Professor Andrew Davies is an Intensivist working at Peninsula Health in Melbourne. He has performed clinical research in the field of critical care for 20 years, as a participating investigator in over 50 studies (mostly clinical trials), predominantly in the areas of critical care nutrition, mechanical ventilation and acute lung injury and severe sepsis. He is a past Vice Chair of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS-CTG) with a special interest in nutrition in the ICU, and is a past Chair of the Australian and New Zealand Society of Parenteral and Enteral Nutrition (AuSPEN). In this talk, Professor Davies tackles the often overlooked aspect of nutrition in the ICU and it’s potential benefits for our patients.

1. Nutrition in Intensive Care
Three contemporary
clinical questions
Andrew Davies
Frankston Hospital & Baxter Healthcare

2. Nutrition in Intensive Care
Three important questions that
might help our patients
Andrew Davies
Frankston Hospital & Baxter Healthcare

5. The Modern Rationale for Nutrition
Nutrition therapy is important because it improves clinical outcomes
The choice of method
AND
The choice of nutrient matter to our patients
AND
The timing of administration
Nutrition is not just support but a powerful critical care intervention
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6. Simply
““Feed the PrisonersFeed the Prisoners””
in our ICUsin our ICUs

7. Optimising Enteral Nutrition

8. Overall Performance
The proportion of prescribed calories received
62%

9. Suboptimal Nutritional Delivery
% patients did not meet overall energy adequacy of 80%
69

10. Clinical Question Number 1
Should we really try to meet our patient’s nutrition target?

11. Arguments from the literature
More is better

12. Arguments from the literature
More is better
Less is better

13. Arguments from the literature
More is better
Less is better
There’s a sweetspot (and it is < 100%)

14. Doig G, Simpson F. www.evidencebased.net 2005 and JAMA 2008

15. Doig G, Simpson F. www.evidencebased.net 2005 and JAMA 2008

16. Placing nasojejunal feeding tubes

17. Placing nasojejunal feeding tubes

18. ARDSnet. JAMA 2012; 307(8):795

19. NEJM 2015; 372(25):2398

20. So
Less might be OK (if both are less than 80%)
But what if we actually deliver 100% in one of the arms?

21.  Effect on mortality of full predicted energy (10 trials, 3155 participants)

Random effects analysis: OR 1.02, 95%CI 0.74-1.41
Systematic Review: 80-120% vs < 80% of target

22.  Effect on hospital length of stay of full predicted energy (5 studies, 389 patients)
MD 4.71 days, 95%CI -0.33 - 9.75
Systematic Review: 80-120% vs < 80% of target

23. Clinical Question Number 1
Should we really try to meet our patient’s nutrition target?

24. Overall Performance
The proportion of prescribed calories received
62%

25. 2014;100:616-625
TARGET Feasibility Study
FRESUBIN
1000
FRESUBIN
2250
Calories, kcal/ml
Carbohydrates, g
Fat, g
Protein, g
Fibre, g
Osmolality mosm/kg H2O
1.0
12.5
2.7
5.5
2.0
360
1.5
18.0
5.8
5.6
1.5
430

26. 2014;100:616-625
Aim to determine if substitution of 1.0 kcal/ml with 1.5kcal/ml EN
delivers more calories when delivered at same rate
Peake S, et al. Am J Clin Nutr 2014;100:616

27. 2014;100:616-625
Mean (SD) kcal/day Mean (SD) kcal/kg IBW/day
Peake S, et al. Am J Clin Nutr 2014;100:616
Daily calorie delivery over first 10 feeding days

28. 2014;100:616-625
Peake S, et al. Am J Clin Nutr 2014;100:616
1.0 kcal/ml 1.5 kcal/ml P value
Volume delivered, ml/day (mean, SD) 1259 (428) 1221 (381) 0.63
Calories delivered, kcal/day (mean, SD) 1259 (428) 1832 (571) < 0.001
Calories delivered, kcal/kg IBW /day (mean, SD) 19.0 (6.0) 27.3 (7.4) < 0.001
Goal CALORIES achieved, (%)* 72 102 < 0.001
46% increase in calorie delivery with 1.5 kcal/ml
EN

