PEG Tube insertion in Cystic Fibrosis Patient

PIG Meeting: 29th April 2021

22-year-old for a PEG tube insertion to supplement nutrition

Background

  • CF, end-stage disease
  • Lung transplant 2019. Complex post-operative period requiring ECMO
  • Lung rejection late 2020
  • Recent decision not to proceed to further lung transplant due to disease severity
  • NYHA class 4 dyspnoea, wheelchair bound. 24-hour oxygen. BiPAP for sleeping
  • Pancreatic insufficiency. IDDM
  • Protein C deficiency – bilateral DVT’s and SVC thrombosis. Anticoagulated with warfarin
  • Nutritional deficit, increased metabolic demand unable to be met due to dyspnoea and general exhaustion

Issues

  • CF team and patient requesting PEG to aid in nutrition and improve QoL
  • Patient extremely high risk for GA or even sedation
  • Would not be able to use BiPAP due to need for endoscopy
  • Already ceased warfarin on review at perioperative clinic
  • Very challenging case in a remote location

Discussion

1. Anaesthetic options

  • Local with minimal or no sedation. Use of high flow nasal prongs/THRIVE.
  • Is an open procedure an option? Would negate need for endoscopy and allow use of BiPAP
  • Patient engaged and keen to try under LA

2. Location of procedure

  • Procedural anaesthetist keen to move to theatre 10
  • Proceduralist prefers endoscopy
  • Difficult situation as endoscopy very remote but procedure likely to happen more efficiently there
  • Possible to organise additional anaesthetist support in endoscopy for this case

3. End of life discussion

  • Recent decision (less than a week ago) that lung transplant won’t be proceeding
  • Patient and her mother understand now that her life is very limited
  • No formal documentation of ceiling of care
  • Discussion with CF specialist, has an appointment the day after the procedure
  • Discussion with patient regarding limitations with anaesthesia care and unsuitability for ICU. Understands same and keen to try and have procedure with as little intervention as possible

Plan

  • Investigate possibility of open or radiologically guided procedure
  • Liaise further with CF team regarding end of life wishes. She has been cared for them for many years and it is a discussion that would be better performed by them.
  • Liaise with DA of day to allocate extra anaesthetist if procedure is in endoscopy suite

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