learning objectives define iatrogenic malnutrition describe the nature of the evidence related to...
TRANSCRIPT
Learning Objectives
• Define iatrogenic malnutrition
• Describe the nature of the evidence related to optimal amount of calories/protein
• List key variables to consider in assessing nutritional risk in ICU patients
• List strategies to improve nutritional adequacy in the critical care setting.
A different form of malnutrition?
Health Care Associated Malnutrition
Nutrition deficiencies associated with physiological derangement and organ
dysfunction that occurs in a health care facility
Patients who will benefit the most from nutrition therapy and who will be harmed the most from
by iatrogenic malnutrition (underfeeding)
Adjunctive Supportive Care
ProactivePrimaryTherapy
Early and Adequate Nutrition is therapy that modulates the underlying disease process and impacts patient outcomes
Early Feeding Supports Gastrointestinal Structure and
Function• Maintenance of gut barrier function
• Increased secretion of mucus, bile, IgA• Maintenance of peristalsis and blood flow
•Attenuates oxidative stress and inflammation•Supports GALT
•Improves glucose absorption
Alverdy (CCM 2003;31:598)Kotzampassi Mol Nutr Food Research 2009 Nguyen CCM 2011
Early vs. Delayed EN: Effect on Infectious
Complications
Updated 2009www.criticalcarenutrition.com
Early vs. Delayed EN: Effect on Mortality
Updated 2009www.criticalcarenutrition.com
Feeding the Hypotensive Patient?
DiGiovine et al. AJCC 2010
The 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!
Increasing Calorie Debt Associated with worse Outcomes
Caloric debt associated with: Longer ICU stay
Days on mechanical ventilation Complications
Mortality
Adequacy of EN
Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006
0200
400600
8001000
12001400
16001800
2000
1 3 5 7 9 11 13 15 17 19 21
Days
kcal
Prescribed Engergy
Energy Received From Enteral Feed
Caloric Debt
• Point prevalence survey of nutrition practices in ICU’s around the world conducted Jan. 27, 2007
• Enrolled 2772 patients from 158 ICU’s over 5 continents
• Included ventilated adult patients who remained in ICU >72 hours
Effect of Increasing Amounts of Calories from EN on Infectious
Complications
Heyland Clinical Nutrition 2010
Multicenter observational study of 207 patients >72 hrs in ICU followed prospectively for development of infection
for increase of 1000 cal/day, OR of infection at 28 days
Relationship between increased nutrition intake and physical function (as defined by SF-36 scores)
following critical illness
Multicenter RCT of glutamine and antioxidants (REDOXS Study)First 364 patients with SF 36 at 3 months and/or 6 months
for increase of 30 gram/day, OR of infection at 28 days
Heyland Unpublished Data
Model *
Estimate (CI)P values
(A) Increased energy intake
PHYSICAL FUNCTIONING (PF) at 3 months 3.2 (-1.0, 7.3) P=0.14
ROLE PHYSICAL (RP) at 3 months 4.2 (-0.0, 8.5) P=0.05
STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 3 months
1.8 (0.3, 3.4) P=0.02
PHYSICAL FUNCTIONING (PF) at 6 months 0.8 (-3.6, 5.1) P=0.73
ROLE PHYSICAL (RP) at 6 months 2.0 (-2.5, 6.5) P=0.38
STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 6 months
0.70 (-1.0, 2.4) P=0.41
Faisy BJN 2009;101:1079
Mechancially Vent’d patients >7days (average ICU LOS 28 days)
More (and Earlier) is Better!
If you feed them (better!)They will leave (sooner!)
Permissive Underfeeding(Starvation)?
187 critically ill patients Tertiles according to ACCP recommended levels of
caloric intake Highest tertile (>66% recommended calories) vs.
Lowest tertile (<33% recommended calories) in hospital mortality Discharge from ICU breathing spontaneously
Middle tertile (33-65% recommended calories) vs. lowest tertile Discharge from ICU breathing spontaneously
Krishnan et al Chest 2003
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 audit
• Setting: 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
Association between 12 day average caloric adequacy and
60 day hospital mortality(Comparing patients rec’d >2/3 to those who rec’d
<1/3)A. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are included as zero calories*
B. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.*
C. In ICU for at least 4 days before permanent progression to exclusive oral feeding. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.*
D. In ICU at least 12 days prior to permanent progression to exclusive oral feeding*
*Adjusted for evaluable days and covariates,covariates include region (Canada, Australia and New Zealand, USA, Europe and South Africa, Latin America, Asia), admission category (medical, surgical), APACHE II score, age, gender and BMI.