29. Peake S, et al. Am J Clin Nutr 2014;100:616
Survival
The authors’ responsib
SLP, EJR, and PJW: were
research (project concepti
oversight); MJC, ARD, A
writing committee and w
MJC, SF, SSR, and SLP:
other participating site in
duct of experiments and
study design, analyzed da
the preparation of the ma
and writing committees, h
script. Fresenius Kabi had
or interpretation of the re
REFERENCES
1. De Beaux, Chapma
D, Satanek M. Ente
vey in an Australian
29:619–22.
2. De Jonghe B, App
Melchior JC, Outin
practices in intensi
delivered? Crit Car
FIGURE 4. Kaplan-Meier estimates of survival time to day 90.
INCREASED CALORIE DELIVERY TO THE CRITICA
P = 0.06 log-rank test

30. The Augmented versus Routine
approach to Giving Energy Trial
(TARGET)

31. Funding
National Health and Medical Research Council
Health Research Council of New Zealand
Endorsement
ANZICS Clinical Trials Group
Coordinating Centre
ANZIC Research Centre, Monash University
Medical Research Institute of NZ
Support
NHMRC Centre for Research Excellence in Nutrition, Adelaide Australia
Fresenius Kabi Deutschland GmbH
4000 patient study in 51 ICUs in ANZ

32. Aims
Primary
To determine if augmentation of calorie delivery using energy dense EN
in mechanically ventilated patients improves 90-day survival compared to
routine care
Secondary
To determine if augmentation of calorie delivery using energy dense EN
in mechanically ventilated patients improves functional outcomes
compared to routine care

33. Clinical Question Number 2
Is there a role for supplemental PN in ICU patients?

34. Overall Performance
The proportion of prescribed calories received
62%

35. PN has now entered a new era

36. NEJM 2014 Oct 30; 371(18):1673-84. Epub 2014 Oct 1.

40. JAMA 2013 309 (20): 2130.

41. JAMA 2013 309 (20): 2130.

42. So what do we know about
Supplemental PN?

45. A subsequent Supplemental PN study:
In Australia and NZ
• In a more severely unwell critical care population than EPANIC
• With NICE-SUGAR control (< 10mmol)
• No IV dextrose
• Standard ANZ energy targets
• With an intervention designed to avoid overnutrition

46. Research Question - wider program
“Does a supplemental PN strategy improve short and
longer term clinical outcomes in critically ill patients
with at least 1 organ system failure compared to a
standard strategy”

47. Pilot Study Design
• Study Design
– Prospective, concealed, randomized, multi-centre trial
– Feasibility study aiming at a program of research
• Sites
– 2 in Australia, 4 in New Zealand
• Sample size:
– 100 patients

48. Clinical Question Number 3
Should intensivists be interested in diet and lifestyle
interventions that might reverse heart disease?

52. Is plant-based nutrition therapeutic?

54. 3 3 6 1 2 9
M E D I C A L S C I E N C E
C a n lifestyle c h a n g e s r e v e r s e c o r o n a r y h e a r t
d i s e a s e ?
T h e Lifestyle H e a r t Tr ia l
In a p r o s p e c t i v e , r a n d o m i s e d , c o n t r o l l e d t r i a l t o
d e t e r m i n e w h e t h e r c o m p r e h e n s i v e lifestyle
c h a n g e s a f f e c t c o r o n a r y a t h e r o s c l e r o s i s a f t e r 1
y e a r , 2 8 p a t i e n t s w e r e a s s i g n e d t o a n e x p e r i m e n t a l
g r o u p ( l o w - f a t v e g e t a r i a n d i e t , s t o p p i n g s m o k i n g ,
s t r e s s m a n a g e m e n t tr a in i ng , a n d m o d e r a t e
ex erci se ) a n d 2 0 t o a u s u a l - c a r e c o n t r o l g r o u p . 1 9 5
c o r o n a r y a r t e r y l e s i o n s w e r e a n a l y s e d b y
W e c a r r i e d o u t tr ia ls i n 1 9 7 7 a n d 1 9 8 0 t o a s s e s s t h e
s h o r t - t e r m ef f ec t s o f lifestyle c h a n g e s o n c o r o n a r y h e a r t
d i s e a s e w i t h n o n - i n v a s i v e e n d p o i n t m e a s u r e s
( i m p r o v e m e n t s i n c a r d i a c r i s k factors, f u n c t i o n a l s t a t u s ,
m y o c ar d ia l perfusion,2 a n d left v e n t r i c u l a r function3).
H o w e v e r , t h e subjects o f t h o s e s t u d i e s w e r e n o t living i n t h e
c o m m u n i t y d u r i n g t h e trial, a n d w e d i d n o t u s e a n g i o g r a p h y
t o a s s e s s c h a n g e s i n c o r o n a r y a t h e r o s c l e r o s i s .
Lancet 1990; 336:129

