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Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
Nutrtion In The Icu
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Nutrtion In The Icu

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    • 1. Optimizing the Benefits and Minimizing the Risk of Nutrition Support in the Critically Ill Evidence Based on Canadian Clinical Practice Guidelines Dalhousie Critical Care Lecture Series
    • 2. Objectives <ul><ul><li>Be familiar with recommendations for nutrition of the critically ill patient. </li></ul></ul><ul><ul><li>Have knowledge of options for different enteral formulations available for specific patient populations, including diabetics and renal failure patients </li></ul></ul><ul><ul><li>Discuss the options if the patient doesn’t tolerate gastric feeding. </li></ul></ul><ul><ul><li>What are the indications for TPN and list the risks associated with it. </li></ul></ul><ul><ul><li>Discuss the feeding recommendations for severe acute pancreatitis. </li></ul></ul>
    • 3. Value of Specialized Nutrition Support <ul><li>Benefits </li></ul><ul><ul><li>Prevent starvation </li></ul></ul><ul><ul><li>Preservation of lean body mass </li></ul></ul><ul><ul><li>Support organ function </li></ul></ul><ul><ul><li>Support immune function </li></ul></ul><ul><ul><li>Stress ulcer prophylaxis </li></ul></ul><ul><li>Risks </li></ul><ul><ul><li>Increased mortality </li></ul></ul><ul><ul><li>Increased infectious complications </li></ul></ul><ul><ul><li>Increased workload </li></ul></ul><ul><ul><li>Increased costs </li></ul></ul>
    • 4. If you’ve ever questioned the risks of nutrition…..
    • 5.  
    • 6. EN vs. PN in the Critically Ill Patient
    • 7. EN vs. PN in the Critically Ill Patient
    • 8. Enteral vs Parenteral Nutrition <ul><li>Recommendation </li></ul><ul><li>According to 1 level 1 and 12 level 2 studies, when considering nutrition support for critically ill patients, we strongly recommend the use of EN over PN. </li></ul>www.criticalcarenutrition.com EN is the Winner! TPN
    • 9. TPN
    • 10. EN: Sooner vs. later <ul><li>Early vs Delayed nutrition </li></ul><ul><ul><li>Early: within 24-36 hours of admission to ICU </li></ul></ul><ul><ul><li>Late: delayed EN (>48-72 hrs) or D5W till po intake </li></ul></ul><ul><li>8 PRCTs </li></ul><ul><li>Includes critically ill surgical, trauma and burns patients </li></ul>
    • 11. Early vs Delayed Nutrient Intake Criticalcarenutrition.com
    • 12. Early vs Delayed Nutrient Intake Criticalcarenutrition.com
    • 13. Does it Matter What you Feed? JAMA 2001;286:944
    • 14. Cocktail Approach? <ul><li>Specific nutrients found to have effects on immune system, metabolism, and GI structure and function </li></ul><ul><ul><li>Arginine </li></ul></ul><ul><ul><li>Glutamine </li></ul></ul><ul><ul><li>Omega-3 fatty acids </li></ul></ul><ul><ul><li>Nucleic acids </li></ul></ul><ul><ul><li>others </li></ul></ul><ul><li>Rationale for combining substances into products? </li></ul>
    • 15. Underlying Rationale Wheeler NEJM 1999;340:207 Surgical Critically ill
    • 16. Population Nutrients Immunonutrition: What Nutrient for What Population? Possible Benefit … … … … … Omega 3 FFA … … … … Possible Benefit … Antioxidants … EN Possibly Beneficial EN Possibly Beneficial … PN Beneficial (? receiving EN) Possible Benefit Glutamine No benefit No benefit No benefit Harm No benefit Benefit Arginine Acute Lung Injury Burns Trauma Septic General Elective Surgery Critically Ill
    • 17. Is more EN better? <ul><li>RCT of 82 patients suffering severe head injury </li></ul><ul><li>Control: </li></ul><ul><ul><li>EN started at 25 ml/hr and advanced per protocol </li></ul></ul><ul><ul><li>rate adjusted based on gastric residual 50-150ml </li></ul></ul><ul><li>Experimental arm </li></ul><ul><ul><li>started at full rate </li></ul></ul><ul><ul><li>rate adjusted on gastric residual < 200ml </li></ul></ul><ul><ul><li>1/3 patients rec’d small bowel feeds </li></ul></ul>Taylor CCM 1999;27:2525
    • 18.  
