ASPEN/SCCM Critical Care Nutrition Guidelines: What s New and Updated?

Transcription

1 ASPEN/SCCM Critical Care Nutrition Guidelines: What s New and Updated? Todd W. Rice, MD, MSc Associate Professor of Medicine Vanderbilt University WiSPEN Annual Fall Symposium 2016 September 16, 2016

2 Objectives 1. Briefly outline some of the recommendations which changed with the newest guidelines 2. Understand role of nutrition risk assessment in providing nutrition to ICU patients 3. Understand the data / studies investigating trophic enteral feeds in critically ill patients 4. Learn recent data on GRV and recommendation to not routinely check GRV in ICU patients

3 Historical Timeline ASPEN SCCM Guidelines Current 2016 Guidelines Effort Committee convened Jan 2012 Harmonization process with Canadians over 2 yrs Lit searches, >750 RCTs entered, DAFs completed Manuscript compiled over one year Jan-Dec 2014 Sections written, GRADE tables constructed, editing Manuscript submission Jan 19, 2015 Review process 3 Boards 2 Journals Final acceptance June 2015 ASPEN, Sept 2015 SCCM Available online Jan 15, 2016 and in print Feb 15, 2016

4 Concept of Nutritional Risk Jens Kondrup Components: Impaired nutrition status and disease severity J Kondrup (Curr Opin Clin Nutr Metab Care 2014;17:177)

5 Dosing of EN No EN if low nutritional risk, low dz severity (NRS or Nutric Score 5) for first week 1,2 Trophic or full feeds appropriate for ALI/ARDS and pts expected to be on MV 72 hrs 3 Advance to goal as tolerated over hrs If high nutrition risk (NRS , Nutric 6) 1,2 Attempt to provide > 80% goal 4 1 Kondrup J (Clin Nutr 2002) 2 Heyland DK (Clin Nutr 2015) 3 Rice T (JAMA 2012) 4 Heyland DK (CCM 2011;39:1)

6 EN Benefits: Achieved at Different Doses? Non-Nutrition benefits - Lower dose, needed in all patients Gastrointestinal responses Gut integrity Commensal bacteria Gut/lung axis of inflamm Secretory IgA, GALT tissue Motility/contractility Trophic effect epithelium Absorptive capacity Reduced bact virulence Immune responses Modulate regulatory cells Promote Th-2 >Th-1 lymphocytes Stimulate oral tolerance Maintain MALT tissue Duod colon receptors Modulate adhesion molecules Metabolic responses Incretin to insulin sens Reduce hyperglycemia (AGES) Attenuate stress metab Enhance fuel utilization Nutrition benefits Higher dose, needed in high risk patients Protein, calories Micronutrients, anti-oxidants Maintain LBM Stimulate protein synthesis S McClave, R Martindale, T Rice, D Heyland (CCM 2014;42:2600)

7 Caloric requirements Kcal/kg/d Nutritional Assessment Set Goals of Therapy Published predictive equations no more accurate Indirect calorimetry Protein requirements Greater emphasis Higher doses gm/kg/d Fewer restrictions Survival 1 28-Day Mortality 2 MJ Allingstrup (Clin Nutr 2012;31:462) 1 P Weijs (JPEN 2012;36:60) 2

8 Monitor Tolerance and Adequacy GRVs should not be used as part of routine care 1 Montejo Multicenter RCT 1 GI Complications %Goal Feeds 500cc GRV (n=160) 47.8% * 89% * 200cc GRV (n=169) 63.6% 83% Reignier Multicenter RCT 2 VAP Infect Mortality Deficit No GRV used (n=227) 16.7% 26.4% 27.8% 319 kcal Routine GRV (n=222) 15.8% 27.0% 27.5% 509 kcal 1 JC Montejo (Intens Care Med 2010;36:1386) 2 J Reignier (JAMA 2013;309:249)

9 Formula Selection in the ICU Start with standard polymeric isotonic formula (most ICU pts) Evaluate candidacy for immune-modulating formula (Surg ICU) Consider use of specialty formulas Gut dysfunction (diarrhea) Small peptide/mct semi-elemental Prebiotic soluble fiber > mixed fiber formula Obesity formulas (Class II and III) Cannot recommend certain formulas Organ-failure formulas Rarely use hepatic, renal failure Don t use pulmonary failure Disease-specific (diabetic) EN SA McClave, B Taylor, RG Martindale (SCCM/ASPEN Guidelines 2015)

