ESPEN Nutritional Support Recommendations

1 ESPEN Congress Istanbul 2006A Patient's Journey through Complicated PancreatitisESPEN Nutritional Support RecommendationsR. Meyer (Switzerland) ESPEN ESPEN -- Nutritional Support Nutritional Support RecommendationsRecommendations(An Evidence based Approach and the (An Evidence based Approach and the Application in Europe)Application in Europe)RR mymyMeier MDMeier MDAssociate ProfessorAssociate ProfessorUniversity HospitalUniversity HospitalLiestalLiestal, Switzerland, SwitzerlandESPENESPEN--FELANPE Symposium Istanbul 2006 FELANPE Symposium Istanbul 2006 NutritionalNutritionaldeficienciesdefici enciesand and malnutritionmalnutritionarearea a significantsignificantproblemproblemin in clinicalclinicalpracticepracticePrevalen cePrevalenceof of MalnutritionMalnutrition ambulatoryambulatoryoutpatientsoutpatien ts11--15%15% institutionalizedinstitutionalizedpatien tspatients2525--60%60% hospitalizedhospitalizedpatientspatients 3535--65%65%Omran et al.

2 Nutrition 2000 ConsequencesConsequencesof of MalnutritionMalnutritionPoorPoornutritio nalnutritionalstatusstatusreflectsreflec tsthetherate ofrate of inin--hospitalhospitalcomplicationscompl ications lengthlengthof of hospitalhospitalstaystay mortalitymortality costscosts rere--admissionsadmissionsRCT: RCT: Complications andComplications andmortalitymortalityMeta-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, Hospital ororcommunitycommunityOral supplements Oral supplements orortube tube feedingfeedingComplicationsComplications 28%28%vs.

3 Vs. 46%46%1)1)InfectionsInfections24%24%vs. vs. 44%44%2)2)MortalityMortality17 %17 %vs. vs. 24%24%1)1)1)P < ; 2)10 RCTs onlyStratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003 CostsCosts1 hospital 1 hospital day day = = 250; 1 250; 1 complicationcomplication= = 8080 NNLOSLOSNNCompCompTotal, Total, Per Per ptpt, , Not atNot at--riskrisk28482848663353354,2984,2981, 5091,509 AtAt--riskrisk13121312994094092,9842,984 2,2752,275 TotalTotal416041607,2837,283 Extra cost Extra cost per per at riskat riskpatient: patient: 766766 Stratton RJ, Green CJ, Elia M.

4 Disease-related malnutrition. CABI Publishing 2003 Important ImplicationImportant ImplicationThe Nutritional statusThe Nutritional statusmust be known inmust be known inall patientsall patientsESPEN Guidelines ESPEN Guidelines forforNutritionNutritionScreening IScreening I All patientsAll patientsshouldshouldbebescreenedscreened ononadmissionadmissionto to hospitalhospital IfIfthethepatient is at patient is at riskrisk, a , a nutritionnutritionplanplanis is workedworkedout out by by thethestaffstaff MonitoringMonitoringand and definingdefiningoutcome has tooutcome has tobebeorganizedorganized CommunicationCommunicationof of resultsresultsof screening, assessment of screening, assessment and and nutritionnutritioncarecareplans plans shouldshouldbebecommunicatedcommunicated to to otherotherhealthcarehealthcareprofession als professionals whenwhenthethepatient is patient is AuditAuditof of Screening 2002.

5 Clin Nutr Education GuidelinesESPEN Guidelines for ESPEN Guidelines for NutritionNutritionScreening IIScreening is not at patient is not at riskrisk, but , but maymayneedneedto to beberere--screenedscreenedat at specifiedspecifiedintervals, intervals, weeklyweeklyduringduringhospital hospital is at patient is at riskriskand a and a nutritionnutritionplan is plan is workedworkedout by out by is at patient is at riskrisk, but , but metabolicmetabolicororfunctionalfunction alproblems problems preventpreventa standard plan a standard plan is doubtdoubtas as whetherwhetherthethepatient is patient is atat--riskriskScreening is a rapid and simple Screening is a rapid and simple processprocessconductedconductedby by admittingadmittingstaffstaffTheTheoutcom eoutcomeof screening must of screening must bebelinkedlinkedto to defineddefinedcoursescoursesof action:of action.