    • 19. Is more better? Taylor CCM 1999;27:2525 p=0.08 p=0.046 p=0.02 Good Outcome
    • 20. Aggressive Gastric Feeding may be a BAD THING! <ul><li>Observational study of 153 medical/surgical ICU patients receiving EN in stomach </li></ul><ul><li>Intolerance= residual volume>500ml, vomiting, or residual volume 150-500x2. </li></ul><ul><li>Patients followed for development of VAP (diagnosed invasively) </li></ul>Mentec CCM 2001;29:1955
    • 21. <ul><li>Incidence of Intolerance= 46% </li></ul><ul><li>Statistically associated with worse clinical outcomes! </li></ul><ul><li>Risk factors for Intolerance </li></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Catecholamines </li></ul></ul><ul><ul><li>High residuals before and during EN </li></ul></ul>Aggressive Gastric Feeding may be a BAD THING!
    • 22. Strategies to Maximize the Benefits and Minimize the Risks of Enteral Nutrition
    • 23. Use of Nurse-directed Feeding Protocols Start feeds at 25 ml/hr Check Residuals q4h <ul><li>> 200 ml </li></ul><ul><li>hold feeds </li></ul><ul><li>add motility agent </li></ul><ul><li>reassess q 4h </li></ul><ul><li>< 200 ml </li></ul><ul><li>advance rate by 25 ml </li></ul><ul><li>reassess q 4h </li></ul>Heyland NCP 1999;14:23
    • 24. <ul><li>Gastric feeds </li></ul><ul><ul><li>easy to establish </li></ul></ul><ul><ul><li>majority of patients tolerate gastric feeds </li></ul></ul><ul><ul><li>delayed gastric emptying significant problem and may increase gastroesophageal regurgitation and risk of aspiration. </li></ul></ul><ul><li>Small bowel feeds </li></ul><ul><ul><li>post-op, small bowel motility returns first </li></ul></ul><ul><ul><li>may reduce risk of aspiration? </li></ul></ul><ul><ul><li>more invasive or resource intensive method </li></ul></ul>Small Bowel vs. Gastric Feeding
    • 25. Does Postpyloric Feeding Reduce Risk of GER and Aspiration? <ul><li>RCT of 33 critically ill patients requiring EN </li></ul><ul><li>Postpyloric vs. gastric </li></ul><ul><li>Immediate EN as per protocol </li></ul><ul><li>Radioisotope added to feed to facilitate detection of GER and aspiration </li></ul><ul><li>Serial sampling of oropharynx and trachea for six hours over first three days </li></ul>Heyland CCM 2001;29:1495-1501
    • 26. Amount of Gastroesophageal Regurgitation Mean Net CPM/GM P=0.04 Day 1 * Day 2 NS Day 3 NS
    • 27. Amount of Aspiration Mean Net CPM/GM * P=0.09 Day 1 NS Day 2 NS Day 3 NS
    • 28. Does Postpyloric Feeding Reduce Risk of GER and Aspiration? P=0.004 P=0.09 11.7 75 33 Total 0 5 1 D4 1.8 11 3 D2 4.1 27 8 D1 5.8 32 21 Stomach % positive for Aspiration % positive for GER # of patients Tube Position
    • 29. <ul><li>4 studies that document increased delivery of protein and calories with small bowel feeding; 2 show no difference </li></ul><ul><li>One study that documents time goal quicker with small bowel </li></ul><ul><li>Fewer interruptions with high gastric residuals with small bowel </li></ul><ul><li>2 studies document delay in initiating feeds secondary to delay in obtaining small bowel access </li></ul>Small Bowel vs. Gastric Feeding: A meta-analysis Effect on Nutritional Endpoints
    • 30. Small Bowel vs. Gastric Feeding: A meta-analysis Effect on VAP Criticalcarenutrition.com
    • 31. Body Position Reduces VAP! <ul><li>RCT of semirecumbent vs. supine body position </li></ul><ul><li>Majority of patients enterally fed (stomach) </li></ul><ul><li>Semirecumbent position associated with significant reduction in VAP (8% vs 34%) </li></ul><ul><li>Enteral nutrition a significant risk factor for VAP </li></ul>Drakulovic Lancet 1999;354:1851 Feed Upright (and if you can’t, then small bowel)
    • 32. Pro-motility agents?
