Gastrostomy Placement Research Articles

Outcomes following feeding gastrostomy (FG) insertion in patients with learning disability: a retrospective cohort study using the health improvement network (THIN) database

ObjectivesTo measure the rates of lower respiratory tract infection (LRTI) and mortality following feeding gastrostomy (FG) placement in patients with learning disability (LD). Following this to compare these rates between...

Predictive Model for Gastrostomy Placement in Adolescents With Developmental Disabilities and Cerebral Palsy.

Factors associated with gastrostomy placement in adolescents with developmental disabilities (DDs) and cerebral palsy (CP) are poorly investigated. We aimed to develop and validate a machine learning (ML) model for gastrostomy placement in adolescents with DDs and CP. We performed a multinational, double-blinded, case-control study including 130 adolescents with severe DD and CP (72 males, 58 females; mean age 16 ± 2 years). Data on etiology, diagnosis, spasticity, epilepsy, clinical history, and functional assessments such as the Eating and Drinking Ability Classification System, Manual Ability Classification System, and Gross Motor Function Classification System were collected between 2005 and 2015. Analysis included Fisher exact test, multiple logistic regressions, and a supervised ML model, named PredictMed, to identify factors associated with gastrostomy placement. "Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis" guidelines were followed. Poor motor function (P < 0.001), trunk muscle tone disorder (P < 0.001), male gender (P < 0.01), epilepsy (P = 0.01), and severe neuromuscular scoliosis (P = 0.04) were factors linked with gastrostomy placement in univariate analysis. Epilepsy (P = 0.03), poor motor function (P = 0.04), and male gender (P = 0.04) were associated with gastrostomy placement in multivariate analysis with 95% accuracy. Epilepsy, poor motor function, trunk muscles tone disorder, and male gender were accurate, sensitive, and specific factors associated with gastrostomy need.

Incidence and treatment of leak at the gastrojejunostomy in Roux-en-Y gastric bypass: a cohort study of 40,844 patients

BackgroundLeak at the gastrojejunostomy (GJ) after Roux-en-Y gastric bypass is a rare but life-threatening complication. ObjectivesTo assess incidence, risk factors, treatment, and outcome of leaks at the GJ after Roux-en-Y gastric bypass in a nationwide cohort. SettingSweden. MethodsLeaks at GJ within 30 days postoperatively in 40,844 patients (age 41 yr, females 76%, and body mass index of 42.4 kg/m2) between 2007 and 2014 in the Scandinavian Obesity Surgery Registry were assessed. Register data and outcomes were verified by reviewing patient charts. Logistic regression was done to estimate odds ratios (ORs) for significant risk factors. ResultsLeak at the GJ was registered in 262 (.6%) patients, with 44% diagnosed within the first 3 postoperative days. Risk factors were male sex (OR 1.5 [1.1–1.9]), age ≥49 years (OR 1.9 [1.3–2.7]), diabetes (OR 1.4 [1.1–1.9]), conversion to open surgery (OR 3.9 [2.2–6.9]), and operative time ≥90 minutes (OR 2.6 [1.8–3.8]). In most patients, the leak resulted in a severe complication. Reoperative surgery was done in 85%, with the placement of a feeding gastrostomy in 24%. Stents were used at some time point in 31% of leaks. Of all patients with leaks, 25% required intensive care, 4% developed multiorgan failure, and 1% died. Median duration of stay for patients with leaks was 22 days, versus 2 days for others (P < .001). ConclusionGJ leaks occurred in .6% of patients. Risk factors were male sex, age ≥49 years, diabetes, operative time ≥90 minutes, and conversion to open surgery. Surgical reintervention was common. Mortality was 1%.