55. Lifestyle program
In patients with 1-3 vessel IHD and EF >25%
Low fat vegetarian diet (no caloric restriction) with no animal products except
egg white and low fat yoghurt
No caffeine, maximum of 2 units alcohol per day
Moderate aerobic exercise (3 hrs/week at target HR zones)
Stress management training (1 hr/day) – meditation and visualisation
Group support (2 meetings a week)

56. 1 3 1
T A B L E I I I - C O M P L I A N C E W I T H E X E R C I S E , S T R E S S M A N A G E M E N T , A N D D I E T A R Y C H A N G E S
* Pe rce nt a ge o f m i n i m u m r e c o m m e n d e d l e v e l o f c o m b i n e d lifestyle c h a n g e ; I n c l u d e s all t h e a b o v e pl us s m o k i n g c e s s a t i o n
T A B L E I V - C H A N G E S I N R I S K F A C T O R S
Lancet 1990; 336:129

57. * Pe r c e n t a g e o f m i n i m u m r e c o m m e n d e d l e v e l o f c o m b i n e d lifestyle c h a n g e ; I n c l u d e s all t h e a b o v e p l u s s m o k i n g c e s s a t i o n
T A B L E I V - C H A N G E S I N R I S K F A C T O R S
s e s s i o n s w e r e l e d b y a c l i ni c a l ps yc hol og is t w h o f a c ili t a te d
d i s c u s s i o n s o f strategies f o r m a i nt a i n i n g a d h e r e n c e t o t h e
p r o g r a m m e , c o m m u n i c a t i o n skills, a n d e x p r e s s i o n of feelings a b o u t
relationships a t w o r k a n d a t h o m e .
D i f f e r e n c e s i n b a s e l i n e c h a r a c t e r i s t i c s o f t h e t w o g r o u p s w e r e
t e st e d f o r statistical significance b y c o n v e n t i o n a l t t e s t s .
Com p a r i s o ns o f t h e t w o s t u d y grou ps’ b a s e l i n e c o r o n a r y a r t e r y
l esi o n c h a r a c t e r i s t i c s ( m e a s u r e d b y quantitative c o r o n a r y
a t h e r o s c l e r o s i s i n t h e s e patients f o r t h e following r e a s o n s :
quantitative analys es o f c o r o n a r y ar ter iograms t e n d t o a s s e s s
s t e n o s e s a s b e i n g l ess s e v e r e t h a n d o qualitative a s s e s s m e n t s ;
w e ana lys ed all d e t e c t a b l e lesions, includin g m i n o r o n e s ; a n d
w e e x c l u d e d f r o m analysis 3 3 l e s i o n s t h a t w e r e 1 0 0 %
o c c l u d e d a t b a s e l i n e .
A d h e r e n c e t o t h e diet, exercise, a n d s t r e s s m a n a g e m e n t
Lancet 1990; 336:129

58. e n
i c
s,
4 1
h e
e r
1 ]
3 3
h e
o l
e .
f e r
e s
r y
t h o u g h patients al rea dy
r e d u c e d f at c o n s u m p t i o n t o 3 1 5 % o f c a l o r i e s a n d
T A B L E V - C H A N G E S I N A N G I N A S Y M P T O M S
* S c a l e o f 1 t o 7, 1 l e a s t s e v e r e .
Angiographic lesions
Lifestyle group 40.0% to 37.8% at 1 year
Control group 42.7% to 46.1% at 1 year
Lancet 1990; 336:129

59. Angiographic lesions at 5 years
Lifestyle Overall progression -3.1%
Control Overall progression 11.8%
JAMA 1998; 280:2001

60. Courtesy of Dr Caldwell Esselstyn
Strict plant-based diet

61. Plant-based diets can improve outcomes in
- Diabetes
- Hypertension
- Cancer
- Inflammatory bowel disease
- Parkinson’s & Alzheimers