1. Dr Nikhilesh Jain DNB (Med) MRCP (Ireland) IDCCM Director and Operational Head Dept of Critical Care Services CHL Hospitals,Indore

2. Why discuss it?  Nutrition support is an essential component of management  Reduces disease severity, diminishes complications, reduced LOC and favourable patient outcomes  Significant numbers receive a poor nutrition support  Why not review the same? JPEN 2009;33:277-316,ICM 2009;35:2018-27 Chest 2006;129:960-67, JPEN 2011;35:473-487 CCM 2008;36:1762-67, Injury 2011;42:50-56

3. Myth 1  Starvation/under nutrition is OK - Attenuates metabolic response to stress and limits oxidative injury - Association of poor outcomes with decreased energy and protein provisions - Optimal nutrition associated with 50% decrease in mortality in ventilated patients - No known illness/disease that benefits from starvation Nutr Clin Pract 2009;24:305-15,Mol Nutr Food Res 2009;53:770-79 Crit Care Clin 1998;14:423-40,JPEN 2012;36:60-68, Chest 2011;140:1254-60

4. To continue further……  ASPEN, Canadian and European guidelines recommend initiation of enteral nutrition within 48 hours  Obesity Paradox  20-25Kcal/kg/day with at least 1-2gm/kg protein  Starvation for bowel is akin to cardiac asystole for heart  EN improves outcome for diseases in which bowel rest was considered standard of care CCM 2006;34:1251-53,CCM 2011;39:967-74, JPEN 1985;9:280-87 Nutr Clin Pract 2004;19:37-49, Gut 1988;29: 1309-15 BMJ 2004;328:1407, Lancet 2006;367:1101-11,JAMA 2012;307:795-803

5. Myth No 2  Parenteral Nutrition is safe - Strong recommendation of Enteral over Parenteral - Adverse sequelae include a double hit from PN - Greater proportion of immunologic, endocrine and infective complications - Development of liver dysfunction sec to PN - Impaired humoral and cellular immunity - Can be given if PEM is present at baseline and patient is unable to tolerate enteral with a higher likelihood of harm ICM2003;29:867-69,Crit Care2007;11:R10, Arch Surg1997;132:1303- 09, Nutrition1995;11:339-44, JAMA 1998;280:2013-19, Clin Nutr 2009;28:378-86,NEJM 2011;365:506-17, AJRCCM2013;187:247-55

6. Myth No 3  EN is contraindicated in presence of pressors - Vasoconstrictors and hypotension lead to a decrease in gut flow - Postulated earlier that with GI feeding intestinal ischemia may worsen - In actuality EN increases gut blood flow and protects against bowel ischemia - Enteral infusion of nutrients prevents adverse structural and functional alterations - Improved blood flow across vascular beds and hepatic energy stores Am J Crit Care 2010;19:261-68,CCM 2000;28:2217-23 Nutr Clin Prac 2003;18:285-93,World J Surg 1998;22:6-11

7. Myth No 4  Early EN is not important in patients receiving mechanical ventilation - Nutrition is not considered a priority as there are other issues of acuity in patients on mech venti. - Early EN (within 2 days of admission) associated with a significant reduction in ICU and Hospital mortality Chest 2006;129:960-67, CCM 2008;36:1762-67 Chest 2004;125:1446-57

8. Myth No 5  EN is contraindicated with high residual volumes - Measurements and risk of aspiration and pneumonia are presumptive - Volume of GRV does not predict aspiration risk - Upper acceptable limit as per SCCM guidelines is 500ml CCM 2005;33:324-30, ICM 2010;36:1386-93 JAMA 2013;309:249-56

9. Myth No 6  Post pyloric feeding reduces the risk of aspiration - Risk of pneumonia is unrelated to feeding - Patients should be initially taken on an oro - gastric tube with early EN initiation - If not tolerated an initial trial of pro kinetic agents post-pyloric feeding tube should be placed - In patients with known gastric dysmotility and supine position (ECMO pt) postpyloric tube is required ICM 2006;32:639-49,Crit Care 2003;7:R46-51,Crit Care 2013;17:R127 CCM 2000;28:2657-59

10. Myth No 7  EN is contraindicated in patients without bowel sounds/postop ileus - No ICU studies to validate bowel sounds manuver - Presence of bowel sounds requires presence of air and gastric emptying - No correlation between bowel myoelectric activity and bowel sounds - Auscultation of bowel sounds has limited clinical utility - In ICU neither presence/absence of bowel sounds nor passage of flatus/stool is required to establish initiation of feeding JPEN 2009;33:277-316,Ann Surg 1990;211:711-84 Ann Surg 1972;175:510-22,Lancet 1963;2:64-67

11. Myth No 8  EN is contraindicated following GI surgery - It is assumed that postop ileus precludes enteral feeding and bowel distension following feeding can lead to anastomotic disruption - GIT produces 6 litres/day and it is illogical to assume that an additional one litre of fluid can be harmful - Early EN following bowel surgery is associated with improved wound healing and greater wound strength, Prefer a semi elemental formula - Lower risk of leaks,fistulas and infections with early EN - Slow initiation of EN and discontinuation with evaluation in patients with abd pain should be followed Surg Today 2009;39:225-30,J Surg Res 2011;169:202-08, Am J Surg 2001;182:621-24, Arch of Surg 2003;138:206-14 JPEN 2007;31:410-415

12. Myth No 9  EN is contraindicated in patients with open abdomen - Decompressive celiotomy for abd compartment syndrome -Early EN (within 4 days) is associated with improved outcomes -Earlier closure of abdominal cavity and less rates of fistula formation Arch Surg 2004;139:209-14, J Trauma 1986;26:874-81 Nutr Clin Pract 2003;18:253-58, JPEN 2007;31:410-15

13. Myth No 10  EN is contraindicated in patients with pancreatitis - EN reduces early infectious complications, organ failure, length of stay and mortality - Should begin within 24 hrs after admission and following initial period of resuscitation and control of nausea and pain - Either gastric/jejunal route can be used Surg Clin N Am 1991;71:579-95, Curr Opin Crit Care 2009;15:131-38 Arch Surg 2008;143:1111-17

14. Myth No 11  Patients must be fed semi recumbent at 45 degrees - Nursing a patient semi recumbent at 45 degrees is not feasible at all times in ICU - Attempts to do above do not decrease the risk of VAP - Patient tends to slide down in an uncomfortable position - On the contrary it enhances flow of mucus in lungs enhancing colonization and pneumonia CCM 2006;34:396-402,Am J Crit Care 2005;14:325-332 CCM 2008;36:518-25,Am J Crit Care 2010;19:e100-08

15. To Conclude………  The challenge remains in terms of our ability to follow EBM