Nutrition Support in Adults - Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition

627 Pages·2006·4.97 MB·English

by  Stroud

National Collaborating Centre
for Acute Care
Nutrition Support for Adults
Oral Nutrition Support, Enteral Tube
Feeding and Parenteral Nutrition
METHODS, EVIDENCE & GUIDANCE
FEBRUARY 2006
Commissioned by the National Institute for
Clinical Excellence
1
Nutrition support in adults
Oral nutrition support, enteral tube
feeding and parenteral nutrition
METHODS, EVIDENCE & GUIDANCE
Published by the National Collaborating Centre for Acute Care at The Royal College of Surgeons of England,
35-43 Lincoln’s Inn Fields, London, WC2A 3PE
First published 2006
© National Collaborating Centre for Acute Care 2006
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and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the
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The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such
names are exempt from the relevant laws and regulations and therefore for general use.
The rights of National Collaborating Centre for Acute Care to be identified as Author of this work have been asserted by them in
accordance with the Copyright, Designs and Patents Act, 1988.
ISBN 0-9549760-2-9
Citing this document:National Collaborating Centre for Acute Care, February 2006. Nutrition support in adults Oral nutrition support,
enteral tube feeding and parenteral nutrition.
National Collaborating Centre for Acute Care, London. Available from www.rcseng.ac.uk
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NUTRITION SUPPORT INADULTS
FOREWORD
Malnutrition is both a cause and a consequence of ill-health. It is surprisingly common in the UK, especially in
those who are unwell. Many older people and those with any long-term medical or psycho-social problems are
chronically underweight and so are vulnerable to acute illness. Even people who are well-nourished eat and drink
less if they are ill or injured and although this may only be short-lived as part of an acute problem, if it
persists the person can become undernourished to an extent that may impair recovery or precipitate other
medical conditions.
The consequences of malnutrition include vulnerability to infection, delayed wound healing, impaired function of
heart and lungs, decreased muscle strength and depression. People with malnutrition consult their general
practitioners more frequently, go to hospital more often and for longer, and have higher complication and
mortality rates. Surgical patients, who have malnutrition for example, have around three times as many post-
operative complications and four times greater risk of death than well nourished patients having similar
operations. If poor dietary intake or complete inability to eat persists for weeks, the resulting malnutrition can be
life-threatening in itself.
The provision of normal food and drink along with physical help to eat if necessary, when unwell will often suffice.
However, if this fails, is impractical or is unsafe, measures to provide nutrition support may be indicated. These
include, either alone or in combination: extra oral intake such as extra food and special drinks ; feeding via a tube
into the gastro-intestinal tract (enteral tube feeding - ETF); or giving nutrients intravenously (parenteral nutrition -
PN). Choosing the most effective and safest route is essential, yet current knowledge of nutrition support amongst
most UK health professionals is poor.
The need for nutrition support is essentially absolute if patients are unable to meet the majority of their nutrient
needs for prolonged periods (e.g. in complete dysphagia or intestinal failure). However, when nutritional intakes
are closer to meeting needs, or when the likely period of inadequate intake is uncertain, decisions are more
complex, especially as providing nutrition support is not without risk. Oral supplementation can cause pneumonia
in dysphagic patients, while ETF and PN can cause gastrointestinal problems, infections, metabolic upset and
trauma. ‘These risks will need to be discussed with patients and even in those instances where they are able to
provide informed consent, difficult clinical and ethical issues can arise particularly where such patients do not
want to ‘artificially’ prolong their life. Likewise with patients who are unable to express a wish either because
they are unconscious and thus unable to communicate but in need of immediate nutritional support or because
they lack capacity to provide informed consent, in which case clinicians will need to act in accordance with what
they determine to be in the best interests of the patient.’
