Nutrition in critical illness:

Transcription

1 Nutrition in critical illness: from theory to daily practice Aim of the presentation Summarize the guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. Gaps between theory and daily practice. Elina Ioannou RD MSc Limassol General Hospital Mal nutri Impaired immune function Impaired ventilatory drive Weakened respiratory muscles Prolonged ventilatory dependence Critically ill patient is the patient cared for in an ICU environment who has an urgent or lifethreatening complication. tion Increased infectious morbidity & mortality ICU patients and critically ill patients don t refer to homogenous populations (trauma, burn, surgical, head injury, acute pancreatitis, etc) Critical illness Catabolic stress-sir Objectives of nutrition support in critical illness To preserve lean body mass To maintain immune function Increased infection morbidity Multi-organ dysfunction Disproportionate mortality Prolonged hospitalization To avert metabolic complications 1

2 Guidelines Levels of evidence Grading of recommendation Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Mc Clave SA et al. JPEN J Parenter Enteral Nutr 2009; 33(3): Nutrition support in critically ill patients: An overview Seres D. Oct2012 American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Enteral Nutrition Practice Recommendations Bankhead R et al. JPEN J Parenter Enteral Nutr 2009;33(2): ESPEN Guidelines on Enteral Nutrition: Intensive Care Kreymann KG et al. Clin Nutr 2006; 25: Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients Heyland DK et al. JEPEN J Parenter Enteral Nutr 2003; 27(5): All levels of evidence Level I: Large, randomized trials with clear-cut results; low risk of false-positive (alpha) error or false-negative (beta) error Level II: Small, randomized trials with uncertain results; moderate to high h risk of false-positive (alpha) and/or false-negative (beta) error Level III: Nonrandomized, contemporaneous controls Level IV: Nonrandomized, historical controls Level V: Case series, uncontrolled studies, and expert opinion A Supported by at least 2 level I Supported by at least 2 level I (large RCT n > 100) investigations B Supported by 1 level I investigation C Supported by level 2 (small RCTs n < 100) investigations only D Supported by at least 2 level III (non- RCT contemporaneous controls) investigations E Supported by level IV (non- RCT historical controls) or level V evidence (case series, uncontrolled studies, expert opinion) A.S.P.E.N./SCCM Enteral Nutrition All ICU patients who are not expected to be on a full oral diet within 3 days should receive EN. EN should be considered when a patient is hemodynamically stable and has a functioning GI track Application of EN in critical illness 1. Assessment 2. Daily requirements 3. Dose of EN & Achieving target rate 4. Onset of EN 5. Formula type-route 6. Administration rate 7. Monitor: i. Tolerance ii. Adequacy iii. Complications 8. Supplemental PN (?) 1.Assessment Before initiation of feedings, assessment should include: Weight loss evaluation Nutrient intake prior to admission Level of disease severity Comorbid conditions Function of the GI track Traditional nutrition assessment tools (albumin, prealbumin, anthropometry) are not validated in critical care. (Martindale and Maerz. Curr Opin Crit Care 2006; 12: ; Raguso et al Curr Opin Clin Nutr Metab Care 2003;6: ) 2. Energy Requirements Energy Ireton-Jones formula For spontaneously breathing ICU patients: EEE=629-11*(A) + 25*(W)-609*(O) For ventilator-dependent ICU patients: EEE= *(A) 11*(A) +5*(W) +244*(G) +239*(T) +804*(B) EEE=estimated energy expenditure, O=presence of obesity (score 0 if absent, 1 of present), G=gender (score 0 of female, 1 if male), B= burns (score 0 if absent, 1 if present), A=age in years, W=weight in kg 2

3 Daily Requirements 3. Dose of Nutrition & Achieving Target rate Calories Patients at risk for refeeding Adults (18-65) Elderly (65+) Obese or Morbid Obese Protein ICU patients Severe stress, burns Obese (BMI 30-40): Morbid Obese (BMI 40) Fluids 15-20kcal/kg 20-30kcal/kg ~25kcal/kg 20-25kcal/kg IBW g/kg g/kg 2.0g/kg IBW 2.5g/kg IBW 1ml/kcal Target goal of EN should be determined and clearly identified at the time of the initiation of nutrition support therapy. Provision of more energy than actually expended should be avoided in the critically ill. Malnourished patients are at risk for refeeding syndrome: Hypophosphatemia Hypokalemia Hypomagnesemia Vitamin (eg, thiamine) and trace mineral deficiencies Volume overload Edema Critically obese patient: EN should not exceed 60-70% of target energy requirements. Safe starting point for most critically ill patients: 18 kcal/kg per day. 4. EN Onset 5. Formula selection Early EN vs delayed feedings Early EN: reduces infectious morbidity and mortality. SCCM-A.S.P.E.N.: EN should be started within 24-48h The feedings should be advanced toward goal over the next hours. ESPEN: EN should be started <24h Standard intact nutrients Standard Intact Nutrient Normal Normal Renal function Need for fluid restriction GI Absorption Compromised (high PO4 or high K+) Renal Formula Severe compromise (malabsoprtion) Defined formula (elemental or peptide formulas A recent open-labelled randomized trial: early enteral feeding (within hours) may have a positive effect on the hormonal profile (thyroidstimulating hormone; triiodothyronine(t3); thyroxine (T4); cortisol; testosterone) of patients with traumatic brain injury. (Chourdakis M et al, J Parenter Enteral Nutr 2012;36(1): ) No Standard Intact Nutrient Yes Fluid Restricted Formula Farver K Enteral Feeding Guidelines Harboview Medical Center Route No significant difference in the efficacy of jejunal vs gastric feeding in critically ill patients. Either gastric or small bowel feeding is acceptable in the ICU. Types of feeding tubes Short term access: anticipated need for enteral feeding <6-8 weeks Nasogastric, Nasoduodenal Patients with nasal obstruction or severe facial fractures should have these tubes placed orally. Long term access: anticipated need for enteral feeding >6-8 weeks PEG, Open gastrostomy, transgastric jejunostomy, surgical jejunostomy Immunonutrition Not a well established benefit from administrating immunemodulating formula (enriched with arginine, nucleotides, and ω-3 fatty acids,,g glutamine) to ICU patients. 3

