Nutrition - post stroke

1. Nutrition - post stroke Wendy Ennifer Stroke Specialist

2. Overview How to refer to Dietitians Oral Feeding Nutritional assessment Refeeding Syndrome Secondary Prevention Complications & considerations of enteral feeding Tubes – Problem solving Guidelines for risk management Hand Control mittens Mental Capacity Conclusions

3. Dietetic/Nutrition Services for stroke • Nutrition Support Team – See nutrition support patients (no dietary advice required) + Percutaneous Endoscopic Gastrostomy (PEG)/Radiological Gastrostomy (RIG) referrals.

4. Oral Feeding On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication (1) • People with acute stroke who are unable to take adequate nutrition and fluids orally should: • receive tube feeding with a nasogastric tube within 24 hours of admission • be considered for hand controlled mittens (posey mittens)/Nasal Bridal or gastrostomy if they are unable to tolerate a nasogastric tube. (covered in Mandatory Training) • All people with acute stroke should have their hydration assessed on admission, reviewed regularly and managed so that normal hydration is maintained (30mls/kg >60 & 35mls/kg if <60) • Nutrition support should be initiated for people with stroke who are at risk of malnutrition (This may include oral nutritional supplements, specialist dietary advice and/or tube feeding). • MUSTSCORE 2> Screening to assess body mass index (BMI) (STEP 1), percentage unintentional weight loss 3/6 months (STEP 2) & No oral intake (STEP 3).

5. Nutritional Assessment of stroke patients • Stroke is followed by a phase of hypermetabolism and hypercatabolism – response to injury proportionate to degree of brain damage. (3) • NBM – Calculate estimated requirements (Schofield) + Stress Factor/Activity Factor. (4) • Increased energy/nitrogen requirements + insulin resistance and glucose intolerance + fluid and electrolyte imbalance + acid-base imbalance. • Texture Modified Diets i.e. pureed/soft + thickened fluids – information for home. • Must Score - Nutritional support required (elderly, already malnourished, paralysis of dominant arm). • Supplements/Feeds available (Nutricia).

6. Refeeding Syndrome - Patients At Risk Any patient that has had very little food intake for > 5 days is at some risk of RefeedingSyndrome. High risk Patient has one of the following: • BMI <16kg/m2 • Unintentional weight loss of >15% within the previous 3-6 months. • Very little or no nutrient intake for >10 days. • Low levels of potassium, phosphate or magnesium prior to feeding. Or patient has two or more of the following: • BMI <18.5kg/m2 • Unintentional weight loss >10% within the previous 3-6 months. • Very little or no nutrient intake for >5 days. • A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics. Severely high risk • Very little intake for > 15 days and BMI <14kg/m2 Ref: BHR Policies - Refeeding

7. Secondary Prevention Eating five or more portions of fruit and vegetables per day eating two portions of fish per week, one of which should be oily (salmon, trout, herring, pilchards, sardines, fresh tuna). All patients should be advised to reduce and replace saturated fats in their diet with polyunsaturated or monounsaturated fats by: using low-fat dairy products replacing butter and lard with products based on vegetable and plant oils reducing meat intake. Patients who are overweight or obese (as determined by body mass index (BMI) or waist:hip measurement ratio) should be offered: advice and support to aid weight loss, which may include diet, behavioural therapy and physical activity medication to aid weight loss only after dietary advice and exercise has been started and evaluated. All patients, but especially patients with hypertension, should be advised to reduce their salt intake by: not adding salt to food/using as little as possible in cooking/choosing lower sodium/salt foods. Patients who drink alcohol should be advised to keep within recognised safe drinking limits of no more than three units per day for men and two units per day for women Patients should be advised that there is no evidence that oral vitamin supplementation will reduce the risk of stroke or other vascular events.

8. Complications of enteral feeding • Aspiration pneumonia - Same risk with gastrostomy feeding as nasogastric feeding. • If aspiration is a risk: • Confirm the gastric position of the tube regularly. • elevate the head and upper body by at least 30° and maintain during and 1hr after feed. • Use prokinetic agents to stimulate gastric emptying such as metoclopromide or erythromycin. • Consider a post-pyloric feeding route i.e. nasojejunal, jejunostomy • Diarrhoea – search for underlying cause as rarely attributable to the enteral feed itself (As per enteral feeding policy) • Existing bowel inflammatory diseases/major bowel resection or C. Difficile toxin. • Drugs (prolonged use of antibiotics and enteral administration of magnesium or electrolytes can cause osmotic diarrhoea). • Feed is contaminated – changed every 24hrs.

9. Tubes -Problem Solving Variety of methods if aspiration is difficult (turn pt onto left side, retrying after one hour and adjusting the position of the tube). What do you do if giving several medications? Do not mix various drugs together in the pestle and mortar because if the tube becomes blocked it may be difficult to determine how much of the drug has been given - Administer each drug separately. How should you flush an enteral feeding tube? Flush the feeding tube with 10ml of water for adults between medications to prevent drug-drug interactions. When all the medication have been administered, flush the tube with 15-30ml of water (for adults). Use push, pause method for flushing. This creates greater turbulence and is therefore more effective at clearing tube. What can be done if the tube becomes blocked? Have patience. Try flushing the feeding tube with 15-30 ml of water (warm or cold) in a 50 ml syringe, using a pull/push action. Do not use Lemonade, cola or soda water . No evidence that more successful than water and Cola (acidic) may coagulate protein in feed causing further blockage. If above fails use small syringe (20 ml) with caution and seek specialist advice. If tube blocked by feed consider use of mechanical declogging device, pancreatic enzyme or declogging system (CorPack Clog Zapper).

