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Learning Objectives Define iatrogenic malnutrition Describe the nature of the evidence related to optimal amount of calories/protein List key variables.

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Presentation on theme: "Learning Objectives Define iatrogenic malnutrition Describe the nature of the evidence related to optimal amount of calories/protein List key variables."— Presentation transcript:

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2 Learning Objectives Define iatrogenic malnutrition Describe the nature of the evidence related to optimal amount of calories/protein List key variables to consider in assessing nutritional risk in ICU patients List strategies to improve nutritional adequacy in the critical care setting.

3 A different form of malnutrition?

4 Health Care Associated Malnutrition Nutrition deficiencies associated with physiological derangement and organ dysfunction that occurs in a health care facility Patients who will benefit the most from nutrition therapy and who will be harmed the most from by iatrogenic malnutrition (underfeeding)

5 Adjunctive Supportive Care Proactive Primary Therapy Early and Adequate Nutrition is therapy that modulates the underlying disease process and impacts patient outcomes

6 Early Feeding Supports Gastrointestinal Structure and Function Maintenance of gut barrier function Increased secretion of mucus, bile, IgA Maintenance of peristalsis and blood flow Attenuates oxidative stress and inflammation Supports GALT Improves glucose absorption Alverdy (CCM 2003;31:598) Kotzampassi Mol Nutr Food Research 2009 Nguyen CCM 2011

7 Early vs. Delayed EN: Effect on Infectious Complications Updated 2009

8 Early vs. Delayed EN: Effect on Mortality Updated 2009

9 Feeding the Hypotensive Patient? DiGiovine et al. AJCC 2010 The beneficial effect of early feeding is more evident in the sickest patients, i.e, those on multiple vasopressor agents. Prospectively collected multi-institutional ICU database of 1,174 patients who required mechanical ventilation for more than two days and were on vasopressor agents to support blood pressure.

10 Optimal Amount of Protein and Calories for Critically Ill Patients? Early EN (within hrs of admission) is recommended!

11 Increasing Calorie Debt Associated with worse Outcomes Caloric debt associated with: Longer ICU stay Days on mechanical ventilation Complications Mortality Adequacy of EN Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006 Caloric Debt

12 Point prevalence survey of nutrition practices in ICUs around the world conducted Jan. 27, 2007 Enrolled 2772 patients from 158 ICUs over 5 continents Included ventilated adult patients who remained in ICU >72 hours

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14 Effect of Increasing Amounts of Calories from EN on Infectious Complications Heyland Clinical Nutrition 2010 Multicenter observational study of 207 patients >72 hrs in ICU followed prospectively for development of infection for increase of 1000 cal/day, OR of infection at 28 days

15 Relationship between increased nutrition intake and physical function (as defined by SF-36 scores) following critical illness Multicenter RCT of glutamine and antioxidants (REDOXS Study) First 364 patients with SF 36 at 3 months and/or 6 months for increase of 30 gram/day, OR of infection at 28 days Heyland Unpublished Data Model * Estimate (CI) P values (A) Increased energy intake PHYSICAL FUNCTIONING (PF) at 3 months3.2 (-1.0, 7.3) P=0.14 ROLE PHYSICAL (RP) at 3 months4.2 (-0.0, 8.5)P=0.05 STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 3 months 1.8 (0.3, 3.4)P=0.02 PHYSICAL FUNCTIONING (PF) at 6 months0.8 (-3.6, 5.1)P=0.73 ROLE PHYSICAL (RP) at 6 months2.0 (-2.5, 6.5)P=0.38 STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 6 months 0.70 (-1.0, 2.4) P=0.41

16 Faisy BJN 2009;101:1079 Mechancially Ventd patients >7days (average ICU LOS 28 days)

17 More (and Earlier) is Better! If you feed them (better!) They will leave (sooner!)

18 Permissive Underfeeding (Starvation)? 187 critically ill patients Tertiles according to ACCP recommended levels of caloric intake Highest tertile (>66% recommended calories) vs. Lowest tertile (<33% recommended calories) in hospital mortality Discharge from ICU breathing spontaneously Middle tertile (33-65% recommended calories) vs. lowest tertile Discharge from ICU breathing spontaneously Krishnan et al Chest 2003

