1. IN ICU NUTRITION? WHAT’S NEW

2. Hippocrates 400 B.C. Hippocrates 400 B.C. ‘A slender and restricted diet is always dangerous in chronic and in acute diseases’ ‘Let food be thy medicine’

3. SICS Nutrition Network Set up in June 2006 Set up in June 2006 Links 30 dietitians, 6 pharmacists, 10 ICU Nutrition nurses, and 17 doctors. Meets 3x/year at QMH. Around 12-18/meeting Links 30 dietitians, 6 pharmacists, 10 ICU Nutrition nurses, and 17 doctors. Meets 3x/year at QMH. Around 12-18/meeting Guidelines on practical issues planned Guidelines on practical issues planned Website with protocols/guidelines/teaching Website with protocols/guidelines/teaching Educational meetings Educational meetings Current projects on assessment/weighing Current projects on assessment/weighing Encouraging projects in nutrition Encouraging projects in nutrition

4. SICS Nutrition Network Meetings – videoconferencing Meetings – videoconferencing Presentations of local projects/audits Presentations of local projects/audits Ideas for new projects discussed Ideas for new projects discussed Reports on conferences/equipment Reports on conferences/equipment Discussion on topical issues e.g. nutrition teams, education, weighing, screening Discussion on topical issues e.g. nutrition teams, education, weighing, screening Reviews of topics planned e.g. pre-and post-op feeding Reviews of topics planned e.g. pre-and post-op feeding Article circulation planned Article circulation planned

5. ‘Best Practice’ statements Starting and stopping feed Starting and stopping feed Adding water to feeds Adding water to feeds Use of MUAC Use of MUAC Use of different weights (ideal, actual etc) Use of different weights (ideal, actual etc) Nasal bridles Nasal bridles

6. Education Module on SICS website Module on SICS website Teaching powerpoint on website Teaching powerpoint on website Junior doctors’ induction Junior doctors’ induction FY2 teaching by nutrition nurse FY2 teaching by nutrition nurse Consultants’ mandatory training Consultants’ mandatory training Chapter for ABC of Intensive Care Chapter for ABC of Intensive Care Website Website

7. Audits Nutrition audit of Scottish Units 2006 – widely diverse practice and knowledge Nutrition audit of Scottish Units 2006 – widely diverse practice and knowledge HDU feeding – Fife, Forth Valley HDU feeding – Fife, Forth Valley International Nutrition QI audit: 9 units last 2 years International Nutrition QI audit: 9 units last 2 years Helped to inform changes in practice Helped to inform changes in practice Nutrition Audit form on website Nutrition Audit form on website

8. % patients receiving PN/year

11. The Downward Spiral of Malnutrition in Severe Illness Decreased energy and nutrient intake Muscle catabolism and weight loss Delayed recovery Secondary infections Depression and lethargy Further decreased intake Serious complications e.g. pneumonia Morbidity / Mortality

12. Current Projects: Nutritional Screening Required by QIS and NICE for: Required by QIS and NICE for: All patients on admission to hospital and regularly thereafter MUST introduced by BAPEN - being widely implemented MUST introduced by BAPEN - being widely implemented Not helpful in ICU – all high risk Not helpful in ICU – all high risk Need to identify the severely malnourished Need to identify the severely malnourished Improves feeding of these patients Improves feeding of these patients

13. Nutritional State and Complications in SHDU, WGH 2003

14. SNACC – 3 phases Few ICU nutrition studies have looked at nutritional status – probably crucial Few ICU nutrition studies have looked at nutritional status – probably crucial Fife ICU nutritional screening tool Fife ICU nutritional screening tool 1. Pilot study completed – to repeat in WGH + external validity study. 1. Pilot study completed – to repeat in WGH + external validity study. 2. Systematic review started (funded) 2. Systematic review started (funded) 3. Larger study 2010-11 - will need funding – nutritional state and outcomes 3. Larger study 2010-11 - will need funding – nutritional state and outcomes Aim to focus nutritional intervention Aim to focus nutritional intervention

15. What’s New in IC Weighing ICU patients

16. Weighing Patients Essential for nutrition screening Essential for nutrition screening Nutritional requirement calculations Nutritional requirement calculations Indirect calorimetry Indirect calorimetry Drug dosages Drug dosages Cardiac output monitoring – LIDCO, PAFC, PICCO Cardiac output monitoring – LIDCO, PAFC, PICCO Fluid balance Fluid balance ARDS tidal volumes ARDS tidal volumes

17. Weighing Patients  Estimation of weight can be up to 20% out: i.e. 80 kg instead of 100kg and vice versa  Estimation of height also inaccurate but measuring height with tape fairly accurate  We need to weigh patients in ICU

