L.Mageswary Dietitian Hospital Selayang

Transcription

1 L.Mageswary Dietitian Hospital Selayang AUG ASMIC 2015

2 Learning Objectives 1. To understand the importance of nutrition support in ICU 2. To know the right time to feed 3. To understand the indications for enteral formulas 4. To know how much feeding is adequate 5. To appreciate good feeding practices

3 Critically lll Starvation Lack of nutrient intake & caloric demand Minimal loss of protein Reduced protein catabolism to preserve lean body mass Mobilization of fat for energy Hypermetabolism Activated state, REE Increased lean body mass wasting Accelerated protein catabolism for energy & protein synthesis Protein (muscle &visceral) for energy and glucose formation (Gluconeogenesis)

4 Hypercatabolic & Hypermetabolic Malnutrition (Reported as being as high as 40% in ICU) Impaired immunological functions Impaired ventilatory drive Weaken respiratory muscles prolonged ventilatory dependence infection morbidity mortality Dark D et al, Journal of Intensive Care Medicine 1993 Giner M et al. Nutrition 12:23 29, 1996

5

6 CAN PATIENT EAT NORMALLY? YES No Special Support Needed NO Specialized Nutritional Support Needed IS GIT FUNTIONAL? YES Naso-Gasrric or Naso-Enteral Tube Feeding NO Total Parenteral Nutrition(TPN) Needed FULL AMOUNT TOLERATED? YES Tube- feeding Alone Sufficient NO Supplement as Needed with Peripheral Parenteral Nutrition (PPN) IS PATIENT AT HIGHER RISK FOR ASPIRATION? IS PATIENT AT HIGH-RISK FOR ASPIRATION? YES Use Post-Pyloric Feeding NO May Use Intra- Gastric Feeding YES Use Post-Pyloric Feeding NO May Use Intra- Gastric Feeding

7 ENTERAL NUTRITION 1. Promotes gut mucosal growth & development 2. Helps maintain the barrier function and may help prevent translocation of bacteria & toxins 3. Support the immune system 4. Results in better nutrient use with fewer metabolic disturbances 5. Less expensive comparing cost of PN versus En, estimated EN saves $425 per day over Chellis MJ et al (JPEN 1996)

8 14 15 AUG ASMIC 2015

9 When to Initiate Feeding? Critically ill patients who are hemodynamically stable with functioning GIT & adequately resuscitated All appropriate patients will have enteral nutrition initiated by hours Following hospitalisation, trauma, injury or admission to ICU Caloric goal to be reached by hours after initiation

10 Why Early Feeding? Early use of the enteral route may play a significant role in preventing GI mucosal atrophy Development of the systemic inflammatory syndrome (SIRS) Multiple organ failure (MOF) Multiple organ dysfunction (MOD)

11 Time Required To Regain Post Operative GI Propulsion Stomach Liquid: 3 8 hrs Solids: hrs hours Small Bowel hours Colon

12 Meta-analysis of RCT Early Enteral Feeding Outcome NO TRIAL Anastomotic dehiscence Infection: Any type Wound Infection Pneumonia Intra-abdominal abscess Vomiting Death Favours Early Feeding Favours NBM Relative Risk

13 14 15 AUG ASMIC 2015

14 Dose dependent Effect of EN As little as 10ml/H of feed of enteral feeding may be sufficient to provide the desired `GI protective effect` (Level B) Early feeding with 55 to 60% goals target Maintain gut integrity and gut barrier function Provide immune benefit McClave. J of critical illness. 2001:16: ;

15 These changes are time dependent; the longer they are left NPO, the greater the complications.

16 Objective Objective: To describe current nutrition practices in intensive care units and determine best achievable practice relative to evidence-based Critical Care Nutrition Clinical Practice Guidelines. Research Design An international, prospective, observational, cohort study conducted January to June adult intensive care units from 20 countries. Total subjects = 2946

17 Result Average adequacy of total calories and protein over the 12 days of observation Calorie adequacy = 59.0% (site range, 20.5% 94.4%) Protein adequacy = 60.3% (site range, 18.6% 152.5%)

18 EN Intake kcal Calorie Debt Caloric Debt Prescribed Engergy Energy Received From Enteral Feed Days Increasing caloric debt is associated with Increase days on mechanical ventilation Longer ICU stay Increase mortality Villet et al Clinical Nutrition 2005; Faisy et al British Journal of Nutrition 2009; Tsai et al Clinical Nutrition 2011

19 Underfeeding 21.9% patients remain NPO 3 days mean duration 5.2 days (range 0 16 days) Problem initiating feeding Physician order 65% of goal volume Only 15% of patients reach goal feeds within 3 days Problems delivering feeding Only 80% of ordered volume is given Cessation of EN in 80% patients (diagnostic, procedures, high GRV ect.) Net effect only average 50% of goal volume Slow advancement Fanklin, McClave (JPEN 2006;30:S32) McClave (CCM 1999;27:1252) Heyland (JPEN 2003;27:74) Jones (J Crit Care 2008;23:301)

20 Overfeeding Hyperglycemia Hyperlipidemia Fat deposition (bedridden) Increased metabolic rate, cardiac demand, respiration & CO2 Overfeeding CHO COPD Neuromuscular disease patients, loss muscle mass & gain fat mass Monitor with Respiratory quotient (RQ) > 1.0 Retain CO2 Accurate initial assessment of calorie requirement & periodic reassessment prevents overfeeding Reducing excessive calorie is far more therapeutic than reducing CHO

