Percutaneous Endoscopic Gastrostomy (PEG)/Gastrostomy Tube Placement Procedure Note

Procedure: Percutaneous Endoscopic Gastrostomy (PEG) / Gastrostomy Tube Placement

Date: [Date]

Procedure Start Time: [Start time] (If unavailable, document "Time not recorded")

Procedure End Time: [End time] (If unavailable, document "Time not recorded")

Location: [Location]

Primary Proceduralist: [Name, credentials]

Assistant(s): [Name(s), credentials] (If none, document "None")

Sedation Provider: [Endoscopist-directed / Anesthesia service / Other]

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Indication: [Enteral feeding / Decompression / Other]

Urgency: [Elective / Urgent / Emergent]

Pre-Procedure

Indication and Medical Necessity

[Brief narrative summarizing: primary diagnosis prompting enteral access, expected duration of use, rationale for PEG over alternatives such as NG/ND tube or radiologic/surgical gastrostomy, and goals of therapy] (2–4 sentences. If a surrogate decision-maker was involved, note relationship and alignment with goals of care.)

Contraindication and Risk Assessment

(Document that each item was assessed. Provide brief clarifying comments for positive findings. If any item was not assessed, state "Not assessed" with reason. Do not infer absence from missing data.)

• Anatomic/technical feasibility: [Transillumination, stomach-to-abdominal wall apposition, absence of interposed structures, prior gastric surgery status]
• Abdominal wall/intra-abdominal concerns: [Infection at site / peritonitis / ascites with degree and management if present]
• Hemodynamic and respiratory stability: [Assessment summary]
• Coagulopathy/thrombocytopenia: [INR, PTT, platelets with values and dates; thresholds applied; correction given if any]
• Goals-of-care discussion: [Summary for patients with advanced dementia or limited life expectancy, including decision-makers and care goals] (If not applicable, document "Not applicable")

Antithrombotic Management

(Include only if patient is on antiplatelet or anticoagulant therapy; otherwise omit this section.)

• Current agent(s) and last dose: [Agent(s) with last administration date/time]
• Periprocedural plan executed: [Held / Continued / Bridged] (Include rationale if non-standard)
• Post-procedure resumption plan: [Agent(s), timing, conditions for resumption]

Informed Consent

Consent obtained from [patient / surrogate with relationship]. Procedure, alternatives, and material risks discussed including bleeding, infection, perforation, aspiration, sedation risks, tube malfunction, buried bumper syndrome, and potential need for surgical intervention. Questions answered. (If emergency consent exception, document the basis and why delay would be harmful.)

Time-Out

Time-out performed immediately before procedure confirming correct patient, procedure, site, allergies, antibiotic prophylaxis plan, and antithrombotic plan.

Prophylaxis and Pre-Procedure Medications

• Antibiotic prophylaxis: [Agent, dose, route, time administered] (Note allergy alternative if applicable)
• Skin preparation: [Prep agent]; sterile technique and draping confirmed
• Local anesthetic: [Agent, concentration, volume, injection site]

Sedation Plan

• Modality: [Moderate sedation / Deep sedation / MAC / General anesthesia]
• ASA Physical Status: [ASA class]
• Monitoring: [Pulse oximetry / Noninvasive blood pressure / ECG / Capnography]
• Personnel model: [Endoscopist-directed with independent observer / Anesthesia service] (If anesthesia-directed, reference separate anesthesia record)

Procedure Details

Preliminary Endoscopy

[Extent of exam and relevant findings] (Describe esophagus, stomach, duodenum as examined; note strictures, ulcers, masses, or other findings affecting PEG feasibility. Document any pre-placement interventions and whether they altered risk.)

Patient Positioning and Site Selection

• Position: [Supine / Other]
• Site selection method: [Transillumination / Finger indentation / Both]; adequate apposition confirmed
• Preparation: Sterile preparation and draping confirmed
• Oxygen delivery: [Room air / Nasal cannula at specified flow / Mask]
• Baseline tolerance: [Statement on patient tolerance at start]

Technique

Technique used: [Pull technique / Introducer (push) technique / Hybrid]

(Include only the technique-specific details that apply.)

