Advanced Enteral Nutrition Program For Dietitians. Week 5 Underfeeding in the ICU: Good or Bad? Presented on December 9, 2015

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1 Advanced Enteral Nutrition Program For Dietitians Week 5 Underfeeding in the ICU: Good or Bad? Presented on December 9, 2015

2 Sponsor Disclosure: Financial support for this presentation was provided by Nestlé HealthCare Nutrition, Inc. The views expressed herein are those of the presenter and do not necessarily represent Nestlé s views. The material herein is accurate as of the date it was presented, and is for educational purposes only and is not intended as a substitute for medical advice. Reproduction or distribution of these materials is prohibited Nestlé. All rights reserved. 2

3 Underfeeding in the ICU: Good or Bad? Stephen A. McClave, MD Louisville, Kentucky 3

4 Objectives Identify flaws in the literature claiming that underfeeding is better than full feeding Describe the significance of studies which show underfeeding has similar outcomes to full feeding Explain how nutritional risk impacts the decision to underfeed the ICU patient 4

What We re Hearing: Early Aggressive EN is Bad for

important to preserve autophagy Trophic feeds are better

is not that important Autophagy M Schetz (Crit Care 2013;

5 What We re Hearing: Early Aggressive EN is Bad for Patients No Forced Mandatory Feeds first week More important to preserve autophagy Trophic feeds are better First week does not count Better to do nothing Nutrition is not that important Autophagy M Schetz (Crit Care 2013; 17:302) RP Dellinger (CCM 2013; 41:580) CA Braunschweig (JPEN 2014) 5

6 Is Underfeeding Better than Full Feeding? Observational Studies Krishnan 1 Worse top tertile (got PN, propofol) Ash 2 Worse top quartile (got signif PN, propofol) Low Feed Arabi 3 Worse closer to goal (all PO days) PRCTs Ibrahim 4 Pneumonia worse full feeds (got EN 27% vs 7%) Arabi 5 Worse mortality full vs 70% feeds (got EN 71% vs 59%) Singer TICACOS 6 Rx by IC <mort, >infect, durat MV, ICU LOS Casaer EPaNiC 7, post hoc 8 - Early supp PN + EN worse Braunschweig INTACT 9 Intens higher mort than stand Rx Guidelines Surviving Sepsis 10 Extrapolation from EPaNIC Full Feed 1 Chest 2003;124:297 2 JPEN 2005;29:S10 3 JPEN 2010;34:280 4 JPEN 2002;26:174 5 AJCN 2011;93:569 6 Int Care Med 2011;37:601 7 NEJM 2011;365:506 8 Am J Resp Crit Care Med 2013;187:247 9 JPEN CCM 2013;41:580 6

7 Confounding Factor in Arabi Observational Study Hosp Mortality (OR) 1 st 2 nd 3 rd Signif Arabi 1 All patients p=0.02 Heyland 2 All patients p= All pts (no all PO) p< JPEN 2010;34(3):280 2 CCM 2011;39(12):1 7

8 Underfeeding Better than Full Feeding? Chance of Being Discharged Alive (All pts n=4640) Day 3 Day 5 Day 7 0% 100% 0% 100% 0% 100% Explanation: Feeding suppresses Autophagy! Casaer MP (Amer J Respir Crit Care Med 2013;183:247) 8

9 Underfeeding Better than Full Feeding? Receipt of EN both groups EPaNiC Study and Re-analysis Late PN Patients (n=2328) Receipt EN only first week Day 3 Day 5 Day 7 MP Casear (NEJM June 2011;365:506 ) (Am J Resp Crit Care Med 2013;187:247) 9

Underfeeding Better than Full Feeding? INTACT Study Intensive vs Standard Nutrition Rx in ALI Braunschweig Results IMNT (n=40) SNST (38) %Goal cal 84.7% 55.4% (p<0.0001) Mortality 40.0% 16% (p=0.