6 In In thethetwotwolatter cases, latter cases, referralreferralshouldshouldbebemade to an made to an expertexpertfor more for more Screening 2002, Clin Nutr 2003A A completecompletenutritionnutritionassess mentassessmentconsistsconsistsof a of a combinationcombinationof of subjectivesubjectiveand and objectiveobjectiveparametersparametersbu tbutno no singlesingleparameterparameterhas has beenbeenshownshownto to bebeusefulusefulin all in all patientspatients A A nutritionalnutritionalassessmentassessme ntparameterparametershouldshouldbebehigh lyhighlysensitive and sensitive and specificspecific, , unaffectedunaffectedbybyfactorsfactorsun relatedunrelatedto to nutritionnutrition, and.

7 And correlatecorrelatewithwithresponserespon seto to nutritionalnutritionaltherapytherapy Most Most nutritionalnutritionalparametersparamete rslack lack sensitivitysensitivityand and specificityspecificity;;thereforetherefo re, , methodsmethodsof of identifyingidentifyingmalnourishedmalnou rishedpatientspatientsarearenotnotentire lyentirelysatisfactorysatisfactoryAssess mentAssessmentof of thetheNutritionalNutritionalstatusstatus ScreeningScreeningAssessmentAssessmentSc reening is Screening is thetheentryentryto to aastructuredstructuredprocessprocessNutr itionalNutritionalscreeningscreeningIs a tool for rapid and simpleIs a tool for rapid and simpleevaluation of patients at risk ofevaluation of patients at risk

8 OfundernutritionundernutritionNutritiona lNutritionalscreeningscreeningHistoryHis tory:: WeightWeightlosslossoverovertimetime Appetit, Appetit, nauseanausea Food Food intakeintakeFirst First measurementsmeasurements:: Body Body weightweight HeightHeightBMIBMIS creeningScreeningtoolstools NutritionalNutritionalRiksRiksIndexIndex 11 SubjectiveSubjectiveglobal assessmentglobal assessment22 MalnutritionMalnutritionUniversal Universal ScreeningScreeningToolTool(MUST)(MUST)33 NutritionalNutritionalRiskRiskScreeningS creening(NRS 2002)(NRS 2002)44 MNA (elderly)MNA (elderly)

9 551 1 VeteransVeteransAffairsAffairs, New , New EnglEnglJ J MedMed199119912 2 DetskyDetskyet al, JPEN, 1984et al, JPEN, 19843 BAPEN3 BAPEN4 4 KondrupKondrupet al, et al, ClinClinNutrNutr200320035 5 VellasVellaset al, Nutrition 1999et al, Nutrition 1999 Recommended by ESPENR ecommended by ESPENN utritionalNutritionalriskriskscreeningsc reeningSubjectiveSubjectiveglobal global assessmentassessment(SGA)(SGA)IIPatientP atient sshistoryhistory((weightweightlossloss, , changechangein in dietarydietaryintakeintake, , gigi--symptomssymptoms,,functionalfuncti onalcapacitycapacity))IIIIP hysicalPhysicalexaminationexamination((m usclesmuscles, , subcutaneoussubcutaneousfatfat, , edemaedema, , ascitesascites))ClinicianClinician ssoveralloveralljudgementjudgement normal normal nutritionalnutritionalstatusstatus mildlymildly significantlysignificantlyDetskyDetskyet al, JPEN, 1984et al, JPEN, 1984malnourishedmalnourished0 (LOW) 0 (LOW) 1 (MEDIUM)

10 1 (MEDIUM) 2 2 or more or more (HIGH)(HIGH)ROUTINE CLINICAL CAREROUTINE CLINICAL CAREOBSERVE OBSERVE TREAT TREAT Acute disease effectAcute disease effectAddAddaascorescoreof 2of 2if thereif therehashasbeen orbeen orisislikely tolikely tobe nobe noorornutritional intake fornutritional intake for> 5 > 5 daysdaysHospitalHospital--refer to dietitian orrefer to dietitian orimplement local policiesimplement local food first followed byGenerally food first followed byfood fortification and food fortification and supplementssupplementsCare HomesCare Homes(as(asfor hospitalfor hospital))