Nutritional Management of Critically Ill Patients with GI dysfunction: What are the evidence?

Transcription

1 Nutritional Management of Critically Ill Patients with GI dysfunction: What are the evidence? 劉偉倫醫師 加護醫學部主治醫師品質管理中心主任

2 Prevalence of malnutrition in hospitals 8 studies, 1347 hospitalized patients 40% to 50% malnutrition or at risk for malnutrition Critically ill patients: -- 41% underfeed -- 27% overfeed -- 32% fed appropriately Agardi 1984, Sullivan 1989, Messner 1991, Mowe 1991 Crit Care Med 1990; 18:1320

3 Prevalence of malnutrition in hospitals 台大醫院 35-68%, 1983 慈濟醫院 52.8%, 1996 三軍總醫院:1991年 內科及外科病人於 一週內未達90% EER之人數:26%及57% The incidence of malnutrition is higher in surgical patients

4 Malnutrition Leads to Poor Clinical Outcomes Caloric Balance and Outcome in ICU Mortality Negative > kcal 86% Negative < kcal 39% Positive caloric balance 27% 0% 20% 40% 60% 80% 100% Bartlett et al. Surgery 92: 771, 1982

5 Prevalence of malnutrition and mortality 12-month follow-up of mortality The prevalence rate of malnutrition was 36%. Middleton, M. H., G. Nazarenko, et al. (2001).

6 is very important!!

7 Crit Care Nurse. 2014:34(4):14-22.

8 長時間使用 TPN 造成小腸絨毛萎縮

9 Beneficial Effects of Enteral Feeding Normal intestinal villus, during fed state Deterioration of gut due to fasting McClave. J of Critical Illness. 2001:16:

10 禁食易造成細菌性轉移

11 腸道營養愈早愈好 If the gut works Use it! ASAP

12 Common Perceived Barriers to Early Enteral Feeding Diminished or absent bowel sounds Gastroparesis Aspiration risk No adverse outcome with prolonged NPO status Post-operative ileus (Marik P CCM 2001;29(12): )

13 Which route to deliver nutrients? Enteral (首選) Oral NG ND Blind Endoscopy PEG NJ Jejunostomy Parenteral

14 Initiate Enteral Feeding In the ICU patient population, neither the presence nor the absence of bowel sounds and evidence of passage of flatus and stool is required for the initiation of enteral feeding (Grade B). "Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: JPEN J Parenter Enteral Nutr 2009, 33(3):

15 Initiate Enteral Feeding Enteral feeding should be started early within the first hours following admission (Grade C). The feedings should be advanced toward goal over the next hours (Grade E). "Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: JPEN J Parenter Enteral Nutr 2009, 33(3):

16 Initiate Enteral Feeding Very early feeding (< 6hrs) Journal of Critical Care 2015(30)

17 Enteral Feeding Intolerance JPEN J Parenter Enteral Nutr 2015;39(4):

18 Enteral Feeding Intolerance JPEN J Parenter Enteral Nutr 2015;39(4):

19 Inadequate enteral feeding % Enteral Volum e N= 44 MICU/CCU pts * Goal MD Order Infused * 可避免的 灌食中斷: 66% McClave, S. A., et al. CCM 1999; 27:

20 Reasons for Feeding Interruptions Critical Care Medicine. 23(6): , June 1995.

21 柳營奇美 MICU 病人

22 Reasons for Feeding Interruptions Critical Care Medicine. 23(6): , June 1995.

23 Monitor Gastric Residual Volume (GRV) Intolerance to enteral nutrition Gastroparesis with increased GRV Gastroesophageal reflux Regurgitation or vomiting Risk of aspiration and VAP Routine monitoring GRV

24 A long habit of not thinking a thing wrong, gives it a superficial appearance of being right. --- Thomas Paine Common Sense, 1776

25 Monitor Gastric Residual Volume (GRV) Metheny NA, et al. AJCC. 2012;21(2): e33-e40.

26 30% critically ill patients GRV>200 ml Normal patients: none > 200 ml GRV hold feeding

27 Two feeding protocol: 150 ml v.s. 250 ml Similar vomiting rate Twice enteral feeding interruption: 53% v.s. 23%

28 Gastric residual volume during enteral nutrition in ICU patients: the REGANE study --- Intensive Care Med (2010) 36: To compare the effects of increasing the limit for gastric residual volume (GRV) in the adequacy of enteral nutrition. Patients were randomized to be included in a control (GRV = 200 ml) or in study group (GRV = 500 ml). *Nomogram for the management of high gastric residual volume (HGRV).

29 Gastric residual volume during enteral nutrition in ICU patients: the REGANE study --- Intensive Care Med (2010) 36: Frequency of the remaining gastrointestinal complications was similar in both groups.

30 Gastric residual volume during enteral nutrition in ICU patients: the REGANE study --- Intensive Care Med (2010) 36: Outcome variables (days on mechanical ventilation, ventilator-free days, SOFA day 5, SOFA day 10, ICU length of stay and hospital mortality) were also similar in both groups.

