Nutrition Guidelines Bundle (AIRRP) 4/12/2016

Transcription

1 Cynthia Lowen, RD, LD, CNSC, CCRP Medical Scientific Liaison, Nestlé Health Science Clinical Instructor, University of Louisville Sponsor Disclosure: This presentation has been prepared and sponsored by Nestlé HealthCare Nutrition, Inc. 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. Copyright 2016 Nestlé. All rights reserved. At the completion of this presentation, the participant will be able to complete the following: 1. Identify the benefits of early enteral nutrition in the critically ill patient. 2. Describe obstacles to appropriately feeding in the critical care setting. 3. Discuss methods for nutritionally supporting the ICU patient, as per recommendations from the 2016 ASPEN/SCCM Critical Care Nutrition Guidelines. Nutrition Guidelines Bundle (AIRRP) Assess patients on admission to the ICU for nutrition risk, and calculate both energy and protein requirements to determine goals of nutrition therapy. Initiate EN within hours following the onset of critical illness and admission to the ICU and increase to goals over the first week of ICU stay. Take steps as needed to Reduce Risk of aspiration or improve tolerance to gastric feeding (use prokinetic agent, continuous infusion, chlorhexidine mouthwash, elevate the head of bed and divert level of feeding in the GI tract). Implement enteral feeding Protocols with institution-specific strategies to promote delivery of EN. Do not use gastric residual volumes as part of routine care to monitor ICU patients on EN. Start PN early when EN is not feasible or sufficient in high risk or poorly nourished patients. McClave S, et al. JPEN 2016;40: Table 2, page 163 1

2 Why a Bundle? Institute of Health concept for improving processes of care 3-5 evidence-based practices proven to improve patient outcomes Unique attributes: Must use all components together Based on Level 1 Trials Focuses on HOW to deliver best care, not WHAT care Bundle Review Literature Develop Guideline Create A Bundle Resar R, et al. Joint Commission Journal on Quality and Patient Safety 2005;31: Nutrition Risk A1: A determination of nutrition risk is suggested. NRS-2002' Nutric Score² ' Kondrup J, et al. Clin Nutr 2003;22: ² Heyland DK, et al. Critical Care. 2011;15(6):R268. McClave S, et al. JPEN 2106;40: Nutrition Risk Screening Malnutrition and Disease Severity NRS 2002 Validated in a retrospective analysis of 128 controlled nutrition support trials ESPEN preferred screening tool for hospitalized patients Quick, easy-to-use Validated to identify those who will benefit from nutrition intervention Kondrup J, et al. Clin Nutr 2003;22: Looks at malnutrition and disease severity 2

3 Concept of Nutritional Risk: NRS 2002 Age >70 yrs : Add 1 point Kondrup J, et al. Clin Nutr 2003;22: Score >3 Consider EN/PN Score >5 High risk Concept of Nutritional Risk:NRS 2002 ie, decreased mobility, increased LOS, death Components: Impaired nutrition status and disease severity J Kondrup. Curr Opin Clin Nutr Metab Care 2014;17:177. Utility of NRS 1085 adm for selective abdominal surgery Multi-Center Cohort Study 120 patients with NRS > 5 43 received adequate pre-op nutrition Conclusion: Preoperative nutritional support (> 7 days) should be provided to a patient with an NRS score of at least 5 and associated with: Total complications 25.6% vs 50.6% (p=0.008) Nosocomial infections of 16% vs 34% (p=0.04) Post-op LOS 14 vs 18 days (p=0.018) Jie B,et al. Nutrition 2012;28: p=0.008 for overall complications; p=0.040 in infectious complications p= for non-infectious complications 3

4 Concept of Nutritional Risk: Nutric Score Six Factors : Disease severity: Age Initial APACHE II score Initial SOFA score Interleukin-6 (may leave off) Comorbidities Poor nutritional status: Hosp LOS prior to ICU Low Risk: 0-5 points High Risk: *6-10 points *with IL-6 >5 w/o IL-6 Heyland DK, et al. Crit Care 2011;6:1. The Concept of Nutrition Risk Not all patients derive the same benefit Previously well-nourished, short ICU stay = little benefit Moderate to Severe Nutrition Risk More benefit (nutritional/non-nutritional) More likely to be harmed by underfeeding SA McClave, RG Martindale, TW Rice, DK Heyland. CCM 2014:42:

