Protein targets in critical illness Danielle Bear HEE / NIHR Clinical Doctoral Fellow & Critical Care Dietitian Guy s and St Thomas NHS Foundation Trust, London, UK @danni_dietitian
CONFLICTS Conference fees, advisory board, consulting and honoraria from: Nutricia Nestle Nutrition Baxter Fresenius Kabi Abbott Nutrition
OBJECTIVES 1. To understand current literature supporting recommended protein targets in critical illness 2. To discuss the current controversies surrounding recommended protein targets in critical illness 3. To understand factors which may impact protein targets in critical illness 4. To calculate protein targets for various patient groups of critically ill patients
CRITICAL CARE NUTRITION GUIDELINES ESPEN GUIDELINES ESPEN Guidelines on Enteral Nutrition: Intensive care $ K.G. Kreymann a,, M.M. Berger b, N.E.P. Deutz c, M. Hiesmayr d, P. Jolliet e, G. Kazandjiev f, G. Nitenberg g, G. van den Berghe h, J. Wernerman i, DGEM: $$ C. Ebner, W. Hartl, C. Heymann, C. Spies Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients* Daren K. Heyland, MD, FRCPC, MSc*; Rupinder Dhaliwal, RD*; John W. Drover, MD, FRCSC, FACS ; Leah Gramlich, MD, FRCPC ; Peter Dodek, MD, MHSc ; and the Canadian Critical Care Clinical Practice Guidelines Committee From the *Department of Medicine and the Department of Surgery, Queen s University, Kingston, Ontario; Department of Medicine, Division of
PROTEIN TARGETS 1.2g/kg 1.5g/kg 2.0g/kg 2.5g/kg General ICU Trauma Protein losses in exudate (12-30g/L) CRRT Surgical Trauma Burns Obesity
SYSTEMATIC REVIEW Clinical trials investigating different protein intakes in critical illness 12 investigating nitrogen balance 3 investigating whole-body protein turnover 1 investigating change in body composition All showed improvements with increased protein intakes Plasma amino acid profile Nitrogen balance Protein turnover Clinical outcomes Hoffer & Bistrian. AJCN 2012; 96:591 600
Higher protein is associated with reduced mortality
PROTEIN TRACERS AND MUSCLE BIOPSY
Observational study investigating equivalent of 1g/kg/day parenteral amino acids on 3-hour whole body protein turnover. n=13 studied once & n=7 twice Whole body protein balance increased on both occasions Due to increased protein synthesis Amino acid oxidation not increased
MUSCLE ULTRASOUND
Higher parenteral amino acid intake (0.9g/kg/day vs 1.1g/kg/day) ü Improved handgrip strength (ICU and hospital discharge) ü Improved Fatigue score ü Reduced muscle wasting Ferrie et al. JPEN 2016;40:795-805
Computed Tomography Low Muscle mass associated with Mortality Ventilator-free days and LOS 63-70% of patients have low muscle mass Poulsen CCM 2011, Moisey Crit care 2013, Weijs Crit Care 2014, Braunschweig JPEN 2014
PROTEIN INTAKES IN PATIENTS WITH LOW MUSCLE MASS Higher protein intake associated with reduced mortality (28 day, hospital and 6-month) in patients with LOW muscle mass VARS NOMINATION Looijaard et al, 2017, Unpublished
Association Between Nutritional Adequacy and SF-36 Scores SF-36 Adjusted Estimate* (95% CI) p-value Physical Functioning Role Physical Physical Component Scale 3-month (n=179) 6-month (n=202) 3-month (n=178) 6-month (n=202) 3-month (n=175) 6-month (n=200) 7.29 (1.43, 13.15) 0.02 4.16 (-1.32, 9.64) 0.14 8.30 (2.65, 13.95) 0.004 3.15 (-2.25, 8.54) 0.25 1.82 (-0.18, 3.81) 0.07 1.33 (-0.65, 3.31) 0.19 *Every 25% increase in nutritional adequacy; adjusted for age, APACHE II score, baseline SOFA, Functional Comorbidity Index, admission category, primary ICU diagnosis, body mass index, and region Wei et al, 2015 CCM.
Higher protein leads to worse outcome Study Intervention Results EPaNIC Early vs late PN êmuscle quality in early PN group éweakness in early PN group (MRC-sum score) Faster recovery in late PN group MUSCLE-UK Nil - observational é Protein intake with é muscle wasting
HOW DOES IT WORK IN PRACTICE?
