A R T H U R R. H. V A N Z A N T E N, MD PHD I N T E R N I S T - I N T E N S I V I S T H O S P I T A L MEDICAL DIRECTOR G E L D E R S E V A L L E I

Transcription

1 FEEDING THE OBESE CRITICALLY ILL PATIENT A R T H U R R. H. V A N Z A N T E N, MD PHD I N T E R N I S T - I N T E N S I V I S T H O S P I T A L MEDICAL DIRECTOR G E L D E R S E V A L L E I HOSPITAL, EDE, THE NETHERLANDS E - M A I L : Z A N T E N Z G V. N L 1

2 Take Home Message The obesity paradox in critically ill is debated Not all obese patients are the same Nutritional approach may need to vary Challenge the prevailing dogma that hypocaloric feeding (undernourishment) is acceptable Protein intake is relevant

3 WHO definitions Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. Body mass index (BMI), a person s weight (in kilograms) divided by the square of his or her height (in metres). A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight. Overweight and obesity are major risk factors for a number of chronic diseases, including diabetes, cardiovascular diseases and cancer.

4 Obesity Trends* Among U.S. Adults (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

5 Obesity Paradox Obesity paradox, also more inclusively known as reverse epidemiology, is a term for a medical hypothesis which holds that obesity may, counterintuitively, be protective and associated with greater survival in certain groups of people, such as very elderly individuals or those with certain chronic diseases. Examples: Chronic Kidney Disease, Alzheimers disease, COPD

6 and the critically ill BMI 30 kg/m 2 BMI kg/m 2 BMI < 30 kg/m *P < Days Wacharasinth P et al. Crit Care. 2013; 17(3): R122.

7 Hypotheses Obesity Paradox in Critically ill Patients Obese ICU patients have energy reserves (energy deficit hypothesis) Fat tissue may modulate the inflammatory response (mitigated inflammatory response)

8 IL-6 concentration (pg/ml) Interleukin-6 at presentation of septic shock P< BMI < 25 n=138 BMI n=112 BMI > 30 n=132 Wacharasinth P et al. Crit Care. 2013; 17(3): R122.

9 Hypotheses Obesity Paradox in Critically ill Patients Obese ICU patients have energy reserves (energy deficit hypothesis) Fat tissue may modulate the inflammatory response (mitigated inflammatory response) Patient may have been more exclusively selected due to the (wrong) assumption that outcomes are less beneficial

10 Weight bias among UK trainee dietitians, doctors, nurses and nutritionists Only 1.4% of participants could be said to have expressed 'positive or neutral attitudes' (i.e. achieved a Fat Phobia Scale score 2.5). There are unacceptable levels of weight bias among UK students training to become nurses, doctors, nutritionists and dietitians. The results of the present study suggest that a promising approach for future interventions would be the provision of balanced education about the controllability of obesity, focusing upon genetic and environmental factors, as well as diet and exercise. Swift JA, J Hum Nutr Diet Aug;26(4):

11 Admission bias against obese among intensivist?

12 Obesity paradox confounding in septic ICU patients Crude analysis Adjusted analysis baseline characteristics Adjusted analysis + sepsis interventions N P P P BMI< BMI Reference Reference Reference BMI BMI BMI > OR 95% CI OR 95% CI OR 95% CI Arabi YM et al. Crit Care. 2013; 17(2): R72.

13 Obesity paradox confounding in global ICU patients 60-day in-hospital death n = 8,829 infection in the ICU BMI >40 BMI >40 BMI BMI non-adjusted non-adjusted BMI * adjusted BMI adjusted BMI BMI BMI<18.50 * BMI< OR 95% CI OR 95% CI Sakr Y et al. Crit Care Med 2015

14 Hypotheses Obesity Paradox in Critically ill Patients Obese ICU patients have energy reserves (energy deficit hypothesis) Fat tissue may modulate the inflammatory response (mitigated inflammatory response) Patient may have been more exclusively selected due to the (wrong) assumption that outcomes are less beneficial Obese patients receive dosages of antibiotics in sepsis and lower resuscitation volumes leading to a smaller adjusted effect of BMI

15 Why divergent results among studies on obese ICU patients? Weight not precisely recorded Interventions are based on formulae Interventions are caloric driven Not all obese are equal (LBM) indirect calorimetry rarely performed Most studies low protein intake Not all obese are equal (comorbidities) Target set is not intake realized Most studies do not add micronutrients

16 Transverse computed tomography image at the 3 rd lumbar vertebrae intermuscular fat abdominal skeletal muscle subcutaneous adipose tissue visceral fat Braunschweig CA et al. JPEN J Parenter Enteral Nutr. 2014; 38(7):

17 Sarcopenic obesity in trauma patients N=149 patients, Median age: 79 years old 57% males, ISS: 19 Prevalence of sarcopenia: 71% All Patients Sarcopenic Patients (n=106) Non-sarcopenic Patients (n=43) BMI (kg/m 2 ) 25.8 (22.7, 28.2) 24.4 (21.7, 27.3) 27.6 (25.5, 30.4) Underweight, % Normal Weight, % Overweight, % Obese, % Moisey Crit Care 2013 Sept;17(5):R206

