Guidelines on EnteralNutrition H. LochsGuidelines on Enteral Nutrition Ethical and legal Aspects A:The law clearly differentiates between oral intake and enteralnutrition. The provision

ESPEN Congress Brussels 2005

Guidelines on Enteral Nutrition

H. Lochs


H. Lochs, L. Valentini

Medizinische Klinik mit Schwerpunkt Gastroenterologie,Hepatologie undEndokrinologie

[email protected]


Authors and contributors to the ESPEN guidelines

Allison Simon United Kingdom ∗ Anker Stefan United Kingdom ∗ Arends Jann Deutschland ∗ Assis- CamiloMaria Portugal ∗ Berger Mette Switzerland ∗ Berner Yitshal N. Israel ∗ Berry Elliot Israel ∗ Bodoky GyoergyHungary ∗ Bondolfi Alberto Switzerland ∗ Bozzetti Federico Italia ∗ Braga Marco Italia ∗ Buehler Ernst Germany ∗ Cabré Eduard Spain ∗ Cano Noël France ∗ Cederholm Tommy Sweden ∗ Cicoira Marieantoinette Italy ∗ Coti- Bertrand Pauline Switzerland ∗ Dardai Ernő Hungary ∗ DeJong Cornelis HC Netherlands ∗ Deutz N.E.P. Netherlands ∗ Druml Wilfred Oesterreich ∗ Fearon Kenneth United Kingdom ∗ Fiaccadori Enrico Italia ∗ Grimble Robert United Kingdom ∗ Hammarqvist Folke Sweden ∗ Harsanyi Laszlo Hungary ∗Hebuterne Xavier France ∗ Herbst Brigitte Deutschland ∗ Hiesmayr Michael Österreich ∗ Howard Pat United Kingdom ∗ John Matthias Deutschland ∗ Jolliet Philippe Suisse ∗ Jonkers- Schuitema Cora Netherlands ∗Kazandjiev Georgi Bulgaria ∗ Kyle Ursula Switzerland ∗ Koerner Uwe Germany ∗ Kondrup Jens Denmark ∗Kreymann Georg Deutschland ∗ Laviano Alessandro Italia ∗ Leon- Sanz Miquel Spain ∗ Ljungqvist Olle Sweden ∗ Lochs Herbert Deutschland ∗ Macallan Derek United Kingdom ∗ MacFie John United Kingdom ∗Meguid Michael M. USA ∗ Meier Rémy Schweiz ∗ Melchior Jean Claude France ∗ Messing Bernhard France ∗ Milinic Nikola Serbia & Montenegro ∗ Milne Annemie United Kingdom ∗ Muscaritoli Maurizio Italia ∗Nitenberg Gérard France ∗ Norman Kristina Deutschland ∗ Ockenga Johann Deutschland ∗ Odlund- OlinAnn Sweden ∗ Oehmichen Frank Germany ∗ Palmblad Jan Sweden ∗ Pap Akos Hungary ∗ PedersenPreben Ulrich Denmark ∗ Pertkievics Marek Poland ∗ Pichard Claude Switzerland ∗ Pirlich Matthias Deutschland ∗ Plauth Mathias Deutschland ∗ Ponikowski Piotr Poland ∗ Raguso Comasia Switzerland ∗Riggio Oliviero Italia ∗ Sauerwein Hans P. Netherlands ∗ Schneider Stephane France ∗ Schols Annemie Netherlands ∗ Schütz Tatjana Deutschland ∗ Schwenk Achim United Kingdom ∗ Selga Guntars Latvia ∗Sobotka Lubos Czech Republic ∗ Soeters Peter Netherlands ∗ Stanga Zeno Switzerland ∗ Tesinsky Pavel Czech Republik ∗ Tisdale Michael United Kingdom ∗ Toigo Gabriele Italia ∗ Valentini Luzia Deutschland ∗Van den Berghe Greet Belgium ∗ Van Gemert Wim Netherlands ∗ Van Gossum André Belgium ∗ Volkert Dorothee Deutschland ∗ Von Meyenfeldt Maarten Netherlands ∗ Weimann Arved Deutschland ∗ WernermanJan Sweden ∗ Wheatley Carolyn United Kingdom

