Enteral nutrition management in stroke patients: a narrative review

OBJECTIVE

We aimed to summarize the enteral nutrition (EN) management of stroke patients according to recent evidence.

BACKGROUND

Stroke patients have a high incidence of dysphagia, which is the main cause of malnutrition, and stroke with malnutrition leads to high recurrence and mortality. Insufficient food intake caused by dysphagia is the main cause of malnutrition in stroke patients, which is associated with poor prognosis, increased mortality, and deteriorated outcomes in patients with stroke. Dehydration is also worthy of attention.

METHODS

Non-systematic searches of the PubMed database were conducted to retrieve relevant English-language articles, and the CNKI and Wanfang database were searched for relevant Chinese-language articles. Fifteen recent guidelines or expert consensuses on the clinical nutritional management of stroke patients were published between 2013 and 2021, of which eight are from China.

CONCLUSIONS

Before providing nutritional support, swallowing, hydration, and risk of malnutrition need to be screened by a dietitian or professional. Although the initiation time of nutritional support is different in each guideline, tube feeding is preferable for patients with dysphagia. The appropriate dosage, formula, and treatment of complications need to be further studied. Also, nutritional support for stroke patients at different stages needs to be further improved. The continuous improvement and details of stroke nutrition guidelines contribute to standardized clinical nutrition practices and benefit patients.

Enteral feeding and the microbiome in critically ill children: a narrative review

OBJECTIVE

This narrative review summarizes our current knowledge on the interplay between enteral nutrition (EN) and gut microbiota in critically ill children, using examples from two commonly encountered diagnoses in the pediatric intensive care unit (PICU): severe sepsis and acute respiratory distress syndrome (ARDS). This review will also highlight potential areas of therapeutic interventions that should be explored in future studies.

BACKGROUND

Critically ill children display extreme dysbiosis in their gut microbiome. Factors within the PICU that are often associated with dysbiosis include the use of broad-spectrum antibiotics, proton-pump inhibitors (PPIs), intravenous morphine, and fasting. Dysbiosis can potentially lead to adverse clinical outcomes (e.g., nosocomial infection, and prolonged hospitalization). EN may modulate dysbiosis. The gut microbiota is involved in the breaking down of macronutrients, mainly carbohydrates and proteins. Fermentation of undigestible carbohydrate (e.g., inulin and oligosaccharides), and amino acids by large intestine microbiota produces short chain fatty acids (SCFAs). SCFAs serve as the main fuel source for enterocytes and help to maintain healthy gut lining. Changes to selected components of macronutrients can result in alterations in gut microbiome and have potentially beneficial effects in patients in the PICU.

METHODS

A comprehensive search of the MEDLINE, Cochrane Library and Google Scholar databases was conducted using appropriate MESH terms and keywords. In this narrative review, we provide a summary of current knowledge on effect of EN on gut microbiota in pediatric studies, but also describes animal- and lab-based, as well as adult studies where relevant.

CONCLUSIONS

The gut microbiome can be altered by dietary modifications and common PICU practices and treatment. Although there are strong associations in restoring eubiosis and improvement in clinical outcomes, proving causality remains challenging. Further microbiome research is needed to provide mechanistic insights into the impact of the ever changing gut microbiome. In the future, new microbiota targeted therapies could potentially be the treatment of challenging PICU conditions and restore homeostasis in these children.

Home enteral nutrition for postoperative elderly patients with esophageal cancer

BACKGROUND

The clinical value of enteral nutrition (EN) after radical resection of esophageal cancer (EC) has been well recognized during hospital stay; however, whether using EN agents should be continued at home after the patient is discharged remains unclear, especially for the elderly postoperative patients. Here we investigated the effects of continued EN on nutrition and immune status in elderly patients who had undergone radical EC surgery.

METHODS

Sixty eligible elderly patients undergoing surgical treatment for EC in our center during the period from October 2016 to October 2018 were randomly divided into EN group and control groups, with 30 patients in each group. Among them, the EN group continued to take an orally administered EN agent (Ensure®) daily in addition to daily routine diets after discharge; however, patients in the control group only received regular diets after discharge. The nutritional status and immune indicators were evaluated at discharge and 4 and 8 weeks after discharge (weeks 4 and 8) and compared between EN and control groups.

