Reduced Fasting Protocol for Endoscopic Percutaneous Gastrostomy in Intubated Patients

Background: Previous studies have shown that ICU patients receive only a fraction of their calculated nutritional goals, and that cumulative caloric deficit in the ICU has been correlated with poor outcome. One reason for this underfeeding is the frequent interruption of enteral nutrition. Many ICU patients receive enteral feeding formula via a nasogastric (NG) tube. Feeding is typically held for several hours prior to procedures due to the theoretical risk of aspiration. An alternative is to continue feeding up until the procedure begins, then stop the feeding and place the NG to suction. This evacuates the contents of the stomach and minimizes the risk of aspiration, while reducing the interruption of feeding that can result in malnutrition. Methods: This study is a review of prospectively gathered data including 55 sequential patients who underwent bedside percutaneous endoscopic gastrostomy (PEG) placement in a mixed ICU under a reduced fasting protocol. This was compared with a historical cohort of 33 critically ill trauma patients who fasted for at least 8 hours prior to the procedure. Under the reduced fasting protocol, enteral feeding via NG was continued up until the time of the procedure. The NG was then placed to suction, and sedation was given. The NG was left in place until the esophagus was cannulated, then it was removed. The PEG was placed in standard fashion, and feeding was resumed via the PEG immediately following the procedure. Results: We have documented no peri-procedural vomiting or aspiration. New diagnosis of pneumonia within 3 days occurred in 2/55 of the feeding group and 4/33 of the fasting group. Overall mortality was higher for the feeding group: 13/55 vs. 1/33, however when adjusted for baseline characteristics, the difference was no longer significant. Under our protocol, the interruption of feeding averaged approximately one hour, rather than the 8 or 9 hour interruption required by standard protocols. This saved an average of approximately 700 kilocalories per patient. Conclusion: We believe that continuing feeding via NG up until the time of bedside PEG is safe and advantageous for intubated patients in the ICU. Since there was minimal gastric content, it may also be safe for other procedures.