IN ICU NUTRITION? WHAT’S NEW. Hippocrates 400 B.C. Hippocrates 400 B.C. ‘A slender and restricted diet is always dangerous in chronic and in acute diseases’

IN ICU NUTRITION?

WHAT’SNEW

Hippocrates 400 Hippocrates 400 B.C.B.C.

‘‘A slender and restricted diet is always A slender and restricted diet is always dangerous in chronic and in acute dangerous in chronic and in acute

diseases’diseases’

‘Let food be thy medicine’‘Let food be thy medicine’

SICS Nutrition NetworkSICS Nutrition Network Set up in June 2006Set up in June 2006 Links 30 dietitians, 6 pharmacists, 10 ICU Links 30 dietitians, 6 pharmacists, 10 ICU

Nutrition nurses, and 17 doctors. Meets Nutrition nurses, and 17 doctors. Meets 3x/year at QMH. Around 12-18/meeting3x/year at QMH. Around 12-18/meeting

Guidelines on practical issues plannedGuidelines on practical issues planned Website with Website with

protocols/guidelines/teachingprotocols/guidelines/teaching Educational meetingsEducational meetings Current projects on assessment/weighingCurrent projects on assessment/weighing Encouraging projects in nutritionEncouraging projects in nutrition

SICS Nutrition NetworkSICS Nutrition Network Meetings – videoconferencingMeetings – videoconferencing Presentations of local projects/auditsPresentations of local projects/audits Ideas for new projects discussed Ideas for new projects discussed Reports on conferences/equipmentReports on conferences/equipment Discussion on topical issues e.g. nutrition Discussion on topical issues e.g. nutrition

teams, education, weighing, screeningteams, education, weighing, screening Reviews of topics planned e.g. pre-and Reviews of topics planned e.g. pre-and

post-op feedingpost-op feeding Article circulation plannedArticle circulation planned

‘‘Best Practice’ statementsBest Practice’ statements

Starting and stopping feedStarting and stopping feed Adding water to feedsAdding water to feeds Use of MUACUse of MUAC Use of different weights (ideal, actual Use of different weights (ideal, actual

etc)etc) Nasal bridlesNasal bridles

EducationEducation

Module on SICS websiteModule on SICS website Teaching powerpoint on websiteTeaching powerpoint on website Junior doctors’ inductionJunior doctors’ induction FY2 teaching by nutrition nurse FY2 teaching by nutrition nurse Consultants’ mandatory trainingConsultants’ mandatory training Chapter for ABC of Intensive CareChapter for ABC of Intensive Care WebsiteWebsite

AuditsAudits

Nutrition audit of Scottish Units 2006 Nutrition audit of Scottish Units 2006 – widely diverse practice and – widely diverse practice and knowledgeknowledge

HDU feeding – Fife, Forth ValleyHDU feeding – Fife, Forth Valley International Nutrition QI audit: 9 International Nutrition QI audit: 9

units last 2 yearsunits last 2 years Helped to inform changes in practiceHelped to inform changes in practice Nutrition Audit form on websiteNutrition Audit form on website

% patients receiving PN/year% patients receiving PN/year

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E WD I F V M X A K N Q G S P H B C R

Unit

The Downward Spiral of The Downward Spiral of Malnutrition in Severe IllnessMalnutrition in Severe Illness

Depression and

lethargy

Secondary infections

Delayed recovery

Muscle catabolism and weight loss

Decreased energy and

nutrient intake

Further decreased intake

Serious complications

e.g.pneumonia

Morbidity / Mortality

Current Projects:Current Projects:Nutritional ScreeningNutritional Screening

Required by QIS and NICE for:Required by QIS and NICE for:

All patients All patients on admission to hospital and on admission to hospital and regularly thereafterregularly thereafter

MUST introduced by BAPEN - being MUST introduced by BAPEN - being widely implementedwidely implemented

Not helpful in ICU – all high riskNot helpful in ICU – all high risk Need to identify the severely Need to identify the severely

malnourishedmalnourished Improves feeding of these patientsImproves feeding of these patients

Nutritional State and Complications Nutritional State and Complications in SHDU, WGH 2003in SHDU, WGH 2003

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Complications No Complications