üwho is the patient? üif you should feed (safety and feasibility) üwhen you should feed (timing) ühow you should feed (route) üwhat you should FEED (type and amount) üwhat you are trying to achieve
NUTRITIONAL STATUS & ASSESSMENT Weight Height BMI Parameter LIMITATION Calibration of bed scales Fluid shifts Unable to stand Demispan/Ulna length inaccurate As above Weight History Diet History Can ask family (?not as accurate) Medical notes if up to date As above Biochemical parameters Often associated with inflammation
NUTRIC VARIABLE RANGE POINTS Score Developed based on acute and chronic factors that affect nutritional status Patients are considered high nutrition risk with a score of 5 Age <50 50 - <75 75 APACHE II <15 15 - <20 20 28 28 SOFA <6 6 - <10 10 Number of co-morbidities 0 1 2 Days from hospital to ICU admission 0 - <1 1 0 1 2 0 1 2 3 0 1 2 0 1 0 1
http://www.scymed.com/enmi/smnxpw/pwfbd770_m.htm Ferreira et al. JAMA 2001; 286(14):17541758 The APACHE II and SOFA Scores are required for calculation the NUTRIC score
NRS 2002 Nutritional Risk Screening (NRS 2002) Table 1: Initial screening Yes No 1 Is BMI <20? 2 Has the patient lost weight within the last 3 months? 3 Has the patient had a reduced dietary intake in the last week? 4 Is the patient severely ill? (e.g. in intensive therapy) Yes: If the answer is 'Yes' to any question, the screening in Table 2 is performed. No: If the answer is 'No' to all questions, the patient is re-screening at weekly intervals. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. NRS is a two-step screening tool. Patients in the ICU automatically progress to step 2. Kondrup et al. Clin Nutr 2003; 22(4):415-421
NRS 2002 NRS 2002 may not be specific enough as it classifies all critically ill patients as high risk which may not be the case Absent Score 0 Mild Score 1 Impaired nutritional status Normal nutritional status Wt loss >5% in 3 mths or Food intake below 50-75% of normal requirement in preceding week. Table 2: Final screening Absent Score 0 Mild Score 1 Severity of disease (» increase in requirements) Normal nutritional requirements Hip fracture* Chronic patients, in particular with acute complications: cirrhosis*, COPD*. Chronic hemodialysis, diabetes, oncology. Moderate Score 2 Wt loss >5% in 2 mths or BMI 18.5-20.5 + impaired general condition or Food intake 25-50% of normal requirement in preceding week Moderate Score 2 Major abdominal surgery* Stroke* Severe pneumonia, hematologic malignancy. Severe Score 3 Wt loss >5% in 1 mth (>15% in 3 mths) or BMI <18.5 + impaired general condition or Food intake 0-25% of normal requirement in preceding week in preceding week. Severe Score 3 Head injury* Bone marrow transplantation* Intensive care patients (APACHE>10). Score + Score: = Total score: Age if ³ 70 years: add 1 to total score above = age-adjusted total score: Score ³3: the patient is nutritionally at-risk and a nutritional care plan is initiated Score < 3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. Kondrup et al. Clin Nutr 2003; 22(4):415-421
NOT ALL ICU PATIENTS ARE THE SAME! Age Body Mass Index Muscle mass Severity of illness Admission category Length of stay (LOS) in hospital prior to ICU Predicted ICU LOS Co-morbidities
But which weight do I use? Ideal or actual body weight will lead to underfeeding in some patients and overfeeding in others Should be based on Fat Free Mass (FFM), but no reliable bedside tool Might be a place for BIA or CT in the future Protein Target (BMI_20_30 formula) BMI 20 30 1.2 g/kg actual body weight (ABW) BMI <20 1.2 g x height (m2) x 20 BMI >30 1.2 g x height (m2) x 27.5 Weijs et al, Clin Nutr; 2011
What do I do in practice? Underweight (BMI <18.5kg/m 2 ) Use actual body weight Normal weight (BMI 19-25kg/m 2 ) Use actual body weight Overweight and obese Use ideal body weight (adjusted to BMI 23 kg/m 2 )
HOW DO YOU MEET THE TARGETS IN PRACTICE?
HOW DO YOU MONITOR THESE PATIENTS IN PRACTICE?
CASE STUDIES What would you consider in your nutrition assessment? Does this patient have any additional considerations which may affect their protein target? Which weight would you use to calculate the protein target? What protein target would you aim for?
CASE STUDY 1 71 year old admitted with type 2 respiratory failure due to exacerbation of COPD. PMHx COPD, hypertension Intubated and ventilated, propofol for sedation, but weaning off Anthropometry Weight 73kg; Height 161cm; BMI 28kg/m 2 You review her 72 hours into her ICU admission.
CASE STUDY 2 76 year old adm from theatre following bowel resection and washout for four quadrant faecal peritonitis with multiple perforations around anastomosis. Abdomen left open 2/52 ago, had anterior resection for Colon Ca (short ICU stay, but managed on the ward) Intubated and ventilated, propofol for sedation Anthropometry Weight 62kg; Height 178cm; BMI 19.5kg/m 2 4kg weight loss since admission with 5% weight loss in 3 months prior to surgery Referral for PN on day 1 post-op
CASE STUDY 3 19 year old adm following high speed road traffic accident Left subdural haemorrhage and diffuse brain swelling Multiple C-Spine fractures Complex bilateral facial and basal skull fractures Large bilateral lung contusions Intubated and ventilated, sedated and paralysed Anthropometry Weight 120kg; Height 178cm; BMI 38kg/m 2 You review within 72 hours of admission to the ICU
CONCLUSIONS Higher protein intakes in critical illness may improve outcome Individualised nutrition assessment is required to determine appropriate protein intakes and methods of delivery for each patient Monitoring is essential!
REFERENCES Protein Intakes McClave et al. JPEN 2016; 40(2): 159-211 Singer et al. Clin Nutr 2014; 33; 246-251 Choban et al. JPEN 2013; 37; 714-44 Ishibashi et al. Crit Care Med 1998; 26; 1529-35 Diaz et al. J Trauma. 2010;68(6):1425-1438 Cheatham et al. Crit Care Med. 2007;35(1):127-131. Hourigan et al. Nutr Clin Pract. 2010;25(5):510-516.