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Nutrition therapy in Nutrition therapy in critical illness critical illness

แพทยหญิงศภุวรรณ บูรณพริคณะแพทยศาสตร มหาวิทยาลยัเชยีงใหม

10Lecture

Nutrition therapy in critical illnessNutrition therapy Nutrition therapy in critical illnessin critical illness

Supawan Buranapin, MD

Chiang Mai University8 July 2010

Malnutrition in critically ill patientsMalnutrition in critically ill patientsMalnutrition in critically ill patients

A disorder of body composition results from macronutrient and/or micronutrient deficiency.Consequently followed by reduced organ function, abnormal results of blood chemistry studies, reduced body mass and less optimal clinical outcomes.Commonly occur in critically ill

Cerra FB. Chest 1997;111:769-778.

Negative impact of hypocaloric feeding and Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU ptsenergy balance on clinical outcome in ICU pts

Villet S, Clin Nutr 2005; 24: 502-509

Prospective observational studyN= 48, 669 ICU daysICU-pts > 5d on ICU- high risk pts (30-d mortality: 38%)Time to start feeding 3.1 + 2.2 dCummulative energy deficit: 12600 +10520 kcalMean energy delivery: 1090 +930 kcal EN, PN, EN+PNCorrelation between caloric deficit and pts’outcome (p=0.001)- Infections- Length of hospital stay

Nutrition support in the critically ill population

Nutrition support in the Nutrition support in the critically ill populationcritically ill population

as adjunctive care to provide exogenous fuels to support patient during stress response 3 main objectives: 1. To preserve lean body mass2. To maintain immune function3. To avert metabolic complications

Additionally goals: attempting to Attenuate metabolic response to stressPrevent oxidative cellular injuryFavorably modulate immune response

Nutrition requirementNutrition requirementNutrition requirement

Energy requirement

Protein requirement

Fluid requirement

Vitamins & minerals requirement

Question 1

• How much energy requirement would be appropriate for critically ill patient?

• A. 20 kcal/kg/d• B. 25 kcal/kg/d• C. 30 kcal/kg/d• D. 35 kcal/kg/d

Answer 1

• 25 kcal/kg/d

Energy requirementEnergy requirementEnergy requirement

Direct measurement of energy requirement :Indirect calorimetry (metabolic cart)Calculation :

Harris-Benedict’s equationCerra’s estimationHoliday-Segar’s equationOthers

Metabolic cartMetabolic cart

Harris-Benedict’s equationHarrisHarris--BenedictBenedict’’s equations equation

Basal energy expenditureMale BEE = 66.5 + 13.7wt(kg) + 5ht(cm)- 6.8age(year)Female BEE = 655 + 9.6wt(kg) + 1.8ht(cm) – 4.7age (year)

Activity factorsOn respirator 0.7 – 0.9Confined to bed 1.2Ambulatory 1.3

Stress factors

Metabolic Response Metabolic Response Metabolic Response

Example:Energy requirements for patient with sepsis in bed = BEE x 1.30 x 1.2

ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996Long CL, et al. JPEN 1979;3:452-456

InjuryMinor surgeryLong bone fractureCancerPeritonitis/sepsisSevere infection/multiple traumaMulti-organ failure syndromeBurns

Stress Factor1.00 – 1.101.15 – 1.301.10 – 1.301.10 – 1.301.20 – 1.401.20 – 1.401.20 – 2.00

ActivityConfined to bedOut of bed

Activity Factor1.21.3

MalnutritionMalnutritionMalnutrition

Ideal Weight

Actual Weight

In malnutrition, energy expenditure must be calculated based on actual body weight.

ObesityObesityObesity

Ideal WeightActual Weight

In obesity, energy expenditure must be calculated on adjusted ideal weight (AIBW)

Adjusted Ideal body weight (AIBW)Adjusted Ideal body weight (AIBW)Adjusted Ideal body weight (AIBW)

AIBW= IBW+ 25% of the difference between actual weight and IBWIBW

MaleHeight 150 cm, weight 48 kgEvery 2.5 cm above 150 cm of height, add 2.7 kg

FemaleHeight 150 cm, weight 45 kgEvery 2.5 cm above 150 cm of height, add 2.3 kg

Calorie CalculationCalorie CalculationCalorie Calculation

“Rule of Thumb”

Calorie requirement = 25 kcal/kg/day

Kaplan-Meier analysis of the probability of survival

KaplanKaplan--Meier analysis of the Meier analysis of the probability of survival probability of survival

Singh N. Respir Care 2009;54:1688 –1696.

