Metabolic monitoring in the ICU

Transcription

1 Metabolic monitoring in the ICU Jean-Daniel Chiche, MD PhD MICU & Dept of Host-Pathogen Interaction Hô pital Cochin & Institut Cochin, Paris-F

2 Conflicts of interest - Disclosure GE Healthcare Received honorarium for participation to Medical Advisory Board for ventilation & CIS activities ( ) Travel expenses Seoul 2015 Nestlé Healthcare Received honorarium for participation to Medical Advisory Board

3 25 years of failed novel intervention trials Being less pessimistic... improved ICU outcomes (better general care, less iatrogenic harm) many positive outcome RCTs from doing less (ventilation, sedation, Tx..) excess reliance on protocols, guidelines? Starting to understand what may be good for populations.. but for the individual??

4 It s all about people!

5 But we care for individuals

6 Individuals are unique! differing host response to insult different trajectory of disease progression different severity of disease progression affected not just by genes but by age, comorbidity, drugs... Photo credit: Kallel Koven

7 Interplay between critical ilness & chronic health

8 Sedation Nutrition Transfusio n Shock Coma & Neuro dysfunction ARF Infection Organ failure AKI ICU / Hospital Mortality

9

10 JAMA. 2014;311(13): JAMA. 2014;311(13):1295-

11 Sedation Nutrition Transfusio n Shock Patients & Family Coma & Neuro dysfunction ARF Infection Organ failure AKI The global burden of critical illness

12 ICU-acquired weakness

13

14 Try the ICU Diet

15

16

17

18 Impact of Systemic Aggression Age and comorbidities predispose patients to shock and critical illnesses The normal response to aggression involves simultaneous expression of genes involved in the systemic inflammatory, innate immune, and compensatory antiinflammatory responses, as well as suppression of genes involved in adaptive immunity Differences in the magnitude and duration of these changes are associated with complicated outcomes

19 Impact of Systemic Aggression In addition to organ dysfunction taken into account by SOFA scores, systemic aggression triggers novel pathophenotypes Critical illness neuromyopathy Immune dysfunction Heterotopic ossifications & joints abnormalities Cognitive dysfunction Depression Acute cardiovascular events Dementia Tumor growth,

20 Individuals are unique and so are our treatment approaches!!! Regardless of etiology timing severity confirmed diagnosis age gender co-morbidity Photo credit: Kallel Koven

21 Frailty as an important determinant of critical illness Syndrome of decreased reserve and resistance to stressors, including sepsis Results from cumulative declines across multiple physiologic systems Defined by 3 criteria unintentional weight loss self-reported exhaustion weakness (as evidenced by reduced grip strength) slow walking speed low physical activity

22 J Am Geriatr Soc 54: , 2006

23 Most ICU patients have some sort of comorbid state Male individuals, 2010 Female individuals, 2010.

24 The complex ICU patient Patients with complex multi-organ failure have prolonged ICU stays weeks to months Some have prior nutritional deficits Some (few) have clear contra-indications to EN But many of these develop gut dysfunction during their episode: Gut stasis Constipation Ileus bleeding

25 The complex ICU patient (2) Prolonged ventilation & immobility: Muscle loss Continuous Renal Replacement Therapy Nutrient loss Underfeeding Protein and calorie deficit

26 The few things I know about nutrition Use enteral feeding every time it is possible Use it early Feed with whatever works Use some sort of glycemic control Use common sense How much? Fortunately, smart people publish guidelines

27

28 Body weight vs energy intake

29 The problem of obesity

30 Can we predict energy expenditure?

31 kcal/ m2/ hour Energy expenditure in healthy subjects 54 The surest things can change Disease states Temperature 15% Stress 12% 42 73% Drugs, hormones men Treatments Nutrition Basal metabolism Thermogenesis Physical activity women years Fleisch A. Helv Med Acta 1951;1:23-44

32 Change in energy expenditure Propacetamol External cooling

33

34

35 weight & height + age (gender) REE (M) = 14 x kg + 5 x cm 7 x years REE (F) = 10 x kg x cm 5 x years weight & height + age (gender) +hypermetabolism weight & height + minute ventilation + temperature

36

37 Undernutrition vs Overnutrition Autophagia? Tissue repair? Autophagia? Tissue repair?

38 Overnutrition & Lung Function Nutrient intake & consumption increase in metabolic rate increase in CO 2 production increase in minute ventilation High glucose intake induces lipogenesis RQ > 1 + further increase in CO 2 production In case of weaning failure / high minute ventilation (> 150 ml.kg -1.min -1 ) in otherwise unstressed patient, consider the possibility of overnutrition / high glucose intake

39 Do We Have a problem? Is it plausible that an initial nutritional deficit may have a detrimental effect? To what extent is the concept of relative underfeeding merely an excuse for poor performance? If this is true, how might we address it?