Complications and early mortality in percutaneous endoscopic gastrostomy placement in lombardy: A multicenter prospective cohort study

BackgroundPercutaneous endoscopic gastrostomy (PEG) is the most common endoscopic procedure used to provide nutritional support. AimTo prospectively evaluate the mortality and complication incidences after PEG insertion or replacement. MethodsAll patients who underwent PEG insertion or replacement were included. Details on patient characteristics, ongoing therapies, comorbidities, and indication for PEG placement/replacement were collected, along with informed consent form signatures. Early and late (30-day) complications and mortality were assessed. Results950 patients (47.1% male) were enrolled in 25 centers in Lombardy, a region of Northern Italy. Patient mean age was 73 years. 69.5% of patients had ASA status 3 or 4. First PEG placement was performed in 594 patients. Complication and mortality incidences were 4.8% and 5.2%, respectively. The most frequent complication was infection (50%), followed by bleeding (32.1%), tube dislodgment (14.3%), and buried bumper syndrome (3.6%). At multivariable analysis, age (OR 1.08 per 1-year increase, 95% CI, 1.0–1.16, p = 0.010) and BMI (OR 0.86 per 1-point increase, 95% CI, 0.77−0.96, p = 0.014) were factors associated with mortality.PEG replacement was carried out in 356 patients. Thirty-day mortality was 1.8%, while complications occurred in 1.7% of patients. ConclusionsOur data confirm that PEG placement is a safe procedure. Mortality was not related to the procedure itself, confirming that careful patient selection is warranted.

Obesity Paradox in Intracerebral Hemorrhage.

Background and Purpose- Although obesity is an established risk factor for cardiovascular disease and stroke, studies have shown evidence of an obesity paradox-a protective effect of obesity in patients who already have these disease states. Data on the obesity paradox in intracerebral hemorrhage is limited. Methods- Clinical data for adult intracerebral hemorrhage patients were extracted from the National Inpatient Sample between 2007 and 2014. Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality, discharge disposition, length of stay, tracheostomy or gastrostomy placement, and ventriculoperitoneal shunt placement. Results- There were 99 212 patients who were eligible. Patients with both obesity (OR=0.69; 95% CI=0.62-0.76; P<0.001) and morbid obesity (OR=0.85; 95% CI=0.74-0.97; P=0.02) were associated with decreased odds of in-hospital mortality. Morbid obesity was significantly associated with increased odds of a tracheostomy or gastrostomy placement (OR=1.42; 1.20-1.69; P<0.001) and decreased odds of a routine discharge disposition (OR=0.84; 0.74-0.97; P=0.014). Conclusions- Obesity and morbid obesity appear to protect against mortality in intracerebral hemorrhage.

Abstract 269: Patients &gt;65 Years of Age Have Higher Mortality After In-hospital Cardiac Arrest With Lower Utilization of Healthcare Resources