Stratified according to mean calorie delivery Mean calorie delivery of ≤ 50% of recommended significantly reduced probability of survival

Complications of underfeedingComplications of underfeedingComplications of underfeeding

Loss of lean body mass (muscle wasting), including cardiac and respiratory muscles

Prolonged weaning form mechanical ventilation Delayed wound healingImpaired host defensesIncrease nosocomial infections

Robert SR. Crit Care Nurse. 2003;23:49-57.

Complications of overfeedingComplications of overfeedingComplications of overfeeding

AzotemiaHepatic steatosisHypercapnia, which may lead to prolonged weaning from mechanical ventilationHyperglycemiaHyperlipidemiaFluid overload

Robert SR. Crit Care Nurse. 2003;23:49-57.

NutrientsNutrientsNutrientsProtein 4 kcal/gCarbohydrates

enteral 4 kcal/gparenteral 3.4 kcal/g

Lipids 9 kcal/gWaterVitamins

– Water soluble– Fat soluble

Minerals– Electrolytes– Trace elements and ultra trace minerals

Macronutrients during StressMacronutrients during Stress

Carbohydrate

At least 100 g/day needed to prevent ketosis

Carbohydrate intake during stress should be between 30%-40% of total calories

Glucose intake should not exceed 5 mg/kg/min

Barton RG. Nutr Clin Pract 1994;9:127-139ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA

Macronutrientes during StressMacronutrientes during Stress

Fat

Provide 20%-35% of total calories

Maximum recommendation for intravenous lipid infusion: 1.0 -1.5 g/kg/day

Monitor triglyceride level to ensure adequate lipid clearance

Barton RG. Nutr Clin Pract 1994;9:127-139ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

Macronutrients during StressMacronutrients during Stress

Protein

Requirements range from 1.2-2.0 g/kg/day during stress

Comprise 20%-30% of total calories during stress

Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

Determining Protein Requirements Determining Protein Requirements for Hospitalized Patientsfor Hospitalized Patients

Stress Level

Calorie:Nitrogen Ratio

Percent Potein / Total

Calories

Protein / kg Body Weight

No Stress

> 150:1

< 15% protein

0.8 g/kg/day

Moderate Stress

150-100:1

15-20% protein

1.0-1.2 g/kg/day

1.5-2.0 g/kg/day

> 20% protein

< 100:1

Severe Stress

Protein and calorie requirementProtein and calorie requirementProtein and calorie requirementProtein

Maintenance 0.8-1.0 g/kgCatabolic patients 1.2-2.0 g/kgChronic renal failure(renal replacement therapy) 1.2-1.5 g/kgAcute renal failure + catabolic 1.5-1.8g/kg

EnergyTotal calories 20-30 kcal/kg

Fluid 30-40 ml/kg

Task Force for the revision of safe practices for parenteral nutrition. JPEN 2004;28:S39-S70.

Key Vitamins and MineralsKey Vitamins and MineralsKey Vitamins and Minerals

Vitamin A

Vitamin C

B Vitamins

Pyridoxine

Zinc

Vitamin E

Folic Acid,Iron, B12

Wound healing and tissue repair

Collagen synthesis, wound healing

Metabolism, carbohydrate utilization

Essential for protein synthesis

Wound healing, immune function, protein synthesis

Antioxidant

Required for synthesis and

replacement of red blood cells

Specific substratesSpecific substratesSpecific substrates

Immunonutrition:

– Omega-3 fatty acids: EPA

– Glutamine

– Arginine

Pre-pro-synbiotic

Omega-3 fatty acidsOmegaOmega--3 fatty acids3 fatty acidsMetabolized to the 3-series of prostanoids and the 5-series of leukotrienes, which are less inflammatory and less immunosuppessive.Whereas omega-6 fatty acids are precursors of the 2-and 4-series prostanoids, which are vasoconstrictive and induce platelet aggregation (impair cytotoxic T-lymphocyte function, cytokine secretion, leukocyte migration and reticuloendothelial system function). Needed for ≥ 1g/day for effectiveness immune enhancing

Role of glutamine in metabolic stressRole of glutamine in metabolic stress

Considered “conditionally essential” for critical patients

Depleted after trauma

Provides fuel for the cells of the immune system and GI tract

Helps maintain or restore intestinal mucosal integrity

Smith RJ, et al. JPEN 1990;14(4 Suppl):94S-99S; Pastores SM, et al. Nutrition1994;10:385-391Calder PC. Clin Nutr 1994;13:2-8; Furst P. Eur J Clin Nutr 1994;48:607-616Standen J, Bihari D. Curr Opin Clin Nutr Metab Care 2000;3:149-157

Role of arginine in metabolic Role of arginine in metabolic stressstress

Provides substrates to immune system (immune enhancing agent)Increases nitrogen retention after metabolic stressImproves wound healing in animal modelsStimulates secretion of growth hormone and is a precursor for polyamines and nitric oxideNot appropriate for septic or inflammatory patients (immune system is already stimulated).

