Scientists have observed that standard timing for percutaneous endoscopic gastrostomy (PEG) placement in patients with traumatic brain injury (TBI), between seven and 14 days after the injury, is best for minimizing related mortality. However, further study is needed.
PEG placement, a frequently performed procedure providing patients with nutrients via enteral feeding, comes with risks. Short-term mortality in the general population following placement has been shown to be as high as 25%.
In patients with TBI, early enteral feeding significantly improves morbidity and mortality. PEG is often necessary, because oral intake is not possible in many of these patients due to altered consciousness, swallowing dysfunction or facial trauma. Previous studies of PEG-related deaths focused on a general patient population, not specifically TBI, according to study author Greesha Pednekar, MD, in the Department of Anesthesiology at the University of Texas Health Sciences Center at Houston. “Further, there are no studies examining timing of PEG placement with mortality.”
Closer Look at Timing
The investigators, which included lead author Rabail Chaudhry, MD, at the same institution, analyzed data from the Nationwide Inpatient Sample database for 2011 to 2013. This database is the largest one of its kind in the United States, containing information from over 7 million patients. From these data, 96,625 patients were classified as having TBI, of which 3,343 received PEG. These patients then were categorized on when they received the PEG (Table).
The standard- and late-timing PEG groups had higher ratings on the Charlson Comorbidity Index. “Regardless of that,” Dr. Pednekar said, “we found out that the late and standard groups had lower mortality as opposed to the early group, even though the early group had less morbidities. That was an interesting observation.” Additionally, the standard PEG group exhibited a similar comorbidity load as the late group, but had better survival and significantly fewer complications.
“Our study,” said Dr. Chaudhry, summarizing their findings, “used a nationally representative sample to determine that TBI patients who undergo an early or late PEG placement have a higher rate of in-hospital mortality, when compared to patients with standard timing of PEG placement.” Dr. Pednekar concurred: “We feel the correct timing of PEG placement would be between 7 [and] 14 days—neither too early nor too late.”
However, additional study is needed to confirm these findings. “Due to the limitations of utilizing an administrative database,” Dr. Chaudhry said, “we are unable to account for the patient’s baseline medical status, as mortality can be associated with many other confounding factors.” Dr. Pednekar noted that mistakes in the data also could cloud the information. “If there has been an error at the entry level—while entering the data—it can then give us inaccurate results. We need prospective clinical trials to correlate timing between PEG placement and outcome.”
In the upcoming full manuscript of their study, the authors have included additional information. “We have stratified the sample by ICD-based injury severity score (ICISS) to determine the effects of PEG timing on mortality and other patient outcomes when stratified by high, medium and low mortality risk, based on other comorbidities and injuries,” Dr. Chaudhry said. “Based on this analysis, we suggest that an effective scoring system like ICISS may be needed to predict outcomes after PEG in various trauma populations.” She added, “Additional studies will also be needed to examine the optimal timing to initiate feeding after PEG placement in these patients.”
The researchers presented their findings at the 2016 PostGraduate Assembly in Anesthesiology, sponsored by the New York State Society of Anesthesiologists.