Feeding the septic patient How and when? Masterclass ICU nurses

Feeding the septic patient How and when? Masterclass ICU nurses

Case Male, 60 - No PMH - L 1.74 m and W 85 kg Pneumococcal pneumonia Stable hemodynamics - No AKI MV in prone position (PEEP 16 - FiO2 60%) Intensivist / fellow / nurses discuss the following questions at the bedside:

Questions What is the caloric need of this patient and does over-/underfeeding really matter? When should we start nutrition and what do we do if enteral nutrition fails? What is the protein need of this patient and how do we effectuate a positive nitrogen balance? Does this patient benefit from specific supplements?

Critical illness metabolism Hypermetabolism Increased gluconeogenesis Insulin resistance Endogenous lipolysis Loss of protein reserve

What is the respiratory quotient? RQ = VCO 2 VO2 Lipids 0.7 Carbohydrates 1.0 Protein 0.8 Complete nutrition 0.8-0.85

What is his caloric need? Predictive equations: Harris-Benedict, ESPEN (25 kcal/kg/dd), Faisy, Penn State University Indirect calorimetry Measures VO2 and VCO2 EE = (3.941 VO2 (l/min) + 1.11 VCO2 (l/min)) 1440 (kcal/dd) Ventilator-derived VCO2 with RQ of administered nutrition

High variability in caloric needs 62 patients with severe sepsis Xinying Wang CW. Ann Nutr Metab 2015;66:188-195

What should we use? Because RQ of most feedings = 0.86 EE (kcal/dd) = VCO2 (ml//min) 8.19 Stapel SN. Crit Care 2015;19:370

Our patient.. Caloric needs 2630 / 2597 kcal Actual intake 2628 kcal

Does over-/underfeeding matter? Early overfeeding and late underfeeding are both associated with increased mortality Wijs PJM. Crit Care 2014;18:701

When should we start feeding? Early enteral nutrition < 24 hrs is beneficial Doig GS. Intensive Care Med 2009;35:2018-2027

Underfeeding very frequent Singer P. Intensive Care Med 2015;41:154-156

Trophic vs full EN in patients with ALI Multi-centre trial (N=44) Patients with ALI < 48 hrs planned for EN Trophic (10-20 kcal/h for 6D) vs full EN Primary outcome: VFD s through D 28 EDEN trial ARDSNET. JAMA 2012;307:795-803

ARDSNET. JAMA 2012;307:795-803

Trophic vs full EN N = 1000 400 vs 1300 kcal/d for the first 6 days 30 NS Full NS Trophic 20 10 0 VFD s (days) 60 D-Mortality (%) GI complaints (%) Higher glucose levels and higher insulin dose in full feeding group ARDSNET. JAMA 2012;307:795-803

Early adequate caloric intake is not necessary Maric PE. Intensive Care Med 2016

PEN if enteral nutrition fails? Certainly not early - maybe after 5-7 days

EPaNIC trial Multicenter RCT comparing early start SPN (D3) versus late start (D8) Adult ICU patients nutritionally at risk (NRS > 2) but not chronically malnourished (BMI 17) 60 P = 0.02 P = 0.008 P = 0.02 P = 0.001 45 30 15 0 ICU stay > 3D New infection MV > 2D Hospital stay > 15D Casaer MP. NEJM 2011

CALORIES trial RCT (MC - adults) early EN vs PEN in unplanned admissions (start < 36 hrs) Patients > 18 years expected to require nutritional support for at least 2 days Exclusively for 5 D, until ICU discharge or death Energy target 25 kcal/kg Harvey SE. N Engl J Med 2014;371:1673-1684

Clinical outcome 40 EN PEN P = 0.57 P = 0.40 P = 1.00 P = 0.006 P < 0.001 30 % 20 10 0 30-D mortality 90-D mortality SAE Hypoglycemia Vomiting Harvey SE. N Engl J Med 2014;371:1673-1684

What is the protein need of this patient? Nitrogen balance NB (g/day) = Protein intake (g/day)/6.25 - urine urea nitrogen (g/day)/0.85-2 However - effect of positive nitrogen balance unclear

The importance of the skelet muscle mass Low muscle mass Normal muscle mass 50 40 47,5 Mortality (%) 30 20 32,3 20 10 0 Male 7,5 Female BMI not an independent predictor for mortality when muscle mass is accounted for Wijs PJM. Crit Care 2014;18:R12

Our patient.. Protein loss 154.4 gr Protein intake 112.5 gr Protein balance - 41.9 gr / day

How do we effectuate a positive nitrogen balance? 0 Nitrogen balance Nitrogen balance (g/d) -2-4 -6-8 -10-12 -14 D3 D7 AA 0.8/kg AA 1.2/kg Ferrie S. JPEN 2016

Are that any specific supplements that may help? Glutamine Selenium

Glutamine sensitive tissues Rapidly replicating cells

Glutamine N = 502 SIGNET study New infections Mortality ICU Mortality 6 M 60 60 45 45 % 30 % 30 15 15 0 Glutamine Selenium Both Neither 0 Any glutamine Any selenium 126 127 124 125 For patients treated > 5 days selenium reduced the number of new infections No differences in secondary outcomes Andrews PJD. BMJ 2011;342:d1542

Glutamine supplement Glutamine No glutamine Antioxidants No antioxidants 40 P = 0.05 P = 0.48 40 30 32,4 27,2 30 30,8 28,8 Secondary outcomes Glutamine No glutamine P-value % 20 % 20 In-hospital mortality 37.2% 31% 0.02 10 10 6 M mortality 43,7% 37,2% 0.02 0 Mortality 28 D 0 Mortality 28 D Urea 13,4% 4% < 0.001 No interaction between glutamine and antioxidants N = 1218 Heyland D. N Engl J Med 2013

ASPEN guidelines 2016 Start EN within 24-48 hrs as soon as resuscitation is complete and patient is hemodynamically stable Do not use TPN or combination TPN/EN in the acute phase of severe sepsis No evidence for supplementation of zinc, selenium and antioxidants Protein delivery of 1.2-2 gr/kg No immune modulating formulas McClave SA. JPEN 2016;40:159-211

Our patient.. Early enteral nutrition - no TPN Protein intake 1.3 gr/kg/day Caloric intake 2600 kcal/day No glutamine or selenium supplementation Indirect calorimetry AND nitrogen balance 1 /week