07_SSC_Nutrition_06_03_14.pptx

SSC 2012 Guidelines Nutrition

F. Machado, D. Angus

• Nutrition– General– Other

Copyright 2014 SCCM/ESICM

SSC Nutrition• Extensive literature

– Often not recent– Often small studies with methodological

issues– Often not directly assessing sepsis

• Only four statements included in guidelines– When to start– Amounts to be given– The use of parenteral nutrition– Immunonutrition

Slide 2Copyright 2014 SCCM/ESICM

Nutrition• We suggest administering oral or enteral

feedings, as tolerated, rather than complete fasting or provision of only intravenous glucose within the first 48 hours after a diagnosis of severe sepsis/septic shock (Grade 2C).


Marik and Zaloga. Crit Care Med. 2001;29:2264–2270 Heyland et al. JPEN J Parenter Enteral Nutr. 2003;27:355-373

Doig et al. Intensive Care Med. 2009;35:2018–2027

Reviews of Early Feeding

Indirectness: not in septic patientsWeak evidence but no sign of harm


• Marik and Zaloga. Crit Care Med. 2001;29:2264-2270 (15 studies, n=753; mortality data only on 6)

– Enteral feeding in up to 36 hours of hospital admission or after surgery– No difference in mortality – Lower risk of infection relative risk 0.45 (0.30–0.66) – Shorter hospital length of stay: 2.2 days (0.81–3.63)

• Heyland et al. JPEN J Parenter Enteral Nutr. 2003;27:355-373 (8 studies , n=317)

– Enteral feeding started in 24 to 48 hours– Trends towards reduction in mortality and infectious disease

complications • Doig et al. Intensive Care Med. 2009;35:2018-2027 (6 studies, n=234; 3 trauma, 1 surgical, 1 burn, 1 critically ill)

– Enteral feeding in the first 24 hours of ICU admission or injury– Significant reduction in mortality [odds ratio = 0.34 (0.14–0.85)] – Significant reduction in pneumonia [odds ratio = 0.31 (0.12–0.78)]

Nutrition• We suggest avoiding mandatory full caloric

feeding in the first week, but rather suggest low-dose feeding (e.g., up to 500 kcal per day), advancing only as tolerated (Grade 2B).


Taylor et al. Crit Care Med. 1999;27:2525–2531 Ibrahim et al. JPEN J Parenter Enteral Nutr. 2002;26:174–181

Arabi et al. Am J Clin Nutr. 2011;93:569–577 Rice et al. Crit Care Med. 2011;39:967–974

Rice et al. JAMA. 2012;137:795–803

n= 200

Target Control: 25-30 kcal/kg/day

Trophic feeding : 240-480 kcal/day

Up to day 6


• Possible increase in gastrointestinal complications with enhanced feeding


JAMA. 2012;137:795–803


JAMA. 2012;137:795–803


N= 233 Target: permissive 60%-70%; enhanced: 90%-100%

Hospital mortality Underfeeding 30.0% vs. target group 42.5%

Relative risk, 0.71 (0.50, 0.99); P= 0.04Not powered for mortality assessment

Percentage of energy intake requirementsPermissive 60% vs enhanced 71%

Target not achieved in the enhanced group


Nutrition• We suggest using intravenous glucose and

enteral nutrition rather than total parenteral nutrition alone or in conjunction with enteral feeding (Grade 2B).


Braunschweig et al. Am J Clin Nutr. 2001;74:534–542 Heyland et al. JPEN J Parenter Enteral Nutr. 2003;27:355–373

Gramlich et al. Nutrition. 2004;20:843–848 Dhaliwal et al. Intensive Care Med. 2004;30:1666–1671

Peter et al. Crit Care Med. 2005; 33:213–220 Simpson and Doig. Intensive Care Med. 2005;31:12–23

Casaer et al. N Engl J Med. 2011;365:506–517

N = 4640Early parenteral nutrition: within 48 hours of ICU admission

Late parenteral nutrition: on day 8



Nutrition• We suggest using nutrition with no specific

immunomodulating supplementation in patients with severe sepsis (Grade 2C).


Arginine• Arginine should not be used• Can lead to unwanted vasodilation,

hypotension, and enhanced inflammation• Only small and underpowered studies

reported


Bower et al. Crit Care Med. 1995;23:436–449. Galbán et al. Crit Care Med. 2000;28:643–648.

Caparrós et al. JPEN J Parenter Enteral Nutr. 2001;25:299–308 Preiser et al. JPEN J Parenter Enteral Nutr. 2001;25:182–18

Glutamine• Glutamine should not be used • No impact on mortality • Some positive secondary outcomes

(reduction in infections and organ dysfunction)


– Meta-analyses• Heyland et al. JPEN. 2003;27:355• Jian et al. Zhonghua Shao Shang Za

Zhi. 2009;25:325• Avenell A et al. Proc Nutr Soc.

2006;65:236• Avenell A et al. Proc Nutr Soc.

2009;68:261• Novak et al. Crit Care Med.

2002;30:2022

– Single Studies• Fuentes-Orozco et al. Clin Nutr.

2004;23:13• Beale et al. Crit Care Med.

2008;36:131• Grau et al. Crit Care Med.

2011;39:1263• Wernerman et al. Acta Anaesthesiol

Scand. 2011;55:812• Andrews et al. BMJ. 2011;342:d1542

Glutamine-supplemented parenteral or enteral nutrition in critically ill patients No effect on mortality



After guidelines were published …


Omega-3 Fatty Acids


• Omega-3 fatty acids should not be used• Previous studies showing benefit used omega-6

enriched diets in the control arms– Pontes-Arruda et al. Crit Care Med. 2006;34:2325– Gadek et al. Crit Care Med. 1999;27:1409– Singer et al. Crit Care Med. 2006;34:1033

• More recent studies showed no benefit and possible harm– Friesecke et al. Intensive

Care Med. 2008;34:1411– Barbosa et al. Crit Care.

2010;14:R5– Gupta et al. Indian J Crit

Care Med. 2011;15:108

– Rice et al. JAMA. 2011; 306:1574

– Stapleton et al. Crit Care Med. 2011;39:1655

– Grau-Carmona et al. Clin Nutr. 2011;30:578

60-day hospital mortality: 26.6% vs. 16.3%, P=.054

JAMA. 2011;306:1574–1581

75% with sepsis or pneumonia


Summary• SSC guidelines

– Generally supportive of minimal nutritional intervention during initial ICU stay• Statements largely suggestions, rather

than recommendations• Lack of large, robust, targeted

randomized controlled trials


07_SSC_Nutrition_06_03_14.pptx

Documents

small studies

unpowered studies

surgical patients

early enteral nutrition

enteral feedings

ill patients

trauma patients

mortality data