08 - Indications, Contraindications, Complications and Monitoring of en
08 - Indications, Contraindications, Complications and Monitoring of en
08 - Indications, Contraindications, Complications and Monitoring of en
Topic 8
Module 8.1
Indications, Contraindications, Complications and Monitoring of EN
Matthias Pirlich
Learning objectives
To
To
To
To
To
Contents
1. What exactly is EN?
2. Indications for EN
2.1 Definition of malnutrition and nutritional risk
2.2 Specific indications for EN according to the ESPEN guidelines 2006
3. Contraindications to EN
4. Gastrointestinal complications of EN
4.1 Diarrhoea
4.2 Nausea and vomiting
4.3 Constipation
5. Aspiration
6. Tube related complications
7. Metabolic complications
8. Monitoring of EN
9. Summary
10. References
Key Messages
2
1. What exactly is EN?
Enteral nutrition is one form of the so-called artificial nutrition and includes both
feeding via nasogastric/enteral or percutaneous (gastric or jejunal) tube and oral
nutritional supplementation. Thus, enteral nutrition comprises all forms of nutritional
support that imply the use of dietary foods for special medical purposes as defined in
the European legal regulation of the commission directive 1999/21/EC of 25 March 1999
(1). Enteral nutrition is a safe, effective and generally well tolerated approach of
nutritional therapy in patients with normal functioning gastrointestinal tract.
The main goal of EN is prevention or treatment of malnutrition in order to improve
outcome. This is obvious from a pathophysiological point of view, but there is also strong
evidence from a number of excellent studies which show that malnutrition is an
independent risk factor for poor outcome in terms of morbidity, delayed convalescence
after surgery or trauma, higher readmission rates, increased length of hospital stay,
higher treatment costs, and higher mortality rates (2,3).
In this context it is worth mentioning the editorial accompanying the 2006 ESPEN
guidelines on Enteral Nutrition (4): Although nutritional support is therapy in most
cases it is exactly what it says supportive rather than specific treatment of the
underlying disease.
2. Indications for EN
In general there are two indications for enteral nutrition to maintain or improve
nutritional status irrespective of the underlying disease or clinical setting:
Anticipated inadequate oral food intake for more than 7 days
Present or imminent malnutrition
The SGA (Subjective Global Assessment) was established by Detsky and coworkers (5)
and relies on the patients history regarding weight loss, dietary intake, gastrointestinal
symptoms, functional capacity, and physical signs of malnutrition (loss of subcutaneous
fat or muscle mass, oedema, ascites). The NRS (Nutritional Risk Screening 2002) was
established by Kondrup and coworkers (6) and considers weight loss, food intake, BMI,
disease severity and age. Both scores are useful to identify patients at nutritional risk
who might benefit from enteral nutrition.
The criteria for the definition of nutritional risk in geriatric patients were modified due to
their reduced capacity to recover from nutritional deficits, which therefore require early
intervention (7). The recommended cut-off value for BMI is higher than in younger adults
(< 20 kg/m), and weight loss of >5 % in 3 months is considered as critical as a weight
loss of >10 % in 6 months.
3
2.2. Specific indications for EN according to the ESPEN guidelines
The 2006 ESPEN guidelines on EN have reviewed and analyzed hundreds of
interventional studies to create evidence-based recommendations for the use of EN in
different diseases and clinical settings (8). The following table summarizes the main
indications for EN considering the evidence levels provided by the ESPEN guidelines. The
grades of recommendation are:
Grade A: Meta-analysis of randomized controlled trials or at least one randomized
controlled trial
Grade B: At least one well-designed controlled trial without randomization or at least
one other type of well-designed, quasi-experimental study or well-designed nonexperimental descriptive studies such as comparative studies, correlation studies,
case-control studies
Grade C: Expert opinion and/or clinical experience of respected authorities
Table 1: Specific indications for EN in selected diseases/clinical situations
Disease/Setting Indication
Grade
Intensive Care
Surgery
Non-surgical
oncology
Crohns Disease
4
acute phase mainly when treatment with corticosteroids is not
feasible.
Use combined therapy (EN and drugs) in undernourished
C
patients or in patients with inflammatory stenosis of the
intestine.
Maintenance of remission: Use ONS in case of persistent
intestinal inflammation (steroid dependent patients).
B
Ulcerative colitis
Pancreas
Renal disease
Infectious
Disease
Chronic Heart
Failure
COPD
5
application including routes for enteral feeding and choice of formulae are given in the
full text of the ESPEN guidelines (published in the April 2006 edition of Clinical Nutrition
and on-line via www.espen.org).
