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

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

Learning Objectives Convince you that efforts to improve nutrition in the ICU are worthwhile Familiarize you with the recommendations of the Canadian Critical Care Nutrition Clinical Practice Guidelines Make you aware of current nutrition practices in ICUs in your own geographic region and throughout the world Enable you to identify gaps between guideline recommendations and current practices in ICUs Provide tools to begin to narrow that GAP!

Underlying Pathophysiology Of Critical Illness   Caloric debt associated with:   Longer ICU stay   Days on mechanical ventilation   Complications   Mortality EN Intake Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006 Caloric Debt

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 continents Included ventilated adult patients who remained in ICU >72 hours

Hypothesis There is a relationship between amount of energy and protein received and clinical outcomes (mortality and # of days on ventilator) The relationship is influenced by nutritional risk BMI is used to define chronic nutritional risk

What Study Patients Actually Rec’d Average Calories in all groups: –1034 kcals and 47 gm of protein Result: Average caloric deficit in Lean Pts: –7500kcal/10days Average caloric deficit in Severely Obese: –12000kcal/10days

Relationship Between Increased Calories and 60 day Mortality BMI GroupOdds Ratio 95% Confidence Limits P-value Overall < < < < < >= Legend: Odds of 60-day Mortality per 1000 kcals received per day adjusting for nutrition days, BMI, age, admission category, admission diagnosis and APACHE II score.

BMI Group Adjusted Estimate 95% CIP-value LCLUCL Overall < < < < < >= Relationship Between Increased Energy and Ventilator-Free days Legend: # of VFD per 1000 kcals received per day adjusting for nutrition days, BMI, age, admission category, admission diagnosis and APACHE II score.

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

Effect of Increasing Amounts of Protein from EN on Infectious Complications Multicenter observational study of 207 patients >72 hrs in ICU followed prospectively for development of infection for increase of 30 gram/day, OR of infection at 28 days Heyland Clinical Nutrition 2010

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

Faisy BJN 2009;101:1079 Mechancially Vent’d patients >7days (average ICU LOS 28 days)

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

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 administered 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 (in press)

Optimal Amount of Calories for Critically Ill Patients: Depends on how you slice the cake! Sample restriction approaches have included limiting analyzed patients to those: 1.In the ICU for at least 96 hours, 2.In the ICU at least 96 hours prior to progression to exclusive oral feeding and 3.Eliminating days after progression to exclusive oral feeding from the calculation of nutrition intake. Statistical adjustment approaches have included using regression techniques to adjust for: 1.ICU length of stay (LOS), 2.Evaluable nutrition days and 3.Relevant baseline patient characteristics or some combination thereof. Heyland Crit Care Med 2011 (in press)

Association between 12 day average caloric adequacy and 60 day hospital mortality 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.

Association Between 12-day Caloric Adequacy and 60-Day Hospital Mortality Quality Improvement Target

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

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

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

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Rice CCM 2011;39:967 No difference between groups! Didn’t measure infection nor physical function

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Average age 51 Few comorbidities Average BMI 29 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! Large multicenter trial of this concept (EDEN study) by ARDSNET just finished

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

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

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

Objectives of International Survey Quality Improvement To determine current nutrition practice in the adult critical care setting (overall and subgroups) Illuminate gaps between best practice and current practice To identify nutrition practices to target for quality improvement initiatives Generate New Knowledge To determine factors associated with optimal provision of nutrition To determine what nutrition practices are associated with best clinical outcomes

History of International Surveys 3 previous surveys in Canada – 2001, 2003, 2004 – N > 50 Extended to other countries – Focus on North America in 2007 (n=167) – Focus on Australasia in 2008 (n=169) – Focus back on North America in 2009 (n=172) 2011, Focus on Latin America

Methods Eligibility Criteria ICU Site –>8 beds –Availability of individual with knowledge of clinical nutrition to collect data Patient –In ICU > 72 hours –Mechanically ventilated within 48 hours

Methods Prospective observational cohort study Start date: 16 th September 2009 Aim 20 consecutive patients –Min 8 pts Data included: –Hospital and ICU demographics –Patient baseline information (e.g. age, admission diagnosis, APACHE II) –Baseline Nutrition Assessment –12 days Daily Nutrition data (e.g. type of NS, amount NS received) –60 day hospital outcomes (e.g. mortality, length of stay)

