|Year : 2014 | Volume
| Issue : 4 | Page : 237-240
Artificial nutrition in intracerebral hemorrhage: Could clinical decision-making be supported with the application of the Essen score?
Dominique Wakefield1, Anahita Dehbozorgi2, Muhammad J H. Rahmani1
1 Department of Stroke Medicine, Conquest Hospital, The Ridge, St Leonards on Sea, East Sussex Healthcare Trust, England, United Kingdom
2 Department of Nutrition and Dietetics, Chelsea and Westminster Hospital, London, England, United Kingdom
|Date of Submission||22-Nov-2013|
|Date of Acceptance||10-Apr-2014|
|Date of Web Publication||22-Aug-2014|
GP Registrar Conquest Hospital, The Ridge, St Leonards on Sea, East Sussex Healthcare Trust, TN37 7RD
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Intracerebral Hemorrhage (ICH) accounts for 10% of all patients presenting with acute stroke in the United Kingdom (UK).The 30-day mortality from ICH ranges from 35 to 52 per cent one-half of these deaths occur within the first two days. The significant mortality associated with ICH poses a significant challenge for the clinician, particularly with regard to decision-making around the 'appropriateness' of interventions, which may not improve or support the short-term or long-term outcomes. Aim: To examine whether the Essen Score in conjunction with dysphagia assessments could aid prognostication and decision-making, particularly with regards to artificial nutritional support and end-of-life care decision-making in patients with ICH. Materials and Methods: We retrospectively reviewed the notes of 42 patients admitted to our Stroke Unit with a primary diagnosis of spontaneous ICH, between December 2011 and June 2013. Data on survival, mortality, presence of dysphagia, and the utilization of artificial nutrition were recorded. The Essen score was applied to the same cohort of patients, with subsequent comparison of the predicted and actual outcomes. Result: Sixteen patients (38%) had an Essen score >7, with an average survival of three days. Ten patients (24%) had Essen scores <3. To date the average survival in this group is 305 days. Conclusion: We would postulate that discussions with the families of ICH patients presenting with Essen scores >7 and total dysphagia, need to focus on limiting any invasive medical treatment, including the use of artificial feeding, among cases highly unlikely to benefit from it. This highlights the potential use of the Essen score as a tool in conjunction with clinical judgment, to facilitate discussions around short-term and long-term goals set for individual patients, among the multidisciplinary team, family, and carers.
Keywords: Artificial nutrition, Essen score, intracranial bleed, stroke
|How to cite this article:|
Wakefield D, Dehbozorgi A, Rahmani MJ. Artificial nutrition in intracerebral hemorrhage: Could clinical decision-making be supported with the application of the Essen score?. Int J Nutr Pharmacol Neurol Dis 2014;4:237-40
|How to cite this URL:|
Wakefield D, Dehbozorgi A, Rahmani MJ. Artificial nutrition in intracerebral hemorrhage: Could clinical decision-making be supported with the application of the Essen score?. Int J Nutr Pharmacol Neurol Dis [serial online] 2014 [cited 2020 Aug 6];4:237-40. Available from: http://www.ijnpnd.com/text.asp?2014/4/4/237/139405
| Introduction|| |
Intracerebral Hemorrhage (ICH) accounts for 10% of all patients presenting with acute stroke in the UK.  The most common cause of intracerebral hemorrhage is hypertension. Less common causes of intracerebral hemorrhage include trauma, infections, tumours, blood clotting deficiencies, aneurysms, and arteriovenous malformations. The 30-day mortality from ICH ranges from 35 to 52%, , one half of these deaths occur within the first two days. 
The presentation of ICH in the acute setting poses a significant challenge for the clinician, particularly with regard to decision-making around the 'appropriateness' of interventions, which may not improve or support the short-term or long-term outcomes. The issues surrounding artificial nutrition in such patients is a prominent feature of debate  when considering the potentially invasive feeding methods versus the questionable benefit of these interventions, in a population with a high mortality of within 48 hours of onset of symptoms.
In 2006, the Essen score emerged as a simple prognostic tool for use in patients admitted with ICH.  This tool is validated to predict mortality for scores >7 and complete recovery in patients with scoring <3.
Our Stroke Unit has not previously utilized prognostic tools to support clinical decision-making for patients admitted with ICH. Considering the frequently encountered issues regarding the ethical and clinical implications associated with the use of artificial nutrition in ICH patients early in their admission, we recognized the potential benefits of applying the Essen tool in order to support discussions and decision-making in practice.
Our aim was to conduct a review on the case notes of patients diagnosed with ICH, by reviewing the mortality and survival data, followed by application of the Essen score, to compare the predicted and actual outcomes. In order to ascertain whether the retrospective application of the Essen score correlated with the actual prognosis and whether it would be appropriate to consider incorporating the Essen score in our future clinical practice to aid prognostication and decision-making, particularly with regard to artificial nutritional support and end-of-life care decision-making in patients with ICH.
| Materials and methods|| |
We audited notes of patients admitted to our Stroke Unit with a primary diagnosis of spontaneous ICH between December 2011 and June 2013, and examined the data on survival, mortality, presence of dysphagia, and utilization of artificial nutrition.
The Essen score [Table 1] is then applied to the same cohort of patients with subsequent comparison of the predicted and actual outcomes. The Essen ICH score comprises of three measures; National Institutes of Health Stroke Scale (NIHSS) total score, , the NIHSS consciousness level, and age. The maximum score attainable is 10; scores >7 are predictive of death, while a score <3 predicts complete recovery.