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20 Optimal Amount of Calories for Critically Ill Patients: Depends on how you slice the cake! Objective: To examine the relationship between the amount of calories recieved and mortality using various sample restriction and statistical adjustment techniques and demonstrate the influence of the analytic approach on the results. Design: Prospective, multi-institutional audit Setting: 352 Intensive Care Units (ICUs) from 33 countries. Patients: 7,872 mechanically ventilated, critically ill patients who remained in ICU for at least 96 hours. Heyland Crit Care Med 2011

21 Association between 12 day average caloric adequacy and 60 day hospital mortality (Comparing patients recd >2/3 to those who recd <1/3) A. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are included as zero calories* B. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.* C. In ICU for at least 4 days before permanent progression to exclusive oral feeding. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.* D. In ICU at least 12 days prior to permanent progression to exclusive oral feeding* *Adjusted for evaluable days and covariates,covariates include region (Canada, Australia and New Zealand, USA, Europe and South Africa, Latin America, Asia), admission category (medical, surgical), APACHE II score, age, gender and BMI.

22 Association Between 12-day Caloric Adequacy and 60-Day Hospital Mortality Heyland CCM 2011 Optimal amount= 80-85%

23 More (and Earlier) is Better! If you feed them (better!) They will leave (sooner!)

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25 JAMA 1994;271:56

26 Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Single center study of 200 mechanically ventilated patients Trophic feeds: 10 ml/hr x 5 days Rice CCM 2011;39:967

27 Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Rice CCM 2011;39:967 What other outcomes might be important?

28 Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure survivors who received initial full-energy enteral nutrition were more likely to be discharged home with or without help as compared to a rehabilitation facility (68.3% for the full-energy group vs. 51.3% for the trophic group; p =.04). Rice CCM 2011;39:967

29 Rice et al. JAMA 2012;307

30 Still no measure of physical function!

31 Rice et al. JAMA 2012;307 Enrolled 12% of patients screened

32 Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Average age 52 Few comorbidities Average BMI All fed within 24 hrs (benefits of early EN) Average duration of study intervention 5 days No effect in young, healthy, overweight patients who have short stays!

33 Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Randomized Good follow up ITT No blinding 1.How representative are these patients to ALL the patients in your ICU? May miss an important negative effect in high risk patients 2.What about the physically recovery of underfed patients? No benefit, potential harm, minimal cost advantage= Do not use routinely! Internally valid

34 ICU patients are not all created equal…should we expect the impact of nutrition therapy to be the same across all patients?

35 How do we figure out who will benefit the most from Nutrition Therapy?

36 Health Care Associated Malnutrition Do Nutrition Screening tools help us discriminate those ICU patients that will benefit the most from artificial nutrition? Patients who will benefit the most from nutrition therapy and who will be harmed the most from by iatrogenic malnutrition (underfeeding)

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38 All ICU patients treated the same

39 Albumin: a marker of malnutrition ? Low levels very prevalent in critically ill patients Negative acute-phase reactant such that synthesis, breakdown, and leakage out of the vascular compartment with edema are influenced by cytokine-mediated inflammatory responses Proxy for severity of underlying disease (inflammation) not malnutrition Pre-albumin shorter half life but same limitation

40 Subjective Global Assessment?

41 When training provided in advance, can produce reliable estimates of malnutrition Note rates of missing data

42 mostly medical patients; not all ICU rate of missing data? no difference between well-nourished and malnourished patients with regard to the serum protein values on admission, LOS, and mortality rate.

43 We must develop and validate diagnostic criteria for appropriate assignment of the described malnutrition syndromes to individual patients.