10 Immunonutrition and Anti-Inflammatory Elective Surgery, SICU Use arg/fish oil formula 1 Infection 41% (OR=0.59) Hosp LOS 2.38 days Crit Care MICU Don t recommend arg/fo formula No difference mortality, infection, LOS ALI/ARDS No recommendation anti-inflammatory lipid profile formula 2-8 Gadek, Singer, Pontes-Arruda, Grau-Carmona Constant infusion All benefit Rice ARDSNet, Stapleton Bolus infusion Harm, no benefit Van Zanten Meta-Plus Constant infusion - Harm Elective Surg Critical ICU ARDS or ALI 1 JW Drover (JACS 2011;212(3);385) 2 JE Gadek (CCM 1999;27:1409) 3 P Singer (CCM 2006;34:1033) 4 A Pontes-Arruda (CCM 2006;34:2325) 5 T Grau-Carmona (Clin Nutr 2011;30:578) 6 T Rice (JAMA 2012;307:795) 7 R Stapleton (CCM 2011;39:1655) 8 A Van Zanten (JAMA 2014;312:514)

11 Adjunctive Therapy Soluble fiber Consider routine use in all pts Use for diarrhea (Consistent 4 trials: 3 better 1-3, 1 no different 4 ) Probiotics Use for select patient populations Where RCTs have shown safety and benefit 4 Do not use routinely for general ICU pts McClave, Taylor, Martindale (SCCM ASPEN 2015 Guidelines) (p=0.05) Antioxidants Use for all pts requiring Specialized Nutr Support Selenium, zinc, copper, Vit C, Vit E Enteral glutamine Do not use 1 Spapen (Clin Nutr 2001;20:301) 2 Heather (Heart Lung 1991;20:409) 3 Rushdi (Clin Nutr 2004;23:1344) 4 Hart (JPEN 1988;12:465) 5 Zhang (World J Gastro 2010;16:3970)

12 Use of Parenteral Nutrition Differences EN vs PN decreasing Withhold PN in low risk If EN not feasible (NRS or Nutric Score 5) Initiate exclusive PN ASAP in high risk or severely malnourished pt if EN not feasible (NRS , Nutric Score 6) Add supp PN after 7-10 days if EN < 60% goal high or low risk 1 Maximize efficacy of PN Use protocols Do not use parenteral glutamine 2 Hypocaloric dosing (80%) first week 3 Withhold soy-based lipids first week Moderate glucose control ( mg/dl) Transition off PN when EN provides > 60% goal 1 Heiddeger (Lancet 2012 Dec 3) 2 Heyland REDOXS Trial (NEJM2013; 368:1489) 3 Jiang (Clin Nutrit 2011;30:730)

13 Organ Failure Subsets MOF Organ failure (pulmonary, renal, hepatic) Use standard polymeric formulas Push protein to 2.0 gm/kg/d (2.5 for dialysis) Pancreatitis Assess disease severity 1 Use APACHE II 8, RC 3, CRP>150 to initiate SNS Mild AP Advance directly to Reg Diet per pt wishes Mod-severe AP Start gastric or jejunal within hrs 2 Probiotics Consider use in SAP on EN 3 PN Use after one week if EN not feasible 1 Tenner (Am J Gastr 2013;108:1400) 2 Chang (Crit Care 2013;17:R118) 3 Zhang (World J Gastro 2010;16:3970)

14 Additional Disease Subsets Sepsis (support Surviving Sepsis Campaign recs) Avoid PN regardless of nutritional risk over first week Use trophic feeding initially, advance to full after 48 hrs Arginine is safe, but don t use Arg FO formula Luiking, Deutz (Clinical Science 2015;128:57 67)

15 ASPEN/SCCM CCN Guidelines: Bundle Statements JPEN 2016;40(2):

16 ASPEN/SCCM Crit Care Nutr Guidelines Remain flexible Rawlins Management, Rx decisions based on totality of information 1 Notion that evidence can be placed in hierarchies is illusionary ASPEN SCCM Guidelines Rigorous evidence-based Expert consensus involved (voting, recs with very low QOE) Guidelines never take priority over clinical judgment Should be interpreted in context of institutional setting Importance Organizes info, provides references, good start 1 M Rawlins [Clin Med 2008;8(6):579-88]