RESULTS

Body mass index (BMI), Patient-Generated Subjective Global Assessment (PG-SGA) score, hemoglobin, serum albumin, serum prealbumin, CD4 and CD8 T cell counts, CD4/CD8 ratio, IgA, IgG, and IgM showed no significant difference between EN group and control group at discharge (all P>0.05). In week 4, the serum prealbumin level was significantly higher in the EM group than in the control group (P<0.05). In week eight, the EM group had significantly higher BMI, PG-SGA score, serum albumin, serum prealbumin, CD4 and CD8 T cell counts, CD4/CD8 ratio, IgA, IgG, and IgM than the control group (all P<0.05).

CONCLUSIONS

Home EN helps improve immune function in elderly patients who have undergone radical surgery for EC and is worthy of clinical promotion. To optimize its efficacy, a home EN should last no less than eight weeks after discharge.

Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States

Malnutrition, particularly under-nutrition, is highly prevalent among adult patients with a diagnosis of gastrointestinal (GI) cancer and negatively affects patient outcomes. Malnutrition is associated with clinical and surgical complications for patients undergoing therapy for GI cancers and the costs associated with those complications is a high burden for the US health system. Our objective was to identify high-quality evidence for nutrition support interventions associated with cost savings for patient care, followed by a complex economic value analysis to project cost savings for the US health system. A narrative literature search was conducted in which combined keywords in the areas of therapeutic nutrition (nutrition, malnutrition), a specific therapeutic area [GI cancer (esophageal, gastric, gallbladder, pancreatic, liver/hepatic, small and large intestine, colorectal)], and clinical outcomes and healthcare cost, to look for nutrition interventions that could significantly improve clinical outcomes. Medicare claims data were then analyzed using the findings of these identified studies and this modeling exercise supported identifying the cost and healthcare resource utilization implications of specific populations to determine the impact of nutrition support on reducing these costs as reflected in the summary of the evidence. Eight studies were found that provided clinical outcomes and health cost savings data, 2 of those had the strongest level of evidence and were used for Value Analysis calculations. Nutrition interventions such as oral diet modifications, enteral nutrition (EN) supplementation, and parenteral nutrition (PN) have been studied especially in the peri-operative setting. Specifically, peri-operative immunonutrition administration and utilization of enhanced recovery pathways after surgery have been associated with significant improvement in postoperative complications and decreased length of hospital stay (LOS). Utilizing economic modeling of Medicare claims data from GI cancer patients, potential annual cost savings of $242 million were projected by the widespread adoption of these interventions. Clinical outcomes can be improved with the use of nutrition interventions in patients with GI cancers. Healthcare costs can be reduced as a result of fewer in-hospital complications and shorter lengths of hospital stay. The application of nutrition intervention provides a positive clinical and economic value proposition to the healthcare system for patients with GI cancers.

Enteral immunonutrition versus enteral nutrition for patients undergoing esophagectomy: a randomized controlled trial

BACKGROUND

In recent years, immunonutrition has been introduced and proposed to have a positive modulatory effect on inflammatory and immune responses and gut function for surgical patients, especially for patients undergoing gastrointestinal cancer resection. We conducted this parallel-group, randomized and double-blind clinical controlled trial to investigate the efficacy of perioperative enteral immunonutrition (EIN) on clinical and immunological outcomes of patients undergoing esophageal resection.

METHODS

A randomized, parallel-group, double-blind, clinical trial was conducted between December 1, 2017 and March 1, 2018. This study enrolled 120 patients with esophageal cancer. And 112 patients were divided into two groups randomly: EIN group and enteral nutrition (EN) group. The EIN contained extra immunonutritional substrates, including a consistent combination of arginine, RNA and the omega-3 fatty acids compared with EN. Immune indicators were measured at preoperative day 7, postoperative day (POD) 1, 3, 7 and post-discharge day (PDD) 30.

RESULTS

There were 56 participants randomized to each group. Finally, 53 patients in EIN and 50 patients in EN were analyzed. Immune indicator was the primary outcome in this study. EIN yielded a significantly lower rate of CD8/CD3 (%) at POD 3 compared with EN group (P=0.005). The rate of CD4/CD8 (%) in EIN group was higher than that in EN group at POD3 (P=0.004). The serum levels of IgM at POD 3 and 7 were significantly higher in EN group compared with EIN group (P=0.025 and P=0.009, respectively). The rate of NK (%) and the serum level of IgA were significantly higher in EIN group compared with EN group at PDD 30 (P=0.022 and P=0.041, respectively). No significant differences were found in 2-year progressionfree survival and overall survival.

CONCLUSIONS

Immunonutrition is a safe and feasible nutritional treatment, which has a positive modulatory impact on immune responses after esophagectomy. Although no significant difference was found in clinical and survival outcomes between EIN and EN groups, immunonutrition could still have a positive effect on immunological function of patients undergoing esophagectomy.

