The 2013 Canadian Critical Care The 2013 Canadian Critical Care Nutrition Clinical Practice Nutrition Clinical Practice Guidelines: Guidelines: What are the Latest What are the Latest Recommendations? Recommendations? Daren K. Heyland MD Professor of Medicine Queen’s University, Kingston, ON Canada On behalf of the Canadian Critical Care Nutrition Clinical Practice Guidelines Committee 1
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Daren K. Heyland MD Professor of Medicine Queen’s University, Kingston, ON Canada
Daren K. Heyland MD Professor of Medicine Queen’s University, Kingston, ON Canada On behalf of the Canadian Critical Care Nutrition Clinical Practice Guidelines Committee. The 2013 Canadian Critical Care Nutrition Clinical Practice Guidelines: What are the Latest Recommendations?. 1. - PowerPoint PPT Presentation
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The 2013 Canadian Critical Care Nutrition The 2013 Canadian Critical Care Nutrition Clinical Practice Guidelines: Clinical Practice Guidelines:
What are the Latest Recommendations?What are the Latest Recommendations?
Daren K. Heyland MD
Professor of MedicineQueen’s University, Kingston, ON Canada
On behalf of the Canadian Critical Care Nutrition Clinical Practice Guidelines Committee
1
Disclosures
I have received speaker honoraria and/or I have been paid from grants from the following companies:
– Nestlé
– Fresenius Kabi
– Baxter
– Abbott
1
Learning Objectives
Better understand the process by which CPGs are developed
Become familiar with recent randomized nutrition trials in critically ill adult patients
Enteral Fish oilsPN and type of Lipids New Sections
Review the updated analyses and recommendations of the Canadian CPGs
““Early Early Trophic”Trophic”(10 ml/hr)(10 ml/hr)
N-3 + GLA +N-3 + GLA +AntioxidantsAntioxidants(Module delivered (Module delivered as as bolusbolus bid) bid)
ControlControlStandard ENStandard EN(480 cal/ 20 g pro)(480 cal/ 20 g pro)
n = 250 n = 250
n = 250 n = 250
NIH NHLBI
OMEGA: 60-Day MortalityOMEGA: 60-Day Mortality
P=0.05P=0.14P=0.14
Rice et al JAMA Oct 2011
bolus: dilute effect?50% pts underfed
(trophic)protein in placebo
include but analyze without
11 Spanish ICUs 89 patients with diagnosis of Sepsis on admission Randomized to:
• Fish Oil/Borage Oil formula OR• Standard polymeric formula
Outcomes: new organ dysfunction
Grau-Carmona Clin Nutr 2011
Clinical Outcomes
Grau-Carmona Clin Nutr 2011
Fish Oils: Trend towards lower SOFA scores (NS)
First multicentre study to use “usual care” in control group…….no effect on
mortality
89 patients from 5 centres in US
Mechanically ventilated patients with Acute lung injury (ALI)
Randomized to (separate from EN):• BOLUS fish oils 7.5 mls q 6 hrs, 9.75g EPA & 6.75 gm DHA/day OR• placebo i.e. normal saline X 14 days
EN or PN as per MDs discretion
Stapleton CCM 2011
Clinical Outcomes
Stapleton CCM 2011
Fish Oils ONLYBolus
Separate from EN
X aggregate with RCTs of fish oil,
borage oil
Fish Oils: Effect on mortality (n = 6)
2009: RR 0.67, 95% CI 0.51, 0.97, p = 0.003
No effect , statistical heterogeneity!
INTERSEPT, Stapleton data not included
Fish oils: effect on mortality removing bolus RCT (n =5)
Significant effect, no statistical heterogeneity!
EN Fish oils with new RCTs
Effect on mortality disappears when bolus study is included• statistical heterogeneity present
Effect on mortality is significant when bolus study excluded Infections (2 RCTs): no effect Reduction in ICU LOS still significant (heterogeneity) Concerns of control group, negative results of large studies
2013 Recommendations
Fish Oils/borage oil: Downgraded recommendation to “should be considered”
Fish Oils alone: insufficient data
Use of PN and type of lipids
1
EN + PN
No change from 2009we recommend that PN not be started
not be started at the same time as EN.
Insufficient evidence in those who are
not tolerating EN (case by case)
NEJM 2011Lancet 2012
Early Supplemental PN vs. LateCombined EN + PN
Strongly recommend that early PN & high IV
glucose not be used in low risk, short ICU stay
Insufficient evidence in those who are not
tolerating EN (case by case)
large multicentreearly PN: worse infections, LOSearly PN: no diff mortalityhigh glucose loadinglow risk patients
used indirect calorimetryNo difference mortalityreduced infections day 4-28
+ Abrishami 2010+ Chen 2011
Lipid Free PN?
Recommendation: • Based on 2 level 2 studies, in critically ill patients who are not
malnourished, are tolerating some EN, or when parenteral nutrition is indicated for short term use (< 10 days), withholding soy bean emulsions should be considered.
• There are insufficient data to make a recommendation about withholding lipids high in soybean oil in critically ill patients who are malnourished or those requiring PN for long term (> 10 days).
• Practitioners will have to weigh the safety and benefits of withholding lipids high in soybean oil on an individual case-by-case basis in these latter patient populations.
There are no new randomized controlled trials since the 2009 update and hence there are no changes to the recommendation.