Background: Studies have shown that age is not an independent predictor of short-term and long-term neurological outcomes after cardiopulmonary resuscitation. These findings were reported for both in-hospital and out-of-hospital cardiac arrest. Yet, elderly patients are less aggressively treated and have higher mortality. We investigated the current outcomes and therapeutic approach in a large unselected population of patients. Methods: In a retrospective cohort study, using the 2014 Nationwide Inpatient Sample, we analyzed patients &gt;65 years of age with in-hospital cardiac arrest. We performed univariate analysis of age, sex, race, hospital location, hospital teaching status, insurance type, hospital bed size, Charlson Comorbidity Index and other relevant comorbidities such as ventricular arrhythmias and we included variables with p&lt;0.2 in the multivariate logistic regression model. Results: A total of 39397 patients, who underwent in-hospital cardiopulmonary resuscitation (CPR) were identified. Patients &gt;65 years of age (55%) had mean age of 78+/_0.06, vs 50+/_0.22, p&lt;0.001 and a higher percentage of them were female (46% vs 40%, p&lt;0.001). They were less likely to have ESRD (9% vs 11%, p&lt;0.001), abuse drugs (0.7% vs 10%, p&lt;0.001) and alcohol (0.3% vs 11.5%, p&lt;0.001) and had lower incidence of ventricular tachycardia or ventricular fibrillation (20% vs 23%, p&lt;0.001). They were more likely to have chronic kidney disease (25% vs 11%, p&lt;0.001), diabetes mellites (29% vs 21%, p&lt;0.001), hypertension (69% vs 50%, p&lt;0.001) and heart failure (26% vs 17%, p&lt;0.001). Patients &gt;65 years of age had higher mortality (OR=1.51, 95%CI =1.43-1.61, p&lt;0.001) and were less likely to undergo therapeutic hypothermia (OR=0.66, 95%CI=0.56-0.79, p&lt;0.001), receive cardioverter-defibrillator (OR=0.77, 95%CI=0.64-0.92, p=0.005) and extracorporeal membrane oxygenation (OR=0.32, 95%CI =0.23-0.45, p&lt;0.001). There was no difference in utilization of short-term mechanical circulatory support, dialysis in the setting of acute kidney injury and blood product transfusion. There was also no difference in the incidence of ischemic stroke and placement of percutaneous endoscopic gastrostomy with lower utilization of tracheostomies (OR=0.64, 95% CI= 0.56-0.73, p&lt;0.001) and higher utilization of palliative care consult (OR=1.44, 95% CI=1.33-1.56, p&lt;0.001) in older patients. Patients &gt;65 years of age had lower length of stay (Coef. =-1.46, 95% CI=-1.85- -1.08), p&lt;0.001) and the total charges from hospital stay (Coef. =-49889$, 95% CI= -56803$- -42975, p&lt;0.001). Conclusion: Patients &gt;65 years of age, who underwent in-hospital CPR had higher mortality, which could be related to lower utilization of healthcare resources and contribute to a shorter hospital stay and lower total charges. Furthermore, our study unravels lower utilization of a palliative care consult in a younger population of patients.

National Multicenter and Multiyear Review of Complications Following Fluoroscopic Gastrostomy in Patients Covered by Medicare and Medicaid

Abstract Objective This study aims to assess the postoperative complication rates associated with fluoroscopically placed gastrostomy tubes. Background Fluoroscopically placed gastrostomy tubes are a relatively common procedure performed by interventional radiologists. Few studies have been performed in the United States to access the complication profile of fluoroscopically placed gastrostomy tubes. Methods Total 51 million Medicare Standard Analytic Patient Records derived from Medicare parts A and B records from 2007 to 2012 were retrospectively analyzed. Only the patients undergoing fluoroscopic gastrostomy were included in this study. Patient demographics were stratified by age, sex, comorbidities, and peri- and postoperative complications as defined by International Classification of Diseases (ICD) 9 codes. Results Total 30,327 patients undergoing fluoroscopic gastrostomy were analyzed. Perioperative complications following these procedures were low, with 61 (0.02%) patients experiencing pneumoperitoneum, 130 (0.43%) experiencing ileus, 16 (0.05%) experiencing esophageal/gastric perforation, and 30 (0.09%) patients experiencing intra-abdominal injury. Most common postoperative complications included abdominal wall pain (n = 2,808, 9.25%), bleeding (n = 1,353, 4.46%), and mechanical complications (n = 1,435, 4.73%). Conclusion Fluoroscopic guidance is a safe method for gastrostomy placement, with exceedingly low rates of peri- and postoperative complications.

Swallowing Function in Survivors of Oropharyngeal Cancer Is Associated With Advanced T Classification.

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing in the United States. The aim of this study was to characterize the functional status of OPSCC survivors to identify predictors of swallowing dysfunction in this patient population. OPSCC survivors (n = 81) treated at the Michael E. DeBakey Veterans Affairs Medical Center between 2005 and 2015 with at least 2 years of clinical follow-up were reviewed. Functional status was ascertained using (1) gastrostomy and tracheostomy placement and retention, (2) gastrostomy use at last follow-up, (3) patient-reported diet, and (4) modified barium swallow. Median follow-up duration was 5.6 years; 67% of patients had ≥10-pack-year tobacco exposure; 96% of tumors for which p16 data were available were p16 positive. At last follow-up, 82% of patients reported a regular diet, and only 9 patients required gastrostomy use. Gastrostomy use at last follow-up was higher in patients with T3 and T4 tumors compared with those with T1 and T2 tumors (P = .01). The relationship between T classification and gastrostomy use persisted even when the analysis was limited to p16+ tumors and p16+ tumors with ≥10-pack-year history of tobacco exposure. Advanced T classification at presentation is a critical predictor of gastrostomy use in long-term OPSCC survivors irrespective of p16 status or tobacco exposure history. 2b.

