SASPEN: Meet the Expert. Pr. Me'e M Berger Service of Intensive Care & Burns CHUV Lausanne Switzerland

Transcription

1 SASPEN: Meet the Expert Pr. Me'e M Berger Service of Intensive Care & Burns CHUV Lausanne Switzerland 40

2 Ensuring my patients are properly fed. Nutrition therapy must be planned as any other ICU therapy Which requires: Ø Assessment of nutritional risk Ø Deciding about the timing of feed initiation ESICM guideline Ø Determining energy target protein needs (adapting product?) Ø Choice of the feeding route (EN > PN, but ) does the gut work? Ø Deciding about the feed progression rate Ø Monitoring

3 Changes with age: sarcopenia Parise G. et al., Curr Opin Clin Nutr & Metab Care 2000, 3: Malnutrition (and physiologic muscle loss) is more frequent in elderly patients We are not equal facing the same illness or trauma

4 Acute Skeletal Muscle Wasting in Critical Illness Puthucheary et al, JAMA 2013; 310:1591 Our patients change during their stay µ

5 Case - 38 years old lady (weight 55kg), par 2, day 29 th post delivery, underlying diabetes mellitus on insulin Presents with epigastric pain, associated with 1 week of fever, vomiting and reduced oral intake. Emergency Dpt: alert, conscious, hemodynamically stable, but tachycardic. CXR à pneumoperitoneum. Emergency exploratory laparotomy. Intraoperative finding was large pyloric ulcer perforation à Distal gastrectomy + Roux-en-Y Post op: admitted to ICU. Extubated on PO day 1

6 Nutritional risk assessment ICU On what variable would you determine a «risk»? Body mass index alone? (normal?) Weight loss alone? (non) Time without feeding? (1 week) Subjective global assessment (SGA)? Severity of critical illness? Food intake during last days? Nutrition Risk score Kondrup 2002? NUTRIC score?

7 ESPEN Score Kondrup 2002 Hospital malnutrition (Clin Nutr 2003)

8 Case - 38 years old lady (weight 55kg), par 2, day 29 th post delivery, underlying diabetes mellitus on insulin Post op: admitted to ICU. Extubated on PO day 1 Nut: TPN was started at day 1 post op (700kcal/day). Requires reintubation on day 3 post op ßacute pulmonary oedema? Nut: Nasogastric feeding started on day 4 post op (30mls/hr of nourishing fluid), supplement with TPN 1000kcal/day. Nut: PO day 5: possible leak à kept NBM, and TPN to 1500kcal

9 2017 ESICM guidelines Reintam et al, Intensive Care Med (2017) 43: ESICM s Working Group on Gastrointestinal Function within the Metabolism, Endocrinology and Nutrition Section (MEN). Reintam-Blaser et al. N=24 international authors

10 Table 1. General principles and precautions for using EEN in critically ill patients at risk for intolerance. Starting EN Energy Target Monitoring & Protocol Individualized

11 General recommendations to delay EN uncontrolled shock uncontrolled hypoxemia and acidosis uncontrolled upper GI bleeding bowel obstruction We suggest DELAYING EN 15. Overt bowel ischaemia 16. High-output fistula without distal feeding access 18.b. Abdominal compartment syndrome 21. Gastric aspirate > 500 ml/6 h expert opinion = Grade 2D

12 Early enteral nutrition 20 starts 1. early EN in critically ill adult patients a. early EN (over early PN) in critically ill adult patients b. early EN (over delayed EN) in critically ill adult patients 2. shock receiving vasopressors or inotropes when shock is controlled 3. stable hypoxemia, compensated or permissive hypercapnia and acidosis 4. use of neuromuscular blocking agents per se is not a reason to delay EN 5. therapeutic hypothermia 6. ECMO 7. patients managed in prone position 8. traumatic brain injury 9. stroke (ischemic or hemorrhagic) 10. spinal cord injury 11. severe acute pancreatitis 12. after gastrointestinal surgery 13. after abdominal aortic surgery 14. abdominal trauma after the continuity of the GI tract is confirmed/ restored 17. open abdomen 18a. intra-abdominal hypertension without abdominal compartment syndrome 19. upper GI bleeding after the bleeding has been stopped + no sign of rebleeding 20. Bleeding is controlled with or without liver support strategies 22. absent bowel sounds unless bowel ischemia or obstruction is suspected 23. diarrhoea

13 Energy Target determination upon ICU admission case Equation based: 30 kcal/kg/d 1650 kcal? Based on Harris & Benedict 1270 kcal? Equation based: 20 kcal/kg/d 1100 kcal? VCO 2 x 8.19? (Stapel et al, Crit Care 2016) Indirect calorimetry? Other

14 «Default» requirements ICU first week Burns Energy* kcal/kg 20 >30* Obese: calorimetry / consider ideal body weight Elderly >60 years: metabolism àharris-benedict * Proteins g/kg Glucides g/kg Lipids g/kg * Validated by calorimetry à 70 kg ATP/j