0.4 0.6 0.8 1.0 1.2 1.4 1.6
UnadjustedAdjusted
Odds ratios with 95% confidence intervals
Association Between 12-day Caloric Adequacy and 60-Day Hospital
Mortality
Heyland CCM 2011
Optimal amount= 80-85%
More (and Earlier) is Better!
If you feed them (better!)They will leave (sooner!)
JAMA 1994;271:56
Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure
• Single center study of 200 mechanically ventilated patients
• Trophic feeds: 10 ml/hr x 5 days
Rice CCM 2011;39:967
Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure
Rice CCM 2011;39:967
What other outcomes might be important?
Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure
“survivors 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
Rice et al. JAMA 2012;307
Rice et al. JAMA 2012;307
Still no measure of physical function!
Rice et al. JAMA 2012;307
Enrolled 12% of patients screened
Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure
• Average age 52
• Few comorbidities
• Average BMI 29-30
• All 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!
Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure
Randomized Good follow up ITT No blinding
1. How representative are these patients to ALL the patients in your
ICU? May miss an important negative effect in ‘high risk’ patients
2. What about the physically recovery of underfed patients?
No benefit, potential harm, minimal cost advantage= Do not use routinely!
Internally valid
ICU patients are not all created equal…should 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?
Health Care Associated Malnutrition
Do Nutrition Screening tools help us discriminate those ICU patients that will benefit the most from artificial nutrition?
Patients who will benefit the most from nutrition therapy and who will be harmed the most from
by iatrogenic malnutrition (underfeeding)
All ICU patients treated the same
Albumin: a marker of malnutrition?
• Low levels very prevalent in critically ill patients• Negative acute-phase reactant such that synthesis,
breakdown, and leakage out of the vascular compartment with edema are influenced by cytokine-mediated inflammatory responses
• Proxy for severity of underlying disease (inflammation) not malnutrition
• Pre-albumin shorter half life but same limitation
Subjective Global Assessment?
• When training provided in advance, can produce reliable estimates of malnutrition
• Note rates of missing data
• mostly medical patients; not all ICU• rate of missing data?• no difference between well-nourished and malnourished patients with regard to the serum protein values on admission, LOS, and mortality rate.
“We must develop and validatediagnostic criteria for appropriate
assignment of thedescribed malnutrition syndromes
to individual patients.”
Nutrition Statusmicronutrient levels - immune markers - muscle mass
Starvation
Acute-Reduced po intake
-pre ICU hospital stay
Chronic-Recent weight loss
-BMI?
InflammationAcute
-IL-6-CRP-PCT
Chronic-Comorbid illness
A 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 patients
• Historical po intake and weight loss only available in 171 patients
• Outcome: 28 day vent-free days and mortality
Heyland 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] <.001
Baseline APACHE II score 26.0 [21.0 to 31.0] 20.0 [15.0 to 25.0] <.001
Baseline SOFA 9.0 [6.0 to 11.0] 6.0 [4.0 to 8.5] <.001
# of days in hospital prior to ICU admission 0.9 [0.1 to 4.5] 0.3 [0.0 to 2.2] <.001
Baseline Body Mass Index 26.0 [22.6 to 29.9] 26.8 [23.4 to 31.5] 0.13
Body Mass Index 0.66
<20 6 ( 4.3%) 25 ( 5.4%)≥20 122 ( 88.4%) 414 ( 90.0%)
# of co-morbidities at baseline 3.0 [2.0 to 4.0] 3.0 [1.0 to 4.0] <0.001
Co-morbidity <0.001
Patients with 0-1 co-morbidity 20 (14.5%) 140 (30.5%)Patients with 2 or more co-morbidities 118 (85.5%) 319 (69.5%)
C-reactive protein¶ 135.0 [73.0 to 214.0] 108.0 [59.0 to 192.0] 0.07
Procalcitionin¶ 4.1 [1.2 to 21.3] 1.0 [0.3 to 5.1] <.001
Interleukin-6¶ 158.4 [39.2 to 1034.4] 72.0 [30.2 to 189.9] <.001
171 patients had data of recent oral intake and weight loss Non-survivors by day 28
(n=32) Survivors by day 28
(n=139) p values
% Oral intake (food) in the week prior to enrolment 4.0[ 1.0 to 70.0] 50.0[ 1.0 to 100.0] 0.10
% of weight loss in the last 3 month 0.0[ 0.0 to 2.5] 0.0[ 0.0 to 0.0] 0.06
Variable
Spearman correlation with VFD within 28
days
p valuesNumber of
observations
Age -0.1891 <.0001 598
Baseline APACHE II score -0.3914 <.0001 598
Baseline SOFA -0.3857 <.0001 594
% Oral intake (food) in the week prior to enrollment 0.1676 0.0234 183
number of days in hospital prior to ICU admission -0.1387 0.0007 598
% of weight loss in the last 3 month -0.1828 0.0130 184
Baseline BMI 0.0581 0.1671 567
# of co-morbidities at baseline -0.0832 0.0420 598
Baseline CRP -0.1539 0.0002 589
Baseline Procalcitionin -0.3189 <.0001 582
Baseline IL-6 -0.2908 <.0001 581
What are the nutritional risk factors associated with clinical outcomes?
