Optimal provision of enteral    nutrition in the ICU               Liesl Wandrag     NIHR Clinical Doctoral Research Fello...
Outline•   Importance of nutrition on ICU•   Over/underfeeding•   EN Indications•   Feeds, dose, timing•   Poor feed toler...
Why is nutrition important on ICU?
Surgery, Trauma &                 Critical IllnessMetabolic Response                   Nutritional intake BMR             ...
Starvation
Trauma or Infection
Stress Response            Rehabilitation ResponseMuscle     (Catabolic Phase)          (Anabolic Phase)gain (g)          ...
Muscle breakdown & potential building strategies                   on ICU                                           ICU Mu...
Major burn            40                                              Major trauma or                                     ...
Major burn        200                                               Major trauma or                                       ...
Over- and underfeeding harmfulGlucose control, liver function derangement,   MalnutriƟon, ↓infecƟons, ↑ venƟlaƟon         ...
Underfeeding• ICU patients received 79% of Energy  requirement and 61% of protein  requirement• 25% of ICU patients underf...
Underfeeding worsens outcomeAlberda et al (Intensive Care Medicine, 2009)•   Observational study•   N=2772•   Mean energy ...
Causes of underfeeding•   Delayed start•   Frequent interruptions (theatre, procedures)•   Ventilation mode•   Sedation (g...
Early EN & outcome studies• Arthinian et al, 2006: N=404920% ↓ in ICU mortality25% decrease in hospital mortality• Heyland...
NUTRIC score            (Nutrition Risk Score in ICU)                       Heyland et al, 2011Identifying patients at hig...
Assessment of ICU patientsA: Anthropometry• Usual methods not reliable in ICU > oedema• Admission weight, surrogate measur...
Indications for Enteral NutritionMost common form of nutrition support• Sedated and ventilated patients• Intact GI• Top-up...
Contra-indications•   GI failure•   GI Ischaemia•   Paralytic ileus•   Intractable vomiting/diarrhoeaUsually trial EN firs...
Route: EN vs PN3 Meta-analysis:• Heyland et al, 2003: No mortality difference, EN  significant ↓ infecƟons.• Gramlich et al...
Timing• Within 24-48h of ICU admission (Kreymann et al,  2006 & McClave, 2009)• Early EN associated with a trend towards  ...
Dose• Start around 30ml/h with regular GRV  checks, increase to target in 24h• Monitor for Refeeding Syndrome• GRV: 300-50...
GRV and stomach capacity
Poor GI absorptionMetoclopramide 10mg   Erythromycin 250mg BDTDS IV                IV
Types of feed     Feed                    Use               Energy (kcal/ml)    Protein                                   ...
Immuno-nutrition• Later session by Mrs Ella Segaran
Energy requirements…
Gold standard: Indirect calorimetry
Difficulties with gold standard…
Prediction Equations• 20-25kcal/kg (American College of Chest Physicians)• 25-30kcal/kg (European Society of Enteral & Par...
Frankenfield ‘09• N=202• Indirect calorimetry• Compared to 8 predictive equations
Reminder…Harris Benedict:Mifflin:Penn State:
Accuracy rates  Frankenfield’09
Accuracy rates  Frankenfield’09
Accuracy rates  Frankenfield’09
Frankenfield studyLimitations:• Penn State = Author’s own equation• Some might not find it practical in large units• Maxim...
Tight Calorie Control Study (TICACOS)                     Singer et al, 2011                     N=112     MEE            ...
Protein Requirements…
Protein Requirements• 1.2g/kg/day in the general ICU population• 1.5-2.0g/kg/day for patients on CRRT• 1.2-2.0g/kg/day - l...
Protein balance according to            protein intake            0.9   1.2         1.5NegativeProteinBalance             ...
Other Requirements   Nutrient                         Requirement  Carbohydrate          Glucose oxidation rate: 4-7mg/kg ...
Monitoring•   Medical changes: ventilation, activity, temperature.•   Biochemistry: U & E’s, LFT’s, Inflammatory markers.•...
Feeding ProtocolsProtocols should:* Promote early feeding* Indicate gradual increases in enteral nutrition* Suggest a gast...
ICU sample feed protocol                      www.criticalcarenutrition.com
International Guidelines
Summary• Optimum macro- and micronutrient requirements for ICU  patients are still not known• It remains unclear whether m...