Barbul A. JPEN 1986;10:227-238; Barbul A, et al. J Surg Res 1980;29:228-235

“Giving arginine to a septic patient is like putting gasoline on an already burning fire.”

- B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL

Probiotics:live microorganisms which, when administered in adequate amounts, confer a health benefit on the host

Prebiotic:food for probiotic Complex CHOs –not metabolizedEnergy source for probiotics

Syn-biotics:Pairing of pre- and pro-biotics

Oral

Enteral feeding

– Nasogastric tube & nasoenteric tube

– Gastrostomy/PEG

– Jejunostomy/PEJ/jejunostomy via gastrostomy

Parenteral nutrition

Combination of EN & PN

Route of Nutrition supportRoute of Nutrition supportRoute of Nutrition support

Which route of feeding is prefer for critcally ill pt?

A. enteralB. parenteralC. both EN and PND. NPO

Question 2.

Answer 2

• Enteral route

Aihara R. J Healthcare Quality 2002;24:22-29

Nutrition support decision treeNutrition support decision treeNutrition support decision treePatient admitted to intensive care unitPatient admitted to intensive care unit

Nursing assessment, including nutritional screeningNursing assessment, including nutritional screening

Physician nutritional assessmentPhysician nutritional assessment

Registered dietitian nutritional assessmentRegistered dietitian nutritional assessment

Enteral FeedsEnteral Feeds

Taper TherapyTaper Therapy

Functioning gastrointestinal (GI) tract

Functioning gastrointestinal (GI) tract

Therapeutic Oral DietTherapeutic Oral Diet

Nonfunctioning GI tract Nonfunctioning GI tract

Parenteral FeedsParenteral Feeds

Choice of therapyChoice of therapy

Central Central Peripheral Peripheral

Effects of PN compared with Effects of PN compared with EN:EN: nutrition on GI functionsnutrition on GI functions

Zaloga GP. Lancet 2006;367:1101-11.

Gut atrophy*Loss of gut hormone secretionReduced gut absorptionAltered gut microfloraLoss of gut barrier Increased bacterial adherenceIncreased microbe translocationDecreased gut blood flow that is worse with vasopressor administration

Increased apoptosisDecreased gastric, intestinal, and pancreatic secretions*Increased gut permeability Slower healing of anastomotic sitesHepatic dysfunction*Decreased drug clearance by liver*Hepatic injury*Rare hepatic failure*Cholestasis, gallstones*

Effects of PN compared with EN: Effects of PN compared with EN: nutrition on immune system functionnutrition on immune system function

Parenteral nutrition is associated with:B and T cell dysfunctionMacrophage and neutrophil dysfunctionImpaired chemotaxisImpaired phagocytosisImpaired bacterial/fungal killingLoss of gut associated lymphoid tissueDecreased IgA secretionReticuloendothelial dysfunctionIncreased infectionsIncreased proinflammatory cytokines

Zaloga GP. Lancet 2006;367:1101-11.

Gastric versus post-pyloric feeding: a systematic review Gastric versus postGastric versus post--pyloric pyloric

feeding: a systematic review feeding: a systematic review Post-pyloric feeding has no clinical advantages over gastric feeding in most critically ill medical, neurosurgical and trauma patientsEarly gastric feeding with an oro-gastric or naso-gastric tube is favored in most critically ill patientsPromotility agents are recommended in patients with high gastric residualsPost-pyloric feeding is recommended in patients at high risk of aspiration, in patients undergoing major intra-abdominal surgery and patients who are intolerant of gastric feeding

Marik PE. Critical Care 2003, 7:R46-R51

Algorithms for critical-care nutrition supportAlgorithms for criticalAlgorithms for critical--carecare nutrition supportnutrition support

At ICU admission:Should this patient be fed?

At ICU admission:Should this patient be fed?

Can EN be started within 24 hours?Can EN be started within 24 hours?

