Metabolic Control in Critical Care: Nutrition Therapy

Transcription

1 LOGO Metabolic Control in Critical Care: Nutrition Therapy ผศ.นพ.พรพจน เปรมโยธ น สาขาโภชนาการคล น ก ภาคว ชาอาย รศาสตร คณะแพทยศาสตร ศ ร ราชพยาบาล

2 2016 SCCM/ASPEN Guidelines

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4 Nutrition Therapy in the ICU 1. Assess nutritional risk 2. Calculate energy & protein requirements 3. Optimize enteral nutrition 4. Start parenteral nutrition when EN is not feasible or sufficient

5 1. Assess nutritional risk Nutritional risk screening [NRS 2002] Low risk NRS score 0-2 At risk NRS score 3-4 At high risk NRS score 5 NUTRIC score Low risk NUTRIC score 0-4 High risk NUTRIC score 5 (if interleukin-6 is not included, otherwise 6) ASPEN / SCCM guidelines 2016

6 Nutrition Risk: Implications Patients at low nutrition risk with normal baseline nutrition status and low disease severity do not require specialized nutrition therapy over the first week in the ICU Patients at high nutrition risk or severely malnourished should be advanced toward goal over hours while monitoring for refeeding syndrome ASPEN / SCCM guidelines 2016

7 Nutrition Risk Screening (NRS 2002)

8 3 4

9 NUTRIC Score NUTRIC 6 without IL-6

10 NUTRIC Score

11 Nutrition Risk: Implications Patients at low nutrition risk with normal baseline nutrition status and low disease severity do not require specialized nutrition therapy over the first week in the ICU Patients at high nutrition risk or severely malnourished should be advanced toward goal over hours while monitoring for refeeding syndrome ASPEN / SCCM guidelines 2016

12 Nutrition Therapy in the ICU 1. Assess nutritional risk 2. Calculate energy & protein requirements 3. Optimize enteral nutrition 4. Start parenteral nutrition when EN is not feasible or sufficient

13 Energy and Protein Requirements Energy requirements Indirect calorimetry (IC) In the absence of IC, use simplistic weightbased equation kcal/kg/day or other published equations Protein requirements g/kg/day

14 Underfeeding and overfeeding leads to poor outcomes

15 Indirect Calorimetry Zusman and Singer Critical Care (2017) 21:128

16 Effects of Energy Delivery on Mortality % Adcal/REE: Administered calories x 100 Resting energy expenditure N=1,171 Lowest mortality At 70-80% Zusman and Singer Critical Care (2017) 21:128

17 Effects of Energy Deficit on Mortality Lowest mortality at 10-20% Energy deficit Weijs et al. Critical Care 2014, 18:701

18 Effects of Protein Intake on Mortality Benefits of higher protein was absent in sepsis high anabolic resistance < >1.2 g/kg/d Weijs et al. Critical Care 2014, 18:701

19 Nutritional Requirements in Patients with Acute Kidney Injury AKI, non AKI, RRT CRRT stress high stress Protein/AA (g/kg/d) up to 1.7 Energy (kcal/kg/d) Water, e lytes as tolerated supplement with water soluble vitamins & trace elements ASPEN Guidelines Brown KO et al. JPEN : 366 KDIGO Kidney Int Suppl. 2012;2:1-138.

20 Lessons from Recent RCTs

21 EPaNIC study N Engl J Med 2011;365:

22 N = 4,640 61% cardiac surgery > 80% SICU Short LOS No malnutrition

23 Early PN group: day1 IV glucose 400 kcal day2 IV glucose 800 kcal Day3-7 EN, add PN to reach 100% target Overfeeding Late PN group: Day1-7 EN + 5%D for hydration Day8+ EN, add PN to reach 100% target

24 Early PN group: More ICU infection (26.2% vs. 22.8%) Longer MV & RRT time Higher cost

25 Early PN group: Worse recovery from ICU-acquired weakness Lancet Respir Med 2013; 1:

26 Autophagy is impaired in early PN Lancet Respir Med 2013; 1:

27 EAT-ICU trial Intensive Care Med (2017) 43:

28 Standard care 25 kcal/kg/day EN ± PN after d7 Early goal-directed nutrition therapy IC Q2days, aim100%ree 24hr UUN OD Protein 1.5 g/kg/day EN ± PN to reach goal

29 91% Adcal/REE 56 % Adcal/REE Intensive Care Med (2017) 43:

30 1 o Outcome: Physical component summary score of SF-36 at 6 months No difference between groups 2 o Outcomes: mortality, organ failures, serious adverse reactions or infections in ICU, LOS (ICU or hospital stay), days alive without life support at 90 days No difference between groups Intensive Care Med (2017) 43:

