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Hvidovre HospitalStaff meeting 17. januar 8.15 - 9.00
Ernæring er et vigtigt element i patientbehandlingen.
Opdatering af den videnskabelige baggrund for screening og ernæringsterapi hos indlagte
patienter
Malnutrition
Impairedfunction
Low intake Inflammatorymetabolism
Increasedrequirements
Decreasedrequirements
Complicationsaccording to
primary condition
DiseaseStarvation
-
Screening: NRS 2002
SD 1 2 3 Outcome Outcome Outcome
NS Pos No Pos No Pos No
0
inf/GI surg/PN (1) tox/canc/ON (2) LOS/femur/ON (3) LOS/fem/ON (4) surv/fem/EN (5)
muscl/GI surg/PN (6) muscl/COPD/ON (7) compl/GI surg/PN (8) compl/canc/ON (9) compl/GI surg/EN (10) inf/GI surg/EN (11) inf/cirrh/EN (12) inf/GI surg/PN (13) inf/spine/ (14) tox/canc/ON (15) tox/canc/PN (16) surv/canc/PN (17)
inf/trauma/EN (18) inf/GI surg/PN (19) inf/GI surg/EN (20) LOS/GI surg/PN (21)
inf/GI surg/PN (22) inf/traum/EN (23) inf/GI surgPN (24) compl/GI surg/PN (25) compl/GI surg/PN (26) compl/GI surg/PN (27)
inf/burns/EN (28) LOS/traum/EN (29) surv/traum/PN (30) surv/BMT/PN (31)
LOS/traum/EN (32) surv/burns/PN (33)
1
ADL/geria/ON (34) QL/canc/EN (35) CI/cirrh/PN (36) inf/GI surg/EN (37) inf/ GI surg/PN (38) tox/canc/PN (39) tox/canc/PN (40) tox/canc/ON (41) enc/cirrh/EN (42) surv/GI surg/PN (43) surv/canc/PN (44) surv/geria/ON (45)
QL/canc/ON (46) QL/canc/ON (47) QL/HIV/ON (48) inf/canc/PN (49) inf/pancr/PN (50) inf/GI surg/PN (51) inf/GI surg/PN (52) inf/ GI surg/PN (53) inf/spine/PN (54) inf/ GI surg/PN (55) muscl/COPD/ON (56) muscl/COPD/ON (57) compl/ GI surg/PN (58) compl/cirrh/PN (59) compl/canc/PN (60) compl/canc/ON(61) compl/cirrh/PN (62) tox/canc/PN (63) tox/canc/PN (64) tox/canc/PN (65) rec/canc/PN (66) resp/canc/PN (67) resp/canc/PN (68) resp/ canc/EN (69) resp/canc/ON (70) tox/canc/ON (71) surv/canc/PN (72) surv/canc/PN (73) surv/canc/ON (74) surv/cirrh/PN (75) surv/cirrh/PN (76)
compl/ GI surg/PN (77) compl/ GI surg/PN (78) inf/ GI surg/ON (79) inf/ GI surg/PN/EN (80) inf/cirrh/EN (81) inf/ GI surg/ON (82) inf/ GI surg/EN (83) inf/ GI surg/EN (84) ADL/geria/ON (85) LOS/ GI surg/EN (86) compl/ GI surg/PN (87) LOS/cirrh/PN (88) surv/ATIN/PN (89) surv/ATIN/PN (90) surv/canc/PN (91) surv/stroke/ON (92) surv/cirrh/ON (93)
inf/GI surg/PN (94) inf//GI surg/PN (95) inf/GI surg/PN (96) inf/BMT/PN (97) inf//GI surg/PN (98) inf//GI surg/PN (99) inf/GI surg/PN (100) compl/GI surg/PN (101) compl//GI surg/ (102) compl/GI surg/PN (103) compl/GI surg/PN (104) compl//GI surg/EN (105) compl/BMT/PN (106) LOS/GI surg/EN (107) surv/ATIN/PN (108) surv/ATIN/PN (109)
None None
2
wound/GI surg/PN (110) inf/cirrh/ON (111) muscl/COPD/EN (112) muscl/COPD/ON (113) walk/COPD/ON (114) walk/COPD/ON (115) tox/cancer/EN (116) LOS/femur/EN (117) surv/cirrh/ON (118) surv/cirrh/EN (119) surv/HIV/PN (120)
CI/GI surg/PN (121) walk/COPD/ON (122)
inf/GI surg/PN (123) compl/GI surg/PN (124) survival/GI surg/PN (125)
compl/ATIN/PN (126) None None
Kondrup et al. Clin Nutr 2003;22:321-36.
