Matthew Edwardson, MD

Dubin P, Boehme A, Siegler J, Shaban A, Sudkamp J, Albright K, et al. New Model for Predicting Surgical Feeding Tube Placement in Patients With an Acute Stroke Event. Stroke. 2013

Prediction of which stroke patients will eventually require surgical feeding tube placement is challenging, and having this knowledge early in the hospital course would facilitate reduced length of stay. Dubin and colleagues addressed this problem by developing the PEG score.

The authors retrospectively analyzed data from 407 patients with ischemic or hemorrhagic stroke admitted to Tulane University Hospital. Using logistical regression analysis they came up with separate “PEG” scores for ischemic and hemorrhagic stroke (ischemic stroke PEG score: age >80 years=1, 24-hour NIHSS score 8-14=1, NIHSS >14=2, black race=1, cortical location=1; hemorrhagic stroke PEG score: 24-hour NIHSS score 8-14=1, NIHSS>14=2, black race=1, midline shift >3mm=1, edema on follow up head CT=1). A PEG score ≥ 3 was highly predictive of surgical feeding tube placement in both groups (OR 15.68 and 12.49 for ischemic and hemorrhagic stroke respectively). 

Before you rush to send all of your patients with high PEG scores for surgical feeding tube placement on hospital day 2, some peculiarities of this study suggest further validation is warranted. Baseline dysarthria and level of consciousness were important variables in prior prediction algorithms, but were not significant in the PEG score analysis. Possibly more concerning, black race was predictive in the PEG score analysis. To my knowledge, there is no physiologic reason why those of black race should have more difficulty recovering swallowing ability after stroke. This might suggest that the small subset of patients with black race had worse strokes than the rest of the cohort. Other possibilities include a cultural reason for poor participation in swallowing trials or bias on the part of the speech pathologist and/or physician that those of black race were less likely to recover swallowing ability. The authors should be commended for trying to advance our knowledge of a poorly studied aspect of post-stroke management. However, the questions raised here suggest further work is required to validate the PEG score using data from other stroke registries or in prospective fashion.