Nutrition in critical care
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This document discusses enteral nutrition in critically ill patients. It provides rationale for using enteral nutrition rather than parenteral nutrition, including that enteral nutrition favors intestinal villous trophicity, promotes gut motility, reduces bacterial translocation from the gut, and is less costly. It discusses various access techniques for enteral nutrition, including percutaneous endoscopic gastrostomy and contraindications. It also covers administration methods for enteral nutrition such as bolus, continuous, intermittent, and cyclic. The document references guidelines from SCCM/ASPEN from 2009 and 2013 on enteral nutrition and provides data on new randomized controlled trials and evidence from 2009 to 2013 on various topics related to enteral and parenteral nutrition.
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Nutrition in critical care
- 1. ENTERALNUTRITION INENTERALNUTRITION IN CRITICALLYILLPATIENTSCRITICALLYILLPATIENTS SEYEDMOHAMMADREZA HASHEMIAN MD.FCCM AMERICAN COLLEGE OF CRITICAL CARE FELLOWSHIPAMERICAN COLLEGE OF CRITICAL CARE FELLOWSHIP ASSOCIATEPROFESSOROFCRITICALCARESBMUASSOCIATEPROFESSOROFCRITICALCARESBMU MASIH DANESHVARIHO SPITAL SMRHASHEMIAN@YAHOO.COM
- 3. RATIONALE FOREN……. • FAVOURS INTESTINAL VILLOUS TROPHICITY • PROMOTES GUT MOTILITY • REDUCES TRANSLOCATION OF BACTERIA FROM GUT • LESS COSTLY THAN PN
- 4. ACCESS TECHNIQUES • CHECK TUBE POSITION
- 5. PERCUTANEOUS ENDOSCOPIC ENTEROSTOMY 1- PERCUTANEOUS ENDOSCOPIC GASTROSTOMY PEG: METHODOFCHOICE CONSIDERED IN PAT. WITH NORMAL GASTRIC EMPTYING
- 6. PERCUTANEOUS ENDOSCOPIC GASTROSTOMY CONTRAINDICATIONS: GASTRIC CANCER GASTRIC ULCER ASCITIS COAGULATION DISORDERS (Source: Kudsk KA, Jacobs DO. Nutrition. In: Surgery: Basic Science and Clinical Medicine. Norton JA, et al., eds. New York: Springer-Verlag, 2001(2) Part 7, Section 91:136)
- 7. ADMINISTRATION OF EN • BOLUS • CONTINUOUS • INTERMITTENT • CYCLIC
- 11. • GLA GLA
- 20. GUIDELINE DEVELOPMENT Effect size Confidence Intervals Validity Homogeneity Adequacy of control group Biological plausibility Generalizability Safety Feasibility Cost evidence integration of values+ practice guidelines 2009 2013
- 21. LANGUAGE OF RECOMMENDATIONS CONDITIONS LANGUAGE OF RECOMENDATION No reservations about endorsing intervention. “ strongly recommend” Evidence supportive but minor uncertainties about safety, feasibility, or costs of intervention. “recommend” Supportive evidence weak and/or major uncertainties about safety, feasibility, or costs of intervention. “ should be considered” Inadequate or conflicting evidence. “ insufficient data”
- 22. NEWEVIDENCE
- 23. Topic 2009 2013 Total Enteral vs Parenteral 12 2 14 Early vs. delayed 14 2 16 Indirect Calorimetry 1 1 2 Arginine containing 24 2 26 Fish Oils/Borage Oils 4 4 8 Protein/peptides 4 1 5 Fibre 6 2 8 Small Bowel vs. Feeding 11 4 15 Probiotics 11 12 23 NEWRCTS PERTOPIC
- 24. Topic 2009 2013 Total Combination EN + PN 5 3 8 PN Branched Chain A Acids 5 1 6 Intensive insulin 22 3 25 PN Type of lipids 5 4 9 PN Glutamine 17 11 28 Antioxidants 16 8 24 PN Selenium 11 7 18 NEWRCTS PERTOPIC
- 25. New Topic # RCTs Intentional Underfeeding: Trophic vs Full Feeds 2 Intentional Underfeeding: Hypocaloric EN 1 Fish Oils only 1 Threshold of GRVs 2 Discarding GRVs 1 EN: ß Hydroxyl Methyl Butyrate (HMB) 1 Early Supplemental PN vs Late 1 PN + EN Glutamine 1 Optimal glucose control: CHO Restricted Formula + Insulin Therapy 1 Vitamin D 1 NEWTOPICS (N=10)
Editor's Notes
- The concept that enteral feeding should be preferred whenever possible is gaining acceptance [2], for the reasons outlined in Table 1. Indeed, complete bypass of the gut leads to adverse structural and functional modifications of the mucosal barrier, which can be reversed by enteral feeding [3]. This favorable effect stems from factors such as the stimulation of epithelial cell metabolism by direct contact with nutrients, increase in mucosal blood flow, and secretion of class A immunoglobulin, as well as enterotrophic gastrointestinal hormones such as gastrin and enteroglucagon [4]. Preventing mucosal atrophy is certainly an important goal, as animal studies indicate that the associated increase in gut permeability can induce translocation of bacteria and toxins from the gut lumen to the circulation [5], although there is no proof of such an occurrence in critically ill patients
- Cyclic feeding Administration of enteral formula via continuous drip over a defined period of 8 to 12 hours, usually nocturnally
- Need to check these numbers again MV: Updated on June 28 th 2013: - changed date to 2013 (from 2012) - included articles changed from ~305 to 275 (309 is the amount of RCTS NOT accounting for duplicates) - changed to 45 topics (was 44) - Updated: 67 new RCTs across 27 topics Canadian Clinical Practice Guidelines in 2013 February 10th 2012 Rupinder Dhaliwal
- Total n = 58 of all RCTs MV: Updated on June 28 th 2013 – changed date to 2013 (from 2012) , updated fish oils (from 3 to 4), Canadian Clinical Practice Guidelines in 2013 February 10th 2012 Rupinder Dhaliwal
- Total n = 58 of all RCTs MV: Updated on June 28 th 2013 – changed date to 2013 (from 2012), updated intensive insulin (changed 4 to 3), lipid type (3 to 4), Aox (7 to 8), Selenium (6 to 7). Canadian Clinical Practice Guidelines in 2013 February 10th 2012 Rupinder Dhaliwal
- Total n = 66 MV: Updated on June 28 th 2013 – threshold GRVs (changed from 1 to 2 new RCTs) Canadian Clinical Practice Guidelines in 2013 February 10th 2012 Rupinder Dhaliwal