Euro-OOPS:Analysis of 5051 patient admissions in 24 departments in 12 countries in
Europe & Middle East
Complications and nutritional risk (NRS 2002)% (N)
NoComplication
Non-infectious Complication
InfectiousComplication
Total
Not at-risk 89 (3021)
6(218)
5 (165)
100 (3404)
At-risk 69*(1143)
16*(270)
14*(234)
100 (1647)
* P<0.001
Complications were independenly associated with NRS-2002 components (nutritional status or severity of disease), also when adjusted for:
Speciality (geriatry, gastroenterology, oncology, internal medicine, surgical, ICU)Diagnoses (19 most frequent)ComorbiditySurgery
CancerAgeRegion (Western Europe, Eastern Europe, Middle East)
Sorensen et al. 2008. Clin Nutr 27: 340-9.
Type of complications
NS
P<0.001
P<0.001
P<0.001
P<0.001
NS
NS
P<0.001
NS
NS
P=0.020P=0.003
NS
NSP<0.001
P=0.002
P=0.010
P<0.001
P=0.005
NS
P=0.003
P<0.001
P=0.002
NS
NS
P<0.001
NS
0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0 4,5 5,0
M Cardiac failure grade 1
M Cardial arrhytmia
M Kidney failure grade 2
M Lobar atelectasis
S Anastomosis leakage
S Anoxic encephalopathy
S Bile duct obstruction
S Cardiac arrest
S Decubitus
S Deep venous thrombosis
S GI-bleeding
S GI-perforation, obstruction or ischemia
S Hepatic Encephalopathy
S Postoperative bleeding
S Pulmonary emboli
S Respiratory failure grade 2
S Wound dehiscence
M Urinary infection: cystitis
M Wound infection grade 3
S Gastroenteritis
S Intraperitoneal abscess
S Other urinary infections (pelvis, urether, urethra)
S Pulmonary infection grade 1-3
S Sepsis and/or bacteriaemia
S Septic shock
S Skin infection
S Upper respiratory infection
Non
-inf
ectio
usIn
fect
ious
At risk
Not at risk
Sorensen et al. 2008. C
lin Nutr 27: 340-9.
Primary disease determines type of complication- nutritional status makes it happen
Death and complications after surgery in the EuroOOPS studyTotal mortality: 80/2193 = 3.7%
Not at risk
Complications, N Death, N (%)
Y 200 6 (3.0)
N 1414 1 (<)
Total 1614 7 (0.4)
At risk
Complications Death, N (%)
Y 220 63 (28.6)
N 359 10 (2.7)
Total 579 73 (13)
Log regression:OR for DeathAt-risk: 13.1Complication: 12.5
NS:AgeComorbidityCancer
Unpublished secondary analysis
Treatment improves outcome
Control Intervention
Energy intake, kcal 1115 ± 381 1553 ± 3411)
Protein intake, g 44 ± 17 65 ± 161)
% reaching 75% of energy target 30 831)
Complications, % 20 62)
SF-36 Physical Summary 32 ± 9 37 ± 113)
Re-admissions in 6 mths, % 46 274)
1)P<0.001 2) P = 0.035 3) P = 0.030 4) P = 0.027
Starke et al. Clin Nutr 2011;30:194-201.
2 N = 132 patients at risk (NRS-2002) in a department of general internal medicine were randomized to standard treatment or individual nutrition care. Mean ± SD
Early enteral nutrition within 24h of colorectal surgery versus later commencementof feeding for postoperative complications.
…there is no obvious advantage in keeping patients ’nil by mouth’ following gastrointestinal surgery, and this review support the notion on early commencement of enteral feeding.