(validation of our candidate variables)
The Development of the NUTrition Risk in the Critically ill Score (NUTRIC
Score).
• % oral intake in the week prior was dichotomized into patients who reported less than 100% versus everyone else
• Weight loss was dichotomized as patients who reported any weight loss versus everyone else.
• BMI was dichotomized as <20 versus other
• Comorbidities was left as integer values range 0-5
• The remaining candidate variables were categorized into five equal sized groups (quintiles).
The Development of the NUTrition Risk in the Critically ill Score (NUTRIC
Score).
For example, exact quintiles and logistic parameters for age
Exact Quintile Parameter Points
19.3-48.8 referent 0
48.9-59.7 0.780 1
59.7-67.4 0.949 1
67.5-75.3 1.272 1
75.4-89.4 1.907 2
The Development of the NUTrition Risk in the Critically ill Score (NUTRIC
Score). Variable Range PointsAge <50 0
50-<75 1>=75 2
APACHE II <15 015-<20 120-28 2>=28 3
SOFA <6 06-<10 1>=10 2
# Comorbidities 0-1 02+ 1
Days from hospital to ICU admit 0-<1 01+ 1
IL6 0-<400 0400+ 1
AUC 0.783Gen R-Squared 0.169Gen Max-rescaled R-Squared 0.256
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.
The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).
0 1 2 3 4 5 6 7 8 9 10
Nutrition Risk Score
Mo
rta
lity
Ra
te (
%)
02
04
06
08
0
ObservedModel-based
n=12 n=33 n=55 n=75 n=90 n=114 n=82 n=72 n=46 n=17 n=2
The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).
0 1 2 3 4 5 6 7 8 9 10
Nutrition Risk Score
Da
ys o
n M
ech
an
ica
l Ve
ntil
ato
r
02
46
81
01
21
4 ObservedModel-based
n=12 n=33 n=55 n=75 n=90 n=114 n=82 n=72 n=46 n=17 n=2
The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).
0 50 100 150
0.0
0.2
0.4
0.6
0.8
1.0
Nutrition Adequacy Levles (%)
28
Da
y M
ort
alit
y
11 111
1
111
22
2
22 2
22
2
33
333
33
3
3
333
3
3
33
33
444444
4444
4
444
44 4444
44
4
44
4 444 4 44
44
4
55 5555 5 55 5 5 5 5 5
5 55555 5
5
55
555 55 55555
55
5 555 555
66 66 6666666
6 66
6
666 666 66 6
6
66
66
6 6
666
6 66
66
77
7
77
7
7
7
7
7
7
7
7
7
77
7
7
77
7
7
7 7
7
88
8
8
8
8
8
8
88
88
8
88
8
8
88
8
8
8
99
9
9
9
9
9
9
9
1010
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?
• Clinical– BMI– Projected long length of stay
• Others?
Do we have a problem?
Preliminary Results of INS 2011
Overall Performance: Kcals
84%56%
15%
N=211
Failure Rate% patients who failed to meet minimal quality targets (80% overall energy
adequacy)
Strategies to Maximize the Benefits and Minimize the Risks
of EN
• feeding protocols
• motility agents
• elevation of HOB
• small bowel feeds
weak evidence
stronger evidence
Canadian CPGs www.criticalcarenutrition.com
Use of Nurse-directed Feeding Protocols
Start feeds at 25 ml/hr
Check Residuals
q4h
> 250 ml
•hold feeds
•add motility agent
•reassess q 4h
< 250 ml
•advance rate by 25 ml
•reassess q 4h
2009 Canadian CPGs www.criticalcarenutrition.com
“Should be considered as a strategy to optimize delivery of enteral nutrition in critically ill adult patients.”