• Pull technique: [Site confirmation method; local anesthetic infiltration; skin incision; needle entry into stomach with endoscopic confirmation; guidewire placement and retrieval; tube passage through oropharynx and out abdominal wall; internal bumper seating; external bolster applied]
• Introducer technique: [Gastropexy/T-fasteners: number placed and planned removal timing; tract creation/dilation method; tube insertion and seating; external bolster applied]
• Conversion: [Reason for conversion and steps completed] (Include only if conversion occurred)

Device Specifications

• Tube Type: [PEG / G-tube]; [Bumper / Balloon]; [Low-profile / Standard]
• Size: [French size]
• External Bumper Distance from Skin: [Measurement in cm] (If not measured, document "Not measured")
• Balloon Volume and Fill Solution: [Volume in mL and solution] (If bumper tube, document "Not applicable")
• Dressing: [Dressing type applied]
• Securement device: [Device used / None]

Confirmation of Placement

• Endoscopic confirmation: Intragastric position confirmed
• Patency check: [Flush and/or aspiration performed; result]
• Hemostasis: [Stoma and gastric puncture site assessed; hemostasis confirmed / intervention required]

Sedation Medications

(If anesthesia-directed, document "Sedation per anesthesia record" and note any anesthesia-related complications affecting outcome.)

• Agents and total doses: [Medication(s), total dose, route]
• Reversal agents: [Agent and dose / None]
• Sedation time frame: [Start time – Stop time] (If time-based billing applies)
• Notable events: [Significant vital sign changes, desaturation, or hypotension / None]

Specimens

[Specimen source(s), labeling, and destination / No specimens obtained]

Complications

[No immediate complications / Description of adverse event(s) including timing, severity, interventions performed, and patient response] (Always complete this section. If procedure aborted, document reason and next-step plan.)

Estimated Blood Loss

[Numeric estimate in mL / Minimal]

Post-Procedure

Immediate Condition and Disposition

• Patient tolerance: [Hemodynamic and respiratory stability; pain/nausea status]
• Recovery location: [Endoscopy recovery / PACU / ICU / Ward]
• Disposition: [Home / Return to ward / ICU / Other]

Feeding Initiation Plan

• When tube may first be used: [Specific time or interval post-placement]
• Initial regimen: [Continuous / Bolus]; [Starting rate or volume]
• Advancement: [Stepwise plan or reference to nutrition protocol]
• Aspiration precautions: [Head-of-bed elevation parameters]
• Hold feeds and notify team if: [Abdominal pain, distension, fever, leakage, vomiting, respiratory distress]

Tube Care Instructions

• External bolster: Maintain 1–2 cm slack from abdominal wall; avoid excessive tension
• Site care: [Cleaning protocol and dressing change frequency]
• Tube mobilization/rotation: [Instructions and timing] (Contraindicated for PEG-J or jejunal extension)
• Flush protocol: [Volume and frequency; before/after medications and feeds]
• Securement: [Method to prevent accidental dislodgement]
• Warning signs requiring evaluation: [Infection, bleeding, leakage, tube migration]
• T-fasteners: [Number placed; removal timing; responsible service] (Include only if placed)

Follow-Up

• Contact for concerns: [Service and phone number]
• Tube exchange timing: [Earliest exchange date if applicable]
• Red flags requiring urgent evaluation: Peritonitis signs, severe abdominal pain, uncontrolled bleeding, tube dislodgement before tract maturity (typically 2–4 weeks)

Antithrombotic Resumption

[Resumption plan with timing and conditions / Defer to ordering service] (Include only if applicable.)

Attestation

[Electronic signature, credentials, date/time]

(If trainee involvement, document attending supervision level and key portions performed by each participant.)