Andersen et al. Cochrane Database of Systematic Reviews 2006, Issue 4. Update 2011
RCT: Complications % mortality
Evidence for nutrition support:Meta-analysis of
27 RCTs with 1710 patients (complications) and 30 RCTs with 3250 patients (mortality).
Neurology, GI disease, liver disease, malignant disease, elderly, abdominal surgery, orthopaedic surgery, critical illness/injury, burns.
Hospital or communityOral supplements or tube feeding
Complications 28% vs. 46%1)
Infections2) 24% vs. 44%1)
Mortality 17 % vs. 24%1)
1) P <0.001; 2)10 RCTs only
Stratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003
Hvorfor screenes for nyligt kostindtag?
30 d mortality and intake at a lunch on Nutrition Day 200612,727 hospitalised patients examined on the same day, in 748 wards from 16 different specialties in 256 hospitals and 25 countries.Hiesmayr et al. Clin Nutr 2009;28:484-91
Portion of lunch eaten N HR P
All 4,477 1.00
About 50% 2,999 1.28 NS
About 25% 1,323 1.97 <0.0001
Nothing (eating allowed) 644 2.71 <0.0001
Adjusted for age, gender, affected organ systems, comorbidities, previous ICU stay, LOS before NutritionDay, number of drugs, specialty, number of beds, dedicated nutrition care, ability to walk, help needed, BMI, weight loss/3 months, amount eaten during the last week, number of snacks eaten on NutritionDay
Hvor hurtigt går det galt, hvis man ikke gør noget?
113 patients ranked according to administered amounts of protein/AA and divided into 3 equally large groups
28 days' survival in the ICU
Time (Length of stay in the ICU)
Per
cen
t su
rviv
al
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
40
60
80
100
Low protein&AA
Medium protein&AA
High protein&AA
[6]
[20]
[19]
Log-rank P = 0.03;Log-rank test for trend: P = 0.01.
1.46 g/kg per d
1.06 g/kg per d
0.79 g/kg per d
Alli
ngst
rup
et a
l. C
lin N
utr
2012
;31:
462-
8.
Characteristics of the 3 groups, mean SDLow Medium High
Age 60 17 62 15 57 19
Weight 70 16 82 16 81 16
BMI 24 4 27 5 26 5APACHE II 23 7 22 6 22 7Protein/AA, g/kg per d 0.79 29 1.06 0.23 1.46 0.29
N balance, Protein eq, g/kg per d -0.59 0.48 -0.35 0.41 -0.20 0.58
Energy, kcal/kg per d 21.7 6.7 24.7 5.6 27.2 6.7
Energy balance, kcal/kg per d -6.4 9.1 -3.5 6.3 -1.5 6.9
Protein in energy provided, % 15 3 18 3 22 3Proteineq out of REE,% 21 7 21 7 21 7
10 day survival (K-M), % 49 79 88
Allingstrup et al. Clin Nutr 2012;31:462-8.
Protein provision and N balance in ICU patientsMean SD; N = 38 in each group
Protein/AA provisiong/kg per day
N b
alan
ce (
Pro
t eq/k
g p
er
d)
0.0 0.5 1.0 1.5 2.0 2.5-1.5
-1.0
-0.5
0.0
0.5
Allingstrup et al. Clin Nutr 2012;31:462-8.
~ 200 g LBM/day 0.5 % LBM/day Twice the loss of healthy individuals on a protein-free diet
Usual care: 47 g prot/AA 0.6 g/kg per d (Alberda)
28 days' survival in the ICU
Time (Length of stay in the ICU)P
erce
nt
surv
ival
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
40
60
80
100
Low protein&AA
Medium protein&AA
High protein&AA
[6]
[20]
[19]
ACUTE PEM
<75 75-99 100-124 125-149 150-174 175-199-1.0
-0.5
0.0
0.5
1.0
Weight change according to energy balance1382 patients without edema.Median & interquartile range(N) = number in each group
(84)
(368)
(442)
(279)
(128)
(55)
Energy intake as % of requirement
We
igh
t c
ha
ng
e (
kg
/we
ek
)
Clinical Nutrition Unit Rigshospitalet Copenhagen 2010
Er der noget galt med hospitalskosten - eller med vores viden om hvad ptt kan spise?
Observational, interview-based study22 patients at nutritional risk (NRS-2002) and with decreased intake (<75%). 65 interviews.Sorensen et al. Clin Nutr 2012;31:637-46.