    • 33. EN >>>PN Feeding Protocols Small bowel > gastric Semi-recumbent position Pro-motility drugs
    • 34. TPN
    • 35. Underlying Rationale <ul><li>What if you can’t provide adequate nutrition enterally? </li></ul><ul><li>… to TPN or not to TPN, </li></ul><ul><li>that is the question! </li></ul>
    • 36.  
    • 37. Supplemental PN: Benefit? Mortality 35.7% 25.0% 0.001 0.39 Deegan Clin Inten Care 1999;10:131 A Retrospective Study Study Outcomes 0.01 6305.5 ±1464.9 4388.7 ±2159.2 Total Energy Rec’d/day (kJ) 36.4 19.6 Hospital stay (days) 0.001 18.3 8.7 ICU stay (days) 0.04 75.0 ±19.9 51.2 ±25.2 Total Protein Rec’d/day (g) P value Combo group (n =28) Enteral group (n=28) Description
    • 38. TPN
    • 39. Prospective Studies Criticalcarenutrition.com
    • 40. Prospective Studies Criticalcarenutrition.com
    • 41. TPN
    • 42. TPN: Mechanisms of Harm <ul><li>Overfeeding </li></ul><ul><li>Hyperglycemia </li></ul><ul><li>Lipids- immunosuppression </li></ul><ul><li>Atrophy of GIT (lack of enteral stimulation) </li></ul><ul><li>Increase in line related sepsis </li></ul>
    • 43. Strategies to Maximize the Benefits and Minimize the Risks of Parenteral Nutrition
    • 44. <ul><li>60 Trauma Patients </li></ul><ul><li>not tolerating EN </li></ul><ul><li>before 5th day </li></ul><ul><li>comparable groups </li></ul>TPN w/o lipids TPN w/ lipids Outcomes <ul><li>duration of MV </li></ul><ul><li>LOS </li></ul><ul><li>death </li></ul><ul><li>infections </li></ul><ul><li>T-cell function </li></ul>R Lipids in Critically Ill Patients? Battistella J Trauma 1997;43:52
    • 45. Lipids in Critically Ill Patients? 2.4 1.4 0.04 Battistella J Trauma 1997;43:52 * Depressed T-cell function in Lipids Group 0.0001 21 ±2 28 ±2 Nonprotein calories 0.78 -9 ± 5 -9 ±7 Nitrogen balance 5 (19%) 13 (43%) Line Sepsis 0.05 13 (48%) 22 (73%) Pneumonia Infections/patient 39 72 Total Infections P value No Lipids (n =27) Lipids (n=30) Outcomes
    • 46. Lipids in Critically Ill Patients? Battistella J Trauma 1997;43:52 Days
    • 47. TPN
    • 48. Dose of TPN <ul><li>40 patients in university hospital requiring TPN </li></ul><ul><ul><li>45% requiring mechanical ventilation; more in standard group </li></ul></ul><ul><ul><li>? APACHE scores </li></ul></ul><ul><ul><li>8 patients excluded from analysis </li></ul></ul><ul><li>Randomized to: </li></ul><ul><ul><li>Standard: 25 kcal/kg, protein 1.5 g/kg </li></ul></ul><ul><ul><li>Hypocaloric: 1 L fat-free TPN (1000 calories/day) </li></ul></ul>McCowen Crit Care Med 2000;28:3603
    • 49. Dose of TPN <ul><li>Less protein, dextrose, fat, and calories in hypo group </li></ul><ul><li>More insulin in standard group but no difference in glucose levels </li></ul><ul><li>Trend towards increase in infections associated with standard TPN (p=0.20) </li></ul>McCowen Crit Care Med 2000;28:3603
