Assessment of factors affecting mortality in patients with percutaneous endoscopic gastrostomy tube placement in the intensive care unit

Abstract

Aim: It was aimed to evaluate the clinical outcomes, complications, and factors affecting mortality of percutaneous endoscopic gastrostomy (PEG) applied to patients in the intensive care unit (ICU).
Material and Method: PEG procedures which were performed in the ICU between January 2016 and January 2021 and patients' age, gender, comorbidities, trauma history, serum CRP, albumin levels, CRP albumin ratios (CAR), and PEG-related complications were reviewed. Patients were divided into two groups, patients without mortality (Group 1) and patients with mortality (Group 2), and a comparison between groups was made.
Results: Of all patients, 49 (39.2%) patients had mortality. The mean age of the patients in group 2 was 69.57±16.78 years, which was higher than the other group (p<0.001). Nephrological diseases and diabetes were significantly more common in Group 2, whereas neurologic diseases were less common (p=0.005, p=0.005, 0.044, respectively). The median length of stay (LOS) of the patients in Group 1 was 50 days, while the median LOS of the patients in Group 2 was found to be significantly higher, with 81 days (<0.001). The mean CRP of Group 2 was 81.63±54.06, which was higher than the other group, while the mean of albumin was found to be 2.29±0.5 and was lower than Group 1 (p<0.001, p<0.001). The mean CAR of Group 1 was 15.96±16.81, which was significantly lower than that of Group 2 (p<0.001). The optimal CAR cut-off value for mortality discrimination was found to be 20,216 with a sensitivity of 73.5%, a specificity of 78.9%, a positive predictive value of 69.2%, a negative predictive value of 82.2%, and 76.8% test accuracy. A CAR value of ≥ 20.216 increased the odds of death 9.3-fold (OR 10.385, CI 95% 4.481-24.065, p<0.001).
Conclusion: We suggest that CAR ratio, low albumin, and high CRP levels could be predictors of early mortality. Considering that PEG is an elective procedure, we believe that it can be a safe and effective procedure when nutritional support is provided by alternative means and appropriate conditions are met.

Keywords

• Percutaneous endoscopic gastrostomy
• complications
• CRP/Albumin ratio
• mortality

Abstract

Amaç:Yoğun bakım ünitesinde kritik hastalara uygulanan perkütan endoskopik gastrostominin(PEG) klinik sonuçları, komplikasyonları ve mortaliteyi etkileyen faktörlerin değerlendirmesi amaçlandı. Gereç ve Yöntem:Ocak 2016-Ocak 2021 tarihleri arasında sadece yoğun bakım ünitesinde PEG takılan 109 hastanın yaşı, cinsiyeti,ek hastalıklar, travma öyküsü, PEG açılmadan önceki serum CRP ve albumin düzeyleri,CRP albumin oranı (CAR),PEG‘e bağlı gelişen komplikasyonlar retrospektif olarak tarandı.Hastalar mortalite görülmeyen (grup 1) ve mortalite görülen(grup 2) olmak üzere 2 gruba ayrılarak değişkenler arasında karşılaştırma yapıldı. Bulgular:Grup 2 olan hastalarınki ise 69,57±16,78 yıl olarak bulundu(p<0,001).Grup 1’de nörolojik,diabet ve nefrolojik hastalıklar grup 2’ye göre istatistiki anlamlılık izlendi (p=0,044, p=0,005).Grup 2 CRP değeri 81,63±54,06, albumin 2,29±0,5 idi (p<0,001).Grup 1 hastalarda CAR ortalaması 15,96±16,81 (p<0,001).Mortalite ayrımı için en uygun CAR cut-off değeri 73,5% sensitivite, 78,9% spesifite, 69,2% pozitif prediktif değer,%82,2 negatif prediktif değer ve 76,8% test kesinliği ile 20,216 olarak bulunmuştur( p<0,001) . Sonuç:CAR oranı, düşük albümin ve yüksek CRP seviyeleri erken mortalitenin öngörücüsü olabileceğini düşünmekteyiz.PEG elektif bir işlem olduğundan hastalar alternatif yollarla beslenme desteği sağlanıp uygun koşullar sağlandığında güvenli ve etkili bir yöntem olabileceğini düşünmekteyiz.

Keywords

• Perkutan endoskopik gastrostomi
• komplikasyonlar
• CRP/Albumin oranı
• mortalite
• Percutaneous endoscopic gastrostomy
• complications
• CRP/Albumin ratio
• mortality

References

1. Alverdy J, Chi HS, Sheldon GF. The effect of parenteral nutrition on gastrointestinal immunity. The importance of enteral stimulation. Ann Surg 1985; 202: 681–4.
2. Deitch EA, Ma WJ, Ma L, Berg RD, Specian RD. Protein malnutrition predisposes to inflammatory-induced gut-origin septic states. Ann Surg 1990; 211: 560–7.
3. Kirby DF, Delegge MH, Fleming CR. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology 1995; 108: 1282–301.
4. Smith BM, Perring P, Engoren M, Sferra JJ. Hospital and long-term outcome after percutaneous endoscopic gastrostomy. Surg Endosc 2008; 22: 74–80.
5. Loser C, Wolters S, Folsch UR. Enteral long-term nutrition via percutaneous endoscopic gastrostomy (PEG) in 210 patients: a four-year prospective study. Dig Dis Sci 1998; 43: 2549–57.
6. Figueiredo FA, da Costa MC, Pelosi AD, Martins RN, Machado L, Francioni E. Predicting outcomes and complications of percutaneous endoscopic gastrostomy. Endoscopy 2007; 39: 333–8.
7. Blomberg J, Lagergren P, Martin L, Mattsson F, Lagergren J. Albumin and C-reactive protein levels predict short-term mortality after percutaneous endoscopic gastrostomy in a prospective cohort study. Gastrointest Endosc 2011; 73: 29–36.
8. Lang A, Bardan E, Chowers Y, et al. Risk factors for mortality in patients undergoing percutaneous endoscopic gastrostomy. Endoscopy 2004; 36: 522–6.