4 6. EN Administration Pump-assisted feedings: 24hour feeding Enhances tolerance in critically ill patients Required in small-bowel l feedings Conservative initiation and advancement Initiate with full-strength formula at 30ml/h Increase 20ml/h every 6 hours as tolerated 7.i. Monitoring tolerance Gastric feeds Check GRVs Other complications (increasing abdominal distension and/or emesis) Jejunal feeds Residual volumes are not helpful. Monitor abdomen for distension and bowel sounds every 4-6 hours. Hold feeds for emesis, abdominal pain or distension. Max dosage: 120ml/h New ICU Limassol Hospital Enteral feeding guidelines EN formula 30ml/h After 6 hours Time of GR check: 6am 12pm 18pm 12am 7.ii. Monitoring adequacy Check for GR GRV <250ml GRV 250ml Provide >50-60% of goal calories over the first week of hospitalization Increase adm. rate per 20ml/h After 6 hours Stop feeding for 2hours with closed tube Close tube for 12 hours-cont. prokinetic drugs Check for GR GRV <250ml GRV 250ml Check for GR GRV 250ml Prokinetic drugs. Closed tube for another 2 hours 7.iii. Complications Vomiting Diarrhea (due to other reasons, eg antibiotics) Constipation Aspiration (due to high GRVs) Measures for reducing risk of aspiration: Head of bed elevated Continuous infusion Use of motility agents (prokinetic i drugs such as metoclopramide and erythromycin) or narcotic antagonists (naloxone and alvimopan) in patients with intolerance to enteral feeding (e.g. high gastric residuals) Diverting the level of feeding by jejunal tube placement Metabolic complications Hyponatremia-Hypernatremia Hypokalemia-Hyperkalemia Hypophoshatemia-Hyperphospatemia Hypomagnesimia Hyperglycemia 8. Parenteral Nutrition For adequately nourished patients who have contraindications to enteral nutrition, DO NOT initiate early parenteral nutrition. PN is associated with increased risk of infection, prolonged mechanical ventilation, ICU stay, hospital stay. For malnourished patients who have contraindications to enteral nutrition that are expected to persist one week or less, DO NOT initiate parenteral nutrition. Initiating supplemental PN prior to this 7-10 day period in the patient already receiving EN does not improve outcome and may be detrimental to the patient. For malnourished patients who have contraindications to enteral nutrition that are expected to persist >one week, we consider administration of PN. In patients on PN efforts should be made to initiate EN. As tolerance improves, PN is reduced but not terminated until >60% of target energy requirements are being delivered by the enteral route. 4

5 Intensive care unit protocol for weaning from parenteral nutrition (PN) to enteral nutrition (EN). Journal of Parenteral and Enteral Nutrition Volume 34 Number 6 November Guidelines, Guidelines, Guidelines: What Are We to Do With All of These North American Guidelines? Rupinder Dhaliwal, RD1; Sarah M. Madden, MSc1; Naomi Cahill, RD, MSc1,3; Khursheed Jeejeebhoy, MBBS, PhD, FRCPC4,5; Jim Kutsogiannis, MD, MHS, FRCPC6; John Muscedere, MD, FRCPC1,2; Steve McClave, MD7; and Daren K. Heyland, MD, FRCPC1,2,3 Dervan N et al. Nutr Clin Pract 2012;27: Worldwide practices Variation from 14%-67% in nutrition support practices in the ICUs throughout the world. Of patients receiving nutrition support in the ICU: Use of PN ranging from 12%-71% Use of EN ranging from 33%-92% Heyland DK et al. JPEN J Parenter Enteral Nutr. 2003; 27(5): Bridging the Guideline-Practice Gap in Critical Care Nutrition Barriers to adequate enteral nutrition intake 1. Delayed initiation of EN 2. Slow advancement of infusion rate 3. Underprescription 4. Incomplete delivery of prescribed nutrition 5. Frequent interruption of EN Diagnostic tests Surgical procedures Gastrointestinal intolerance Feeding tube problems Routine nursing procedures How do we overcome the barriers? 1. Monitor tolerance of EN (GRVs, pain and/or distension, physical exam, passage of flatus and stool) 2. Inappropriate cessation of EN should be avoided. 3. Holding EN for gastric residual volumes<250ml in the absence of other signs of intolerance should be avoided. 4. The time period that t a patient t is made nil per os prior to, during, and immediately following the time of diagnostic tests or procedures should be minimized to prevent inadequate delivery of nutrients and prolonged periods of ileus. 5. Use of enteral feeding protocols should be implemented as they increase the overall percentage of goal calories provided. When ICU protocols are followed, rates of GI tolerance in the range of 70-85% can be achieved. Adequate EN Minimize the complications of EN Need for standardized protocols that address theses barriers (Cahill NE and Heyland DK JPEN J Parenter Enteral Nutr 2010;34: , Kim H et al J Crit Care 2012 Ebub ahead of print) Better outcome for the critically ill patient 5

6 ICU team: Checklist! Thank you for your attention! ti 6