Association between serum lactate levels and enteral feeding intolerance in septic patients treated with vasopressors: a retrospective cohort study

Background

To assess the association between serum lactate levels and intolerance to enteral nutrition (EN) in septic patients treated with vasopressors.

Methods

This retrospective study was conducted between January 1, 2015 and May 1, 2018 in an intensive care unit (ICU). Patients with sepsis who were given EN and treated with vasopressors were included. EmpowerStats software and R (version 3.3.2) was used to examine the association between serum lactate levels and intolerance to EN.

Results

Among the 132 septic patients (age, 60.6±18.1 years) enrolled, 35 (26.5%) patients suffered intolerance to EN. Multiple logistic regression analysis demonstrated that an elevated lactate level was an independent risk factor for EN intolerance [odds ratio (OR): 2.7; 95% confidence interval (CI): 1.6–4.4; P<0.001]. The area under the receiver operating characteristic (ROC) curve for serum lactate levels was 0.764 (95% CI: 0.664–0.864). Stratified analysis suggested that age was the most prominent interactive factor for serum lactate levels in EN intolerance. Serum lactate levels were closely correlated to EN intolerance in elderly patients (age ≥65 years) (OR: 9.5; 95% CI: 2.1–42.4; P=0.0261 for interaction), while no such association was identified in younger patients (age <65 years; OR: 1.7; 95% CI: 1.0–2.9; P=0.052).

Conclusions

Serum lactate levels were associated with an increased risk of EN intolerance in patients with sepsis, especially in elderly individuals. An elevated serum lactate level may be an early predictor of EN intolerance in elderly septic patients treated with vasopressors. However, further studies are called for to verify these findings.

Nutritional survey in critically ill children: a single center study in China

BACKGROUND

The incidence of malnutrition in children, who were admitted to the pediatric intensive care unit (PICU), has kept high level over the past 30 years. In addition, nutrition status of critically ill children deteriorates further during the changing of their conditions and may have a negative effect on patients' outcomes. This study aimed to determine the nutritional status of critically ill children and to survey current nutrition practices and support in PICU.

METHODS

In this prospective observational study, 360 critically ill children stayed in the PICU not less than 3 days from Feb. to Nov. in 2017 were enrolled. Each patient underwent nutrition assessment. Nutritional status was determined using Z-scores of length/height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ), body mass index-for-age (BAZ), based on the World Health Organization child growth standards. We also observed the patients' intake of calories and protein during the first 10 days after admission.

RESULTS

Three hundred and sixty were enrolled in the study. One hundred and eighty-six patients (51.67%) were malnourished at PICU admission, above 50% and 56.45% (105/186) of malnourished patients had severe malnutrition. Except fasting in case of clinical instability in 5.3% (19/360), nutrition was provided in the form of oral feeding in 26.6% (96/360), enteral nutrition (EN) in 56.1% (202/360), parenteral nutrition (PN) in 6.4% (23/360) and mixed support (EN + PN) in 5.6% (20/360). Totally 384 times interruption of feeding happened in the process of EN, and 1.9 times feeding interruption happened to each patient. Twenty-seven point two percent of these patients had more than three times feeding interruption. The severe malnutrition group had significantly greater length of ICU stay and higher mechanical ventilation support rate (P=0.007, P=0.029). Total 44 (44/360, 12.22%) patients died in the study, and the malnutrition was not statistically different between survivor group and death group (P=0.379). More than 85% of the patients had lower daily nutritional intake compared with prescribed goals. Sixty-eight point three percent of the patients received the required calories during EN with median time of 2 [2-4] days. Only 32.7% of patients underwent EN received estimated protein requirements.

CONCLUSIONS

These results showed that malnutrition was common among children admitted to PICU. Furthermore, nutrition delivery was generally inadequate in critically ill children, and nutritional status was getting worsening during PICU.

The feeding route after esophagectomy: a review of literature

Enhanced recovery programs effectively optimize perioperative care and reduce postoperative morbidity. In esophagectomy, several components of the ERAS program are successfully introduced. However, timing and type of postoperative feeding remain a matter of debate. Adequate nutritional support is essential in patients undergoing an esophagectomy. These patients often present with weight loss and their eating pattern is strongly altered by the procedure and reconstruction. Total parenteral nutrition (TPN) is associated with severe septic complications and enteral nutrition (EN) does not increase major complications. Therefore, early EN after esophagectomy is favored over TPN. However, with enteral feeding tubes minor complications occur frequently (13-38%) and in some cases this can hamper recovery. Based on experience in other types of upper gastro-intestinal surgery, early start of oral feeding could improve time to functional recovery after surgery. The total length of stay was significantly shorter in four prospective studies (6-12 vs. 8-13 days). However, large randomized controlled trials are lacking and the potential benefit of early oral feeding after esophageal surgery remains elusive. EN is nowadays the optimal feeding route after esophagectomy. TPN should only be used in specific cases in which EN is contraindicated. Early initiation of oral intake is promising and could improve postoperative recovery. However, further research is needed to substantiate these results.