18. Weighing Patients Craig Hurnauth: ICU S/N at SJH Craig Hurnauth: ICU S/N at SJH Audit of 13/14 NHS trusts in Scotland Audit of 13/14 NHS trusts in Scotland 12 trusts do not weigh patients in ICU on admission - use estimate/notes/family 12 trusts do not weigh patients in ICU on admission - use estimate/notes/family 1 weighs every day with hoist + weekly 1 weighs every day with hoist + weekly 5 use MUST 5 use MUST 7 do not screen, 1 adapted screening tool 7 do not screen, 1 adapted screening tool 7 units in England – similar results 7 units in England – similar results

19. Methods of Weighing Hoist: time consuming, needs several nurses, risky for unstable patients or trauma patients Hoist: time consuming, needs several nurses, risky for unstable patients or trauma patients Weigh beds £16000 each Weigh beds £16000 each Digital bed scales – scales for each wheel of the bed – weighs bed + patient, mobile, minimal manpower, no disruption to patient Digital bed scales – scales for each wheel of the bed – weighs bed + patient, mobile, minimal manpower, no disruption to patient

20. Methods of Weighing Progress since audit: Progress since audit: 2 units have bought weigh beds 2 units have bought weigh beds 5 are considering bed scales 5 are considering bed scales

21. Challenges in Critical Care Nutrition 1. Keeping up with evidence - guidelines 1. Keeping up with evidence - guidelines 2. Screening/weighing 2. Screening/weighing 3. Prevention and treatment of complications 3. Prevention and treatment of complications 4. Outdated surgical practices/ Peri- operative feeding 4. Outdated surgical practices/ Peri- operative feeding 5. Achieving calorific and protein targets 5. Achieving calorific and protein targets 6. Immunonutrition 6. Immunonutrition

22. Guidelines

23. Guidelines CCCTG Nutritional Support updated: 2009 www.criticalcarenutrition.com CCCTG Nutritional Support updated: 2009 www.criticalcarenutrition.com ESPEN Parenteral Nutrition guidelines 2009, EN 2006, (ASPEN guidelines) ESPEN Parenteral Nutrition guidelines 2009, EN 2006, (ASPEN guidelines) NICE guidelines on Nutrition Support in Adults NICE guidelines on Nutrition Support in Adults QIS Standards QIS Standards MUST (BAPEN) MUST (BAPEN)

24. Screening/Refeeding Syndrome Prisoners of war 1944-5, 1944: conscientious objectors in USA studied Prisoners of war 1944-5, 1944: conscientious objectors in USA studied Starvation: early use of glycogen stores and gluconeogenesis from amino acids Starvation: early use of glycogen stores and gluconeogenesis from amino acids 72 hrs: fatty acid oxidation; use of fatty acids and ketones for energy source, low insulin levels 72 hrs: fatty acid oxidation; use of fatty acids and ketones for energy source, low insulin levels Atrophy of organs, reduced lean body mass Atrophy of organs, reduced lean body mass

25. Refeeding syndrome Carbohydrate feeding: shift to CH metabolism Carbohydrate feeding: shift to CH metabolism Insulin release, Mg lost in urine Insulin release, Mg lost in urine Phosphate and potassium shift into cells. Phosphate and potassium shift into cells. Magnesium, potassium and phosphate drop Magnesium, potassium and phosphate drop May get Lactic acidosis May get Lactic acidosis Sodium and water shift out of cells – oedema Sodium and water shift out of cells – oedema Insulin causes sodium retention Insulin causes sodium retention Protein synthesis needs potassium and phosphate - these drop more Protein synthesis needs potassium and phosphate - these drop more Thiamine deficiency occurs (co-factor in CH metabolism): encephalopathy, weakness Thiamine deficiency occurs (co-factor in CH metabolism): encephalopathy, weakness

26. Refeeding Syndrome in ICU Unlikely to be a clear diagnosis Unlikely to be a clear diagnosis Many effects: oedema, arrhythmias, pulmonary oedema, cardiac decompensation, respiratory weakness, fits, hypotension, leukocyte dysfunction, diarrhoea, coma, rhabdomyolysis, sudden death Many effects: oedema, arrhythmias, pulmonary oedema, cardiac decompensation, respiratory weakness, fits, hypotension, leukocyte dysfunction, diarrhoea, coma, rhabdomyolysis, sudden death Screen: nutritional history and electrolytes Screen: nutritional history and electrolytes Remember in HDU patients/malnourished ward patients Remember in HDU patients/malnourished ward patients Poor awareness among doctors! Poor awareness among doctors!

