Nutrtion In The Icu

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Information about Nutrtion In The Icu

Published on March 4, 2008

Author: fergua

Source: slideshare.net

Optimizing the Benefits and Minimizing the Risk of Nutrition Support in the Critically Ill Evidence Based on Canadian Clinical Practice Guidelines Dalhousie Critical Care Lecture Series

Objectives Be familiar with recommendations for nutrition of the critically ill patient. Have knowledge of options for different enteral formulations available for specific patient populations, including diabetics and renal failure patients Discuss the options if the patient doesn’t tolerate gastric feeding. What are the indications for TPN and list the risks associated with it. Discuss the feeding recommendations for severe acute pancreatitis.

Be familiar with recommendations for nutrition of the critically ill patient.

Have knowledge of options for different enteral formulations available for specific patient populations, including diabetics and renal failure patients

Discuss the options if the patient doesn’t tolerate gastric feeding.

What are the indications for TPN and list the risks associated with it.

Discuss the feeding recommendations for severe acute pancreatitis.

Value of Specialized Nutrition Support Benefits Prevent starvation Preservation of lean body mass Support organ function Support immune function Stress ulcer prophylaxis Risks Increased mortality Increased infectious complications Increased workload Increased costs

Benefits

Prevent starvation

Preservation of lean body mass

Support organ function

Support immune function

Stress ulcer prophylaxis

Risks

Increased mortality

Increased infectious complications

Increased workload

Increased costs

If you’ve ever questioned the risks of nutrition…..

 

EN vs. PN in the Critically Ill Patient

EN vs. PN in the Critically Ill Patient

Enteral vs Parenteral Nutrition Recommendation According to 1 level 1 and 12 level 2 studies, when considering nutrition support for critically ill patients, we strongly recommend the use of EN over PN. www.criticalcarenutrition.com EN is the Winner! TPN

Recommendation

According to 1 level 1 and 12 level 2 studies, when considering nutrition support for critically ill patients, we strongly recommend the use of EN over PN.

TPN

EN: Sooner vs. later Early vs Delayed nutrition Early: within 24-36 hours of admission to ICU Late: delayed EN (>48-72 hrs) or D5W till po intake 8 PRCTs Includes critically ill surgical, trauma and burns patients

Early vs Delayed nutrition

Early: within 24-36 hours of admission to ICU

Late: delayed EN (>48-72 hrs) or D5W till po intake

8 PRCTs

Includes critically ill surgical, trauma and burns patients

Early vs Delayed Nutrient Intake Criticalcarenutrition.com

Early vs Delayed Nutrient Intake Criticalcarenutrition.com

Does it Matter What you Feed? JAMA 2001;286:944

Cocktail Approach? Specific nutrients found to have effects on immune system, metabolism, and GI structure and function Arginine Glutamine Omega-3 fatty acids Nucleic acids others Rationale for combining substances into products?

Specific nutrients found to have effects on immune system, metabolism, and GI structure and function

Arginine

Glutamine

Omega-3 fatty acids

Nucleic acids

others

Rationale for combining substances into products?

Underlying Rationale Wheeler NEJM 1999;340:207 Surgical Critically ill

Population Nutrients Immunonutrition: What Nutrient for What Population? Possible Benefit … … … … … Omega 3 FFA … … … … Possible Benefit … Antioxidants … EN Possibly Beneficial EN Possibly Beneficial … PN Beneficial (? receiving EN) Possible Benefit Glutamine No benefit No benefit No benefit Harm No benefit Benefit Arginine Acute Lung Injury Burns Trauma Septic General Elective Surgery Critically Ill

Is more EN better? RCT of 82 patients suffering severe head injury Control: EN started at 25 ml/hr and advanced per protocol rate adjusted based on gastric residual 50-150ml Experimental arm started at full rate rate adjusted on gastric residual < 200ml 1/3 patients rec’d small bowel feeds Taylor CCM 1999;27:2525

RCT of 82 patients suffering severe head injury

Control:

EN started at 25 ml/hr and advanced per protocol

rate adjusted based on gastric residual 50-150ml

Experimental arm

started at full rate

rate adjusted on gastric residual < 200ml

1/3 patients rec’d small bowel feeds

 

Is more better? Taylor CCM 1999;27:2525 p=0.08 p=0.046 p=0.02 Good Outcome

Aggressive Gastric Feeding may be a BAD THING! Observational study of 153 medical/surgical ICU patients receiving EN in stomach Intolerance= residual volume>500ml, vomiting, or residual volume 150-500x2. Patients followed for development of VAP (diagnosed invasively) Mentec CCM 2001;29:1955

Observational study of 153 medical/surgical ICU patients receiving EN in stomach

Intolerance= residual volume>500ml, vomiting, or residual volume 150-500x2.