Characteristics Total
n=269
Feeding 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
Heyland JPEN 2010
15.2% using the recommended
threshold volume of 250 ml
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 protocol
• Patients rec’ing motility agents 61.3% in protocolized sites vs 49.0% in those without
Heyland JPEN 2010
0
20
40
60
80
Calories from EN Total Calories
Protocol
No Protocol
P<0.05
P<0.05
Can we do better?
The same thinking that got you into this mess won’t get you out of it!
Impaired motility Medications Metabolic, electrolyte abnormalities Underlying disease
Reasons for Inadequate Intake
Prophylactic use of motility agents
Slow starts and slow ramp ups Interruptions
Mostly related to procedures Not related to GI dysfunction
Can be overcome by better feeding
protocols
Protocol to Manage Interruptions to EN due to non-
GI Reasons
Can be downloaded from www.criticalcarenutrition.com
Enhanced Protein-Energy Provision
via the Enteral Routein Critically Ill Patients:
The PEP uP Protocol
• Different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds.
• 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 polymeric• Tolerate higher GRV threshold (250 ml or more)• Motility agents and protein supplements are started
immediately• Nurse reports daily on nutritional adequacy.
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 Enterally
Begin 24 hour volume-based feeds. After initial tube placement confirmed, start Pepatmen 1.5. Total volume to receive in 24 hours is 17ml x weight (kg)= <write in 24 target volume>. Determine initial rate as per Volume Based Feeding Schedule. Monitor gastric residual volumes as per Adult Gastric Flow Chart and Volume Based Feeding Schedule. OR Begin Peptamen 1.5 at 10 mL/h after initial tube placement confirmed. Hold if gastric residual volume >500 ml and ask Doctor to reassess. Reassess ability to transition to 24 hour volume-based feeds next day. {Intended for patient who is hemodynamically unstable (on high dose or escalating doses of vasopressors, or inadequately resuscitated) or not suitable for high volume enteral feeding (ruptured AAA, upper intestinal anastomosis, or impending intubation)}OR
NPO. Please write in reason: __________________ ______. (only if contraindication to EN present: bowel perforation, bowel obstruction, proximal high output fistula. Recent operation and high NG output not a contraindication to EN.) Reassess ability to transition to 24 hour volume-based feeds next day.
Stable patients should be able to tolerate goal rate
We use a concentrated solution to maximize
calories per ml
Drs need to justify why there are keeping patients
NPO
If unstable or unsuitable, just use
trophic feeds
We want to minimize the use of NPO but if selected, need to reassess next day
The PEP uP Protocol
Note, there are only a few absolute
contraindications to EN
Note indications for trophic feeds
It’s not just about calories...
Protein supplement Beneprotein® 14 grams mixed in 120 mls sterile water
administered bid via NG
So in order to minimize this, we order:
Loss of lean muscle mass
Inadequate protein intake
Immune dysfunction
WeakProlonged mechanical
ventilation
Other Strategies to Maximize the Benefits and Minimize the Risks of
EN
• Motility 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 more
– Reassess need for motility agents daily
The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients:
The PEP uP Protocol!
