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A RISK-STRATIFYING TOOL TO ENABLE LATE-STAGE PEG INSERTION IN MND
  1. Alexander Thompson1,
  2. Victoria Blackwell2,
  3. Rachael Marsden1,
  4. Clare Lawson2,
  5. Jeanette Brooks2,
  6. Annabel H Nickol2,
  7. Kevin Talbot1,
  8. James E East2,
  9. Philip Allan2,
  10. Martin R Turner2
  1. 1Nuffield Department of Clinical Neurosciences, University of Oxford
  2. 2Oxford University Hospitals NHS Foundation Trust

Abstract

Background Guidelines caution against percutaneous endoscopic gastrostomy (PEG) in MND patients with forced vital capacity (FVC) below 50% predicted. However, radiological approaches (RIG) may be equally challenging in patients with advanced disease, and less reliable.

Objectives To review Oxford MND Centre PEG patient characteristics, including the introduction of a risk stratification tool to identify those vulnerable to sedation-related complications, in whom a procedural adaptation was undertaken.

Methods MND patients undergoing PEG insertion over the last four years were analysed. Cases stratified as higher risk underwent insertion in a semi-supine position, by a consultant gastroenterologist and experienced team using reduced sedation, and with intra-operative nasal non-invasive ventilation available.

Results PEG was undertaken in 107 patients. All were successful in terms of immediate placement and recovery. Four deaths occurred within one month of insertion. Across the entire cohort one third had pre-procedure FVC<50% (overall mean 58±30%). Of 58 patients undergoing stratification, 40 were deemed high-risk, 16 with FVC<50%. Higher-risk patients received lower sedative doses (midazolam 2.3±1.2 mg vs 2.8±1.0 mg, p=0.027; fentanyl 47±21 µg vs 60±21 µg, p=0.012).

Conclusions PEG can be safely performed in MND patients with advanced respiratory involvement. Screening and procedural adaptation for higher risk cases is associated with lower sedative doses.

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