Patients followed for development of VAP (diagnosed invasively)

Incidence of Intolerance= 46% Statistically associated with worse clinical outcomes! Risk factors for Intolerance Sedation Catecholamines High residuals before and during EN Aggressive Gastric Feeding may be a BAD THING!

Incidence of Intolerance= 46%

Statistically associated with worse clinical outcomes!

Risk factors for Intolerance

Sedation

Catecholamines

High residuals before and during EN

Strategies to Maximize the Benefits and Minimize the Risks of Enteral Nutrition

Use of Nurse-directed Feeding Protocols Start feeds at 25 ml/hr Check Residuals q4h > 200 ml hold feeds add motility agent reassess q 4h < 200 ml advance rate by 25 ml reassess q 4h Heyland NCP 1999;14:23

> 200 ml

hold feeds

add motility agent

reassess q 4h

< 200 ml

advance rate by 25 ml

reassess q 4h

Gastric feeds easy to establish majority of patients tolerate gastric feeds delayed gastric emptying significant problem and may increase gastroesophageal regurgitation and risk of aspiration. Small bowel feeds post-op, small bowel motility returns first may reduce risk of aspiration? more invasive or resource intensive method Small Bowel vs. Gastric Feeding

Gastric feeds

easy to establish

majority of patients tolerate gastric feeds

delayed gastric emptying significant problem and may increase gastroesophageal regurgitation and risk of aspiration.

Small bowel feeds

post-op, small bowel motility returns first

may reduce risk of aspiration?

more invasive or resource intensive method

Does Postpyloric Feeding Reduce Risk of GER and Aspiration? RCT of 33 critically ill patients requiring EN Postpyloric vs. gastric Immediate EN as per protocol Radioisotope added to feed to facilitate detection of GER and aspiration Serial sampling of oropharynx and trachea for six hours over first three days Heyland CCM 2001;29:1495-1501

RCT of 33 critically ill patients requiring EN

Postpyloric vs. gastric

Immediate EN as per protocol

Radioisotope added to feed to facilitate detection of GER and aspiration

Serial sampling of oropharynx and trachea for six hours over first three days

Amount of Gastroesophageal Regurgitation Mean Net CPM/GM P=0.04 Day 1 * Day 2 NS Day 3 NS

Amount of Aspiration Mean Net CPM/GM * P=0.09 Day 1 NS Day 2 NS Day 3 NS

Does Postpyloric Feeding Reduce Risk of GER and Aspiration? P=0.004 P=0.09 11.7 75 33 Total 0 5 1 D4 1.8 11 3 D2 4.1 27 8 D1 5.8 32 21 Stomach % positive for Aspiration % positive for GER # of patients Tube Position

4 studies that document increased delivery of protein and calories with small bowel feeding; 2 show no difference One study that documents time goal quicker with small bowel Fewer interruptions with high gastric residuals with small bowel 2 studies document delay in initiating feeds secondary to delay in obtaining small bowel access Small Bowel vs. Gastric Feeding: A meta-analysis Effect on Nutritional Endpoints

4 studies that document increased delivery of protein and calories with small bowel feeding; 2 show no difference

One study that documents time goal quicker with small bowel

Fewer interruptions with high gastric residuals with small bowel

2 studies document delay in initiating feeds secondary to delay in obtaining small bowel access

Small Bowel vs. Gastric Feeding: A meta-analysis Effect on VAP Criticalcarenutrition.com

Body Position Reduces VAP! RCT of semirecumbent vs. supine body position Majority of patients enterally fed (stomach) Semirecumbent position associated with significant reduction in VAP (8% vs 34%) Enteral nutrition a significant risk factor for VAP Drakulovic Lancet 1999;354:1851 Feed Upright (and if you can’t, then small bowel)

RCT of semirecumbent vs. supine body position

Majority of patients enterally fed (stomach)

Semirecumbent position associated with significant reduction in VAP (8% vs 34%)

Enteral nutrition a significant risk factor for VAP

Pro-motility agents?

EN >>>PN Feeding Protocols Small bowel > gastric Semi-recumbent position Pro-motility drugs

TPN

Underlying Rationale What if you can’t provide adequate nutrition enterally? … to TPN or not to TPN, that is the question!

What if you can’t provide adequate nutrition enterally?

… to TPN or not to TPN,

that is the question!

