DGEM Guidelines Enteral Nutrition

Transcription

1 ESPEN Congress Cannes 2003 Organised by the Israel Society for Clinical Nutrition Education and Clinical Practice Programme Session: Nutritional Guidelines: ESPEN and other Societies German Society of Parenteral and Enteral Nutrition: Recommandations for Enteral Nutrition Except ICU Professor Herbert Lochs Berlin, Germany DGEM Guidelines Enteral Nutrition Nutritional Status Basics of enteral Nutrition Ethics, Legal Intensive Care Medicine Surgery, Transplantation Oncology Gastroenterology Hepatology Nephrology Diabetes Cardiology/ Pulmonology HIV/ Wasting Geriatrics/Neurology ESPEN For personal use only. 1

2 DGEM Guidelines Enteral Nutrition - Surgery, Transplantation AG: A. Weimann, K.W. Jauch, M. Kemen J.M. Hiesmayr, T. Horbach, R.E. Kuse, K. H. Vestweber Preoperative Nutrition In malnourished patients preoperative nutrition is indicated even if that leads to delay of the operation ( A ) Enteral Nutrition is preferable vs. Parenteral nutrition ( C ) Preoperative immunonutrition for 5 7 days is recommended for malnourished cancer patients ( A ) ESPEN For personal use only. 2

3 Perioperative Immunonutrition in GI Cancer Gianotti et. al. Gastro 2002 Preop Nutrition Preop+Postop Nutrition No Support Infections ( % ) LOS ( days ) Postoperative Nutrition When to begin? Routine postoperative starvation is not necessary ( A ) Early postoperative nutrition reduces p.o. complications( IIa ) After anastomosis in the upper GI tract enteral nutrition should be started via a tube distal of the anastomosis (A ) After anastomosis in the colon or rectum oral nutrition can be started on the first p.o. day ( A ) ESPEN For personal use only. 3

4 Enteral Nutrition Outcome Lewis et. al. BMJ 2001 Postoperative Nutrition enteral vs. parenteral Complications n, patients,(%) LOS ( days ) 13,4 enteral 54 ( 34 % ) parenteral 78 ( 49 % ) p< 0,005 15,0 p < 0,009 Adverse effects, n (%) 56 ( 35 % ) 22 ( 14 % ) Bozetti et. al. Lancet 2001 ESPEN For personal use only. 4

5 Postoperative Nutrition Enteral vs. parenteral Bozetti et. al. Lancet 2001 Postoperative Nutrition Patients who prospectively can not eat adequately for more than 7 days should receive enteral nutrition postoperatively without delay even if they are not malnourished ( C ) ESPEN For personal use only. 5

6 Postoperative enteral Nutrition Early enteral nutrition ( within 24 hours p.o. ) is advisable after big oropharyngeal or abdominal operations In polytrauma ( A ) These patients should receive immunmodulating diet. A start with 5 10 ml/h is adequate. ( A ) 25 n Early Postoperative Nutrition Complications Septic Respiratory Failure Suture leak 5 0 Enteral nutrition n= 21 Control n = 22 Singh et. al. J. Am. Coll. Surg ESPEN For personal use only. 6

7 Enteral Nutrition Transplantation Malnutrition correlates with a worse prognosis after liver transplantation Sip feeding or tube feeding is therefore indicated in malnourished patients while on the waiting list for LTX ( C ) Malnutrition and Liver Transplantation Prognostic Role ESPEN Mortality [%] BCM > 0.3 x KG BCM < 0.3 x KG Müller et al, Hepatology 1992, 15: ESPEN For personal use only. 7

8 Enteral Nutrition Transplantation Oral nutrition should be started after heart, lung and kidney transplantation without complications ( C ) Enteral Nutrition should be started within 24 h after liver and pancreas transplantation ( C ) DGEM Guidelines Enterale Nutrition - Gastroenterology AG: H. Lübke, R. Meier, H. Lochs S. Bischoff, N. Engelmann, P. Thul, C. Löser, V. Keim ESPEN For personal use only. 8

9 Enteral Nutrition Crohn s disease - Malnutrition Sip feeding and tube feeding in addition to the standard diet improves the nutritional status,and the consequences of malnutrition like growth retardation ( A ) Enteral Nutrition in IBD Effect on growth and weight gain Growth (cm )/ year Children Diet Diet + overnight Tube Feeding Weight gain (Í kg/ 2 months ) Adults Die t Diet + Sip Feeding (~ 550 kcal /d) Belli et al. Gastroenterology 1988, Harries et al. Lancet 1983 ESPEN For personal use only. 9

10 Enteral Nutrition Crohn s disease- Acute Phase Enteral nutrition is effective as therapy of the acute phase, however less than steroids. It is therefore indicated if steroid therapy is not possible ( A ) In malnourished patients a combination of enteral nutriton and steroids is recommended ( C ) Enteral Nutrition versus Steroids in CD Griffith et al, Gastroenterology 1995 ESPEN For personal use only. 10

11 Elemental versus Polymeric Diets in CD Griffith et al, Gastroenterology 1995 DGEM Guidelines Enteral Nutrition Nutritional Status Basics of enteral Nutrition Ethics, Legal Intensive Care Medicine Surgery, Transplantation Oncology Gastroenterology Hepatology Nephrology Diabetes Cardiology/ Pulmonology HIV/ Wasting Geriatrics/Neurology ESPEN For personal use only. 11

12 Enteral Nutrition Pancreatitis In light and moderate pancreatitis enteral nutrition is only recommended in malnourished patients (C ) If the patient is not malnourished and can eat within < 7 days enteral nutrition offers no advantage( A ) Enteral Nutrition Pancreatitis Early enteral nutrition (<48 h) improves prognosis in severe pancreatitis ( A ) Continuous tube feeding with an elemental diet is therefore recommended( A ) If adequate enteral nutrition is not possible (e.g. Ileus ) low volume jejunal nutrition ( ml/ h ) should be performed in addition to parenteral nutrition ( C ) ESPEN For personal use only. 12

13 Enteral Nutrition in Crohn s Disease Lochs et al, Gastroenterology 1991 Efficacy of different treatments in active Crohn s disease 100 % Remission Tube feedingeccds IV Prednisolon ECCDS IV Prednisolon Rutgeerts Budesonid Rutgeerts Infliximab Targan Mesalamin Prantera Prednisolon Prantera 0 ESPEN For personal use only. 13

14 Sip feeding in steroid dependent CD Verma et. al., Gut 2001 Nonresponders Responders continuing Responders stopping Months in remission ESPEN For personal use only. 14