See guidelines on www.espen.org, and in the learning center

http://www.espen.org/


Israel: 2

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1 2

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152

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USA:1

Guidelines on Enteral Nutrition Methods

Steering committee Tasks

Central organising group

Herbert Lochs

Claude Pichard

Niklaas Deutz

Composition of working groups

Strategic decicions

Final agreement on each section

Intersection coherence of the text

Proof reading of the final version

Luzia Valentini

Brigitte Herbst

Tatjana Schütz

Kristina Norman

Coordination of translation

Communication with the workinggroups

Contact between working groupsand steering committee

Keeping the time schedule

Oranisation of the consensusconference

Simon Allison Editing

MethodologyMichael Koller

Guidelines on Enteral Nutrition Methods

Working groups

• Ethical Aspects 8 experts

• Intensive Care 8 experts

• Surgery & Transplantation 6 experts

• Oncology 7 experts

• Gastroenterology: Gut 8 experts

• Gastroenterology: Pancreas 7 experts

• Hepatology 7 experts

• Nephrology 5 experts

• Cardiology & Pulmonology 8 experts

• Wasting in HIV 7 experts

• Geriatrics 11 experts


Ethical and legal Aspects

A:The law clearly differentiates between oral intake and enteral nutrition. The provision of adequate fluid and nutrients by mouth (and this includes oral nutritional supplements in most instances) as well as help with drinking and eating where necessary is regarded by the law as basic care.

The provision of fluid and food by tube is regarded as a medical treatment.

Q: How does the law regard enteral nutrition? Is it basic care or a medical treatment?


Ethical and legal AspectsPersistent vegetative state

Q: In cases of severe brain damage where the prospect of recovery is extremely unlikely, how does the law regard withdrawal of food and fluid administration by tube?

A: …..The courts will not entertain an application to withdraw treatment within 12 months of the onset of the condition, by which time it becomes possible to determine whether the patient has lost all features of personhood although brain stem function persists i.e. a persistent vegetative state. The court may then give permission for doctors to stop treatment, “if it is in the best interests of the patient”.


Ethical and legal AspectsDementia

Q: What is the role of enteral feeding in dementia?

A: In early or mild dementia…. the supervision of meals and the provision……have proved adequate to ensure proper nutrition.

With intercurrent reversible illness, the patient should be considered in the same way as those without dementia.

In the late stages of disease, Alzheimer’s…… artificial tube feeding has more risks than benefits, and should not be undertaken.

Guidelines on Enteral NutritionIntensive Care

Comment on the prefinal guidelines on www.espen.org until Sept. 25th 2005



Intensive Care

A 60a old patient with esophagealresection due to cancer sufferspostoperaitve infection and mild sepsiswith an Apache II score of 14.

He is malnourished with a BMI of 18 and long time smoker.

A fine needle jejunostomy has benplaced during operation and the patientreceives enteral nutrition.



Guidelines on Enteral Nutrition Intensive Care

Is immune modulating diet indicated in this patient?

Immunonutrition is only indicated in non-surgicalpatients with mild sepsis (APACHE <15).no

Immunonutrition is indicated only in surgicalpatients with mild sepsis (APACHE < 15).yes



Guidelines on Enteral Nutrition Intensive Care

Surgical patients with a mild sepsis (APACHE < 15) should receive immune modulating enteral nutritionwith a diet enriched with arginine, nucleotides and n-3 fatty acids.Grade of recommendation: B

ESPEN consensus group composition: G. Kreymann, M. Berger, N. Deutz, P. Jolliet, G. Kazandzhiev, G. Nitenberg, G. van den Berghe, J. Wernermann

Guidelines on Enteral NutritionIntensive Care




Gastroenterology: Gut

A lady, 34a, suffers from Crohn‘s diseasesince 5 years.

She was on chronic steroid treatmentsince 1 year and stopped 1 month agodue to severe side effects.

Two weeks ago an active phase has begun with bloody diarrhea 10 timesdaily, pain, and weight loss.

Endoscopy showed stenosis and inflammation of the terminal ileum and the right colon.



Guidelines on Enteral Nutrition Gut

Should this patient get enteral nutrition as primary therapy for the active CD?

no

Enteral nutrition is not effective as primarytherapyThe patient should get parenteral nutrition to put the bowel at rest.

yes She sould get enteral nutrition since it is effective for active CD




Enteral nutrition is effective as therapy of the acutephase, however less than steroids. It is thereforeindicated if steroid therapy is not possible ( A )

Griffiths et. al. Gastro 1995

In malnourished patients a combination of enteral nutrition and steroids is recommended ( C )


What diet would you give this patient?

(low molecular, modified, standard formulas)

There are no significant differences. Therefore a standard diet (high molecular formula) isconsidered the treatment of choice.