All patients included in our study were discussed with our regional Neurosurgical Center and were deemed to be for nonsurgical conservative management. In addition, all relevant patients were discussed with the High Dependency Unit (HDU)/Intensive Therapy Unit (ITU), and those included in the study were patients deemed not to be candidates for intensive care.
|Table 1: Essen scoring for calculating prognosis following intracerebral hemorrhage |
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Patients for neurosurgical management, intubated patients (or those under the care of ITU/HDU), patients with traumatic bleeds, subdural hematomas, subarachnoid hemorrhage, pediatric patients and brain malignancy (including brain metastases), were excluded from the study.
| Results|| |
Forty-two patients were included in our study, 24 patients were male (57%) and the average age range was 70-79 years. Sixteen patients (38%) had an Essen score >7, with an average survival of three days (average Essen score 8.8).
All patients with Essen scores >7 had total dysphagia. Only three of those patients received artificial nutrition; one received total parenteral nutrition (TPN) and two nasogastric (NG) feeding.
Ten patients (24%) had Essen scores <3, to date the average survival in this group is 305 days (average Essen score 1.7). In comparison all our patients with Essen scores <3 were assessed as having a suitable swallow, not requiring artificial nutritional support at any stage during their care.
Sixteen patients (38%) had Essen scores between 3 and 7, and again, all of these patients had a safe swallow with a current average survival of 391 days.
| Discussion|| |
Clinicians are often confronted with making challenging decisions regarding the use of artificial nutritional support when managing stroke patients. Research shows that one out of five patients admitted to hospital following an acute stroke are malnourished and have a rapid deterioration of nutritional status, where the increased metabolic demands cannot be met due to feeding difficulties. Although nutritional supplementation is commonly indicated in stroke patients, it remains unclear how we should best support the patients' nutritional status during the dysphagia phase. Questions such as, 'When should enteral feeding commence' and 'What route should be used' are often asked. The dilemma becomes more profound in patients with ICH when a definitive time period of survival is uncertain. Although delivering nutritional support in these patients is the key to prevent nutritional losses and its associated effects, it is also important to take into consideration the patient's prognosis and prevent any unnecessary stress and discomfort potentially caused by commencing artificial nutritional support.
The Essen score provided predictions of mortality and survival with 100% accuracy, when compared with our cohort's actual outcomes. All patients with Essen scores >7 had total dysphagia, necessitating artificial nutritional support, in comparison to those with scores <3, who were all assessed as having minor, if any, degree of dysphagia, with no indication for artificial feeding.
When considering our results with the findings of the FOOD Trials,  which reported that early tube feeding for stroke patients, within seven days of admission, did not provide any clinically significant outcomes compared to delayed feeding, we would propose that the commencement of artificial nutrition in patients with Essen scores >7 with total dysphagia is unlikely to support a favorable prognosis and may potentially cause unnecessary distress. This highlights the potential use of the Essen score as a tool in conjunction with clinical judgment to facilitate discussions around short-term and long-term goals set for individual patients among the MDT, family, and carers.
| Conclusions|| |
We would postulate that discussions with family, carers, and the MDT, with ICH patients presenting with Essen scores >7 and total dysphagia, need to focus on limiting any invasive medical treatment, including the use of artificial feeding among cases highly unlikely to benefit from it.
Incorporating the Essen ICH score, in combination with clinical judgment, into our stroke service will support our teams confidence in making prognostic estimations and facilitating discussions surrounding artificial nutritional and end-of-life care.
However, a larger sample and more research on the association between dysphagia and poor short-term prognosis in ICH is required, to take decisions on whether to initiate or withhold artificial nutrition and to institute end-of-life care.
Limitations of this study
This study is limited by its sample size, observer error/bias on NIHSS assessment, and the uncertainty of nutritional intervention impacting the acute outcome. We intend to continue to review the accuracy of the Essen ICH model in practice and further investigate the association between total dysphagia and poor prognosis in ICH.
1. Date of admission, date of diagnosis, date of death or discharge, age, GCS (Glasgow Coma Score) on admission, National Institutes of Health Stroke Scale (NIHSS) on admission, gender, whether artificial nutrition was given, indications/argument for starting nutrition
2. Indications/dispute for stopping nutrition, if given what method of artificial nutrition (TPN/NG) was used, and over what period.
| References|| |
|1.||Royal College of Physicians. National clinical guideline for stroke. Available from: http://www.rcplondon.ac.uk/resources/stroke-guidelines. 4 th ed. 24 September 2012 [Last accessed on 2014 May 28]. |
|2.||Fogelholm R, Murros K, Rissanen A, Avikainen S. Long term survival after primary intracerebral hemorrhage: A retrospective population based study. J Neurol Neurosurg Psychiatry 2005;76:1534-8. |
|3.||Van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral hemorrhage over time, according to age, sex, and ethnic origin: A systematic review and meta-analysis. Lancet Neurol 2010;9:167-76. |
|4.||Rordorf G, McDonald C. Spontaneous intracerebral hemorrhage: Prognosis and treatment. In: BasowDS, editors.Up-To-Date. Available from: http://www.uptodate.com/contents.Topic 1084 Version 16.0. [Last accessed on 2014 May 29]. |
|5.||Asplund K, Britton M. Ethics of life support in patients with severe stroke. Stroke 1989;20:1107-12. |
|6.||Weimar C, Benemann J, Diener HC; German Stroke Study Collaboration. Development and validation of the Essen Intracerebral Hemorrhage Score. J Neurol Neurosurg Psychiatry 2006;77:601-5. |
|7.||Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: A clinical examination scale. Stroke 1989;20:864-70. |
|8.||Available from: http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf. [Last accessed on 2013 Nov 12]. |
|9.||Dennis MS, Lewis SC, Warlow C; FOOD Trail Collaboration. Effect of timing of method of central tube feeding for dysphagic stroke patients (FOOD): A multicenter randomized controlled trail. Lancet 2005;365:764-72. |