17 Nutritional Risk

18 Introduction Not all patients derive same benefit from nutrition therapy Previously well nourished, mild critical illness, short stay ICU Little benefit Moderate to severe nutritional risk More likely to benefit More likely to be harmed by iatrogenic underfeeding Benefit of nutrition Rx depends on: Route Timing Interruptions Dosing Content Mobility SA McClave, RG Martindale, TW Rice, DK Heyland (CCM 2014:42:2600)

19 Concept of Nutritional Risk Jens Kondrup Components: Impaired nutrition status and disease severity J Kondrup (Curr Opin Clin Nutr Metab Care 2014;17:177)

20 Concept of Nutritional Risk: NRS 2002 Age >70 yrs : Add 1 point Kondrup J (Clin Nutr 2002) Score >3 Consider EN/PN Score >5 High risk

21 Six Factors : Concept of Nutritional Risk: Nutric Score Disease severity: Age Initial APACHE II score Initial SOFA score Interleukin-6 Comorbidities Poor nutritional status: Hosp LOS prior to ICU Low Risk: 0-5 points High Risk: 6-10 points Heyland DK (Crit Care 2011;6:1) (Clin Nutr 2015)

22 Paradigm Shift: Assess Risk- Therapy- Response Observational Studies NRS-2002 Jie Study 1 - High Risk patients (n=120)with NRS Score > 5 Insufficient Pre-Op Sufficient Pre-Op Controls (n=77) Sufficient Nutr Rx(n=43) Overall complications 51% 26% * Nosocomial infection 34% 16% * No benefit (sufficient vs insufficient ) Low Risk pts (n=965) NRS < 5 Nutric Score Heyland Study 2 (n=1199) (no Interleukin-6 used) EN Rx Effect on High Risk Pts (p<0.0001) Low Risk (p=ns) 1 B Jie (Clin Nutr 2012) 2 DK Heyland (Crit Care 2011;15:R268) (Clin Nutr 2015 Jan)

23 Paradigm Shift: Assess Risk- Therapy- Response Randomized Controlled Trials Starke Study (NRS Score >3) (n=132) Energy Protein Complic Antibiot Re-Hosp Intervent (n=66) 24 kcal/kg* 1.0 gm/kg* 6.0%* 1.5%* 25.7%* Controls (n=66) 18 kcal/kg 0.7 gm/kg 19.7% 12.1% 42.4% 1 J Starke (Clin Nutrit 2011;30:194)

24 Nutritional Assessment Additional assessments Evaluate co-morbidities Function of the GI tract Risk of aspiration Avoid use Protein markers (albumin, transferrin, prealbumin) Selective anthropometrics (no AMC, TSF, CHI) Use height, ABW, UBW, IBW, BMI Markers of inflammation/infection: Procalcitonin, IL-1, IL-6, CRP, TNF, Citrulline Emerging assessment tools CT scan Mid-thigh US Mourtzakis (Appl Phys Nutr Metab 2008;33:997)

25 How much should we feed patients? (especially early in critical illness) What are the data on trophic feeds?

26 Quantity of Feeds Limited data suggest initiating EN w/in 24 hrs is beneficial (esp trauma) 1 But those data don t address quantity of enteral feeding If we start enteral feeds within hours, do we have to get to target or goal rates as soon as possible? 1. Doig et al. Intensive Care Med. 2009;35(12):

27 Full calorie Feeds in Critically Ill Patients Haddad, et al. (Crit Care Med. 2003) 1 Prospective study of 203 critically ill patients Decreased mortality for patients who received 20-90% of daily goal calories Rubinson, et al (Crit Care Med. 2004) MICU patients who were NPO > 96 hrs Receiving > 25% calories was associated with significantly lower risk of bloodstream infection (RR = 0.27; ) Difficulty: Only an Association- can t determine cause and effect 1. Haddad SH, et al. Am J Resp Criti Care Med. 2003;31:A83 2. Rubinson et al. Crit Care Med. 2004;32:350-7.

28 Feeding Volumes Clinical Outcomes: Humans Prospective cohort (n=187) Feb 1999-Oct teaching hospitals ICU LOS 96 hours 70% EN, 20% EN/PN 46% overall mortality O.R * * * * <33% 33-65% 66+% * P < 0.05 Tertile II: 9-18 kcal/kg/d Krishnan JA, et al. Chest. 2003; 124:297

29 Hormesis Beneficial or stimulatory effect obtained via the application of an agent at a low dose, whereas higher doses result in detrimental effects or toxicity Ex: Alcohol Glade MJ, Nutrition: 2001; 17:983

