When to start SPN in critically ill patients? Refereeravond IC

Transcription

1 When to start SPN in critically ill patients? Refereeravond IC

2 Introduction (1) Protein/calorie malnutrition is very frequent in critically ill patients Protein/calorie malnutrition is associated with a worse outcome In approximately 10-15% of patients early enteral nutrition is either contraindicated or not tolerated

3 However... TPN has multiple side-effects

4 Guidelines based on expert opinion ESPEN: consider after two days ASPEN: consider after seven days if no malnutrition present

5 EPaNIC trial Multicenter RCT comparing early start SPN (D3) versus late start (D8) Adult ICU patients nutritionally at risk (NRS > 2) but not chronically malnourished (BMI 17) Stratification according to 16 diagnostic categories and randomisation 1:1 Primary endpoint: duration of ICU dependency Casaer MP. NEJM 2011

6 Enrollment

7 Early and late group Early: glucose 20% (D1 400 kcal and D2 800 kcal) - D3 start additional SPN to reach calculated nutritional target - diminished/stop when 80% of target covered by EN - restarted when EN < 50% Late: D1 -D7 glucose 5% and SPN added on D8 if EN was insufficient to reach calculated target Both groups EN started on D2 with standing orders

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9 Results Study groups perfectly matched - sepsis 22% and mean APACHE II 23. However mostly postoperative cardiac surgery with short ICU stay As expected patients in the early SPN group needed higher mean daily insulin levels to reach target glucose levels

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12 Predefined subgroup analysis Risk of infection much lower in late SPN group when EN contraindicated for the first 7 days

13 Secondary analysis No benefit of early SPN in more severely ill patients Risk of later discharge increases with amount of macronutrients Casaer MP. AJRCCM 2013

14 = more sick medical patients

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16 EDEN trial Multicenter open label trial in ARDSnet hospitals - stratification by site and presence of shock Trophic versus full EN for the first 6 days of mechanical ventilation ALI < 48 hours and MV < 72 hours. No data on preexistent malnutrition. Severe malnutrition excluded ARDSnet. JAMA 2012

17 Enrollment

18 Trophic and full EN strategy Started within 6 hours after enrollment and continued until D6, extubation or death - after D6 full EN - glucose 4-8 mmol/l Trophic: kcal/h (first 272 patients), the rest 20 kcal/hour Full: see algorithm - goal non-protein calories/kg/day and gr/kg protein

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20 Endpoints Primary: VFD's through D28 Multiple secondary endpoints No baseline differences between groups APACHE III score 90

21 Caloric intake

22 Gastro-intestinal intolerance

23 VFD's through Day ,9 15 Days Trophic Full

24 60-day mortality ,2 22,2 15 % Trophic Other secondary endpoints no differences also when analysed by BMI Full

25 Other results Higher glucose levels and insulin dose in Full group More positive fluid balance in Full group

26 Heidegger trial RCT in two mixed medical/surgical ICU's (tertiary care university hospitals) Inclusion if after D3 < 60% of nutritional needs were covered by EN AND expected to stay more than 5 days AND functional GI tract 1:1 randomization stratified for sex and admission category (medical/surgical) Heidegger CP. Lancet 2013

27 Nutrition scheme

28 SPN and EN group All patients started on D1 with EN (goal males 30 kcal/kg IBW, females 25 kcal/kg IBW - protein 1.2 gr/kg) SPN: started on D4 - continued for 5 days - energy requirement determined by indirect calorimetry. No glutamine etc. In both groups glucose < 8.5 mmol/l

29 Enrollment Primary outcome: nosocomial infection from D9 - D28

30 Results No differences in baseline characteristics Apache II 23 Indirect calorimetry in only 65% Protein delivery D4 - D8 1.2 gr/kg in SPN and 0.8 gr/kg in EN group

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32 Nosocomial infections EN TPN supplement P = More antibiotic free days in TPN group

33 Kaplan- Meier

34 Individual infections No differences in LOS or mortality

35 Conclusions In previously non- malnourished patients it is save AND probably better to withhold SPN for the first 7 days if EN is insufficient to meet caloric needs in most patient groups Uncertainty for the most severely ill (e.g persistent high SOFA). If full EN appears impossible for 7 days, SPN on D4 is reasonable If enteral nutrition is absolutely contraindicated for more than 7 days, starting TPN on D4 is reasonable In case of preexistent severe malnutrition (BMI < 17) AND inability to reach nutritional targets with EN on D4, starting SPN is reasonable

36 Vincent JL. Lancet 2013