Nutrition Support Blog: Enteral Nutrition Post Stem-Cell Transplant?
August 22, 2013
The catchphrase “If the gut works, use it” has been around for years. I learned this maxim when I was in my undergraduate dietetics program, and even then it was not a new concept. The basic preference for using the GI tract for providing nutrition is one of the few universally agreed upon recommendations among the numerous international nutrition support guidelines. However, once I started work I quickly realized that the definition of “when the gut works” is very subjective, and quite different between various practitioners. Several investigators have reported that in practice, parenteral nutrition (PN) is frequently over utilized (1-3). Discussions with clinicians in our training programs over the past 10 years have identified that the discrepancy between when enteral nutrition (EN) can be used and when it is used is a frequent source of frustration on the job.
Nevertheless, on the whole, I think we have made great strides in the past 20 years. Through experience, education and the availability of new research we have gradually demonstrated that most patients who are unable to eat can safely receive EN. Those with acute pancreatitis, post-op with new anastomosis, post-variceal bleeding, stable on vasopressor agents and many other populations formerly the exclusive domain of PN are now fed routinely with EN. One of the last bastions of routine PN use in our facility is the heme-oncology patients, especially those receiving stem-cell transplants.
Certainly it would seem obvious that patients with impaired immune function after chemo and radiation therapy would be the ideal candidates to avoid the infection risks associated with PN. However, in a population without enteral access, concerns about mucositis, sinusitis risk, thrombocytopenia, nausea and diarrhea diminish the enthusiasm for initiating EN. Additionally, there is limited research with stem-cell populations and EN. The results of research in other critically ill populations may have limited generalizability to the stem-cell population. Our experiences with patients receiving stem-cell transplants who required ICU care have demonstrated that placement of enteral access and feeding is feasible and generally well tolerated. In spite of this, the lack of good randomized data demonstrating clear outcome advantages of EN in this population, combined with potential inconvenience of properly managing GI symptoms, severely limits our use of EN post stem-cell transplant.
A new study may help expand our understanding of the potential role of EN in the adult stem-cell transplant population (4). We have not completed our review of this research yet, but you can look to our next e-journal club posting for our critique. The last time we reviewed nutrition support data in stem-cell transplants was 2007, and that was only a pilot, observational study (5). http://www.healthsystem.virginia.edu/pub/dietitian/inpatient/dh/E-journal%20Club/febmarch07.html
While we may not have all the answers yet, every bit of new data helps us provide the best care that we can.
“Research is what I'm doing when I don't know what I'm doing.”
-- Wernher von Braun
1) Elke G, Schädler D, Engel C, et al. German Competence Network Sepsis (SepNet). Current practice in nutritional support and its association with mortality in septic patients--results from a national, prospective, multicenter study. Crit Care Med. 2008;36(6):1762-1767.
2) Saalwachter AR, Evans HL, Willcutts KF, et al. A nutrition support team led by general surgeons decreases inappropriate use of total parenteral nutrition on a surgical service. Am Surg. 2004;70(12):1107-1111.
3) Martin K, DeLegge M, Nichols M, et al. Assessing appropriate parenteral nutrition ordering practices in tertiary care medical centers. JPEN J Parenter Enteral Nutr. 2011;35(1):122-130.
4) Guièze R, Lemal R, Cabrespine A, et al. Enteral versus parenteral nutritional support in allogeneic haematopoietic stem-cell transplantation. Clin Nutr. 2013 Jul 31.[Epub ahead of print].
5) Seguy D, Berthon C, Micol J, et al. Enteral Feeding and Early Outcomes of Patients Undergoing Allogeneic Stem Cell Transplantation Following Myeloablative Conditioning. Transplantation 2006;82(6):835-839.