Early outcomes of gastrostomy feeding in paediatric allogenic bone marrow transplantation: A retrospective cohort study

Nutrition support is an essential component of care for a child undergoing bone marrow transplantation (BMT). Enteral nutrition (EN) is becoming increasingly recognised as having advantages over parenteral nutrition (PN) and recommended as first-line nutrition support. EN has traditionally been provided via nasogastric tube (NGT). Gastrostomies avoid certain complications associated with NGTs and could provide a preferential alternative. To compare nutritional and post-transplantation outcomes during admission, the primary outcome being PN use, between children who had a gastrostomy placed prophylactically prior to BMT versus those who had not. Electronic medical records of children transplanted between January 2014 and May 2018 within a single-centre were retrospectively reviewed. Outcomes between the gastrostomy group (n=54) and non-gastrostomy group (n=91) were compared. Multivariate regression analyses showed children in the gastrostomy group were less likely to require PN (odds ratio (OR) 0.4; 95% confidence interval (CI) 0.2-0.9; P=0.049), initiated PN later if required (hazard ratio 0.6; 95% CI 0.4-0.8; P=0.005), more often received EN as first-line nutrition support (P<0.001) and more frequently required EN post-discharge (OR 2.4; 95% CI 1.1-5.4; P=0.029). No differences were found between groups on length of admission, day 100 overall survival, incidence of graft-versus-host-disease, positive blood cultures and changes in weight or albumin during admission. Providing EN via gastrostomy is feasible in this population and may be more acceptable to older children than NGTs. Weighing up the potential benefits against the potential risks of prophylactic gastrostomy placement in these high-risk children is a challenging decision. Further research investigating safety, longer-term outcomes and family perceptions of gastrostomy feeding is required.

Percutaneous endoscopic gastrostomy for refractory epilepsy and medication refusal

ObjectiveCurrent guidelines for percutaneous endoscopic gastrostomy (PEG) placement focus largely on maintaining enteral feeding when oral feeding is no longer possible or adequate with an emphasis on nutrition and quality...

Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy

IntroductionHead and neck cancer (HNC) patients often experience malnutrition before and during treatment. Prophylactic gastrostomy has emerged as an efficient tool for ensuring adequate nutrition. However, there is no suitable algorithm able to identify patients at high risk of malnutrition. The aim of this study was to describe the nutritional management, to assess the impact of prophylactic gastrostomy, and to identify predictors of malnutrition. MethodsThis retrospective study included 152 patients treated with surgery, radiotherapy, or chemotherapy for HNC. The patients were classified according to their gastrostomy status (prophylactic or non-prophylactic). Nutritional, tumoral and treatment characteristics were reported. Clinical and nutritional outcomes were measured 6 weeks after the beginning of treatment. In order to describe the nutritional management and the impact of prophylactic gastrostomy on patients, univariate analysis was generated using chi-square test and Mann–Whitney test or Student's t-test. Logistic regression was performed to identify factors associated with malnutrition. ResultsForty-one patients received prophylactic gastrostomy whereas 111 patients had no nutritional support. Prophylactic gastrostomy placement was associated with a lower initial body mass index, with severe malnutrition, and with initial oral intake disorder. Patients who did not experienced prophylactic gastrostomy had much worse outcomes such as hospital readmissions (P=0.042), relative weight loss at 6 weeks (P<0.0001), dysphagia, severe malnutrition, and poor state of health (P=0.001). Our complication rates (4.9%) were lower than the usual range (5.9–9.3%) and no life-threatening complication was reported. Positive N status, oral intake disorder, concomitant radiochemotherapy, nasopharyngeal, and hypopharyngeal tumor site were significant predictive factors for malnutrition. ConclusionsProphylactic percutaneous endoscopic gastrostomy showed advantages in terms of hospital readmissions, relative weight loss at 6 weeks, dysphagia, severe malnutrition, and poor state of health. Tumoral, nutritional and treatment characteristics seem to be predictors for malnutrition. Hence, physicians should integrate these factors in their nutrition algorithm approach.

