sccm/aspen critical care guidelines...
TRANSCRIPT
S C C M / A S P E N C R I T I C A L C A R E
G U I D E L I N E S W H A T ’ S N E W ?
Rebecca Stevenson RD Global Medical Affairs Nutricia
New SCCM & ASPEN Guidelines 2016
Content
The development of the guidelines Nutritional Assessment Initiate EN Dosing of EN Monitoring tolerance and adequacy of EN Selection of appropriate enteral form Other patient groups
SCCM & ASPEN Guidelines 2016
SCCM & ASPEN Guidelines 2016
GUIDELINES; Should never take priority over clinical judgement, they should be interpreted in context of the institutional setting importance. They are there to help you organize data, provide reference, a good start.
The evidence supporting the guidelines is GRADED mostly low to very low, as quality of studies are not comparable to pharmaceutical studies (budgets are much lower) and difficult feeding studies are difficult to blind.
(Prof Steve McClave, ASPEN 2016)
Introduction
Delivering early nutrition support therapy, primarily by the enteral route, is seen as a
proactive therapeutic strategy that may reduce disease severity, diminish complications,
decrease LOS in the ICU, and favorably impact patient outcomes
The target of these guidelines is intended to be the adult (≥18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical
ICU (MICU) or surgical ICU (SICU)
Historically see as a adjunctive care
Evolved to nutrition therapy
A. Nutritional Assessment
A2. We suggest not using nutrition indicators or surrogate markers and they are
not validated in the critical care setting.
ASPEN 2009 ASPEN 2016 Difference
No recommendation A1. Based on expert opinion Determine nutritional risk screening (e.g. using NRS 2002 or NUTRIC score) in those patients
admitted to ICU that can not take an adequate oral intake. High nutritional
risk identifies those patients most likely to benefit early EN therapy.
New recommendation
A3b. Indirect calorimetry (IC) used when available to measure energy
requirements, in the absence of IC use a simplistic weight based equation 25-
30kcal/kg/bwt
Very low grade of evidence
B. Initiate EN
B2. We suggest the use of EN over PN in critically
ill patients who require nutrition support therapy.
ASPEN 2009 ASPEN 2016 Difference
A4. EN should be started within 24-48 hours
following admission. The feedings should be
advanced towards goal over the next 48-72 hours
B1. We recommend that nutrition support is in the form of early EN initiated within 24-48 hours in the critically ill patient who is unable to maintain volitional intake
Similar
A3. EN is the preferred route of feeding over PN
for critically ill who requires nutrition support
therapy
B2. We suggest to use of EN over PN in critically ill patients who require nutrition support therapy
Similar
Early EN associated with reduced mortality
Updated meta-analysis of 21RCTs that met their criteria Early EN vs withholding early EN (delayed EN or STD) was associated with a significant reduction in mortality (RR = 0.70; 95% CI, 0.49–1.00; P = 0.05)
C. Dosing of EN
ASPEN 2009 ASPEN 2016 Difference
C2. >50-65% of goal calories should be provided in order to achieve the clinical benefit of EN over the first week of hospitalization (25-30kcal/kg)
C3. patients who are at high nutritional risk (e.g. NRS 2002≥5, or NUTRIC ≥5 should be advanced towards goal as quickly as tolerated over 24-48 hours while monitoring for refeeding. 80% goal energy & protein within 48-72 hours to achieve clinical benefits of EN over first week of hospitalization
Increase from 65% to 80% target should be met. Includes protein goal whereas, 2009 only specified energy
C4. Protein Requirements
Optimal protein and energy targeting
using measured energy expenditure and
1.2-1.5g protein per kg body weight was
associated with 50% reduction in
hospital mortality
Highest protein provision had highest
28-day survival
Importance of successful feeding
Allingstrup MJ, et al. Clin Nutr 2012;31:462–468; Weijs PJ, et al. JPEN J Parenter Enteral Nutr 2012;36:60–68.
This content may not be amended, modified or commercially exploited without prior written consent.
