Nutrition Therapy in Stroke

Hertanto W Subagio
Department of Clinical Nutrition
Faculty of Medicine Diponegoro University
Curriculum Vitae :
• Nama : Prof. Dr.dr.Hertanto W Subagio,MS,SpGK (K).
• Institusi asal :
- Universitas Diponegoro , Departemen Ilmu Gizi Klinik

• Pendidikan :
- Dokter Umum - 1979
- Doktor Ilmu Kedokteran-2002
- Sp Gizi Klinik Konsultan – 2004
- Guru Besar Ilmu Gizi - 2006

• Riwayat Pekerjaan :
- Dosen FK Undip 1980 – sekarang.
- WD1 FK Undip : 2007-2010
- WR1 Undip : 2001-2015
- Majelis Wali Amanah Undip 2016 - 2020
- Dokter Mitra di RSUP dr Kariadi Semarang
 The
Awareness of Skeleton
Hospital Malnutrition:
The Skeleton in the Hospital Closet
in the Hospital ClosetEvidence
Critical
BUTTERWORTH CHARLES E. Jr. M.D.

• Height not recorded in 56% of cases

Nutrition Today: March-April 1974 - Volume 9 - Issue 2 - ppg 4-8
Original Article: PDF Only

The Skeleton in the Hospital Closet

• Body wei ght not recorded
• Height not recorded in 56% of cases
in 23% of cases
• Body• 61% of thosenotwhose
weight weight was
recorded recordedoflocases
in 23% st > 6 kg
• 61% of those whose • weight was recorded lost > 6 kg
37% had albumi
• 37% had albumin < 3.0 g/dL
n < 3.0 g/dL
nvinced that iatrogenic malnutrition has become a significant factor in determining
“I am convinced that iatrogenic malnutriti on has
disease outcomes in many patients.”
become a signif icant factor in determini ng
disease outcomes in many patients.”
Butterworth CE. Nutr Today 1994
2017 …………. ?

“THE SKELETONS ARE STILL RATTLING IN

THE HOSPITAL CLOSET”

1975 2017
 The Metabolic Response to Injury

The three responses that have been considered the hall-mark of serious insult are
hypermetabolism, hypercatabolism, and glucose intolerance.
Summary of metabolic change during injury:

• Increased Metabolisme :
- Hyperglycemia,
- Insulin Resistance
• Increased Catabolism :
- mobilizes substrates to provide energy
- wasting
• Salt and water retention : oedema
 Metabolic changes in acute Neurotrauma patients

Dionyssiotis Y, Papachristos A, Petropoulou K, Papathanasiou J, Papagelopoulos P. Nutritional Alterations Associated with Neurological and Neurosurgical
Diseases. The Open Neurology Journal. 2016;10(1):32-41.
Medical Nutrition Therapy
Wirth et al. Experimental & Translational Stroke Medicine 2013, 5:14 http://www.etsmjournal.com/content/5/1/14
 Nutrition Assessment
• Glasgow Coma Scale (GCS), vital signs
Physical examination • Muscle wasting, loss of subcutaneous fat, edema
• Neurological : paralysis
• Weight, height, BMI, Ideal body weight
Anthropometrics • Body composition
• Blood glucose, electrolytes
Laboratory • Albumin, pre-albumin, CRP

•Screening by water test

•GUSS (Gugging Swallowing Screen)
Screening dysphagia •FEES (Fiberoptic endoscopic evaluation of
swallowing)
 Nutritional requirement :

• There is no specific need in stroke patients

• Sufficient energy intake 20-30 kcal/kg/day
• Individualized protein needs (taking into account co-
morbidities)  Usually 1.0–1.5g/kg
• Glycaemia needs to be maintained at (sub) normal levels, but
no “diabetic” formula has proven to help reach that goal.

ESPEN LLL Programme 2016

Masalah dalam memenuhi requirement
• Gangguan Kesadaran
• Glucose control
• Dysphagia
• Stress ulcer : hematemesis
• Intolerance
• Depresi
 Glucose Control in Neurosurgical Patients

• A strategy of blood glucose control should include a nutrition protocol

with the preferential use of the enteral route
Recommendation
• Avoid excessive caloric intake especially carbohydrates
• No more than 25-30 kcal/kgBW/day
• 25% of intake in the form of lipids
• Insulin therapy according to needs
• Initiating blood glucose control without adequate provision of calories
and carbohydrates will increase the risk of hypoglycaemi