Web based Data Capture System

Benchmarking Individual ICUs compared to: Canadian Clinical Practice Guidelines All ICUs ICUs from same geographic region

Recommendations: Based on 8 level 2 studies, we recommend early enteral nutrition (within hrs following resuscitation) in critically ill patients. Early vs Delayed Nutrition Intake

Canada: 32 USA: 63 Australia & New Zealand: 22 Europe: 14 Latin America: 10 Asia: 16 Mexico: 2 Brazil:1 Colombia:5 Peru:1 Venezuela:1 Italy: 2 UK: 7 Ireland: 2 Norway: 1 Switzerland: 1 Czech Republic: 1 China: 1 Taiwan: 1 India: 10 Iran : 1 Japan: 1 Singapore: 2 Who participated in 2009? : 157 ICUs

ICU Characteristics CharacteristicsTotal (n=157) Hospital Type Teaching116 (73.9%) Non-teaching41 (26.1%) Size of Hospital (beds) Mean (Range)503 (50, 1500) ICU Structure Open49 (31.2%) Closed104 (66.2%) Other4 (2.6%) Size of ICU (beds) Mean (Range)19 (6, 64) Designated Medical Director149 (94.9%) Presence of Dietitian(s)145 (92.4%) FTE Dietitians (per 10 beds) Mean (Range)0.4 (0.0, 1.7)

Patient Characteristics CharacteristicsTotal n=3028 Age (years) Median [Q1,Q3]61 [48, 73] Sex Female1215 (40.1%) Male1813 (59.9%) Admission Category Medical1952 (64.5%) Surgical: Elective366 (12.1%) Surgical: Emergency710 (23.4%) BMI (kg|m2) Median [Q1, Q3]26.0 [22.8, 30.8] Apache II Score Median [Q1, Q3]22 [17, 28] Presence of ARDS Yes413 (13.6%)

Outcomes at 60 days CharacteristicsTotal n=2948 Length of Mechanical Ventilation (days) Median [Q1, Q3]7.2 [3.3, 15.2] Length of ICU Stay (days) Median [Q1, Q3]10.3 [5.9, 19.8] Length of Hospital Stay (days) Median [Q1,Q3]18.9[10.4, 36.7] Patient Died (within 60 days) Yes738(24.7%)

We strongly recommend the use of enteral nutrition over parenteral nutrition

Type of Artificial Nutrition n=3028 patients

Use of EN Only n=17567 patients days

Use of PN Only n=2294 patients days

We recommend that parenteral nutrition not be started at the same time as enteral nutrition. In the patient who is not tolerating adequate enteral nutrition, there are insufficient data to put forward a recommendation about when parenteral nutrition should be initiated. Practitioners will have to weigh the safety and benefits of initiating PN in patients not tolerating EN on an individual case-by-case basis. We recommend that PN not be started in critically ill patients until all strategies to maximize EN delivery (such as small bowel feeding tubes, motility agents) have been attempted. Role of Supplemental PN

Use of EN + PN n=1157 patients days

EN in Combination with PN % of patients received motility agents before PN started

We recommend early enteral nutrition (within hrs following admission) in critically ill patients

Timing of Initiation of EN

An evidence based feeding protocol should be considered as a strategy to optimize delivery of enteral nutrition

Use of a Feeding Protocol CharacteristicsTotal n=157 Feeding Protocol Yes129 (82.2%) Gastric Residual VolumeThreshold Mean (range)240 (50, 500) Algorithms included in Protocol Motility agents90 (72.6%) Small bowel feeding69 (55.6%) Withholding for procedures69 (55.6%) HOB Elevation117 (94.4%) Other19 (15.3%)

In critically ill patients who experience feed intolerance (high gastric residual volumes, emesis) the use of a motility agent and small bowel feeding tubes are recommended

Strategies to Optimize EN Delivery: Motility Agents

Strategies to Optimize EN Delivery: Small Bowel Feeding

Composition of EN and Pharmaconutrient Supplementation recommendations Arginine-supplemented formulasRecommend NOT be used Glutamine supplementation Enteral should be considered in burn and trauma Parenteral strongly recommended in PN pts Fish oil enriched formulaRecommended in ARDS Combined vitamins and trace elements Should be considered PolymericRecommend