D.D. Monitoring Tolerance and Adequacy of EN
ASPEN 2009 ASPEN 2016 Difference
No recommendation D2a. GRVs NOT to be used as part of routine care to monitor ICU patients
receiving EN
New guidelines
D2. holding EN for GRV <500mls should
be avoided in absence of other signs of
intolerance
D2b. In ICUs where GRVs are still utilized, holding EN for GRV<500mls
in the absence of other signs of intolerance should be avoided
Same
Rationale: GRVs do not correlate with incidence of pneumonia, regurgitation, or aspiration.
Should GRV be measured?
Absence of gastric
volume monitoring
was not inferior to
routine gastric
residual volume
monitoring
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Reignier J, et al. JAMA 2013;309:249–256.
D. EN Protocol
ASPEN 2009 ASPEN 2016 Difference
D.3 Use EN protocol increases increases the
overall percentage of goal calories provided
and should be implemented
D3a. EN feeding protocols designed and implemented to increase the overall percentage of goal calories provided. D3b. suggest considering volume based feeding protocol or a top-down multi-strategy protocol.
New recommendation
E. Selection of appropriate enteral formula General immune-modulating enteral formulas (supplemented with arginine, glutamine, nucleic acid, omega 3 fatty acids and antioxidants)
ASPEN 2009 ASPEN 2016 Difference
E1. Immune modulating EN use in appropriate patients (major elective surgery, trauma, burns, head & neck cancer), & critically ill patients on mechanical ventilation, with caution in severe sepsis
E2. Should NOT be used routinely in the MICU. Consider in TBI & peri-operative patients in the SICU E.1 Standard polymeric formula, when initiating EN in the ICU setting. We suggest avoiding the routine use of all specialty formulas in critically ill patients in the medical ICU and disease specific formulas in the surgical ICU
Only recommended now for TBI and
peri-operative SICU
ASPEN 2009 ASPEN 2016 Difference
ARDs & severe ALI (acute lung injury)
should be on an EN formula with an anti-
inflammatory lipid profile (ie, omega 3 fish
oils, borage oils) & antioxidants
CAN NOT make a recommendation at this time (as per 2009) due to conflicting data.
cannot make a recommendation
• We suggest avoiding the routine use of all specialty formulas in critically ill patients in MICU and disease specific in the SICU
• IMN only in postoperative phase
• Pulmonary formulas with omega 6 may drive inflammation – no recommendation
E.3 Fish oils – specialty formulas
6 RCTS in ARDS, ALI and sepsis. Great heterogeneity of method of infusion. Aggregating studies showed no sig reduction ICU LOS, duration of mechanical ventilation. Rice study contained
additional 16g protein/day in control compared to 4g in study group.
Date of download: 2/25/2016 Copyright © 2016 American Medical
Association. All rights reserved.
From: Enteral Omega-3 Fatty Acid, γ-Linolenic Acid, and Antioxidant Supplementation in Acute Lung Injury
JAMA. 2011;306(14):1574-1581. doi:10.1001/jama.2011.1435
Bolus study and the control product had higher protein content Study stopped due to futility. Possible indication of harm in supplemented
patients with ALI
F4.Glutamine
ASPEN 2009 ASPEN 2016 Difference
Glutamine should be considered in burn,
trauma & mixed ICU patients
EN glutamine should NOT be added to an EN regimen routinely in critically ill patients
New recommendation
Metaplus
ASPEN 2009 ASPEN 2016 Difference
B.1 Start PN> 8 days in the case
enteral nutrition not
reaching calorie targets
G1. patient at low nutrition risk NRS≤3 or NUTRIC ≤5 exclusive PN
be withheld over the first 7 days following ICU admission if the
patient cannot maintain volitional intake and if early EN is not
feasible G2. if patient is determined to be
high nutrition risk (NRS≥5 or NUTRIC ≥5 or severely
malnourished, when EN is not feasible, we suggest initiating PN as soon as possible following ICU
admissions
New recommendation –
consider early PN in those malnourished
or high nutritional risk
G. When to use PN
EPaNIC primary endpoints Late PN Early PN P-value
