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Post-Operative(Artificial) NutritionWHO, WHEN AND HOW TO FEED?

Content

• Early feeding (ON, EN)

• Nasojejunal feeding and jejunostomy

• Nasogastric feeding

• Tip position check

• Estimating internal length

• TPN/IV glutamine

2017

GRADES

A• At least one meta-analysis, systematic review, or RCT rated as 1++, and

directly applicable to the target population; or A body of evidence consisting

principally of studies rated as 1+, directly applicable to the target population,

and demonstrating overall consistency of results

B• A body of evidence including studies rated as 2++, directly applicable to the target

population (eg systematic review, high quality case control, cohort)

• A body of evidence including studies rated as 2+, directly applicable to the target

population and demonstrating overall consistency of results (lower quality case

control and cohort)

• Extrapolated evidence from studies rated as 1++ or 1+

O• Evidence level 3 or 4 (e.g. case reports, case series, expert opinion)

• Extrapolated evidence from studies rated as 2++ or 2+

GPP• Good practice points/expert consensus: Recommended best practice based on the

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Malnutrition

2018www.espen.org

Nutritional status at D30 post surgery compared topre-OP assessment

D30 post-OP

2016

D30 post-OP

D30 post-OP

Esophagectomy2016

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Esophagectomy

Chronic gastro-intestinal symptoms

• Dysphagia

• Reflux

• Postprandial dumping

• Anorexia

• Malabsorption

• Feeling bloated

• Odynophagia

• Abdominal fullness

• Diarrhea/constipation

Follow/up and assessment

• Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuation of nutrition therapy including qualified dietary counselling after discharge, is advised for patients who have received nutrition therapy perioperatively and still do not cover appropriately their energy requirements via the oral route.

GPP

• N = 70 (total laryngectomy)

• 77% sarcopenic

• Sarcopenic group: • 50% wound complications

• 13 patients with pharyngocutaneous fistula

• Nonsarcopenic group:• 13% wound complications

• No patients with fistula

2017

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Early ON

• Oral intake, including clear liquids, shall be initiated within hours after surgery in most patients.

A

Return of normal bowel function

Better intra-hospital outcomes//safe

2016

2016

Early ON after upper GI: LO(hospital)S 2016

early

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Early

2013

After Gastrectomy

• RCT/ n= 84 /elective or partial

• Group 1:

• Prophylactic nasogastric or nasojejunal decompression after gastrectomy

• Group 2:

• No tube

• Outcomes:

• No difference

• 72 % moderate to severe discomfort from the NG or NJT

2007

After Laryngectomy

• RCT/ n = 65 patients

• Group 1:

• Orally with a clear liquid diet on the first postoperative day, then advanced to a regular diet

• Group 2:

• No oral food until day 8

• Outcomes:

• There was no significant difference between two groups for either the incidence of fistula or the length of hospital stay.

2003

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Immunonutrition?

• Peri- or at least postoperative administration of specific formula enriched with immunonutrients (arginine, omega-3-fatty acids, ribonucleotides) should be given in malnourished patients undergoing major cancer surgery

• There is currently no clear evidence for the use of these formulae enriched with immunonutrients vs. standard oralnutritional supplements exclusively in the preoperative period

B

O

Oral peri-operative immunonutrition?

• N = 264

• Group 1:

• Control group

• Group 2:

• Immunonutrients 7 days before and 5 days post colorectal surgery

• Outcomes:

• Significant decrease in infectious complications (23.8% vs. 10.7%, P=0.0007) especially wound infections

2016

Early EN (tube feeding)

• Early tube feeding (within 24 h) shall be initiated in patients:

- In whom early oral nutrition cannot be started

- And in whom oral intake will be inadequate (<50%) for more than 7 days.

- Special risk groups are:

• Patients undergoing major head and neck or gastrointestinal surgery for cancer (A)

• Patients with severe trauma including brain injury (A)

• Patients with obvious malnutrition at the time of surgery (A/GPP)

A/GPP

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Which formula?

• In most patients a standard whole protein formula is appropriate.

GPP

Early EN after intestinal surgery

• 13 trials/ n = 1173 patients

• Increased vomiting with early EN

• Conclusion:

• There is no obvious advantage in keeping patients ‘nil by mouth’ following gastrointestinal surgery. Early enteral nutrition is associated with reduced mortality, though the mechanism is not clear. This review supports the notion that early commencement of enteral feeding may be of benefit.

2009

Post-pyloric tube?

•With special regard to malnourished patients, placement of a nasojejunal tube (NJ) or needle catheter jejunostomy (NCJ) should be considered for all candidates for tube feeding undergoing major upper gastrointestinal and pancreatic surgery.

B

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Post-pyloric

• During surgery:

• Nasojejunal tube distal to the anastomosis

• Surgical (needle) jejunostomy (NCJ)

Pancreaticoduodenectomy

• RCT

• Group 1 (n = 34): Nasojejunal (NJT)

• Group 2 (n = 34): Jejunostomy (JT)

Nasojejunal feeding is safer than jejunostomy and it is associated with only minor complications. Nasojejunal feeding can significantly decrease the incidence of delayed gastric emptying and shorten the postoperative hospital stay

2014

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27

2006

2013

NCJ for early TF

N = 80

2000

Nasogastric feeding

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Kurt Boeykens: Blue Book ESPEN 2019

EnFIT

Enfit 2018

How long a 20-minute feed with the current legacy device would take after a transition to ENFit?

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Decompression/venting

Enfit

• Residual enteral formula and medications could potentially accumulate in the male port of the feeding tube or extension set

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Placement of the NG-tube

Position-check!

