Hirose, Hitoshi

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Percutaneous endoscopic gastrostomy tubeplacement in patients with extracorporealmembrane oxygenationRyan Cobb, Jay S. Jenoff, Nicholas C. Cavarocchi andHitoshi Hirose*Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USAReceived: 14 November 2012; Revised: 22 December 2012; Accepted: 23 December 2012; Published: 21 January 2013AbstractIntroduction: Inadequate nutritional support after mechanical circulatory device placement is known toincrease postoperative infections and to decrease survival. The extracorporeal membrane oxygenation(ECMO) patients with complicated postoperative recovery may require long-term nutritional support usingpercutaneous endoscopic gastrostomy (PEG) tube feeding. In this study, the feasibility of PEG procedure onpatients on ECMO was evaluated.Methods: Between November 2010 and July 2012, 43 patients were placed on venoarterial or venovenousECMO for cardiogenic shock or severe respiratory failure. All of the long-term ECMO patients weresupported with tube feeding. Four patients underwent PEG tube placement for long-term nutritional supportwhile they were on ECMO. Procedure management consisted of cessation of anticoagulation 12 hours beforeand 12 hours after procedure. Anticoagulation was continued while on ECMO. Data were retrospectivelyanalyzed to investigate complications related to the PEG placement.Results: The studied patients consisted of two males and two females with a mean age of 55.597.9 years. Theinterval of ECMO to PEG placement was a mean 16.894.2 days. The mean total length of ECMO supportfor these patients was 22.795.6 days. PEG was successfully performed in the operating room or bedside inall patients. There were no ECMO-device-related issues during or after the PEG procedure. There wereno postoperative short-term or long-term PEG-related complications, such as, acute gastric bleeding ordislodgement of the PEG tube.Conclusions: PEG placement for ECMO patients can be done without increasing the risk of device orintra-abdominal organ injury with carefully coordinated efforts from both the intensive care team andsurgical services.Keywords: ECMO; nutrition; PEG; anticoagulationIntroductionInadequate nutritional support after mechanical cir-culatory device placement is known to increasepostoperative infections and mortality. Patients inthis intensive care setting are hypercatabolic, whichmakes an emphasis on nutrition crucial. An enteral routeis preferred over parenteral to maintain gastrointestinalintegrity and to prevent morbidity directly related to par-enteral support, such as parenteral nutrition-associatedliver disease, and infection (1, 2). Most hospital protocolscall for the placement of nasogastric tubes (NGTs) toprovide enteral access for nutritional support in patientswith these devices. NGTs have been linked to interrup-tion of the lower esophageal sphincter, which can leadto aspiration pneumonia, gastrointestinal bleeding, andesophagitis (3). In patients requiring ventilator assistance,higher rates of ventilator-associated pneumonia werefound among patients with NGTs vs. percutaneousendoscopic gastrostomy (PEG) tubes (4). In addition,repeated removal and re-insertion of the NGT may inflictnasopharyngeal trauma, which may occasionally requirenasopharyngeal packing by otolaryngology specialtyservice. This leads to interruption of crucial nutritionalsupport and leads to an increased risk of develop-ing infection, which may further contribute other organfailure. Compared to NGTs, PEG tube placementCLINICAL RESEARCH ARTICLEMechanical Circulatory Support 2013. # 2013 Ryan Cobb et al. This is an Open Access article distributed under the terms of the Creative CommonsAttribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, andreproduction in any medium, provided the original work is properly cited.1Citation: Mechanical Circulatory Support 2013, 4: 20093 - http://dx.doi.org/10.3402/mcs.v4i0.20093(page number not for citation purpose)provides consistent nutritional support with less riskof the above-mentioned complications and low risk ofprocedure-related complications (5, 6).In the past, there have been concerns about intra-operative and postoperative gastrointestinal bleeding withPEG placement in patients on constant anticoagulationfor life support devices, such as extracorporeal membraneoxygenation (ECMO). Titrating an ECMO patient offof anticoagulation for PEG placement raised concernsfor clotting and dysfunction of the ECMO device. TheECMO patients with complicated postoperative recoverymay require long-term nutritional support using tubefeedings. Placement of a PEG in the ECMO patientrequires knowledge of the anticoagulation management.In our institution, ECMO anticoagulation