Gastric challenge: Use full-strength concentration

Consider prokinetic with challenge Goal: at least 80% of requirements at 72 h

Assess q12h

Gastric challenge: Use full-strength concentration

Consider prokinetic with challenge Goal: at least 80% of requirements at 72 h

Assess q12h

Is progression on target to reach at least 80% by 72h?

Is progression on target to reach at least 80% by 72h?

Acceptable conditions:• Tolerating adequate oral diet• <24 h to oral intake • Palliative care

Acceptable conditions:• Tolerating adequate oral diet• <24 h to oral intake • Palliative care

Acceptable conditions:• Acute pancreatitis*• Enteric anastomosis*• Ischemic bowel• Enteric fistula • Imminent endoscopy • Bowel obstruction• High nasogastric losses • Severe exacerbation of inflammatory

bowel disease*may still opt for element enteral feeding

Acceptable conditions:• Acute pancreatitis*• Enteric anastomosis*• Ischemic bowel• Enteric fistula • Imminent endoscopy • Bowel obstruction• High nasogastric losses • Severe exacerbation of inflammatory

bowel disease*may still opt for element enteral feeding

Begin TPNReassess q12h for EN eligibility

Begin TPNReassess q12h for EN eligibility

• Continue EN to maximum tolerated

• Supplement with PN• Continue EN challenges q12h

• Continue EN to maximum tolerated

• Supplement with PN• Continue EN challenges q12h

Is goal met?Is goal met?Increase rate to 100% of requirements Increase rate to 100% of requirements

• Use prokinetic• Use postpyloric tube• Use prokinetic• Use postpyloric tube

No

No

No

No

Yes

Yes

Yes

Yes

Algorithms for critical-carenutrition support

Algorithms for criticalAlgorithms for critical--carecarenutrition supportnutrition support

Martin CM. CMAJ. 2004;170:197-204.

Is stool clinically significant?

Is stool clinically significant?

Continue same enteral feeding

Continue same enteral feeding

Are medications the possible cause?

Are medications the possible cause?

Change medications, feed to tolerance

Change medications, feed to tolerance

Is the patient receiving antibiotics?

Is the patient receiving antibiotics?

Check stool for C. difficile toxin, feed to tolerance

Check stool for C. difficile toxin, feed to tolerance

Consider elemental formulation

Consider elemental formulation

Continue same enteral feeding

Continue same enteral feedingIs the diarrhea resolved? Is the diarrhea resolved?

Advance to goal rate as tolerance improves

Advance to goal rate as tolerance improves

Is diarrhea present?Is diarrhea present?

Decrease rate until tolerance achievedDecrease rate until tolerance achieved

NoNo

NoNo

NoNo

NoNo

Yes

Yes

Yes

Yes

Yes

Algorithms for critical-care nutrition support

Algorithms for criticalAlgorithms for critical--carecare nutrition nutrition supportsupport

• Clinically significant stools:• Liquid stools > 300 mL/d or• >4 loose stools per day or • Risk of contamination of wounds or catheters

• Medications that commonly cause diarrhea: • Metoclopramide• Quinidine • Xylitol• Magnesium • Erythromycin • Aminophylline • Sorbitol• Phosphorus

Martin CM. CMAJ. 2004;170:197-204.

Question 3

• We should hold tube feeding when residual volume more than……

A.50 mlB.100 mlC.150 mlD.200 ml

Answer 3

• 200 ml

Algorithms for critical-care nutrition support

Algorithms for criticalAlgorithms for critical--carecare nutrition nutrition supportsupport

Martin CM. CMAJ. 2004;170:197-204.

Assess gastrointestinal tolerance to tube feeding q 4h

Intolerant patients have:

Clinically significant stools or

Readily apparent abdominal distension or

Increased abdominal girth or

Clinically detected aspiration or

Gastric residuals >200 mL for nasogastric feeds

Outcome of the RCT compared

intervention and control groups

Outcome of the Outcome of the RCT compared RCT compared

intervention and intervention and control groupscontrol groups

Martin CM. CMAJ. 2004;170:197-204.

Prokinetic drugsProkinetic drugsMetoclopramide (5HT4 receptor agonist)

most widely used in gastric feeding intolerancestimulates gastric and duodenal motility, via an action on efferent myenteric cholinergic neurons releasing acetylcholinesome contribution from its properties as dopamine antagonist 10 mg 4 times a day more effective than placebo but the effects rapidly diminish by 3 daysfeeding success in high gastric residual volumes is <20%not effective in pts with brain injuryrisk of irreversible tardive dyskinesia with long-term or high-dose use

Fraser RJL. Nutr Clin Prac 2010;25:26-31.

