Mediastinitis complicating a percutaneous endoscopic gastrostomy: a case report

BACKGROUND: Since its introduction in the early 1980s, percutaneous endoscopic gastrostomy has become the most popular method for performing a gastrostomy for long-term enteral feeding. It has been associated, however, with a lot of minor and major complications. CASE PRESENTATION: A case of mediastinitis with concominant sepsis caused by a masked esophageal perforation after percutaneous endoscopic gastrostomy in a multi-traumatized, brain-injured patient is presented. Ten – fourteen days after the procedure, the patient became febrile and gradually septic with tenderness of the sternum and upper abdomen. Computerized tomography of the thorax revealed mediastinitis. An urgent left thoracotomy and laparotomy were performed for drainage of the mediastinum, removal of the gastrostomy and insertion of a jejunostomy tube. The patient improved soon after the surgery. He was successfully weaned off the ventilator and was discharged from the Intensive Care Unit. CONCLUSION: Perforating mediastinitis is a rare but potentially lethal complication of percutaneous endoscopic gastrostomy. When diagnosed and properly treated it may have a favourable outcome

Can we use influencing factors to predict aspiration pneumonia in the United Kingdom?

Background The current study builds upon the work of others in looking at influencing factors of aspiration pneumonia in people with a swallowing problem. This study differs from previous researches on this topic, focusing on the United Kingdom (UK) population and involving more recently defined influencing factors of aspiration pneumonia. The study aims to explore the multifactorial nature of aspiration pneumonia in a UKdysphagic client group, as well as different disease specific variables. Methods Speech and Language Therapists collected data on 33 influencing factors over a period of 6 months during routine bedside swallowing assessment of 687 patients. All subjects were adults referred with suspected dysphagia and included acute inpatients, head and neck cancer patients and adults with learning disabilities. The study population included 400 males and 287 females and ages ranged from 17 to 102 giving a mean age of 72.9 years. The influence of the different variables included in the study was evaluated using multivariate logistic regression analysis. Results The results show that 13 statistically significant influencing factors were implicated in the development of aspiration pneumonia for this group. Out of these, nine correlate with the previous work undertaken in the United States. These were poor mobility, nil by mouth status, age, dependency for feeding, number of medications, Chronic Obstructive Pulmonary Disease (COPD), number of medical conditions, stroke and alcohol abuse. Four further influencing factors were shown to be significant in the UK population, these were dysphagia, only oral intake, bedfast, and male gender. Conclusions This study confirms that in the UK there are influencing factors in the development of an aspiration pneumonia. It would be prudent to remember that a direct link is yet to be established when applying this knowledge to inform clinical management

Basic geriatric assessment does not predict in-hospital mortality after PEG placement

<p>Abstract</p> <p>Background</p> <p>Percutaneous endoscopic gastrostomy (PEG) is an established procedure for long-term nutrition. However, studies have underlined the importance of proper patient selection as mortality has been shown to be relatively high in acute illness and certain patient groups, amongst others geriatric patients. Objective of the study was to gather information about geriatric patients receiving PEG and to identify risk factors associated with in-hospital mortality after PEG placement.</p> <p>Methods</p> <p>All patients from the GEMIDAS database undergoing percutaneous endoscopic gastrostomy in acute geriatric wards from 2006 to 2010 were included in a retrospective database analysis. Data on age, gender, main diagnosis leading to hospital admission, death in hospital, care level, and legal incapacitation were extracted from the main database of the Geriatric Minimum Data Set. Self-care capacity was assessed by the Barthel index, and cognitive status was rated with the Mini Mental State Examination or subjectively judged by the clinician. Descriptive statistics and group comparisons were chosen according to data distribution and scale of measurement, logistic regression analysis was performed to examine influence of various factors on hospital mortality.</p> <p>Results</p> <p>A total of 1232 patients (60.4% women) with a median age of 82 years (range 60 to 99 years) were included. The mean Barthel index at admission was 9.5 ± 14.0 points. Assessment of cognitive status was available in about half of the patients (n = 664), with 20% being mildly impaired and almost 70% being moderately to severely impaired. Stroke was the most common main diagnosis (55.2%). In-hospital mortality was 12.8%. In a logistic regression analysis, old age (odds ratio (OR) 1.030, 95% confidence interval (CI) 1.003-1.056), male sex (OR 1.741, 95% CI 1.216-2.493), and pneumonia (OR 2.641, 95% CI 1.457-4.792) or the diagnosis group ‘miscellaneous disease’ (OR 1.864, 95% CI 1.224-2.839) were identified as statistical risk factors for in–hospital death. Cognitive status did not have an influence on mortality (OR 0.447, CI 95% 0.248-1.650).</p> <p>Conclusion</p> <p>In a nationwide geriatric database, no component of the basic geriatric assessment emerged as a significant risk factor for mortality after PEG placement, emphasizing individual decision-making.</p