How to meet protein requirements in the ICU? Kate Fetterplace APD Senior Dietitian PhD Candidate

Transcription

1 How to meet protein requirements in the ICU? Kate Fetterplace APD Senior Dietitian PhD Candidate

2 Acknowledgments & Conflicts Supervisors and collaborators A/Prof Adam Deane A/Prof Christopher MacIsaac A/Prof Jeffery Presneill Dr Audrey Tierney Dr Marina Mourtzakis Dr Adrienne Forsyth A/Prof Linda Dehehy Mrs Lisa Beach Ms Laura Knight Dr Thomas Rechnitzer Conflicts of interest: received honorarium / sponsorship support from Baxter, Fresenius Karbi, Nestle and Nutricia

3 Muscle Blood Muscle Synthesis Muscle Protein Amino Acids Amino Acids Protein Metabolism Muscle Breakdown Muscle loss occurs when Muscle Breakdown > Muscle Synthesis In healthy adults balance between synthesis and breakdown During metabolic stress (major surgery, trauma) imbalance occurs leading to net loss of body protein Regulated by proinflammatory modulators such as TNF-alpha and IL-6

4 Protein Recommendations SCCM & ASPEN 2016 ESPEN PN 2009 Canadian g/kg actual body weight Likely higher in burn or multitrauma patients Quality: Low g/kg ideal body weight Quality: Level B Insufficient data to make a recommendation on the use of high protein diets in critically ill patients McClave et al JPEN 2017, Singer et al Clin Nut 2009, CCPG Crit Care Nut 2015

5 Provision of protein and energy in relation to measured requirements 113 critically ill patients single centre Variable Unadjusted HR 95% CL P value Adjusted for Age HR 95% CL P value APACHI II 1.10 ( ) ( ) 0.03 Age 1.07 ( ) < Protein g/d 0.98 ( ) ( ) 0.03 Energy kcal/d 0.99 ( ) P = ( ) 0.38 Allingstrup et al Clin Nutr 2012

6 Higher Protein Provision May Influence Survival Variable Protein/kg/day mean (SD) N balance g/kg per day mean (SD) Low Protein (54g) (n= 37) Medium Protein (84g) (n=38) High protein (115g) (n=38) 0.79 (0.29) 1.06 (0.23) 1.46 (0.29) 0.59 (0.48) (0.41) -0.2 (0.58) ICU Mortality n (%) 10 (27) 9 (24) 6(16) Morality between the high and low group was significantly different (p = 0.011) Survival probability: Low 49%, Medium 79%, High 88% Allingstrup et al Clin Nutr 2012

7 Protein delivery & clinical outcomes in the critically ill: A systematic review and meta-analysis Literature between 1966 and 2015 Inclusion criteria: RCTs comparing two different nutrition strategies for > 48hrs Reported a statistically significant difference in protein delivery (p <0.05) MV critically ill patients Outcome of mortality Davies et al Criti Care & resus June 2017

8 Protein delivery & clinical outcomes in the critically ill: A systematic review and meta-analysis 14 studies including 3238 patients Mean protein delivered: Low mean (SD): g/day (20.45) or 0.67g/kg/day (0.38) High mean (SD): g/day (28.47) or 1.02g/kg/day (0.42) Lower protein had no influence on mortality OR (Cl p = 0.618) Davies et al Criti Care & Resus 2017

9 Amino Acid Tracers Professor Olav Rooijackers, Stockholm, Sweden Stable-isotope labelled phenylalanine and tyrosine tracers Used to measure protein synthesis, breakdown and oxidation Critically ill patients are able to utilise extra enteral and parenteral amino acid to build new body protein Protein feeding yielded a detectable, although small, improvement in whole body protein balance Liebau F et al CC 2015, Liebau F et al. Am J Clin Nut 2015

10 Positive Protein Balance WB Breakdown Synthesis Conclusion: Protein intakes of > 1.2 g/kg/day result in a positive protein balance Protein Balance Phe oxidation Liebau et al. Critical Care (2015) 19:106