04:12 PM Abstract No. 149 Technical cost analysis of angiography suite gastrostomy tube placement in comparison with endoscopically placed percutaneous endoscopic gastrostomy tube

Gastrostomy tube placement is a commonly performed procedure, with greater than 200,000 gastrostomy tubes placed in the United States annually [1]. This procedure is performed for a wide range of etiologies including neurological dysfunction and malignancy for the purposes of enteral feeding, nutritional supplementation, and gastric decompression [2]. Gastrostomy tubes are commonly placed via percutaneous endoscopy by a gastroenterologist or with fluoroscopy guidance by an interventional radiologist. Older studies indicate increased chances of technical success with radiology-based placement and decreased risk of respiratory complications with the trade-off of mildly greater expense than PEG placement [3,4,5]. However, there is a dearth of recent data in the literature revisiting this subject. The purpose of this study is to conduct a retrospective analysis and identify the costs associated for gastrostomy placement by service. Retrospective chart review was conducted utilizing Current Procedural Terminology (CPT) codes 43246 and 49440 to select patients that had gastrostomy tube placement in Augusta University Medical Center from January 1, 2016 to August 31, 2017. Preferred Medical Marketing Corporation software was used to extract procedural billing data for each patient. Statistical analysis was conducted utilizing a two-tailed T test. Institutional cost analysis completed at Augusta University Medical Center indicates that a gastrostomy tube placed under fluoroscopic guidance by a radiologist costs $4,633.54 with a standard deviation of $666.23 on average while endoscopic placement by a gastroenterologist costs $5,866.07 with a standard deviation of $645.70. This was a statistically significant difference with P-value < 0.001. There is a statistically significant decreased cost to the patient when gastrostomy tube is placed under fluoroscopic guidance by a radiologist in comparison with endoscopically by a gastroenterologist. Given the current financial burden of the United States healthcare system, this data should be strongly considered by providers when referring for gastrostomy tube placement.Tabled 1Average interventional radiology G-tube placement cost$4633.54Standard deviation$666.2395% confidence interval$4471.03–$4796.04Average gastroenterologist G-tube placement cost$5866.07Standard deviation$645.0795% confidence interval$5620.70–$6111.44P value<0.001 Open table in a new tab

03:45 PM Abstract No. 48 Novel approach of transgastric balloon occlusion to increase technical success during pediatric percutaneous gastrostomy/gastrojejunostomy tube placement

Obtaining adequate gastric distension via insufflation is a key step in creating a safe percutaneous window during gastrostomy/gastrojejunostomy (G/GJ) placement. In some instances, this may be limited due to rapid egress of air from the stomach into the duodenum, despite the use of glucagon. Herein, we describe an adjunctive novel technique of transgastric balloon occlusion to maximize gastric insufflation and assess the outcome of this technique use during G/GJ placement in children. A single-center, IRB-approved, retrospective review of 15 patients with a mean age 4.8±5.6 y (0-16y; 6F, 9M) and mean weight 20.9±18.9 kg (3-54.2 kg) who had G/GJ placement utilizing transgastric balloon occlusion over a 2-year period. The standard technique was antegrade placement with administration of glucagon. After initial percutaneous failure, the practice of positioning a balloon in the proximal duodenum was adopted to temporarily obstruct the gastric outlet. Clinical history, patient demographics, procedure reports, balloon type, technical success, and outcomes were reviewed. The addition of a transgastric balloon occlusion was successful in salvaging G/GJ tube placement in 10/15 (67%) patients (3G, 7GJ) which likely would have been unsuccessful using standard practice. Major underlying disorders included cardiac (n=5), neurologic (n=3), oncologic (n=2) and other (n=5). Of 5 unsuccessful placements, 3 were attributed to persistent colonic interposition/high position, 2 to high stomach position. Subsequently, 4 of 5 underwent surgical gastrostomy placement. No procedure-related complications were reported. The novel use of transgastric balloon occlusion may improve the technical success of G/GJ placement in children with challenging percutaneous access. Further studies are needed to assess the efficacy and identify optimal techniques and materials based on patient and disease characteristics.

