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Nutrition in Acute Stroke. Andreas H. Leischker, M.D., M.A. Head Working Group „Neurology“, German Society for Nutritional Medicine Working Group „Nutrition in Stroke“, ESPEN. Nutrition in Acute Stroke: How it started. Baseline.
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Nutrition in Acute Stroke Andreas H. Leischker, M.D., M.A. Head Working Group „Neurology“, German Society for Nutritional Medicine Working Group „Nutrition in Stroke“, ESPEN
Baseline No national and no international Guidelines on nutrition in acute stroke
Ten years ago… First meeting of a interdisciplinary working group „ Nutrition in patients with acute stroke“ August 2005 Frankfurt/Germany
Working Group Members • Rainer Wirth (Geriatrician, DGEM and DGG) • E.W. Busch (Neurologist, DGN) • Beate Schlegel ( Nutritionist, DGEM) • Kristian Hahn ( Geriatrician, DGG) • Jens Kondrup ( Nutritionist , ESPEN) • Andreas Leischker (Geriatrician, DGEM and DGG) andreas.leischker@alexianer.de
German Guideline- Societyes German socirétyforNeurology(DGN) German Society forGeriatrics (DGG) German Society for Nutritional medicine (DGEM)
Two years later..First Milestone „DGEM-Guideline Nutrition of patients with acute stroke“ • Review by the Medical Societyes DGEM, DGN und DGG • Aktuell. Ernähr Med 2007;32:332-348 andreas.leischker@alexianer.de
3 years later….. Expirydateofguidelineisexhausting. andreas.leischker@alexianer.de
DGEM Guideline Clinical Nutrition„Neurology“ • Stroke • Parkinsons Disease • Huntingtons Disease • Multiple Sclerosis andreas.leischker@alexianer.de
“Guideline Clinical Nutrition in patients with stroke” Wirth R, Smoliner C, Jäger M, Warnecke T, Leischker AH, Dziewas R and the DGEM Steering Committee, Experimental & Translational Stroke Medicine 2013, 5:14 http://www.etsmjournal.com/content/5/1/14 andreas.leischker@alexianer.de
4023 without dysphagia 2007 Normal nutrition 2016 Normal nutrition PLUS ONS FOOD Trial Part 1- ONSDennis M, Lewis, S, Cranswick G Health Technology Assessment 2006 Randomisation within one month after admission andreas.leischker@bonifatius-lingen.de
Average amount of ONS per patient 14 liters 34 days andreas.leischker@bonifatius-lingen.de
FOOD Trial Part 1Dennis M, Lewis, S, Cranswick G: Health Technology Assessment 2006 27,9 % of patients did not tolerate ONS
100% 80% Rankin 0 Rankin 1 60% Rankin 2 Percentage of patients Rankin 3 Rankin 4 40% Rankin 5 Dead 20% 0% Normal diet Normal diet plus supplements Allocated treatment Modified Rankin Scale after 6 month´s andreas.leischker@bonifatius-lingen.de
FOOD Trial Part 1:Pressure sores during hospital stay • No ONS: 1,3 % • ONS: 0,7 % P= 0,05
ONS is not recommended in general Recommendation ONS
Who shouldrecieve ONS Patients with • malnutrition • riskformalnutrition • Riskforpressuresores AWMF Leitlinie Ernährung des Schlaganfallpatienten 2007
„Patients with prolonged dysphagia anticipated to last for more than 7 days should receive tube feeding (within 72 hours) (C)
Dysphagia Screening • Water Swallowing Test ( WST) • Multiple Consistency Test( Gugging Swallowing Screen,GUSS) • Swallowing Provocation Test andreas.leischker@alexianer.de
Dysphagia Screening • Screening for malnutrition should start as early as possible, on the latest within 48 hours after admission (C) • When the patient is in a clinically stable condition, the screening is repeated in weekly intervals during the first month. When the clinical condition changes, screening should be repeated earlier (C). AWMF Leitlinie 2007
Assessment Stroke patients without pathological findings in the initial bedside testing (dysphagia screening) should be referred to a further swallowing assessment if other known clinical predictors of dysphagia are present, such as • a severe neurological deficit, • marked dysarthria or aphasia • a distinct facial palsy Grade C Recommendation andreas.leischker@alexianer.de
Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) andreas.leischker@alexianer.de 25 andreas.leischker@alexianer-krefeld.de
Good news:Prevalenceofdysphagiafollowingacutestroke • First day: about 50 % • After six weeks:6,7 % • After sixmonths: 3,2 % N.B.: About 10 % ofpatientsgetsecondstrokewithinthefirstweek after admission !