Poor Intermediate Good

SNACC – 3 phasesSNACC – 3 phases

Few ICU nutrition studies have looked at Few ICU nutrition studies have looked at nutritional status – probably crucialnutritional status – probably crucial

Fife ICU nutritional screening toolFife ICU nutritional screening tool 1. Pilot study completed – to repeat in 1. Pilot study completed – to repeat in

WGH + external validity study.WGH + external validity study. 2. Systematic review started (funded)2. Systematic review started (funded) 3. Larger study 2010-11 - will need 3. Larger study 2010-11 - will need

funding – nutritional state and outcomesfunding – nutritional state and outcomes Aim to focus nutritional interventionAim to focus nutritional intervention

What’s New in ICWhat’s New in ICWeighing ICU patients

Weighing PatientsWeighing Patients

Essential for nutrition screeningEssential for nutrition screening Nutritional requirement calculationsNutritional requirement calculations Indirect calorimetryIndirect calorimetry Drug dosagesDrug dosages Cardiac output monitoring – LIDCO, Cardiac output monitoring – LIDCO,

PAFC, PICCOPAFC, PICCO Fluid balanceFluid balance ARDS tidal volumesARDS tidal volumes

Weighing PatientsWeighing Patients

Estimation of weight can be up to 20% Estimation of weight can be up to 20% out:out:

i.e. 80 kg instead of 100kg and vice versai.e. 80 kg instead of 100kg and vice versa Estimation of height also inaccurate but Estimation of height also inaccurate but

measuring height with tape fairly accuratemeasuring height with tape fairly accurate

We need to weigh patients in ICUWe need to weigh patients in ICU

Weighing PatientsWeighing Patients

Craig Hurnauth: ICU S/N at SJHCraig Hurnauth: ICU S/N at SJH Audit of 13/14 NHS trusts in ScotlandAudit of 13/14 NHS trusts in Scotland 12 trusts do not weigh patients in ICU on 12 trusts do not weigh patients in ICU on

admission - use estimate/notes/familyadmission - use estimate/notes/family 1 weighs every day with hoist + weekly1 weighs every day with hoist + weekly 5 use MUST5 use MUST 7 do not screen, 1 adapted screening tool7 do not screen, 1 adapted screening tool 7 units in England – similar results7 units in England – similar results

Methods of WeighingMethods of Weighing

Hoist: time consuming, needs several Hoist: time consuming, needs several nurses, risky for unstable patients or nurses, risky for unstable patients or trauma patientstrauma patients

Weigh beds £16000 eachWeigh beds £16000 each Digital bed scales – scales for each Digital bed scales – scales for each

wheel of the bed – weighs bed + wheel of the bed – weighs bed + patient, mobile, minimal manpower, patient, mobile, minimal manpower, no disruption to patientno disruption to patient

Methods of WeighingMethods of Weighing

Progress since audit:Progress since audit: 2 units have bought weigh beds2 units have bought weigh beds 5 are considering bed scales5 are considering bed scales

Challenges in Critical Care NutritionChallenges in Critical Care Nutrition 1. Keeping up with evidence - guidelines1. Keeping up with evidence - guidelines 2. Screening/weighing2. Screening/weighing 3. Prevention and treatment of 3. Prevention and treatment of

complicationscomplications 4. Outdated surgical practices/ Peri-4. Outdated surgical practices/ Peri-

operative feedingoperative feeding 5. Achieving calorific and protein targets 5. Achieving calorific and protein targets 6. Immunonutrition6. Immunonutrition

GuidelinesGuidelines

GuidelinesGuidelines

CCCTG Nutritional Support updated: CCCTG Nutritional Support updated: 2009 www.criticalcarenutrition.com2009 www.criticalcarenutrition.com

ESPEN Parenteral Nutrition guidelines ESPEN Parenteral Nutrition guidelines 2009, EN 2006, (ASPEN guidelines)2009, EN 2006, (ASPEN guidelines)

NICE guidelines on Nutrition Support NICE guidelines on Nutrition Support in Adultsin Adults

QIS StandardsQIS Standards MUST (BAPEN)MUST (BAPEN)

Screening/Refeeding SyndromeScreening/Refeeding Syndrome

Prisoners of war 1944-5, 1944: Prisoners of war 1944-5, 1944: conscientious objectors in USA studiedconscientious objectors in USA studied