Transnasal stent-assisted targeting technique for percutaneous jejunostomy placement in patients with hiatal hernias.

To report the transnasal stent-assisted targeting technique for percutaneous jejunostomy placement in patients with hiatal hernias. Four patients, including three (75%) females and one (25%) male, with mean age of 77.5years (range 73-78years), and with a hiatal hernia and intrathoracic stomach precluding gastrostomy placement and loop snare placement into the mid-jejunum underwent the transnasal stent-assisted targeting technique for percutaneous jejunostomy placement. In all patients, a duodenal stent was inserted into the jejunum in a transnasal fashion. The stent was partially unsheathed in an anterior loop of jejunum and percutaneously targeted using an 18-gauge needle through which a guidewire was advanced, trapped within the stent, and removed through the nose. The tract was serially dilated and a jejunostomy was placed. Technical success, procedure time, fluoroscopy time, radiation exposure, complications, time to enteral feeding, and follow-up were recorded. Technical success was 100% (4/4) with all four patients requiring only one needle pass before successful jejunal cannulation. Mean procedure time was 108min. Mean fluoroscopy time was 44min. Mean dose area product was 3969.3 μGym2. No minor or major complications occurred. All four patients received enteral feeding oneday after the procedure. Mean follow-up was 366days. The transnasal stent-assisted targeting technique is a novel method for primary jejunostomy placement in patients with hiatal hernias.

Development and Validation of a Prognostic Model of Swallowing Recovery and Enteral Tube Feeding After Ischemic Stroke

Predicting the duration of poststroke dysphagia is important to guide therapeutic decisions. Guidelines recommend nasogastric tube (NGT) feeding if swallowing impairment persists for 7 days or longer and percutaneous endoscopic gastrostomy (PEG) placement if dysphagia does not recover within 30 days, but, to our knowledge, a systematic prediction method does not exist. To develop and validate a prognostic model predicting swallowing recovery and the need for enteral tube feeding. We enrolled participants with consecutive admissions for acute ischemic stroke and initially severe dysphagia in a prospective single-center derivation (2011-2014) and a multicenter validation (July 2015-March 2018) cohort study in 5 tertiary stroke referral centers in Switzerland. Severely impaired oral intake at admission (Functional Oral Intake Scale score <5). Recovery of oral intake (primary end point, Functional Oral Intake Scale ≥5) or return to prestroke diet (secondary end point) measured 7 (indication for NGT feeding) and 30 (indication for PEG feeding) days after stroke. In total, 279 participants (131 women [47.0%]; median age, 77 years [interquartile range, 67-84 years]) were enrolled (153 [54.8%] in the derivation study; 126 [45.2%] in the validation cohort). Overall, 64% (95% CI, 59-71) participants failed to recover functional oral intake within 7 days and 30% (95% CI, 24-37) within 30 days. Prolonged swallowing recovery was independently associated with poor outcomes after stroke. The final prognostic model, the Predictive Swallowing Score, included 5 variables: age, stroke severity on admission, lesion location, initial risk of aspiration, and initial impairment of oral intake. Predictive Swallowing Score prediction estimates ranged from 5% (score, 0) to 96% (score, 10) for a persistent impairment of oral intake on day 7 and from 2% to 62% on day 30. Model performance in the validation cohort showed a discrimination (C statistic) of 0.84 (95% CI, 0.76-0.91; P < .001) for predicting the recovery of oral intake on day 7 and 0.77 (95% CI, 0.67-0.87; P < .001) on day 30, and a discrimination for a return to prestroke diet of 0.94 (day 7; 95% CI, 0.87-1.00; P < .001) and 0.71 (day 30; 95% CI, 0.61-0.82; P < .001). Calibration plots showed high agreement between the predicted and observed outcomes. The Predictive Swallowing Score, available as a smartphone application, is an easily applied prognostic instrument that reliably predicts swallowing recovery. It will support decision making for NGT or PEG insertion after ischemic stroke and is a step toward personalized medicine.

