Enteral and Parenteral
Guidelines
ESPEN
FELANPE
Asuncion, October 2010
Prof. Rémy Meier MD
University Hospital
Liestal, Switzerland
Research
Clinical results
Guidelines
Aims of the
ESPEN-Guidelines
The ESPEN-Guidelines „Enteral and
Parenteral Nutrition“ aim to assist clinical
practitioners, dietitians and nurses who
provide enteral and parenteral nutrition
support to patients in all care settings as
well as to give information to decisionmakers in the health care system
Methodology for the
development of the ESPEN
Guidelines on enteral and
parenteral nutrition
• Systemic review
• Evidence based
• Consensus based
Manpower EN
• 13 disease-specific working
groups
• 88 experts in clinical nutrition
• 20 countries
Manpower PN
• 11 disease-specific working
groups
• 87 experts in clinical nutrition
• 16 countries
Evidence gathering
• Structured literature search
• Defined search strategy
(including criteria, specific key words)
• Assessment of the quality and the
strength of the literature
• Defining the level of evidence
• Defining the grade of recommendation
The quality and strength of the
supporting evidence was graded
• According to the criteria of SIGN (Scottish
Intercollegiale Guideline Network, No 39,
1999) and
• According to the criteria of AHCPR
(Agency for Health Care Policy and Research,
No 92-0023, 1993)
Grades of recommendations and
levels of evidence
Grades of recommendations
A
Levels of
evidence
Ia
Requirement
Meta-analysis of randomized controlled trials
At least one randomized controlled trial
Ib
B
IIa
IIb
III
C
IV
At least one well-designed controlled trial
without randomization
At least one other type of well-designed,
quasi-experimental study
Well-designed non-experimental descriptive
studies such as comparative studies,
correlation studies, case-control studies
Expert options and/or clinical experience of
respected authorities
The recommendations were not
only based on the evidence levels
of the studies but also on the
judgement of the working group
concerning the consistency,
clinical relevance and validity of
the evidence
The preparation and publication of the
ESPEN-Guidelines on Enteral and
Parenteral Nutrition
were exclusively funded by ESPEN
Problems with
Recommentations
ESPEN Guidelines 3 recommentations level
A-C
but others have
4-5 levels of recommendations
A-E
ESPEN-EN-Guidelines 2006
Surgery I
Recommendation A
• Preoperative fasting from midnight is
unnecessary in most patients
• Interruption of nutritional intake is
unnecessary after surgery in most patients
• Use nutritional support in patients with
severe nutritional risk for 10-14 days prior
to major surgery even if surgery has to be
delayed.
Nutritional risk refers to at
least one idem:
-
Weight loss > 10-15% within 6 months
BMI < 18.5 kg/m2
Subjective Global Assessment Grade C
Serum albumin <30 g/l
(with no evidence of hepatic or renal
dysfunction)
ESPEN-EN-Guidelines 2006
Surgery II
Recommendation A
• Patients undergoing surgery who are considered
to have no specific risk for aspiration, may drink
clear fluids until 2 h before anaesthesia. Solids
are allowed until 6 h before anaesthesia
• Initiate normal food intake or enteral feeding early
after gastrointestinal surgery
• Oral intake, including clear liquids, can be
initiated within hours after surgery to most
patients undergoing colon resections
ESPEN-EN-Guidelines 2006
Surgery III
Recommendation A
• Apply tube feeding in patients in whom early oral
nutrition can not be initiated, with special regard to
those
- undergoing major head and neck or
gastrointestinal surgery for cancer
- with severe trauma
- with obvious undernutrition at the time of surgery
• Initiate tube feeding for patients in need within 24 h
after surgery
• Placement of a needle catheter jejunostomy or
naso-jejunal tube is recommended for all candidates
for TF undergoing major abdominal surgery
ESPEN-EN-Guidelines 2006
Surgery IV
Recommendation A
• Placement of a needle catheter
jejunostomy or naso-jejunal tube is
recommended for all candidates for TF
undergoing major abdominal surgery.
• Use EN preferably with
immuno-modulating substrates
(arginine, ω-3 fatty acids and nucleotides)
perioperatively independent of
the nutritional risk for those patients
This patients are specified
Those patients who benefit are patients
- undergoing major neck surgery for cancer
(laryngectomy, pharyngectomy)
- undergoing major abdominal cancer surgery
(oesophagectomy, gastrectomy, and
pancreato-duodenectomy)
- after severe trauma
ESPEN-PN-Guidelines 2009
• What was new ?
