The routine use of a flumazenil infusion following percutaneous endoscopic gastrostomy placement to reduce early post-procedure mortality.

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) insertion offers secure enteral nutrition, but there is a significant mortality associated with the procedure. We reviewed our sedation practice and the effect of yearly protocol changes to establish if the routine reversal of midazolam with a flumazenil infusion improved mortality. METHODS: Since 2003 yearly protocol changes have been introduced, including pre-assessment and sedation reversal. We retrospectively audited one-week and one-month mortality and aspiration rates. RESULTS: The average one-week mortality rate was 9.2%. The pooled death rates within the first week for patients prior to routine sedation reversal (n=522) was 10.7% and for patients who received routine reversal (n=144) was 5.4% (p=0.087). Within the first month, death rates were 26.3% prior to reversal and 21.4% in the sedation reversal group (p=0.30). CONCLUSIONS: The routine use of flumazenil infusion in appropriate patients is safe. Flumazenil infusion may have a role to play in selected patients at highest risk of aspiration. A prospective, randomised study is warranted.

Assessment by a multidisciplinary clinical nutrition team before percutaneous endoscopic gastrostomy placement reduces early postprocedure mortality.

BACKGROUND: The purpose of this study was to determine whether preassessment by a multidisciplinary nutrition team before percutaneous endoscopic gastrostomy (PEG) placement can reduce postprocedure mortality. This was a prospective single-center audit. METHODS: Patients who had been referred to the Gastroenterology Department for consideration of PEG placement between 1995 and 2004 were included. In the index year, 2003-2004, where a formal nutrition team assessment was commenced, 79 patients were enrolled into our study group on a consecutive basis. These patients were subdivided into 3 groups; group A, PEG placed (51 patients); group B, PEG not placed due to severe comorbidity (19 patients); and group C, PEG not placed as deemed unnecessary (9 patients). Comparison was made with previous years where no formal preassessment had occurred. At Staffordshire General Hospital, a comparison of mortality post-PEG placement was made between the index group and previous years. Secondary measures included complication rates and frequency of biochemical monitoring. RESULTS: One week post-PEG mortality fell from 10%-20% in previous years to 0% in the index year (p < .02). This improved survival extended to 3 months postprocedure (p < .016). Three patients (6%) had biochemical evidence of refeeding syndrome postplacement. Biochemical monitoring was inadequate, with only 27/51 (53%) patients being completely monitored. No complications pertaining to the endoscopy were reported. CONCLUSIONS: This study demonstrates that early post-PEG mortality can be reduced by preassessment of patients by a multidisciplinary nutrition team and is evidence supporting the recommendations of the National Confidential Enquiry into Patient Outcome and Death report.