27. Risk of re-feeding syndrome Two or more of the following: BMI less than 18.5 kg/m 2 (<16) BMI less than 18.5 kg/m 2 (<16) unintentional weight loss greater than 10% within the last 3-6 months (>15%) unintentional weight loss greater than 10% within the last 3-6 months (>15%) little or no nutritional intake for more than 5 days (>10) little or no nutritional intake for more than 5 days (>10) Hx alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics Hx alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics Critically low levels of PO 4 2-, K + and Mg 2+ Critically low levels of PO 4 2-, K + and Mg 2+ NICE Guidelines for Nutrition Support in Adults 2006

28. Managing refeeding problems provide Thiamine (Pabrinex)/multivitamin/trace element supplementation provide Thiamine (Pabrinex)/multivitamin/trace element supplementation start nutrition support at 10-15 kcal/kg/day start nutrition support at 10-15 kcal/kg/day increase levels over 3-5 days increase levels over 3-5 days restore circulatory volume restore circulatory volume monitor fluid balance and clinical status monitor fluid balance and clinical status replace phosphate, magnesium and K+ replace phosphate, magnesium and K+ Reduce feeding rate if problems arise Reduce feeding rate if problems arise NICE Guidelines for Nutrition Support in Adults 2006

29. Complications Ileus- caused by: fluid overload, pain, hyperglycaemia, hypokalaemia, opioids, immobility, sepsis – trickle of feed if gut intact. Consider Neostigmine/prokinetics Ileus- caused by: fluid overload, pain, hyperglycaemia, hypokalaemia, opioids, immobility, sepsis – trickle of feed if gut intact. Consider Neostigmine/prokinetics Constipation: avoid and treat; drugs Constipation: avoid and treat; drugs Diarrhoea: exclude infections, optimise fluid balance and electrolytes, replace loss Diarrhoea: exclude infections, optimise fluid balance and electrolytes, replace loss Intolerance: ? Sepsis, NJ feeding, PKs Intolerance: ? Sepsis, NJ feeding, PKs Feeding aids fluid and electrolyte balance

30. Overfeeding Lactic acidosis Lactic acidosis Hyperglycaemia Hyperglycaemia Increased infections Increased infections Liver impairment (Alk phos, ALT, GGT, acalculous cholecystitis) Liver impairment (Alk phos, ALT, GGT, acalculous cholecystitis) Persistent pyrexia Persistent pyrexia Underfeeding probably even more dangerous – studies starting to emerge – need to get the balance right Underfeeding probably even more dangerous – studies starting to emerge – need to get the balance right

31. Outdated surgical practices

33. Outdated surgical practice Reluctance to feed at all Reluctance to feed at all Prolonged semi-starvation Prolonged semi-starvation Sips of water/Over-IV hydration Sips of water/Over-IV hydration Incidence and treatment of ileus Incidence and treatment of ileus Nervous surgeon syndrome Nervous surgeon syndrome Evidence from ERAS – pre-op CH loading Evidence from ERAS – pre-op CH loading Benefits of early post-op feeding Benefits of early post-op feeding Over/under-use of PN Over/under-use of PN

34. Intake in HDU

35. Calorific and Protein Targets 25kcl/kg/day up to 30 in recovery phase 25kcl/kg/day up to 30 in recovery phase Aim to provide energy as close as possible to target to avoid negative energy balance Aim to provide energy as close as possible to target to avoid negative energy balance Protein 1.3 – 1.5g/kg/day (optimal prtn sparing) Protein 1.3 – 1.5g/kg/day (optimal prtn sparing) CVVH – lose AAs in filter – need to give 20% more using amino acid supplements CVVH – lose AAs in filter – need to give 20% more using amino acid supplements Protein deficits may be very important Protein deficits may be very important Increasing evidence that patients with deficits in 1 st 3-5 days do worse (?severely malnourished) Increasing evidence that patients with deficits in 1 st 3-5 days do worse (?severely malnourished) Indirect calorimetry – the future? Indirect calorimetry – the future?

36. Maintaining enteral intake Follow a protocol; use prokinetics/NJs Follow a protocol; use prokinetics/NJs Gastric residuals: do not stop feed until you have 2 residuals of >250mls (check clinical signs) 400mls may be ok Gastric residuals: do not stop feed until you have 2 residuals of >250mls (check clinical signs) 400mls may be ok Starting and stopping feed: Starting and stopping feed: Extubations, fasting for theatre, scans, minor procedures Can catch up on feed that is missed Can catch up on feed that is missed

37. ESPEN: PN in ICU All patients receiving less than their targeted enteral feeding after 2 days should be considered for supplementary PN All patients receiving less than their targeted enteral feeding after 2 days should be considered for supplementary PN All patients not able to receive EN within 24- 48 hours should be given PN All patients not able to receive EN within 24- 48 hours should be given PN CCCN: Inadequate enteral nutrition <80% of target after 3 days: PN CCCN: Inadequate enteral nutrition <80% of target after 3 days: PN Do not delay nutrition in malnourished Do not delay nutrition in malnourished Keep 10ml/hr EN if possible Keep 10ml/hr EN if possible