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FOREWORD
The aim of these guidelines is to improve the practice of nutrition support by providing evidence and information
for all healthcare professionals, patients and their carers so that malnutrition whether in hospital or in the
community, is recognized and treated by the best form of nutrition support at the appropriate time. However,
although the recommendations have been systematically developed and based on trial evidence wherever possible,
the Guideline Development Group (GDG) have met with some difficulties: the breadth of our remit was enormous;
time and resources were finite; and the evidence base for nutrition support is difficult to interpret. The last of these
was most problematic. Most of the evidence consists of many small trials, applying different interventions and
outcome measures, to very variable populations. This not only leads to individual trials being statistically
underpowered but makes combining them into meta-analyses more difficult. The varied study settings also create
difficulties in making firm recommendations for patients in the community when most research was conducted in
hospitals. Furthermore, in the case of the more ‘invasive’ ETF and PN techniques, problems with the evidence are
near insurmountable. It is unethical to include patients who are unable to eat at all for significant periods in any
randomized trial of ETF or PN (where feeding may be withheld). The scientific trials therefore examine ‘elective’
supplementary usage of ETF and PN rather than their use in patients with an absolute need for such support and
so the results do not necessarily apply to routine clinical practice.
In the light of the problems above, many of the recommendations in this guideline are derived from a combination
of clinical evidence, clinical experience and expertise. Many are also quite general, applying to all patients with
malnutrition whatever their disease or care setting. However, all healthcare professionals who have contact with
patients should find the recommendations relevant for we believe that they contain an obvious, simple message:
‘Do not let your patients starve and when you offer them nutrition support, do so by the safest, most simplest,
effective route.’
This is essential to good patient care,
Mike Stroud
Chair, Guideline Development Group.
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NUTRITION SUPPORT INADULTS
Contents
Guideline Development Group membership 3. Organisation of Nutrition Support in
and acknowledgments 6 hospital and the community 56
3.1. Introduction 56
Stakeholder Involvement 8 3.2. Nutrition support in the community 56
3.3. Nutrition support in Hospital 56
Abbreviations 10 3.4. Methods 58
3.5. Clinical evidence 58
3.6. Cost effectiveness evidence 60
Glossary of Terms 12
3.7. Conclusion 60
3.8. Recommendations for clinical practice 61
1. Introduction and methods 27
3.9. Research recommendations 62
1.1. The need for guidelines in
nutrition support 27
4. Screening for malnutrition and the risk
1.2. What is a guideline? 28
of malnutrition in hospital and
1.3. Remit of the guideline 28
the community 63
1.4. What the guideline covers 29
4.1. Nutritional assessment 63
1.5. What the guideline does not cover 29
4.2. Why and how to screen 63
1.6. Who the guideline is for 30
4.3. Methods 64
1.7. Who developed the guideline? 30
4.4. Studies considered for this review 65
1.8. Methodology 30
4.5. Clinical evidence 65
1.9. Hierarchy of clinical evidence 33
4.6. Cost-effectiveness evidence 65
1.10. Health economics methods 33
4.7. Consensus development methods 66
1.11. Forming and grading the recommendations 35
4.8. Impact of nutritional assessment on
1.12. Specific problems with evidence relating
the patient 68
to the development of nutrition
4.9. Recommendations for clinical practice 69
support guidelines 36
4.10. Research recommendations 69
1.13. Patient-centred care 37
1.14. Summary of the recommendations 37
5. Indications for nutrition support 70
1.14.3Research recommendations 51
5.1. Introduction 70
5.2. Methodology 70
2. Malnutrition and the principles