5 Set Goals of Nutrition Therapy: Calories Caloric requirements for BMI < 30: Indirect calorimetry kcal/kg/d Published predictive equations no more accurate A3a. Suggest that IC be used to determine energy requirements A3b. In absence of IC, suggest use of a published predictive equation or simplistic weight-based equation to determine energy requirements. Caloric Requirements for BMI > 30: Indirect Calorimetry-65-70% of target kcal/kg ABW/day for BMI and kcal/kg IBW/day for BMI >50 Q5. For all classes of obesity where IC not available McClave S, et al. JPEN 2016;40: Mogenson K, et al. JPEN 2011;35:135(S31-4). Set Goals of Nutrition Therapy: Protein Subset Amount Guideline Ref ARF, AKI g/kg ABW/day J1 BMI < g/kg ABW/day C4 BMI Obesity: > 2.0 g/kg IBW/day Q5 BMI Obesity: > 40 Up to 2.5 g/kg IBW/day Q5 Burns g/kg ABW/day M4c Chronically Critically Ill Aggressive high protein P1 CCRT/Frequent HD Up to 2.5 g/kg ABW/day J2 Liver Failure g/kg dry wt or usual wt/day K1/C4 Multi-trauma > g/kg ABW/day C4 Open Abdomen Baseline g/L lost exudate M3b PN in High Risk > 1.2 g/kg ABW/day for first week H2 Sepsis g/ kg ABW/ day N4 ABW=Actual Body Weight McClave S, et al. JPEN 2016;40: Monitoring Protein Provision A4. Based on expert consensus, ongoing evaluation of adequacy of protein provision should be performed. McClave S, et al. JPEN 2016;40:

6 Nutrition Guidelines Bundle (AIRRP) Initiate EN within hours following the onset of critical illness and admission to the ICU and increase to goals over the first week of ICU stay. McClave S, et al. JPEN 2016;40: Table 2, page 163 Benefits of Providing Early EN: Supports structural and functional integrity of intestinal epithelium Modulate stress and systemic immune response Attenuate disease severity B1. Recommend that nutrition support therapy in the form of early EN be initiated within hours in the critically ill patient who is unable to maintain volitional intake. McClave S, et al. JPEN 2016;40: Peterson L, Artis D. Nature Reviews 2014; 14: Structure and Function: Role of Intestinal Epithelial Cells (IEC) Largest mucosal surface in body-400m 2 Single layer of cells Digestion/Absorption Barrier/Immunity Peterson L, Artis D. Nature Reviews 2014;14: Gorden M, et al. TherAdv in Gastro 2008;1: IUd7l4coAqQCKlKAppWmZ4JtoALtcKc_Vt hauh5j2tgdc-lp2hk4q 6

7 Early EN: Supports structural integrity of the Intestinal Epithelium Maintains GALT/MALT Increases brush border enzymes Structural Stimulates epithelial cell proliferation Maintains villus height Jabbar A, et al. NCP 2003;18: Early EN: Supports functional integrity of the gut IgA, pancreatic enzymes Maintain IEC Tight Junctions Functional Promotes contractility Release of endogenous agents Stimulates blood flow JabbarA, et al. NCP 2003;18: Peterson L, Artis D. Nature Reviews 2014;14: Physiologic Consequence of Not Providing EN Increased oxidative stress Reduced Blood Flow Reduced contractility Upregulated systemic immune response Increased oxidative stress Activated neutrophils Loss Of Structure and Function Increased IEC openings Activated macrophages Increased permeability Poor patient outcomes Increased bacterial adherence McClave S, Heyland D. NCP 2009;

