Nutrition Supplementation in the ICU

Transcription

1 Nutrition Supplementation in the ICU ROSEMARY KOZAR MD PHD SHOCK TRAUMA UNIVERSITY OF MARYLAND Canadian Clinical Practice Guidelines NEJM March 27,

2 Use of Enteral vs Parenteral Nutrition Based on one level 1 and 13 level 2 studies, In critically ill patients, strongly recommend the use of enteral nutrition over parenteral nutrition Criticalcarenutrition.org This is reinforced by numerous (older) nutrition studies done in trauma patients Early vs Delayed Nutrition Based on 16 level 2 studies Recommend early enteral nutrition within hours of ICU admission Criticalcare nutrition.org 2

3 2013 INS Survey Next International Nutrition Survey scheduled for April 2017 Intentional underfeeding: Trophic vs Full Feeds Initial Tropic vs. Full EN inpatients with Acute Lung Injury Rice TW, et al. JAMA. 2012;307(8): The EDEN randomized trial all p>0.05 3

4 Initial Tropic vs. Full EN inpatients with Acute Lung Injury The EDEN randomized trial Rice TW, et al. JAMA. 2012;307(8): EDEN??? 1000 relatively young well-nourished pts Maybe not all ICU patients are the same? Would high risk trauma patients also do ok if not fed?? Does it matter how much we feed our patients? Is it hard to show a benefit of nutrition in critically ill trauma patients because they don t actually get what we prescribe? 0 Cumulative Calorie Deficit of a Patient from the Baseline Group

5 Achieving Target Dose To achieve target recommend considering: Starting at target goal Use of pro-motility agents Tolerating higher gastric residual volumes Criticalcarenutrition.org The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP up Protocol! In select patients start the EN at goal rate, not at 25 ml/hr. Target a 24 hour volume of EN rather than an hourly rate Nurses increase hourly rate to make up the 24 hr volume. Start with a semi elemental solution, progress to polymeric. Tolerate higher GRV* threshold (300 ml or more). Motility agents and protein supplements are started immediately, rather than started when there is a problem. A major paradigm shift in how we feed enterally Heyland DK, et al. Crit Care. 2010;14(2):R78. Volume-Based Feeding in the Critically Ill Patient McClaveet al JPEN June 2014 Single center study volume based to rate based feeding protocol in critically ill Volume based feeding pts= 77.6% Rate based feeding pts= 61.5% Significant increase in goal calories with volume based feeds No associated intolerance or aspiration 5

6 Physician Driven Catch Up Protocol Jenny Lee presented at Nutrition Week Feb Cumulative Caloric Deficit baseline Caloric Deficit (kcal) intervention ICU Day But what if you can t achieve your target nutritional goal? Early PN: Location, location, location Europe: early PN to prevent caloric deficit US/Canada: allow hypocaloricen for one week before starting PN 6

7 Combination EN and PN Based on one Level 1 and seven Level 2 studies Do NOTrecommend that PN be started at the time of initiation of EN Criticalcarenutrition.org The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Alberda C et al. Intensive Care Medicine 2009:35. underweight obese TOP-UP Study Just completed, randomized 125 ICU patients Evaluated the effect of early PN in underweight and obese patients Randomized to EN only or EN + PN (use PN only when not at goal EN) Using an omega-3 lipid in PN pts 7

8 Conclusions EN+PN vs EN alone significantly increased calorie/protein delivery over 1st week vs EN alone. Consistent encouraging trends in hospital mortality, QoL and functional endpoints No increased infection risk from PN But TOP UP by NUTRIC NUTRIC SCORE: Nutrition Risk in Critically Ill Nutritional risk assessment tool developed and validated specifically for ICU patients. Quantifies the risk of developing adverse events that may be modifiable by aggressive nutritional intervention. Most other risk scores and assessment tools consider all critically ill patients to be at high nutrition risk. Heyland DK Crit Care 2011:153. 8

9 NUTRIC SCORE Age APACHE SOFA Co-morbidities Days from hospital to ICU admission IL-6 (can be left out) Score 5 may benefit from aggressive nutritional interventions Are higher GRV safe? REGANE study of 329 pts: up to 500 cc safe NUTRIREAstudy of 449 pts: not checking GRV did not increase aspiration or related complications. Montejo JC et al. Intensive Care Med 2010;36:1386 Reignier J et al. JAMA 2013;309:248 Pro-motility Agents Recommend metoclopramide over erythromycin Consider use with initiation of feeds but start if GRV>250 or intolerance (high GRV or emesis) CriticalCareNutrition.org 9

10 Small Bowel Feeds Based on 11 level two studies recommend: Use of SB feeds if your unit can easily achieve If logistically more difficult, consider if: high risk intolerance high risk aspiration Criticalcarenutrition.org Probiotics Based on three Level 1 and twenty Level 2 Use of pro-biotics should be considered Criticalcarenutrition.org Msphere Aug 31, 2016 Analyzed the microbiomes of 115 critically ill subjects and demonstrated rapid dysbiosis from unexpected environmental sources after ICU admission 10

11 Microbiota of normal vs critically ill patients PC2 (3.61%) PC1 (15.04%) (2640) AGP-feces (199) AGP-oral (124) AGP-skin (135) ICU-feces (162) ICU-oral PC3 (2.7%) (136) ICU-skin Findings and Conclusion Large depletions of organisms thought to confer antiinflammatory benefits, such as Faecalibacterium. Conversely, many of the taxa that increased contain well-recognized pathogens such as Enterobacter and Staphylococcus Study suggests that interventions focused on improving the microbiome in critical-care patients should be undertaken Lots We Don t Know and Lot s not covered Didn t cover influence of exercise/mobility/rehab to the effect of nutrition: need both Remember that most nutrition studies are conducted on pts in medical ICU and/or cardiac ICU: different patient populations than trauma Effect of nutritional adequacy in trauma ICU patients is needed and does this differ by age, ect Happy to answer any? 11