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45 Nutrition Status micronutrient levels - immune markers - muscle mass Starvation Acute -Reduced po intake -pre ICU hospital stay Chronic -Recent weight loss -BMI? Inflammation Acute -IL-6 -CRP -PCT Chronic -Comorbid illness A Conceptual Model for Nutrition Risk Assessment in the Critically Ill

46 The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). When adjusting for age, APACHE II, and SOFA, what effect of nutritional risk factors on clinical outcomes? Multi institutional data base of 598 patients Historical po intake and weight loss only available in 171 patients Outcome: 28 day vent-free days and mortality Heyland Critical Care 2011, 15:R28

47 What are the nutritional risk factors associated with clinical outcomes? (validation of our candidate variables) Non-survivors by day 28 (n=138) Survivors by day 28 (n=460) p values Age 71.7 [60.8 to 77.2]61.7 [49.7 to 71.5]<.001 Baseline APACHE II score 26.0 [21.0 to 31.0]20.0 [15.0 to 25.0]<.001 Baseline SOFA 9.0 [6.0 to 11.0]6.0 [4.0 to 8.5]<.001 # of days in hospital prior to ICU admission 0.9 [0.1 to 4.5]0.3 [0.0 to 2.2]<.001 Baseline Body Mass Index 26.0 [22.6 to 29.9]26.8 [23.4 to 31.5]0.13 Body Mass Index 0.66 <20 6 ( 4.3%) 25 ( 5.4%) ( 88.4%) 414 ( 90.0%) # of co-morbidities at baseline 3.0 [2.0 to 4.0]3.0 [1.0 to 4.0]<0.001 Co-morbidity <0.001 Patients with 0-1 co-morbidity 20 (14.5%) 140 (30.5%) Patients with 2 or more co-morbidities 118 (85.5%) 319 (69.5%) C-reactive protein ¶ [73.0 to 214.0]108.0 [59.0 to 192.0]0.07 Procalcitionin ¶ 4.1 [1.2 to 21.3]1.0 [0.3 to 5.1]<.001 Interleukin-6 ¶ [39.2 to ]72.0 [30.2 to 189.9]< patients had data of recent oral intake and weight loss Non-survivors by day 28 (n=32) Survivors by day 28 (n=139) p values % Oral intake (food) in the week prior to enrolment 4.0[ 1.0 to 70.0]50.0[ 1.0 to 100.0]0.10 % of weight loss in the last 3 month 0.0[ 0.0 to 2.5]0.0[ 0.0 to 0.0]0.06

48 Variable Spearman correlation with VFD within 28 days p values Number of observations Age < Baseline APACHE II score < Baseline SOFA < % Oral intake (food) in the week prior to enrollment number of days in hospital prior to ICU admission % of weight loss in the last 3 month Baseline BMI # of co-morbidities at baseline Baseline CRP Baseline Procalcitionin < Baseline IL < What are the nutritional risk factors associated with clinical outcomes? (validation of our candidate variables)

49 The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). % oral intake in the week prior was dichotomized into patients who reported less than 100% versus everyone else Weight loss was dichotomized as patients who reported any weight loss versus everyone else. BMI was dichotomized as <20 versus other Comorbidities was left as integer values range 0-5 The remaining candidate variables were categorized into five equal sized groups (quintiles).

50 The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). For example, exact quintiles and logistic parameters for age Exact QuintileParameterPoints referent

51 The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). VariableRangePoints Age< <751 >=752 APACHE II< < >=283 SOFA<60 6-<101 >=102 # Comorbidities Days from hospital to ICU admit0-< IL60-< AUC0.783 Gen R-Squared0.169 Gen Max-rescaled R-Squared BMI, CRP, PCT, weight loss, and oral intake were excluded because they were not significantly associated with mortality or their inclusion did not improve the fit of the final model.

52 The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).

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54 Interaction between NUTRIC Score and nutritional adequacy (n=211) * P value for the interaction=0.01 Heyland Critical Care 2011, 15:R28

55 Who might benefit the most from nutrition therapy? High NUTRIC Score? Clinical –BMI –Projected long length of stay Others?

