ PEGs can be unintentionally pulled up
into the tube tract with the mushroom partly collapsed. The result can be pain,
swelling, difficulty feeding or no symptoms at all. Infection may eventually
ensue and can be severe.
b.
Bolster height should be checked at least
weekly. Do this by:
i. Grasping
the tube firmly underneath the bolster (with fingers or a clamp).
ii. Pull
up the bolster to about 10cm.
iii. Advance
the tube into the stomach.
iv. Bumpers
that are not ‘buried’ will advance freely into the gastrum.
v. Resistance
on advancing the tube, or inability to spin the tube, suggest ‘buried bumper’.
c.
Diagnostic/Confirmatory Studies: Suspected
buried bumpers should be evaluated. Simple gastrogram (tubogram, Port-PEG) in
radiology cannot confirm bumper position. Therefore, endoscopy or CT abdomen
should be performed.
7.
Follow-up Considerations:
a.
Routine
follow-up in SGB clinic is not necessary
b. Problems with G tubes should ideally be addressed in the clinic (NOT the ED) if possible.
c.
Change to a button is possible.
i. Considerations:
1.
Must measure depth and pick correct size.
2.
Can we get it paid for? (How much would the AMI one cost? Will the payer
cover it?)
