Optimzing Nutrition Delivery in ICU

Critical Care NutritionThe right nutrient/nutritional strategyThe right timingThe right patientThe right intensity (dose/duration)With the right outcome!www.criticalcarenutrition.com

A Continuous Quality Improvement Effort What is done?What ought to be done?What do we need to do differently?Gaps - site reportsHow to change?KT strategiesRCTs, Systematic Reviews, and Evidence-based practice guidelinesSurvey results

Early and Adequate EN Best for the Patient!Role of Supplemental PN

Loss of Gut Epithelial IntegrityUnderlying Pathophysiology of Critical Illness lymphocytes

Disuse Causes Loss of Functional and Stuctural IntegrityIncreased Gut PermeabilityCharacteristics : Time dependent Correlation to disease severityConsequences: Risk of infection Risk of MOFS

Feeding Supports Gastrointestinal Structure and Function

Maintenance of gut barrier function Increased secretion of mucus, bile, IgA Maintenance of peristalsis and blood flowAttenuates oxidative stress and inflammationSupports GALTImproves glucose absorption

Alverdy (CCM 2003;31:598)Kotzampassi Mol Nutr Food Research 2009 Nguyen CCM 2011

Effect of Early Enteral Feeding on the Outcome of Critically ill Mechanically Ventilated Medical PatientsRetrospective analysis of multiinstitutional database4049 patients requiring mech vent > 2 daysCategorized as Early EN if recd feeds within 48 hours of admission (n=2537, 63%)

Artinian Chest 2006:129;960P=0.007P=0.0005P=0.02

Effect of Early Enteral Feeding on the Outcome of Critically ill Mechanically Ventilated Medical Patients Artinian Chest 2006:129;960

Early EN (within 24-48 hrs of admission) is recommended!associated with large reductions in infections and mortalityUpdated CPGs, see www.criticalcarenutrition.com

Optimal Amount of Protein and Calories for Critically Ill Patients

Increasing Calorie Debt Associated with worse Outcomes Caloric debt associated with: Longer ICU stay Days on mechanical ventilation Complications MortalityAdequacy of ENRubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006

Chart1

18000

18002

18003

18000

1800446.1904761905

1800518.4023809524

1800528.1976190476

1800547.4666666667

1800600.9857142857

1800647.5119047619

1800596.3023809524

1800824.819047619

1800957.5738095238

1800974.8738095238

18001158.1119047619

18001106.5071428571

18001114.9

18001181.2904761905

18001309.5952380952

18001478.2642857143

18001500

18001556

Prescribed Engergy

Energy Received From Enteral Feed

Days

kcal

Sheet1

DAYPrescribed EngergyEnergy Received From Enteral Feed

11800

21800

318000

41800446

51800518

61800528

71800547

81800601

91800648

101800596

111800825

121800958

131800975

1418001158

1518001107

1618001115

1718001181

1818001310

1918001478

2018001500

2118001556

221800

23

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Caloric Debt

Prescribed Engergy

Energy Received From Enteral Feed

Days

kcal

Sheet2

Sheet3

Point prevalence survey of nutrition practices in ICUs around the world conducted Jan. 27, 2007Enrolled 2772 patients from 158 ICUs over 5 continentsIncluded ventilated adult patients who remained in ICU >72 hours

Effect of Increasing Amounts of Calories from EN on Infectious ComplicationsHeyland Clinical Nutrition 2010Multicenter observational study of 207 patients >72 hrs in ICU followed prospectively for development of infectionfor increase of 1000 cal/day, OR of infection at 28 days

Relationship between increased nutrition intake and physical function (as defined by SF-36 scores) following critical illness Unpublished data from Multicenter RCT of glutamine and antioxidants (REDOXS Study); n=364for increase of 30 gram/day, OR of infection at 28 days For every 1000 kcal/day received:

Model *Estimate (CI)P valuesAt 3 monthsPHYSICAL FUNCTIONING 3.2 (-1.0, 7.3) P=0.14

ROLE PHYSICAL 4.2 (-0.0, 8.5)P=0.05

STANDARDIZED PHYSICAL COMPONENT SCALE 1.8 (0.3, 3.4) P=0.02

At 6 monthsPHYSICAL FUNCTIONING 0.8 (-3.6, 5.1) P=0.73

ROLE PHYSICAL 2.0 (-2.5, 6.5) P=0.38

STANDARDIZED PHYSICAL COMPONENT SCALE 0.70 (-1.0, 2.4) P=0.41

Faisy BJN 2009;101:1079Mechancially Ventd patients >7days (average ICU LOS 28 days)

113 select ICU patients with sepsis or burnsOn average, receiving 1900 kcal/day and 84 grams of proteinNo significant relationship with energy intake butClinical Nutrition 2012

How do we set optimal targets?