38. Immunonutrition The future: replacement of the body’s own ‘stress substrates’ and reduction of inflammation? ESPEN – new recommendations – glutamine in all PN 0.2-0.4g/kg/day ESPEN – new recommendations – glutamine in all PN 0.2-0.4g/kg/day ??? SIGNET/REDOXs ??? SIGNET/REDOXs glutamine in enteral nutrition for burns and trauma glutamine in enteral nutrition for burns and trauma

39. Omega-6 ү-Linoleic acid (GLA) – borage oil Arachidonic Acid precursor Omega-3 Fish oils: Eicosapentanoic acid (EPA) and Docosahexanoic acid (DHA) Polyunsaturated Fatty Acids

40. Dietary Lipids Ratios in paleolithic diet ω6:ω-3 1:1 Current Western diet 16:1 Current Western diet 16:1 Current UK PN Soybean oil base 7:1 Current UK PN Soybean oil base 7:1 New PN (‘SMOF’) 2.5:1 New PN (‘SMOF’) 2.5:1 Cell membrane composition depends on balance Cell membrane composition depends on balance AA, DHA and EPA are present in inflammatory cell membrane phospholipids AA, DHA and EPA are present in inflammatory cell membrane phospholipids

41. Mechanisms of Action ω-3s EPA/DHA are incorporated quickly into cell membrane: inhibit ω-6 activity ω-3s EPA/DHA are incorporated quickly into cell membrane: inhibit ω-6 activity Promote synthesis of low activity PGs and LTs Promote synthesis of low activity PGs and LTs Decrease expression of adhesion molecules Decrease expression of adhesion molecules Inhibit monocyte prod n of pro-inflamm cytokines Inhibit monocyte prod n of pro-inflamm cytokines Decrease NFkB, increases lymphocyte apoptosis Decrease NFkB, increases lymphocyte apoptosis Decrease pro-inflammatory gene expression Decrease pro-inflammatory gene expression Lipoxins, resolvins and protectins Lipoxins, resolvins and protectins

42. 3 Studies: OXEPA Patients with ARDS fed with GLA, EPA and antioxidants had a reduction in pulmonary neutrophils Improvement in oxygenation Decrease in ventilator days Decrease in ICU and hospital days Gadek, Singer, Pontes-Arruda (sepsis) Recommended by ESPEN in ARDS

43. ESPEN PN Guidelines PN for critically ill surgical patients should probably include ω-3 fatty acids. Fish oil enriched lipid emulsions probably reduce ICU LOS. PN for critically ill surgical patients should probably include ω-3 fatty acids. Fish oil enriched lipid emulsions probably reduce ICU LOS. The tolerance of MCT/LCT and olive oil emulsions is well established. These probably have advantages over LCT based lipid preparations – small studies so far. The tolerance of MCT/LCT and olive oil emulsions is well established. These probably have advantages over LCT based lipid preparations – small studies so far.

44. Anti-oxidants Normal state: reduction > oxidation Normal state: reduction > oxidation Acute stress: injury/sepsis causes acute dysregulation: ROS/RNOS formed Acute stress: injury/sepsis causes acute dysregulation: ROS/RNOS formed Mitochondria are both sources and targets Mitochondria are both sources and targets Observational studies: anti-oxidant capacity inversely correlated with disease severity due to depletion during oxidative stress Observational studies: anti-oxidant capacity inversely correlated with disease severity due to depletion during oxidative stress REDUCTION OXIDATION

45. Antioxidants Glutathione, Vitamins A, C and E Glutathione, Vitamins A, C and E Zinc, copper, manganese, iron, selenium Zinc, copper, manganese, iron, selenium Already added to feeds Already added to feeds Should we give extra? ESPEN: VitC/thiamine/Se/Zn in CVVH/burns Should we give extra? ESPEN: VitC/thiamine/Se/Zn in CVVH/burns Results of SIGNET and REDOXs awaited Results of SIGNET and REDOXs awaited Oxidative stress in critically ill patients contributes to organ damage / malignant inflammation

46. To conclude: Screen your patients Screen your patients Early enteral feeding is best Early enteral feeding is best Hyperglycaemia/overfeeding are bad Hyperglycaemia/overfeeding are bad Keep glucose down <10mmol/l (safely) Keep glucose down <10mmol/l (safely) Nutritional deficit a/w worse outcome Nutritional deficit a/w worse outcome Use EN and PN early to achieve goals Use EN and PN early to achieve goals Audit delivery of nutrition regularly Audit delivery of nutrition regularly Protocols improve delivery of feed Protocols improve delivery of feed Some nutrients show promising results: we should probably start using them now Some nutrients show promising results: we should probably start using them now

47. Please feed me enough and with the right stuff!