RCT: Early Feeding After PEG Placement

Surgery Clinical Trial

— PEG  

Official title:

A Randomized Controlled Trial to Reduce Periprocedural Fasting in Ventilated Trauma and Surgical Intensive Care Patients

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT04110613
• Other study ID #: 19-355
• Status: Recruiting
• Phase: N/A
• Start date: September 19, 2019
• Est. completion date: September 30, 2026

Study information

• Verified date: October 2021
• Source: Carilion Clinic
• Contact: Katie L. Bower, MD
• Phone: 540-981-7434
• Email: klbower[@]vt.edu
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Randomized controlled trial to establish evidence on which to base timing of enteral feeding after bedside PEG placement in ventilated Trauma and Surgical ICU patients.

Description:

Trauma and surgical intensive care unit(TSICU) patients supported with mechanical ventilation are at high risk for complications associated with malnutrition (Ambrosino and Clini 2004; Aubier et al. 1985; Hill et al. 1998). To mitigate this risk, therapeutic enteral nutrition(EN) is delivered via nasogastric(NGT), orogastric(OGT), or nasoenteric tube(NET) as soon as possible after admission to the intensive care unit(ICU) or upon restoration of gastrointestinal(GI) continuity. Despite these interventions, TSICU patients often suffer a calorie deficit associated with enteral nutrition interruption(ENI) for procedures or transitions in care(Peev et al. 2015; McClave et al. 2009). These periods of fasting predict quantified caloric deficit associated with complications of malnutrition(Peev et al. 2015; Segaran, Barker, and Hartle 2016). Reduction in ENI duration before and after ICU procedures has yielded decreased caloric deficits within mixed ICU populations(Segaran, Barker, and Hartle 2016).

When the need for EN is prolonged, percutaneous endoscopic gastrostomy tube(PEG) placement is a bedside procedure employed to promote progress toward rehabilitation and disposition out of the ICU. First described in 1980, the technique found its success in replacing the classic open gastrostomy performed through a laparotomy incision under general anesthesia(Gauderer, Ponsky, and Izant 1980). Approximately 100,000-125,000 PEGs are performed annually in the United States(Mendiratta et al. 2012). Despite 40 years of experience and its routine nature in modern critical care settings, there is little evidence on which to base timing of tube feeds after PEG placement in the mechanically ventilated Trauma and Surgical ICU(TSICU) population.

Pre- and post-PEG tube placement fasting practices are highly variable among surgical intensivists. There is no standard of care, despite truncated periods of periprocedural fasting described as safe in previously published retrospective and prospective observational studies. There is no evidence to support prolonged fasting after PEG placement in TSICU patients, thus an opportunity to improve patient outcomes by providing evidence that will encourage earlier feeding and a reduction in calorie deficits.The aim of the study is to encourage a standard of care among surgical intensivists that will help to mitigate the risk of malnutrition in this highly susceptible patient population.

Trauma and Surgical ICU patients undergoing bedside PEG tube placement will be randomized to one of two groups: FAST and noFAST. The FAST group will have post-PEG tube feeds initiated 4 hours after the procedure. The noFAST group will have post-PEG tube feeds initiated <1 hour after the procedure. Feeds for both are to be initiated at the rate and with the formula the patient was tolerating prior to the procedure.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 1200
• Est. completion date: September 30, 2026
• Est. primary completion date: September 30, 2026
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 100 Years

Eligibility

Inclusion Criteria:

• Adult subjects over 18 years of age

• Negative pregnancy test for women participants of child-bearing age

• Mechanically ventilated surgical and trauma patients with clinical indication for PEG tube placement

• Tolerating tube feeds at goal prior to procedure

Exclusion Criteria:

• Patients with aberant gastrointestinal anatomy

• Patients with gastrointestinal motility disorders

• Patients with feeding intolerance prior to PEG tube procedure

• Pregnant women, children, or other vulnerable populations

• Clinical contraindications for PEG tube placement

• PEG performed in setting other than ICU at bedside

Related Conditions & MeSH terms

• Critical Illness
• Gastrostomy
• Malnutrition
• Mechanical Ventilation
• Procedural Sequelae
• Surgery
• Trauma

Intervention

Dietary Supplement:
• noFast: Start tube feeds within 1 hour of procedure
Earliest possible initiation of tube feeding after bedside PEG tube procedure.

Locations

Country	Name	City	State
United States	Carilion Roanoke Memorial Hospital	Roanoke	Virginia

Sponsors (2)

Lead Sponsor	Collaborator
Carilion Clinic	Virginia Polytechnic Institute and State University

Country where clinical trial is conducted

United States, 

References & Publications (20)

Ali T, Le V, Sharma T, Vega KJ, Srinivasan N, Tierney WM, Rizvi S. Post-PEG feeding time: a web based national survey amongst gastroenterologists. Dig Liver Dis. 2011 Oct;43(10):768-71. doi: 10.1016/j.dld.2011.04.003. Epub 2011 May 31. — View Citation

Ambrosino N, Clini E. Long-term mechanical ventilation and nutrition. Respir Med. 2004 May;98(5):413-20. Review. — View Citation

ASGE Training Committee 2013-2014, Enestvedt BK, Jorgensen J, Sedlack RE, Coyle WJ, Obstein KL, Al-Haddad MA, Christie JA, Davila RE, Mullady DK, Kubiliun N, Kwon RS, Law R, Qureshi WA. Endoscopic approaches to enteral feeding and nutrition core curriculum. Gastrointest Endosc. 2014 Jul;80(1):34-41. doi: 10.1016/j.gie.2014.02.011. Epub 2014 Apr 26. — View Citation