Abstract TMP80: Physician Preferences, Beliefs, and Practices on Post-Stroke Dysphagia Management

Introduction: Dysphagia affects up to 2/3 of stroke patients; however, management practices are widely disparate. Despite lack of evidence for percutaneous endoscopic gastrostomy (PEG) placement, PEGs are placed in up to 23% of stroke patients a mean of 7 days from admission. We surveyed physicians who manage stroke patients in a large network of hospitals to evaluate knowledge and practices around dysphagia management. Methods: A 20 question survey was compiled and included questions regarding provider demographics, clinical experience and practice patterns for dysphagia management, knowledge about clinical variables associated with persistent dysphagia and beliefs about patient and system variables that influence decisions about dysphagia management (Table 1). Results: 171 providers of stroke care in the Memorial Hermann Healthcare System (13 hospitals) were surveyed and 52 (30%) participated (Table 1). Approximately, 67% of providers were extremely or very comfortable with management of post-stroke dysphagia. There was a trend toward an association between provider specialty and comfort, with critical care practitioners likely to feel more comfortable and internal medicine physicians less comfortable (p = 0.07). While 61% of providers recommend PEG placement within 3-7 days of admission, 77% of providers would delay PEG placement if they could. Providers aware of published trials showing poor outcomes after PEG were more likely to want more time (p=0.04). Providers reported that stroke location (86%), dysarthria severity (77%), and age (71%) of patients were most likely to be associated with persistent dysphagia. Conclusions: To our knowledge, this survey represents the first to assess provider practices, knowledge, and beliefs regarding PEG placement and dysphagia management. Most providers in our network would like more time to determine recovery of swallow function prior to placing PEG tubes, if length of stay and other factors were not issues.

Abstract WP447: Race, Socioeconomic Status and Care Decisions After Intracerebral Hemorrhage

Introduction: Spontaneous intracerebral hemorrhage (ICH) is a leading cause of disability. Incidence of dysphagia is similar across racial subgroups, but studies have shown increased odds of percutaneous endoscopic gastrostomy (PEG) placement among minorities, Medicaid enrollees, and those with low household income. Socioeconomic status (SES) indicators such as education or occupation have not been fully investigated as predictors of maximal care after ICH among minorities. Hypothesis: SES is associated with maximal care post-ICH in non-white patients. Methods: Patients with spontaneous ICH without underlying pathology were enrolled into a single center, observational cohort study. SES was imputed using neighborhood socioeconomic characteristics by patient’s zip code, according to an established method which calculates an index from six SES indicators: median household income, median home value, percent &gt;25 years old who completed high school, percent &gt;25 who completed college, percent with income from passive sources (investments, rents), and percent working in management, executive, or professional careers. Neighborhood SES data was obtained from the United States Census Bureau’s 2012-2016 American Community Survey. We used PEG placement as a surrogate for maximal care. Based on a single regression model with an interaction term for SES and race, models were created by racial-ethnic subgroups. Results: Among 607 patients comprised of 245 blacks, 56 Hispanics and 306 non-Hispanic whites, the SES index differed across subgroups (p &lt; 0.001). White patients had the highest index and black patients had the lowest. After adjustment for age, gender, premorbid modified Rankin Scale score, and ICH Score, no association was observed between SES index and PEG placement in black (odds ratio 0.99, 95% confidence interval [0.90, 1.09], p= 0.87) or white patients (OR 0.94, 95%CI [0.84, 1.04], p=0.24). However, higher SES index was associated with reduced likelihood of PEG in Hispanic patients (OR 0.69, 95%CI [0.45, 0.95], p=0.041). Conclusions: A reduced likelihood of maximal care as measured by PEG placement was observed only among Hispanic patients with higher SES index. Further study into culturally-bound decisional factors after ICH is warranted.