Starvation: early use of glycogen stores Starvation: early use of glycogen stores and gluconeogenesis from amino acidsand gluconeogenesis from amino acids

72 hrs: fatty acid oxidation; use of fatty 72 hrs: fatty acid oxidation; use of fatty acids and ketones for energy source, low acids and ketones for energy source, low insulin levelsinsulin levels

Atrophy of organs, reduced lean body Atrophy of organs, reduced lean body massmass

Refeeding syndromeRefeeding syndrome Carbohydrate feeding: shift to CH metabolismCarbohydrate feeding: shift to CH metabolism Insulin release, Mg lost in urineInsulin release, Mg lost in urine Phosphate and potassium shift into cells. Phosphate and potassium shift into cells. Magnesium, potassium and phosphate dropMagnesium, potassium and phosphate drop May get Lactic acidosisMay get Lactic acidosis Sodium and water shift out of cells – oedemaSodium and water shift out of cells – oedema Insulin causes sodium retentionInsulin causes sodium retention Protein synthesis needs potassium and Protein synthesis needs potassium and

phosphate - these drop morephosphate - these drop more Thiamine deficiency occurs (co-factor in CH Thiamine deficiency occurs (co-factor in CH

metabolism): encephalopathy, weaknessmetabolism): encephalopathy, weakness

Refeeding Syndrome in ICURefeeding Syndrome in ICU Unlikely to be a clear diagnosisUnlikely to be a clear diagnosis Many effects: oedema, arrhythmias, Many effects: oedema, arrhythmias,

pulmonary oedema, cardiac pulmonary oedema, cardiac decompensation, respiratory weakness, decompensation, respiratory weakness, fits, hypotension, leukocyte dysfunction, fits, hypotension, leukocyte dysfunction, diarrhoea, coma, rhabdomyolysis, sudden diarrhoea, coma, rhabdomyolysis, sudden deathdeath

Screen: nutritional history and electrolytesScreen: nutritional history and electrolytes Remember in HDU patients/malnourished Remember in HDU patients/malnourished

ward patientsward patients Poor awareness among doctors!Poor awareness among doctors!

Risk of re-feeding syndromeRisk of re-feeding syndrome

TwoTwo or more of the following: or more of the following: BMI less than 18.5 kg/mBMI less than 18.5 kg/m2 2 (<16)(<16) unintentional weight loss greater than 10% unintentional weight loss greater than 10%

within the last 3-6 months (>15%)within the last 3-6 months (>15%) little or no nutritional intake for more than 5 little or no nutritional intake for more than 5

days (>10)days (>10) Hx alcohol abuse or drugs including insulin, Hx alcohol abuse or drugs including insulin,

chemotherapy, antacids or diureticschemotherapy, antacids or diuretics Critically low levels of POCritically low levels of PO44

2-2-, K, K++ and Mg and Mg2+2+

NICE Guidelines for Nutrition Support in Adults 2006NICE Guidelines for Nutrition Support in Adults 2006

Managing refeeding problemsManaging refeeding problems provide Thiamine provide Thiamine

(Pabrinex)/multivitamin/trace element (Pabrinex)/multivitamin/trace element supplementationsupplementation

start nutrition support at 10-15 start nutrition support at 10-15 kcal/kg/day kcal/kg/day

increase levels over 3-5 daysincrease levels over 3-5 days restore circulatory volume restore circulatory volume monitor fluid balance and clinical statusmonitor fluid balance and clinical status replace phosphate, magnesium and K+replace phosphate, magnesium and K+ ReduceReduce feeding rate if problems arisefeeding rate if problems arise

NICE Guidelines for Nutrition Support in Adults 2006

ComplicationsComplications Ileus- caused by: fluid overload, pain, Ileus- caused by: fluid overload, pain,

hyperglycaemia, hypokalaemia, opioids, hyperglycaemia, hypokalaemia, opioids, immobility, sepsis – trickle of feed if gut immobility, sepsis – trickle of feed if gut intact. Consider Neostigmine/prokineticsintact. Consider Neostigmine/prokinetics

Constipation: avoid and treat; drugsConstipation: avoid and treat; drugs Diarrhoea: exclude infections, optimise Diarrhoea: exclude infections, optimise

fluid balance and electrolytes, replace fluid balance and electrolytes, replace lossloss