Prokinetic drugsProkinetic drugs

Erythromycin• acting as a motilin agonist• 3 mg/kg stimulates high-amplitude antral contractions,

which propagate rapidly across pylorus into duodenum• highly successful in promoting feeding in pts with high

gastric residual volumes• prolonged administration (>3 or 4 d) reduced efficacy• by day 7, only 30% of pts continued to receive feedings• prolonged success of enteral feeding delivery is inversely

proportional to erythromycin concentrationsCombination with erythromycin and metoclopramide • highly effective in promoting prolonged feeding• rationale for this synergy is unclear

Fraser RJL. Nutr Clin Prac 2010;25:26-31.

Efficacy of prokinetic therapy over 7 Efficacy of prokinetic therapy over 7 days in feeddays in feed--intolerant critically ill ptsintolerant critically ill pts

Fraser RJL. Nutr Clin Prac 2010;25:26-31.

Studies comparing PN versus EN: Effect on mortality

Studies comparing PN versus Studies comparing PN versus EN: Effect on mortalityEN: Effect on mortality

Heyland DK. JPEN. 2003;27:355-373.

Studies comparing PN versus EN: Effect on infectious complicationsStudies comparing PN versus EN: Studies comparing PN versus EN: Effect on infectious complicationsEffect on infectious complications

Heyland DK. JPEN. 2003;27:355-373.

Studies comparing early versus delayed nutrient intake: Effect on

mortality

Studies comparing early versus Studies comparing early versus delayed nutrient intake: Effect on delayed nutrient intake: Effect on

mortalitymortality

Heyland DK. JPEN. 2003;27:355-373.

Studies comparing early vs delayed nutrient intake: Effect on

infectious complications

Studies comparing early vs Studies comparing early vs delayed nutrient intake: Effect ondelayed nutrient intake: Effect on

infectious complicationsinfectious complications

Heyland DK. JPEN. 2003;27:355-373.

Comparing small bowel VS. gastric route of feeding: effect on pneumonia

Comparing small bowel VS. gastric Comparing small bowel VS. gastric route of feeding: effect on pneumoniaroute of feeding: effect on pneumonia

Heyland DK. JPEN. 2003;27:355-373

Comparing combined EN and PN to EN alone: effect on mortality

Comparing combined EN and PN to Comparing combined EN and PN to EN alone: effect on mortalityEN alone: effect on mortality

Heyland DK. JPEN. 2003;27:355-373

Evaluating PN supplemented with glutamine: effect on mortality

Evaluating PN supplemented with Evaluating PN supplemented with glutamine: effect on mortalityglutamine: effect on mortality

Heyland DK. JPEN. 2003;27:355-373

PrePre-- propro-- and synbiotics in adult and synbiotics in adult ICU patients: Systematic reviewICU patients: Systematic review

Watkinson PJ. Clinical Nutrition 2007;26:182–192

PrePre-- propro-- and synbiotics in adult and synbiotics in adult ICU patients: Systematic reviewICU patients: Systematic review

Watkinson PJ. Clinical Nutrition 2007;26:182–192

The use of pre- pro- or synbiotics in adult critically ill patients confers no statistically significant benefit in the outcome criteria studied.

Effect of immunomodulating diets Effect of immunomodulating diets on mortality with treatment effecton mortality with treatment effect

Marik PE. Intensive Care Med 2008;34:1980–1990.

Odds ratio of the treatment effect of Odds ratio of the treatment effect of immunomodulating diets on mortalityimmunomodulating diets on mortality

Marik PE. Intensive Care Med 2008;34:1980–1990.

Arg: arginine,A-FO: arginine + fish oilFO: fish oilAFG:arginine + fish oil + glutamineGl: glutamine

Use of EN with fish oilUse of EN with fish oilUse of EN with fish oil

The use of products with fish oils, borage oils, and antioxidant should be considered in patients with ARDS.

It was associated with a reduction in days receiving supplemental oxygen, fewer days of ventilator support, fewer days in ICU and fewer new organ failure.

Heyland DK. JPEN. 2003;27:355-373

Effect of immunomodulating diets Effect of immunomodulating diets on acquisition of new infectionson acquisition of new infections

Marik PE. Intensive Care Med 2008;34:1980–1990.

Effect of immunomodulating diets Effect of immunomodulating diets on length of hospital stay (LOS)on length of hospital stay (LOS)

Marik PE. Intensive Care Med 2008;34:1980–1990.

