Presentation on theme: "Iatrogenic Malnutrition in the ICU: Time for a Change!"— Presentation transcript:
1 Iatrogenic Malnutrition in the ICU: Time for a Change! Daren K. HeylandProfessor of MedicineQueen’s University, Kingston General HospitalKingston, ON CanadaAdd data from iatrogenic malnutrition slides
2 Learning Objectives Define iatrogenic malnutrition Describe the nature of the evidence related to optimal amount of calories/proteinList key variables to consider in assessing nutritional risk in ICU patientsList strategies to improve nutritional adequacy in the critical care setting.
3 A different form of malnutrition? Need picture of malnourshed child
4 Health Care Associated Malnutrition Nutrition deficiencies associated with physiological derangement and organ dysfunction that occurs in a health care facilityPatients who will benefit the most from nutrition therapy and who will be harmed the most from by iatrogenic malnutrition (underfeeding)
5 Optimal Amount of Protein and Calories for Critically Ill Patients? Early EN (within hrs of admission) is recommended!Optimal Amount of Protein and Calories for Critically Ill Patients?
7 Point prevalence survey of nutrition practices in ICU’s around the world conducted Jan. 27, 2007 Enrolled 2772 patients from 158 ICU’s over 5 continentsIncluded ventilated adult patients who remained in ICU >72 hours
9 for increase of 1000 cal/day, OR of infection at 28 days Effect of Increasing Amounts of Calories from EN on Infectious ComplicationsMulticenter observational study of 207 patients >72 hrs in ICU followed prospectively for development of infectionfor increase of 1000 cal/day, OR of infection at 28 daysHeyland Clinical Nutrition 2010
10 Relationship between increased nutrition intake and physical function (as defined by SF-36 scores) following critical illnessFor every 1000 kcal/day received:Model *Estimate (CI)P valuesAt 3 monthsPHYSICAL FUNCTIONING3.2 (-1.0, 7.3) P=0.14ROLE PHYSICAL4.2 (-0.0, 8.5)P=0.05STANDARDIZED PHYSICAL COMPONENT SCALE1.8 (0.3, 3.4)P=0.02At 6 months0.8 (-3.6, 5.1)P=0.732.0 (-2.5, 6.5)P=0.380.70 (-1.0, 2.4)P=0.41for increase of 30 gram/day, OR of infection at 28 daysUnpublished data from Multicenter RCT of glutamine and antioxidants(REDOXS Study); n=364
15 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 auditSetting: 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
16 Association between 12 day average caloric adequacy and 60 day hospital mortality(Comparing patients rec’d >2/3 to those who rec’d <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*Remove the 1/3-2/3 data*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.
17 Association Between 12-day Caloric Adequacy and 60-Day Hospital Mortality Optimal amount=80-85%Heyland CCM 2011
18 More (and Earlier) is Better! If you feed them (better!)They will leave (sooner!)
22 Enrolled 12% of patients screened Rice et al. JAMA 2012;307
23 No effect in young, healthy, overweight patients who have short stays! Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failureAverage age 52Few comorbiditiesAverage BMI 29-30All fed within 24 hrs (benefits of early EN)Average duration of study intervention 5 daysNo effect in young, healthy, overweight patients who have short stays!
24 Nutritional Management of ICU Patients: Are these both the same? Low Risk34 year former football player,BMI 35otherwise healthyinvolved in motor vehicle accidentMild head injury and fractured R leg requiring ORIFHigh Risk72 womenBMI 35PMHx COPD, poor functional statusAdmitted to hospital 1 week ago with CAPNow presents in respiratory failure requiring intubation and ICU admission
25 ICU-acquired Weakness (ICUAW) Muscle weakness develops in 25%-60% of patients who have been mechanically ventilated for > 1 week1Prolongs:1-4mechanical ventilationweaning from the ventilatorICU stayICUAW main clinical manifestation of critical illness neuromyopathy (CINM)5de Jonghe B, et al. Crit Care Med ;30:Garnacho-Montero J, et al. Crit Care Med ;33:van den Berghe G, et al. Crit Care Med ;31:Hermans G, et al. Am J Respir Crit Care Med ;175:de Jonghe B, et al. Crit Care Med ;37(suppl.):S309-S315.
