Hvidovre Hospital Staff meeting 17. januar 8.15 - 9.00   Ernæring er et vigtigt element i        patientbehandlingen.Opdat...
Screening: NRS 2002
SD                              1                                                        2                                ...
Euro-OOPS:Analysis of 5051 patient admissions in 24 departments in 12 countries in                         Europe & Middle...
Type of complications 0,5                       0,0                                                          1,0    1,5   ...
Death and complications after surgery in the EuroOOPS study Total mortality: 80/2193 = 3.7%Not at risk                  Co...
Treatment improves outcome2 N = 132 patients at risk (NRS-2002) in a department of generalinternal medicine were randomize...
Early enteral nutrition within 24h of colorectal surgeryversus later commencementof feeding for postoperative complication...
RCT: Complications % mortality                         Evidence for nutrition support:                              Meta-a...
Hvorfor screenes for nyligt kostindtag?
30 d mortality and intake at a lunch on Nutrition Day 200612,727 hospitalised patients examined on the same day, in 748 wa...
Hvor hurtigt går det galt, hvis man ikke gørnoget?
113 patients ranked according to administered amounts ofprotein/AA and divided into 3 equally large groups                ...
Characteristics of the 3 groups, mean                                     SD                                              ...
ACUTE PEMP r o t e in p r o v is io n a n d N b a l a n c e in IC U p a t ie n t s                                        ...
Weight change according to energy balance                                               1382 patients without edema.      ...
Er der noget galt med hospitalskosten - ellermed vores viden om hvad ptt kan spise?
Observational, interview-based study22 patients at nutritional risk (NRS-2002) and withdecreased intake (<75%). 65 intervi...
Questionnaire in 200 patients based on qualitative studySorensen et al, ESPEN congress 2010Motivation Nutritional status  ...
RCT in 77 at-risk patients (NRS 2002).Sorensen et al., being analysedControl group received therapy as current practice.In...
Hvorfor er det på dag 3, at der skal tagesstilling til ændring i planen?
When to reach target?Author                                         Energy,           Protein,       Target               ...
Recommendation:Based on 14 level 2 studies, we recommend early enteral nutrition(within 24-48 hours following admission to...
75% af behovet skal nås på 3. indlæggelsesdag
Hvordan målet nås…
EuroOOPS*: Nutrition Practice as determinant of      intake ≥75% of requirements in patients at-risk      Questions on pra...
Factors determining intake Of the 1581 at-risk patients with LOS >3 days, 1017 (64%) were judged to have an intake 75% of ...
Konklusioner   Screening er velbegrundet – og ret valideret…   Nyligt kostindtag er en vigtig oplysning   Det går hurti...
130121 hvidovre staff
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130121 hvidovre staff

  1. 1. Hvidovre Hospital Staff meeting 17. januar 8.15 - 9.00 Ernæring er et vigtigt element i patientbehandlingen.Opdatering af den videnskabelige baggrund for screening og ernæringsterapi hos indlagte patienter
  2. 2. Screening: NRS 2002
  3. 3. SD 1 2 3 Outcome Outcome OutcomeNS Pos No Pos No Pos No inf/GI surg/PN (1) muscl/GI surg/PN (6) inf/trauma/EN (18) inf/GI surg/PN (22) inf/burns/EN (28) LOS/traum/EN (32) tox/canc/ON (2) muscl/COPD/ON (7) inf/GI surg/PN (19) inf/traum/EN (23) LOS/traum/EN (29) surv/burns/PN (33) LOS/femur/ON (3) compl/GI surg/PN (8) inf/GI surg/EN (20) inf/GI surgPN (24) surv/traum/PN (30) LOS/fem/ON (4) compl/canc/ON (9) LOS/GI surg/PN (21) compl/GI surg/PN (25) surv/BMT/PN (31) surv/fem/EN (5) compl/GI surg/EN (10) compl/GI surg/PN (26) inf/GI surg/EN (11) compl/GI surg/PN (27) inf/cirrh/EN (12) inf/GI surg/PN (13) 0 inf/spine/ (14) tox/canc/ON (15) tox/canc/PN (16) surv/canc/PN (17) ADL/geria/ON (34) QL/canc/ON (46) compl/ GI surg/PN (77) inf/GI surg/PN (94) None None QL/canc/EN (35) QL/canc/ON (47) compl/ GI surg/PN (78) inf//GI surg/PN (95) CI/cirrh/PN (36) QL/HIV/ON (48) inf/ GI surg/ON (79) inf/GI surg/PN (96) inf/GI surg/EN (37) inf/canc/PN (49) inf/ GI