Dysphagia follow up after discharge At least once per month duringthefirst 6 months
Nasogastric or PEG ? andreas.leischker@alexianer.de
321 pts with dysphagia 162 PEG 159 nasogastral FOOD Trial 3 - PEG vs NG Randomization within 1 week andreas.leischker@alexianer.de
100% 11.1% 18.9% MRS 0 to 3 BetterOutcome = 7.8% (p= 0.0504) 90% 80% 33.3% MRS 4 to 5 40.1% 70% 60% Percentage of patients 50% 40% 30% 47.8% Dead 48.8% 20% 10% 0% NG PEG Allocated treatment Food Trial 3 – Outcome at Follow-Up andreas.leischker@alexianer.de
NG tube andreas.leischker@bonifatius-lingen.de
“Food for Thought ?” andreas.leischker@bonifatius-lingen.de
How are patients fed 6 months later ? andreas.leischker @maria-hilf.de
100% 29.0% 38.4% 80% Normal NG 21.0% 60% 12.0% PEG Percentage of patients 40% Dead 47.8% 48.8% 20% 0% NG PEG Allocated treatment Feeding 6 months after stroke andreas.leischker@bonifatius-lingen.de
If a sufficient oral food intake is not possible during the acute phase of stroke, enteral nutrition should be preferably given via a nasogastric tube andreas.leischker@alexianer.de
“Tube feeding does not interfere with swallow training. Therefore, dysphagia therapy shall start as early as possible also in tube fed patients” Grade A andreas.leischker@alexianer.de
If enteral feeding is likely for a longer period of time (> 28 days), a PEG should be chosen and placed in a stable clinical phase (after 14 – 28 days) (A). AWMF Leitlinie Enterale Ernährung des Schlaganfallpatienten 2007 andreas.leischker@maria-hilf.de
Who shouldget a PEG earlyer? Mechanically ventilated stroke patients should receive a PEG at an early stage (B)
What to do if patients put out the NG tube andreas.leischker@bonifatius-lingen.de
If a nasogastric tube is rejected, not tolerated or repeatedly removed by the patient and if artificial nutrition will probably be necessary for more than 14 days, early feeding via PEG should be started (C). AWMF Leitlinie Enterale Ernährung des Schlaganfallpatienten 2007
Nasal Bridle/Loop A nasal bridle ( nasal loop) is an effective alternative” Anderson Meet al 2004 Beavan J et al 2010 andreas.leischker@alexianer.de
In stroke patients tube feed should preferably be applied with a feeding pump (C).AWMF Leitlinie Enterale Ernährung des Schlaganfallpatienten 2007
Outlook European Society for Parenteral and Enteral Nutrition ( ESPEN) European Guideline on nutrition in stroke „in progress“…
The Coffee Paradox in Stroke • > 3 cups per day linked with fewer strokes (OR 0.44, 95% CI 0.22-0.87, P < 0.02) in healthy subjects • “Heavier daily coffee consumption is associated with decreased stroke prevalence, despite smoking tendency in heavy coffee drinkers” Liebeskind DS, Sanossian N, Fu KA, Wang HJ, Arab L. The coffee paradox instroke: Increasedconsumptionlinkedwithfewerstrokes. NutrNeurosci. 2015 Jun 22. [Epubaheadofprint]