56 Do we have a problem?

57 Preliminary Results of INS 2011 Overall Performance: Kcals 84% 56% 15% N=211

58 Failure Rate % patients who failed to meet minimal quality targets (80% overall energy adequacy)

59 Strategies to Maximize the Benefits and Minimize the Risks of EN feeding protocols motility agents elevation of HOB small bowel feeds weak evidence stronger evidence Canadian CPGs

60 Use of Nurse-directed Feeding Protocols Start feeds at 25 ml/hr Check Residuals q4h > 250 ml hold feeds add motility agent reassess q 4h < 250 ml advance rate by 25 ml reassess q 4h 2009 Canadian CPGs Should be considered as a strategy to optimize delivery of enteral nutrition in critically ill adult patients.

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63 CharacteristicsTotal n=269 Feeding Protocol Yes208 (78%) Gastric Residual Volume Tolerated in Protocol Mean (range)217 ml (50, 500) Elements included in Protocol Motility agents68.5% Small bowel feeding55.2% HOB Elevation71.2 % The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a multicenter observational study Heyland JPEN % using the recommended threshold volume of 250 ml

64 The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a multicenter observational study Time to start EN from ICU admission 41.2 in protocolized sites vs 57.1 hours in those without a protocol Patients recing motility agents 61.3% in protocolized sites vs 49.0% in those without Heyland JPEN 2010 P<0.05

65 Can we do better? The same thinking that got you into this mess wont get you out of it!

66 Impaired motility Medications Metabolic, electrolyte abnormalities Underlying disease Reasons for Inadequate Intake Prophylactic use of motility agents Slow starts and slow ramp ups Interruptions Mostly related to procedures Not related to GI dysfunction Can be overcome by better feeding protocols

67 Protocol to Manage Interruptions to EN due to non-GI Reasons Can be downloaded from

68 Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol

69 Different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds. In select patients, we start the EN immediately at goal rate, not at 25 ml/hr. We target a 24 hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume. Start with a semi elemental solution, progress to polymeric Tolerate higher GRV threshold (250 ml or more) Motility agents and protein supplements are started immediately Nurse reports daily on nutritional adequacy. The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol! A Major Paradigm Shift in How we Feed Enterally

70 Begin 24 hour volume-based feeds. After initial tube placement confirmed, start Pepatmen 1.5. Total volume to receive in 24 hours is 17ml x weight (kg)=. Determine initial rate as per Volume Based Feeding Schedule. Monitor gastric residual volumes as per Adult Gastric Flow Chart and Volume Based Feeding Schedule. OR Begin Peptamen 1.5 at 10 mL/h after initial tube placement confirmed. Hold if gastric residual volume >500 ml and ask Doctor to reassess. Reassess ability to transition to 24 hour volume-based feeds next day. {Intended for patient who is hemodynamically unstable (on high dose or escalating doses of vasopressors, or inadequately resuscitated) or not suitable for high volume enteral feeding (ruptured AAA, upper intestinal anastomosis, or impending intubation)} OR NPO. Please write in reason: __________________ ______. (only if contraindication to EN present: bowel perforation, bowel obstruction, proximal high output fistula. Recent operation and high NG output not a contraindication to EN.) Reassess ability to transition to 24 hour volume-based feeds next day. Stable patients should be able to tolerate goal rate We use a concentrated solution to maximize calories per ml Drs need to justify why there are keeping patients NPO If unstable or unsuitable, just use trophic feeds We want to minimize the use of NPO but if selected, need to reassess next day The PEP uP Protocol Note, there are only a few absolute contraindications to EN Note indications for trophic feeds

71 Its not just about calories... Protein supplement Beneprotein® 14 grams mixed in 120 mls sterile water administered bid via NG So in order to minimize this, we order: Loss of lean muscle mass Inadequate protein intake Immune dysfunction Weak Prolonged mechanical ventilation

72 Other Strategies to Maximize the Benefits and Minimize the Risks of EN Motility agents started at initiation of EN rather that waiting till problems with High GRV develop. –Maxeran 10 mg IV q 6h (halved in renal failure) –If still develops high gastric residuals, add Erythromycin 200 mg q 12h. –Can be used together for up to 7 days but should be discontinued when not needed any more –Reassess need for motility agents daily