    • 50. Timing of TPN 300 patients Major surgery/trauma R TPN IV glucose 1) Successful 2) Failure 3) Glucose 4) Failure: Cross over to TPN Outcomes <ul><li>days in ICU </li></ul><ul><li>mortality </li></ul><ul><li>Nutritional </li></ul>At 15 days Sandstrom Ann Surg 1993;217:185
    • 51. Timing of TPN Sandstrom Ann Surg 1993;217:185 % (days) Minimal nutrition support for more than 2 weeks associated with worse outcomes
    • 52. If you are going to use PN TIGHT GLYCEMIC CONTROL <ul><li>RCT of intensive insulin therapy </li></ul><ul><ul><li>Experimental: 4.4- 6.1 mmol/l </li></ul></ul><ul><ul><li>Standard: 10-11.1 </li></ul></ul><ul><li>Patients </li></ul><ul><ul><li>Mostly surgical; 65% CV surg </li></ul></ul><ul><ul><li>Median APACHE II of 9 </li></ul></ul><ul><li>Cointerventions </li></ul><ul><ul><li>Rec’d 200-300 gms of glucose on day 1 </li></ul></ul><ul><ul><li>up to 60% rec’d combined EN and PN </li></ul></ul>Van den Berge NEJM 2001;345:1359
    • 53. <ul><li>Greatest reduction in deaths due to MODS secondary to sepsis </li></ul><ul><li>Reduced episodes of sepsis by 50% </li></ul><ul><li>Generalizability of findings? </li></ul>If you are going to use PN TIGHT GLYCEMIC CONTROL Van den Berge NEJM 2001;345:1359
    • 54. TPN
    • 55. Effect of Parenteral Glutamine in the Critically Ill
    • 56. If you are going to use TPN <ul><li>Use it late </li></ul><ul><li>Low dose EN </li></ul><ul><li>No lipids </li></ul><ul><li>Monitor glucose – tight control </li></ul><ul><li>Supplement with glutamine </li></ul>Consider: Heyland Right here, right now 2003
    • 57. Aggressive EN Feeding Protocols Small bowel > gastric Semi-recumbent position Pro-motility drugs Limited Role for TPN
    • 58. Canadian ICU Nutrition Support Practice Guidelines Nutrition support? EN >>TPN <ul><li>timing </li></ul><ul><li>Dose </li></ul><ul><li>Duration </li></ul><ul><li>Lipids </li></ul><ul><li>Low dose EN </li></ul><ul><li>glutamine </li></ul><ul><li>timing </li></ul><ul><li>Dose </li></ul><ul><li>composition </li></ul><ul><li>small bowel feeds </li></ul><ul><li>motility agents </li></ul><ul><li>feeding protocols </li></ul><ul><li>malnutrition </li></ul><ul><li>nutrition assessment </li></ul>
    • 59. EN vs PN in pancreatitis <ul><li>For PN </li></ul><ul><li>meets nutrition goals </li></ul><ul><li>avoid stimulation of pancreas </li></ul><ul><li>non-functioning gut </li></ul><ul><li>discontinuous gut </li></ul><ul><li>complications of feeding </li></ul><ul><li>For EN </li></ul><ul><li>stimulation of gut </li></ul><ul><li>protecting gut integrity </li></ul><ul><li>protecting gut motility </li></ul><ul><li>complications of PN </li></ul>
    • 60. EN vs PN in pancreatitis <ul><li>Systematic review of the literature </li></ul><ul><ul><li>Medline, EMBASE, Cochrane, files </li></ul></ul><ul><li>>3000 titles and abstracts </li></ul><ul><li>13 randomized trials involving acute pancreatitis </li></ul>
