Covering the Percutaneous Endoscopic Gastrostomy (PEG) Tube Prevents Peristomal Infection

Abstract

The ideal sedation for pediatric pts having endoscopy remains debatable. Few studies compare complications of deep sedation (DS), moderate sedation(MS)and general anesthesia (GA)in this population. Until more data is available regarding risks vs benefits for the various sedation methods, endoscopists will use the sedation they are most comfortable with. Our aim was to compare sedation and procedure complications associated with the 3 sedation types. Methods: This is a multicenter retrospective review of the medical records of pediatric pts referred for endoscopy between 1/01 and 10/08. Data was collected at SUNY Downstate Medical Center and Winthrop University Hospital(WUH)for pediatric pts receiving either DS(Propofol), MS(Versed/Fentanyl)or GA. All pts received supplemental oxygen and had hemodynamic, respiratory and cardiac monitoring. Pre-procedure, anesthesia, endoscopy, and recovery room records, and subsequent pt follow-up were analyzed. Sedation complications were recorded and defined as systolic(SBP)and/or diastolic blood pressure(DBP)changes of Oor! 20 mmHg, apnea O20 seconds, and desaturation !95%. Endoscopic procedure complications were also collected. Procedural and sedation complications were then compared to each type of sedation. Statistical analysis was performed using Chi square test. Results: A total of 875 procedures were enrolled.204 procedures were performed at SUNY;137 upper endoscopies(EGD): 19 with DS,35 MS, and 83 GA; and 67 colonoscopies: 14 DS,22 MS and 31 GA. There was one adverse event observed: a decrease in SBPO20 mmHg in the group of pts who received DS(3%). There were 10 adverse events in the 57 pts who received MS: 9 decreases in both SBP and DBP Othan 20 mmHg and one increase in both SBP and DBP O20mmHg. There were 6 adverse events: 2 decreases in both SBP and DBP,2 decreases in SBP,1 decrease in DBP, and 1 increase in DBP, all O20 mmHg, in the 114 pts who received GA. There was one perforation noted during a colonoscopy with GA. There were 671 procedures performed at WUH: 455 EGD's,212 colonoscopies,2 EUS's, and 2 ERCP's. All pts received DS at WUH. There were no sedation complications. There was one perforation during a colonoscopy with DS. There were significantly less sedation complications when using DS as compared to moderate sedation(p!0.0001)and GA (p!0.0001). Conclusions: DS had significantly less sedation complications(0.15%)compared to MS(17.5%)and GA(5.3%). There were no procedure related complications with MS. There was one perforation with GA and one with DS. It appears that pts are at increased risk of perforation with DS/GA methods as opposed to MS. Perhaps this is due to pt's being unable to communicate or express pain during the procedure.

Prospective Assessment of Peristomal Infections Using Objective Criteria

“…We also took the temperature and pain score (0–10) on the day of visit and recorded most recent WBC if present within the last week. These data were confirmed by either HEN physician's assistant or physician, and a patient was deemed to have peristomal infection when the combined score was ≥8, as described in the literature . Our typical treatment course consisted of oral cephalexin 500 mg 4 times a day for 10 days.…”

“…Previous articles have used such objective criteria to diagnose infection in the setting of testing a hypothesis, such as work by Jain et al that revealed a reduction in infection rate from 28.6% to 7.4% with the use of cephazolin prophylaxis . Suzuki et al used very similar criteria in a study that demonstrated that covering the gastrostomy tube in the oropharynx led to a significant decrease in infection (odds ratio: 0.05, 95% CI: 0.02–0.13). Other groups have used modified versions of similar criteria.…”

“…All patients >18 years of age who contacted our HEN program with symptoms indicating possibility of peristomal infection and were able to present for an in‐person visit were enrolled in this study. A peristomal infection score described previously in the literature was used, with 3 objective criteria including erythema, induration, and exudates being measured and scored by HEN RNs (Table ) . Additional data including baseline demographics, type and size of enteral tube, indication for tube placement, specialty placing tube, and other comorbidities were recorded.…”

“…The authors state that this article is the first time this score had been utilized but did not describe how the score of 8 was determined and how the criteria were validated. Other groups have also used similar criteria again without describing in detail how the scoring system was validated . Despite the availability of objective criteria, their use in clinical practice remains sparse, perhaps because of lack of validity.…”

Prophylactic Antibiotic Guidelines in Modern Interventional Radiology Practice

“…85 There is evidence that PR-ABX reduces infectious complication after endoscopic placement of G and GJ tubes, with fewer infections seen in those who received PR-ABX. [92][93][94] However, with the very low risk of readily treatable superficial infection, routine use of PR-ABX is difficult to justify. PR-ABX is recommended for patients at high risk for infection, such as malnourished pediatric patients and the immunocompromised.…”