73 The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol! Day 1Day 2Day 3Day 4Day 5Day 6Day 7Total P-value < Adequacy of Calories from EN (Before Group vs. After Group on Full Volume Feeds) Heyland Crit Care 2010

74 Change of nutritional intake from baseline to follow-up of all the study sites (all patients) % calories received/prescribed

75 Change of nutritional intake from baseline to follow-up of all the study sites (all patients) % protein received/prescribed

76 Effect on VAP Updated 2011,www.criticalcarenutrition.com Small Bowel vs. Gastric Feeding: A meta-analysis Other Strategies to Maximize the Benefits and Minimize the Risks of EN

77 Does Postpyloric Feeding Reduce Risk of GER and Aspiration? Tube Position # of patients % positive for GER % positive for Aspiration Stomach D D D4150 Total P=0.004P=0.09 Heyland CCM 2001;29:

78 FRICTIONAL ENTERAL FEEDING TUBE (TIGER TUBE TM ) Flaps to allow peristalsis to pull tube passively forward Sucessful jejunal placement >95%

79 CORTRAK ® A new paradigm in feeding tube placement –Aid to placement of feeding tubes into the stomach or small bowel –The tip of the stylet is a transmitter. –Signal is picked up by an external receiver unit. –Signal is fed to an attached Monitor unit. –Provides user with a real- time, graphic display that represents the path of the feeding tube.

80 A Change to Nursing Report Adequacy of Nutrition Support = 24 hour volume of EN received Volume prescribed to meet caloric requirements in 24 hours Please report this % on rounds as part of the GI systems report

81 When performance is measured, performance improves. When performance is measured and reported back, the rate of improvement accelerates. Thomas Monson

82 What if you cant provide adequate nutrition enterally? … to add PN or not to add PN, that is the question! Health Care Associated Malnutrition

83 Early vs. Late Parenteral Nutrition in Critically ill Adults 4620 critically ill patients Randomized to early PN –Recd 20% glucose 20 ml/hr then PN on day 3 OR late PN –D5W IV then PN on day 8 All patients standard EN plus tight glycemic control Cesaer NEJM 2011 Results: Late PN associated with 6.3% likelihood of early discharge alive from ICU and hospital Shorter ICU length of stay (3 vs 4 days) Fewer infections (22.8 vs 26.2 %) No mortality difference

84 Early vs. Late Parenteral Nutrition in Critically ill Adults ? Applicability of data –No one give so much IV glucose in first few days –No one practice tight glycemic control Right patient population? –Majority (90%) surgical patients (mostly cardiac-60%) –Short stay in ICU (3-4 days) –Low mortality (8% ICU, 11% hospital) –>70% normal to slightly overweight Not an indictment of PN –Early group only recd PN for 1-2 days on average –Late group –only ¼ recd any PN Cesaer NEJM 2011

85 What if you cant provide adequate nutrition enterally? … to TPN or not to TPN, that is the question! Case by case decision Maximize EN delivery prior to initiating PN Use early in high risk cases

86 ICU patients BMI <25 R PN for 7 days Control The TOP UP Trial Fed enterally Primary Outcome 60-day mortality BMI >35 Stratified by: Site BMI Med vs Surg

87 In Conclusion Health Care Associate Malnutrition is rampant Not all ICU patients are the same in terms of risk Iatrogenic underfeeding is harmful in some ICU patients or some will benefit more from aggressive feeding (avoiding protein/calorie debt) BMI and/or NUTRIC Score is one way to quantify that risk Need to do something to reduce iatrogenic malnutrition in your ICU! –Audit your practice first! –PEP uP protocol in all –Selective use of small bowel feeds then sPN in high risk patients

88 Yes YES Day 3 >80% of Goal Calories No NO No problem Anticipated Long Stay? Yes No Maximize EN with motility agents and small bowel feeding Yes YES Not tolerating EN at 96 hrs? No NO Supplemental PN? Start PEP UP High Risk? Carry on!

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90 Questions?


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