Immune nutrients: summary of clinical Immune nutrients: summary of clinical practice recommendationspractice recommendations

recommended, should be considered, should not be used, no recommendation due to inadequate data

Dietary formulasDietary formulasDietary formulas

1. Polymeric diet: nutren, ensure, panenteral, isocal, blenderized diet (BD)

2. Semi-elemental or elemental diet: peptamen

3. Disease specific formula: glucerna SR, Nutren balance, Aminoleban-EN, Nepro, immunonutrition

4. Modular formula: protein powder

Enteral deliveryEnteral delivery

IntermittentlyMore physiologic

Free the patient from feeding equipment

400 cc q 4 hr is well tolerated

May cause aspiration and abdominal discomfort

May not appropriate for critically ill patients

Enteral deliveryEnteral delivery

Continuous feedingVia infusion pump over 24 hr

Less nursing supervision

Small residual volume

Lower risk of aspiration

Use when feeding into duodenum or jejunum

More appropriate for critically ill patients

ZieglerTR. N Engl J Med 2009;361:1088-97.

Hypocaloric parenteral nutritionHypocaloric parenteral nutritionHypocaloric parenteral nutrition

Hypocaloric feeding of PN (reduced both CHO and fat or withhold lipids) was associated with a trend toward a reduction in infectious complications, no difference in mortality or length of stay between groups.

In critically ill patients who are not malnourished, are tolerating some EN, or when PN is indicated for short-term use (< 10 days), hypocaloric PN should be considered.

There are insufficient data about the use of hypocaloric PN in : those requiring PN for long term (>10 days), obese and malnourished critically ill patients.

Heyland DK. JPEN. 2003;27:355-373

Lipids in parenteral nutritionLipids in parenteral nutritionLipids in parenteral nutrition

No effect of withholding lipids on mortality.A meta-analysis showed a significant reduction in infections in the group that received no lipids.In critically ill patients who are not malnourished and are tolerating some EN, or when PN is indicated for short term use (< 10 days), withholding lipids should be considered.There are insufficient data about withholding lipids in critically ill patients who are malnourished or those requiring PN for long term (> 10 days).

Heyland DK. JPEN. 2003;27:355-373

Consequences of hyperglycemia in Consequences of hyperglycemia in hospitalized patientshospitalized patients

Insulin resistance (‘glucose toxicity’)Increased proteolysis in the skeletal muscleImmune dysregulation in macrophages, neutrophils, immunoglobulins and complementIncreased oxidative stressImpaired wound healing (glycosylation of collagen)HyperosmolalityGlycosuria, osmotic diuresis, and dehydration

Inclusion of lipids in PN regimens allows for a lower supply of glucose and helps to avoid hyperglycemia and its deleterious consequences

Risk ratios of Risk ratios of mortality mortality

comparing comparing intensive insulin intensive insulin therapy (IIT) to therapy (IIT) to conventional conventional

glycemic controlglycemic control

Griesdale DEG. CMAJ 2009;180(8):821-7

Risk ratio of hypoglycemic eventsRisk ratio of hypoglycemic eventsRisk ratio of hypoglycemic events

Griesdale DEG. CMAJ 2009;180(8):821-7

Intensive insulin therapy and mortality Intensive insulin therapy and mortality among critically ill patients: a metaamong critically ill patients: a meta--analysis analysis

26 trials,13567 patientsPt in surgical ICUs appear to benefit from IIT (RR 0.63, 95% CI 0.44–0.91)Pt in other ICU did not (medical ICU: RR 1.0, 95% CI 0.78–1.28; mixed ICU: RR 0.99, 95% CI 0.86–1.12)The different targets of IIT (BS ≤ 110 mg/dL v. ≤ 150 mg/dL) did not influence either mortality or risk of hypoglycemiaInterpretation: IIT significantly ↑ risk of hypoglycemia and conferred no overall mortality benefit among critically ill patients. However, it may be beneficial to pt admitted to a surgical ICU.

Griesdale DEG. CMAJ 2009;180(8):821-7

Goal for blood glucose levelsGoal for blood glucose levels

Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dLOnce insulin is started, a glucose range of 140-180 mg/dL is recommended for the majority of critically ill patientsIntravenous insulin protocol has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia

Diabetes Care 2010;33(suppl1):S4-10.

Guidelines for the provision and assessment of nutrition support

therapy in the adult critically ill patient: Society of Critical Care Medicine and

American Society for Parenteral and Enteral Nutrition 2009

Martindale RG. Crit Care Med 2009;37:1757-61.