15 Substrate metabolism 36 h fas3ng 75 g proteins 144 g CO 2 H 2 O GNG à 180 g 36 g FFA 40 g CC 60 g 36 g Pyruvate lactate Triglycerides 160 g 120 g CO 2 H 2 O

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17 Day 1 = study enrollment. Energy received = EN + PN + i.v. infusions with 10% glucose Early PN in Critically Ill Patients With Short-term Relative Contraindications to Early Enteral Nutrition: RCT Doig G et al. JAMA 2013, 309 (20): Early PN à Shorter ventilation time Better strength D60

18 Provision of protein and energy in relation to measured requirements in intensive care patients Allingstrup M et al, Clin Nutr, 2012 Apache SOFA Low n= g/d Medium n= g/d High n= g/d Day survival in the ICU in 3 groups of patients, ranked according to decreasing provision of protein during their ICU stay. Mantel log-rank P = 0.021; Breslow Gehan: P = Log-rank test for trend: P = 0.011

19 Case continued NBM while at ward. TPN was continued with1400kcal/ day. After 8 days in general ward, readmission to ICU for septic shock (Blood culture: CRE). Multiple attempts to give NG feeding failed (intolerance ß unsettled bowel pathology). TPN was continued and increased to 1600kcal. She was only able to tolerate NG feeding after 9 days in ICU

20 Energy Target over time Use the same target as on admission? VCO 2 x 8.19? (Stapel et al, Crit Care 2016) Indirect calorimetry? Other

21 EE from ventilator-derived VCO2 Replace VO2 by VCO2 in the Weir formula RQ =VCO2/VO2 VO2 = VCO2/RQ Assume a RQ of 0.85 Weir formula EE= 3.941*VO 2 (L/min) +1.11*VCO 2 (L/min) * 1440 EE = 8.19 * VCO 2 Stapel S. et al. Crit Care 2015,19:370

22 Case continued She was only able to tolerate NG feeding after 9 days in ICU. After 2days of NG feeding, she had episode of bleeding from the abdominal wound and need to go for another emergency surgery. Intraoperatively noted there was anastomotic dehiscence with duodenal stump blow out. The surgery was complicated with DIVC and massive blood loss. Abdominal packing done. Post surgery, she was kept NBM. Relaporotomy and removal of packing done 2 days after. Feeding jejunostomy done a week after and feeding was initiated at day 1 post insertion

23 4000 SPN1: Comparison of Energy Targets at day 3 R 2 = Target change Calculated vs meaured I.Calorimetry kcal/d N=184 Mean value means nothing to the individual patient!! Equation Target kcal/d MEASURED EQUATIONS IC ICM 98 kcal /IBM /actual BW Heidegger et al, Lancet 2013: 381:385

24 Protein delivery of the SPN study Berger et al, Nutr Clin Pract 2017;32: ,8 89,8 Target = 1.2 g/kg 77 83,6 79,6 78,3 75 Protein (g/d) EN SPN 34,5 19,1 8,6 17,3 34,5 50, ,4 55,1 54,7 p< , Days after admission

25 Energy expenditure & caloric balance after burn Hart et al. Ann Surg 2002; 235: Fat mass Muscle mass Body weight 110% of measured EE

26 Proposed Feeding strategy in the ICU Energy Endogenous production TOTAL energy expenditure Σ Endogenous production + exogenous supply Progressive early EN GRV>300 ml Supplemental PN Time (hrs) Indirect calorimetry Days Adapted from Oshima et al, Clin Nutr 2017;36:651

27 No indirect calorimeter available? EE (kcal/day) can be calculated at the bedside as 8.19 VCO 2 (ml/min). This equation is derived from the rewritten Weir formula using an RQ of 0.86, which is the RQ of most nutritional products Not all ICUs have mechanical ventilators that measure VCO 2 continuously. Most modern ventilators do have this option available and cost < metabolic monitor

28 ICALIC group Q-NRG Monitor the energy expenditure

29 Resting energy expenditure, calorie and protein consumption in critically ill patients: a retrospective cohort study Zusman et al, Crit Care 2016 Association of administered calories/resting energy expenditure (Adcal/REE) % with 60-day mortality (left), and protein intake by daily requirement (1.3 g/ kg/d) with 60-day mortality (right)

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31 Outcome according to energy balance Bartlett et al, Surgery, 92: 772, ICU patients at risk of MODS Cumulative caloric balance at the time of ICU discharge 61% Survived Died % 39% 86% 27% Positive 0-10K negative >10K negative

32 Cutoff of underfeeding complications Concept of cumulated energy deficit Villet et al 2006: Cut off Complications kcal certain: -130 kcal/kg Critical level: kcal -100 kcal/kg Dvir et al 2006: problem starts kcal - 50 kcal/kg Problem: Catch up feeding > 110 % mree is not tolerated

33 Lady, 76 yrs 76 kg (BMI 26.3 kg/m2) : Aortic type A Dissection : Tamponnade ß retro-cardiac hematoma Atrial fibrillations : Refeeding syndrome : VAP à Klebsiella pneumoniae Extubated on 28th 2 nd case - reserve