10 Underfeeding Better than Full Feeding? INTACT Study Intensive vs Standard Nutrition Rx in ALI Braunschweig Results IMNT (n=40) SNST (38) %Goal cal 84.7% 55.4% (p<0.0001) Mortality 40.0% 16% (p=0.02) Hosp LOS, ICU LOS, infections, durat MV no different Comments Power analysis indicated (n=200) needed to complete study Stopped early by data safety monitoring board Cause of death no plausible mechanism (% died withdraw of care) High risk of Type 1 alpha error CA Braunschweig (JPEN

6days (n=508) vs Full feeds (n=492) 25% Goal calories No

11 Does Underfeeding Equal Full Feeding? 80% Goal calories ALI/ARDS patients on MV Trophic 20cc/hr x 6days (n=508) vs Full feeds (n=492) 25% Goal calories No difference: Mortality, vent-free days, MOF, or infection jama.ama-assn.org (Feb 9, 2012) 11

12 Does Underfeeding Equal Full Feeding? Why would trophic feeds work? BMI BMI Age 52 yrs, BMI 30, ICU LOS 5d 25% Goals calories is sufficient Early initiation more important Minimizing interruptions important Less fluids in ARDS important 1 BMI range less nutrition effect 2 Significance of Surviving Sepsis Recs Extrapolation of ARDS study to all sepsis No extremes of age, BMI, disease severity Starting trophic OK, but not locked in for 7d 1 T Rice (JAMA 2012) 2 C Alberda (Int Care Med 2009) 12

Does Underfeeding Equal Full Feeding? PRCT presented at Annual Surgical Infection Society Sept 2013 Eric Charles, Univ of Virginia SICU setting (n=83) 12.

13 Does Underfeeding Equal Full Feeding? PRCT presented at Annual Surgical Infection Society Sept 2013 Eric Charles, Univ of Virginia SICU setting (n=83) kcal/kg/d vs kcal/kg/d (normal Prot 1.5 gm/kg/d) Power Analysis predicted (n=116) needed to complete study No difference ICU or Hosp LOS, infection, mortality High risk Type 2 Beta error EJ Charles (Am J Clin Nutr 2014;100: ) WG Cheadle President Surg Infect Soc 13

Does Underfeeding Equal Full Feeding? Arabi 2011 Single Center Study Permiss vs Full 1 Mixed ICU Age 50-52 BMI 28.5 AP II 25.2 Permiss Under (n=120) Full (n=120) Intended 60-70% 90-100% Received 59.

14 Does Underfeeding Equal Full Feeding? Arabi 2011 Single Center Study Permiss vs Full 1 Mixed ICU Age BMI 28.5 AP II 25.2 Permiss Under (n=120) Full (n=120) Intended 60-70% % Received 59.0% 71.4% 28d Mort 18.3% 23.3% Hosp Mort 30.0% 42.5%* YM Arabi Arabi 2015 Multicenter Study Permissive Under vs Full Feeds 2 Mixed ICU Age BMI 29.0 AP II 21.0 SOFA 9.9 Permiss Under (n=894) Full (n=446) Intended 40-60% % Received 46% 71% Infection 35.9% 37.9% ICU LOS 13d 13d ICU/90d Mort 16.1/27.2% 19.1/28.9% 1 Am J Clin Nutr 2011;93:569 2 NEJM 2015;372:2398 *p=

Dosing of EN Low dose EN (trophic or none) - Low nutritional risk, low dz

Dose (Trophic or full feeds) - ALI/ARDS, MV 72 hrs 3 High Dose EN -

2002 5, Nutric 6) 1,2 Attempt to provide > 80% goal 4 1 Kondrup J (Clin

15 Dosing of EN Low dose EN (trophic or none) - Low nutritional risk, low dz severity (NRS or Nutric Score 5) for first week 1,2 Low or High Dose (Trophic or full feeds) - ALI/ARDS, MV 72 hrs 3 High Dose EN - Advance to goal as tolerated over hrs High nutritional 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) 15

16 Does Permissive Underfeeding Extend to Protein? Caloric requirements Kcal/kg/d 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 16

17 Article Discussion Arabi YM, Aldawood AS, Haddad SH, Al-Dorzi HM, Tammin HM, Jones G, Mehta S, McIntyre L, Solaiman O, Sakkiha MH, Sadat M, Afesh L, PermiT Trial Group. Underfeeding or Standard Enteral Feeding in Critically Ill Adults. N Engl J Med 2015 Jun 18; 372(25):

18 Case Presentations 18

19 Q and A Session 19

20 Wrap-Up Test Questions Fax responses by Friday to Complete evaluation forms and fax Certificate of Completion Continuing professional education units To do list 20

21 Thank you! Nutrition-related resources and tools are available from Nestlé Nutrition Institute: 21

IS THERE A PLACE IN THE ICU FOR PERMISSIVE UNDERFEEDING AND WHERE? ENGELA FRANCIS RD(SA)

IS THERE A PLACE IN THE ICU FOR PERMISSIVE UNDERFEEDING AND WHERE? ENGELA FRANCIS RD(SA) DEFINITION: PERMISSIVE UNDERFEEDING No clear definition in literature Permissive underfeeding definition prior to