Adjunctive Supportive CareProactivePrimaryTherapyEarly and Adequate Nutrition is therapy that modulates the underlying disease process and impacts patient outcomes

Increasing Calorie Debt Associated with worse Outcomes Caloric debt associated with: Longer ICU stay Days on mechanical ventilation Complications MortalityAdequacy of ENRubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006

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Early vs. Delayed EN: Effect on Infectious ComplicationsUpdated 2009www.criticalcarenutrition.com

Early vs. Delayed EN: Effect on MortalityUpdated 2009www.criticalcarenutrition.com

Feeding the Hypotensive Patient?DiGiovine et al. AJCC 2010The beneficial effect of early feeding is more evident in the sickest patients, i.e, those on multiple vasopressor agents. Prospectively collected multi-institutional ICU database of 1,174 patients who required mechanical ventilation for more than two days and were on vasopressor agents to support blood pressure.

Optimal Amount of Protein and Calories for Critically Ill Patients?Early EN (within 24-48 hrs of admission) is recommended!

Point prevalence survey of nutrition practices in ICUs around the world conducted Jan. 27, 2007Enrolled 2772 patients from 158 ICUs over 5 continentsIncluded ventilated adult patients who remained in ICU >72 hours

HypothesisThere 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 riskBMI is used to define chronic nutritional risk

What Study Patients Actually RecdAverage Calories in all groups: 1034 kcals and 47 gm of proteinResult: Average caloric deficit in Lean Pts:7500kcal/10daysAverage caloric deficit in Severely Obese:12000kcal/10days

Relationship Between Increased Calories and 60 day MortalityLegend: 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 GroupOdds Ratio95% Confidence LimitsP-valueOverall0.760.610.950.014

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.

BMI GroupAdjustedEstimate95% CIP-valueLCLUCLOverall3.51.25.90.003

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

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

Multicenter RCT of glutamine and antioxidants (REDOXS Study)First 364 patients with SF 36 at 3 months and/or 6 monthsfor increase of 30 gram/day, OR of infection at 28 days Heyland Unpublished DataRelationship between increased nutrition intake and physical function (as defined by SF-36 scores) following critical illness

Model *Estimate (CI)P values(B) Increased protein intake PHYSICAL FUNCTIONING (PF) at 3 months 2.9 (-0.7, 6.6) P=0.11

ROLE PHYSICAL (RP) at 3 months 4.4 (0.7, 8.1) P=0.02

STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 3 months 1.9 (0.5, 3.2) P=0.007

PHYSICAL FUNCTIONING (PF) at 6 months 0.2 (-3.9, 4.3) P=0.92

ROLE PHYSICAL (RP) at 6 months1.7 (-2.5, 5.9) P=0.43

STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 6 months 0.7 (-0.9, 2.2) P=0.39

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

Permissive Underfeeding(Starvation)?187 critically ill patientsTertiles according to ACCP recommended levels of caloric intakeHighest tertile (>66% recommended calories) vs. Lowest tertile (

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 recieved 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 auditSetting: 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

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: In the ICU for at least 96 hours, In the ICU at least 96 hours prior to progression to exclusive oral feeding and 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: ICU length of stay (LOS), Evaluable nutrition days and Relevant baseline patient characteristics or some combination thereof.

Heyland Crit Care Med 2011

Association between 12 day average caloric adequacy and 60 day hospital mortality(Comparing patients recd >2/3 to those who recd

Association Between 12-day Caloric Adequacy and 60-Day Hospital Mortality Heyland CCM 2011

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failureSingle center study of 200 mechanically ventilated patientsTrophic feeds: 10 ml/hr x 5 days Rice CCM 2011;39:967

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failureRice CCM 2011;39:967Did not measure infection nor physical function!

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failuresurvivors who received initial full-energy enteral nutrition were more likely to be discharged home with or without help as compared to a rehabilitation facility (68.3% for the full-energy group vs. 51.3% for the trophic group; p = .04). Rice CCM 2011;39:967

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failureAverage age 51Few comorbiditiesAverage BMI 29All 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 equalshould we expect the impact of nutrition therapy to be the same across all patients?

How do we figure out who will benefit the most from Nutrition Therapy?

