In this article, we will summarize the guidelines and recommendations about initiation of enteral or tube feeding in a patient of acute stroke with dysphagia.
Summary of Recommendations: When to start enteral feeding in a patient of stroke?
- Each patient of stroke should be evaluated for dysphagia as soon as possible.
How to evaluate for dysphagia in a patient of acute stroke?There are five ways of assessing dysphagia;
- Water swallowing test
- Multiple consistency test.
- Swallowing provocation test
- Video fluoroscopic swallowing study (VFSS)
- Fiberoptic endoscopic evaluation of swallowing (FEES)
Video fluoroscopic swallowing study (VFSS) is the gold standard of swallowing evaluation.
Importance of starting early nutrition in a patient of acute stroke
If a patient doesn't pass the swallowing evaluation. Then we should think about alternate modes of nutrition. As nutrition in a patient of stroke affects the outcome, decreases the risk of infections, bedsores, and also decrease the mortality rate and is associated with better outcomes and prognosis.
Alternative modes of nutrition
We have three alternative modes of nutrition.
- Via Nasogastric tube
- Via G-tube (PEG)
- Parenteral nutrition
When to start nutrition in the patient of stroke?
Hydration should be started as soon as possible. But nutrition can be delayed up to 72 hours but shouldn't be delayed for more than 7 days.
Best way of starting the nutrition.
NG tube is the best initial approach to start enteral nutrition instead of PEG, because of following reasons.
- It is less invasive
- 70-80% of patients of acute stroke improve and able to take orally within 14 days of acute stroke. So it can be reversed easily.
When to Place PEG?
PEG should be done if;
- If dysphagia remains for 28 days or more.
- Can be done earlier if it is anticipated that dysphagia will not resolve within 28 days.
- If patient is being mechanically ventilated, PEG can be done early that is within 14 days.
- If there is risk of frequent dislodgement of nasogastric tube.
When to start parenteral nutrition?
Parenteral hydration should be started as soon as possible if a patient of stroke can't take adequate fluid orally or via Nasogastric tube. If enteral feeding is contraindicated, then parenteral nutrition should be started within 72 hours. Or if a patient can't take enough calories via enteral tube then parenteral feeding should also be started along with enteral feeding.
How to start enteral feeding in a patient of stroke? Precautions and How to minimize risks?
References:Guideline clinical nutrition in patients with stroke, Rainer Wirth, Christine Smoliner,Martin Jäger,Tobias Warnecke, Andreas H Leischker, Rainer Dziewas and The DGEM Steering Committee*, Experimental & Translational Stroke Medicine20135:14 DOI: 10.1186/2040-7378-5-14,© Wirth et al.; licensee BioMed Central Ltd. 2013 November 2013