18 Sarcopenic obesity in trauma patients Proportion of Deceased Patients P-value Sarcopenic patients 32% Non-sarcopenic patients 14% Sarcopenic patients higher mortality All Patients Sarcopenic Patients Non-Sarcopenic Patients P-value Ventilator-free days 25 (0,28) 19 (0,28) 27 (18,28) ICU-free days 19 (0,25) 16 (0,24) 23 (14,27) Sarcopenic patients longer LOS and ventilation duration Moisey Crit Care 2013 Sept;17(5):R206

19 LBM: CT-scan and mortality Skeletal Muscle Similar BMI Different LBM Adipose Tissue Weijs et al. Critical Care :R12

20 LBM: CT-scan and mortality Survival Normal LBM Low skeletal muscle area, as assessed by CT scan during the early stage of critical illness, is a risk factor for mortality in mechanically ventilated critically ill patients, independent of sex and APACHE II score. Muscle mass is primary predictor, not sex. Low LBM BMI is not an independent predictor of mortality when muscle area is accounted for. Weijs et al. Critical Care :R12

21 Rectus femoris ultrasound preliminary data Quick Study Kreima J, Gelderse Vallei Hospital, Ede, the Netherlands

22 Longer time to extubation and ICU and hospital discharge Outcome Normal Weight Overweight Obese Extreme Obesity Extreme Obesity Extreme Obesity Extreme Obesity BMI (n = 3,490) BMI (n = 2,604) BMI (n = 1,772) BMI 40 (n = 524) BMI (n = 348) BMI (n = 118) BMI 60 (n = 58) Time to extubation, HR (95% CI) Reference 1.04 ( ) 0.94 ( ) 0.88 ( )a 0.97 ( ) 0.77 ( )a 0.66 ( )a 1.02 ( ) 0.91 ( )a 0.85 ( )a 0.92 ( ) 0.74 ( )a 0.54 ( )a 0.97 ( ) 0.85 ( )b 0.80 ( )a 0.89 ( ) 0.70 ( )a 0.44 ( )b Time to ICU discharge, HR (95% CI) Reference 1.03 ( ) 0.98 ( ) 0.96 ( ) 1.02 ( ) 0.88 ( ) 0.79 ( ) 1.00 ( ) 0.92 ( )a 0.86 ( )a 0.92 ( ) 0.79 ( )a 0.60 ( )a 0.95 ( ) 0.86 ( )b 0.82( )a 0.89 ( )c 0.75 ( )a 0.54 ( )b Time to hospital discharge, HR (95% CI) Reference 1.04 ( ) 1.11 ( )a 1.14 ( )c 1.21 ( )a 1.05 ( ) 0.99 ( ) 1.02 ( ) 1.00 ( ) 0.92 ( ) 0.97 ( ) 0.84 ( ) 0.63 ( )a 0.98 ( ) 0.96 ( ) 0.91 ( ) 0.96 ( ) 0.84 ( ) 0.64 ( )a ap.05 bp.001 This content c.05 may not < P be amended,.10 modified or commercially exploited without prior written consent Martino Chest 2011;140:1198

23 Comorbidities in obesity Prospective observational study of 183 critically ill patients with a BMI Raham ISRN Obesity 2012

24 Comorbidities in obesity 0-1 co-morbidity (n=38) 2 or more co-morbidities (n=145) p values Discharged alive from ICU by day (94.7%) 112 (77.2%) 0.02 Maximum SOFA score 7.5[5.0 to 11.0] 9.0[6.0 to 13.0] 0.04 Delta SOFA score 1.5[0.0 to 3.0] 2.0[1.0 to 5.0] 0.07 Number of days on MV 2.0[1.0 to 5.0] 4.0[2.0 to 7.0] 0.09 Number of days in ICU 3.0[3.0 to 11.0] 6.0[3.0 to 10.0] 0.04 ICU free days in the first 28 days 24.5[17.0 to 25.0] 20.0[3.0 to 24.0] Mortality at Day 14 2 (5.3%) 24 (16.6%) 0.08 Mortality at Day 28 2 (5.3%) 30 (20.7%) 0.03 Raham ISRN Obesity 2012

25 Mortality rate, BMI and mean caloric intake Mortality rate all patients < > Calories delivered Alberda C et al. Intensive Care Med Oct;35(10):

26 Relationship Between Increased Energy & Ventilator-Free days Adjusted BMI Group Estimate LCL 95% CI P-value UCL Overall < < < < < >= Legend: # of VFD per 1000 kcals received per day adjusting for nutrition days, BMI, age, admission category, admission diagnosis and APACHE II score. Alberda C et al. Intensive Care Med Oct;35(10):

27 What formula? Penn State or modified Penn State if >60 recommended by experts* Curr Opin Crit Care 2012, 18: *Choban JPEN 2013