surg/PN/EN (80) inf/BMT/PN (97) inf/ GI surg/PN (38) inf/pancr/PN (50) inf/cirrh/EN (81) inf//GI surg/PN (98) tox/canc/PN (39) inf/GI surg/PN (51) inf/ GI surg/ON (82) inf//GI surg/PN (99) tox/canc/PN (40) inf/GI surg/PN (52) inf/ GI surg/EN (83) inf/GI surg/PN (100) tox/canc/ON (41) inf/ GI surg/PN (53) inf/ GI surg/EN (84) compl/GI surg/PN (101) enc/cirrh/EN (42) inf/spine/PN (54) ADL/geria/ON (85) compl//GI surg/ (102) surv/GI surg/PN (43) inf/ GI surg/PN (55) LOS/ GI surg/EN (86) compl/GI surg/PN (103) surv/canc/PN (44) muscl/COPD/ON (56) compl/ GI surg/PN (87) compl/GI surg/PN (104) surv/geria/ON (45) muscl/COPD/ON (57) LOS/cirrh/PN (88) compl//GI surg/EN (105) compl/ GI surg/PN (58) surv/ATIN/PN (89) compl/BMT/PN (106) 1 compl/cirrh/PN (59) surv/ATIN/PN (90) LOS/GI surg/EN (107) compl/canc/PN (60) surv/canc/PN (91) surv/ATIN/PN (108) compl/canc/ON(61) surv/stroke/ON (92) surv/ATIN/PN (109) compl/cirrh/PN (62) surv/cirrh/ON (93) tox/canc/PN (63) tox/canc/PN (64) tox/canc/PN (65) rec/canc/PN (66) resp/canc/PN (67) resp/canc/PN (68) resp/ canc/EN (69) resp/canc/ON (70) tox/canc/ON (71) surv/canc/PN (72) surv/canc/PN (73) surv/canc/ON (74) surv/cirrh/PN (75) surv/cirrh/PN (76) wound/GI surg/PN (110) CI/GI surg/PN (121) inf/GI surg/PN (123) compl/ATIN/PN (126) None None inf/cirrh/ON (111) walk/COPD/ON (122) compl/GI surg/PN (124) muscl/COPD/EN (112) survival/GI surg/PN (125) muscl/COPD/ON (113) 2 walk/COPD/ON (114) walk/COPD/ON (115) tox/cancer/EN (116) LOS/femur/EN (117) surv/cirrh/ON (118) surv/cirrh/EN (119) surv/HIV/PN (120) Kondrup et al. Clin Nutr 2003;22:321-36.
  4. 4. Euro-OOPS:Analysis of 5051 patient admissions in 24 departments in 12 countries in Europe & Middle East Complications and nutritional risk (NRS 2002) % (N) No Non-infectious Infectious Total Complication Complication Complication Not at-risk 89 6 5 100 (3021) (218) (165) (3404) At-risk 69* 16* 14* 100 (1143) (270) (234) (1647) * P<0.001Complications were independenly associated with NRS-2002 components (nutritional status or severity ofdisease), also when adjusted for:Speciality (geriatry, gastroenterology, oncology, Cancerinternal medicine, surgical, ICU) AgeDiagnoses (19 most frequent) Region (Western Europe, Eastern Europe, MiddleComorbidity East)Surgery Sorensen et al. 2008. Clin Nutr 27: 340-9.
  5. 5. Type of complications 0,5 0,0 1,0 1,5 2,0 2,5 3,0 3,5 4,0 4,5 5,0 M Cardiac failure grade 1 P=0.020 M Cardial arrhytmia Primary disease determines type of complication P=0.003 Sorensen et al. 2008. Clin Nutr 27: 340-9. M Kidney failure grade 2 NS - nutritional status makes it happen M Lobar atelectasis NS S Anastomosis leakage P<0.001 S Anoxic encephalopathy P=0.002 S Bile duct obstruction P=0.010Non-infectious S Cardiac arrest P<0.001 S Decubitus P=0.005 S Deep venous thrombosis NS S GI-bleeding P=0.003 S GI-perforation, obstruction or ischemia P<0.001 S Hepatic Encephalopathy P=0.002 S Postoperative bleeding NS At risk S Pulmonary emboli NS S Respiratory failure grade 2 P<0.001 Not at risk S Wound dehiscence NS M Urinary infection: cystitis NS M Wound infection grade 3 NS S Gastroenteritis P<0.001 S Intraperitoneal abscess NSInfectious S Other urinary infections (pelvis, urether, urethra) NS S Pulmonary infection grade 1-3 P<0.001 S Sepsis and/or bacteriaemia P<0.001 S Septic shock P<0.001 S Skin infection P<0.001 S Upper respiratory infection NS
  6. 6. Death and complications after surgery in the EuroOOPS study Total mortality: 80/2193 = 3.7%Not at risk Complications, N Death, N (%) Y 200 6 (3.0) N 1414 1 (<) Log regression: OR for Death Total 1614 7 (0.4) At-risk: 13.1 Complication: 12.5At risk Complications Death, N (%) NS: Age Y 220 63 (28.6) Comorbidity Cancer N 359 10 (2.7) Total 579 73 (13) Unpublished secondary analysis
  7. 7. Treatment improves outcome2 N = 132 patients at risk (NRS-2002) in a department of generalinternal medicine were randomized to standard treatment orindividual nutrition care. Mean SD Control InterventionEnergy intake, kcal 1115 ± 381 1553 ± 3411)Protein intake, g 44 ± 17 65 ± 161)% reaching 75% of energy target 30 831)Complications, % 20 62)SF-36 Physical Summary 32 ± 9 37 ± 113)Re-admissions in 6 mths, % 46 274) 1)P<0.001 2) P = 0.035 3) P = 0.030 4) P = 0.027 Starke et al. Clin Nutr 2011;30:194-201.