Methods to Determine Energy Requirements60% Weight based39% Complex formula1% Indirect calorimetryUnpublished observations INS 2011

Small intestinal glucose absorptionin the critically ill and healthTime (mins)3-OMG (mmol/L)ICU patientsn = 28Healthy subjectsn = 16Median (IQR)P

Malabsorption studies: faecesStrack van Schijndel, et al. Clin. Nutr. 2006

More (and Earlier) is Better!If you feed them (better!)They will leave (sooner!)

Optimal Amount of Calories for Critically Ill Patients: Depends on how you slice the cake!Objective: To examine the relationship between the amount of calories recieved and mortality using various sample restriction and statistical adjustment techniques and demonstrate the influence of the analytic approach on the results. Design: Prospective, multi-institutional auditSetting: 352 Intensive Care Units (ICUs) from 33 countries. Patients: 7,872 mechanically ventilated, critically ill patients who remained in ICU for at least 96 hours.

Heyland Crit Care Med 2011

Association between 12 day average caloric adequacy and 60 day hospital mortality(Comparing patients recd >2/3 to those who recd

Association Between 12-day Caloric Adequacy and 60-Day Hospital Mortality Heyland CCM 2011

RCT Level of Evidence that More EN= Improved OutcomesRCTs of aggressive feeding protocolsResults in better protein-energy intakeAssociated with reduced complications and improved survivalTaylor et al Crit Care Med 1999; Martin CMAJ 2004

Meta-analysis of Early vs Delayed ENReduced infections: RR 0.76 (.59,0.98),p=0.04Reduced Mortality: RR 0.68 (0.46, 1.01) p=0.06www.criticalcarenutrition.com

More (and Earlier) is Better!If you feed them (better!)They will leave (sooner!)

Rice et al. JAMA 2012;307

Rice et al. JAMA 2012;307Still no measure of physical function!

Rice et al. JAMA 2012;307Enrolled 12% of patients screened

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failureAverage age 52Few comorbiditiesAverage BMI 29-30All fed within 24 hrs (benefits of early EN)Average duration of study intervention 5 days

No effect in young, healthy, overweight patients who have short stays!

ICU patients are not all created equalshould we expect the impact of nutrition therapy to be the same across all patients?

How do we figure out who will benefit the most from Nutrition Therapy?

StarvationA Conceptual Model for Nutrition Risk Assessment in the Critically Ill

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). When adjusting for age, APACHE II, and SOFA, what effect of nutritional risk factors on clinical outcomes?Multi institutional data base of 598 patientsHistorical po intake and weight loss only available in 171 patientsOutcome: 28 day vent-free days and mortalityHeyland Critical Care 2011, 15:R28

What are the nutritional risk factors associated with clinical outcomes?(validation of our candidate variables)

Non-survivors by day 28 (n=138) Survivors by day 28 (n=460) p values Age 71.7 [60.8 to 77.2]61.7 [49.7 to 71.5]

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). BMI, CRP, PCT, weight loss, and oral intake were excluded because they were not significantly associated with mortality or their inclusion did not improve the fit of the final model.

VariableRangePointsAge

The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).

The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score). Interaction between NUTRIC Score and nutritional adequacy (n=211)*P value for the interaction=0.01 Heyland Critical Care 2011, 15:R28

Who might benefit the most from nutrition therapy?High NUTRIC Score?ClinicalBMIProjected long length of stayOthers?

Do we have a problem?