27 Muscle Matters! Skeletal muscle mass predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patientsPatients > 65 years with an admission abdominal computed tomography scan and requiring intensive care unit stay at a Level I trauma center in were reviewed.Muscle cross-sectional area at the 3rd lumbar vertebra was calculated and sarcopenia identified using sex-specific cut-points.Muscle cross-sectional area was then related to clinical parameters including ventilator-free days, ICU-free days, and mortality.Kozar (in submission)
28 Body Composition Lab CT Imaging Analysis Skeletal MuscleAdipose TissueTo date we have used weight/BMI as a descriptor of patient body composition and we have looked at change in weight as a marker of change in nutritional status or to evaluate success/failure of nutritional interventionHowever, with weight, we cannot discern specific body composition profile or changes in profile;Use of already existing CT scans can provide this information…-L3 bony landmark – literature; longitudinal
29 Physical Characteristics of Patients N=149 patientsMedian age: 79 years old57% malesISS: 19Prevalence of sarcopenia: 71%
31 Low muscle mass associated with mortality Proportion of Deceased PatientsP-valueSarcopenic patients32%0.018Non-sarcopenic patients14%
32 Muscle mass is associated with ventilator-free and ICU-free days All PatientsSarcopenic PatientsNon-Sarcopenic PatientsP-valueVentilator-free days25 (0,28)19 (0,28)27 (18,28)0.004ICU-free days19 (0,25)16 (0,24)23 (14,27)0.002
34 After day 5, when awake, performed muscle testing Prospective multicenter observational trial of 136 patients requiring min 5 days of mechanical ventilationAfter day 5, when awake, performed muscle testingAm J Respir CCM 2008;178:
36 ICU patients are not all created equal…should we expect the impact of nutrition therapy to be the same across all patients?
37 How do we figure out who will benefit the most from Nutrition Therapy? Need picture of malnourshed child
38 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)
41 Albumin: a marker of malnutrition? Low levels very prevalent in critically ill patientsNegative acute-phase reactant such that synthesis, breakdown, and leakage out of the vascular compartment with edema are influenced by cytokine-mediated inflammatory responsesProxy for severity of underlying disease (inflammation) not malnutritionPre-albumin shorter half life but same limitation
43 When training provided in advance, can produce reliable estimates of malnutrition Note rates of missing data
44 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.
45 Mostly surgical patients; 100% data available for SGA
47 “We must develop and validate diagnostic criteria for appropriate assignment of thedescribed malnutrition syndromes to individual patients.”
48 A Conceptual Model for Nutrition Risk Assessment in the Critically Ill ChronicRecent weight lossBMI?AcuteReduced po intakepre ICU hospital stayStarvationNutrition Statusmicronutrient levels - immune markers - muscle massInflammationAcuteIL-6CRPPCTChronicComorbid illness
49 The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). VariableRangePointsAge<5050-<751>=752APACHE II<1515-<2020-28>=283SOFA<66-<10>=10# Comorbidities0-12+Days from hospital to ICU admit0-<11+IL60-<400400+AUC0.783Gen R-Squared0.169Gen Max-rescaled R-Squared 0.256BMI, 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.
50 The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).
51 The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).
52 Interaction between NUTRIC Score and nutritional adequacy (n=211)* The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).Interaction between NUTRIC Score and nutritional adequacy (n=211)*P value for the interaction=0.01Heyland Critical Care 2011, 15:R28
53 P=0.008P=0.04P=0.04Multicenter prospective study of nutrition practice in abdominal surgeryAll patients had nutrition screening, not all patients had peri op nutrition supportBenefit of nutrition support seen in NRS>5 compared to controls, no benefit seen in low risk patients (NRS<5).Patients with NRS >5
54 Who might benefit the most from nutrition therapy in the ICU? High NUTRIC Score?ClinicalBMIProjected long length of stayOthers?
56 Preliminary Results of INS 2011 Overall Performance: Kcals 84%56%15%N=211
57 Nutritional Adequacy of High Risk Patients compared to Low Risk Patients
58 Failure Rate% high risk patients who failed to meet minimal quality targets (80% overall energy adequacy)91.287.078.179.975.675.169.8Unpublished observations. Results of 2011 International Nutrition Survey (INS).