StarvationA Conceptual Model for Nutrition Risk Assessment in the Critically Ill

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). When adjusting for age, APACHE II, and SOFA, what effect of nutritional risk factors on clinical outcomes?Multi institutional data base of 598 patientsHistorical po intake and weight loss only available in 171 patientsOutcome: 28 day vent-free days and mortalityHeyland Critical Care 2011, 15:R28

What are the nutritional risk factors associated with clinical outcomes?(validation of our candidate variables)

Non-survivors by day 28 (n=138) Survivors by day 28 (n=460) p values Age 71.7 [60.8 to 77.2]61.7 [49.7 to 71.5]

What are the nutritional risk factors associated with clinical outcomes?(validation of our candidate variables)

VariableSpearman correlation with VFD within 28 daysp valuesNumber of observationsAge-0.1891

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). For example, exact quintiles and logistic parameters for age

Exact QuintileParameterPoints19.3-48.8referent048.9-59.70.780159.7-67.40.949167.5-75.31.272175.4-89.41.9072

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). BMI, CRP, PCT, weight loss, and oral intake were excluded because they were not significantly associated with mortality or their inclusion did not improve the fit of the final model.

VariableRangePointsAge

The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).

The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).

The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score). Interaction between NUTRIC Score and nutritional adequacy (n=211)*P value for the interaction=0.01 Heyland Critical Care 2011, 15:R28

Who might benefit the most from nutrition therapy?High NUTRIC Score?ClinicalBMIProjected long length of stayOthers?

Can we do better?The same thinking that got you into this mess wont get you out of it!

Aggressive Gastric Feeding may be a BAD THING!

Observational study of 153 medical/surgical ICU patients receiving EN in stomachIntolerance= residual volume>500ml, vomiting, or residual volume 150-500x2.Patients followed for development of VAP (diagnosed invasively)

Mentec CCM 2001;29:1955

Incidence of Intolerance= 46%Statistically associated with worse clinical outcomes!Risk factors for IntoleranceSedationCatecholaminesHigh residuals before and during ENAggressive Gastric Feeding may be a BAD THING!

Strategies to Maximize the Benefits and Minimize the Risks of ENfeeding protocolsmotility agentselevation of HOBsmall bowel feedsweak evidence stronger evidence Canadian CPGs www.criticalcarenutrition.com

www.criticalcarenutrition.comUse of a feeding protocol that incorporates motility agents and small bowel feeding tubes should be considered

Use of Nurse-directed Feeding ProtocolsStart feeds at 25 ml/hrCheck Residuals q4h> 250 mlhold feedsadd motility agentreassess q 4h

< 250 mladvance rate by 25 mlreassess q 4h

2009 Canadian CPGs www.criticalcarenutrition.comShould be considered as a strategy to optimize delivery of enteral nutrition in critically ill adult patients.

The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery:Results of a multicenter observational study

Heyland JPEN Nov 2010

Characteristics Total n=269Feeding Protocol Yes 208 (78%)Gastric Residual Volume Tolerated in Protocol Mean (range)217 ml (50, 500) Elements included in Protocol Motility agents 68.5%Small bowel feeding 55.2%HOB Elevation 71.2 %

The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery:Results of a multicenter observational study

Time to start EN from ICU admission: 41.2 in protocolized sites vs 57.1 hours in those without a protocolPatients recing motility agents: 61.3% in protocolized sites vs 49.0% in those withoutHeyland JPEN 2010 P

Impaired motilityMedicationsMetabolic, electrolyte abnormalitiesUnderlying disease

Reasons for Inadequate Intake

Initial Efficacy and Tolerability of Early Enteral Nutrition with Immediate or Gradual Introduction in Intubated PatientsDesachy ICM 2008;34:1054

This study randomized 100 mechanically ventilated patients (not in shock) to Immediate goal rate vs gradual ramp up (our usual standard).

The immediate goal group recd more calories with no increase in complications

Initial Efficacy and Tolerability of Early Enteral Nutrition with Immediate or Gradual Introduction in Intubated PatientsDesachy ICM 2008;34:1054

329 patients randomized to GRV 200 vs. 500>80% MedicalAverage APACHE II 18Similar nutritional adequacy:85 vs 88% goal caloriesWhat Gastric Residual Volume Threshold Should I use?

Protocol to Manage Interruptions to EN due to non-GI ReasonsCan be downloaded from www.criticalcarenutrition.com

Other Strategies to Maximize the Benefits and Minimize the Risks of ENHead of Bed elevation to 45 (or at least 30 if the patient doesnt tolerate 45)This will reduce regurgitation, aspiration and subsequent PneumoniaList of Contraindications to HOB Elevation unstable c-spine hemodynamically unstable Pelvic fractures with instabilityProne positionIntra-aortic ballon pumpProceduresUnable because of obesity

Impaired motilityMedicationsMetabolic, electrolyte abnormalitiesUnderlying diseaseDysmotility linked to decreased tolerance of EN gastropulmonary route of infectionTrials of Cisapride, Erythromycin, Metoclopramide, Other Strategies to Maximize the Benefits and Minimize the Risks of EN

Pro-motility AgentsBased on 1 level 1 study and 5 level 2 studies, in critically ill patients who experience feed intolerance (high gastric residuals, emesis), we recommend the use of a promotility agent. Given the safety concerns associated with erythromycin, the recommendation is made for metoclopramide. There are insufficient data to make a recommendation about the use of combined use of metoclopramide and erythromycin.