8 Nutritional versus Non-Nutritional Benefits of Early EN Reduce gut/lung axis of inflammation Maintain MALT tissue Production of Secretory IgA at epithelial surfaces Attenuate oxidative stress Systemic Inflammatory Response Syndrome (SIRS) Muscle function, mobility, return to baseline function Dominance of anti-inflammatory Th2 over pro-inflammatory Th1 responses Modulate adhesion molecules to transendothelial migration of macrophages and neutrophils Provide micro & macronutrients, antioxidants Maintain lean body mass Muscle and tissue glycosylation Mitochondrial function Protein synthesis to meet metabolic demand Absorptive capacity Influence anti-inflamm GI receptors Virulence of pathogenic organisms Motility, contractility Gut permeability Support commensal bacteria Stimulate oral tolerance Butyrate production Promote insulin sensitivity, hyperglycemia (AGEs) Nutritional: May need full dose EN Non-Nutritional: Trophic dose EN? S McClave et al. CCM 2014;42: Early vs Delayed/No EN: Mortality McClave S, et al. JPEN 2016;40: RR = 0.70 p = 0.05 Early vs Delayed/No EN: Infectious Morbidity RR = 0.74 p = 0.01 McClave S, et al. JPEN 2016;40:

9 Early EN Benefit Summary B1. We recommend that nutrition support therapy in the form of early EN be initiated within hours in the critically ill patient who is unable to maintain volitional intake. Provision of early EN is associated with significant decrease in mortality and infectious morbidity. McClave S, et al. JPEN 2016;40: Nutrition Bundle Statement #3: Take steps as needed to Reduce Risk of aspiration or improve tolerance to gastric feeding (use prokinetic agent, continuous infusion, chlorhexidine mouthwash, elevate the head of bed and divert level of feeding in the GI tract). D1: Based on expert consensus, we suggest that patients should be monitored daily for tolerance of EN. We suggest that inappropriate cessation of EN should be avoided.. McClave S, et al. JPEN 2016;40: Gut Dysfunction: 3 Hit Hypothesis Critical Illness Splanchnic Hypoperfusion Gut Mucosal Ischemia Gut Mucosal Barrier Disruption Increased Mucosal Permeability Lumen Bacteria/Endotoxins Enter Circulation Release of Chemokines and Cytokines SIRS, ARDS, and/or MODS Manifested As: Altered Motility Decreased Bowel Sounds Abdominal Distension Diarrhea Delayed Gastric Emptying Increased Gastric Residual Regurgitation Vomiting Gut wall inflammation Alteration in villi Decreased absorptive surface Gut dysfunction is associated with illness severity and worse outcomes during critical illness.* Sertaridou E, et al. Ann of Gastro 2015;28: Chapman M, Deane A. Curr Opin Clin Metab Care 2015;18:

10 Biomarkers of Gut Dysfunction Piton Curr Opin Crit Care 2016;22: Normal Villi Function Damaged Villi Dysfunction Citrulline synthesis From enterocytes No extracellular I-FABP* release Normal enterocyte Mass and Tight Junctions Absence of SIRS Citrulline x I-FABP Citrulline synthesis I-FABP* release Enterocyte mass Permeability Gut barrier function Gut-Induced SIRS, MODS Plasma Citrulline µmol/l Plasma I-FABP < 100 pg/ml *intestinal fatty acid-binding protein Plasma Citrulline < 20 µmol/l Plasma I-FABP > 100 pg/ml Intolerance Secondary to Gut Dysfunction Prevalence of GI symptoms in critically ill patients GI Symptom Incidence Author Absent/Abn Bowel Sounds 41% Reintam 2009 Abd Distension 13% Montejo 1999 Vomiting 48.5% Reintam-Blaser 2015 Diarrhea 2-95% Whelan 2004 High GRV/Delayed Gastric 80% Stupak 2012 Emptyting Any GI symptom 61% Montejo 2002 Reintam-Blaser A, et al. Anaes Int Therapy 2015;47: Reintam A, et al. Acta Anaesthiol Scand 2009;53: Whelan K. Proc Nutr Soc 2004;63: Stupak D, et al. J Clin Gastro 2012;46: Montejo J. CCM 1999;27: Montejo J, et al. 2002;30: Intolerance in the ICU: Selection of Appropriate EN Formula (E4b) Based on expert consensus: Consider use of a commercial-mixed fiber-containing formulations if there is evidence of persistent diarrhea. Suggest avoiding both soluble and insoluble fiber in patients at high risk for bowel ischemia or severe dysmotility. Consider use of small peptide formulations in patient with persistent diarrhea with suspected malabsorption, risk for bowel ischemia or lack of response to fiber. McClave S, et al. JPEN 2016;40:

11 Tools: Gut Dysfunction-Malabsorption Index Retrospective study 31 subacute care pts Avg age: 60 CVA, Resp failure, Abd abscess, pancreatitis, SBS EN and/or PN Malabsorption Index used to identify appropriate feeding 83% correlation between Malabsorption Index and feeding tolerance DeLegge M, et al. JPEN 2001;S25, Exocrine Pancreatic Insufficiency (EPI) as Marker for Gut Dysfunction in Critically Ill Patients Prospective cross-sectional study 563 Med/Surg ICU Patients > 3 days of EN: standard high fiber formula Objective: Determine prevalence of EPI in critically ill patients Exclusion Criteria GRV > 500mL x 3 consecutive days Diarrhea x 3 consecutive days Primary pancreatic disease and/or drugs for pancreatic secretion Characteristics No EPI (N=269) Mod EPI (N=191) Severe EPI (N=103) Age APACHE II Steatorrhea (%) * 11.7* Diarrhea (%) * Serum amylase (U/L) * Serum lipase (U/L) * F. Elastase-1 (mcg/g) * Wang S, et al. Crit Care 2013;17:4171 * p < 0.05 EPI Present in > 50% of Critically Ill Patients without Primary Pancreatic Disease which may lead to Maldigestion and Malabsorption Characteristics Number of Patients EPI (N=294) No EPI (n=269) P- value Shock <0.001 Sepsis Cardiac arrest <0.001 Diabetes <0.001 Hyperlactacidemia <0.001 Mechanical Vent <0.001 CRRT Wang S, et al. Crit Care 2013;17:

12 Exocrine Pancreatic Insufficiency with Aging Average age of MICU patient in U.S. is years 2 Population-Based 914 Asymptomatic Age Part of general health exam Results Prevalence of EPI increases with age 1 Percentage with EPI EPI: < 200 µgm elastace-1/g stool Severe EPI : < 100 µgm elastace-1/g stool AGE 1 Rothenbacher D, et al. Scan J Gastro 2005; 40: Wunsch, et al. Am J Respir Crit Care Med 2011;183: Feeding Intolerance in Critical Care Retrospective analysis of 2009 INS 167 ICUs, 21 countries Mech vent w/i 48 hrs ICU adm No prokinetics >1 day prior to EN 1888 patients qualified 31% experienced intolerance (n=576) Objective: Determine incidence of EN intolerance, factors associated with intolerance and influence of intolerance on clinical outcomes. Gungabissoon U, et al. JPEN 2015;39: Intolerance, Nutritional Adequacy and Outcomes P value <.0001 <.0001 <.0001 < < Gungabissoon U, et al. JPEN 2015;39:

13 Do tolerance and delivery of calories and protein alter outcomes in critically ill patients? C3. Based on expert consensus, we suggest that patients who are at high risk or severely malnourished should be advanced toward goal as quickly as tolerated over hours Efforts to provide >80% of estimated or calculated goal energy and protein within hours should be made. What is Adequate Provision of Calories? Mortality Prospective Audit (n=7872) INS Data 7872 Patients Mech Vent ICU > 72 hrs % Goal Calories Delivered Heyland DK, CCM 2011;39: Calorie Deficit Associated with Worsened Outcomes >20, , ,000 <5000 Cumulative Energy Deficit (kcal) Cumulative energy deficit correlated to: Hosp LOS (p=0.0001) Complications (p=0.0003) Infections (p=0.004) Duration of mech vent (p=0.0002) Villet S, et al. Clin Nutri 2005;24:

