Percutaneous endoscopic gastrostomy under conscious sedation in patients with amyotrophic lateral sclerosis is safe: an observational study.

Abstract

Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease that causes muscle weakness with respiratory and swallowing dysfunction, eventually leading to death. Permanent enteral feeding is indicated in almost all patients. A percutaneous endoscopic gastrostomy (PEG) tube is considered the first choice, usually performed under conscious sedation (intravenous midazolam). Guidelines are very cautious with respect to sedation in ALS because of the risk for respiratory complications. In our tertiary referral hospital, conscious sedation has been used for many years.Our aim was to review 30-day complications in PEG performed under conscious sedation in ALS patients (without noninvasive positive pressure ventilation during the procedure). A retrospective review, including all ALS patients undergoing PEG under conscious sedation from October 2009 to April 2016, was performed. Analysis included 45 (44% men) patients receiving intravenous midazolam sedation (mean dose 5 mg) during PEG placement, age 36-91 years (mean: 68.7 years). Forced vital capacity (FVC) was 24-116% (mean 68%), of which mild to moderate dysfunction (FVC 50-69%) was present in 42.2% of patients and (very) severe dysfunction (FVC <50%) in 8.8%. No respiratory complications (e.g. aspiration pneumonia) were observed. Other complications, for example, infection, bleeding and peritonitis occurred in, respectively, 8.9, 2.2 and 0%. Mean survival after PEG placement was 13.4 months (range: 1-45 months). Conscious sedation during PEG insertion in ALS patients did not lead to respiratory complications or to an increase in other complications. Our data indicate that conscious sedation can be used safely in ALS patients with mild to moderate pulmonary dysfunction.