Use of EN Formula and Pharmaconutrients Arginine-supplemented formulas8.2%(0.0%-94.7%) Glutamine supplementation (All)5.9%(0.0%-95%) Fish oil enriched formula (ARDS)18.9% (0.0%-100%) Selenium Supplementation (All)3.1% (0.0%-100%) Polymeric85.9% (0.0%-100.%)

We recommend that hyperglycemia (blood sugars >10mmol/l) be avoided

Blood Glucose >10 mmol/l

Overall Performance Adequacy of Nutrition Support = Calories received from EN + appropriate PN+Propofol Calories prescribed

Overall Performance: Kcals 87% 58% 6.8%

Overall Performance: Kcals

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

Where can we do better? Inadequate EN delivery –timing of initiation of EN –feeding protocols –small bowel feeding and motility agents Optimize Pharmaconutrition –use of glutamine, antioxidants, omega-3 FFA. Tighten (not tight) glycemic control

How to Change? CPGs to bedside Guidelines Bedside Dissemination and Implementation Strategies

Special JPEN Issue Dedicated to KT Knowledge Translation (KT) –describes the process of moving evidence learned from clinical research and summarized in CPGs to its incorporation into clinical and policy decision-making. –defined as “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of patients, provide more effective health services and products and strengthen the health care system.” synthesisdisseminationexchangeethically-sound application of knowledge –Knowledge transfer, knowledge exchange, research utilization, implementation science, dissemination, and diffusion are other terms that have been used interchangeably to describe the same concept. Nov 2010, Available online at

Understanding Adherence to Guidelines in the ICU: Development of a Comprehensive Framework Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK CPG Characteristics ADHERENCE Implementation ProcessInstitutional Factors Provider Intent Hospital characteristics -Structure - Processes -Resources -Patient Case-mix KnowledgeAttitudes Familiarity Awareness MotivationSelf-efficacy Outcome expectancy Agreement ICU characteristics -Structure - Processes -Resources - Patient Case-mix -Culture Provider Characteristics - Profession -Critical care expertise -Educational background -Personality Patient Characteristics

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, rather than started when there is a problem. 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 Heyland Crit Care 2010

Creating a Culture of Clinical Excellence in Critical Care Nutrition: The ‘Best of the Best’ Award Heyland DK, Heyland R, Jones N, Dhaliwal R, Day A

Recognition and Reward Recognition a powerful motivator of human performance

Determining the Best of the Best DeterminantWeighting Overall Adequacy of EN plus appropriate PN10 % patients receiving EN5 % of patients with EN initiated within 48 hours3 % of patients with high gastric residual volumes (HGRV) receiving motility agents 1 % of patients with HGRV receiving small bowel tubes1 % of patient glucose measurements greater than 10 mmol/L (excluding day 1; fewest is best) 3  Rank all eligible ICUs by determinants  Multiply ranking by weighting  ICU with highest score is crowned ‘Best of the Best’

Best of the Best Award Eligible sites:  Data on 20 critically ill patients  Complete baseline nutrition assessment  Presence of feeding protocol  No missing data or outstanding queries  Permit source verification by CCN Awarded to ICU that demonstrate:  Highest ranking nutritional performance

2009 Best of the Best Of >200 ICUS competing Internationally 1. Instituto Neurologico de Antioquia, Medellin, Colombia 1. Royal Prince Alfred Hospital, Sydney, Australia 1. The Alfred, Melbourne, Australia TOP Performers

Determinants to Top Performance What site and hospital characteristics are associated with top BOB ranking? Hospital/ICU characteristics**Rankingp values Region Australia and New Zealand vs. Canada China vs. Canada Europe and South Africa vs. Canada India vs. Canada Latin America vs. Canada USA vs. Canada+30.4< Hospital size (per 100 beds) ICU structure Closed vs. open or other Presence of Dietitian(s) Yes vs. No (Best Rank=1rst thus a negative number is associated with a better ranking) Heyland JPEN 2010

International Nutrition Survey 2011  Participate on May 11 th 2011  Data on min 20 critically ill patients  Complete baseline nutrition assessment  No missing data or outstanding queries  Permit source verification  Benchmarked Site Report  Compare your performance to other ICUs  Compare your performance to the Canadian CPGs  Highlight gaps in practice and barriers to improving

International Nutrition Survey 2011  Debriefing session with INS participants and other interested parties  Today, 5 pm, SOLANA (1rst Floor, South Tower)