31 Monitoring Tolerance and Adequacy of Enteral Nutrition Holding EN for gastric residual volumes <500 ml in the absence of other signs of intolerance should be avoided (Grade B). "Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: JPEN J Parenter Enteral Nutr 2009, 33(3):

32 --- JPEN J Parenter Enteral Nutr. 2005;29(3):

33 Gastric residual volume during enteral nutrition in ICU patients

34 --- JAMA. 2013;309(3): patients Not monitoring RGV v.s. RGV >250mL VAP rates, MV duration, ICU stay length, or mortality rates: no difference Reach 100% calorie goal: more in not monitoring RGV group

35 Conclusion Routinely hold feeding due to high GRV may not necessary More vomiting more VAP If GRV monitoring is applied a cutoff value > 250 ml ~500mL

36 Feeding Interruptions due to Tests or Procedures Diarrhea, Abdominal distention (Critical Care Medicine. 23(6): , June Heyland, Daren MD MSc; Cook, Deborah J. MD FRCPC, MSc; Winder, Barb RPDt; Brylowski, Lili MSc RPDt; Van demark, Helen RPDt RD; Guyatt, Gordon MD FRCPC, MSc )

37 Effect of Evidence-Based Feeding Guidelines on Mortality of Critically Ill Adults --- JAMA. 2008;300(23):

38 Breakdown of protein Amino acid Simplest form Protein Chain of > 100 amino acids 2006 Nestlé Nutrition HealthCare, Switzerland Peptide Chain of amino acids < 99 amino acids

39 Breakdown of protein Intact Protein >100 HCI Acid Pepsin Stomach Intact proteins + polypeptides >10 Trypsin Chymotrypsin Small Intestine Smaller peptides + amino acids + Absorption via 2 separate carriers one for amino acids & one for peptides in the intestine >10 = amino acid = di-peptide = tri-peptide = oligo-peptide

40 游離胺基酸在壓力情況下Carrier 活性受到影響 Most occurs in jejunum Dual mechanism via 2 separate carriers ~ 75% absorbed as peptides During stress 1. Amino acid carriers 2. Peptide carriers remain intact

41 胜肽配方可透過腸道黏膜細胞至肝門靜脈

42 Increased tolerance in ICU patients Peptide-based diet: Faster gastric emptying times Designed for maximum absorption in edematous gut Stimulates enzyme activity Promotes growth of intestinal mucosal cells Increases visceral protein status Enhances absorption and therefore reduces diarrhea (Meredith 1990; Donald 1994; Zaloga 1992)

43 MCT oil 可加速胃排空 Delayed gastric emptying can delay enteral feeds absorption Stress of acute injury, medications and stress response can slow down GI motility and gastric emptying Puts patient at risk for reflux and aspiration pneumonia LCT MCT (Bach 1996; Pfeuffer & Schrezenmeir 2001)

44 乳清蛋白有較快的胃排空速度 Whey Protein Whey : soluble protein Casein : clots into stomach Facilitates gastric emptying time Delays gastric emptying time More accessible & faster to digest Easily to absorb Slower to digest & absorb Slower release of amino acid 'FAST' 'SLOW' (Mahe 1996) 2006 Nestlé Nutrition HealthCare, Switzerland

45 Patient profile 黃先生,83 y/o man Gastric cancer, Pneumonia with acute respiratory failure 熱量需求 1100kcal 住院天數 攝取熱量 佔所需熱 量% 14% 68% 64% 11% 5% 37% 49% 嘔吐 改濃縮 配方 消化情況 差 差 置放NJ, NJ 置 轉病房 失敗 放成功 開始PPN support 改用peptide-based diet

46 Patient profile 黃先生,83 y/o man Gastric cancer, Pneumonia with acute respiratory failure 熱量需求 1100kcal 住院天數 19 攝取熱量 900 佔所需熱 82% 量% % 98% 32% 49% 82% 100% 改益力 佳,停 改bag 消化情況 壯+高 PPN feeding 蛋粉 差 改回佳 轉病房 出院 易得

47 高滲透壓會增加腹瀉的風險 Isotonic

48 Peptide base diets improve tolerance in the ICU patients Peptide based diets associated with less diarrhea in ICU patients (Meredith JW et al. Journal Trauma 1990;30; ) (Carl RH. Pharm Prac News. Feb. 1995;1-2) MCT to decrease fat malabsorption Low osmolality to assure tolerance

49 Patient profile 洪先生,72 y/o man HCV related liver cirrhosis, Pneumonia with acute respiratory failure 熱量需求 1300kcal 使用天數 攝取熱量 佔所需熱量% 46% 74% 102% 74% 90% 8次 3次 +200g 450 g 1次 2次 解便情況 開始灌食佳易得

50 Patient profile 李先生,86 y/o man HCV related liver cirrhosis, KP necrotizing pneumonia with acute respiratory failure 熱量需求 1500kcal 使用天數 攝取熱量 佔所需熱量% 30% 61% 81% 95% 1050g 560g 350g 120g 解便情況 原為一般配方奶 此天第4餐起改為第1-5餐為佳易得 晚點心沛力體

51 Peptide-based diet 營養品名 peptide% MCT% 二胜肽 含有 雙備素 三胜肽 比例不清 Twinline 比例不清 楚 楚 mosm/l 價格 A液+B液->470~510 健保給付+廠商support 每餐可提供90cc=90大卡 創快復 Alitraq 一包76克=300大卡=220元 0.73元/大卡 沛力體 Peractive 一罐237ml=308大卡=150元 0.49元/大卡 380 一罐430克=1999.5大卡=800 元 0.4元/大卡 佳易得 Peptamen

52 Good Nutrition Support for ICU patients Better tolerance for early enteral nutrition Reduce GRV and diarrhea Better glucose control Support natural antioxidative defence system

53 建議營養支援方式的選擇

54 Take Home Message Early enteral feeding is standard of care. Do not routinely hold feeding for high gastric residual volume. Use peptide-based diet for enteral feeding intolerance patients. Avoid unnecessary feeding interruption for procedures.