59 Strategies to Maximize the Benefits and Minimize the Risks of EN weak evidencefeeding protocolsmotility agentselevation of HOBsmall bowel feedsstronger evidenceCanadian CPGs
60 Use of Nurse-directed Feeding Protocols Start feeds at 25 ml/hr< 250 mladvance rate by 25 mlreassess q 4h> 250 mlhold feedsadd motility agentreassess q 4hCheck Residuals q4h“Should be considered as a strategy to optimize delivery of enteral nutrition in critically ill adult patients.”2009 Canadian CPGs
61 The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a multicenter observational studyP<0.05Time to start EN from ICU admission 41.2 in protocolized sites vs 57.1 hours in those without a protocolPatients rec’ing motility agents 61.3% in protocolized sites vs 49.0% in those withoutP<0.05Heyland JPEN 2010
62 The same thinking that got you into this mess won’t get you out of it! Can we do better?The same thinking that got you into this mess won’t get you out of it!
63 A Major Paradigm Shift in How we Feed Enterally The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!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 polymericTolerate higher GRV threshold (300 ml or more)Motility agents and protein supplements are started immediatelyNurse reports daily on nutritional adequacy.A Major Paradigm Shift in How we Feed Enterally
64 The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!Adequacy of Calories from EN(Before Group vs. After Group on Full Volume Feeds)Day 1Day 2Day 3Day 4Day 5Day 6Day 7TotalP-value0.080.00030.100.190.480.180.11<0.0001Heyland Crit Care 2010
65 % calories received/prescribed Change of nutritional intake from baseline to follow-up of all the study sites (intervention group only)% calories received/prescribed
66 Health Care Associated Malnutrition What if you can’t provide adequate nutrition enterally?… to add PN or not to add PN,that is the question!
67 Early vs. Late Parenteral Nutrition in Critically ill Adults 4620 critically ill patientsRandomized to early PNRec’d 20% glucose 20 ml/hr then PN on day 3OR late PND5W IV then PN on day 8All patients standard EN plus ‘tight’ glycemic controlResults:Late PN associated with6.3% likelihood of early discharge alive from ICU and hospitalShorter ICU length of stay (3 vs 4 days)Fewer infections (22.8 vs 26.2 %)No mortality differenceCesaer NEJM 2011
68 Early vs. Late Parenteral Nutrition in Critically ill Adults ? Applicability of dataNo one give so much IV glucose in first few daysNo one practice tight glycemic controlRight 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 overweightNot an indictment of PNEarly group only rec’d PN for 1-2 days on averageLate group –only ¼ rec’d any PNCesaer NEJM 2011
72 Adult patients were eligible for enrollment within 24 hours of ICU admission if they were expected to remain in the ICU on the calendar day after enrollment, were considered ineligible for enteral nutrition by the attending clinician due to a short-term relative contraindication and were not expected to PN or oral nutritionDoig, ANZICS, JAMA May 2013
73 Who were these patients? Overall, standard care group remained unfed for 2.8 days after randomization40% of standard care group never rec’d any artificial nutrition; remained in ICU 3.5 days
74 Intervention not intense enough? 40% of both groups got EN (delayed)40% of standard care group got PN for an average of 3.0 daysAverage PN use in early PN group was 6.0 days
75 Main inference: No harm by early PN (in contrast to EPaNIC) Doig, ANZICS, JAMA May 2013
76 What if you can’t provide adequate nutrition enterally? … to TPN or not to TPN,that is the question!Case by case decisionMaximize EN delivery prior to initiating PNUse early in high risk cases
77 Start PEP UP within 24-48 hrs At 72 hrs>80% of Goal Calories?YESNoNOYesAnticipated Long Stay?High Risk?YesCarry on!NoMaximize EN with motility agents and small bowel feedingNo problemYESYesNOTolerating EN at 96 hrs?NoSupplemental PN?No problem
78 R The TOP UP Trial Primary Outcome 60-day mortality PN for 7 days Stratified by:SiteBMIMed vs SurgICU patientsRBMI <2560-day mortalityBMI >35Fed enterallyControl
79 Muscle Outcome Assessments in TOP UP Measures of muscle mass and functionmitochondrial complex I activityUS of femoral quad (baseline and follow up CTs when available)Hand grip strength6 min walk testSF 36 (RP and PCS)
80 Reliability of US measure of Quad Muscle Layer Thickness 46 pairs of within operator measurements with an ICC of .9873 pairs of operator 1 to operator 2 measurements with an ICC of .94.There was a small but statistically significant difference between the operator 1 and 2 results Mean (operator 1-2) (95% CI) = cm ( to ), p=
82 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 riskNeed to do something to reduce iatrogenic malnutrition in your ICU!Audit your practice first! (JOIN International Critical Care Nutrition Survey in 2013)PEP uP protocol in allSelective use of small bowel feeds then sPN in high risk patients