Physician opinions on decision making for percutaneous endoscopic gastrostomy (PEG) feeding tube placement.

BACKGROUND: Percutaneous endoscopically placed gastrostomy (PEG) tubes are useful for long-term enteral nutrition; however, they are associated with lack of benefit for patients with advanced dementia, at end of life, and for some stroke patients with early regain of swallowing function. We surveyed physician opinions on decision making with the aim to identify factors that can lead to inappropriate PEG placement, as a first step of a quality improvement initiative to prevent inappropriate PEG placements at our facility. METHODS: A survey was distributed to 231 physicians, with questions about discussion topics, contraindications, responsibilities, and practices in decision making for PEG placement. Five-point Likert scales were used for most responses. RESULTS: Of 62 respondents, the majority were general surgeons (51.6%) and neurologists (30.6%). Levels of agreement were very low that PEG placement is contraindicated in advanced dementia (> 56% disagreed) and at end of life (55% disagreed) with scores of 2.4 and 2.5 (out of 5), respectively. Agreement level was low (score of 2.85) for delaying PEG for stroke patients by at least 2 weeks. Agreement was high for the discussion topics, for allowing 1-7 days for processing information, and for consulting the nutrition service. Over 98% of respondents chose primary team and 58% chose both primary and endoscopy teams as being responsible for discussions with patients and care partners in the decision-making process. CONCLUSIONS: Greater awareness is needed of the lack of benefit of PEG feeding in advanced dementia, at end of life, and for some stroke patients with early regain of swallow function. Disagreement exists as to whether the primary team and endoscopist share in the responsibility for discussions in decision making for PEG placement.

A Call to Action to Bring Safer Parenteral Micronutrient Products to the U.S. Market.

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) started an intensive review of commercially available parenteral vitamin and trace element (TE) products in 2009. The chief findings were that adult multi-TE products currently available in the United States (U.S.) provide potentially toxic amounts of manganese, copper, and chromium, and neonatal/pediatric multi-TE products provide potentially toxic amounts of manganese and chromium. The multivitamin products appeared safe and effective; however, a separate parenteral vitamin D product is needed for those patients on standard therapy who continue to be vitamin D depleted and are unresponsive to oral supplements. The review process also extended to parenteral choline and carnitine. Although choline and carnitine are not technically vitamins or trace elements, choline is an essential nutrient in all age groups, and carnitine is an essential nutrient in infants, according to the Food and Nutrition Board of the Institute of Medicine. A parenteral choline product needs to be developed and available. Efforts are currently under way to engage the U.S. Food and Drug Administration (FDA) and the parenteral nutrient industry so A.S.P.E.N.'s recommendations can become a commercial reality.

Trace elements in parenteral nutrition: a practical guide for dosage and monitoring for adult patients.

Parenteral nutrition (PN) is a life-sustaining therapy for hundreds of thousands of people who have severe impairment of gastrointestinal function. Trace elements are a small but very important part of PN that can be overlooked during busy practice. Serious complications can result from trace element deficiencies and toxicities, and this is especially problematic during times of product shortages. Practical information on parenteral trace element use can be gleaned from case reports, some retrospective studies, and very few randomized controlled trials. A general knowledge of trace element metabolism and excretion, deficiency and toxicity symptoms, products, optimal dosages, and strategies for supplementation, restriction, and monitoring will equip practitioners to provide optimal care for their patients who depend on PN.

A.S.P.E.N. position paper: recommendations for changes in commercially available parenteral multivitamin and multi-trace element products.

The parenteral multivitamin preparations that are commercially available in the United States (U.S.) meet the requirements for most patients who receive parenteral nutrition (PN). However, a separate parenteral vitamin D preparation (cholecalciferol or ergocalciferol) should be made available for treatment of patients with vitamin D deficiency unresponsive to oral vitamin D supplementation. Carnitine is commercially available and should be routinely added to neonatal PN formulations. Choline should also be routinely added to adult and pediatric PN formulations; however, a commercially available parenteral product needs to be developed. The parenteral multi-trace element (TE) preparations that are commercially available in the U.S. require significant modifications. Single-entity trace element products can be used to meet individual patient needs when the multiple-element products are inappropriate (see Summary/A.S.P.E.N. Recommendations section for details of these proposed modifications).