Intolerance: ? Sepsis, NJ feeding, PKsIntolerance: ? Sepsis, NJ feeding, PKs

Feeding aids fluid and electrolyte balanceFeeding aids fluid and electrolyte balance

OverfeedingOverfeeding Lactic acidosisLactic acidosis HyperglycaemiaHyperglycaemia Increased infectionsIncreased infections Liver impairment (Alk phos, ALT, GGT, Liver impairment (Alk phos, ALT, GGT,

acalculous cholecystitis)acalculous cholecystitis) Persistent pyrexiaPersistent pyrexia Underfeeding probably even more Underfeeding probably even more

dangerous – studies starting to emerge – dangerous – studies starting to emerge – need to get the balance rightneed to get the balance right

Outdated surgical practices

Outdated surgical practiceOutdated surgical practice

Reluctance to feed at allReluctance to feed at all Prolonged semi-starvationProlonged semi-starvation Sips of water/Over-IV hydrationSips of water/Over-IV hydration Incidence and treatment of ileusIncidence and treatment of ileus Nervous surgeon syndromeNervous surgeon syndrome Evidence from ERAS – pre-op CH loadingEvidence from ERAS – pre-op CH loading Benefits of early post-op feedingBenefits of early post-op feeding Over/under-use of PNOver/under-use of PN

Intake in HDUIntake in HDU

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Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

NBM Sips Fluids Oral TPN NG

Calorific and Protein TargetsCalorific and Protein Targets 25kcl/kg/day up to 30 in recovery phase25kcl/kg/day up to 30 in recovery phase Aim to provide energy as close as possible to Aim to provide energy as close as possible to

target to avoid negative energy balancetarget to avoid negative energy balance Protein 1.3 – 1.5g/kg/day (optimal prtn sparing)Protein 1.3 – 1.5g/kg/day (optimal prtn sparing) CVVH – lose AAs in filter – need to give 20% CVVH – lose AAs in filter – need to give 20%

more using amino acid supplementsmore using amino acid supplements Protein deficits may be very importantProtein deficits may be very important Increasing evidence that patients with deficits Increasing evidence that patients with deficits

in 1in 1stst 3-5 days do worse (?severely 3-5 days do worse (?severely malnourished)malnourished)

Indirect calorimetry – the future?Indirect calorimetry – the future?

Maintaining enteral intakeMaintaining enteral intake

Follow a protocol; use prokinetics/NJsFollow a protocol; use prokinetics/NJs Gastric residuals: do not stop feed Gastric residuals: do not stop feed

until you have 2 residuals of >250mls until you have 2 residuals of >250mls (check clinical signs) 400mls may be (check clinical signs) 400mls may be okok

Starting and stopping feed:Starting and stopping feed:

Extubations, fasting for theatre, scans, Extubations, fasting for theatre, scans, minor proceduresminor procedures

Can catch up on feed that is missedCan catch up on feed that is missed

ESPEN: PN in ICUESPEN: PN in ICU All patients receiving less than their All patients receiving less than their

targeted enteral feeding after 2 days should targeted enteral feeding after 2 days should be considered for supplementary PNbe considered for supplementary PN

All patients not able to receive EN within 24-All patients not able to receive EN within 24-48 hours should be given PN48 hours should be given PN

CCCN: Inadequate enteral nutrition <80% of CCCN: Inadequate enteral nutrition <80% of target after 3 days: PNtarget after 3 days: PN

Do not delay nutrition in malnourishedDo not delay nutrition in malnourished Keep 10ml/hr EN if possibleKeep 10ml/hr EN if possible

ImmunonutritionImmunonutrition

The future: replacement of the body’s own ‘stress substrates’ and reduction of inflammation?