    • 61. RCT’s in Pancreatitis PN vs Standard EN vs PN Am J Surg Sax 1987 Am J Clin Nutr Louie 2002 Gut Windsor 1998 Nitrition Olah 2002 JPEN McClave 1997 BJS Kalfrentzos 1997 Am J Gastr Abou-Assi 2002 EN with glutamine EN with probiotics (lactobacillus) Clin Nutr Ockenga 2002 PN with parenteral glutamine Hepatogastr Halllay 2001 BJS Olah 2002 Nutr Hosp Hernandez-Ara 1996 Eur J Surg Pupelis 2000 EN vs Standard (post-op) BJS Powell 2000 EN vs Standard
    • 62. EN vs PN in Acute Pancreatitis EN feed n Population Study polymeric 25 abstract severe (>4days) Louie 2002 polymeric 34 pseudorand acute Windsor 1998 polymeric 89 pseudorand acute Olah 2002 semi-elemental 38 mild, acute on chronic McClave 1997 semi-elemental 38 severe Kalfarentzos 1997 elemental 53 acute Abou-Assi 2002
    • 63.  
    • 64.  
    • 65. Study design <ul><li>38 patients with severe necrotizing </li></ul><ul><ul><li>Imrie, APACHE, CRP and CT </li></ul></ul><ul><ul><li>within 48 hours </li></ul></ul><ul><li>standardized operative therapy </li></ul><ul><li>isocal, isoN </li></ul><ul><ul><li>semi-elemental feeds via NJ (2 pts excluded) </li></ul></ul><ul><li>concealed rand, not blinded, not ITT </li></ul>Kalfarentzos BJS 1997
    • 66. Patient Characteristics Kalfarentzos BJS 1997 39(22-73) 40(25-83) Hosp LOS 23+/a-6 22+/-6 Antibiotics days 15(11-19) 14(12-16) hemodialysis 11(7-31) 15(6-16) vent days 12(5-24) 11(5-21) ICU LOS 16 14 gallstones PN n=20 EN n=18
    • 67. Patient Outcomes: Kalfarentzos *values in parentheses are total numbers of complications 2 1 mortality 15(27)* 8(10)* patients with any comp 10(15)* 5(6)* patients with septic comp 4 2 pneumonia/ARDS 2 1 UTI 3 1 bacteremia 2 0 pancreatic fistula 1 0 pseudocyst 0 1 abscess 4 1 infected pancreas 9 4 hyperglycemia 2 0 CRBI
    • 68. Results <ul><li>Mortality similar </li></ul><ul><li>Complications </li></ul><ul><ul><li>OR 3.75 95%CI 0.95,14.7 </li></ul></ul><ul><li>Cost </li></ul><ul><ul><li>£30 vs £100 </li></ul></ul><ul><li>Inference </li></ul><ul><ul><li>7 </li></ul></ul>Kalfarentzos BJS 1997
    • 69. Summary <ul><li>Practice guidelines for the critically ill patients now available. </li></ul><ul><li>There is evidence that EN is safe and effective in acute severe pancreatitis. </li></ul>
    • 70. If you’re thirsty for more……… <ul><li>www.criticalcarenutrition.com </li></ul><ul><ul><li>Web based clinical practice guidelines </li></ul></ul><ul><ul><li>(pending publication of guidelines) </li></ul></ul><ul><ul><li>Tools and training kits to improve practice </li></ul></ul><ul><ul><li>Survey of current practice online </li></ul></ul><ul><ul><li>Compare your results to other sites and the clinical practice guidelines </li></ul></ul><ul><ul><li>Research related news </li></ul></ul>

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