Note: Especially in geriatrics a variety of specific indications exists, because this group of
patients carries the highest risk for malnutrition. This broad topic is treated in detail in
the LLL-module nutritional therapy in elderly patients.
A specifically difficult clinical situation is the nutritional support of incurable patients. The
consensus (expert opinion level) of the ESPEN non-surgical oncology working group is,
that cancer patients with incurable disease should receive enteral nutrition in order to
minimize weight loss as long as the patient consents and the dying phase has not yet
started. When the end of life is very close, prevention or treatment of malnutrition is no
longer an indication for EN. In this situation most patients only require minimal amounts
of food and little water to reduce thirst and hunger. This helps to avoid dehydration and
states of confusion.
The situation becomes even more complex when the patient is not able to give consent
or when it is uncertain whether tube feeding will be beneficial and the prognosis of the
underlying condition is uncertain. The ethical and legal aspects of such situations have
been extensively discussed by Krner and colleagues (9).
3. Contraindications to EN
Contraindications to EN encompass the clinical situations where there is insufficient
gastrointestinal function, or severe metabolic and circulatory instability (10), and in
particular:
Gastrointestinal
Intestinal obstruction / ileus
Intestinal ischaemia
Severe peritonitis
Nausea / vomiting
Malassimilation
Metabolic
Diabetic ketoacidosis
Diabetic coma
Hepatic coma
Circulatory
Severe acute cardiac insufficiency
Shock of any origin
Nausea and malassimilation are not strict contraindications, and EN might be possible
when the underlying condition is adequately treated or specific formulae are applied.
General contraindications for endoscopic tube placement are discussed in the LLL-module
8.3 Techniques of EN. According to the ESPEN guidelines PEG placement is not
recommended in patients with liver cirrhosis or in those on chronic ambulatory peritoneal
dialysis due to the increased risk of peritonitis and other complications. In patients with
advanced cirrhosis, however, oesophageal varices are not associated with increased risk
of bleeding, and thus, nasogastric tube feeding is possible (11).
4. Gastrointestinal complications of EN
Enteral nutrition is a safe, effective and generally well-tolerated approach to nutritional
therapy in patients with a normally functioning gastrointestinal tract. Interruption of
enteral nutrition is frequently related to gastrointestinal complications however. It is
important to understand, that most complications are the result of application errors.
6
Complications of EN can be divided into those of gastrointestinal, tube related and
metabolic origin.
Frequency
10-40 %
up to 50 %
10-15 %
25-50 %
rare
very rare
?
Compliance
Tube malposition / displacement
Nausea / Vomiting
Diarrhoea
Infections
Severe metabolic complications
Aspiration
4.1 Diarrhoea
Diarrhoea is a fairly common gastrointestinal complication of EN. There is a wide range of
prevalence data for diarrhoea in the literature which is most likely explained by the
different definitions used. The most common definition of diarrhoea is: stool mass > 200
g/24 h, or a frequency of more than 3 liquid stools per day. The prevalence of EN related
diarrhoea is estimated to be 25 % on general wards and up to 60 % in ICU patients.
Reasons for diarrhoea include intolerance of bolus application or a high delivery rate,
high osmolality, bacterial contamination or inappropriate temperature of the formula diet.
Bolus application
High delivery rate
High osmolality
Bacterial contamination of the formula diet
Formula diet is too cold
Gastrointestinal infections
Malabsorption
7
diarrhoea. Before intolerance of EN is considered, one must also exclude gastrointestinal
infections and disturbances of nutrient absorption (e.g. due to milk protein allergy,
exocrine pancreatic insufficiency or lactose intolerance,).
The work-up for diarrhoea occurring during EN should include the following issues:
When bolus application has initially been performed switch to continuous application
using an electronic pump system. Continuous application of EN is generally better
tolerated than bolus application, even if the latter appears to be more physiologic.
Decrease the delivery rate (sometimes it is effective to decrease the delivery rate
only for one or two days and than increase the rate to the initial level). The maximum
tolerated delivery rate does usually not exceed 120 ml/h which is equivalent to the
physiologic flux into the duodenum.
Avoid bacterial contamination of the formula diet: change the drip line daily; review
the manufacturers guidelines for the use of the formula; when open systems are
used, the formula diet should be delivered within 6 to 10 hours; feeds should not
made up in advance
Diabetes mellitus
Vagotomy
Systemic scleroderma
Myopathies
Medication:
Opioids
Anticholinergics
Erythromycin
8
Delayed gastric emptying is the most common cause of nausea related to tube feeding
and this may be aggravated by pain, ascites, immobilisation, sedatives, antibiotics etc.