Key references•   Finfer et al (NICE-SUGAR Study Investigators). Intensive versus conventional glucose    control in criti...
Key references•   Singer P et al. European Society for Enteral and Parenteral Nutrition. Guidelines on    parenteral nutri...
Thank you
Liesl wandrag   optimal provision of enteral nutrition in icu [compatibility mode]
Liesl wandrag   optimal provision of enteral nutrition in icu [compatibility mode]
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Liesl wandrag optimal provision of enteral nutrition in icu [compatibility mode]

  1. 1. Optimal provision of enteral nutrition in the ICU Liesl Wandrag NIHR Clinical Doctoral Research Fellow Imperial College London
  2. 2. Outline• Importance of nutrition on ICU• Over/underfeeding• EN Indications• Feeds, dose, timing• Poor feed tolerance• Energy requirements• Protein requirements• Feeding protocols
  3. 3. Why is nutrition important on ICU?
  4. 4. Surgery, Trauma & Critical IllnessMetabolic Response Nutritional intake BMR Psychological Protein Breakdown Physical Hospital procedures loss lean body mass MALNUTRITION
  5. 5. Starvation
  6. 6. Trauma or Infection
  7. 7. Stress Response Rehabilitation ResponseMuscle (Catabolic Phase) (Anabolic Phase)gain (g) Injury GAIN 9 KG LOSS 9 KGMuscleloss (g) Injury resolved
  8. 8. Muscle breakdown & potential building strategies on ICU ICU Muscle Mass Breakdown Immobility & Disuse Atrophy Building Age Infection/ Sepsis Steroids, Insulin, Growth Hormone Hypoxia induced inflammation “Novel” (Arginine, Glutamine, Cytokines Creatine, BCAA, EAA ROS/NO HMB, Leucine via mTOR) Hormonal effect (Catecholamines Early mobilisation Glucocorticoids) Electrical Muscle Stimulus Drugs (NMBA(?), sedation, corticosteroids) Mechanical Loading ↓Nutrition (GI problems, ↑GRV, sedation, delays)L Wandrag, unpublished
  9. 9. Major burn 40 Major trauma or surgery with critical 30 illness NET Major surgeryNITROGEN uncomplicated 20EXCRETION g/day 10 NORMAL RANGE Starvation 10 20 30 40 Insult or DAYS Starvation
  10. 10. Major burn 200 Major trauma or surgery with critical 175 illness% RMR 150 Major surgery uncomplicated 125 100 NORMAL RANGE Starvation 75 10 20 30 40 50 Insult or DAYS Starvation
  11. 11. Over- and underfeeding harmfulGlucose control, liver function derangement, MalnutriƟon, ↓infecƟons, ↑ venƟlaƟon immune response, worsened ICU outcomes
  12. 12. Underfeeding• ICU patients received 79% of Energy requirement and 61% of protein requirement• 25% of ICU patients underfed at any point of their ICU stay• Underfed patients: received 30% of Energy requirements and 38% protein only. Reid, 2006: JHND 19:13-22
  13. 13. Underfeeding worsens outcomeAlberda et al (Intensive Care Medicine, 2009)• Observational study• N=2772• Mean energy intake: 1034kcal/d• Mean protein intake: 47g/d• ↑ of 1000kcal/d associated with ↓ mortality [OR for 60d mortality 0.76; 95% CI 0.61-0.95, p=0.014]• Only in patients with BMI<25 and ≥ 35 (no benefit BMI 25-35)• ↑ of 1000kcal/d associated with ↑ of 3.5 venƟlator free days [95% CI 1.2-5.9, p=0.003]
  14. 14. Causes of underfeeding• Delayed start• Frequent interruptions (theatre, procedures)• Ventilation mode• Sedation (gastric dysmotility)• Gastric tolerance (drugs, infection, mechanical)• Human factor: Premature cessation of feed when gastric residual volumes are misinterpreted McClave 1999; Reid 2006; Wandrag 2011
  15. 15. Early EN & outcome studies• Arthinian et al, 2006: N=404920% ↓ in ICU mortality25% decrease in hospital mortality• Heyland et al, 2011: N=207Early EN may be associated with ↓ infecƟonsafter 96h on ICU
  16. 16. NUTRIC score (Nutrition Risk Score in ICU) Heyland et al, 2011Identifying patients at high nutritional risk most likely to benefit from aggressive nutrition therapy• Age, ICU scores, BMI, weight loss in last 3 months, IL-6, CRP, PCT• Each variable assigned points based on strength of association with 28d mortality• As score ↑, mortality and duraƟon of mechanical venƟlaƟon↑• Final NUTRIC score predictive of 28d mortality, except BMI• Final model = ‘adequate’ > Further work required to define