Enteral and parenteral nutrition in cancer patients: a systematic review and meta-analysis

BACKGROUND

In cancer patients, weight loss is an ominous sign suggesting disease progression and shortened survival time. As a result, providing nutrition support for cancer patients has been proposed as a logical approach for improving clinical outcomes. Nutrition support can be given to patients through enteral nutrition (EN) or parenteral nutrition (PN). The purpose of the review was to compare the outcomes of PN and EN in cancer patients.

METHODS

A literature search was conducted in Ovid MEDLINE and OLDMEDLINE, Embase Classic and Embase, and Cochrane Central Register of Controlled Trials. Studies were included if over half of the patient population had cancer and reported on any of the following endpoints: the percentage of patients that experienced no infection, nutrition support complications, major complications or mortality. Risk ratios (RR) and 95% confidence intervals (CIs) using Review Manager Version 5.3 were calculated. Primary endpoints were stratified according to type of EN for subgroup analysis, grouping studies into either tube feeding (TF) or standard care (SC). Additionally, another subgroup analysis was conducted comparing studies with protein-energy malnutrition (PEM) patients and studies without PEM patients.

RESULTS

The literature search yielded 674 articles of which 36 were included for the meta-analysis. There were no difference in the endpoints between the two study interventions except that PN resulted in more infection when compared with EN (RR =1.09, 95% CI: 1.01-1.18; P=0.03).

CONCLUSIONS

Other than increased incidence of infection, PN has not resulted in prolonging the survival, increasing nutrition support complications, or major complications when compared with EN in cancer patients.

Serum carnitine as an independent biomarker of malnutrition in patients with impaired oral intake

Carnitine is a vitamin-like compound that plays important roles in fatty acid β-oxidation and the control of the mitochondrial coenzyme A/acetyl-CoA ratio. However, carnitine is not added to ordinary enteral nutrition or total parenteral nutrition. In this study, we determined the serum carnitine concentrations in subjects receiving ordinary enteral nutrition (EN) or total parenteral nutrition (TPN) and in patients with inflammatory bowel diseases to compare its levels with those of other nutritional markers. Serum samples obtained from 11 EN and 11 TPN patients and 82 healthy controls were examined. In addition, 10 Crohn’s disease and 10 ulcerative colitis patients with malnutrition who were barely able to ingest an ordinary diet were also evaluated. Carnitine and its derivatives were quantified using liquid chromatography-tandem mass spectrometry (LC-MS/MS). The carnitine concentrations in EN and TPN subjects were significantly lower compared with those of the control subjects. Neither the serum albumin nor the total cholesterol level was correlated with the carnitine concentration, although a significant positive correlation was found between the serum albumin and total cholesterol levels. Indeed, patients with CD and UC showed significantly reduced serum albumin and/or total cholesterol levels, but their carnitine concentrations remained normal. In conclusion, only a complete blockade of an ordinary diet, such as EN or TPN, caused a reduction in the serum carnitine concentration. Serum carnitine may be an independent biomarker of malnutrition, and its supplementation is needed in EN and TPN subjects even if their serum albumin and total cholesterol levels are normal.

The role of dietary nutrition in stomach cancer

Stomach cancer mortality still represents a significant proportion of all cancer deaths. The majority of patients with advanced cancer experience cancer anorexia-cachexia syndrome with weight loss, reduced appetite, fatigue, and weakness. Neoplastic cachexia is a very common clinical manifestation of upper gastrointestinal (GI) tract cancer and is generally assumed to be secondary to the mechanical effects of the tumor on the upper digestive tract. The main reasons are obstruction to swallowing, early satiety, nausea and vomiting. Another reason for weight loss is the co-existence of systemic inflammation. Nutritional treatment in the group of patients with gastric cancer is still used too rarely and the knowledge about it is still very limited. Nutritional support should be given for patients both in the pre- and postoperative period. Nutrition should also be used in palliative treatment in patients with unresectable stomach cancer. The main principles of nutritional support and its influence are presented in this publication.