In ventilated patients a high PEEP might induce vomiting (with the risk of aspiration). In
some patients after initiating EN abdominal distension and nausea might occur only
transiently.
The work-up of nausea/vomiting occurring during EN should include the following
issues:
If delayed gastric emptying is considered: reduce delivery rate, try prokinetic drugs
4.3 Constipation
Constipation is a rare gastrointestinal complication of EN. Decreased fluid intake, the use
of high energy dense formulae and lack of dietary fibre are possible reasons for
constipation associated with EN. Furthermore, immobilisation and decreased bowel
motility (as a result of sedatives or opioids) may contribute to constipation.
The work-up of constipation occurring during EN should include the following issues:
If these steps fail consider stool softener (e.g. lactulose) or bowel stimulants
5. Aspiration
Aspiration is the most critical complication of EN and may result in pneumonia and
sepsis. Patients with neurological impairment, decreased level of consciousness or with
diminished gag reflexes are at high risk of aspiration. Further risk factors are:
postoperative or drug induced delayed gastric emptying, high GI reflux, supine position
or incompetent lower oesophageal sphincter.
Problem
Gastric reflux
Nausea / Vomiting
Meteorism
Pain
GI-Bleeding
Diarrhoea
Tube malposition
Tube occlusion
days
191
112
62
20
17
16
37
12
Measure gastric reflux, adjust the delivery rate (prolong delivery period)
Complications of percutaneous
endoscopic gastrostomy (PEG)
Pain
Local wound infection
Sepsis
Perforation / peritonitis
Buried bumper
5-7 %
15 %
<1%
< 0.5 %
rare
Pressure ulcer
10
When long term EN (> 4 weeks) is anticipated, insertion of gastrostomy tube should be
considered (13).
Local wound infections are the most common complication of percutaneous
gastrostomies.
The infection rate can be reduced by pre-interventional use of antibiotics (30 min before
PEG insertion using a 3rd generation cephalosporine or a broad spectrum penicillin). This
is recommended especially in patients with impaired immune function or malignant
disease.
A frequent complication of all kinds of feeding tubes is tube obstruction. This can be
avoided by adequate flushing with water (40 ml or more) before and after feeding or
whenever an interruption of feeding is necessary. When fine-bore tubes are used flushing
should be performed every 4 to 6 hours even during feeding. However, clogging might
also occur due to precipitates of administered medication. Application of warm water,
sodium bicarbonate or pancreatic enzymes is not always successful in dislodging the
blockage, and, therefore, tube replacement might be necessary.
7. Metabolic complications
Compared to parenteral nutrition EN is a more physiologic approach to nutritional support
which is reflected by a lower frequency and severity of metabolic complications.
However, disturbances of the hydration status might occur, if treatment focuses only on
caloric intake and fluid balance is ignored. Overhydration and dehydration are usually
accompanied by hyponatraemia and hypernatraemia, respectively, and are treated by
fluid restriction or additional fluid supplements. A severe form of dehydration is called the
tube-feeding syndrome, where a hyperosmolaric formula diet causes diarrhoea and
intestinal fluid losses, acidosis, and impairment of renal function. Such disturbances can
be avoided when adequate monitoring of EN is performed.
11
The refeeding syndrome is associated with hypophosphataemia, hypokalaemia,
hypomagnesaemia, thiamine deficiency and fluid retention and can ultimately result in
cardiac arrhythmias and congestive cardiac failure. Milder forms of the refeeding
syndrome are probably not so uncommon and may be identified by hypophosphataemia.
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Thiamine (and other vitamin) deficiency
Fluid retention
Neuromuscular dysfunction
Hypoventilation
Lactic acidosis
Cardiac arrhythmia
Congestive heart failure
12
Energy intake is gradually increased over a week until daily nutritional requirements are
met. Additional potassium and phosphate should be given intravenously to prevent
deficiency (15, 16).
8. Monitoring of EN
It is important to monitor EN for two reasons: 1. to monitor the patients progress if
enteral feeding is to be successful and adequate for the patients needs; and 2. to
recognize possible (metabolic) complications early.
It is important to mention that in many clinical situations monitoring of nutrition cannot
be separated from monitoring of other medical interventions (e.g. fluid balance in
necrotizing pancreatitis with renal failure). The following recommendations can only be
used for rough orientation and should be adjusted to the patients individual needs.