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 TotalP-value 0.08 0.0003 0.10 0.19 0.48 0.18 0.11 <0.0001
Adequacy of Calories from EN (Before Group vs. After Group on Full Volume Feeds)
Heyland Crit Care 2010
Change of nutritional intake from baseline to follow-up of all the study sites (all patients)
% calories received/prescribed
% c
alo
rie
s re
ceiv
ed
/pre
scri
be
d
326326
326326
331331
331331
360360
360360
371371
371371
372372372372
373373373373
374374
374374
375375
375375
390390
390390
Baseline Follow-up
20
30
40
50
60
70
80
p value <0.0001
Intervention sites
% c
alo
rie
s re
ceiv
ed
/pre
scri
be
d
p value=0.65
327327 327327
p value=0.65p value=0.65
359359
359359
p value=0.65p value=0.65
362362
362362
p value=0.65p value=0.65p value=0.65p value=0.65p value=0.65p value=0.65
376376
376376
p value=0.65
377377
377377
p value=0.65
378378378378
p value=0.65
379379
379379
p value=0.65
380380
380380
p value=0.65p value=0.65
404404
404404
p value=0.65p value=0.65
Baseline Follow-up
20
30
40
50
60
70
80
Control sites
Change of nutritional intake from baseline to follow-up of all the study sites (all patients)
% protein received/prescribed
% p
rote
in r
ece
ive
d/p
resc
rib
ed
326326
326326
331331
331331
360360
360360
371371
371371
372372
372372
373373 373373
374374
374374
375375
375375390390
390390
Baseline Follow-up
20
30
40
50
60
70
80
p value <0.0001
Intervention sites
% p
rote
in r
ece
ive
d/p
resc
rib
ed
p value=0.78
327327 327327
p value=0.78p value=0.78
359359
359359
p value=0.78p value=0.78
362362 362362
p value=0.78p value=0.78p value=0.78p value=0.78p value=0.78p value=0.78
376376
376376
p value=0.78
377377
377377
p value=0.78
378378
378378
p value=0.78
379379
379379
p value=0.78
380380
380380
p value=0.78p value=0.78
404404
404404
p value=0.78p value=0.78
Baseline Follow-up
20
30
40
50
60
70
80
Control sites
Effect on VAP
Updated 2011,www.criticalcarenutrition.com
Small 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?
Tube Position
# of patients
% positive for GER
% positive for
Aspiration
Stomach 21 32 5.8
D1 8 27 4.1
D2 3 11 1.8
D4 1 5 0
Total 33 75 11.7
P=0.004 P=0.09
Heyland CCM 2001;29:1495-1501
FRICTIONAL ENTERAL FEEDING TUBE(TIGER TUBETM)
Flaps to allow peristalsis to pull tube passively forward
Sucessful jejunal placement >95%
CORTRAK® A new paradigm in feeding tube placement
– Aid to placement of feeding tubes into the stomach or small bowel
– The tip of the stylet is a transmitter.
– Signal is picked up by an external receiver unit.
– Signal is fed to an attached Monitor unit.
– Provides user with a real-time, graphic display that represents the path of the feeding tube.
A Change to Nursing Report
Adequacy of Nutrition Support =
24 hour volume of EN receivedVolume prescribed to meet caloric
requirements in 24 hours
Please report this % on rounds as
part of the GI systems report
When performance is measured, performance improves.
When performance is measured and
reported back, the rate of improvement
accelerates. Thomas Monson
What if you can’t provide adequate nutrition enterally?
… to add PN or not to add PN,
that is the question!
Health Care Associated Malnutrition
Early vs. Late Parenteral Nutrition in Critically ill Adults
• 4620 critically ill patients
• Randomized to early PN
– Rec’d 20% glucose 20 ml/hr then PN on day 3
• OR late PN
– D5W IV then PN on day 8
• All patients standard EN plus ‘tight’ glycemic control
Cesaer NEJM 2011
• Results:
Late PN associated with
• 6.3% likelihood of early discharge alive from ICU and hospital
• Shorter 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 data– No one give so much IV glucose in first few days– No one practice tight glycemic control
• Right 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 overweight
• Not an indictment of PN– Early group only rec’d PN for 1-2 days on average– Late group –only ¼ rec’d any PN
Cesaer NEJM 2011
What if you can’t provide adequate nutrition enterally?
… to TPN or not to TPN,
that is the question!
•Case by case decision•Maximize EN delivery
prior to initiating PN•Use early in high risk
cases
ICU patientsBMI <25 R
PN for 7 days
Control
The TOP UP Trial
Fed enterally
Primary Outcome
60-day mortality
BMI >35
Stratified by:SiteBMI
Med vs Surg
In Conclusion• Health Care Associate Malnutrition is rampant• Not all ICU patients are the same in terms of ‘risk’• Iatrogenic 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 risk• Need to do something to reduce iatrogenic malnutrition in
your ICU!– Audit your practice first!– PEP uP protocol in all– Selective use of small bowel feeds then sPN in high risk patients
Yes
YES
Day 3
>80% of Goal
CaloriesNo
NO
No problem
Anticipated Long Stay?
Yes No
Maximize EN with motility agents and small bowel feeding
Yes
YES Not tolerating
EN at 96 hrs? No
NO
Supplemental PN?
Start PEP UP
High Risk?
Carry on!
www.criticalcarenutrition.com
Questions?