Artificial Nutritional Support

The presence of severe dysphagia and cognitive and complex physical impairments may render oral feeding unsafe or insufficient to meet nutritional requirements. If the gastrointestinal tract is functional, the options for delivering enteral nutritional support are either via a fine-bore nasogastric tube or via a catheter inserted by percutaneous endoscopic gastrostomy (PEG). Decisions concerning the choice of route are influenced by the anticipated duration of dysphagia and benefits versus risks. Impact on nutritional status, rehabilitation, quality of life, safety, tolerance, flexibility, ease of use, costs of insertion, removal, and maintenance are all important considerations. In the majority of cases dysphagia resolves within the acute phase of stroke, i.e., approximately 2-3 weeks. For relatively short time periods, enteral feeding by fine-bore nasogastric catheter is usually undertaken. This can be preferable because of the technical simplicity of intubation, maintenance and removal, low cost, and ease of use. Discomfort and risks of aspiration, accidental endotracheal intubation, and displacement or perforation of the esophagus are the potential complications, most of which are uncommon, although aspiration may occur in up to 10% of patients.

For feeding over longer time periods, a PEG tube inserted under local anesthetic offers greater comfort, toleration, ease of use, and reported improvements in nutritional status. However, costs are greater and this more invasive procedure carries a technique-related fatality of 1-2%. Minor complications include sto-mal sepsis, leaking, and outlet blockage. Peritonitis, perforation, gastrointestinal bleeding, and intestinal obstruction can occur, but are rare. Most enter-ostomy catheters are made from nonacid-hardening polyurethane or silicone and can be left in situ for up to 6 months. No consensus exists concerning the time period within which gastrostomy feeding should be initiated following stroke, but it should he considered where dysphagia is likely to persist beyond 14 days, and earlier for those intolerant of nasogastric tube feeding. In a small number of cases, enteral nutrition may be contraindicated following stroke owing to gastrointestinal bleeding resulting from severe stress ulceration. Rarely, nonstroke-related contraindications may also be present, i.e., gastrointestinal failure, ascites, Crohn's disease, bleeding, and clotting disorders.

In considering the relative merits of PEG versus nasogastric feeding poststroke, a systematic review found that PEG was superior in terms of weight maintenance and other indicators of nutritional status. PEG was also associated with significantly lower end-of-trial case fatality rates and treatment failures in the limited evidence derived from only two randomized, controlled clinical trials. Issues relating to the optimum timing of commencement of artificial feeding have not been clarified in systematic reviews; however, some guidelines emphasize the need to consider the institution of nutritional support within 5 days of a nil oral regime. Failure to provide nutritional support for patients who have not met or are unlikely to meet their nutritional requirements for >7 days is viewed as unethical. In the presence of dysphagia, those unable to meet their nutritional requirements by the oral route should be assessed for nasogastric feeding within 7 days.

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