International Journal of Clinical Medicine, 2013, 4, 369-373 Published Online August 2013 (
Reduced Fasting Protocol for Endoscopic Percutaneous
Gastrostomy in Intubated Patients
Catherine Ho, John Culhane
Department of Surgery, Arrowhead Regional Medical Center, Colton, USA
Received May 1st, 2013; revised June 13th, 2013; accepted June 28th, 2013
Copyright © 2013 Catherine Ho, John Culhane. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Previous studies have shown that ICU patients receive only a fraction of their calculated nutritional goals,
and that cumulative caloric deficit in the ICU has been correlated with poor outcome. One reason for this underfeeding
is the frequent interruption of enteral nutrition. Many ICU patients receive enteral feeding formula via a nasogastric
(NG) tube. Feeding is typically held for several hours prior to procedures due to the theoretical risk of aspiration. An
alternative is to continue feeding up until the procedure begins, then stop the feeding and place the NG to suction. This
evacuates the contents of the stomach and minimizes the risk of aspiration, while reducing the interruption of feeding
that can result in malnutrition. Methods: This study is a review of prospectively gathered data including 55 sequential
patients who underwent bedside percutaneous endoscopic gastrostomy (PEG) placement in a mixed ICU under a re-
duced fasting protocol. This was compared with a historical cohort of 33 critically ill trauma patients who fasted for at
least 8 hours prior to the procedure. Under the reduced fasting protocol, enteral feeding via NG was continued up until
the time of the procedure. The NG was then placed to suction, and sedation was given. The NG was left in place until
the esophagus was cannulated, then it was removed. The PEG was placed in standard fashion, and feeding was resumed
via the PEG immediately following the procedure. Results: We have documented no peri-procedural vomiting or aspi-
ration. New diagnosis of pneumonia within 3 days occurred in 2/55 of the feeding group and 4/33 of the fasting group.
Overall mortality was higher for the feeding group: 13/55 vs. 1/33, however when adjusted for baseline characteristics,
the difference was no longer significant. Under our protocol, the interruption of feeding averaged approximately one
hour, rather than the 8 or 9 hour interruption required by standard protocols. This saved an average of approximately
700 kilocalories per patient. Conclusion: We believe that continuing feeding via NG up until the time of bedside PEG
is safe and advantageous for intubated patients in the ICU. Since there was minimal gastric content, it may also be safe
for other procedures.
Keywords: Aspiration; Gastrostomy; PEG; NPO; Pneumonia; ICU; Feeding; Enteral; NG Tube; Fasting
1. Introduction
Adequate nutrition is essential for recovery from severe
illness. ICU patients typically receive only a fraction of
their calculated nutritional goals [1], and cumulative ca-
loric deficit in the ICU has been correlated with poor
outcome [2,3]. One reason for this underfeeding is the
frequent interruption of enteral nutrition. Many ICU pa-
tients receive enteral feeding formula via a nasogastric or
orogastric tube. Tube feeding is typically held for several
hours prior to procedures due to the theoretical risk of as-
The American Society of Anesthesiologists has re-
cently published practice guidelines for recommended
fasting intervals for elective surgery in healthy patients
[4]. These guidelines are often applied to intubated pa-
tients receiving enteral feeding as well, but they are not
intended for this patient population. There is little evi-
dence in the literature to guide decisions about pre-pro-
cedural fasting in intubated patients with feeding tubes.
In an effort to minimize interruptions in feeding, we
have developed a protocol to minimize the NPO period
for bedside PEG. We continue feeding up until the pro-
cedure begins, then stop the feeding and place the NG
tube to suction. This evacuates the stomach and mini-
mizes the risk of aspiration. This protocol has the benefit
Copyright © 2013 SciRes. IJCM
Reduced Fasting Protocol for Endoscopic Percutaneous Gastrostomy in Intubated Patients
of reducing interruptions of feeding that can result in
2. Methods
This study is an analysis of prospectively gathered data.
Fifty five sequential patients underwent bedside PEG
placement in the ICU according to our protocol. All pa-
tients were already intubated. Enteral feeding via NG
was continued up until the equipment was mobilized for
the procedure. At that time, the NG was placed to suction,
and sedation was given. The NG was left in place until
the esophagus was cannulated, then it was removed. The
PEG was then placed in standard fashion, and feeding
was resumed via the PEG immediately after the proce-
dure. These patients compose the feeding group.