ESPEN – new recommendations –ESPEN – new recommendations –glutamine in all PN 0.2-0.4g/kg/day glutamine in all PN 0.2-0.4g/kg/day

??? SIGNET/REDOXs??? SIGNET/REDOXs glutamine in enteral nutrition for glutamine in enteral nutrition for

burns and traumaburns and trauma

Omega-6ү-Linoleic acid (GLA) – borage oil Arachidonic Acid precursor

Omega-3 Fish oils: Eicosapentanoic acid (EPA) and Docosahexanoic acid (DHA)

Polyunsaturated Fatty Acids

Dietary LipidsDietary Lipids

Ratios in paleolithic diet Ratios in paleolithic diet ωω6:6:ωω-3 1:1-3 1:1 Current Western diet 16:1Current Western diet 16:1 Current UK PN Soybean oil base 7:1Current UK PN Soybean oil base 7:1 New PN (‘SMOF’) 2.5:1 New PN (‘SMOF’) 2.5:1 Cell membrane composition depends on Cell membrane composition depends on

balancebalance AA, DHA and EPA are present in AA, DHA and EPA are present in

inflammatory cell membrane inflammatory cell membrane phospholipidsphospholipids

Mechanisms of ActionMechanisms of Action

ωω-3s -3s EPA/DHA are incorporated quickly into cell EPA/DHA are incorporated quickly into cell membrane: inhibit membrane: inhibit ωω-6 activity -6 activity

Promote synthesis of low activity PGs and LTsPromote synthesis of low activity PGs and LTs Decrease expression of adhesion moleculesDecrease expression of adhesion molecules Inhibit monocyte prodInhibit monocyte prodnn of pro-inflamm cytokines of pro-inflamm cytokines Decrease NFkB, increases lymphocyte apoptosisDecrease NFkB, increases lymphocyte apoptosis Decrease pro-inflammatory gene expressionDecrease pro-inflammatory gene expression Lipoxins, resolvins and protectinsLipoxins, resolvins and protectins

3 Studies: OXEPA3 Studies: OXEPA

Patients with ARDS fed with GLA, EPA and antioxidants had a reduction in pulmonary neutrophils

Improvement in oxygenation Decrease in ventilator days Decrease in ICU and hospital days Gadek, Singer, Pontes-Arruda (sepsis) Recommended by ESPEN in ARDS

ESPEN PN GuidelinesESPEN PN Guidelines

PN for critically ill surgical patients PN for critically ill surgical patients should probablyshould probably include include ωω-3 fatty -3 fatty acids. acids. Fish oil enriched lipid Fish oil enriched lipid emulsions emulsions probably probably reduce ICU LOS.reduce ICU LOS.

The tolerance of MCT/LCT and olive The tolerance of MCT/LCT and olive oil emulsions is well established. oil emulsions is well established. These probably have advantages These probably have advantages over LCT based lipid preparations – over LCT based lipid preparations – small studies so far.small studies so far.

Anti-oxidantsAnti-oxidants

Normal state: reduction > oxidation Normal state: reduction > oxidation Acute stress: injury/sepsis causes acute Acute stress: injury/sepsis causes acute

dysregulation: ROS/RNOS formed dysregulation: ROS/RNOS formed Mitochondria are both sources and Mitochondria are both sources and

targetstargets Observational studies: anti-oxidant Observational studies: anti-oxidant

capacity inversely correlated with capacity inversely correlated with disease severity due to depletion disease severity due to depletion during oxidative stressduring oxidative stress

REDUCTION

OXIDATION

AntioxidantsAntioxidants

Glutathione, Vitamins A, C and EGlutathione, Vitamins A, C and E Zinc, copper, manganese, iron, seleniumZinc, copper, manganese, iron, selenium Already added to feedsAlready added to feeds Should we give extra? ESPEN: Should we give extra? ESPEN:

VitC/thiamine/Se/Zn in CVVH/burnsVitC/thiamine/Se/Zn in CVVH/burns Results of SIGNET and REDOXs awaitedResults of SIGNET and REDOXs awaited Oxidative stress in critically ill patients

contributes to organ damage / malignant inflammation

To conclude:To conclude:Screen your patientsScreen your patientsEarly enteral feeding is best Early enteral feeding is best Hyperglycaemia/overfeeding are badHyperglycaemia/overfeeding are badKeep glucose down <10mmol/l (safely)Keep glucose down <10mmol/l (safely)Nutritional deficit a/w worse outcomeNutritional deficit a/w worse outcomeUse EN and PN early to achieve goalsUse EN and PN early to achieve goalsAudit delivery of nutrition regularlyAudit delivery of nutrition regularlyProtocols improve delivery of feedProtocols improve delivery of feedSome nutrients show promising results: Some nutrients show promising results:

we should probably start using them nowwe should probably start using them now

Please feed me enough and with the right stuff!