10. Considerations for enteral feeding • The majority of DM patients will require an increase in their medication once they commence on feed – due to severity of their illness. • Enteral feeding may be required despite oral intake (risk of dehydration during the weaning process). • Overnight feeding useful – helps resume normal eating (consider catheterisation). • Should we be feeding patient – medical hx of dementia – risk feeding?

11. Guidelines for Risk Management of patients with dysphagia • Patient referred to SALT • Salt dysphagia assessment • Patient showing signs of aspiration on all consistencies – recommended alternative feeding • Discussion with medical team regarding PEG referral or risk management. • Decision is made by team to risk manage feeding • SALT advises on safest diet (custard thick and Puree B).

12. STROKE FLOW CHART Screening/swallow assessment completed. Compromised swallow + no contraindications to insertion of NGT. *If doubts re appropriateness of NG feeding, (i.e. dementia, acutely unwell) withhold NGT and contact Nutrition Support Team for further advice. INSERTION OF NGT Patient repeatedly pulling out NGT. Difficulty inserting NGT Unable to obtain aspirate Aspirate pH >5 Exclude organic cause for restlessness/tube removal e.g. .pain, discomfort, hypoglycaemia, alcohol/ drug withdrawal, drug induced, neuropath logical condition. • Identify problem • Conscious resistance by patient • Confusion/agitation of patient • Compromised respiratory status, coughing ++ oxygen desaturation when NGT inserted • Epistaxis, bleeding from upper GI tract • Resistance/obstruction of nasopharyrngeal /upper GI tract Follow guidelines for obtaining aspirate Found in Insertion of Nasogastric tube policy available on the Intranet. Follow guidelines found in Insertion of Nasogastric tube policy available on Intranet. ** If pulling out NGT > 3 times in 3 days Contact Dietitian/NST for MDT for discussion with NOK to determine whether patient had any advance decisions/reason to believe patient lacks capacity or dispute between those involved in making best interests decisions. Contact Nutrition Support Team (NST) for further advice If patient considered to have full mental capacity and pulling out/refusing NGT. Determine reason & Consider risk feeding,/ gastrostomy.... *** If considered reduced mental capacity – complete Assessment of Capacity and Best Interests Decision Making. Consider use of hand control mittens, nasal bridle and risk feeding.

13. Mental Capacity • *Consent of a competent adult patient must be sought for any treatment, including feeding via a tube. • It is ethically and legally wrong for a carer to under estimate the capacity of a patient in order to achieve what the carer believes to be in the patient’s best interest. • **For an incompetent adult patient, the doctor undertaking care is responsible in law for any decision to withhold give or withdraw a medical treatment. The doctor’s duty is to act in a way which he or she believes to be in the patient’s best interest. Before making a decision about starting, stopping or continuing treatment, the doctor should seek to ascertain the patient’s previously expressed views about the type of treatment he or she would wish to receive should the present state of incompetence occur. Full consultation with the family and the health care team is needed from the outset, at present in England relatives or a nominated proxy cannot make a decision on behalf of an adult patient. • ***In cases of doubt the clinician should complete Mental capacity form In patients where the answer is negative or uncertain: All attempts should be made to overcome the lack of capacity e.g. asking SALT to help with communication.

14. Hand Control Mittens • Mittens must not be applied until the decision has been clearly documented in the medical notes and Risk Assessment Tool/Record and Deprivation of Liberty checklist completed. • Hand control mittens may be applied by any Registered Nurse or Doctor who have had appropriate training to use this device and are familiar with the policy and procedure. • Risk Assessment Tool – Does the patient have mental capacity? • Deprivation of Liberty Checklist-Safeguarding for adults

15. Conclusions • NG Feeding within 24 hrs of admission (to offset catabolic losses and reduce risk of complications). • Nutrition support should be initiated for people with stroke who are at risk of malnutrition. (MUST should be used to do this). • In those patients identified at high risk of Refeeding Syndrome, nutrition support should be introduced cautiously with appropriate monitoring. • To reduce risks of aspiration elevate the head and upper body by at least 30° and maintain during and 1hr after feed. • When all the medication have been administered, flush the tube with 15-30ml water for adults to prevent blockages. • Check Flowchart for problems inserting NGT’s. • All patients should be assumed to have capacity to make decisions on their own unless demonstrated otherwise. • Hand control mittens policy

16. References • National Clinical Guidelines for Stroke (3rd Edition) • The recommendations below are from Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (National Institute for Health and Clinical Excellence, 2006). • Manual of Dietetic Practice (Thomas 2002) • PEN (Pocket Guide to Clinical Nutrition (2007)