30 Trophic Feeds The minimum amount of enteral nutrition required for the mucosal benefits is unknown As little as 10-40% of caloric requirements preserves mucosal structure in dogs 1 and pigs 2 Trophic= nourishment or growth Low volume continuous feeds for the purpose of nourishing the intestinal mucosa 1. Owens L, et al. J of Nutrition. 2002;132: Burrin DG, et al. Am J Clin Nutr. 2000;71:16

31 Trophic vs. Full-Calorie Feeds Pro Trophic Feeds Decreased feeding intolerances/complications Decreased cost Less Hassle Con Malnutrition (weight loss, protein loss) Worse immune function Loss of muscle strength (i.e. Diaphragm weakness) Full-Calorie Feeds Pro? Slow malnutrition Better immune function Maintain muscle strength Con Increased GI intolerances/complications Hyperglycemia Increased CO 2 / azotemia Increased septic complications Fuel for inflammatory fire

32 Rice, et al: Trophic vs. Full Feeds in Critically Ill Mechanically Ventilated Patients Acute Respiratory Failure with expected MV > 2 days Mostly MICU patients 20% ALI; 18% Pneumonia 40% on vasopressors at enrollment Initiation of feeds on average 1 day after start of MV GRV threshold 300 cc Trophic (N=98) vs. Full-Calorie (N=102) EN Trophic feeding group 10 cc/hr for up to 6 days Full-Cal feeding group goal feeds ASAP Enteral Feeds started within 6 hrs of randomization in both More Diarrhea and Elevated GRV in Full Group Rice TW, et al. Crit Care Med. 2011;39(5):

33 Rice, et al: Summary - Main Outcomes Outcome Trophic Full-Cal P-value Death at Hosp D/C (%) VFD to day ± ± ICU free days to day ± ± Rice TW, et al. Crit Care Med. 2011;39(5):

34 1000 mech vent patients with ALI Mostly Medical Pneumonia (65%); Sepsis (15%) 38% on vasopressors at enrollment GRV threshold 400 cc Factorial design with n-3 fatty acid / placebo Trophic (N=508) vs. Goal (N=492) for first 6d Primary endpoint: Ventilator-free days

35 Enteral Feeding Timeline +/- Vent ALI Criteria Ramp up Full Feeds Specimen sampling Specimen sampling Specimen sampling Day -3 +/- Vent ALI Criteria Trophic Feeds 20 kcal / hr Ramp up Full Feeds hrs Enteral Feeding started

36 EDEN: Enteral Feeds Delivered * * * * * * * * * * * * *P<0.001

37 EDEN: Percent of Feeding Days with Specific GI Intolerances Percent of On Study Days P=0.05 P<0.001 Trophic (N=508) Full (N=492) P=0.003 P=0.003 efig 1: NHLBI ARDS Network. JAMA. 2012; 307(8):795.

38 EDEN: Outcomes P=0.89 P=0.67 P=0.77 NHLBI ARDS Network. JAMA. 2012; 307(8):795.

39 Optimal Initial Amount of Enteral Feeding in Critically Ill Patients: Systematic Review and Meta-Analysis Meta-analysis of adult ICU patients Initial trophic vs full feeding 4 RCTs (N=1540 participants total) Primary analyses: Mortality Choi EY, Park DA, Park J. JPEN. 2015;39(3):

40 Optimal Initial Amount of Enteral Feeding in Critically Ill Patients: Systematic Review and Meta-Analysis No diff in Mortality (OR 0.95; ; P=0.65) Subgroup analysis: Trophic >33% of goal: OR 0.61 ( ; P=0.04) No difference in Hospital or ICU LOS Serious GI Intolerance: 23% trophic vs 31% full (OR 0.66; ; P=0.12) Choi EY, Park DA, Park J. JPEN. 2015;39(3):

41 894 critically ill patients 7 hospitals in Saudia Arabia and Canada 75% medical, 21% non-op trauma 96% MV, 55% on pressors Randomized, open label trial 40-60% goal cal + protein vs % goal kcal for up to 14 days Primary Endpoint: 90 day mortality Arabi YM, et al. NEJM. 2015;372(25):

42 Arabi YM, et al. NEJM. 2015;372(25):

43 Arabi YM, et al. NEJM. 2015;372(25):

44 Arabi YM, et al. NEJM. 2015;372(25):

45 Arabi YM, et al. NEJM. 2015;372(25):

46 Arabi YM, et al. NEJM. 2015;372(25):

47 Long-term (to 12 mos) follow-up of EDEN pts Two studies: Quality of life and mental health from all centers Physical and cognitive function from subset of 5 ctrs A priori established endpoints for the trial Needham DM, et al. BMJ. 2013;346:f1532. Needham DM, et al. AJRCCM. 2013;188(5):

