Annette Stralovich-Romani, RD, CNSC Adult Critical Care Nutritionist UCSF Medical Center NO DISCLOSURES Incidence & consequences of malnutrition Underfeeding in the ICU Causes/ consequences Nutrition intervention What is the optimal amount of calories/protein in the critically ill patient? Strategies for improving enteral nutrient delivery On hospital admission: 30-50% On ICU admission: 50-55% Malnutrition contributes to: Increased morbidity & mortality Decreased function & quality of life Increased frequency and length of hospital stay Higher healthcare cost Nutritional status declines with length of stay Early identification & intervention can lead to costeffective and beneficial outcomes 1
Preexisting malnutrition / nutritional compromise Admission to hospital / ICU Stress / Inflammation Hormonal Response: Catecholamines, glucagon, cortisol Humeral Response: Cytokines (TNF, IL-1, IL-6) Hypermetabolism (increased energy expenditure) Accelerated proteolysis (LBM breakdown) Insulin resistance Nosocomial infections VAP, C.Difficile, Central line infection UNDERFEEDING Prevalence: 40-50% of prescribed EN received in the first 2 weeks after ICU admission Causes: GI Symptoms Underestimating nutrient needs (energy/protein) Feeding tube displacement / replacement Prematurely discontinuing EN Delayed administration Low volume TF infusion (trophic feeding) Interruptions in TF administration (avoidable vs. unavoidable) Prospective, observational study Characterize EN interruptions (avoidable vs. unavoidable) & determine impact on caloric deficits between patients Group 1: > 1 EN interruption Group 2: No interruptions 94 SICU patients (mean age 63yo, 71% male) Gastric feeding TF held for GRV > 500mL Primary outcome: percentage of unavoidable interruptions Secondary outcomes: 30-day mortality, surgical ICU LOS, hospital LOS, VFDs and total complications per patient Unavoidable PEG placement IR or surgical procedures (if no controlled airway or patient not in supine position GI bleed Reintubation/extubation GRV > 500mL Tracheostomy GI surgery 74% 26% Avoidable IR or surgical procedures (if controlled airway & patient in supine position) GRV < 500 ml Imaging studies (when radiologist did not request patient to be fasted) Transient interruptions (lasting ten minutes or less) were not considered. Yeh, DD et al. JPEN. 2015 2
RESULTS Group 1 compared to Group 2: Accumulated double caloric deficit Additional 1.5 days in ICU, 8 days longer in hospital NO statistical difference in 30-day VFDs, in-hospital mortality, 30-day mortality 30day BOTTOM LINE: Focus should be on how to MAXIMIZE nutrient delivery rather than trying to eradicate interruptions. Yeh, DD et al. JPEN. 2015 Early Enteral Nutrition(24-48 hours) Gastric Feeding No difference in aspiration risk between gastric vs. small bowel feeding GRV threshold (250-500 ml) Aim for Goal Volume Feeding Canadian Critical Care Clinical Nutrition Practice Guidelines 2013 www.criticalcarenutrition.com. Optimal amount of energy and protein required to reduce morbidity and mortality is controversial Few observational studies have shown permissive underfeeding resulted in improved clinical outcomes compared to full feeding Several large observational studies have shown a cumulative energy deficit or caloric debt is associated with adverse clinical outcomes 3
3 prospective randomized studies (EDEN, Rice, Arabi) Compared trophic to full feeding Results: No difference in long-term outcome (28 day mortality) between two feeding strategies Reported more GI complications with the full EN feeding strategy Trend toward improved physical function in the full fed group Recommend low dose EN for first week of ICU stay Key Points: Relatively young (mean age = 52) Few co-morbidities Well-nourished (BMI 29-30) Average duration of study intervention 5 days No effect in young, healthy, overweight patients who have short stays! SSC (Surviving Sepsis Campaign) recommends avoiding mandatory full caloric feeding and using low dose EN the first week in the ICU The 2013 Canadian Critical Care Nutrition Practice Guidelines (based on multiple randomized trials and large scale observational studies) recommend: Optimizing the dose of EN NOT use intentional underfeeding in those first 5 ICU days (all patients). Prospective, multicenter observational study Determine: Effect of energy & protein intake on outcome Whether patients with pre-existing malnutrition or lack of nutritional reserve benefit more from aggressive EN provision 2772 patients (158 ICU s over 5 continents) Included ventilated patients in ICU >72 hours BMI used as marker of nutritional status prior to admission Average daily nutrient intake: 1034 kcal; 47gm protein 4
Mortality (%) 5/9/2015 Relationship of Caloric Intake, 60 day Mortality and BMI 60 BMI All Patients 50 < 20 20-25 40 25-30 30-35 35-40 30 >40 20 Secondary analysis of large nutrition database 2270 mechanically ventilated patients with sepsis and / or pneumonia ICU stay > 3 days receiving EN ONLY Older (mean age 62); low to normal BMI Nutrition intervention 11 days Average daily nutrient intake: 1057 kcal; 49gm protein 10 0 0 500 1000 1500 2000 Calories Delivered Results: Increasing 1000 kcal & 30 gm protein daily more VFDs and lower mortality in septic patients Elke, G et al. Crit Care 2014 Objective: To examine the relationship between the amount of prescribed calories received and 60-day hospital mortality Prospective, multi-institutional audit 352 ICUs (33 countries) 7872 mechanically ventilated patients (> 96 hrs in ICU) Heyland et al CCM, 2011 5
RESULTS: Optimal target = 80-85% of prescribed amount (best clinical outcome) No additional benefit attaining 100% prescribed amount Conclusions: Regardless of BMI, practice of permissive underfeeding is not advised (including the obese critically ill) Recommended 80-85% target should be feasible goal for ALL ICUs world wide Heyland DK, et al. Crit Care Med. 2011. Protein-Energy Provision via the Enteral Route in Critically Ill Patients (PEP up ) 1 Designed by Heyland et al to make up for lost EN infusion time 1 Shift from traditional rate-based to volume-based feeding approach RN to adjust hourly rate to reach goal EN volume Trial included 18 mixed med/surg ICUs (80-85% MICU) Implementation of protocol resulted in increased calorie & protein delivery Feed Early Enteral Diet Adequately for Maximum Effect (FEED ME) 2 Designed by Taylor et al 2 Surgical / Trauma ICU patients Modified version of PEP up Protocol resulted in increased delivery of EN volume, calories & protein No significant increases in GRV, emesis and only minimal increase in diarrhea 1. Heyland et al. CCM 2013 2. Taylor et al. Nutr Clin Prac 2014 6
Pilot in Neuro ICUs 28 beds Collect baseline data % prescribed amount received, GRVs, interruptions (number, time held, reason) Enteral Product (up to RD discretion) Ramp Up to goal infusion rate 24-h clock (07:00-07:00) Makeup rate calculation: (FEED ME protocol) GRV threshold: 350 ml No routine use of promotility agents 120 ml / hr (maximum hourly infusion rate) NO bolus feeding Post implementation data collection identify barriers Taylor B et al, Nutri Clin Prac 2014 Increased risk for nutrition depletion due to acute illness Early nutrition intervention improves outcomes Intentional underfeeding is not recommended Maximize nutrient delivery (80-85% goal) but further randomized trials needed Consider 24 hour volume based feeding strategy Teamwork is key to successful nutrition delivery THANK YOU! 7