14 Relationship of Calorie Intake and 60-day Mortality by BMI Prospective Observational Cohort Study INS 167 Mixed ICUs 37 countries 2772 Patients Mech Vent w/i 48 ICU > 72 Provision of higher calories associated with significant reduction in mortality <20 & > 35. Alberda C, et al. Intens Care Med 2009;35: Protein: The Most Important Macronutrient in Critical Care McClave S, et al. JPEN 2016;40: Maintenance of LBM Wound Healing Immune Function Protein Why High Protein? Goals: Maintain lean body bass Maintain quality of muscle mass 1.6%/day median rate of muscle loss in mixed ICU 1 Greater protein intake associated with reduced infection and lower mortality 2,3,4 Death occurs earlier in tertile of mixed ICU patients with lowest provision of protein 5 Muscle mass important for short and long term outcomes in ICU and can be modified by protein feeding 6 No data to support a lower protein intake 6 1 Reid C, et al. Clin Nutr 2004;23: Heyland D, et al. Clin Nutr 2011;30: Elke G, et al. Crit Care 2014;18:R29. 4 Alberda C, et al. Inten Care Med 2009:35: Allingstrup M, et al. Clin Nutr 2012;31: Weijs P. Curr Opin Clin Nutr Metab Care 2014;17:

15 What is the Sufficient Dose of Protein? Prospective Observational Cohort Methods: Burn > 15% & Vent (n=13) Severe Sepsis (n=100) kcal/kg/day and IC pro g/kg/day and NB Daily NB & qod IC EN within 24 hrs Supp PN at MD discretion Results: Risk of death decreased by 2% for each g of protein & AA provided Provision of protein related to Hazard of Mortality: observed mortality was 50% of expected mortality. Allingstrup MJ. Clin Nutr 2012;31: Low (n=37) Medium (n=38) High (n=38) Severity APACHE II Nutrition Outcome Pro&AA g/kg/day **.79 **1.06 **1.46 Energy Kcal/kg/day * ICU LOS (days) ICU Mortality (n,%) 10(27) 9(24) 6(16) *Statistically significant difference in energy in the low pro group compared to medium & high protein **Protein was significantly different between L,M & H Conclusion: Death occurred earlier in the tertile of patients with lowest provision of protein and amino acids. What is the Sufficient Dose of Protein? Subset Amount Guideline Ref ARF, AKI g/kg ABW/day J1 BMI < g/kg ABW/day C4 BMI Obesity: > 2.0 g/kg IBW/day Q5 BMI Obesity: > 40 Up to 2.5 g/kg IBW/day Q5 Burns g/kg ABW/day M4c Chronically Critically Ill Aggressive high protein P1 CCRT/Frequent HD Up to 2.5 g/kg ABW/day J2 Liver Failure g/kg dry wt or usual wt/day K1/C4 Multi-trauma > g/kg ABW/day C4 Open Abdomen Baseline g/L lost exudate M3b PN in High Risk > 1.2 g/kg ABW/day for first week H2 Sepsis g/ kg ABW/ day N4 ABW=Actual Body Weight McClave S, et al. JPEN 2016;40: ICU-Acquired Weakness (ICU-AW) Bilateral, symmetrical muscle weakness not associated with pre-existing neuromuscular problems and secondary to muscle loss in the ICU Etiology Incidence Risk Factors Treatment Microcirculatory Disturbances Cytokines SIRS Sepsis Drug interaction 80% > 7 days MV 50% 4-6 days MV 33% in 3 days MV Corticosteroids Neuromuscular blockers/sedation Malnutrition PN MOF Immobilization Bed rest Adequate protein Early mobilization -Bed position -Sitting on bed -Transfer to chair -Resistance exercise -Ergometer bicycle -Neuromuscular Electrostimulation Koukourikos K, et al. ACTA Inform Med 2014;22:

16 Effect of Protein Intake on Time to Discharge Alive and Mortality Retrospective analysis of 2013 INS (65% MICU) Mech vent within 48 ; > 3 day ICU stay EN, PN, Pro Supplement, Propofol 2828 > 4 days ICU and 1584 > 12 days ICU Objective: Determine if 60-day mortality varied by protein intake Nicolo M, et al. JPEN 2016;40: Results Achieving at least 80% of prescribed protein intake is associated with improved survival. Nicolo M, et al. JPEN 2016;40: Types of Protein to Consider Hoffman J, Falvo M. J Sports Sci and Med 2004;3: Biological Value = N2 for tissue formation x 100 N2 absorbed from food PDCAAS=Protein Digestibility corrected AA score (fecal digestibility of protein) Net Protein Utilization= N2 for tissue formation x 100 N2 consumed/ingested 16