48 Needham DM, et al. BMJ. 2013;346:f1532

49 Needham DM, et al. BMJ. 2013;346:f1532

50 Needham DM, et al. AJRCCM. 2013;188(5):

51 Needham DM, et al. AJRCCM. 2013;188(5):

52 Gastric Residual Volumes

53 GRV: Evidence McClave (JPEN 1992) 1 : 20 normals, 10 ICU pts GRV did not correlate with exam or X-ray findings 15% of normals, 50% of ICU patients: GRV> 150 cc No normals, 30% ICU patients: GRV > 200 cc Spain (JPEN 1999) 2 : 75 ICU pts 26% had one GRV > 200 cc Only 4 pts (5.3%) had more than 1 GRV > 200 cc 80% of pts with GRV > 200cc never had second GRV > 200cc Mentec (CCM 2002) 3 : 153 med/surg ICU pts 21/40 patients who vomited never had GRV > 150 cc 6/19 pts vomited prior to having GRV > 150 cc GRV > 500cc correlated with vomiting, but not GRV >150cc 1. McClave SA, et al. JPEN. 1992;16: Spain DA, et al. JPEN. 1999;23: Mentec H, et al. Crit Care Med. 2001;29:

54 GRV: Evidence Pinilla (JPEN 2001) 1 : GRV threshold of 250 cc vs. 150 cc GRV > 150cc (53%) vs. GRV > 250cc (23%) (P=0.005) No difference in vomiting (7% vs. 6% in lower GRV) Pts w/ higher GRV trended to reach goal rates faster McClave (Crit Care Med 2005) 2 : GRV threshold of 200 cc vs. 400 cc Calorimetric microspheres with fluorometry and blue food coloring to assess aspiration / regurgitation No difference in aspiration (21.6% vs. 22.6%) or regurg (35% vs. 28%) 1. Pinilla JC, et al. JPEN. 2001;25: McClave SA, et al. Crit Care Med. 2005;33:

55 449 mechanically ventilated patients Ventilated > 2 days EN w/in 36 hrs of MV 9 French ICUs Randomized, non-inferiority design GRV > 250 ml q6h vs no GRV measurement Primary endpoint: % pts with VAP Reignier J, et al. JAMA. 2013; 309(3):

56 Reignier J, et al. JAMA. 2013; 309(3):

57 Reignier J, et al. JAMA. 2013; 309(3):

58 Reignier J, et al. JAMA. 2013; 309(3):

59 Gastric Residual Volumes Recommendations: Do not routinely measure GRVs in ICU patients Do not hold feeds for a single, elevated GRV Use GRVs in conjunction with other clinical parameters (abd pain, cramping, distention, nausea, vomiting) to assess tolerance Do not stop feeds for GRVs < cc unless associated with other clinical signs Pro-kinetic agents/post-pyloric tubes may be tried if elevated GRV McClave SA, Snider HL. JPEN. 2002;26 (6 suppl):s43-8.

60 Continuing Education #1 Which of the following is the WORST assessment of nutritional risk in critically ill patients? A. Nutric Score B. Serum Albumin C. Nutritional Risk Screening (NRS) Score D. Paraspinal Muscle mass

61 Continuing Education #2 Which of the following statements about targeted caloric goals in critically ill patients is true? A. Targeting full calorie enteral feeding in the first few ICU days is beneficial in all critically ill patients B. Full calorie enteral feeds early in the course of critical illness results in improved physical and cognitive function at 12 months C. Initial trophic enteral feedings resulted in similar short and long-term outcomes in patients with ARDS as initial full calorie enteral feeds D. Initial trophic enteral feedings result in similar outcomes in patients who are malnourished

62 Continuing Education #3 Use of which of the following Gastric Residual Volumes routinely in the care of critically ill patients has been shown to reduce VAP and decrease time on mechanical ventilation? A. 150 ml B. 200 ml C. 250 ml D. 400 ml E. None

63 Summary Numerous changes to the guidelines, but still use guidelines as guidelines and not as absolute dictum Individualize enteral (and parenteral) nutrition prescription according to nutritional risk assessment Initial trophic feeds are probably okay in many critically ill patients but initiate early Routine, scheduled GRV checks probably not improving safety or outcomes

64 QUESTIONS???