Preliminary Results of INS 2011Overall Performance: Kcals84%56%15%N=211

Failure Rate% high risk patients who failed to meet minimal quality targets (80% overall energy adequacy) Unpublished observations, Results of 2011 INS

Chart1

75.5684975.5684926.66667100

78.0680378.0680333.33333100

91.1527391.1527333.33333100

75.0524575.0524525100

86.9821486.9821466.66667100

69.8299669.829960100

79.8604579.860450100

% patients not achieve minimum of 80% over stay in ICU

Oct2011

type of Nutrition

type_NSRegionmeanmeanmaxmin

1Canada83.5462183.5462110054.41176

1Australia and New Zealand71.6717671.6717610035.97884

1USA75.4100675.4100610031.28205

1Europe54.5822154.5822194.230774.929577

1Latin America83.9924783.9924710044.07583

1Asia61.313261.31321009.52381

1Total71.0479671.047961004.929577

2Canada4.3075384.30753817.647062.702703

2Australia and New Zealand5.2524375.25243720.231212.73224

2USA6.171816.1718124.50982.185792

2Europe7.3450137.34501340.314142.659574

2Latin America6.2774646.27746427.488154.265403

2Asia7.6034147.60341439.333333.030303

2Total6.2539396.25393940.314142.185792

3Canada9.5917869.59178628.571432.44898


3USA8.2151798.21517938.116593.361345

3Europe34.9505834.9505891.794875.769231

3Latin America7.763137.7631328.436023.433476

3Asia26.8680226.868021001.792115

3Total17.435417.43541001.792115

4Canada2.554472.5544732.558142.747253


4USA10.2029510.2029539.83741.360544

4Europe3.1221923.12219242.253522.162162

4Latin America1.9669391.9669399.0452261.550388

4Asia4.2153644.21536440.206191.298701

4Total5.2627065.26270642.682931.298701

hour to EN

sistersitemeanmeanmaxmin

Canada35.6290735.6290764.9928613.58158

Australia and New Zealand29.812329.812354.958336.691667

USA48.669948.669995.6217917.8902

Europe38.1994438.1994471.764719.407407

Latin America48.0815148.0815186.9564127.40833

Asia37.7696937.76969152.14055.546491

Total39.5364639.53646152.14055.546491

Type of Feed

type_feedRegionmeanmeanmaxmin

1Canada79.5918479.591841000

1Australia and New Zealand67.5675767.567571000

1USA48.4848548.484851000

1Europe78.3783878.378381000

1Latin America73.1343373.134331000

1Asia64.7058864.705881000

1Total68.1415968.141591000

2Canada2.0408162.04081616.666670


2USA27.2727327.272731000

2Europe6.7567576.7567571000

2Latin America10.4477610.447761000

2Asia4.7058824.7058821000

2Total12.3893812.389381000

3Canada31.6252831.6252841.2523.88889


3USA29.4561329.4561340.7142915

3Europe30.9251430.925144514.75

3Latin America36.2139536.213954529.31818

3Asia30.9780430.9780446.7647111.11111

3Total31.7730631.7730657.8571411.11111

Type of formula

type_formulaRegionmeanmeanmaxmin

1Canada5.05.066.70.0


1USA15.015.094.70.0

1Europe1.41.411.10.0

1Latin America13.013.050.00.0

1Asia2.32.328.60.0

1Total8.28.294.70.0

2Canada8.58.555.60.0


2USA9.69.658.30.0

2Europe8.78.765.00.0

2Latin America0.00.00.00.0

2Asia2.32.318.80.0

2Total6.66.665.00.0

Regionmeanmeanminmax

Canada63.263.20.0100.0


USA21.421.40.0100.0

Europe29.229.20.0100.0

Latin America25.025.00.033.3

Asia44.444.40.0100.0

Total34.034.00.0100.0


Canada5.35.30.0100.0


USA0.00.00.00.0

Europe0.00.00.00.0


Asia0.00.00.00.0

Total2.82.80.0100.0


Canada13.113.12.529.9


USA14.014.01.434.2

Europe8.78.71.215.6


Asia13.213.21.921.9

Total13.113.11.234.2

Adequacies

type_NS_AdequacyRegionmeanmeanminmaxmean

1Canada64.964.949.985.064.5

1Australia and New Zealand60.660.637.084.459.4

1USA48.948.915.166.748.9

1Europe56.556.518.184.361.0

1Latin America54.154.125.080.151.4

1Asia60.360.312.6147.663.5

1Total57.257.212.6147.657.7

2Canada61.161.147.781.460.9


2USA45.045.015.864.644.5

2Europe51.451.415.273.655.8

2Latin America51.751.721.174.449.0

2Asia54.654.612.492.457.3

2Total52.752.712.492.453.2

3Canada56.256.238.481.455.8


3USA39.439.415.157.638.6

3Europe48.048.015.576.652.3