28 What body weight? Actual body weight (ICU bed) Ideal body weight Adjusted body weight

29 Guidelines how to feed the obese ICU patient Canada Insufficient Evidence USA Provide 50-70% of target energy requirements (>14 kcal/kg actual body weight) and > g/kg IBW/d protein)* Europe Choban P et al. JPEN J Parenter Enteral Nutr Nov;37(6):

30 ASPEN International guidelines BMI < 30 BMI BMI > 40 Proteins g/kg actual body weight/day 2.0 g/kg ideal body weight/day 2.5 g/kg ideal body weight/day Calories 25 kcal/kg/day or formula 60-70% target kcal/kg actual weight kcal/kg ideal body weight/day Advice Proteins higher in burn and trauma Permissive underfeeding, high protein Permissive underfeeding, high protein Martindale G. Crit Care Med. 2009;37(5):

31 Obese critically ill after bariatric surgery Patients who have undergone sleeve gastrectomy, gastric bypass, or biliopancreatic diversion ± duodenal switch have increased risk of nutrient deficiency. In acutely ill hospitalized patients with history of these procedures, evaluation for evidence of depletion of iron, copper, zinc, selenium, thiamine, folate, and vitamins B12, and D is suggested as well as repletion of deficiency states.

32 How are Obese Patients Actually Being Fed? Nutritional Prescription Total 25-<30 30-<35 35<-40 >=40 P-value Mean Energy [Kcal/kg/day] (SD) 24.0 (5.8) 23.8 (3.7) 20.2 (3.4) 17.9 (2.8) 15.0 (4.0) < Mean Protein [grams/kg/day] (SD) 1.2 (0.3) 1.2 (0.3) 1.0 (0.2) 0.9 (0.2) 0.8 (0.3) < Nutrition Received Mean Energy [Kcal/kg/day] (SD) 14.0 (7.6) 13.6 (6.7) 11.2 (5.9) 9.8 (5.1) 8.1 (4.4) < Mean Protein [grams/kg/day] (SD) 0.6 (0.4) 0.6 (0.3) 0.5 (0.3) 0.4 (0.3) 0.4 (0.3) < Received EN protein supplements 173 (6.2%) 50 (6.1%) 28 (7.1%) 17 (10.5%) 22 (12.9%) Point prevalence survey of nutrition practices in ICU s around the world conducted Jan. 27, 2007 Enrolled 2772 patients from 158 ICU s over 5 continents Included ventilated adult patients who remained in ICU >72 hours Alberda C et al. Intensive Care Med Oct;35(10):

33 Nutritional deficits Daily Average intake in all groups: 1034 kcals and 47 grams of protein Average caloric deficit in Lean Patients: 7500kcal/10days Average caloric deficit in Severely Obese: 12000kcal/10days Alberda C et al. Intensive Care Med Oct;35(10):

34 Proteins or Calories Proteins are calories Protein balance: synthesis vs. break-down Energy is important Proteins are important Protein-Energy balance: protein to energy ratio

35 Changes in skeletal muscles after ICU admission Muscle wasting occurred early and rapidly during the first week of critical illness and was more severe among those with multiorgan failure compared with single organ failure. Puthucheary ZA et al., JAMA 2013

36 Changes in skeletal muscles after ICU admission Day 1 Day 7 Day 1 Day 7 CD68 + Puthucheary ZA et al., JAMA 2013

37 Loss of muscle protein (kg) in 10 days Loss of muscle protein (%) in 10 days Effect of high protein intake on Lean Body Mass in ICU patients in vivo neutron activation Datenreihe ,1 g 1,5 g ,1 g 1,5 g -1.8 kg of proteins reflects 9 kg of muscle mass Ishibashi N et al. Crit Care Med 1998

38 Tertiles of protein intake and survival rate g/day Mortality 16% 84.3 g/day Mortality 24% P = g/day Mortality 27%

39 Importance of achieving both energy and protein targets Mortality 14.7% Mortality 19.5% No target achieved: Mortality 20.4% Weis P. JPEN. 2012;36:60-68

40 Hospital mortality per protein intake group P = P = Sepsis 0.8 g/kg per day Non-sepsis 1.2 g/kg per day Weijs P. Crit Care 2014;18:701

41 Consequences of higher protein-energy ratio high-protein enteral formula enteral protein supplements parenteral amino acid supplementation beware of non-nutritional calories

42 Non-nutritional Calories Glucose Propofol in individual patients can add up to 35% of total caloric intake Trisodium Citrate

43 Antioxydants/vitamins/ trace elements/selenium Consider to use Antioxydants/vitamins/trace elements/selenium in all ICU patients RDA is available in 1500 ml of EN Many patients do not reach this targets for days

44 What we do? actual BW start with formula, EEN, aiming at full EN (no trophic) start multivitamins and trace elements until 1500 ml EN per day proteins kg/kg per day ideal body weight Highest protein formula+protein supplements Check non-nutritional calories to prevent overfeeding Monitor intake

45 Take Home Message The obesity paradox in critically ill is debated Not all obese patients are the same Nutritional approach may need to vary Challenge the prevailing dogma that hypocaloric feeding (undernourishment) is acceptable Protein intake is relevant

46 THANK YOU