Low molecular tube feeding formulas are superior.

Benefits of modified enteral formulas (fat modified, ω-3 fatty acids, glutamine, TGF-β-enrichment) have been clearly shown, therefore this formulas are recommended.

ESPEN consensus group composition: Lochs H, Cornelius D, Hammarquist F, Heburtene X, Leon Sanz M,Schütz T, van Gemert W, van Gossum A.


There are no significant differences in the effect of low and high molecular tube feeding formulas. Nutritional support with a standard diet (high molecular formula) is considered the treatment of choice. Low molecular formulas are therefore not generally recommended. (A)

Enteral nutritional therapy for induction of remission in Crohn's disease (Cochrane Review). Zachos M, Tondeur M, Griffiths AM. In: The Cochrane Library, Issue 3, 2004

Favors high molecular Favors low molecularESPEN consensus group composition: Lochs H, Cornelius D, Hammarquist F, Heburtene X, Leon Sanz M,

Schütz T, van Gemert W, van Gossum A.


Surgery

A 65a old male patient with colon cancer, has lost 10 kg in the last 6 months, but isstill in good condition ( BMI 22 ) and has almost normal laboratory tests. He shouldget left hemicolectomy



Guidelines on Enteral Nutrition Surgery

Should operation be delayed and this patient getpreoperative nutrition?

... only when nutritional therapy can be institutedby a nutritional support team in an inpatient setting

... in all patients with moderate and severemalnutrition

... only to treat severe undernutrition. Patients withmild or moderate malnutrition will benefit fromprompt surgery

ESPEN consensus group: A. Weimann, M. Braga, L. Harsanyi, A. Laviano, O. Ljungqvist, P. Soeters

Guidelines on Enteral Nutrition Surgery

... only to treat severe undernutrition. Patient withmild or moderate malnutrition will benefit fromprompt surgeryLevel of recommendation: A

Comment:

In case of severe undernutrition enteral nutrition has proven beneficial with regard to the rate of complications (Ib). These patients were preoperatively fed for at least 10 days.

Shukla HS, Rao RR, Banu N, Gupta RM, Yadav RC. Enteral hyperalimentation in malnourished surgical patients. J Med Res 1984; 80: 339-346.

Von Meyenfeld M, Meijerink W, Roufflart M, Builmaassen, Soeters P. Perioperativenutrtional support: a randomized clinical trial. Clin Nutr 1992; 11: 180-186.

ESPEN consensus group: A. Weimann, M. Braga, L. Harsanyi, A. Laviano, O. Ljungqvist, P. Soeters


Geriatrics

An 85a old lady was operated for a hip fracture. She tolerated the operation well, however she is not eating adequately and it is difficult to mobilise her. First hand feeding is tried with little success. After 3 weeks she has lost 4 kg and a PEG isintroduced.



Guidelines on Enteral Nutrition Geriatrics

Should this patient get oral supplements or tube feeding?

Data are inconclusive and no recommendation canbe given at present.

Enteral nutrition (oral supplements as well as tube feeding) increases total energy and nutrient intake in geriatric patients.

Supplementary tube feeding decreases dietary intake and does therefore not increase total energy and nutrient intake in geriatric patients.

ESPEN consensus group composition: D. Volkert, Y.N. Berner, E. Berry, T. Cederholm, P. Coti, A. Milne, S. Palmblad, St. Schneider, L. Sobotka, Z. Stanga.


Does enteral nutrition improve total energy and nutrient intake in geriatric patients?

Enteral nutrition (oral supplements as well as tube feeding) increases energy and nutrient intake in geriatric patients.Level of evidence: Ia



Routine postoperative oral supplementation in the elderly is recommended after orthopedic surgery…

... in malnourished patients to reduce mortality.

... in all patients (independent of nutritional status) in order to reduce complications.

… only in malnourished patients (BMI < 20 kg/m², weight loss > 10%/6 mo) to improve nutritional status



Routine postoperative oral supplementation in the elderly is recommended after orthopedic surgery…

.... in all patients (independent of nutritional status)in order to reduce complications

Level of recommendation: A


Guidelines on Enteral NutritionWhat can you do?

During the congress

visit activity centre in the central exhibitionarealearn about background issues and read summaries of statements

After you get home

visit www.espen.orgdownload prefinal guidelines and comment on it until September 25th.

Documents

Guidelines on EnteralNutrition H. LochsGuidelines on Enteral Nutrition Ethical and legal Aspects A:The law clearly differentiates between oral intake and enteralnutrition. The provision