3Latin America49.549.521.675.048.2

3Asia55.455.410.098.254.9

3Total49.749.710.098.249.5

4Canada56.656.640.281.456.4


4USA41.4109141.4109115.7660959.6528940.1

4Europe46.2841946.2841915.2057673.5791950.7

4Latin America48.0761548.0761521.1409272.657446.7

4Asia52.6067152.6067112.2762392.4166854.9

4Total49.0171949.0171912.2762392.4166849.4

Best vs. Worst

Obsstudy_dayMean of All SitesBest Performing SiteWorst Performing Site

119.04257.5950.154

4233.25682.4995.24

7350.3686.99910.653

10460.582105.99615.103

13567.31111.1629.698

16670.807111.16221.4

19772.484111.16224.273

22873.769111.16214.689

25974.817111.16215.012

281077.859111.16215.403

311178.549111.16216.166

341279.45111.16230.03

07 vs 08 vs 09

Obsstudy_dayYear 2007Year 2008Year 2009

1113.314.810.8

4235.038.633.0

7352.054.848.9

10461.363.757.4

13565.970.063.1

16670.474.265.4

19772.376.767.2

22872.778.868.8

25975.780.171.2

281075.279.871.5

311177.082.072.8

341279.082.172.5

Oct2011

% ICU days

83.5%

54.6%

71.0 %

100.0%

4.9%

TubeLoc

% ICU days

4.3%

7.3%

6.3%

40.3%

2.2%

Other Figures

% ICU days

9.6%

35.0%

17.4%

100.0%

1.8%

% ICU days

27.0%

10.7%

20.2%

Time to Initiation of EN (hours)

30hrs

49 hrs

40hrs

152 hrs

6 hrs

% patients with HGRV

79%

48%

68%

% patients with HGRV

10.4%

4.7%

12%

HOB Elevation (degree)

% received motility agents before PN started

% patient-days

% receive/prescribed

% receive/prescribed

Mean of All Sites

Best Performing Site

Worst Performing Site

ICU Day

% received/prescribed

Year 2007

Year 2008

Year 2009

ICU Day

% received/prescribed

Gastric confirmed169066.87

Gastric presumed561

Post-pyloric duodenal confirmed320

Post-pyloric duodenal presumed67

Post-pyloric jejunal confirmed122

Post-pyloric jejunal presumed43

No tube in place12

Blood Glucose > 10mmol/L

type_NSRegionmeanmeanmaxmin

1Canada17.0935417.0935446.96976.306306

1Australia and New Zealand15.7360415.7360430.681825

1USA15.906615.906639.743594.100946

1Europe9.8078369.80783627.941181.818182

1Latin America13.4847113.4847132.768362.094241

1Asia20.9018820.9018850.537633.076923

1Total15.9815415.9815450.537631.818182

EN with PN combined

type_feedRegionmeanmeanmaxmin

1Canada55.5555655.555561000


1USA66.6666766.666671000

1Europe58581000

1Latin America70701000

1Asia73.9130473.913041000

1Total64641000


Canada75.675.626.66667100

Australia and New Zealand78.178.133.33333100

USA91.291.233.33333100

Europe75.175.125100

Latin America87.087.066.66667100

Asia69.869.80100

Total79.979.90100


Canada75.5684975.5684926.66667100

Australia and New Zealand78.0680378.0680333.33333100

USA91.1527391.1527333.33333100

Europe75.0524575.0524525100

Latin America86.9821486.9821466.66667100

Asia69.8299669.829960100

Total79.8604579.860450100

% patient days

20.9%

9.8%

16.0%

% received motility agents before PN started

56%

67%

64%



Cahill, J Crit Care 2012 Dec;27(6):727-734

www.criticalcarenutrition.comUse of a feeding protocol that incorporates motility agents and small bowel feeding tubes should be considered

Use of Nurse-directed Feeding ProtocolsStart feeds at 25 ml/hrCheck Residuals q4h> 250 mlhold feedsadd motility agentreassess q 4h

< 250 mladvance rate by 25 mlreassess q 4h

2009 Canadian CPGs www.criticalcarenutrition.comShould be considered as a strategy to optimize delivery of enteral nutrition in critically ill adult patients.

The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery:Results of a multicenter observational studyTime to start EN from ICU admission: 41.2 in protocolized sites vs 57.1 hours in those without a protocolPatients recing motility agents: 61.3% in protocolized sites vs 49.0% in those withoutHeyland JPEN Nov 2010 P

Can we do better?The same thinking that got you into this mess wont get you out of it!

