The practice of initiating early and adequate nutrition in critically ill patients is a cornerstone of ICU management. Adequate nutrition combats the dangerous catabolic state that accompanies critical illness. A few of the benefits of this practice are a decrease in disease severity with resultant lessened hospital and ICU lengths of stay, reduced infection rates, and a decrease in hospital mortality. Enteral nutrition (EN) is the route of nutritional support most associated with safe and effective provision of enhanced immunologic function and the ability to preserve the patient’s lean body mass while avoiding metabolic and infectious complications.
Dr. John P. Gaillard
Since its inception in 1980, percutaneous endoscopic gastrostomy (PEG) tubes have become the preferred method for delivering EN in ICUs across the United States. When comparing PEG and nasogastric tubes (NGTs), evidence shows reduced bleeding events, less tube dislodgement, and decreased tube obstructions with a faster rate of recovery of previous swallowing function that prevents delays in medical care and increased mortality rate. Although PEG tubes do not entirely prevent acid reflux or aspiration events, they are positively correlated to significantly reduced rates of both which result in a survival benefit seen in a 2012 study (Psychiatry Clin Neurosci. 2012 Aug;66[5]:418).
The majority of PEG tubes placed in the United States has unquestionably shifted to the ICU patient population since 2014 according to the largest health care database search on this topic published in 2019 (Ann Am Thorac Soc. 2019 Jun;16[6]:724). The safety and efficacy of this procedure has only improved, yet the delayed timing of placement remains problematic and often exceeds what is medically necessary or financially feasible.
To understand this issue, it is important to consider that despite intensivists being globally recognized as procedurally sound with enhanced ultrasound expertise, their endoscopic experience is usually limited to bronchoscopy without formal training in upper gastrointestinal endoscopy. This is the leading theory to explain why intensivists are performing their own percutaneous tracheostomies but not gastrostomies. Fortunately, the FDA-approved Point of Care Ultrasound Magnet Aligned Gastrostomy (PUMA-G) System has shown analogous safety and efficacy when compared with the traditional endoscopically placed PEG tube technique (J Intensive Care Med. 2022 May;37[5]:641).
A case series was published in 2021 that included three intensivists who underwent a 3-hour cadaver-based training course for the PUMA-G System with a mandatory minimum successful placement of three gastric tubes (J Clin Ultrasound. 2021 Jan;49[1]:28). Once they demonstrated competence in the technique, the procedure was performed on mechanically ventilated and sedated patients without any reported complications peri-procedurally or over the next 30 days. The evidence that intensivists can use their current skillset to rapidly become competent in this ultrasound-guided bedside procedure is without question.
PEG tube placement by intensivists is a procedure that will undoubtedly benefit patients in the ICU and assist in offloading the operation costs of a significant number of critical care units and their associated organizations. This is an area ripe for growth with further education and research.