5.3. Appropriate Nutrition Support and
of nutrition support 53
ethical/legal issues 71
2.1. Introduction 53
5.4. Rationale for recommendations 72
2.2. The causes of malnutrition 53
5.4.1 Recommendations for clinical practice 72
2.3. The effects of malnutrition 54
5.5. Algorithms 74 - 76
2.4. The prevalence of malnutrition 54
2.5. Principles underlying intervention 55
6. What to give in hospital and
the community 77
6.1. Background 77
6.2. General Principles 77
6.3. Calculating requirements 78
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CONTENTS
6.4. Concerns with prescribing levels 79 9.11. Recommendations for clinical practice 119
6.5. Recommendations for clinical practice 80 9.12. Types of enteral feeds 119
6.6. Re-feeding Problems 80 9.13. Mode of delivering Enteral Tube Feeding 121
6.7. Recommendations for research 83 9.14. Recommendations for clinical practice 122
9.15. Motility Agents 122
7. Monitoring of nutrition support in 9.16. Recommendations for clinical practice 123
hospital and the community 84 9.17. Complications of enteral tube feeding 123
7.1. Introduction 84 9.18. Recommendations for clinical practice 124
7.2. Methods 84 9.19. Research recommendations 124
7.3. Recommendations for clinical practice 85
7.4. Research Recommendations 90 10.Parenteral nutrition in hospital
and the community 125
8. Oral Nutrition Support in hospital 10.1. Introduction 125
and the community 91 10.2. PN versus no PN 125
8.1. Introduction 91 10.2.3Elective PN in surgical patients 127
8.2. Oral nutritional support versus standard 10.3. Recommendations for clinical practice 128
care in malnourished patients 91 10.4. Parenteral versus enteral tube feeding 129
8.3. Dietary advice versus standard care 96 10.5. Recommendations for clinical practice 132
8.4. Oral nutritional supplements versus 10.6. Venous access for PN 132
dietary advice 97 10.7. Recommendations for clinical practice 134
8.5. Recommendations for clinical practice 98 10.8. Peripheral PN versus central PN 134
8.6. Oral nutrition support in surgical patients 98 10.9. PN via a tunnelled catheter versus
8.7. Recommendations for clinical practice 103 PN via a non-tunnelled catheter 136
8.8. Oral nutrition support in pancreatitis patients 103 10.10.Tailored PN preparations versus
8.9. Oral multivitamin and mineral standard PN preparations 137
supplementation in malnourished patients 103 10.11. Recommendations for clinical practice 137
8.10. Nutrition support in patients with dysphagia106 10.12.Delivery of PN cyclically versus continuously 138
8.11. Recommendations for clinical practice 108 10.13.Recommendations for clinical practice 139
8.12. Research recommendations 108 10.14.Complications from PN 139
10.15.Recommendations for clinical practice 140
9. Enteral tube feeding in hospital and 10.16.Research recommendations 140
the community 110
11. Supporting patients in the community 141
9.1. Introduction 110
9.2. General Indications for Enteral Tube Feeding110 11.1 Home enteral tube feeding 141
9.3. Recommendations for clinical practice 111 11.2 Recommendations for clinical practice 141
9.4. Enteral tube feeding versus standard care 111 11.3 Home parenteral nutrition 142
9.5. Recommendations for clinical practice 115 11.4 Recommendations for clinical practice 142
9.6. Enteral tube feeding routes of access 115 11.5 Working in partnership with patients,
9.7. Recommendations for clinical practice 117 families and carers 143
9.8. Percutaneous Endoscopic Gastrostomy 11.6 Recommendations for clinical practice 146
(PEG) versus Nasogastric (NG) Feeding 117 11.7 Research recommendations 146
9.9 Recommendations for clinical practice 119
9.10. Commencing enteral tube feeding after 12. Audit criteria 147
insertion of a percutaneous endoscopic
gastrostomy 119 12. Bibliography 153
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NUTRITION SUPPORT INADULTS
Guideline Development Group membership
and acknowledgments
GGuuiiddeelliinnee DDeevveellooppmmeenntt GGrroouupp
DDrr MMiikkee SSttrroouudd ((CChhaaiirr)) Institute of Human Nutrition, Southampton General Hospital; British Association of Parenteral