  8. 8. Early enteral nutrition within 24h of colorectal surgeryversus later commencementof feeding for postoperative complications.…there is no obvious advantage in keeping patients ’nil bymouth’ following gastrointestinal surgery, and this reviewsupport the notion on early commencement of enteral feeding.Andersen et al. Cochrane Database of Systematic Reviews 2006, Issue 4. Update 2011
  9. 9. RCT: Complications % mortality Evidence for nutrition support: Meta-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, burns. Hospital or community Oral supplements or tube feedingComplications 28% vs. 46%1)Infections2) 24% vs. 44%1)Mortality 17 % vs. 24%1)1) P <0.001; 2)10 RCTs only Stratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003
  10. 10. Hvorfor screenes for nyligt kostindtag?
  11. 11. 30 d mortality and intake at a lunch on Nutrition Day 200612,727 hospitalised patients examined on the same day, in 748 wards from 16 differentspecialties in 256 hospitals and 25 countries.Hiesmayr et al. Clin Nutr 2009;28:484-91 Portion of lunch eaten N HR P All 4,477 1.00 About 50% 2,999 1.28 NS About 25% 1,323 1.97 <0.0001 Nothing (eating allowed) 644 2.71 <0.0001 Adjusted for age, gender, affected organ systems, comorbidities, previous ICU stay, LOS before NutritionDay, number of drugs, specialty, number of beds, dedicated nutrition care, ability to walk, help needed, BMI, weight loss/3 months, amount eaten during the last week, number of snacks eaten on NutritionDay
  12. 12. Hvor hurtigt går det galt, hvis man ikke gørnoget?
  13. 13. 113 patients ranked according to administered amounts ofprotein/AA and divided into 3 equally large groups 28 days survival in the ICU Allingstrup et al. Clin Nutr 2012;31:462-8. 100 High protein& AA 0.79 g/kg per d [19] Medium protein& AA 1.06 g/kg per d Low protein& AA 1.46 g/kg per d 80 [20] Percent survival 60 [6] 40 Log-rank P = 0.03; Log-rank test for trend: P = 0.01. 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 Time (Length of stay in the ICU)
  14. 14. Characteristics of the 3 groups, mean SD Low Medium High Age 60 17 62 15 57 19 Weight 70 16 82 16 81 16 BMI 24 4 27 5 26 5 APACHE II 23 7 22 6 22 7 Protein/AA, g/kg per d 0.79 29 1.06 0.23 1.46 0.29 N balance, Protein eq, g/kg per d -0.59 0.48 -0.35 0.41 -0.20 0.58 Energy, kcal/kg per d 21.7 6.7 24.7 5.6 27.2 6.7 Energy balance, kcal/kg per d -6.4 9.1 -3.5 6.3 -1.5 6.9 Protein in energy provided, % 15 3 18 3 22 3 Proteineq out of REE,% 21 7 21 7 21 7 10 day survival (K-M), % 49 79 88Allingstrup et al. Clin Nutr 2012;31:462-8.
  15. 15. ACUTE PEMP r o t e in p r o v is io n a n d N b a l a n c e in IC U p a t ie n t s M e a n  S D ; N = 3 8 in e a c h g r o u p N b a la n c e ( P r o t e q /k g p e r d ) 0 .5 0 .0 - 0 .5 - 1 .0 200 g LBM/day 0.5 % LBM/day Twice the loss of healthy individuals on a protein-free diet 28 days survival in the ICU Usual care: 47 g prot/AA 0.6 g/kg per d (Alberda) 100 High protein& AA - 1 .5 [19] Medium protein& AA Low protein& AA 0 .0 0 .5 1 .0 1 .5 2 .0 2 .5 80 [20] Percent survival P r o t e in /A A p r o v is io n g /k g p e r d a y 60 [6] 40Allingstrup et al. Clin Nutr 2012;31:462-8. 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 Time (Length of stay in the ICU)
  16. 16. Weight change according to energy balance 1382 patients without edema. Median & interquartile range (N) = number in each group (55) (128) 1.0 (279)Weight change (kg/week) (442) 0.5 (368) (84) 0.0 -0.5 -1.0 <75 75-99 100-124 125-149 150-174 175-199 Energy intake as % of requirement Clinical Nutrition Unit Rigshospitalet Copenhagen 2010
  17. 17. Er der noget galt med hospitalskosten - ellermed vores viden om hvad ptt kan spise?