protocol wasestablished (7). Using this protocol, PEG placement wasperformed in selected ECMO patients who requiredlong-term nutritional support. Current study was per-formed to assess the feasibility of PEG procedure on thepatient on ECMO.MethodsBetween November 2010 and July 2012, 43 patientsunderwent peripherally cannulated venoarterial or veno-venous ECMO placement for cardiogenic shock or severerespiratory failure in our institution with the end goal ofbridge to recovery, bridge to ventricular assist device, orbridge to decision. Among them, 18 patients required10 days or more of ECMO support. All of the long-termECMO patients were supported with tube feeding. Fourpatients underwent PEG tube placement for long-termnutritional support while they were on ECMO. Tubefeeding was held 68 hours prior to procedure. Otherprocedure management consisted of cessation of anti-coagulation 12 hours before and 12 hours after theprocedure. Procedure was performed either in the in-tensive care unit or in the operating room, depending onthe previous history of abdominal surgery. An intensivist,who was primarily taking care of the patient, was presentduring the procedure. If the patients were considered tobe ventricular assist device candidates, the left midabdomen would be the preferred area for PEG becausethe upper left quadrant would be occupied by the deviceand the drive line. The location of the PEG stoma wasdiscussed with the cardiac surgeon, the abdominal sur-geon, and the intensivist (Fig. 1). During the PEG pro-cedure, one dose of short-acting muscular relaxant andintravenous sedatives was administered. The procedurewas done in standard fashion. Anticoagulation wasrestarted 12 hours after the procedure and continuedwhile on ECMO, aiming partial thrombin time (PTT) of4555 sec. Tube feed via PEG tube was restarted 6 hoursafter procedure. Data were retrospectively analyzed toinvestigate complications related to the PEG placement.This study was approved by the internal review board.ResultsThe studied patients consisted of two males and twofemales with mean age of 55.597.9 years (Table 1). Themean interval of ECMO to PEG placement was 16.894.2 days. The mean total length of ECMO support forthese patients was 22.795.6 days. All of the patients wereon tube feedings of some sort prior to PEG. One patienthad nasopharyngeal trauma from the transesophagealechocardiography (TEE) requiring multiple transfusionsdespite of lowering the anticoagulation goal. PEG wasFig. 1. Illustration shows typical percutaneous gastrostomy (PEG) procedure on the patient on venoarterial: extracorporealmembrane oxygenation (ECMO) on left (A), and PEG procedure on the patient with HeartMate II left ventricular assist device(LVAD) on right (B). Prior PEG procedure, an intensivists draw line for the anticipate LVAD placement, which should notoverlap to the PEG stoma.Ryan Cobb et al.2(page number not for citation purpose)Citation: Mechanical Circulatory Support 2013, 4: 20093 - http://dx.doi.org/10.3402/mcs.v4i0.20093successfully performed in the operating room or bedsidein all patients. There were no ECMO device issues relatedto the PEG procedure. No additional membranousoxygenator exchanges were required after temporallystopping anticoagulation for the PEG procedure. Therewere no postoperative short-term or long-term PEG-related complications, such as, acute gastric bleeding ordislodgement of the PEG tube. The prealbumin levelimproved appropriately after PEG.DiscussionOnce bleeding complication occurs in ECMO patients,medical management becomes a difficult, although notimpossible, task. Anticoagulation can be held shortperiod of time to control hemostasis; however, it is notpossible to completely stop anticoagulation while onECMO due to the risk of device clotting. This directlycauses hemodynamic and respiratory compromise.All four patients were on ECMO for more than5 days and required a steady, reliable source of nutritionalsupport. Parenteral nutrition remains an option but notpreferred over enteral nutrition. With parenteral nutri-tion comes an increased risk of access site infection andsubsequent bacteremia and sepsis. In addition, somepatients on long-term parenteral nutrition may developparenteral nutrition-associated liver disease (2). Earlyinitiation of enteral support remains the goal. There hasbeen some concern over early initiation of enteralnutritional support in patients on ECMO. Three studiesexplored initiation of enteral support within the first2448 hours. Two studies showed tolerance of earlyenteral feeding while on ECMO with no adverse effectsdirectly attributable to enteral feeding (8, 9).In most settings, nutrition by NGT is standard, as longas NGT access is established and maintained. One of themany problems that arise