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Critical Care Nutrition The right nutrient/nutritional strategy The right timing The right patient The right intensity (dose/duration) With the right.

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Presentation on theme: "Critical Care Nutrition The right nutrient/nutritional strategy The right timing The right patient The right intensity (dose/duration) With the right."— Presentation transcript:

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3 Critical Care Nutrition The right nutrient/nutritional strategy The right timing The right patient The right intensity (dose/duration) With the right outcome!

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6 A Continuous Quality Improvement Effort What is done? What ought to be done? What do we need to do differently? Gaps - site reports How to change? KT strategies RCTs, Systematic Reviews, and Evidence-based practice guidelines Survey results

7 Early and Adequate EN Best for the Patient! Role of Supplemental PN

8 Loss of Gut Epithelial Integrity INTESTINAL EPITHELIUM SIRS Bacteria DISTAL ORGAN INJURY (Lung, Kidneys) via thoracic duct Underlying Pathophysiology of Critical Illness lymphocytes

9 Disuse Causes Loss of Functional and Stuctural Integrity Increased Gut Permeability Characteristics : Time dependent Correlation to disease severity Consequences: Risk of infection Risk of MOFS

10 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

11 Effect of Early Enteral Feeding on the Outcome of Critically ill Mechanically Ventilated Medical Patients Retrospective analysis of multiinstitutional database 4049 patients requiring mech vent > 2 days Categorized as Early EN if recd feeds within 48 hours of admission (n=2537, 63%) Artinian Chest 2006:129;960 P=0.007 P= P=0.02

12 Effect of Early Enteral Feeding on the Outcome of Critically ill Mechanically Ventilated Medical Patients Artinian Chest 2006:129;960

13 Early EN (within hrs of admission) is recommended! …associated with large reductions in infections and mortality Updated CPGs, see

14 Optimal Amount of Protein and Calories for Critically Ill Patients

15 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

16 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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18 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

19 Relationship between increased nutrition intake and physical function (as defined by SF-36 scores) following critical illness Unpublished data from Multicenter RCT of glutamine and antioxidants (REDOXS Study); n=364 for increase of 30 gram/day, OR of infection at 28 days Model * Estimate (CI) P values At 3 months PHYSICAL FUNCTIONING3.2 (-1.0, 7.3) P=0.14 ROLE PHYSICAL4.2 (-0.0, 8.5)P=0.05 STANDARDIZED PHYSICAL COMPONENT SCALE1.8 (0.3, 3.4)P=0.02 At 6 months PHYSICAL FUNCTIONING0.8 (-3.6, 5.1)P=0.73 ROLE PHYSICAL2.0 (-2.5, 6.5)P=0.38 STANDARDIZED PHYSICAL COMPONENT SCALE0.70 (-1.0, 2.4) P=0.41 For every 1000 kcal/day received:

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

21 113 select ICU patients with sepsis or burns On average, receiving 1900 kcal/day and 84 grams of protein No significant relationship with energy intake but…… Clinical Nutrition 2012

22 How do we set optimal targets?

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24 Methods to Determine Energy Requirements 60% Weight based 39% Complex formula 1% Indirect calorimetry Unpublished observations INS 2011

25 Small intestinal glucose absorption in the critically ill and health Time (mins) 3-OMG (mmol/L) ICU patients n = 28 Healthy subjects n = 16 Median (IQR) P<0.05 Deane, et al. Crit. Care Med.(2011)

26 Malabsorption studies: faeces Strack van Schijndel, et al. Clin. Nutr. 2006

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

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29 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

30 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.

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

32 RCT Level of Evidence that More EN= Improved Outcomes RCTs of aggressive feeding protocols Results in better protein-energy intake Associated with reduced complications and improved survival Taylor et al Crit Care Med 1999; Martin CMAJ 2004 Meta-analysis of Early vs Delayed EN Reduced infections: RR 0.76 (.59,0.98),p=0.04 Reduced Mortality: RR 0.68 (0.46, 1.01) p=0.06

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

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35 Rice et al. JAMA 2012;307

36 Still no measure of physical function!

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

38 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!

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

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

41 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

42 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

43 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

44 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.

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

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

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

49 Do we have a problem?

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

51 Failure Rate % high risk patients who failed to meet minimal quality targets (80% overall energy adequacy) Unpublished observations, Results of 2011 INS

52 Cahill, J Crit Care 2012 Dec;27(6):

53 Use of a feeding protocol that incorporates motility agents and small bowel feeding tubes should be considered

54 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.

55 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 Nov 2010 P<0.05

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

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

58 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 (300 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

59 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

60 Change of nutritional intake from baseline to follow- up of all the study sites (intervention group only) % calories received/prescribed Heyland CCM 2013 (in press)

61 Other Strategies to Maximize the Benefits and Minimize the Risks of EN Liberalization of gastric residual volumes Motility agents started at initiation of EN rather that waiting till problems with High GRV develop. Small bowel feeding tubes Elevation of head of the bed Have nurse report on nutritional adquacy during daily ward rounds

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

63 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

64 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

65 Lancet Dec 2012

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68 Doig, ANZICS, JAMA May 2013 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 nutrition

69 Who were these patients? Overall, standard care group remained unfed for 2.8 days after randomization 40% of standard care group never recd any artificial nutrition; remained in ICU 3.5 days

70 Intervention not intense enough? 40% of both groups got EN (delayed) 40% of standard care group got PN for an average of 3.0 days Average PN use in early PN group was 6.0 days

71 Doig, ANZICS, JAMA May 2013 Main inference: No harm by early PN (in contrast to EPaNIC)

72 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

73 Yes YES At 72 hrs >80% of Goal Calories? No NO No problem Anticipated Long Stay? Yes No Maximize EN with motility agents and small bowel feeding No YES Tolerating EN at 96 hrs? Yes NO Start PEP UP within hrs High Risk? Carry on! Supplemental PN?No problem

74 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

75 Muscle Outcome Assessments in TOP UP Measures of muscle mass and function –mitochondrial complex I activity –US of femoral quad (baseline and follow up CTs when available) –Hand grip strength –6 min walk test –SF 36 (RP and PCS)

76 Reliability of US measure of Quad Muscle Layer Thickness 46 pairs of within operator measurements with an ICC of 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=

77 Lancet 2009;273:

78 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

79 Questions?


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