A survey of post gastrostomy insertion

A survey of post gastrostomy insertion

nutritional care

Carole-Anne Fleming (Clinical Team Lead for Oncology) and Jenny Gregg (Specialist Dietitian

Surgery/ICU)

Content • Introduction to survey and outline of process

‣ As part of Complex Nutritional Support Dietetic Effective Practice Group who feed into GG&C Food Fluid and Nutritional Care Clinical Nutrition Group

• Results

• Summary

• Conclusion and moving forwards

Presenter

Presentation Notes

Why we conducted a survey Outline of survey process Results Summary Conclusions and moving forward

NICE (2006,2011) Percutaneous

endoscopic gastrostomy (PEG)

tubes placed without apparent complications can be used for enteral

tube feeding 4 hours post insertion.

NICE Guidance

However, no guidance on: • Nutrition vs fluids • Rate of administration • Whether guidance applicable to radiologically inserted gastrostomy (RIG)

Why?

To standardise care and ensure continuity and equity of practice across Greater Glasgow and Clyde.

Why conduct a survey?

Presenter

Presentation Notes

GG&C complex nutritional support dietetic effective practice group identified the need for a standard protocol of nutritional care post primary gastrostomy insertion to ensure continuity of and equity of practice across our large NHS Trust.

• Aim: Investigate current practice and clinical rationale for gastrostomy practice within GG&C for administering nutrition and fluid in adults post primary PEG and RIG insertion.

• Exclusions: Surgical gastrostomy and routine existing gastrostomy replacements.

• Method:

• Webropol survey via email

• All adult acute Dietitians and members of multi disciplinary nutrition teams & cascaded

• It is estimated it was sent to 100 people.

Survey

Presenter

Presentation Notes

Method: Webropol survey conducted via email sent to all adult acute Dietitians and members of multi disciplinary nutrition teams, who were asked to cascade to colleagues. It is estimated it was sent to 100 people.

Results:

Thirty eight responses received: Dietitians n=24 Nutrition Nurses n=5 Gastroenterologists n=5 Surgeons n=2 Interventional Radiologists n=1 Pharmacist n=1

How long after gastrostomy insertion should a tube be used?

How long (hours)

Percentage response Percentage response

How long (hours)

Presenter

Presentation Notes

Participants were asked to consider how long after gastrostomy insertion should a tube be used. Results above show differences in answers between PEG and RIG.82 % waited 4 hours post insertion before using for the first time. The other 15% waited a range of hours between 0-12hours and a further 3% did not state a time and selected other.

On first use of gastrostomy what should be administered?

PEG

Product Product


Presenter

Presentation Notes

in 87% (PEG) and 89% (RIG) sterile water was used initially, the remainder used enteral feed. Those who initially administered sterile water recommended subsequently giving enteral feed after a range of hours 2 (11% PEG and RIG), 4 (34% PEG and 32% RIG), 6 (11% PEG 8% RIG), 10 (26% PEG and 29% RIG) and other (16% PEG and 18& RIG) stating it depended upon tolerance of sterile water.

PEG

What rate should administration be commenced?

RIG

Rate (ml/hr) Rate (ml/hr)


Presenter

Presentation Notes

Those who selected ‘other’ commenced that consideration of nutritional risk and previous enteral feeding tolerance would influence their choice of rate. The clinical rationale given for regimens included NICE CG32, NCEPOD or local guidelines, MDT decision, advice of more experienced colleagues, individual clinical assessment and anecdotal evidence on personal experience with issues in relation to tolerance and pain after procedure being related to feed rather than water and caution with new site and leakage being more easily managed if sterile water used first.

If sterile water used initially how long after would feed be administered?

RIG PEG

How long (hours)

How long (hours)


Summary • 4 hours is predominantly used post insertion of both PEG and RIG as per

NICE

• Majority administer sterile water and then introduce enteral feed at a range of 2-12 or more hours, most frequently used rate is 50ml/hr.

• No evidence base for choice of feed versus sterile water. Anecdotal experience for cautious use of sterile water and low rate to aid hydration and establish tolerance with minimum patient discomfort.

• Patient centred, considers hydration status, effective use of resources, cost and potential wastage of opened feed water packs.

• Cautious approach may only be applicable and necessary where insertion has been complicated or patient has not previously been established on enteral feeding.

Presenter

Presentation Notes

In GG&C the NICE guidelines of enteral feeding after 4 hours is predominantly used post insertion of both PEG and RIG. The Majority initially administer sterile water and then introduce enteral feed at a range of 2-12 or more hours, most frequently used rate is 50mlhr. There is no evidence base for choice of feed versus sterile water but anecdotal experience suggests that cautious use of sterile water and low rate is prudent to aid hydration and establish tolerance with minimum patient discomfort.

Conclusion • Based on this survey:

✓Use gastrostomy 4 hours post insertion

✓Sterile water 50ml/hr until tolerance clinically agreed.

✓Those established in enteral feeding pre insertion and individual clinical assessment indicates the previous enteral feeding regimen may be resumed after 4 hours.

• A proposal to develop a protocol to standardise this best practice has been submitted to the board Clinical Nutrition Group for ratification.

Presenter

Presentation Notes

Based on this survey, best practice in GG&C is that both PEG and RIG tubes placed without apparent complication can be used 4 hours post insertion, sterile water should be administered at 50ml/hr until tolerance clinically agreed.

References

• Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical guideline [CG32] Published date: February 2006 Last updated: August 2017 http://www.nice.org.uk/guidance/CG32 (accessed 21.8.17)

http://www.nice.org.uk/guidance/CG32

Questions?

Documents

A survey of post gastrostomy insertion