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Achieving Nutritional Adequacy in Adult Critical Care: what is the evidence?

Ruly Sjambali

Clarion Hotel Makassar, 25 April 2015 2nd MAKASSAR ANNUAL MEETING ON CLINICAL NUTRITION 2015

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Nutritional Adequacy• Nutritional adequacy is a difficult concept to translate ( Marisa Porrini,

Department of Food, Nutrition and Environmental Sciences, University of Milan, 2011 )

• Nutritional adequacy is comparing the amount of energy /nutients consumed with the amount required

(Colleen M. O’Leary-Kelley et al ,Am J Crit Care May 2005vol. 14 no. 3 222-231)

Nutritional adequacy must :Agee to nutritional requirement (Nutritional assessment, nutritional intake, route of administration, monitoring )Adjust to metabolic (biochemical-physiological functioning ) in critical illness adult patients with dynamic stateAvoid under-feeding, over-feedingScientific evidence ( EBM, Guideline,etc )

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Colleen M. O’Leary-Kelley, Kathleen A. Puntillo, Juliana Barr, Nancy Stotts, Marilyn K. Douglas : Nutritional Adequacy in Patients Receiving Mechanical Ventilation Who Are Fed Enterally : Am J Crit Care May 2005vol. 14 no. 3 222-231

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Consequences of Underfeeding & Overfeeding

Kirsten Martine Schlein, Sarah Pescoe Coulter : Nutrition in Clinical Practice, Feb 2014

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• gastrointestinal intolerance of tube feeding (eg, large gastric residual volumes, nausea and vomiting, ileus, abdominal distention, and diarrhea

• displacement or obstruction of the feeding tube, • interruption of tube feedings for tests and procedures. • withheld in patients with unstable hemodynamic conditions • preparation for surgical or diagnostic procedures, Weaning• various nursing care activities.

Colleen M. O’Leary-Kelley, Kathleen A. Puntillo, Juliana Barr, Nancy Stotts, Marilyn K. Douglas : Nutritional Adequacy in Patients Receiving Mechanical Ventilation Who Are Fed Enterally : Am J Crit Care May 2005vol. 14 no. 3 222-231

Factors to Inadequate nutritional intake in EN

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SCCM & ASPEN Guideline 2009

Nutritional Assessment

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Energy

ESPEN Guideline 2009, ASPEN Guideline 2009

Measured Energy Requirement :• Indirect Calorimetry ( Gold Standard )• Predictive Equations & Clinical Judgement

Penn State Unviersity Equations critically ill esp ventilated, accurate rate : 70% – 75%) ( Kirsten Martine Schlein, Sarah Pescoe Coulter : Nutrition in Clinical Practice, Feb 2014 )

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Penn StatePSU (HBE) = HBE(0.85) + Tmax(175) + Ve(33) – 6344 PSU (modified) = Mifflin(0.96) + Tmax(167) + Ve(31) – 6212PSU (modified for BMI > 30 and age > 60 years) = Mifflin(0.71) + Tmax(85) + Ve(64) – 3085

Tmax is maximum body temperature in the previous 24 hours Ve is minute ventilation at the time of measurement, read from the ventilator, not the calorimeter.

MifflinMen: 10(wt) + 6.25(ht) – 5(age) + 5Women: 10(wt) + 6.25(ht) – 5(age) – 161

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• Acute & Initial Phase of critical illness non-obese : 20 – 25 kcal/kg BW /d ( Espen, grade C ) Initial Goal : 80% of Energy requirement ( Aspen, grade C )

obese ( BMI ≥ 30 ) : 11 – 14 kcal/kg ABW/d ( Aspen, grade D) 22- 25 kcal/kg IBW ( Aspen, Grade D ) Initial Goal : 60 – 70% Energy requirement ( Aspen, grade D )

“ Start slow, go slow target goal calory “ ( Aspen, grade E )

• During recovery ( anabolic flow phase ) 25 – 30 kcal/kg BW/d ( Espen, grade C )

• Severe Under-nutrition 25 – 30 kcal/kg BW/d ( Espen, grade C )

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Carbohydrate / CHO

• Minimal amount requirement : Glucose : 2 g/kg/24 h

Hyperglycemia : Blood Glucose > 10 mmol/LMaintained at 4.5 – 6.1 mmol/L

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Protein

Clinical Nutrition 28 ( 2009 ) 387 - 4000

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Protein

• BMI < 30 1.2 – 2 g/kg ABW /d ( Aspen Guideline 2009, grade E )

• BMI 30 – 40 ≥ 2 g/kg IBW/d ( Aspen Guideline 2009 , grade D • BMI ≥ 40 ≥ 2.5 g/kg IBW/d ( Aspen Guideline 2009, grade D )

Higher protein has not effect on mortality and infectious complication

(Canadian Clinical Practice Guidelines, March 2013 )

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LipidLipid Emulsion :• Soybean Emulsion lipid ( omega 6 + omega 3 )• Fish Oil ( omega 3 )• Olive Oil ( omega 9 )• MCT

Issue : LCT Reducing strategies = soybean oil sparing strategies

Canadian Clinical Practice Guidelines, March 2013

Lipid Emulsion : 0.7 – 1.5 g/kg over 12 h to 24 h ( P. Singer et al, Clinical Nutrition 28 ( 2009 ) 387 - 400

Omega 6 : pro-inflammatory FA >< Omega 3: anti-inflammatory FA

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Micronutrients

Canadian Clinical Practice Guidelines, March 2013

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High Fat / Low CHO

Canadian Clinical Practice Guidelines, March 2013

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Low Fat / High CHO

Canadian Clinical Practice Guidelines, March 2013

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Combination PN and EN

Canadian Clinical Practice Guidelines, March 2013

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SCCM & ASPEN Guideline 2009

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SCCM & ASPEN Guideline 2009

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SUMMARY

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1. Reference :2. Colleen M. O’Leary-Kelley, Kathleen A. Puntillo, Juliana Barr, Nancy Stotts,

Marilyn K. Douglas ; Nutritional Adequacy in Patients Receiving Mechanical Ventilation Who Are Fed Enterally ; Am J Crit Care May 2005vol. 14 no. 3 222-231

3. Clinical Nutrition Week 14, Jan 20144. Clinical Nutrition 28 ( 2009 ) 387 - 40005. Canadian Clinical Practice Guidelines, March 20136. ESPEN Guideline 2009, Kirsten Martine Schlein, Sarah Pescoe Coulter : Nutrition

in Clinical Practice, Feb 20147. Marianne Aloupis ,Carolyn Spencer, Charlene Compher, Michele Nicolo ;

Comparison of Documented Enteral Nutrition Delivery Versus Actual Enteral Nutrition Delivery ; Clinical Nutrition Week 14, Jan 2014

8. Patricia A. Higgins, RN, PhD, Barbara J. Daly, RN, PhD, Amy R. Lipson, PhD, and Su-Er Guo, RN, PhD ; Assessing Nutritional Status in Chronically Critically Ill Adult Patients ; Am J Crit Care. 2006 Mar; 15(2): 166–177.

9. P.Singer et al ; Clinical Nutrition 28 ( 2009 ) 387 - 40010. SCCM & ASPEN Guideline 2009

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Thanks