The recommendations of the
EN guidelines were taken and
the evidences of parenteral
nutrition of each topic were
added
ESPEN-PN-Guidelines 2009
Surgery I
The main goals of perioperative
nutritional support are to minimize
negative protein balance by
avoiding starvation, with the
purpose of maintaining muscle,
immune, and cognitive function,
and to enhance postoperative
recovery!
ESPEN-PN-Guidelines 2009
Surgery II
Recommendation A
• Preoperative parenteral nutrition is
indicated in severely undernourished
patients who cannot be adequately
orally or enterally fed
• Postoperative parenteral nutrition is
beneficial in undernourished patients in
whom enteral nutrition is not feasable
or not tolerated
ESPEN-PN-Guidelines 2009
Surgery III
Recommendation A
• Postoperative parenteral nutrition is
beneficial in patients with
postoperative complications impairing
gastrointestinal function who are
unable to receive and absorb
adequate amounts of oral/enteral
feeding for at least 7 days
ESPEN-PN-Guidelines 2009
Surgery IV
Recommendation A
• In patients who require postoperative
artificial nutrition, enteral feeding or a
combination of enteral and
supplementary parenteral feeding is
the first choice
• Weaning from parenteral nutrition is
not necessary
Recommendations
on Enteral Nutrition
• Total number of recommendations
226
• Recommendations A
= 55 (25%)
• Redommendations B
= 39 (17%)
• Recommendations C
= 132 (58%)
Recommendations
on Parenteral Nutrition
• Total number of recommendations
300
• Recommendations A
= 48 (16%)
• Redommendations B
= 94 (28%)
• Recommendations C
= 158 (56%)
Problem!
Over 50% of the recommendations
are only C „Expert opinions and/or
clinical experience of respected
authorities“
What has changed?
ASPEN Guidelines 1993
- Recommendation A = 16%
- Recommendation B = 29%
- Recommendation C = 55%
Nothing!!!!!!
ESPEN 2006/2009
25%
16%
17%
28%
58%
56%
There is still a lack of
good clinical studies
in clinical nutrition!!
The guidelines do provide eviencebased information about some specific
problems like timing, dosing,
composition and route of application,
and under which conditions limitation or
withdrawal of nutritional support like
other therapies might be adequate
but
they also show where additional studies
are needed
Genereation of new
hypothesis using guidelines
• Guidelines shows were no
enough evicence for a clear
recommendation is available
• This can help to design new
studies to fill in the missing
information
Good clinical trials
•
•
•
•
Db, controlled, randomized trials
Adaequate sample size
Clear endpoints
Single- or multicenter trial
Endpoints
• Selection of endpoints is crucial!
• Mortality is difficult in nutritinal studies
(high number of patients needed)
• Morbidity is often used
• Changes in body composition
but
• QoL, function, mood, costs …. can be
important in special situation
Implementation of guidelines
Nutritional screening of all patients
Nutritional support using guidelines
Continuous training
Monitoring
Regular audits
Guideline
Approach
Screening
Assessment
Patients
at risk
PRCT
Outcome
Multicenter clinical trial of algorithms for
critical-care enteral and parenteral therapy
(ACCEPT)
• 489 ICU patients in 14hospitals
RCT
EBM
40
• 7 – EBM Guidelines
– Early EE
– Preferably EN
• 7 - Controls
p=0.047
Control
p=0.002
35
30
25
20
n.s.
15
10
• Improved outcome
• More EN
• Less PE
5
0
Hosp Mort
%
Martin et al, CMAJ 2004
Hosp stay
ICU stay
days
days
Appropriate use of PN
• First monitoring
Implementation of clinical
practice guidelines
• Control monitoring
• Appropriate / inappropriate was
pre-defined
Results
Appropriate PN
• First monitoring
- with experienced
staff support
- without experienced
staff support
• Control monitoring
Schneider, NCP, 2006
67%
41% (PN days↑53%)
(costs↑ 36%)
80% (costs↓ 50%)
Summary
The guidelines do provide evience-based
information about specific problems like
timing, dosing, composition and route of
application
They also show where additional studies are
needed and under which conditions
limitation or withdrawal of nutritional
support like other therapies might be
adequate
Limitations
• The ESPEN-Guidelines are
separate for enteral- and
parenteral nutrition
• It would be easier to have
combined guidelines
Conclusion
The ESPEN guidelines on enteral and
parenteral nutrition reflect the current
medical knowledge in the field of enteral
and parenteral nutrition therapy and
summarize the evidence when enteral
nutrition is indicated and which goals
can be reached in regard to nutritional
state, quality of life and outcome
Publication
• Clinical Nutrition Vol 25 (2),
April 2006 (Enteral)
• Clinical Nutrition Vol 28, August 2009
(Parenteral)
• www.espen.org/education/
guidelines.htm