 

Supplemental PN: Benefit? Mortality 35.7% 25.0% 0.001 0.39 Deegan Clin Inten Care 1999;10:131 A Retrospective Study Study Outcomes 0.01 6305.5 ±1464.9 4388.7 ±2159.2 Total Energy Rec’d/day (kJ) 36.4 19.6 Hospital stay (days) 0.001 18.3 8.7 ICU stay (days) 0.04 75.0 ±19.9 51.2 ±25.2 Total Protein Rec’d/day (g) P value Combo group (n =28) Enteral group (n=28) Description

TPN

Prospective Studies Criticalcarenutrition.com

Prospective Studies Criticalcarenutrition.com

TPN

TPN: Mechanisms of Harm Overfeeding Hyperglycemia Lipids- immunosuppression Atrophy of GIT (lack of enteral stimulation) Increase in line related sepsis

Overfeeding

Hyperglycemia

Lipids- immunosuppression

Atrophy of GIT (lack of enteral stimulation)

Increase in line related sepsis

Strategies to Maximize the Benefits and Minimize the Risks of Parenteral Nutrition

60 Trauma Patients not tolerating EN before 5th day comparable groups TPN w/o lipids TPN w/ lipids Outcomes duration of MV LOS death infections T-cell function R Lipids in Critically Ill Patients? Battistella J Trauma 1997;43:52

60 Trauma Patients

not tolerating EN

before 5th day

comparable groups

duration of MV

LOS

death

infections

T-cell function

Lipids in Critically Ill Patients? 2.4 1.4 0.04 Battistella J Trauma 1997;43:52 * Depressed T-cell function in Lipids Group 0.0001 21 ±2 28 ±2 Nonprotein calories 0.78 -9 ± 5 -9 ±7 Nitrogen balance 5 (19%) 13 (43%) Line Sepsis 0.05 13 (48%) 22 (73%) Pneumonia Infections/patient 39 72 Total Infections P value No Lipids (n =27) Lipids (n=30) Outcomes

Lipids in Critically Ill Patients? Battistella J Trauma 1997;43:52 Days

TPN

Dose of TPN 40 patients in university hospital requiring TPN 45% requiring mechanical ventilation; more in standard group ? APACHE scores 8 patients excluded from analysis Randomized to: Standard: 25 kcal/kg, protein 1.5 g/kg Hypocaloric: 1 L fat-free TPN (1000 calories/day) McCowen Crit Care Med 2000;28:3603

40 patients in university hospital requiring TPN

45% requiring mechanical ventilation; more in standard group

? APACHE scores

8 patients excluded from analysis

Randomized to:

Standard: 25 kcal/kg, protein 1.5 g/kg

Hypocaloric: 1 L fat-free TPN (1000 calories/day)

Dose of TPN Less protein, dextrose, fat, and calories in hypo group More insulin in standard group but no difference in glucose levels Trend towards increase in infections associated with standard TPN (p=0.20) McCowen Crit Care Med 2000;28:3603

Less protein, dextrose, fat, and calories in hypo group

More insulin in standard group but no difference in glucose levels

Trend towards increase in infections associated with standard TPN (p=0.20)

Timing of TPN 300 patients Major surgery/trauma R TPN IV glucose 1) Successful 2) Failure 3) Glucose 4) Failure: Cross over to TPN Outcomes days in ICU mortality Nutritional At 15 days Sandstrom Ann Surg 1993;217:185

days in ICU

mortality

Nutritional

Timing of TPN Sandstrom Ann Surg 1993;217:185 % (days) Minimal nutrition support for more than 2 weeks associated with worse outcomes

If you are going to use PN TIGHT GLYCEMIC CONTROL RCT of intensive insulin therapy Experimental: 4.4- 6.1 mmol/l Standard: 10-11.1 Patients Mostly surgical; 65% CV surg Median APACHE II of 9 Cointerventions Rec’d 200-300 gms of glucose on day 1 up to 60% rec’d combined EN and PN Van den Berge NEJM 2001;345:1359

RCT of intensive insulin therapy

Experimental: 4.4- 6.1 mmol/l

Standard: 10-11.1

Patients

Mostly surgical; 65% CV surg

Median APACHE II of 9

Cointerventions

Rec’d 200-300 gms of glucose on day 1

up to 60% rec’d combined EN and PN

Greatest reduction in deaths due to MODS secondary to sepsis Reduced episodes of sepsis by 50% Generalizability of findings? If you are going to use PN TIGHT GLYCEMIC CONTROL Van den Berge NEJM 2001;345:1359

Greatest reduction in deaths due to MODS secondary to sepsis

Reduced episodes of sepsis by 50%

Generalizability of findings?