Feed administration
Fluid balance
Laboratory tests
Na, K, Glucose
P, Ca, Urea, Creatinine,
ALT, Blood count
Nutritional status
Weight, albumin,
Bioimpedance analysis
Functional status
Hand grip strength
daily
daily
initially daily
initially twice/week
weekly/every 2nd week
weekly
Figure 9: Monitoring of EN
Monitoring of EN should consider the following issues:
Feed administration: Check delivery rates at intervals to ensure even flow. Aspirate
periodically to check stomach emptying; if necessary measure gastric reflux.
Fluid balance: Fluid balance charts must be strictly maintained throughout enteral
feeding. Check hydration status clinically; in patients with diarrhoea, fever or other
nonphysiological fluid losses assess urinary output daily.
Laboratory tests: Electrolytes and glucose should initially be monitored daily, with
serum urea, calcium, magnesium and phosphate levels twice weekly until feeding is
well established. Keep in mind that many cancer patients have insulin resistance and
might develop diabetes mellitus under EN. Serum albumin should be measured
initially and then at weekly intervals.
Nutritional status: weigh patient daily until feeding is well established, then weigh
patient weekly. If available perform analysis of body composition by bioelectrical
impedance analysis or by anthropometry every second week. A good functional
outcome measure of tube feeding is hand grip strength which can easily be performed
every week.
9. Summary
In this module indications and contraindications for enteral nutrition with special respect
to selected diagnoses and clinical situations are highlighted. In addition diagnosis and
treatment of gastrointestinal, tube-related and metabolic complications of EN are
discussed. Most complications of EN are the result of application errors and can be
13
avoided by an adequate approach and appropriate monitoring. The recommendations are
based on the published ESPEN guidelines on enteral nutrition.
10. References
(1) Lochs H, Allison SP, Meier R, Pirlich M, Kondrup J, Schneider St, van den Berghe G,
Pichard C. Introductory to the ESPEN Guidelines on enteral nutrition: terminology,
definitions and general topics. Clin Nutr 2006; 25: 180-186.
(2) Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related
malnutrition. Clin Nutr 2008; 27: 5-15.
(3) Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based
approach to treatment. CAB international 2003.
(4) Lochs H, Pichard C, Allison SP. Evidence supports nutritional support. Clin Nutr 2006;
25: 177-179.
(5) Detsky AS, McLaughlin JR Baker JP, Johnston N, Whittaker S, Mendelson RA,
Jeejeebhoy KN. What is subjective global assessment of nutritional status? JPEN J
Parenter Enteral Nutr 1987; 11: 8-13.
(6) Kondrup J, Allison SP, Elia M et al. ESPEN guidelines for nutrition screening 2002 Clin
Nutr 2003; 22: 415-421.
(7) Volkert D, Berner YN, Berry E et al. ESPEN guidelines on enteral nutrition: geriatrics.
Clin Nutr 2006; 25: 330-360.
(8) Valentini L, Schtz T, Allison S, Howard P, Pichard C, Lochs H (eds.). ESPEN
guidelines on Enteral Nutrition. Clin Nutr 2006; 25: 177-360.
(9) Krner U, Bondolfi A, Nhler E et al. Ethical and legal aspects of enteral nutrition .
Clin Nutr 2006; 25: 196-202.
(10) American Gastroenterological Association Medical Position Statement: Guidelines
for the use of enteral nutrition. Gastroenterology 1995; 108: 180.
(11) DeLedinghen V, Beau P, Mannant PR, et al. Early feeding or enteral nutrition in
patients with cirrhosis after bleeding from esophageal varices ? A randomized
controlled study. Dig. Dis Sci 1997; 42: 536-541.
(12) Adam S, Batson S: A study of problems associated with the delivery of enteral
feed in critically ill patients in five ICUs in the UK. Intensive Care Med 1997; 23: 261266.
(13) Lser C, ASchl G, Hebuterne X et al. ESPEN guidelines on artifical enteral nutrition
Percutaneous endoscopic gastrostomy (PEG). Clin Nutr 2005; 24: 848-861.
(14) Schnitker M, Mattman PF, Bliss TL. A clinical study of malnutrition in Japanese
prisoners of war. Ann Intern Med 1951; 35: 69-96.
(15) Marinella MA. The refeeding syndrome and hypophosphataemia. Nutr Rev 2003;
61: 320.
(16) Maier-Dobersberger T, Lochs H. Enteral supplementation of phosphate does not
prevent hypophosphataemia during refeeding of cachectic patients. JPEN 1994; 18:
182.
Weblink:
ESPEN-guidelines
http://www.espen.org/Education/guidelines.htm