• 383 ICU’s/20 European countries

• Position check after initial placement?

• Auscultation: 84,7%

• Aspirate appearance: 28,7%

• pH measurement: 3,5%

• RX: 32,7 %

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2008

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2016

pH-method?

• Included 331 intubations (314 patients)

• All tubes placed and controlled initially after placement by or under supervision of the same APN

• No or almost no placement bias

• First large study worldwide using CE marked testing strips in with a pH cutt-off point of 5,5 to distinguish between gastric and respiratory placement.

2014

Conclusions

• A pH ≤ 5,5 rules out lung placement

• Small risk of feeding in the oesophagus

• Don’t use the auscultatory method

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Which method is the most appropriateto determine the correct internal

length of a nasogastric tube?

Importance

• To avoid feeding in the distal oesophagus or near the gastroesophageal sfincter

• To avoid reflux

• To obtain aspirates (to test pH)

• To obtain (correct) gastric residuals

• To avoid coiling upwards of the feeding tube

• To avoid post-pyloric feeding (if intermittent/bolus = risk dumping)

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XEN NEX

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NEX?

• 1951: Royce, Tepper, Watson, Day

• 6 month experience in 30 premature infants

• The tube ‘was estimated by rough measurement to have entered the stomach’.

• This method was further used as a ‘evidence-based’ reference in nursing textbooks.

• 1978: Ziemer and Carroll report the NEX method to be too short, because “gastric contents cannot usually be aspirated until the tubing is advanced further”

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1951

Review

• Four studies demonstrated that NEX is not a safe method, may actually cause harm, and should no longer be taught or used in practice.

Recommendation:

• Randomized controlled trials by using larger sample sizes are needed to determine the accuracy of NGT method for feeding in adults.

2016

Hanson study 1979

• 99 cadavers

• 5 volunteers

• NEX: 72 % correct

• NEX + Formulas: 91,3% till 92,3% correct

1979

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Research project

• How to determine the most appropriate external method to obtain a correct tip position of a NGT?

• RCT (first worldwide)

• Randomisation: NEX (control) vs NEX + formula

• Predictive parameters for (in)correct tube placement?

• Feeding tube placement and data collection:

• Two experienced CNNS

• Parameters for data collection measured and re-measured

50

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3-10 cm

2018

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CONEX = Hanson + 6 cm

Poster ESPEN (The Hague): 2017

Clinical Practice

Plaatsen neusmaagsonde (CONEX)

• https://www.youtube.com/watch?v=dcHzGO2EGRo

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HEN

(HEN)PEG

• If long term TF (>4 weeks) is necessary, e.g. in severe head injury, placement of a percutaneous tube (e.g. percutaneous endoscopic gastrostomy e PEG) is recommended.

GPP

HEN CRITERIA

• Voorschrift: behandelend arts-specialist of een andere arts die samenwerkt met een medisch ziekenhuisteam waarvan de ervaring in deze materie onbetwistbaar is

• Behandeling ‘ten huize van’ de patiënt via sonde

• Aanvraag tot terugbetaling naar adviseur mutualiteit

• Op basis van een omstandig medisch verslag

• Patiënt lijdt aan erkende aandoeningen

• Goedgekeurd voor 12 maand (+ verlenging)

• Maandelijkse factuur voeding&materiaal: ziekenfonds

Juli 2018

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HEN: erkende aandoeningen

A1. Ernstige neurologische pathologieën met afwezigheid van of incoördinatie van de slikreflex.

A2. Sequellen va buccofaryngeale of laryngeale heelkunde en/of radiotherapie

A3. Obstructie van de oropharynx, de slokdarm of de maag

A4. Erfelijke metabole ziekten

HEN: erkende aandoeningen

Ernstige absorptiestoornis in de darmen waarvoor een parenterale voeding nodig is of was t.g.v.

B1. Ideopatische inflammatoire darmziekten (ziekte van Chron, Colitis Ulcerosa) die geneesmiddelenresistent zijn en die uitgebreide segmenten van de darm hebben aangetast.

B2. Uitgebreide intestinale resecties

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PNParenteral nutrition is beneficial in the following circumstances:

• in undernourished patients in whom enteral nutrition is not feasible or not tolerated

• in patients with postoperative complications impairing gastrointestinal function who are unable to receive and absorb adequate amounts of oral/ enteral feeding for at least 7 days

2009

A

EN AND/OR PN

• If the energy and nutrient requirements cannot be met by oral and enteral intake alone (<50% of caloric requirement) for more than seven days, a combination of enteral and parenteral nutrition is recommended.

• Parenteral nutrition shall be administered as soon as possible if nutritional support therapy is indicated and there is a contraindication for enteral nutrition, such as in intestinal obstruction A

GPP

IV Glutamine

• Parenteral glutamine supplementation may be considered in patients who cannot be fed adequately enterally and, therefore, require exclusive PN.

• Positive outcomes:

• Infectious morbidity

• LO(hospital)S but heterogeneity amongst studies

• B: because low/medium quality of the studies + many colorectalsurgery + lack of clear criteria for infections

B

20152010 2013

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Omega-3 FA

• Postoperative parenteral nutrition including omega-3-fatty acidsshould be considered only in patients who cannot be adequately fed enterally and, therefore, require parenteral nutrition.

• Positive outcomes:

• LO(hospital)S but heterogeneity amongst studies

• Infections

• B: lack of clear criteria for infections

2013 2014

B

Omega-3 FA

• Comparison with olive-oil based TPN

• For all trials, there were no significant differences in adverse events and length of hospital stay

2013