Abstract WP453: Intracerebral Hemorrhage Outcomes in the Very Elderly

Background: Intracerebral hemorrhage (ICH) outcomes have been well described, but there is a paucity of data regarding complications and outcomes in the “very elderly.” As the population ages the incidence of ICH in the very elderly will likely increase. Our objective is to describe ICH outcomes in this patient population that may assist in prognostication for this specific group. Methods: Retrospective study of patients admitted to the Neurosciences ICU at our tertiary care center with the diagnosis of primary spontaneous intracerebral hemorrhage from January 2012 to 2018. Only patients with age equal to or greater than 80 years old were included. Results: 1590 patients were initially screened, 187 patients met inclusion criteria. 66% were female and median age of all patients was 85 (80-92). Median ICH score on admission was 2 (IQR 1-3). Location of ICH included: lobar (39%), deep (51%), and cerebellum (10%). ICH etiologies included hypertensive (55%), amyloid angiopathy (25%), coagulopathy (5%), and the remaining 11% were other or unknown. Neurosurgical procedures included external ventricular drains (9%), ventriculoperitoneal shunts (2%) and decompression (4%). Five percent had seizures and an additional 1.5% were treated for status epilepticus. Tracheostomy and percutaneous gastrostomy placement performed in 8.5%. Thirty four percent of patients were designated as comfort measures and ICU mortality was 17%. Disposition at hospital discharge included: home (13%), acute rehabilitation (23%), subacute nursing facility (24%), long term acute care facility (4%), hospice (17%) and death (19%). The median ICU length of stay was 2 (range 0-30) days and median hospital stay was 5 (0-30) days. Patients with an ICH score &gt;1 on admission had a 6 times higher chance of experiencing an unfavorable outcome (LTAC, SNF or death), when compared to patients with lower ICH score. This persisted after correcting for age and sex (OR 3.02-11.2, p&lt;0.001) in a logistic regression prediction model. Conclusions: This study shows that a significant proportion (36%) of ICH patients &gt; 80 years old have a good outcome, with discharge to home or to rehab. ICH score &gt;1 on admission may be used to predict a poor outcome in this patient population, which varies from younger age groups.

Evaluation of a new nurse-led gastrostomy assessment service

Since Percutaneous Endoscopic Gastrostomy (PEG) insertion was descripted in 19801, its use has been steadily increasing and it is estimated that 17,000 PEG tube insertion are performed per year in the UK alone2. Less than half (46%) of UK hospitals have a nutrition nurse3. Though there is evidence to show which patients benefit from gastrostomy placement, there are no standardised gastrostomy assessment guidelines for NNs in clinical practice4. In response to national recommendations a nurse-led gastrostomy assessment service was established at Barnet Hospital.

Evaluation and Treatment of Malnutrition and Associated Gastrointestinal Complications in Children with Cerebral Palsy

The majority of children with cerebral palsy (CP) have feeding difficulties and are especially prone to malnutrition. The early involvement of a multidisciplinary team should aim to prevent malnutrition and provide adequate nutritional support. Thorough nutritional assessment, including body composition, should be a prerequisite for the nutritional intervention. As in typically-developed children nutritional support should start with dietary advice and the modification of oral feeding, if safe and acceptable. However, for prolonged feeding, in the presence of unsafe swallowing and inadequate oral intake, enteral nutrition should be promptly initiated and early gastrostomy placement should be evaluated and discussed with parents/caregivers. Gastrointestinal problems (oropharyngeal dysfunction, gastroesophageal disease, and constipation) in children with CP are frequent and should be actively detected and adequately treated as they can further worsen the feeding process and nutritional status.