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Nutrition in Intensive Care
Three contemporaryclinical questions
Andrew Davies
Frankston Hospital & Baxter Healthcare
Nutrition in Intensive Care
Three important questions that might help our patients
Andrew Davies
Frankston Hospital & Baxter Healthcare
The Modern Rationale for Nutrition
Nutrition therapy is important because it improves clinical outcomes
The choice of methodAND
The choice of nutrient matter to our patientsAND
The timing of administration
Nutrition is not just support but a powerful critical care intervention
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Simply
““Feed the Prisoners” Feed the Prisoners” in our ICUsin our ICUs
Optimising Enteral Nutrition
Overall PerformanceThe proportion of prescribed calories received
62%
Suboptimal Nutritional Delivery% patients did not meet overall energy adequacy of 80%
69
Clinical Question Number 1
Should we really try to meet our patient’s nutrition target?
Arguments from the literature
More is better
Arguments from the literature
More is better
Less is better
Arguments from the literature
More is better
Less is better
There’s a sweetspot (and it is <
100%)
Doig G, Simpson F. www.evidencebased.net 2005 and JAMA 2008
Doig G, Simpson F. www.evidencebased.net 2005 and JAMA 2008
Placing nasojejunal feeding tubes
Placing nasojejunal feeding tubes
ARDSnet. JAMA 2012; 307(8):795
NEJM 2015; 372(25):2398
So
Less might be OK (if both are less than 80%)
But what if we actually deliver 100% in one of the arms?
Effect on mortality of full predicted energy (10 trials, 3155 participants)
Random effects analysis: OR 1.02, 95%CI 0.74-1.41
Systematic Review: 80-120% vs < 80% of target
Effect on hospital length of stay of full predicted energy (5 studies, 389 patients)
MD 4.71 days, 95%CI -0.33 - 9.75
Systematic Review: 80-120% vs < 80% of target
Clinical Question Number 1
Should we really try to meet our patient’s nutrition target?
Overall PerformanceThe proportion of prescribed calories received
62%
2014;100:616-625
TARGET Feasibility Study
FRESUBIN 1000
FRESUBIN 2250
Calories, kcal/ml
Carbohydrates, g
Fat, g
Protein, g
Fibre, g
Osmolality mosm/kg H2O
1.0
12.5
2.7
5.5
2.0
360
1.5
18.0
5.8
5.6
1.5
430
2014;100:616-625
Aim to determine if substitution of 1.0 kcal/ml with 1.5kcal/ml EN
delivers more calories when delivered at same rate
Peake S, et al. Am J Clin Nutr 2014;100:616
2014;100:616-625
Mean (SD) kcal/day Mean (SD) kcal/kg IBW/day
Peake S, et al. Am J Clin Nutr 2014;100:616
Daily calorie delivery over first 10 feeding days
2014;100:616-625
Peake S, et al. Am J Clin Nutr 2014;100:616
1.0 kcal/ml 1.5 kcal/ml P value
Volume delivered, ml/day (mean, SD) 1259 (428) 1221 (381) 0.63
Calories delivered, kcal/day (mean, SD) 1259 (428) 1832 (571) < 0.001
Calories delivered, kcal/kg IBW /day (mean, SD) 19.0 (6.0) 27.3 (7.4) < 0.001
Goal CALORIES achieved, (%)* 72 102 < 0.001
46% increase in calorie delivery with 1.5 kcal/ml EN
Peake S, et al. Am J Clin Nutr 2014;100:616
Survival
P = 0.06 log-rank test
The Augmented versus Routine approach to Giving Energy Trial
(TARGET)
FundingNational Health and Medical Research Council
Health Research Council of New Zealand
EndorsementANZICS Clinical Trials Group
Coordinating Centre ANZIC Research Centre, Monash University
Medical Research Institute of NZ
SupportNHMRC Centre for Research Excellence in Nutrition, Adelaide Australia
Fresenius Kabi Deutschland GmbH
4000 patient study in 51 ICUs in ANZ
Aims
Primary
To determine if augmentation of calorie delivery using energy dense EN
in mechanically ventilated patients improves 90-day survival compared to
routine care
Secondary
To determine if augmentation of calorie delivery using energy dense EN
in mechanically ventilated patients improves functional outcomes
compared to routine care
Clinical Question Number 2
Is there a role for supplemental PN in ICU patients?
Overall PerformanceThe proportion of prescribed calories received
62%
PN has now entered a new era
NEJM 2014 Oct 30; 371(18):1673-84. Epub 2014 Oct 1.
JAMA 2013 309 (20): 2130.
JAMA 2013 309 (20): 2130.
So what do we know aboutSupplemental PN?
A subsequent Supplemental PN study:In Australia and NZ
• In a more severely unwell critical care population than EPANIC
• With NICE-SUGAR control (< 10mmol)
• No IV dextrose
• Standard ANZ energy targets
• With an intervention designed to avoid overnutrition
Research Question - wider program
“Does a supplemental PN strategy improve short and longer term clinical outcomes in critically ill patients with at least 1 organ system failure compared to a
standard strategy”
Pilot Study Design
• Study Design– Prospective, concealed, randomized, multi-centre trial – Feasibility study aiming at a program of research
• Sites– 2 in Australia, 4 in New Zealand
• Sample size:– 100 patients
Clinical Question Number 3
Should intensivists be interested in diet and lifestyle
interventions that might reverse heart disease?
Is plant-based nutrition therapeutic?
Lancet 1990; 336:129
Lifestyle program
In patients with 1-3 vessel IHD and EF >25% Low fat vegetarian diet (no caloric restriction) with no animal products except egg white and low fat yoghurt
No caffeine, maximum of 2 units alcohol per day
Moderate aerobic exercise (3 hrs/week at target HR zones)
Stress management training (1 hr/day) – meditation and visualisation
Group support (2 meetings a week)
Lancet 1990; 336:129
Lancet 1990; 336:129
Angiographic lesions
Lifestyle group 40.0% to 37.8% at 1 year
Control group 42.7% to 46.1% at 1 year
Lancet 1990; 336:129
Angiographic lesions at 5 years
Lifestyle Overall progression -3.1%
Control Overall progression 11.8%
JAMA 1998; 280:2001
Courtesy of Dr Caldwell Esselstyn
Strict plant-based diet
Plant-based diets can improve outcomes in
- Diabetes
- Hypertension
- Cancer
- Inflammatory bowel disease
- Parkinson’s & Alzheimers