40 Energy deficit has significant consequences on outcome

41 Number of patients ICU cumulated energy balance & outcome Patients at risk of organ failure Indirect calorimetry determinations of target Survived Died % 39% 27% Positive 0-10k negative > 10k negative Bartlett et al. Surgery, 92: 772, 1982

42

43 Villet et al, Clin Nutr 2005

44 Villet et al, Clin Nutr 2005

45

46

47

48 Kyle et al, Clin Nutr 2006

49

50 Predictive equations showed proportional bias Overestimation of low REE values Underestimation of high REE values Correction by regression analysis did not improve results

51 Measuring energy expenditure in the ICU

52 Energy expenditure measurements Living organisms consume O 2 & generate heat due to cellular respiration Nutrients + O 2 ATP + heat Direct calorimetry Body heat radiation is captured by circulating water in a highly isolated environment EE= Water volume (ml/sec) x T (water in - out) Precision ± 1% Indirect calorimetry Expired vs. inspired O 2 & CO 2 Precision ± 1-5% EE

53 Indirect calorimetry: parameters Glucose Lipids Proteins O 2 (ml) CO 2 (ml) RQ RQ = O 2 consumption/co 2 production Interpretation lipolysis glycolysis 1.0 lipogenesis

54 Distribution of measured EE in 335 patients on MV as % of predicted EE (HB)

55 Indirect calorimetry in practice Indications Body weight 80 % or 130% IBW Major stress Hyperthyroidia, pheochromocytoma Shivering, spasms, plegia, coma, Long-term ICU stay & mechanical ventilation Difficult weaning Limitations High pressure regimen leaks Hyper / hypoventilation PH Insufficient duration Non-collaboration, agitation

56 Indirect calorimetry in the ICU The Tools

57

58

59

60

61 Indirect calorimetry in the ICU What can we do with it?

62 Patients randomized to receive enteral nutrition with an energy target determined repeated indirect calorimetry measurements; study group, n=56 according to 25 kcal/kg/day; control group, n=56)

63

64

65

66

67 Day 4-8: 248±1479 kcal By Day3: -3856±1311kcal Day 4-8: -2220±2478 kcal

68

69 SUCCESS FAILURE

70 Correlation between respiratory drive (expressed as P0.1) & VO 2 SUCCESS

71

72 Metabolic monitoring Any other use?

73 Bedside measurement of FRC N 2 wash-out / wash-in Volume and concentration of Nitrogen captured Change Oxygen concentration Calculate change in Nitrogen Calculate FRC through metabolic monitoring FRC = VN2/N 2 % start N 2 % end N2% = 1-EtO 2 EtCO 2 VN 2 = V T i x N 2 % in V T e x N 2 % out, where; N 2 % in = 1-FiO 2 N 2 % out = 1-EtO 2 EtCO 2 Metabolic stability is mandatory

74

75

76

77

78 Bedside measurement of FRC What can we expect? Establish a patient s baseline FRC Evaluate the progression of acute lung injury Assess whether a specific therapy or a change in ventilation improves FRC Evaluate the effect of recruitment maneuvers Patient-tailored physiological determination of the best PEEP

79 PEEPxCompl

80 Rec estim = xRec mes P =

81

82 Decremental PEEP trials to set PEEP? - a practical alternative - Recruitment maneuver (RM) FiO 2 P= aw 1, 40 P aw cmh 40 cmh 2 O x40 2 O sec, x40 sec, then then P plat P plat cmh cmh 2 O, 2 O, PEEP= PEEP 16 (20) dr + 2 cmh 2 O ABG 10 min after RM Adjust RR & V T for ph> 7.25 Wean FiO 2 for SpO 2 = % Decrease PEEP 2 cmh 2 O/5 min «PEEP dr», with SpO 2 < target 1,6 1,4 1,2 1 0,8 0,6 0,4 Deflation 0, Maintenance

83 Decremental PEEP trials Volume difference can represent either recruited or de-recruited volume. CRF measurements during a decremental PEEP trial following a recruitment maneuver can identify: the response to recruitment manœuver the level of PEEP where de-recruitment occurs.

84 FRC-guided PEEP setting in ALI -1 FRC (ml) SpO 2 (%)

85 FRC-guided PEEP setting in ALI -1 FRC (ml) CO (L/min)

86 FRC-guided PEEP setting in ALI -2 FRC (ml) SpO 2 (%)

87 FRC-guided PEEP setting in ALI -2 FRC (ml) CO (L/min) Volume expansion 1500 ml saline serum

88 FRC-guided PEEP setting in ALI -2 FRC (ml) SpO 2 (%)

89 Summary Metabolic monitoring can be implemented in the ICU and has potential useful clinical applications in the critically ill Optimization of nutrition therapy Weaning Determination of FRC is potentially helpful to Evaluate the progression of acute lung injury Assess the efficiency of specific therapies or changes in ventilation strategies (PEEP setting, recruitment maneuvers, prone position, )

90