We used our trauma registry to identify a control group
of patients who had PEG’s placed after the standard NPO
period, usually after midnight the previous day. These
patients compose the fasting group.
A qualitative description of the stomach contents and
any evidence of aspiration during the procedure were do-
cumented when the procedure was done. The charts were
reviewed to determine whether pneumonia was diag-
nosed within three days of the procedure. Radiology re-
cords were reviewed to assess any radiologic evidence of
new pneumonia during this time period.
The procedures for the feeding group were all per-
formed by the second author, a surgeon and intensivist,
with assistance from residents. The procedures for the
fasting group were mostly performed by the gastroen-
terology group covering our hospital. A few of the pa-
tients who had PEG’s done by the surgeon were fasting
for other reasons and were included in the fasting group.
Diagnosis of pneumonia was made using American Tho-
racic Society guidelines: new infiltrate, fever, purulent
sputum, and leukocytosis.
The study was approved by the Arrowhead Institu-
tional Review Board.
3. Patients
The patient population was a group of critically ill pa-
tients at Arrowhead Regional Medical Center, a Level 2
Trauma Center located in Colton, California. The popu-
lation was a mixture of medical and surgical ICU patients,
including many trauma patients.
4. Statistics
Comparisons between groups were made using Student’s
t-test for continuous data and Fisher’s Exact Test or
Pearson’s Chi square test for categorical data. Microsoft
Excel spreadsheet was used to tabulate the data and to
perform the calculations.
5. Results
5.1. Baseline Characteristics
Feeding Fasting
Age 47.7 45.8 p = 0.6
Gender (m/f)36/19 20/13 p = 0.7
Trauma 22/55 33/33 p 0.001
(For PNA) 33/55 19/33 p = 0.7
5.2. Outcome
Feeding Fasting
Pneumonia 2/55 4/33 p = 0.2
X-ray change6/55 4/33 p = 1
Aspiration 0/55 NR
Mortality 13/55 1/33 p = 0.004
Trauma Mortality2/22 1/33 p = 0.6
5.3. Description of Gastric Contents
Trace fluid 9 patients
Coating of formula on mucosa 9 patients
Clean 40 patients
We have documented no peri-procedural vomiting or
aspiration. In addition, when the stomach was visualized
during endoscopy for PEG, the gastric contents have
been minimal. There was no large pool of gastric con-
tents in any patient. We used a qualitative assessment of
the gastric contents because it would have been difficult
to measure the exact amount. Residual gastric contents
are often viscous due to thick formula or mucous secre-
tions. Aspirating all of the fluid to measure the volume
would have added significant time to the procedure, pos-
sibly increasing risk to the patient.
The overall mortality for the feeding group is higher,
however we believe this is due to baseline differences.
The records for the fasting group were obtained from a
trauma registry; hence they are all trauma patients. The
feeding group represents a mixed ICU population. Mor-
tality in the trauma subgroup of the feeding group was
not significantly higher than that of the fasting group.
Trauma patients tend to be healthier at baseline, therefore
those who survive their initial injuries long enough to
need a PEG are more likely to survive to discharge.
In order to investigate whether the mortality could be
related to the feeding protocol, we examined the cause of
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Reduced Fasting Protocol for Endoscopic Percutaneous Gastrostomy in Intubated Patients 371
death for every patient in the feeding group who died.
The results were:
Care withdrawn due to brain disease or injury: 10;
Tracheo-innominate fistula: 1;
Abdominal sepsis due to necrotic large bowel on high
dose steroid therapy: 1;
Pneumonia 5 months after the PEG was placed: 1.
Almost all of the deaths were a result of family and
physicians withdrawing life support due to poor neu-
rologic prognosis. Only one death was due to pneumonia,
and this happened 5 months after the PEG procedure. It
is unlikely that any of these deaths were due to the feed-
ing protocol.
Although there was no gross vomiting or aspiration
during the endoscopy, there could have been micro aspi-
ration, which theoretically could have led to pneumonia.
To investigate this possibility, we looked back to see
which patients had treatment for pneumonia initiated
within three days following the procedure. We also
looked to see if there were any changes in chest X-rays
following the PEG. There was no evidence of increased
pneumonia or chest x-ray changes for the feeding group.
