MANAGING NUTRITION AND HYDRATION DURING THE ACUTE STROKE PHASE

Malnutrition is common in patients admitted to hospital following stroke and studies indicate that malnutrition frequently advances throughout the duration of a patients stay in hospital (Daniels & Huckabee, 2008). In addition to this, evidence suggests that nutritional status plays a significant role in determining a patient’s length of stay in hospital and their functional improvement rate (Finestone, Greene-Finestone, Wilson, & Teasell, 1996). It is therefore critical to establish at an early time a means of providing sufficient nutrition and hydration for the patient with bilateral hemispheric stroke.
As bilateral stroke frequently results in a severe dysphagia, it is highly likely that a patient will receive a nil by mouth (NBM) recommendation during the acute stroke phase. Recommendations for enteral (utilizing the gastrointestinal system) tube feeding are as follows:
  • The decision for enteral tube feeding should be considered no later than 72 hours after admission to ensure nutrition and hydration is maintained (Barber, Fink, Gommans, Hanger, & Baker, 2006).

  • The decision to tube feed should be a team one involving doctors, nurses, dieticians and the patient’s family. This will ensure that all relevant issues have been addressed.

  • Collaboration with the team Dietician will allow the selection of the appropriate enteral formula to ensure the patient receives adequate caloric intake whilst they are tube fed.

  • Selection of the appropriate method of tube feeding is required: Nasogastric Tube (NG) v.s. Percutaneous Endoscopic Gastrostomy (PEG). See the table below to help with this decision.

Tube Type
Feeding Method
When to Use & Advantages to Using
Disadvantages & Possible Complications
Nasogastric Tube
NG Tube Route. Sourced from news.bbc.co.uk/2/hi/health/4396273.stm
NG Tube Route. Sourced from news.bbc.co.uk/2/hi/health/4396273.stm

Tube placed into stomach via the nasopharynx.

Intermittent or continuous drip.
Within 72 hours of patient admission if NMB recommended.

Short term alternative to oral intake.

Easily inserted and removed.

No anaesthesia required for insertion.
Some patients can eat with NG tube in.
Small diameter tubes can be well tolerated.
Misplacement of tube into airway.

Tube blockages.
Patient discomfort.
May affect swallow function.
May contribute to reflux and aspiration.
Poor cosmesis
Percutaneous Endoscopic Gastrostomy
PEG Tube route. Sourced from news.bbc.co.uk/2/hi/health/4396273.stm
PEG Tube route. Sourced from news.bbc.co.uk/2/hi/health/4396273.stm

Tube is inserted through the abdominal wall directly into the stomach using endoscopic guidance.

Drip by infusion pump or bolus/gravity syringe.
Generally a long term feeding option for patients whose swallow has not sufficiently recovered after 3-4 weeks. However in the case of a patient with bilateral hemispheric stroke, early placement of PEG (less than 5 days post stroke) is warranted because of the likely requirement for long term nutritional supplementation.

Generally well tolerated.
Endoscopic insertion under light anaesthesia.

Risk of aspiration during insertion procedure.

Infection at tube site.
Potential for reflux.
Tube blockages
Adapted from Groher and Crary (2010) & Barber et al. (2006).

Ethical Issues in Tube Feeding Tube feeding cannot be discussed without consideration of the ethical issues involved with this intervention. Tube feeding is a medical treatment and therefore the decision to place a feeding tube should be based upon whether it will provide any actual benefit to patients when all other factors including the patient’s wishes or those of their family, the risks involved with the procedure and the patients potential quality of life are considered (Angus & Burakoff, 2003).

The FOOD trail collaboration (2005) highlighted the issue that tube feeding often results in keeping patients alive but in a severely disabled state where they require ongoing tube feeding and 24 hour care for the foreseeable future. Thus medical staff can recommend against the placement of a feeding tube for a patient in a persistent vegetative state because the patient will not perceivably benefit from any improvement in quality of life. In direct opposition to this, many families may request tube feeding for a patient in a vegetative state as this fits with their cultural or religious beliefs (Gordon & Alibhai, 2004). Thus it is important that the medical team work collaboratively with the patient’s family to discuss the potential benefits and risks to extending life so that a conclusion is reached with everyone on agreeable terms.

Patients in the bilateral stroke population may have signed an advanced directive (living will/health care power of attorney) stating their medical wishes regarding tube feeding if they are found to be in a cognitively incapacitated state. In such cases, the medical team is ethically bounded to follow the patient’s directives.

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