Questionnaire in 200 patients based on qualitative studySorensen et al, ESPEN congress 2010
Motivation Nutritional status Eating related symptoms
Food sensory experiences and preferences
Pleasure Positive energy and protein balance
NS Savoury, aromatic crispy/crunchyvaried tastes & consistencies & dishessour side-dishes
Force High screening (NRS) intake score. i.e. low pre-admission intake.Oncology
Low appetiteEarly satietyNauseaVomitingPainTaste changesDry mouth
mild flavourseasy to eat sensory specific satiety redundant food choices familiar foodssmall portionsmoisture giving sauces
RCT in 77 at-risk patients (NRS 2002).Sorensen et al., being analysed
Control group received therapy as current practice. Intervention group received nutritional therapy: thorough sensory assessment & nutrition plan adjusted daily.Mean ± SD
Control Sensory intervention
Energy intake, MJ/d 6.8 ± 2.1 8.1 ± 2.2*
Protein intake, g/d 63 ± 21 74 ± 22**
75% energy req., % 70 90**
75% protein req., % 57 83**
<75% at screening 75% energy req., % 66 89***
* P = 0.01** P = 0.030 *** P = 0.015
Hvorfor er det på dag 3, at der skal tages stilling til ændring i planen?
When to reach target?
AuthorPatients Feeding
Energy,kcal per day or kcal/kg per day
Protein, g per day or g/kg per day
Target reached on day
Bourdel 2000 Elderly Supplement 1200 45 2
Henriksen 2002 Abd surgery Supplement - 1 2
Graham 1989 Head trauma Jejunal 3000 - 3
Keele 1997 Abd surgery Supplement 1600 57 3
Rana 1992 Abd surgery Supplement 2000 71 3
Sagar 1979 Abd surgery Jejunal - 47 6
Singh 1998 Abd surgery Jejunal 21 1 4
Smith 1988 Abd surgery Jejunal 1100 35 5
Watter 1997 Abd surgery Jenunal 16 0.6 3
Based on Kondrup et al. Clin Nutr 2003; 22: 321-336
Recommendation: Based on 14 level 2 studies, we recommend early enteral nutrition (within 24-48 hours following admission to ICU) in critically ill patients.www.criticalcarenutrition.com
75% af behovet skal nås på 3. indlæggelsesdag
Hvordan målet nås…
EuroOOPS*: Nutrition Practice as determinant of intake ≥75% of requirements in patients at-riskQuestions on practice based onBeck et al. Guidelines from Council of Europe. Clin Nutr 2001, 20: 455-460.
% patients ≥75%
Practice in department Had: Yes/No Yes No P
Nutrition Committee 18/4 61 50 0.03
Screening Common 11/11 63 56 0.02
Monitoring Common 13/9 65 50 <0.0005
Snacks available 15/7 65 54 <0.0005
Ptt’s satisfaction feedback 14/8 65 50 <0.0005
NS: definition of responsibility, choice of menus; ICUs excluded
Unpublished data fromSorensen et al. Clin Nutr 2008;27:340-9.*5051 patients in 22 departments in 12 countries
Factors determining intakeOf the 1581 at-risk patients with LOS >3 days, 1017 (64%) were judged to have an intake 75% of requirements Logistic regression analysis: OR for intake ≥75% of requirements
OR P
Recent Intake at NRS screening (per score unit) 0.60 <0.0005
Geriatry vs. Surgery 0.29 <0.0005
Gastroenterology vs. Surgery 0.44 0.002
Oncology vs. Surgery 0.21 <0.0005
Internal Medicine vs. Surgery 0.30 <0.0005
TPN or TEN vs. Food or Supplements 3.10 <0.0005
Nutrition Practice Score (per # of practices) 1.33 0.001
Unpublished data fromSorensen et al. Clin Nutr 2008;27:340-9.
Konklusioner
Screening er velbegrundet – og ret valideret… Nyligt kostindtag er en vigtig oplysning Det går hurtigt ned ad bakke… Læs patientens type: nyder eller nøder? Skift strategi efter senest 3 dage:
Mål: ≥75% af behov senest 4. indlæggelsesdag Pas På med sondeernæring