31 What can we learn from EAT-ICU? Early energy overfeeding in EGDN group High anabolic resistance in sepsis (47% in EAT-ICU) EDGN may benefit only malnourished patients (EAT-ICU excluded BMI<17)

32 2.Energy & Protein Goals: Summary Energy: kcal/kg/day Indirect calorimetry: best outcome if given 70-80% of measured REE Protein: g/kg/day CRRT g/kg/day Low risk patients may not need specialized nutrition therapy in first week Moderate-high risk patients target energy & protein goal in hours Avoid overfeeding and underfeeding

33 Nutrition Therapy in the ICU 1. Assess nutritional risk 2. Calculate energy & protein requirements 3. Optimize enteral nutrition 4. Start parenteral nutrition when EN is not feasible or sufficient

34 Why? 3.Optimizing EN (1) Early EN within 48 hours reduces infection, LOS, and mortality Providers usually prescribe only 60-80% of energy requirements Patients usually receive 80% of what is ordered Due to NPO time for tests, procedures, intolerance (half of which is true intolerance) Most pts receive only ~50% of target goal ASPEN / SCCM guidelines 2016

35 3.Optimizing EN (2) How? Withhold EN until patient is fully resuscitated and/or stable Bowel sounds are not required prior to initiating EN Use gastric feeding Use continuous infusion Use standard polymeric formula Immune-modulating formulas should not be used routinely in MICU ASPEN / SCCM guidelines 2016

36 3.Optimizing EN (3) Gastric residual volume (GRV) GRVs should not be used as part of routine care to monitor ICU patients receiving EN GRV ml may raise concern for aspiration Automatic cessation of EN should not occur for GRVs < 500 ml in absence of other signs of intolerance (abdominal distension, vomiting) Siriraj enteral feeding protocol use GRV cutoff at 250 ml ASPEN / SCCM guidelines 2016

37 3.Optimizing EN (4) Diarrhea EN should not be automatically interrupted for diarrhea but rather continued while evaluating the etiology to determine appropriate treatment Underlying GI disease Infectious etiologies including C. difficile Medications (antibiotics, PPIs, prokinetics, metformin, colchicine, laxatives, and sorbitolcontaining preparations e.g. elixir KCl) EN: high osmolarity, rapid bolus, contamination ASPEN / SCCM guidelines 2016

38 3.Optimizing EN (5) Enteral feeding protocols should be designed and implemented to increase the overall % of goal calories provided Siriraj enteral feeding protocol (2559) งานโภชนศาสตร คล น ก ภาคว ชาอาย รศาสตร สาขาเวชบ าบ ดว กฤต สาขาโภชนาการคล น ก ฝ ายการพยาบาล ASPEN / SCCM guidelines 2016

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41 Adjust sedatives, muscle relaxants Correct K Metoclopramide IV

42 Diarrhea protocol CMAJ 2004;170(2):

43 Nutrition Therapy in the ICU 1. Assess nutritional risk 2. Calculate energy & protein requirements 3. Optimize enteral nutrition 4. Start parenteral nutrition when EN is not feasible or sufficient

44 The patient developed bowel ischemia during a hypotensive episode

45 4.Parenteral Nutrition (1) Patients at low nutrition risk: Exclusive PN should be withheld over the first 7 days following ICU admission Patients at high nutrition risk or severely malnourished: Initiate exclusive PN as soon as possible following ICU admission Supplemental PN may be considered after 7 10 days if unable to meet >60% of energy and protein requirements by EN ASPEN / SCCM guidelines 2016

46 4.Parenteral Nutrition (2) PN in the first week of ICU Energy 20 kcal/kg/day or 80% of estimated energy needs (hypocaloric) Protein 1.2 g protein/kg/day Withhold or limit soy-oil based IV fat emulsion, use alternative fat emulsion Maintain glucose mg/dl Parenteral glutamine is not recommended ASPEN / SCCM guidelines 2016

47 100% soy oil: do not use in ICU

48 Nutrition Therapy in the ICU 1. Assess nutritional risk NRS ; low risk = wait 1 week, high risk = start now 2. Calculate energy & protein requirements kcal/kg/d or 70-80% of measured REE(IC), protein 1.2 g/kg/d 3. Optimize enteral nutrition Early EN in first h, GRV and diarrhea management, feeding protocol 4. Start parenteral nutrition when EN is not feasible or sufficient 20 kcal/kg/d, protein 1.2 g/kg/d, use alternative IVFE, glycemia

49 LOGO Thank you for your attention