Initial enteral feedingInitial enteral feedingInitial enteral feedingTraditional nutrition assessment tools are not validated in critical care (albumin, prealbumin, and anthropometry).Nutritional assessment: evaluation of weight loss and previous nutrient intake before admission, level of disease severity, comorbid conditions, and function of GI tractEnteral nutrition (EN) should be initiated in critically ill pt who is unable to maintain adequate energy intake EN is the preferred route over parenteral nutrition (PN) for critically ill pt who requires nutrition support therapyEnteral feeding should be started early within 24–48 hours following admissionAdvance feedings toward goal over the next 48–72 hours

Martindale RG. Crit Care Med 2009;37:1757-61.

Initial enteral feedingInitial enteral feedingInitial enteral feedingIn hemodynamic compromise, EN should be withheld until pt is fully resuscitated and/or stableIn ICU patient, neither the presence nor absence of bowel sounds and evidence of passage of flatus and stool is required for initiation of enteral feeding Either gastric or small bowel feeding is acceptable in the ICU setting. Critically ill patients should be fed via an enteral access tubeplaced in small bowel if at high risk for aspiration or after showing intolerance to gastric feeding Withholding of enteral feeding for repeated high gastric residual volumes alone may be a sufficient reason to switch to small bowel feeding

Martindale RG. Crit Care Med 2009;37:1757-61.

When to use PNWhen to use PNWhen to use PN

In healthy pt before critical illness, PN should be reserved andinitiated only after 7 days of hospitalization (when EN is not available) If PCM at admission and EN is not feasible, initiate PN as soon as possible following admission and adequate resuscitation PN 5–7 days: no outcome effect and may increased risk to ptInitiate PN only anticipated to be used ≥ 7 days

Martindale RG. Crit Care Med 2009;37:1757-61.

Dosing of enteral feedingDosing of enteral feedingDosing of enteral feeding

Detemine target goal of EN Energy requirements: calculated by predictive equations or measured by indirect calorimetry Efforts to provide >50% to 65% of goal calories to achieve clinical benefit of EN over 1st week of hospitalizationIf unable to meet 100% energy requirements after 7–10 days by EN alone, consider supplemental PNAssessment of adequacy of protein provision

Martindale RG. Crit Care Med 2009;37:1757-61.

Dosing of enteral feedingDosing of enteral feedingDosing of enteral feeding

Use of additional modular protein supplements is a common practice (standard enteral formulations tend to have a high nonprotein calorie: nitrogen ratio) In pt with BMI < 30, protein requirements 1.2–2.0 g/kg actual BW/d, and may higher in burn or multiple traumaIn the critically ill obese patient, permissive underfeeding or hypocaloric feeding with EN is recommendedFor BMI is >30, the goal of EN regimen <60-70% of target energy requirements or 11–14 kcal/kg actual BW/d (or 22–25 kcal/kg IBW/d). Protein ≥2.0 g/kg IBW/d for obesity, 2.5 g/kg IBW/d for morbid obesity

Martindale RG. Crit Care Med 2009;37:1757-61.

Monitoring tolerance and adequacy of EN

Monitoring tolerance and Monitoring tolerance and adequacy of ENadequacy of EN

Evidence of bowel motility is not required to initiate ENMonitored for tolerance of EN (pain, distention, passage of flatus and stool, abdominal radiographs)Inappropriate cessation of EN should be avoidedAvoid holding EN for gastric residual volumes <500 mL in the absence of other signs of intolerance NPO pt surrounding diagnostic tests or procedures should be minimized to prevent inadequate delivery of nutrients and prolonged periods of ileus Implement enteral feeding protocols to increases overall percentage of goal calories provided Assessed for risk of aspiration for EN

Martindale RG. Crit Care Med 2009;37:1757-61.

Monitoring tolerance and adequacy of EN

Monitoring tolerance and Monitoring tolerance and adequacy of ENadequacy of EN

Steps to reduce risk of aspiration should be usedIn intubated pt, elevate head of bed 30°– 45°Continuous infusion of EN Agents to promote motility: prokinetic drugs (metoclopramide and erythromycin) or narcotic antagonists (naloxone and alvimopan)Postpyloric tube placement Use of chlorhexidine mouthwash twice a day to reduce risk of ventilator-associated pneumonia

Development of diarrhea associated with EN warrants further evaluation for etiology

Martindale RG. Crit Care Med 2009;37:1757-61.

