What are the indications for Percutaneous Endoscopic Gastrostomy (PEG) tube placement in Intensive Care Unit (ICU) patients?

Indications for PEG Placement in ICU Patients

PEG tube placement is indicated in ICU patients who are expected to require enteral feeding for more than 4-6 weeks and have a functioning gastrointestinal tract but are unable to meet their nutritional requirements orally. 1

Primary Indications for PEG in ICU Patients

Neurological Disorders

• Cerebrovascular accidents (stroke) with persistent dysphagia
• Traumatic brain injury with depressed consciousness
• Prolonged coma states
• Motor neuron diseases (ALS)
• Multiple sclerosis
• Parkinson's disease
• Cerebral palsy
• Severe lower cranial nerve palsies 1, 2, 3

Mechanical Obstruction

• Head and neck cancers
• Oropharyngeal or esophageal cancer
• Radiation enteropathy affecting swallowing 1, 2

Other Indications

• Patients requiring long-term supplementary nutrition due to:
  • Short bowel syndrome
  • Fistulae
  • Cystic fibrosis
  • Prolonged ventilator dependence with inability to meet nutritional needs 1, 2

Timing of PEG Placement

The decision to place a PEG tube should follow this algorithm:

1. Assess expected duration of enteral feeding need:

   • If <4 weeks: Use nasogastric or nasojejunal tubes 1
   • If ≥4-6 weeks: Consider PEG placement 1

2. Assess nutritional risk:

   • In severely malnourished patients: Consider enteral access within 24-48 hours of admission 1
   • In patients at low nutritional risk: Consider enteral access if unable to meet caloric requirements over 5-7 days 1

Contraindications and Cautions

Absolute Contraindications

• Inability to bring the anterior gastric wall in apposition to the abdominal wall
• Uncorrectable coagulopathy
• Peritoneal carcinomatosis
• Peritonitis

Relative Contraindications

• Gastroesophageal reflux
• Previous gastric surgery
• Ascites
• Extensive gastric ulceration
• Neoplastic/infiltrative disease of the stomach
• Gastric outlet obstruction
• Small bowel motility problems
• Peritoneal dialysis
• Hepatomegaly
• Gastric varices
• Late pregnancy 1

Important Considerations

Patient Selection

PEG placement carries significant mortality risk not from the procedure itself but from poor patient selection. Many PEGs are placed inappropriately, with high mortality within weeks of placement due to the underlying condition rather than the procedure 1, 4.

Ethical Considerations

• PEG should not be used as a terminal measure in patients with unfavorable prognosis
• In patients with severe dementia, enteral feeding has not been associated with improved survival, reduced infection risk, or improved functional status 1, 2
• The concept of gastrostomy feeding must be acceptable to the patient and their family/carers 1

Procedural Setting

• PEG placement can be safely performed at the bedside in the ICU, avoiding patient transport and reducing costs 5, 6
• Antibiotic prophylaxis (e.g., single dose of 2.2g co-amoxiclav) should be administered 30 minutes before insertion to reduce peristomal wound infections 1

Post-Placement Care

• PEG tubes should not be removed for at least 14 days after insertion to ensure a fibrous tract is established 1
• Regular assessment of the PEG site for infection, leakage, and monitoring for signs of aspiration are necessary 2

Alternatives to Consider

When PEG is not feasible, consider:

• Radiological or ultrasound-guided placement for patients where endoscopy is contraindicated
• Surgical gastrostomy for patients with altered anatomy
• Percutaneous endoscopic jejunostomy (PEJ) or PEG with jejunal extension (PEG-J) for patients at high risk of aspiration 1

By following these guidelines for PEG placement in ICU patients, clinicians can improve nutritional outcomes while avoiding unnecessary procedures in patients unlikely to benefit.