Nutrition in ECMO. Elize Craucamp RD(SA)

Transcription

1 Nutrition in ECMO Elize Craucamp RD(SA)

2 ECMO What now!? KEEP CALM AND FEED THE ECMO PATIENT Despite the fact that little is known about nutritional strategies for adult ECMO patients! Neither overcomplicate nor oversimplify

3 ECMO n Extracorpeal membrane oxygenation (ECMO) n Venovenous (VV) ECMO n Venoarterial (VA) ECMO n Also referred to as ECLS (Extracorpeal Life Support) n Cardiopulmonary bypass circuit for temporary life support for severe cardiac and/or respiratory failure. n VA and VV ECMO blood is drained from the venous system and oxygenated outside of the body. n VV ECMO blood is returned to the venous system n VA ECMO blood is returned to the arterial system

4 ECMO and Nutrition Common questions ask: n Exact effect of the ECMO system on human gut function? n Enteral or Parenteral nutrition? n Requirements of this patient population? n Specific types of nutrients?

5 ECMO and Nutrition ECMO patients are often critically ill (CI) n CI patients in ICU n Develop increase metabolic activity n Elevated catabolism of protein n Insulin resistance (stress hyperglycemia) n Negative nitrogen balance n IF Enteral/Parenteral feeding insufficient: n Deficiency accumulates n Contributes to lean tissue wasting n Consequently adverse outcomes n Many years ago CI infants on ECMO had the highest rates of whole body protein breakdown ever recorded n CI Adult ECMO patients will also suffer protein breakdown n? The exact degree

6 ECMO Clinical Guidelines (Nutrition)

7 ECMO Clinical Guidelines (Nutrition) Table 2. Nutrition Support Recommendations in Neonates Supported with Extracorporeal Membrane Oxygenation (ECMO) Guideline Recommendations Grade n 1. Nutrition support should be initiated expeditiously in neonates treated with ECMO. D n 2. Neonates treated with ECMO have protein requirements of up to 3 g/kg/d. D n 3. Energy requirements in neonates treated with ECMO are equivalent to healthy subjects. D n 4. Enteral feedings should be initiated when the patient on ECMO has clinically stabilized. D

8 ECMO Clinical Guidelines (Nutrition) n A.S.P.E.N Clinical Guidelines available on: Nutrition support of Neonates Supported with ECMO n Unfortunately no guidelines yet for adults n Several retrospective or observational studies mostly small n No randomised interventional studies on nutrition support in adult ECMO

9 ECMO and Nutrition Studies on porcine models showed: n Increased gut barrier dysfunction n Bacterial translocation Let s look at a few studies..

10 ECMO Literature Scott, LK et al. JPEN 2004; 28: 295 n Retrospective n Chart Review 27 pts on V-V ECMO and EN n Average time on ECMO was 8.7 ± 3.6 d n 26/27 pts received EN via gastric feeding tube alone or with PN n 18 received only EN; remainder received supplemental PN n HOB > 15 degrees unless prone (feeds continued prone) n Prokinetic (erythromycin) used in first 24 hrs in 75%; within 48 hrs in 95% of pts n No intestinal ischemia, GI bleeding, or other complications were noted from early EN

11 n Retrospective audit 2007-mid 2013 n 86 patients reviewed n 55 on VV-ECMO, 31 on VA-ECMO n All patients commenced on enteral nutrition n Overall average 80% of goal tolerated every day in the first two weeks on ECMO n 10 % of patients needed TPN for more than 3 days n Patients who were started on feeding earlier tended to tolerated full goal nutrition

12 ECMO Literature Lukas G, et al. Crit Care Resus 2010; 12: n Retrospective Chart Review n 48 Patients treated with ECMO n 35 had V-A ECMO; 13 had V-V ECMO n Mean nutritional adequacy for all was 62% (SD 19%) n Nutritional adequacy was 55% during and 71% after ECMO removal n Survivors did not achieve better nutritional adequacy than non survivors

13 ECMO Literature Umezawa Makikado LD, et al. JPEN 2012 n Prospective Observational Study over 1 yr n All seven adult pts receiving V-A ECMO for severe hemodynamic failure included n EN with energy target of 25 kcal/kg/d to be reached over 4 days n More than 70% nutrition tolerance achieved in first week for all pts n No serious adverse events attributed to EN