Conclusion: 1) Motility agents have no effect on mortality or infectious complications in critically ill patients. 2) Motility agents may be associated with an increase in gastric emptying, a reduction in feeding intolerance and a greater caloric intake in critically ill patients.

2009 Canadian CPGs www.criticalcarenutrition.com

Other Strategies to Maximize the Benefits and Minimize the Risks of ENMotility agents started at initiation of EN rather that waiting till problems with High GRV develop.Maxeran 10 mg IV q 6h (halved in renal failure)If still develops high gastric residuals, add Erythromycin 200 mg q 12h.Can be used together for up to 7 days but should be discontinued when not needed any moreReassess need for motility agents daily

Enhanced Protein-Energy Provision via the Enteral Routein Critically Ill Patients: The PEP uP Protocol

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 polymericTolerate 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 EnterallyHeyland Crit Care 2010

Change of nutritional intake from baseline to follow-up of all the study sites (Efficacy Analysis)% calories received/prescribed

% protein received/prescribedChange of nutritional intake from baseline to follow-up of all the study sites (Efficacy Analysis)

Effect on VAPUpdated 2011,www.criticalcarenutrition.comSmall Bowel vs. Gastric Feeding: A meta-analysis Other Strategies to Maximize the Benefits and Minimize the Risks of EN

Does Postpyloric Feeding Reduce Risk of GER and Aspiration?P=0.004P=0.09Heyland CCM 2001;29:1495-1501

Tube Position # of patients% positive for GER% positive for AspirationStomach21325.8D18274.1D23111.8D4150Total337511.7

What if you cant provide adequate nutrition enterally?

to add PN or not to add PN,that is the question!

Health Care Associated Malnutrition

Critical Care Nutrition CPGsIf unable to meet energy requirements after 7-10 days by the enteral route, consider initiating PN.Initiating PN prior to this 7-10 day period does not improve outcome and may be detrimental to the patient. AmericansMaximize EN (motility agents, small bowel feeds, etc.) prior to starting PN.

CanadiansAll patient who are not expected to be on normal nutrition within 3 days should receive PN within 24-48 hours if EN is contraindicated or if they can not tolerate adequate amounts of EN.Europeans

Early vs. Late Parenteral Nutrition in Critically ill Adults4620 critically ill patientsRandomized to early PN Recd 20% glucose 20 ml/hr then PN on day 3OR late PND5W IV then PN on day 8All patients standard EN plus tight glycemic control

Cesaer NEJM 2011Results:Late PN associated with 6.3% likelihood of early discharge alive from ICU and hospitalShorter ICU length of stay (3 vs 4 days)Fewer infections (22.8 vs 26.2 %)No mortality difference

Early vs. Late Parenteral Nutrition in Critically ill Adults? Applicability of dataNo one give so much IV glucose in first few daysNo one practice tight glycemic controlRight patient population?Majority (90%) surgical patients (mostly cardiac-60%)Short stay in ICU (3-4 days)Low mortality (8% ICU, 11% hospital)>70% normal to slightly overweightNot an indictment of PNEarly group only recd PN for 1-2 days on averageLate group only recd any PN

Cesaer NEJM 2011

What if you cant provide adequate nutrition enterally?

to TPN or not to TPN,that is the question!

ICU patientsBMI 35Stratified by:SiteBMIMed vs Surg

In ConclusionHealth Care Associate Malnutrition is rampantNot all ICU patients are the same in terms of riskIatrogenic underfeeding is harmful in some ICU patients or some will benefit more from aggressive feeding (avoiding protein/calorie debt)BMI and/or NUTRIC Score is one way to quantify that riskNeed to do something to reduce iatrogenic malnutrition in your ICU!Audit your practice first!Consider updating your feeding protocol!

www.criticalcarenutrition.com

Questions?www.criticalcarenutrition.com

Add pep up slides*R-make sure up to date. DONE*R- make sure up to date. DONE*****Remove the 1/3-2/3 data**Need picture of malnourshed child*Rupinder to update*Get a copy of the one nestle uses for their tool kit***Add slide on interrruptions to EN re procedures.****