and Enteral Nutrition (BAPEN)
MMss CChhrriissttiinnee BBaallddwwiinn Dietitian, Department of Medicine and Therapeutics, Imperial College, London; British Dietetic
Association (BDA)
MMrrss VViicckkyy BBrraaddnnaamm Chief Pharmacist, Bromley Hospitals NHS Trust, Bromley. Royal Pharmaceutical Society of Great
Britain
MMrrss AAnnddrreeaa CCaarrttwwrriigghhtt Senior Nutrition Nurse Specialist, Basildon University Hospital; National Nurses Nutrition Group
(NNNG)
MMiissss GGwweenn CCoolleemmaann Manager, Food for Thought, Patient representative for Alzheimer’s Society
MMrrss LLiinnddaa DDiittcchhbbuurrnn Community Nutrition Nurse Specialist, Fernbank Medical Centre, Birmingham; National Nurses
Nutrition Group (NNNG)
PPrrooffeessssoorr MMaarriinnooss EElliiaa Professor of Clinical Nutrition & Metabolism, Institute of Human Nutrition, Southampton General
Hospital; Royal College of Physicians/Malnutrition Action Group (BAPEN)
PPrrooffeessssoorr RRiicchhaarrdd GGrriiffffiitthhss Professor of Medicine (Intensive Care), Division of Metabolic and Cellular Medicine, School of
Clinical Science, University of Liverpool, and the Intensive Care Society (UK)
MMss JJuuddiitthh JJaacckkssoonn Principal Speech and Language Therapist, Islington PCT based at Whittington Hospital; Royal
College of Speech and Language Therapists Advisor in dysphagia
PPrrooffeessssoorr PPaauull LLiittttllee Professor of Primary Care Research, University of Southampton; Royal College of General
Practitioners
MMrr BBrruuccee MMccEEllrrooyy Associate Director of Pharmacy, University Hospital Birmingham Foundation Trust, Birmingham,
Royal Pharmaceutical Society of Great Britain,
DDrr JJeerreemmyy NNiigghhttiinnggaallee Consultant Gastroenterologist, Digestive Disease Centre, Leicester Royal Infirmary; British Society
of Gastroenterology
MMiissss JJooaannnnaa PPrriicckkeetttt Chief Dietitian, Department Nutrition and Dietetics, North Bristol NHS Trust, British Dietetic
Association
PPrrooffeessssoorr AAllaann SShheennkkiinn Professor of Clinical Chemistry and Hon Consultant Chemical Pathologist, Department of Clinical
Chemistry, University of Liverpool; Intercollegiate Group for Nutrition
MMrrss CCaarroollyynn WWhheeaattlleeyy Chairman, Patients on Intravenous and Nasogastric Nutrition Therapy (PINNT); Patient
Representative for PINNT
7
GUIDELINE DEVELOPMENT GROUP MEMBERSHIP AND ACKNOWLEDGMENTS
NNCCCC--AACC ssttaaffff oonn tthhee GGuuiiddeelliinnee DDeevveellooppmmeenntt GGrroouupp
Ms Susan Murray Project Manager
Ms Louise Thomas Research Associate/Assistant Project Manager
Dr Funsho Akinluyi Research Associate
Ms Rifna Aktar Research Associate
Ms Leticia Barcena Research Associate
Dr John Browne Advisor on methodological issues
Mr Peter B Katz Information Specialist
Ms Veena Mazarello Paes Research Associate
Ms Guldem Okem Health Economist
Dr Arash Rashidian Advisor on methodological issues
Mr Carlos Sharpin Information Specialist and Reviewer
Ms Rachel Southon Information Specialist
Mr David Wonderling Health Economist
AAcckknnoowwlleeddggeemmeennttss
• The development of this guideline was greatly assisted by the following people:
From the NCC-AC: Jennifer Wood, Jacqueline Rainsbury, Sally Williams, Jennifer Hill, Sophie Capo-Bianco
• Annette Kelly, Specialist Speech and Language Therapist (ENT) – The Royal National Throat Nose and Ear Hospital
London; Paula Leslie – Dysphagia Research Speech and Language Therapist, North Tees & Hartlepool PCT and Course
Director MSc Speech & Swallowing Research, University of Newcastle and Heulwen Sheldrick Senior Lecturer,
Manchester Metropolitan University and Senior Speech and Language Therapist, Halton Primary Care Trust
• Karen Harris- St Jean, Patient Representative for Samantha Dickson Research Trust ‡
• Barry Jones, Consultant Gastroenterologist, Dudley Hospital
CCoonnfflliicctt ooff IInntteerreessttss
The Guideline Development Group was asked to declare any possible conflict of interest and none that could interfere with
their work on the guideline were declared. All documentation is held by the National Collaborating Centre for Acute Care.