11 Protein Requirements in the Critically N = 120 Critically ill Ill: A RCT Using PN Aim: to deliver 1.2g/kg/day V. 0.8g/kg/day protein via PN Delivered: 1.1g/kg Vs 0.9g/kg per day protein No difference in mortality (20% vs. 15%) p = 0.47 Greater forearm muscle thickness: mean (SD): 3.2cm (0.4) vs 2.8 cm (0.4), p < Improved handgrip strength: mean (SD): 22 kg (10) vs 18.6 kg (12), p = Ferrie et al JPEN 2016

12 Targeted Full Energy and Protein Delivery in Critically Ill Patients : A Pilot RCT 60 MV critically ill enterally fed patients Standard Care Intervention Energy Target 25kcal/kg 25kcal Protein Target 1.0g/kg 1.5g/kg Formula 1.0kcal/ml standard 1.25kcal/ml high protein + Protein powder (6g bolus) Delivery Method Hourly rate prescription Volume prescription Fetterplace et al Unpublished data

13 Optimise Muscle Protein Synthesis Pulse protein feeding patterns may enhance protein synthesis 25-30g protein per meal (containing g leucine) Fast protein may have benefit over slow proteins Proteins or amino acids are recommended in close proximity to exercise or activity Deutz et al Clin nut 2014, Bauer et al JAMDA 2013

14 Optimal amino acids to maintain muscle mass Leucine is an essential amino acid and has been shown to promote muscle protein synthesis Many amino acid preparations have been studied including BCAA (Valine, Leucine: isoleucine) Systematic review: 22 studies (4 in ICU & 18 muscle wasting condition) Leucine enriched EAA, HMB and creatine have shown some promising results in decreasing muscle loss in the critically ill Wandrag et al J Human Nut & Diet 2014

15 Nutrition Interventions to Optimise Protein Provision High protein formula Enteral or Parenteral Protein Supplementation Enteral or Parenteral Volume based protocols Supplemental PN

16 Current High Protein Formula Type Products Protein provided 25kcal/kg - 60kg Enteral 1.25kcal/ml (Protein Plus, 63g/L) 75g (1.26g/kg) 1.0kcal/ml (Promote, 62g/L) 1.3kcal/ml (Isosource Protein Fibre, 67g/L) Parenteral Olimel (1.1kcal/ml, 56.9g/L) Smofkabiven ( 1.1kcal/ml, 50g/L) Smofkabiven HP (0.95kcal/ml, 63.6g/L) 93g (1.55g/kg) 75g (1.26g/kg) 77g (1.28g/kg) 68g (1.14g/kg) 100g (1.67g/kg)

17 Current Protein Modular Product Protein content Ingredients Beneprotein Protifar 6g protein per scoop 2.2g protein per scoop Synthamin 17 (10%) 50g/500ml Vamin % Whey protein 77% Casein 13% whey IV balanced amino acid (11.4%) 57g/ 500ml IV balanced amino acid

18 What is the Optimal Formula? 60 yo male admitted following a MVA Head injury and multiple injuries and wounds Weight: 75kg BMI: 25

19 What is the Optimal Formula? Nutrition Day 1 (Sedated) Day 3 (Reduced Sedation) Day 7 (No sedation commenced rehab) Energy 20kcal/kg = 1500kcal 25kcal/kg = kcal/kg = 2250 Protein 1.5g/kg = 112g 1.5g/kg = 112g 1.5g/kg = 112g Optimal formula 1L (40ml/hr) Formula 1.5kcal/ml 112g protein 1.25L (50ml/hr) Formula 1.5kcal/ml 90g protein 1.5L (62ml/hr) Formula 1.5kcal/ml 75g protein

20 Optimal Enteral Formula For Critically Ill? 1000ml 1.5kcal/ml High quality protein including Whey protein Protein g/L With and without High quality fibre Osmolality mosmol/kg H20 Optimise Leucine content and contain HMB

21 Future Research What is the optimal protein provision? At present: g/kg per day What is the best type of protein? What is the optimal route for protein supplementation? How can we monitor protein adequacy? Can these interventions improve functional outcomes and maintain lean body muscle mass?

22 Thank you!