Godoy DA, Napoli MD, Biestro A, Lenhardt R. Perioperative Glucose Control in Neurosurgical Patients.
Anesthesiology Research and Practice. 2012;2012:1–13
Godoy D, Di Napoli M, Biestro A, Lenhardt R. Perioperative Glucose Control in Neurosurgical Patients. Anesthesiology Research and Practice.
2012;2012:1-13
Dysphagia
• Dysphagia is defined as difficulty or
discomfort during swallowing, i.e. the
progression of the alimentary bolus from
the mouth to the stomach.
• Dysphagia is classified as esophageal or
oropharyngeal, and from a functional
point of view, as organic or functional.
 Prevalence of dysphagia after stroke
Martino R. et al. Stroke 2005

The prevalence of oropharyngeal functional

dysphagia in neurological patients is very high

• Screening techniques: 37-45%

• Clinical testing: 51-55%
• Instrumental testing: 64-78%
 Dysphagiaafter
Dysphagia afterstroke
stroke and
and mortality
mortality

N Mortality (%) Mortality (%) Mortality (%) RR

dysphagia + dyphagia
Gordon 1987 91 33 22 46 2.1
Smithard 1996 121 21 6 37 6
Mann 1999 128 4 0 8
Broadley 2003 149 17 1.3 32 24.1
489 18 6 30 5.0

Stroke with dysphagia = 5-fold increased mortality!

Goals of dysphagia nutritional management

• To maintain and ensure adequate nutrition and hydration

status
• To implement the correct and safe texture modified diet
upon speech and language therapist recommendations
• To maximise nutritional intake while maintaining safe
eating, ie. to prevent aspiration and choking
Enteral Nutrition
Enteral route should always be preferred except for the following
contraindications:
• Intestinal obstruction or ileus
• Severe shock
• Intestinal ischemia
• High output fistula (?)
• Severe intestinal haemorrhage

ASPEN 2016 recommend postoperative EN when feasible within 24 h

• Better outcome  reduced infection, hospital length of stay, and mortality
•
Enteral Nutrition
• If a sufficient oral food intake is not possible during the acute
phase of stroke, enteral nutrition shall be preferably given via a
nasogastric tube.
• If enteral feeding is likely for a longer period of time (> 28 days), a
PEG should be chosen and shall be placed in a stable clinical
phase (after 14 – 28 days)
• Nasogastric tube feeding does not interfere with swallowing
training. Therefore, dysphagia therapy shall start as early as
possible also in tube‐fed patients.
 Facilitating Enteral Nutrition Tolerance
Feeding intolerance
• Increased gastric residue
• Gastro-esophageal reflux
• Vomiting
• Diarrhea
• Abdominal distension
Strategies
• Elevating head of the bed by
30 to 45 degrees
• Pro-motility agents
• Continuous feeding
• Increases EN rate gradually
• Concentrated enteral formula
(≥ 1,5 kcal/mL)
• Post-pyloric feeding
Parenteral Nutrition
• Although parenteral nutrition hasn’t been studied in this
indication, there does not seem to be any room for this
nutritional treatment, unless EN is contra-indicated.
(ESPEN LLL– 2016)
• With parenteral nutrition only:
• Atrophy of intestinal villi
• Overfeeding
• Hyperglycaemia
ESPEN Congress Lisbon 2015
NUTRITIONAL SUPPORT OF STROKE
PATIENTS
Recommendations
• All stroke patients should be screened for nutritional risk within the first days after
hospital admission.
• Severe swallowing difficulties that do not allow sufficient oral food intake and are
anticipated to persist for more than one week require early enteral nutrition via
feeding tube (at least within 72 hours).
• If a sufficient oral food intake is not possible during the acute phase of stroke, enteral
nutrition shall be preferably given via a nasogastric tube.
• If enteral feeding is likely for a longer period of time (> 28 days), a PEG should be
chosen and shall be placed in a stable clinical phase (after 14 – 28 days) (A)
Recommendations (cont)
• Nasogastric tube feeding does not interfere with swallowing training. Therefore,
dysphagia therapy shall start as early as possible also in tube‐fed patients.
• The majority of conscious dysphagic stroke patients with tube feeding should have
additional oral intake, according to the kind and severity of dysphagia.
• Stroke patients, who are able to eat and who have been identified to be at risk of
malnutrition, who are malnourished or who are at risk for pressure sores should
receive oral nutritional supplements.
• After assessment of the swallowing act (e.g. careful evaluation by the speech‐language
pathologists and/or video‐ fluoroscopic or endoscopic examination) a texture modified
diet and thickened fluids of a safe texture should be given to patients.
TERIMAKASIH