14 ECMO and Nutrition Feeding challenges with ECMO patients n Loss of nutrients in the circuit (as with CRRT) n Micro porous membrane of oxygenator can be blocked by IV lipids (literature on neonates) n Altered gut motility and permeability n Reduced gut perfusion n Reduced gut absorption n Problems with the earlier style of micro porous membrane oxygenators n Not seen with the new generation of diffusional (polymethylpentene) oxygenators

15 ECMO and Nutrition Feeding challenges with ECMO patients n About 10 years ago enteral feeding was often withheld in ECMO patients in certain centres due to the belief was that there was an increased risk for splanchnic ischemia. n Studies showed that enteral nutrition within the first hours is safe and well tolerated in adults. n Also proposed previously that enteral nutrition in VA ECMO unsafe compared to VV ECMO. n Placement of PEG tubes as ECMO patients on anticoagulation therapy.

16 ECMO and Nutrition Altered gut function in ECMO due to: n Heavy sedation and paralysis (sometimes) n Inflammatory effects on the gut function? n Altered gut perfusion due to the non-pulsatile flow of ECMO to the microcirculation n Hemodynamic failure hypotensive and compromise of the splanchnic perfusion n ECMO initiation can lead to oxygenation and hemodynamic unloading improving blood gases n Lower risk for GIT hypoperfusion, mesenteric ischaemia, abdominal distension, diarrhoea

17 ECMO and Nutrition How much and when? n Indirect calorimetry (IC) considered the GOLD STANDARD for determining Resting Energy Expenditure (REE) n IC measurements of oxygen consumption(vo2), carbon dioxide production(vco2) and minute volume n Often confined to research settings n Where possible ALWAYS IC first n IC not really possible / accurate in ECMO n The CO2 is removed across the extracorpeal membrane and cannot be identified by the calorimeter n Instead predictive equations (less accurate)

18 ECMO and Nutrition Indirect Calorimetry n Some consider this gold standard for ICU patient n But need steady state in patient at rest n Steady state condition is aimed at obtaining gas exchange measure at respiratory level of metabolic cellular events n Steady state conditions altered by CRRT and ECMO n Body Temperature n Acid-base status n Bicarbonate containing IVF may alter pco2 n Extracorporeal removal of CO2

19 ECMO and Nutrition n The MEEP study n Aim n Measuring Energy Expenditure in ECMO Patients n To describe a calculation to set nutrition targets for ECMO patients (energy/calories) n Going to combine IC with elimination by the lung assist system (oxygenation and CO2)

20 Current practices n General consensus is to follow existing guidelines for nutrition support in critically ill adult patients n A.S.P.E.N guidelines n ESPEN n Canadian guidelines for nutrition support in critically ill adults

21 Current Practices The usual applies to ECMO patients: n Prevent overfeeding n Be aware of challenging patient populations n Chronically critically ill n Obesity n Obese patients n High protein, hypocaloric feeding to preserve lean body mass, mobilise adipose tissue and minimise overfeeding n 2-2.5g protein/kg Ideal body weight (IBW)

22 Current Practices Summary of feeding guidelines n ECMO CI patients require: n Full & complete nutritional assessment (overweight, underweight) n EN preferred route if safe n Early EN if hemodynamically safe or stable: within 24-48hrs n EN includes oral / tube / sip feeding n PN or SPN when failing to establish EN n Timing of PN / SPN crucial n Prokinetics n ADEQUATE PROTEIN n Dietitian will calculate and advise on appropriate feeding formulas / sip feeds / nutritional recommendations

23 Our Current Practices n Follow existing guidelines on nutrition in critical illness n Often start with enteral nutrition first line (SPN if necessary) n We use a very specific lipid emulsion due to less blockage of membranes n Enteral nutrition as soon as possible and safe (wean Parenteral Nutrition) n Avoid large volumes of enteral feed n Aim for minimum of 1.5g protein/kg usually higher if possible n CRRT n Obese

24 The End and Thank You