17 Therapeutic Role of Whey Protein 26% BCAA: Abundant in leucine for muscle protein synthesis 1 Prebiotic: Selectively supports growth of Bifidobacteria 2 Immunoglobulins: Modulate immune function 2 Antimicrobial: Binds C. Diff and inhibits cholera toxin 2 Cysteine: Increases glutathione synthesis to protect against free radicals 2 Insulinotrophic: Increases maximal plasma insulin concentration >28% 3 Antioxidant: Suppresses oxidative stress 2 Enhanced Gastric Emptying4 1 Ha E, Zemel B. J Nutr Biochem 2003;14: Yalcin A. Curr Pharm Design 2006;12: Power O, et al. Amino Acids 2009;37: Fried M, et al. J Ped 1992;120: Nutrition Guidelines Bundle (AIRRP) Implement enteral feeding Protocols with institution-specific strategies to promote delivery of EN. McClave S, et al. JPEN 2016;40: Table 2, page 163 The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP up Protocol! Different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds. In select patients, start the EN immediately at goal rate, not at 25 ml/hr. Target a 24-hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume. Start with a semi-elemental solution, progress to polymeric as tolerated. Higher GRV threshold (300 ml or more). Motility agents and protein supplements are started immediately, rather than started when there is a problem. Heyland D, et al. JPEN 2015;39:

18 PEPuP Components Heyland D, et al. JPEN 2015;39: Nutrition Guidelines Bundle (AIRRP) Do not use gastric residual volumes as part of routine care to monitor ICU patients on EN. McClave S, et al. JPEN 2016;40: Table 2, page 163 Monitor Tolerance and Adequacy GRVs should not be used as part of routine care 1 Montejo Multicenter RCT 1 GI Complications %Goal Feeds 500cc GRV (n=160) 47.8% * 89% * 200cc GRV (n=169) 63.6% 83% Reignier Multicenter RCT 2 VAP Infect Mortality Deficit No GRV used (n=227) 16.7% 26.4% 27.8% 319 kcal Routine GRV (n=222) 15.8% 27.0% 27.5% 509 kcal 1 Montejo JC, et al. Intens Care Med 2010;36: Reignier J, et al. JAMA 2013;309:

19 GRV: To measure or not to measure? Gastric residual volumes are indicative of gastric emptying and, although they may not be indicative of pulmonary aspiration risk, they should be measured to determine the need for promotility agents and small intestinal feeding with the aim of improving nutrient delivery. Chapman M, Dean A. Curr Opin Clin Nutr Metab Care 2015;18: Nutrition Guidelines Bundle (AIRRP) Start PN early when EN is not feasible or sufficient in high risk or poorly nourished patients. McClave S, et al. JPEN 2016;40: Table 2, page 163 CC Guidelines Parenteral Nutrition Algorithm Is patient high nutrition risk? Is EN Feasible? Use EN Initiate exclusive PN ASAP G2 Withhold PN x 7 days G1 Maintain EN Is EN at < 60% goal rate after 7 days? Use MNT, protocols H1 Hypocaloric (80%) dosing x 1st week H2 Withhold soy-based lipids x 1st week H3a Glucose control ( mg/dL) H5 Transition off when EN >60% goal calories H7 Use supplemental PN G3 McClave S, et al. JPEN 2016;40:

20 Assessment of Nutrition Risk recommended to aid in determination of urgency to feed. Initiate early EN within hours admission to ICU in high nutrition risk patients. Utilize protocols to aid in reducing risk of feeding intolerance and to promote adequate delivery of feeding. Use PN, as necessary, when EN not feasible or adequate. Respect CC Nutrition Guidelines, but use clinical judgement and knowledge of patients to drive nutrition decisions. Question and Answer Time Sponsored By : Sponsor Disclosure: This presentation has been prepared and sponsored by Nestlé HealthCare Nutrition, Inc. 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. Copyright 2016 Nestlé. All rights reserved. 20