Under our protocol, the interruption of feeding aver-
aged approximately one hour, rather than the 8 or 9 hour
interruption required by standard protocols. This saved
an average of about 700 kilocalories per patient. This
does not take into account multiple periods of fasting due
to cancellation and rescheduling of procedures.
6. Discussion
There is little evidence of any improvement in outcome
due to pre-procedure fasting in intubated ICU patients,
but there is evidence that underfeeding may be harmful.
Multiple studies have shown a statistically significant
reduction in mortality and infectious complications with
early enteral nutrition [2,5,6]. The initiation of enteral
nutrition leads to improved patient outcomes as it may
reduce inflammatory cytokines, improve immune func-
tion, reduce septic complications, and promote wound
healing. Overall, studies have demonstrated that enteral
feeding reduces infectious morbidity, hospital length of
stay, and multiple organ failure [6]. Critical care nutrition
guidelines therefore support early enteral nutrition as the
preferred method of providing nutrition to critically ill
patients [2,6,7].
Critically ill patients generally exhibit increased meta-
bolic rate, however, their high metabolic needs are often
inadequately met. Observational studies have shown that
up to 40% of critically ill patients receive no nutritional
support during their ICU stay. Also, 60% of patients who
stay in the ICU at least 3 days remain unfed for 48 hours
or longer [6]. In those patients who are receiving nutria-
tion, interruptions in feeding occur when procedures ei-
ther at the bedside or in the operating room require a
fasting interval prior to the intervention. Underfeeding in
surgical or mixed medical-surgical ICUs is a widely rec-
ognized issue [1].
There is no consensus on withholding feeding for pro-
cedures. Schneider at al. performed a survey study com-
paring the practices of anesthesia, anesthesia critical care,
surgical critical care, and medical critical care depart-
ments in the length of time necessary for withholding
enteral feeding from intubated patients before scheduled
procedures, including extubation and tracheostomy [8].
Significant findings of this study showed that for sched-
uled tracheostomy, surgical critical care departments re-
ported withholding enteral feeding for a median of 4
hours versus all other departments with a median of 6
hours. The fasting interval prior to a procedure in an in-
tubated patient is still debatable and varies in practice.
The American Society of Anesthesiologists has pub-
lished recent practice guidelines for recommended fast-
ing intervals for elective surgery in healthy patients [4].
These guidelines are often applied to critically ill patients
receiving enteral feeding, although they were not in-
tended for this population. The standard 8-hour fasting
period is often extended when procedures are delayed
from the scheduled time. The ideal caloric intake for
most patients in critical care is 25 to 30 kcal/kg/24 hours.
During the 8-hour fasting interval, an average loss of ap-
proximately 700 kilocalories occurs, thereby increasing
the cumulative caloric deficit.
The preoperative standard fasting interval was estab-
lished due to concerns for aspiration of gastric contents;
however the risk posed by gastric contents may be over-
stated. Previous studies have examined the utility of the
use of gastric residual volumes (GRV) in the monitoring
of tube-feeding intolerance. The frequency of gastric
residual volume assessment and the threshold at which
feeding should be withheld is controversial. There are
various feeding protocols and recommendations reported
in the literature, mostly with a threshold GRV of </= 200
ml. A recent study has shown that over a wide range of
GRV, there is no correlation of GRV to aspiration events
[9]. Sorosky et al. developed a protocol which initiates a
full caloric target delivery rate, allows a larger GRV
threshold of up to 500 ml before withholding feeding,
and decreases the number of GRV assessments to once
per day [10]. The study showed no correlation between
GRV values and the rate of pneumonia or other outcome
variables such as the length of ICU stay, duration of me-
chanical ventilation, or ICU and hospital mortality. In the
subgroup of patients who developed ventilator-associated
pneumonia, patients with and without VAP had similar
GRV’s during the study. Of the vomit/regurgitation epi-
sodes in 13 patients only one patient developed ventilator
associated pneumonia (VAP). In the studies of the bene-
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Reduced Fasting Protocol for Endoscopic Percutaneous Gastrostomy in Intubated Patients
fit of early enteral feeding, there was a small statistically
significant increase in rates of vomiting; however, no
complications resulted from the emesis [11]. GRV has
also been evaluated in comparing gastric to postpyloric
feeding. The use of postpyloric feeding showed reduced
GRV but no difference in aspiration pneumonia was seen
between the two routes of feeding [7].