9. Ljungdahl M, Sundbom M. Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: a prospective, randomized trial. Surg Endosc 2006; 20: 1248–51.
10. Lee C, Im JP, Kim JW, et al. Intestine Research Group of the Korean Association for the Study of Intestinal Disease Risk factors for complications and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study. Surg Endosc 2013; 27: 3806–15.
11. Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World J Gastroenterol 2014; 20: 7739–51.
12. Barbosa M, Magalhaes J, Marinho C, Cotter J. Predictive factors of early mortality after percutaneous endoscopic gastrostomy placement: The importance of C-reactive protein. Clin Nutr ESPEN 2016; 14: 19-23.
13. Karasahin O, Tasar PT, Timur O, et al. High C-reactive protein and low albumin levels predict high 30-day mortality in patients undergoing percutaneous endoscopic gastrotomy. Gastroenterology Res 2017; 10: 172-6.
14. Stephens NA, Skipworth RJ, Fearon KC. Cachexia, survival and the acute phase response. Curr Opin Support Palliat Care 2008; 2: 267-74.
15. McMillan DC. An inflammation-based prognostic score and its role in the nutrition-based management of patients with cancer. Proc Nutr Soc 2008; 67: 257-62.
16. Ranzani OT, Zampieri FG, Forte DN, Azevedo LC, Park M. C-reactive protein/albumin ratio predicts 90-day mortality of septic patients. PLoS ONE 2013; 8.
17. Kim MH, Ahn JY, Song JE, et al. The C-reactive protein/albumin ratio as an independent predictor of mortality in patients with severe sepsis or septic shock treated with early goal-directed therapy. PLoS ONE 2015; 10.
18. Oh J, Kim SH, Park KN, et al. High-sensitivity C-reactive protein/albumin ratio as a predictor of in-hospital mortality in older adults admitted to the emergency department. Clin Exp Emerg Med 2017; 4: 19–24.
19. Kaplan M, Ates I, Akpinar MY, et al. Predictive value of C-reactive protein/albumin ratio in acute pancreatitis. Hepatobiliary Pancreat. Dis. Int 2017; 16: 424–30.
20. Mao M, Wei X, Sheng H, et al. C-reactive protein/albumin and neutrophil/lymphocyte ratios and their combination predict overall survival in patients with gastric cancer. Oncol Lett 2017; 14: 7417-24.
21. Saito H, Kono Y, Murakami Y, et al. Prognostic significance of the preoperative ratio of C-reactive protein to albumin and neutrophil-lymphocyte ratio in gastric cancer patients. World J Surg 2018; 42: 1819-25.
22. Zhao Q, Chen S, Feng JF. A novel inflammation-based prognostic index for patients with esophageal squamous cell carcinoma: neutrophil lymphocyte ratio/albumin ratio. Oncotarget 2017; 8: 103535-42.
23. Kinoshita A, Onoda H, Imai N, et al. The C-reactive protein/albumin ratio, a novel inflammation-based prognostic score, predicts outcomes in patients with hepatocellular carcinoma. Ann Surg Oncol 2015; 22: 803-10.
24. Wu M, Guo J, Guo L, Zuo Q. The C-reactive protein/albumin ratio predicts overall survival of patients with advanced pancreatic cancer. Tumour Biol 2016; 37: 12525-33.
25. Duzenli T, Ketenci M, Akyol T, et al. Predictive factors of complications and 30-day mortality in patients undergoing percutaneous endoscopic gastrostomy: the utility of C-reactive protein to albumin ratio. Acta Gastroenterol Belg 2021; 84: 283-8.
26. Sanders DS, Anderson AJ, Bardhan KD. Percutaneous endoscopic gastrostomy: an effective strategy for gastrostomy feeding in patients with dementia. Clin Med 2004; 4: 235–41.
27. Grant MD, Rudberg MA, Brody JA. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA 1998; 279: 1973.
28. Finocchiaro C, Galletti R, Rovera G, et al. Percutaneous endoscopic gastrostomy: a long-term follow-up. Nutrition 1997; 13: 520.
29. Zopf Y, Maiss J, Konturek P, et al. Predictive factors of mortality after PEG insertion: guidance for clinical practice. JPEN J Parenter Enteral Nutr 2011; 35: 50–5.
30. Singh D, Laya AS, Vaidya OU, Ahmed SA, Bonham AJ, Clarkston WK. Risk of bleeding after percutaneous endoscopic gastrostomy (PEG) Dig Dis Sci 2012; 57: 973–80.
31. Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 1987; 93: 48–52.
32. Joshi N, Caputo GM, Weitekamp MR, Karchmer AW. Infections in patients with diabetes mellitus. N Engl J Med 1999; 341: 1906–12.
33. Taylor CA, Larson DE, Ballard DJ, et al. Predictors of outcome after percutaneous endoscopic gastrostomy: a community-based study. Mayo Clin Proc 1992; 67: 1042-9.
34. Higaki F, Yokota O, Ohishi M. Factors predictive of survival after percutaneous endoscopic gastrostomy in the elderly: is dementia really a risk factor? Am J Gastroenterol 2008; 103: 1011–16.