ICU Acquired Weakness: Role of Specific Nutrients

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Bernadette Bailey
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1 ICU Acquired Weakness: Role of Specific Nutrients Dr Jonathan TAN Senior Consultant Dept of Anaesthesiology, Intensive Care & Pain Medicine Tan Tock Seng Hospital, Singapore

2 Purpose? Healthcare professionals? Nutrition Therapy? Are we creating survivors?... Or victims

ICUAW Generalised muscle weakness developing during ICU stay; acute critical illness Loss of flesh and strength Osler W 1892 Critical illness

3 ICUAW Generalised muscle weakness developing during ICU stay; acute critical illness Loss of flesh and strength Osler W 1892 Critical illness Polyneuropathy; CIP Critical illness Myopathy; CIM Retained sensory function Post Intensive care syndrome ;PICS Hermans & Van den Berghe Critical Care 2015

4 ICUAW: OUTCOMES Prolonged ICU, Hospital LOS Prolonged Mech Ventilation Increased Hospital and ICU Mortality ARDS survivors: weakness and decline at 1, 2, 5 years post ICU discharge Functional survival limited! Hermans & Van den Berghe Critical Care 2015 Herridge et al NEJM 2003 & 2011 Needham et al Eden trial 1 year follow up AJRCCM 2013 Fan E et al CCM 2014

5 ICUAW Patients ventilated > 10days: ICUAW up to 67% with 25% still weak after a week ICUAW of 11% in ICU > 24hrs; 24-55% when in ICU 7-10days ARDS: ICUAW 60% at awakening and 36% at hospital discharge Common! Hermans & Van den Berghe Critical Care 2015

6 Pathophysiology Complex functional, structural alterations in nerves and muscles Sepsis mediated microvascular effects Mitochondrial dysfunction Hyperglycaemia Protein catabolism, muscle atrophy - Inflammation; Immobilisation; endocrime stress response; nutrition deficit; microcirculation; dennervation

7 Pathophysiology Altered excitation contraction coupling Deficient Autophagy

8 Risk factors SEPSIS MOF Drugs: Corticosteroids, aminoglycosides, NMBs, Vasopressors Hypergylcaemia Immobilisation Premorbid nutrition deficit and functional status; Frailty; Sarcopenia Mech ventilation induced diaphragmatic atrophy

9 Diagnosis Scoring systems Handgrip strength Respiratory muscle strength Muscle ultrasound: atrophy detection; but muscle size not correlated with function Electrophysiological testing Clinical Biomarkers???

10 Prevention / Treatment Aggressive Sepsis management Avoid risk factors Glycaemic control with Insulin ICU Early Mobilisation strategies Nutrition strategies Lean body mass preservation Recovery of muscle mass and function

11 ICU-Acquired Weakness Sarah E. Jolley, MD; Aaron E. Bunnell, MD; and Catherine L. Hough, MD. CHEST 2016; 150(5):

13 Evaluate! Muscle Ultrasound IC Identify high risk; Sarcopenia Rx: Personalised; Guided

15 Beyond 101 Should THIS patient survive? Evolution and survival of the fittest Autophagy and trophic or intentional underfeeding HMB Anabolic & Anticatabolic agents Mitochondrial failure Specific nutrient magic bullets?

16 Optimal Nutrition & Protein: DuH??!!!!! ASPEN; ESPEN; Canadian; Local EN vs PN Commence within 48hrs IC vs weight based vs equation: calorie target g/protein/day; g/kg Minimise Interruptions Minimise caloric debt Prescribed vs Reality

17 Optimal feeding Recent trials advocate early ICU intentional underfeeding; trophic feeding INS Data: how are YOU doing? < 50% prescribed: Mortality risk up Every 25% increase in calorie delivery in 1 st week incr 3 month post ICU SF36 Calories vs Protein: under vs enough Trials with protein delivery of >1.0g/kg/day show benefit in the higher nutrition delivery group

18 Platelet Function!!??

19 Autophagy Inhibition of autophagy by early nutrition therapy (protein) : reduces tolerance to oxidative stress; incr risk of organ failure Avoid early mandatory feeding to preserve autophagy

23 Optimal feeding Avoid hypergylcaemia: Insulin therapy Avoid over feeding; inappropriate PN Optimal feeding: maintaining autophagy while promoting protein synthesis via mtor pathway Optimal. Personalized. Timing, Amount, Escalation, Route, Constituents.. Coupled with Optimal Rx

24 The Right Whey Highest biological value protein type Non Coagulating Higher Cysteine and Leucine Preserve muscle mass better May increase muscle synthesis Intermittent bolus feeding + Omega 3 FA Confirmation in trials needed Marik PE. Feeding critically ill patients the right whey : thinking outside of the box. A personal view. Ann Intensive Care. 2015;5:11.

increased skeletal muscle mass or secondary measures of function?

25 HMB Metabolite of Leucine (20g to 1g) Increases lean body mass with plateau effects in trained atheletes Prevent muscle loss with bed rest, increased skeletal muscle mass or secondary measures of function? Stabilization of cholesterol membrane in muscle cell? 2-3g/day safe; effective?

28 Protein Duration? Muscle mass +++/- Function ++/- Criticall ill: Inflamm markers decreased but no muscle or functional data

30 Promising? Need a well designed RCT in Critically ill

31 Anabolic; Anticatabolic Anticatabolic: Beta Blockers Burns; De-Cathecolamine Anabolic: Oxandrolone Reduce LOS, faster wound healing, improved survival in burns patients WHEN? Evidence of glycogen stores increasing signal switch to anabolism?

32 Defining current STANDARD of care is difficult Much current areas of uncertainty Top 10 trials for next 10 years suggested, rated

33 Substrate requirements: proteins, carbohydrates, and micronutrients What is optimal protein dose in general and nutritionally high-risk patients Is there any interrelationship between calorie and protein dose? What is the amount of substrate that is actually absorbed in critically ill patients given gut dysfunction and malabsorption? What is the role of whey-based protein (high in leucine) in muscle synthesis and facilitating recovery from critical illness?

34 What combinations of amino acids are optimal: should they mimic normal intake or be aimed at inducing metabolism or supporting hostdefense What is the role of small peptide vs polymeric formulae in patients at high risk of intolerance? What is the appropriate amount of micronutrients to be provided in ICU patients?

35 Nutrition and functional recovery What is the best way to measure the effect of nutrition on physical recovery outcomes of survivors of ICU? Is there a role for bedside measures to monitor the impact of feeding practices on muscle (such as blood, urine, or muscle imaging) and how to correlate these measures with long-term functional and vital outcomes? What is the effect of combination of ranges of proteins + physical activity + monitoring of muscle mass/function?

37 What do I do now????

38 Clin Nutr Oct;35(5):

39 Conclusion Do ALL the BASICS of critical care right Focus on current guidelines and what we know is safe Enough, is good. More? Not necc. Specific assessment and plan for the patient and the resources available Prescribed vs Delivered! New knowledge fast and furious: keep coming to PEN meetings! Functional Living

40 sg-anzics.com Asia Pacific ICU rehab network PENSA 2018

Muscle Wasting & Weakness in Critical Illness

Muscle Wasting & Weakness in Critical Illness Clin A/Prof Michael O Leary Intensive Care Service Royal Prince Alfred Hospital, Sydney Sydney Medical School, The University of Sydney Disclosures I have