GGuuiiddeelliinnee RReevviieeww PPaanneell
The Guideline Review Panel is an independent panel that oversees the development of the guideline and takes responsibility
for monitoring its quality. The members of the Guideline Review Panel were as follows.
MMrr PPeetteerr RRoobbbb ((CChhaaiirr)) Consultant ENT Surgeon, Epsom and St Helier University Hospitals and the Royal Surrey
County NHS Trusts
MMrrss JJooyyccee SSttrruutthheerrss Patient Representative, Bedford
DDrr PPeetteerr DDuunnccaann ((DDeeppuuttyy CChhaaiirr)) Consultant in Anaesthetics and Intensive Care Medicine, Royal Preston Hospital
MMrr MMiikkee BBaallddwwiinn Head of Health Technology Appraisals, Sanofi-Aventis
MMrrss AAnnnnee WWiilllliiaammss Deputy Director of Clinical Governance, Kettering General Hospital NHS Trust,
Northamptonshire
8
NUTRITION SUPPORT INADULTS
Stakeholder Involvement
TThhee ffoolllloowwiinngg ssttaakkeehhoollddeerrss rreeggiisstteerreedd wwiitthh NNIICCEE aanndd wweerree iinnvviitteedd ttoo ccoommmmeenntt oonn ddrraafftt vveerrssiioonnss ooff tthheessee gguuiiddeelliinneess::
CCoollllaabboorraattiinngg CCeennttrreess City and Hackney Primary Care Trust
Patient Involvement Unit for NICE Colchester Primary Care Trust
Croydon Primary Care Trust
CCoommmmeerrcciiaall CCoommppaannyy Department of Academic Psychiatry - Guy’s Hospital
Abbott Laboratories Limited (BASF/Knoll) Derby Hospitals NHS Foundation Trust
Bard Limited Gedling Primary Care Trust
Baxter Oncology Greater Peterborough Primary Care Partnership-North
Britannia Pharmaceuticals Ltd Guys & St Thomas NHS Trust
Clinovia Ltd Hammersmith Hospitals NHS Trust
English Community Care Association Hertfordshire Partnership NHS Trust
Fresenius Kabi Ltd King’s College Hospital NHS Trust
Immogenics Limited Kingston Primary Care Trust
Infant and Dietetic Foods Association Leeds Teaching Hospitals NHS Trust
Intra-Tech Healthcare Ltd Manchester Royal Infirmary
Merck Pharmaceuticals Mid Essex Hospitals NHS Trust
Nestle Clinical Nutrition Middlesbrough Primary Care Trust
Novartis Consumer Health (Novartis Medical Nutrition) National Nurses Nutrition Group
Nutricia Ltd (UK) North Glamorgan NHS Trust - Merthyr Tydfil
Oxford Nutrition Ltd North West Wales NHS Trust
Paines and Byrne Limited Oxfordshire Mental Healthcare NHS Trust
Proprietary Association of Great Britain (PAGB) Powys Local Health Board
SHS International Ltd Princess Alexandra Hospital NHS Trust
Syner-Med (PP) Ltd Queen Victoria Hospital NHS Foundation Trust
Vitaline Pharmaceuticals UK Ltd Royal Liverpool Children’s NHS Trust
Vygon (UK) Ltd Royal United Hospital Bath NHS Trust
Sandwell General Hospital
HHeeaalltthh AAuutthhoorriittyy
Sheffield South West Primary Care Trust
Hampshire & Isle of Wight Strategic Health Authority Sheffield Teaching Hospitals NHS Trust
South & Central Huddersfield PCTs
NNHHSS TTrruusstt
South Birmingham Primary Care Trust
Addenbrookes NHS Trust
South East Sheffield Primary Care Trust
Airedale General Hospital - Acute Trust
South Tees Hospitals NHS Trust
Anglesey Local Health Board
Tameside and Glossop Acute Services NHS Trust
Ashfield and Mansfield District PCTs
The National Implementation Board for Modernisation of
Avon and Wiltshire Mental Health Partnership NHS Trust
NHS Medicines Manufacturing & Preparation
Barnet PCT
The Royal West Sussex Trust
Bolton Hospitals NHS Trust