Aubier M, Murciano D, Lecocguic Y, Viires N, Jacquens Y, Squara P, Pariente R. Effect of hypophosphatemia on diaphragmatic contractility in patients with acute respiratory failure. N Engl J Med. 1985 Aug 15;313(7):420-4. — View Citation

Bechtold ML, Matteson ML, Choudhary A, Puli SR, Jiang PP, Roy PK. Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis. Am J Gastroenterol. 2008 Nov;103(11):2919-24. doi: 10.1111/j.1572-0241.2008.02108.x. Epub 2008 Aug 21. — View Citation

Blaser AR, Starkopf J, Kirsimägi Ü, Deane AM. Definition, prevalence, and outcome of feeding intolerance in intensive care: a systematic review and meta-analysis. Acta Anaesthesiol Scand. 2014 Sep;58(8):914-22. doi: 10.1111/aas.12302. Epub 2014 Mar 11. Review. — View Citation

Boullata JI, Carrera AL, Harvey L, Escuro AA, Hudson L, Mays A, McGinnis C, Wessel JJ, Bajpai S, Beebe ML, Kinn TJ, Klang MG, Lord L, Martin K, Pompeii-Wolfe C, Sullivan J, Wood A, Malone A, Guenter P; ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and Enteral Nutrition. ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]. JPEN J Parenter Enteral Nutr. 2017 Jan;41(1):15-103. doi: 10.1177/0148607116673053. Epub 2016 Nov 5. — View Citation

Cobell WJ, Hinds AM, Nayani R, Akbar S, Lim RG, Theivanayagam S, Matteson-Kome ML, Choudhary A, Puli SR, Bechtold ML. Feeding after percutaneous endoscopic gastrostomy: experience of early versus delayed feeding. South Med J. 2014 May;107(5):308-11. doi: 10.1097/SMJ.0000000000000104. — View Citation

Dubagunta S, Still CD, Kumar A, Makhdoom Z, Inverso NA, Bross RJ, Komar MJ, Mulhisen L, Rogers JZ, Whitmire S, Whilden B. Early initiation of enteral feeding after percutaneous endoscopic gastrostomy tube placement. Nutr Clin Pract. 2002 Apr;17(2):123-5. — View Citation

Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980 Dec;15(6):872-5. — View Citation

Gkolfakis P, Arvanitakis M, Despott EJ, Ballarin A, Beyna T, Boeykens K, Elbe P, Gisbertz I, Hoyois A, Mosteanu O, Sanders DS, Schmidt PT, Schneider SM, van Hooft JE. Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2021 Feb;53(2):178-195. doi: 10.1055/a-1331-8080. Epub 2020 Dec 21. — View Citation

Hill AT, Edenborough FP, Cayton RM, Stableforth DE. Long-term nasal intermittent positive pressure ventilation in patients with cystic fibrosis and hypercapnic respiratory failure (1991-1996). Respir Med. 1998 Mar;92(3):523-6. — View Citation

McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009 May-Jun;33(3):277-316. doi: 10.1177/0148607109335234. — View Citation

Peev MP, Yeh DD, Quraishi SA, Osler P, Chang Y, Gillis E, Albano CE, Darak S, Velmahos GC. Causes and consequences of interrupted enteral nutrition: a prospective observational study in critically ill surgical patients. JPEN J Parenter Enteral Nutr. 2015 Jan;39(1):21-7. doi: 10.1177/0148607114526887. Epub 2014 Apr 7. — View Citation

Schneider AS, Schettler A, Markowski A, Luettig B, Kaufmann B, Klamt S, Lenzen H, Momma M, Seipt C, Lankisch T, Negm AA; *Conference presentation: 36th ESPEN Congress in Leipzig, Germany on August 31st - September 3rd, 2013. Complication and mortality rate after percutaneous endoscopic gastrostomy are low and indication-dependent. Scand J Gastroenterol. 2014 Jul;49(7):891-8. doi: 10.3109/00365521.2014.916343. Epub 2014 Jun 4. — View Citation

Segaran E, Barker I, Hartle A. Optimising enteral nutrition in critically ill patients by reducing fasting times. J Intensive Care Soc. 2016 Feb;17(1):38-43. doi: 10.1177/1751143715599410. Epub 2015 Feb 1. — View Citation

Sivasothy P, Smith IE, Shneerson JM. Mask intermittent positive pressure ventilation in chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease. Eur Respir J. 1998 Jan;11(1):34-40. — View Citation

Stein J, Schulte-Bockholt A, Sabin M, Keymling M. A randomized prospective trial of immediate vs. next-day feeding after percutaneous endoscopic gastrostomy in intensive care patients. Intensive Care Med. 2002 Nov;28(11):1656-60. Epub 2002 Sep 6. — View Citation

Szary NM, Arif M, Matteson ML, Choudhary A, Puli SR, Bechtold ML. Enteral feeding within three hours after percutaneous endoscopic gastrostomy placement: a meta-analysis. J Clin Gastroenterol. 2011 Apr;45(4):e34-8. doi: 10.1097/MCG.0b013e3181eeb732. — View Citation

Vyawahare MA, Shirodkar M, Gharat A, Patil P, Mehta S, Mohandas KM. A comparative observational study of early versus delayed feeding after percutaneous endoscopic gastrostomy. Indian J Gastroenterol. 2013 Nov;32(6):366-8. doi: 10.1007/s12664-013-0348-8. Epub 2013 Aug 17. — View Citation

* Note: There are 20 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Hours fasted	Number of hours patients are not receiving prescribed caloric intake	24 hours before to 72 hours after the procedure
Secondary	Complications	Complications associated with timing to start tube feeds after bedside PEG placement	0-72 hours after the procedure
Secondary	Calorie deficit	Cumulative calorie deficit acquired as a result of peri-procedural fasting	24 hours to 72 hours after procedure