Discharged alive within 8 days 75.2 % 71.7 % P = 0.007
ICU stay (days) median (IQR) 3 (2 – 7)
(mean 8)
4 (2 – 9)
(mean 9) P = 0.02
Time to alive discharge from ICU
Hazard ratio (95%CI) Adjusted cox proportional hazard analysis
1.063 (1.002 – 1.128) P = 0.04
G. When to start PN: data influencing
M. Surgical
ASPEN 2009 ASPEN 2016 Difference
E1. IMN recommended in trauma
M1a. We suggest that, similar to other critically ill patients, early enteral feeding with a high protein polymeric diet be initiated in the immediate post trauma period (within 24-48 hours of injury) once the patient is haemodynamically stable . Energy in the ranges of 20-35kcal/kg depending on phase, lower energy provision in resuscitative phase, higher in rehabilitation phase. 1.2 – 2g/kg/bwt /day protein May benefit from volume based feeding approach
New recommendation Also mention M1b. IMN containing arginine and
fish oil considered in patients with severe
trauma (very low quality of evidence)
AM2b. expert consensus arginine IMN in TBI
ASPEN 2009 ASPEN 2016 Difference
No equivalent recommendations
Expert consensus, EEN (24-48 hours post-injury) in patients treated with OA in the absense of a bowel injury. Suggest providing 15-30g per liter of exudate lost for patients with OA Energy needs determined same for other ICU patients
New recommendation
Multicentred, restrospective data of n-597 patients with OA 307 with no bowel injury showed that use of EN assoss with sign. Reduction in abdominal fascial closure, pneumonia,
compllications and mortality (Burlew et al 2012). EEN restrospective review found early fascial closure and less fistula formation (Collier et al 2007)
M3a.Open Abdomen
ASPEN 2009 ASPEN 2016 Difference
No recommendation
M4a. Based on expert consensus, EN should be provided to burn patients whose GI tracts are functional and for whom volitional intake is inadequate to meet estimated energy needs. M4b. IC be used when available to assess energy need in burn patients with weekly repeated measures. M4c. Protein 1.5g to 2g/kg/d (supported by ESPEN and 2001 American burn association
New recommendation
M4. Burns
M4d. Early initiation within 4-6 hours of injury.
Predictive equations poor accuracy in estimating energy needs in burns >20% total body surface area. Small protein turnover study in 6 adults with mean 70% total body surface area burn, 1.4 /g/kg versus 2.5g/kg
showed increase catabolism with highest dose 2.5g/kg/bwt Wolfe 1983
ASPEN 2009 ASPEN 2016 Difference
No equivalent recommendations
Expert consensus, we suggest the provision of trophic feeding (defined as 10-20g kcal/h or up to 500 kcal/d for the initial phase of sepsis, advancing as tolerated after 24-48 hours to >80% of target goal over the first week. We suggest delivery of 1.2-2g protein /kg /d
New recommendation
Restoring effective circulating volume takes priority in shock states, particularly septic and hypovolemic shock.
Early enteral nutrition can be safely provided to patients on vasopressor support in septic shock
N1. Sepsis
ASPEN 2009 ASPEN 2016 Difference
Q4. Based on expert consensus we suggest that high protein hypocaloric feeding be implemented in the care of the obese patient to preserve lean mass, mobilize stores and minimize the metabolic complications. Use IC and if unavailable use weight based equation 11-14kcal/kg actual body weight BMI 30-50 and 22-25kcal/kg IBW BMI>50. Protein should be provided 2/g/kg IBW with BMI 30-40 up to 2.5g/kg IBW BMI>40.
New recommendation
Q. Obesity
Q1. Early EN initiation within 24-48 hours.
Key take home messages
• Determine nutritional risk in all patients
• Avoid routine use of IMN in the MICU
• Avoid routinely adding glutamine to EN regimen
• IMN only in post-operative phase SICU
• Avoid specialty formulas in SICU
• High protein 1.5 – 2g/kg/bwt/day
• Aim for 80% nutritional target for energy and protein 24-48 hrs
• Use indirect calorimetry if available
• No routine measurement of GRVs
• EEN in sepsis is safe, advance 48-72 hours to >80% target as tolerated
THANK YOU