TPN

Effect of Parenteral Glutamine in the Critically Ill

If you are going to use TPN Use it late Low dose EN No lipids Monitor glucose – tight control Supplement with glutamine Consider: Heyland Right here, right now 2003

Use it late

Low dose EN

No lipids

Monitor glucose – tight control

Supplement with glutamine

Aggressive EN Feeding Protocols Small bowel > gastric Semi-recumbent position Pro-motility drugs Limited Role for TPN

Canadian ICU Nutrition Support Practice Guidelines Nutrition support? EN >>TPN timing Dose Duration Lipids Low dose EN glutamine timing Dose composition small bowel feeds motility agents feeding protocols malnutrition nutrition assessment

timing

Dose

Duration

Lipids

Low dose EN

glutamine

timing

Dose

composition

small bowel feeds

motility agents

feeding protocols

malnutrition

nutrition assessment

EN vs PN in pancreatitis For PN meets nutrition goals avoid stimulation of pancreas non-functioning gut discontinuous gut complications of feeding For EN stimulation of gut protecting gut integrity protecting gut motility complications of PN

For PN

meets nutrition goals

avoid stimulation of pancreas

non-functioning gut

discontinuous gut

complications of feeding

For EN

stimulation of gut

protecting gut integrity

protecting gut motility

complications of PN

EN vs PN in pancreatitis Systematic review of the literature Medline, EMBASE, Cochrane, files >3000 titles and abstracts 13 randomized trials involving acute pancreatitis

Systematic review of the literature

Medline, EMBASE, Cochrane, files

>3000 titles and abstracts

13 randomized trials involving acute pancreatitis

RCT’s in Pancreatitis PN vs Standard EN vs PN Am J Surg Sax 1987 Am J Clin Nutr Louie 2002 Gut Windsor 1998 Nitrition Olah 2002 JPEN McClave 1997 BJS Kalfrentzos 1997 Am J Gastr Abou-Assi 2002 EN with glutamine EN with probiotics (lactobacillus) Clin Nutr Ockenga 2002 PN with parenteral glutamine Hepatogastr Halllay 2001 BJS Olah 2002 Nutr Hosp Hernandez-Ara 1996 Eur J Surg Pupelis 2000 EN vs Standard (post-op) BJS Powell 2000 EN vs Standard

EN vs PN in Acute Pancreatitis EN feed n Population Study polymeric 25 abstract severe (>4days) Louie 2002 polymeric 34 pseudorand acute Windsor 1998 polymeric 89 pseudorand acute Olah 2002 semi-elemental 38 mild, acute on chronic McClave 1997 semi-elemental 38 severe Kalfarentzos 1997 elemental 53 acute Abou-Assi 2002

 

 

Study design 38 patients with severe necrotizing Imrie, APACHE, CRP and CT within 48 hours standardized operative therapy isocal, isoN semi-elemental feeds via NJ (2 pts excluded) concealed rand, not blinded, not ITT Kalfarentzos BJS 1997

38 patients with severe necrotizing

Imrie, APACHE, CRP and CT

within 48 hours

standardized operative therapy

isocal, isoN

semi-elemental feeds via NJ (2 pts excluded)

concealed rand, not blinded, not ITT

Patient Characteristics Kalfarentzos BJS 1997 39(22-73) 40(25-83) Hosp LOS 23+/a-6 22+/-6 Antibiotics days 15(11-19) 14(12-16) hemodialysis 11(7-31) 15(6-16) vent days 12(5-24) 11(5-21) ICU LOS 16 14 gallstones PN n=20 EN n=18

Patient Outcomes: Kalfarentzos *values in parentheses are total numbers of complications 2 1 mortality 15(27)* 8(10)* patients with any comp 10(15)* 5(6)* patients with septic comp 4 2 pneumonia/ARDS 2 1 UTI 3 1 bacteremia 2 0 pancreatic fistula 1 0 pseudocyst 0 1 abscess 4 1 infected pancreas 9 4 hyperglycemia 2 0 CRBI

Results Mortality similar Complications OR 3.75 95%CI 0.95,14.7 Cost £30 vs £100 Inference 7 Kalfarentzos BJS 1997

Mortality similar

Complications

OR 3.75 95%CI 0.95,14.7

Cost

£30 vs £100

Inference

7

Summary Practice guidelines for the critically ill patients now available. There is evidence that EN is safe and effective in acute severe pancreatitis.

Practice guidelines for the critically ill patients now available.

There is evidence that EN is safe and effective in acute severe pancreatitis.

If you’re thirsty for more……… www.criticalcarenutrition.com Web based clinical practice guidelines (pending publication of guidelines) Tools and training kits to improve practice Survey of current practice online Compare your results to other sites and the clinical practice guidelines Research related news

www.criticalcarenutrition.com

Web based clinical practice guidelines

(pending publication of guidelines)

Tools and training kits to improve practice

Survey of current practice online

Compare your results to other sites and the clinical practice guidelines

Research related news

Add a comment

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