  17. 17. Assessment of ICU patientsA: Anthropometry• Usual methods not reliable in ICU > oedema• Admission weight, surrogate measures for heightB: BiochemistryC: Clinical (diagnosis, PMH, ventilation, CRRT, sedation, medications)D: Dietary• Nutritional status prior to admission
  18. 18. Indications for Enteral NutritionMost common form of nutrition support• Sedated and ventilated patients• Intact GI• Top-up feeding/overnight feeding once oral intake commenced
  19. 19. Contra-indications• GI failure• GI Ischaemia• Paralytic ileus• Intractable vomiting/diarrhoeaUsually trial EN first, if failed for ……days consider supplemental PN
  20. 20. Route: EN vs PN3 Meta-analysis:• Heyland et al, 2003: No mortality difference, EN significant ↓ infecƟons.• Gramlich et al, 2004: No mortality difference, EN significant ↓ infecƟons.• Simpson & Doig, 2005: PN signif ↓ mortality, also signif infections (EN delayed by 48h in study). ⇒ Concluded EN route of choice
  21. 21. Timing• Within 24-48h of ICU admission (Kreymann et al, 2006 & McClave, 2009)• Early EN associated with a trend towards ↓mortality and infecƟous complicaƟons• No difference in ICU length of stay has been observed (Heyland et al, 2003)• Feed over 24h for optimal glucose control
  22. 22. Dose• Start around 30ml/h with regular GRV checks, increase to target in 24h• Monitor for Refeeding Syndrome• GRV: 300-500ml. 500ml recommended in recent literature (Montejo, 2010)• Trend of GRV to be monitored, don’t act on a single measurement
  23. 23. GRV and stomach capacity
  24. 24. Poor GI absorptionMetoclopramide 10mg Erythromycin 250mg BDTDS IV IV
  25. 25. Types of feed Feed Use Energy (kcal/ml) Protein (g/100ml)Jevity, Osmolite, Standard feed 1 4 Nutrison Fibre (with/without fibre)Jevity/Osmolite High energy/high 1.2-1.5 5.5-6.4 Plus proteinJevity/Osmolite 1.3-2.0 8 HP, Nepro High Protein Nutrison HP Nepro Renal feed: high energy, 2 7 low electrolytes , high protein Peptamen 1.3 4 Nutrison Malabsorption Peptisorb
  26. 26. Immuno-nutrition• Later session by Mrs Ella Segaran
  27. 27. Energy requirements…
  28. 28. Gold standard: Indirect calorimetry
  29. 29. Difficulties with gold standard…
  30. 30. Prediction Equations• 20-25kcal/kg (American College of Chest Physicians)• 25-30kcal/kg (European Society of Enteral & Parenteral Nutrition, (ESPEN)• Schofield equation (1985) + stress factor (Age, gender and weight specific requirement)• Ireton Jones, 1992 (Age, gender, weight, presence of trauma or burn information required)• Penn State equation, 2009 (Age, gender, weight, max body temperature and minute ventilation required)• Harris Benedict (Age, gender, ideal body weight and height specific equation)
  31. 31. Frankenfield ‘09• N=202• Indirect calorimetry• Compared to 8 predictive equations
  32. 32. Reminder…Harris Benedict:Mifflin:Penn State:
  33. 33. Accuracy rates Frankenfield’09
  34. 34. Accuracy rates Frankenfield’09
  35. 35. Accuracy rates Frankenfield’09
  36. 36. Frankenfield studyLimitations:• Penn State = Author’s own equation• Some might not find it practical in large units• Maximum body temperature in 24h and expired minute ventilation• Performance in very sick patients? Sickest patients excluded from calorimetry• Burns, penetraƟng trauma and spinal injury excluded → unable to draw conclusion for these patients• Statistical power issues with subgroup comparisons
  37. 37. Tight Calorie Control Study (TICACOS) Singer et al, 2011 N=112 MEE 25kcal/kg/dCalorimetry group (MEE) :• Significant ↑ energy delivery (+ 600kcal/d) and protein delivery (+ 13 g/d)• ↓Post ICU mortality in calorimetry group• Limitations: overfeeding as non-nutritional energy not taken into account, sickest patients excluded, protein underfed in both groups→ Individualised nutriƟon beƩer than equaƟons…