There are theoretical reasons why intubated patients
may not benefit from pre-procedural fasting. Fasting
does not guarantee an empty stomach. Gastric contents
contain a mixture of feedings, gastric and salivary secre-
tions and duodenal reflux. Endogenous secretions can
amount to as much as 4.5 liters per day [12]. Even when
the patient is NPO we rely on gastric peristalsis and as-
piration via gastric tubes to ensure gastric emptying. Re-
gular checks for residual volume can prevent accumu-
lation of large gastric volumes even during continuous
tube feeding. A cuffed endotracheal tube may provide
some protection against aspiration, though it is not abso-
lute. Suction through the NG tube can evacuate residual
stomach contents immediately prior to the procedure.
Previous studies have shown that the fasting period for
procedures in intubated patients can be safely reduced or
eliminated. In a study from Shriners Burn Institute, Jen-
kins et al. studied the safety and efficacy of providing
enteral support throughout the operative procedures in
eighty burn patients [13]. Forty patients received enteral
feeding throughout 161 surgical procedures, and 40 pa-
tients had enteral support withheld during 120 procedures.
Nutritional status, calorie counts, and infectious compli-
cations were studied during the first 4 weeks after the
burn injury. The unfed group was found to have signifi-
cant caloric deficit, increased occurrence of wound infec-
tions, and increased albumin supplementation. No pa-
tients in either group experienced aspiration. This study
supports the use of peri-operative enteral feeding to ma-
ximize nutrition for better outcomes and does not show a
negative impact of peri-operative feeding such as aspira-
Pousman et al. implemented a new protocol to re-
duced fasting interval in mechanically ventilated trauma
patients undergoing selected operative and non-operative
procedures [14]. The standard group adhered to the mini-
mum 8-hour fast prior to procedures while the intervene-
tion group permitted patients to receive small bowel feed-
ing up until the time of the procedure. Intragastric feed-
ing continued until 45 minutes prior to the procedure, at
which time the gastric tube was flushed and aspirated.
Although no statistical significance was shown, there
was a trend demonstrating increased delivery of enteral
nutrition and faster achievement of nutrition goals in the
intervention group. Furthermore, there were no differ-
ences in rates of infectious complications including ven-
tilator-associated pneumonia between the two groups.
The authors thus concluded that a reduced fasting proto-
col was possible for selected operative procedures with
improved nutrition support and no increase in complica-
Silent aspiration is common, but generally clinically
insignificant [15], however, witnessed aspiration during
intubation that leads to pneumonia is rare, even in pa-
tients who have not been fasting. Thibodeau et al. re-
corded a 3.5% rate of aspiration during ER intubations,
with none of these patients developing pneumonia [16].
It would be difficult to show that any intervention leads
to an outcome difference for such a rare event. The evi-
dence for benefit of fasting often relies on the surrogate
variable on volume of gastric contents [4]. A strength of
our study is that gastric contents which could potentially
cause aspiration were visualized directly. Gastric volume
was found to be minimal using our protocol.
This study is subject to certain limitations. The NPO
group was a historical control. Information was not pro-
spectively gathered as it was for the feeding group. As-
piration during the procedure for the NPO population
was not specifically mentioned, but no such event was
ever documented on review of the procedure reports. The
gastric contents were seldom described. Many of our pa-
tients were receiving empiric treatment for pneumonia at
the time of the PEG procedure. The incidence is consis-
tent with previous reports in the literature. Two recent
studies of ICU enteral feeding practices reported ventila-
tor associated pneumonia incidence of 41% to 50% [14,
7. Conclusion
In this study, we have shown that it is safe to eliminate a
fasting interval prior to percutaneous endoscopic gas-
trostomy in intubated patients receiving enteral feeding.
Eliminating the fasting period does not lead to increased
complications from aspiration. Our protocol served to
minimize interruption of enteral feeding, thereby maxi-
mizing caloric intake of critically ill patients. We believe
that continuing enteral feeding via NG up until the time
of bedside PEG is safe and advantageous for intubated
patients in the ICU. In addition, since we never saw more
than minimal gastric contents for any patient, the risk of
vomiting and aspiration should be low for any procedure.
This could have implications for the time needed to hold
feeding for other procedures, including surgery in the
operating room.
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