21 How Much to Feed? How much EN? Acute and initial phase Exogenous energy supply > kcal/kg BW/day may be associated with a less favorable outcome (C) Recovery (anabolic flow phase) Aim to provide kcal/kg BW/day Severe under nutrition should receive up to kcal/kg BW/day If these target not reached, supplementary PN should be given. Protein: 1.2 to 2.0 gm/ Actual Body Weight ESPEN Guidelines on Enteral Nutrition: Intensive Care. Clinical Nutrition (2006) 25,

22 Feeding the Obese Patients In the critically ill obese patient, permissive underfeeding or hypocaloric feeding with EN is recommended. For all classes of obesity where BMI is > 30 kg/m 2, the goal of the EN regimen should not exceed 60%-70% of target energy requirements or kcal/kg actual body weight per day or kcal/kg ideal body weight per day Protein should be provided in a range 2.0 g/kg ideal body weight per day for Class I and II patients (BMI 30-40), 2.5 g/kg ideal body weight per day for Class III (BMI 40). ASPEN Recommendation 2009

23 Tropic or trickle feeding Whenever full feeding is not possible 10 to 30 ml/hour should be given To prevent gut mucosa atrophy McClave et al. 2009

24 14 15 AUG ASMIC 2015

25 Does the patient have impaired digestion or absorption? NO Does the patient require electrolyte restriction? NO Does the patient require fluid restriction? OR have high energy needs? NO Does the patient have protein needs? NO Does the patient have hyperglycemia? NO Standard Formula ( kcal/ml) YES YES YES YES YES Elemental or semi-elemental formula Renal Formula High Energy Formula High Protein standard formula OR modular Low CHO, High fiber formula

26 Protein Type Whey protein Whey protein remains in liquid state in stomach Facilitate gastric emptying Soluble non-curdling property Reduces risk of reflux and aspiration pneumonia Greater patient comfort Casein protein Forms curd in stomach Delays gastric emptying

27 Fiber Type Soluble fiber may be beneficial fully resuscitated hemodynamically stable critically ill pts receiving EN who develops diarrhea Insoluble fiber should be avoided in all critically ills Both soluble and insoluble fiber should be avoided in pts at high risk for bowel ischemia or severe dysmotility (Grade C) Guidelines for the provision and assessment of nutrition support therapy in adult critically ill pts: Society of Critical Care Medicine and ASPEN (2009)

28 Immune modulating Formula Avoid Immune Enhancing formulas in actively sepsis patients. Glutamine Reserved for critically ill surgical/ trauma/ burn patients Duration of formula is for up to 10 days or > if pt remains at significant risk of infectious complications PN EN gm/kg/day gm/kg/day NO BENEFIT if total calories intake < 700 kcal/day For therapeutic benefit : 50 to 60% energy should be delivered

29 14 15 AUG ASMIC 2015

30 Nutrition Support Practices Giving enteral feed into the stomach rather than the small intestine permits the use of hypertonic feeds, higher feeding rates, and bolus feeding (grade A). - Starter regimens using reduced initial feed volumes are unnecessary in patients who have had reasonable nutritional intake in the last week (grade A). - Diluting feeds risks infection and osmolality difficulties. Both inadequate or excessive feeding may be harmful. Dietitians or other experts should be consulted on feed prescription (grade C).

31 Method Of Administration Bolus feeding Administered using a syringe High incidence of complications Intermittent Administered by gravity flow or pump Each feeding is given over 30 minutes every 3-6 hours Continuous Pump assisted Utilized in patients who are critically ill or with small bowel feeding Restricts patient ambulation

32 Continuous pump feeding can reduce gastrointestinal discomfort and may maximise levels of nutrition support when absorptive capacity is diminished. However, intermittent infusion should be initiated as soon as possible (grade A). Bolus feeds are discouraged in a critical care setting and contraindicated with jejunal feeding.

33 Feeding Initiation Standard Formula Concentrated/ elemental formula Gastric administration Post Pyloric administration Begin full strength ml/hour Advance by 25 ml/hr every 4 8 hours until goal rate is met Begin full strength at 25 ml/hr for first 12 hours Advance by 25 ml/hr every 6 12 hours until goal rate is met Bolus administration is not recommended Gastric or Post Pyloric Infusion Begin full strength at 25 ml/hr for first 12 hours Advance by 25 ml/hr every 6 12 hours until goal rate is met Bolus administration is not recommended **Head of bed to be elevated 30 to 45 degrees at all times**

34 Feeding Transition WEANING TPN or TEN Wean TPN or TEN off once patient consuming ½ to 2/3 of nutritional needs Abrupt cessation of tube feeding is not recommended, as nutritional status may be compromised. Ceasing feeds during meal times Aims to improve the patient s appetite and oral intake at mealtimes Stop tube feed 1-2 hours before each main meal Feeds can resume when the patient has finished eating, or 1-2 hours afterwards Nocturnal Feeding Overnight feeding (8-16 hours) to encourage oral intake during day More energy-dense formula ( kcal/ml) can be used for meeting need using lower feed rate Administer bolus feeds separate from meals to minimise on appetite

35 What happen to patients post-extubation?

36 Energy = 40-60% Protein = 20-40% Journal of American Dietetic Association 2010

37 Window of Opportunity Window of Opportunity Early Enteral Nutrition Provide Adequate Feeding Apply Good Nutrition Support Practices