Selection of appropriate entaral formula

Selection of appropriate Selection of appropriate entaral formulaentaral formula

Immune-modulating formulations (supplemented with arginine, glutamine, nucleic acid,omega-3 fatty acids, and antioxidants)

Use in major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on mechanical ventilationDeliver ≥ 50-65% of goal energy requirements to get benefitBeing cautious in patients with severe sepsis

Other ICU patients: standard formulationsPatients with ARDS and severe acute lung injury: formulation with omega-3 fish oils, borage oil and antioxidantsIf diarrhea, use soluble fiber-containing or small peptide formulations

Martindale RG. Crit Care Med 2009;37:1757-61.

Adjunctive therapyAdjunctive therapyAdjunctive therapyProbiotic agents: decreasing infection in transplantation, major abdominal surgery, and severe traumaNo recommendation in general ICU population because of lack of consistent outcome effect Provide antioxidant vitamins and trace minerals to all critically ill pt receiving specialized nutrition therapy Consider add glutamine to an EN regimen in burn, trauma and mixed ICU pt Soluble fiber may be beneficial for hemodynamically stable critically ill pt receiving EN who develops diarrheaAvoid insoluble fiber in all critically ill pt Avoid both soluble and insoluble fiber in pt at high risk for bowel ischemia or severe dysmotility

Martindale RG. Crit Care Med 2009;37:1757-61.

When indicated, maximize efficacy of PN

When indicated, When indicated, maximize efficacy of PNmaximize efficacy of PN

If pt is a candidate for PN, maximize efficacy regarding dose, content, monitoring, and choice of additivesUse mild permissive underfeeding at least initially (80% of requirements as the ultimate goal of PN)As pt stabilizes, ↑ PN to meet energy requirements Develop protocol to promote moderately strict control of serum glucose (110-150 mg/dL)Supplementation with parenteral glutamine Periodically repeat efforts to initiate ENAs tolerance improves and the volume of EN calories delivered increases, reduce PN calories suppliedTerminate PN when ≥ 60% of target energy requirements by EN

Martindale RG. Crit Care Med 2009;37:1757-61.

Pulmonary failurePulmonary failurePulmonary failure

Specialty high-lipid low-CHO formulations are not recommended for routine use in ICU pt with acute respiratory failure

Consider fluid-restricted calorically dense formulations for pt with acute respiratory failure

Monitor serum phosphate levels closely, and replaced appropriately when needed

Martindale RG. Crit Care Med 2009;37:1757-61.

Renal failureRenal failureRenal failureUse standard enteral formulations in ICU patients with ARF or AKI Follow standard ICU recommendations for protein and calorie provision If significant electrolyte abnormalities, a specialty formulation designed for renal failure may be considered Pt receiving HD or CRRT, increased protein, up to max of 2.5 g/kg/day. Protein should not be restricted in pt with renal insufficiency as a means to avoid or delay initiation of dialysis therapy

Martindale RG. Crit Care Med 2009;37:1757-61.

Hepatic failureHepatic failureHepatic failure

EN is the preferred route in ICU patients with acute and/or chronic liver disease Nutrition regimens should avoid restricting protein in patients with liver failureUse standard enteral formulations in ICU pt with acute and chronic liver disease. Reserve BCAA for the rare encephalopathic pt who is refractory to standard therapy with luminal-acting antibiotics and lactulose

Martindale RG. Crit Care Med 2009;37:1757-61.

Acute pancreatitisAcute pancreatitisAcute pancreatitis

Place NG tube in Pt with severe acute pancreatitis and start EN as soon as complete fluid volume resuscitation Pt with mild to moderate acute pancreatitis do not require NSTPt with severe acute pancreatitis may be fed enterally by gastric or jejunal route Tolerance to EN may be enhanced by

Minimizing period of ileus by early initiation of EN Displacing level of infusion of EN more distally in GI tract Changing content of EN from intact protein to small peptides and long-chain fatty acids to MCT or a nearly fat-free elemental formulation Switching from bolus to continuous infusion

If EN is not feasible, consider PN PN should not be initiated until after 5 days of hospitalization

Martindale RG. Crit Care Med 2009;37:1757-61.

Nutrition therapy end of life situations

Nutrition therapy end of life Nutrition therapy end of life situationssituations

Specialized nutrition therapy is not

obligatory in cases of end-of-life situations

The decision to provide nutrition therapy

should be based on effective patient/family

communication, realistic goals, and respect

for patient autonomy

Martindale RG. Crit Care Med 2009;37:1757-61.

Thank you Thank you for your attentionfor your attention