in ECMO patients is the needfor repeated TEE to assess cardiac function. DuringTEE, the NGT is removed to optimize imaging and isreinserted after. Nasopharyngeal trauma could occurafter multiple blind instrumentations. Each of the fourpatients in this study had some degree of the nasopha-ryngeal trauma from the multiple instrumentations;the team solved this problem with the use of PEG.Even though PEG requires surgical intervention, it isa relatively low-risk procedure, as long as surgical sitebleeding is kept under control (1). From our experience,the most frequent sites of bleeding for ECMO patientsare surgical sites, including cannulation sites and recentsurgical sites (7). Anticoagulation regimens were de-signed, as described above, to allow for PEG placementwithout excessive risk of bleeding and/or clotting in theECMO device. Zero out of four patients suffered fromPEG-procedure-related complications.All PEG procedures for the ECMO patients wereperformed at the bedside with ECMO intensivists in theTable1.PatientsdemographicsPatientAgeSexTypeofECMOIndicationTotallengthonECMO(days)ECMO-PEG(days)PrealbuminbeforePEG(mg/dl)PrealbuminafterPEG(mg/dl)PTTattimeofPEGOutcome153MVVtoVAARDS2714142929UnabletorecoverfromARDS,carewithdrawn247FVVARDS2814161647aECMOwasweanedinsuccess366FVACardiogenicshock181691133ECMOwasweanedinsuccess456MVACardiogenicshock402351428Unabletorecoverfrompneumonia,ARDS,carewithdrawnARDS:adultrespiratorydistresssyndrome;ECMO:extracorporealmembraneoxygenation;PEG:percutaneousgastrostomy;PTT:partialthrombintime;VA:venoarterialECMO;VV:venovenousECMO.aThispatientwasonargatrobanforheparininducedthrombocytopenia.PEG for ECMOCitation: Mechanical Circulatory Support 2013, 4: 20093 - http://dx.doi.org/10.3402/mcs.v4i0.20093 3(page number not for citation purpose)room. Strict anticoagulation management allowed PEGprocedure to perform without complications and allowedECMO to continue to run safely.ConclusionsPEG placement for ECMO patients can be done withoutincreasing the risk of device or intra-abdominal organinjury with carefully coordinated efforts from both theintensive care team and surgical services.Conflict of interest and fundingThere is no conflict of interest in the present study for anyof the authors.References1. McClave SA, Martindale RG, Vanek WV, McCarthy M, RobertsP, Taylor B, et al. Guidelines for the provision and assessment ofnutrition support therapy in the adult critically ill patient: Societyof Critical Care Medicine (SCCM) and American Society forParenteral and Enteral Nutrition (ASPEN). JPEN J ParenterEnteral Nutr 2009; 33: 277316.2. Xu ZW, Li YS. Pathogenesis and treatment of parenteralnutrition-associated liver disease. Hepatobiliary Pancreat DisInt 2012; 11(6): 58693.3. Newton M, Burnham WR, Kamm MA. Morbidity, mortality,and risk factors for esophagitis in hospital inpatients. J ClinGastroenterol 2000; 30: 2649.4. Kostadima E, Kaditis AG, Alexopoulos EI, Zakynthinos E,Sfyras D. Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients. EurRespir J 2005; 26: 10611.5. Park RH, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJ,et al. Randomized comparison of percutaneous endoscopicgastrostomy and nasogastric tube feeding in patients withpersisting neurological dysphagia. BMJ 1992; 304(6839): 1406.6. Payne KM, King TM, Eisenach JB. The technique of per-cutaneous endoscopic gastrostomy. A safe and cost-effective alternative to operative gastrostomy. J Crit Illn 1991;6: 6119.7. Lamb K, Cowan S, Evans N, Pitcher H, Moritz T, Lazar M, et al.Successful management of bleeding complications in patientssupported with extracorporeal membrane oxygenation with pri-mary respiratory failure. Perfusion. 2012. [Epub ahead ofprint].8. Scott LK, Boudreaux K, Thaljeh F, Grier LR, Conrad SA. Earlyenteral feeding in adults receiving venovenous extracorporealmembrane oxygenation. JPEN J Parenter Enteral Nutr 2004; 28:295300.9. Lukas G, Davies AR, Hilton AK, Pellegrino VA, ScheinkestelCD, Ridley E. Nutritional support in adult patients receivingextracorporeal membrane oxygenation. Crit Care Resusc 2010;12: 2304.*Hitoshi HiroseDepartment of SurgeryDivision of Cardiothoracic SurgeryThomas Jefferson University1025 Walnut Street, Room 605Philadelphia, PA 19107, USATel: 215-955-5654Fax: 215-955-6010Email: Hitoshi.Hirose@jefferson.eduRyan Cobb et al.4(page number not for citation purpose)Citation: Mechanical Circulatory Support 2013, 4: 20093 - http://dx.doi.org/10.3402/mcs.v4i0.20093

Percutaneous endoscopic gastrostomy tube placement in patients with extracorporeal membrane oxygenation

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Percutaneous endoscopic gastrostomy tube placement in patients with extracorporeal membrane oxygenation

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