  38. 38. Protein Requirements…
  39. 39. Protein Requirements• 1.2g/kg/day in the general ICU population• 1.5-2.0g/kg/day for patients on CRRT• 1.2-2.0g/kg/day - likely higher in burns or multiple trauma (SCCM and ASPEN)
  40. 40. Protein balance according to protein intake 0.9 1.2 1.5NegativeProteinBalance Ishibashi et al, CCM 1998, 1529-1535
  41. 41. Other Requirements Nutrient Requirement Carbohydrate Glucose oxidation rate: 4-7mg/kg body weight/min/day Lipids Usually 0.8-1.0g/kg/day Fluid Complex: Individual assessmentVitamins/minerals Full enteral feed should be adequate (apart from Burns ICU where supplementation is required)
  42. 42. Monitoring• Medical changes: ventilation, activity, temperature.• Biochemistry: U & E’s, LFT’s, Inflammatory markers.• Blood sugars.• Blood gasses: PaCO2. Ventilatory wean and CO2 production.• GI tract: GRV, bowel movements, vomiting.• Protocol adherence: Calories received vs prescribed. NBM practices for theatre, procedures.• Fluid balance: fit with clinical aim (+, even or -).• Medication: inotropes, sedation, steroids, drug-nutrient interactions.• Weight: weekly if possible (be aware of oedema)
  43. 43. Feeding ProtocolsProtocols should:* Promote early feeding* Indicate gradual increases in enteral nutrition* Suggest a gastric residual volume cut off, typically around 500ml* Encourage the use of prokinetic agents if gastric feed is not tolerated* Advocate the use of post-pyloric feeding tubes for feeding intolerance* May be associated with enhanced delivery of EN (Heyland et al, PEPup trial, 2010)
  44. 44. ICU sample feed protocol www.criticalcarenutrition.com
  45. 45. International Guidelines
  46. 46. Summary• Optimum macro- and micronutrient requirements for ICU patients are still not known• It remains unclear whether meeting requirements of these nutrients would lead to improved ICU outcomes• Both over- and underfeeding should be avoided• Measured Energy Expenditure remains the most accurate way to determine caloric requirement. Approximately 25kcal/kg/d would be appropriate for most general ICU patients• 1.2g/kg/day protein should be provided• Early nutrition support should be considered (24-48h after ICU admission)• Feeding protocols may allow for a more optimum nutrient delivery
  47. 47. Key references• Finfer et al (NICE-SUGAR Study Investigators). Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009 March 26;360(13):1283-97.• Frankenfield DC et al. Analysis of estimation of resting metabolic rates in critically ill adults. JPEN 2009 Vol 33 (1): 27-36.• Heyland DK et al. Canadian practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. Journal of Parenteral and Enteral Nutrition (JPEN) 2003 Vol 27 (5): 355-373. Guidelines updated: 2009.• Kreymann KG et al. European Society for Enteral and Parenteral Nutrition. Guidelines on enteral nutrition: Intensive Care. Clinical Nutrition (2006) 25: 210-223.• Manual of Dietetic Practice, 4th edition, British Dietetic Association (2007).• Martindale RG et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society of Parenteral and Enteral Nutrition: Executive Summary. Crit Care Med 2009; 37(5): 1757-1761.• National Institute for Clinical Excellence (2006): Nutrition Support for Adults.• Reid CL, Campbell IT, Little RA. Muscle wasting and energy balance in critical illness. Clinical Nutrition 2004; 23: 273 – 280.• Reid CL. Poor agreement between continuous measurement of energy expenditure and routinely used prediction equations in intensive care unit patients. Clinical Nutrition 2007; 26; 649-657.
  48. 48. Key references• Singer P et al. European Society for Enteral and Parenteral Nutrition. Guidelines on parenteral nutrition: Intensive Care. Clinical Nutrition (2009) 28: 387-400.
  49. 49. Thank you

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