  18. 18. Observational, interview-based study22 patients at nutritional risk (NRS-2002) and withdecreased intake (<75%). 65 interviews.Sorensen et al. Clin Nutr 2012;31:637-46.
  19. 19. Questionnaire in 200 patients based on qualitative studySorensen et al, ESPEN congress 2010Motivation Nutritional status Eating related Food sensory experiences symptoms and preferencesPleasure Positive energy NS Savoury, aromatic and protein crispy/crunchy balance varied tastes & consistencies & dishes sour side-dishesForce High screening Low appetite mild flavours (NRS) intake Early satiety easy to eat score. i.e. low pre- Nausea sensory specific satiety admission intake. Vomiting redundant food choices Oncology Pain familiar foods Taste changes small portions Dry mouth moisture giving sauces
  20. 20. RCT in 77 at-risk patients (NRS 2002).Sorensen et al., being analysedControl group received therapy as current practice.Intervention group received nutritional therapy: thorough sensoryassessment & nutrition plan adjusted daily.Mean ± SD Control Sensory interventionEnergy intake, MJ/d 6.8 ± 2.1 8.1 ± 2.2*Protein intake, g/d 63 ± 21 74 ± 22** 75% energy req., % 70 90** 75% protein req., % 57 83**<75% at screening 66 89*** 75% energy req., % * P = 0.01** P = 0.030 *** P = 0.015
  21. 21. Hvorfor er det på dag 3, at der skal tagesstilling til ændring i planen?
  22. 22. When to reach target?Author Energy, Protein, Target Patients Feeding kcal per day or g per day or reached on kcal/kg per day g/kg per day dayBourdel 2000 Elderly Supplement 1200 45 2Henriksen 2002 Abd surgery Supplement - 1 2Graham 1989 Head trauma Jejunal 3000 - 3Keele 1997 Abd surgery Supplement 1600 57 3Rana 1992 Abd surgery Supplement 2000 71 3Sagar 1979 Abd surgery Jejunal - 47 6Singh 1998 Abd surgery Jejunal 21 1 4Smith 1988 Abd surgery Jejunal 1100 35 5Watter 1997 Abd surgery Jenunal 16 0.6 3 Based on Kondrup et al. Clin Nutr 2003; 22: 321-336
  23. 23. Recommendation:Based on 14 level 2 studies, we recommend early enteral nutrition(within 24-48 hours following admission to ICU) in critically illpatients.www.criticalcarenutrition.com
  24. 24. 75% af behovet skal nås på 3. indlæggelsesdag
  25. 25. Hvordan målet nås…
  26. 26. EuroOOPS*: Nutrition Practice as determinant of intake ≥75% of requirements in patients at-risk Questions on practice based on Beck et al. Guidelines from Council of Europe. Clin Nutr 2001, 20: 455-460. % patients ≥75% Practice in department Had: Yes/No Yes No P Nutrition Committee 18/4 61 50 0.03 Screening Common 11/11 63 56 0.02 Monitoring Common 13/9 65 50 <0.0005 Snacks available 15/7 65 54 <0.0005 Ptt’s satisfaction feedback 14/8 65 50 <0.0005 NS: definition of responsibility, choice of menus; ICUs excluded Unpublished data from*5051 patients in 22 departments in 12 countries Sorensen et al. Clin Nutr 2008;27:340-9.
  27. 27. Factors determining intake Of the 1581 at-risk patients with LOS >3 days, 1017 (64%) were judged to have an intake 75% of requirements Logistic regression analysis: OR for intake ≥75% of requirements OR PRecent Intake at NRS screening (per score unit) 0.60 <0.0005Geriatry vs. Surgery 0.29 <0.0005Gastroenterology vs. Surgery 0.44 0.002Oncology vs. Surgery 0.21 <0.0005Internal Medicine vs. Surgery 0.30 <0.0005TPN or TEN vs. Food or Supplements 3.10 <0.0005Nutrition Practice Score (per # of practices) 1.33 0.001 Unpublished data from Sorensen et al. Clin Nutr 2008;27:340-9.
  28. 28. Konklusioner Screening er velbegrundet – og ret valideret… Nyligt kostindtag er en vigtig oplysning Det går hurtigt ned ad bakke… Læs patientens type: nyder eller nøder? Skift strategi efter senest 3 dage: Mål: ≥75% af behov senest 4. indlæggelsesdag Pas På med sondeernæring

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