PWE-017 A multi-disciplinary approach to percutaneous endoscopic gastrostomy insertion in motor neurone disease

Abstract Aims Patients with Motor Neurone Disease (MND) often require a Percutaneous Endoscopic Gastrostomy (PEG) as a palliative procedure during the later stages of their illness, due to swallowing difficulties. More recently these are being inserted earlier before the inevitable decrease in nutritional intake and subsequent fall in albumin levels. This allows patients to eat food they enjoy rather than concentrating on maintaining intake. Insertion has traditionally been done with local anaesthetic and OGD, which can be difficult and traumatic. We propose a method of insertion using TIVA (Totally Intravenous Anaesthetic) in theatre with no intubation, performed by the surgical team, with a pathway including pre-operative anaesthetic assessment. Methods Data was collected from all PEG insertions performed in theatre from 1/1/2011 to 1/9/2019. MND patients following our pathway were compared to all other indications for PEG insertions. Length of stay (LOS), 30-day re-admission rates, 30-day, 90-day and 1-year mortality were analysed. Results 98 patients were identified. Median LOS was 3 days (mean 12.2) with a 3% 30-day mortality, 12.2% 90-day mortality and 34.7% 1-year mortality. In the MND group there were 27 patients. Median LOS was 2 days (mean 8.6) with a 7.4% (2 patients) 30-day mortality, which remained 7.4% at 90 days. There were 13 re-admissions (13.3%) overall compared to 0% in the MND group (p = 0.04 (Chi-squared test)). Conclusions PEG insertion under TIVA for MND patients is safe. A set pathway for admission and pre/post-insertion care increases efficiency with reduced length of stay and improves patient outcomes with no re-admissions.

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Overview and audit against Motor Neurone Disease (MND) Association guidelines of a MND consultant’s practice over the last 3 years at the [Hospital]

Res Medica ◽

10.2218/resmedica.v24i1.1563 ◽

2017 ◽

Vol 24 (1) ◽

pp. 65-74 ◽

Cited By ~ 1

Author(s):

Dominic Adam Worku ◽

Unnat Krishna ◽

Karen E Morrison

Keyword(s):

End Of Life ◽

End Of Life Care ◽

Primary Care Physicians ◽

Diagnostic Delay ◽

Motor Neurone ◽

Motor Neurone Disease ◽

Life Care ◽

Endoscopic Gastrostomy ◽

Bulbar Onset ◽

Prompt Diagnosis

Background: Motor neurone disease (MND) is an incurable neurodegenerative condition. Recent guidelines from the MND Association UK (MNDA) emphasise prompt diagnosis and monitoring of quality of life (QOL). However, primary literature indicates that diagnosis is often delayed through several factors, including unawareness of how MND presents and delays through multiple secondary referrals. The [hospital] operates an internationally-recognised MND clinic whose service has not been audited against the MNDA UK guidelines for the last 3 years.Aim: To assess how well the MND consultant’s service ensures prompt diagnosis and the provision of end-of-life care or appropriate respiratory or nutritional support.Methods: Using the [hospital’s] database, records from 77 patients consulted consecutively in the MND clinic were obtained. Service parameters were compared against reference standards for diagnostic delay and treatment provision.Results: 84.4% of referrals came from neurologists outside of the MND service, with only 13% from general practitioners. On average, it took 14.7 months for patients to be seen in the MND clinic following symptom onset. Riluzole and percutaneous endoscopic gastrostomy (PEG) were prescribed faster in bulbar-onset versus limb-onset patients, by 4 times and 9 times respectively. End-of-life care discussion was recorded for 26% of patients.Conclusion: Diagnosing MND remains challenging for primary care physicians, which may be alleviated by disseminating recent Red Flag Committee guidelines. Investigation and treatment provision differed between MND subtypes, given the poorer prognosis associated with bulbar-onset. End-of-life care documentation remains low, which is an issue for the multi-disciplinary team (MDT) to resolve through incorporating palliative services.

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