Trafford Primary Care Trusts
Carlisle and District Primary Care Trust
University College Londons Hospital NHS Trust
9
STAKEHOLDER INVOLVEMENT
University Hospital Birmingham NHSFT Co-operative Pharmacy Association
Vale of Aylesbury Primary Care Trust Faculty of Dental Surgery
Vale of Glamorgan Local Health Board Faculty of Public Health
Food Standards Agency
PPaattiieenntt//CCaarreerr OOrrggaanniissaattiioonn
Infection Control Nurses Association of the British Isles
Age Concern England Institute of Sport and Recreation Management
Alzheimer’s Society Intensive Care Society
British Dyslexia Association Malnutrition Advisory Group (MAG)
British Liver Trust National Care Standards Commission
Children’s Liver Disease Foundation Nutrition Society
Depression Alliance Royal College of Anaesthetists
Diabetes UK Royal College of General Practitioners
Eating Disorders Association, The Royal College of General Practitioners Wales
Fibroid Network Charity Royal College of Nursing (RCN)
Help the Aged Royal College of Paediatrics and Child Health
Help the Hospices Royal College of Pathologists
L’Arche UK Royal College of Physicians of Edinburgh
Motor Neurone Disease Association Royal College of Physicians of London
National Council for Disabled People, Black, Minority and Royal College of Radiologists
National Kidney Federation (NFK) Royal College of Speech and Language Therapists
Parkinson’s Disease Society Royal Pharmaceutical Society of Great Britain
Patients on Intravenous and Nasogastric Nutrition Therapy Society of Cardiothoracic Surgeons
(PINNT) The British Psychological Society
Relatives and Residents Association The Royal Society of Medicine
Samantha Dickson Research Trust, The University of Liverpool - Department of Child Health
Sue Ryder Care West Midlands Specialised Services Agency
The Stroke Association
Women’s Health Concern RReesseeaarrcchh BBooddyy ((ddooiinngg rreesseeaarrcchh))
GeneWatch UK
PPrrooffeessssiioonnaall OOrrggaanniissaattiioonn
Keele University
All Wales Dietetic Advisory Committee MRC Human Nutrition Research
All Wales Senior Nurses Advisory Group (Mental Health)
Association of Clinical Biochemists, The SSoocciiaall CCaarree OOrrggaanniissaattiioonn
Association of Surgeons of Great Britain and Ireland The Disabilities Trust
British Association for Parenteral & Enteral Nutrition
SSttaattuuttoorryy BBooddyy
(BAPEN)
British Association of Head and Neck Oncologists British National Formulary (BNF)
British Association of Oral and Maxillofacial Surgeons Department of Health
British Association of Otolaryngologists, Head & Neck Healthcare Commission
British Association of Paediatric Surgeons Medicines and Healthcare Products Regulatory Agency
British Association of Perinatal Medicine National Institute for Health and Clinical Excellence
British Dietetic Association National Patient Safety Agency
British Geriatrics Society National Public Health Service - Wales
British Pharmaceutical Nutrition Group NHS Health and Social Care Information Centre
British Psychological Society, The NHS Quality Improvement Scotland
British Society of Gastroenterology Perigon (formerly The NHS Modernisation Agency)
British Society of Paediatric Gastroenterology,Hepatology & Scottish Intercollegiate Guidelines Network (SIGN)
Nutrition Welsh Assembly Government (formerly National Assembly
College of Occupational Therapists for Wales