Enhanced Protein-Energy Provision via the Enteral Routein Critically Ill Patients: The PEP uP Protocol

Different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds.In select patients, we start the EN immediately at goal rate, not at 25 ml/hr.We target a 24 hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume.Start with a semi elemental solution, progress to polymericTolerate higher GRV threshold (300 ml or more)Motility agents and protein supplements are started immediatelyNurse reports daily on nutritional adequacy.The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!A Major Paradigm Shift in How we Feed Enterally

The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol! Adequacy of Calories from EN (Before Group vs. After Group on Full Volume Feeds)Heyland Crit Care 2010

Day 1Day 2Day 3Day 4Day 5Day 6Day 7TotalP-value0.080.00030.100.190.480.180.11

Change of nutritional intake from baseline to follow-up of all the study sites (intervention group only)% calories received/prescribedHeyland CCM 2013 (in press)

Other Strategies to Maximize the Benefits and Minimize the Risks of ENLiberalization of gastric residual volumesMotility agents started at initiation of EN rather that waiting till problems with High GRV develop.Small bowel feeding tubesElevation of head of the bedHave nurse report on nutritional adquacy during daily ward rounds

What if you cant provide adequate nutrition enterally?

to add PN or not to add PN,that is the question!

Health Care Associated Malnutrition

Early vs. Late Parenteral Nutrition in Critically ill Adults4620 critically ill patientsRandomized to early PN Recd 20% glucose 20 ml/hr then PN on day 3OR late PND5W IV then PN on day 8All patients standard EN plus tight glycemic control

Cesaer NEJM 2011Results:Late PN associated with 6.3% likelihood of early discharge alive from ICU and hospitalShorter ICU length of stay (3 vs 4 days)Fewer infections (22.8 vs 26.2 %)No mortality difference

Early vs. Late Parenteral Nutrition in Critically ill Adults? Applicability of dataNo one give so much IV glucose in first few daysNo one practice tight glycemic controlRight patient population?Majority (90%) surgical patients (mostly cardiac-60%)Short stay in ICU (3-4 days)Low mortality (8% ICU, 11% hospital)>70% normal to slightly overweightNot an indictment of PNEarly group only recd PN for 1-2 days on averageLate group only recd any PN

Cesaer NEJM 2011

Lancet Dec 2012

Doig, ANZICS, JAMA May 2013Adult patients were eligible for enrollment within 24 hours of ICU admission if they were expected to remain in the ICU on the calendar day after enrollment, were considered ineligible for enteral nutrition by the attending clinician due to a short-term relative contraindication and were not expected to PN or oral nutrition

Who were these patients?Overall, standard care group remained unfed for 2.8 days after randomization

40% of standard care group never recd any artificial nutrition; remained in ICU 3.5 days

Intervention not intense enough? 40% of both groups got EN (delayed) 40% of standard care group got PN for an average of 3.0 days Average PN use in early PN group was 6.0 days

Doig, ANZICS, JAMA May 2013Main inference: No harm by early PN (in contrast to EPaNIC)

What if you cant provide adequate nutrition enterally?

to TPN or not to TPN,that is the question!

Case by case decisionMaximize EN delivery prior to initiating PNUse early in high risk cases

YESAt 72 hrs>80% of Goal Calories?Anticipated Long Stay?NoMaximize EN with motility agents and small bowel feedingNoYESTolerating EN at 96 hrs?High Risk?Carry on!Supplemental PN?No problem

ICU patientsBMI 35Stratified by:SiteBMIMed vs Surg

Muscle Outcome Assessments in TOP UPMeasures of muscle mass and functionmitochondrial complex I activityUS of femoral quad (baseline and follow up CTs when available) Hand grip strength6 min walk testSF 36 (RP and PCS)

Reliability of US measure of Quad Muscle Layer Thickness 46 pairs of within operator measurements with an ICC of .98 73 pairs of operator 1 to operator 2 measurements with an ICC of .94. There was a small but statistically significant difference between the operator 1 and 2 results Mean (operator 1-2) (95% CI) = -0.061 cm (-0.100 to -0.022), p= 0.0028.

Lancet 2009;273:

In ConclusionHealth Care Associate Malnutrition is rampantNot all ICU patients are the same in terms of riskIatrogenic underfeeding is harmful in some ICU patients or some will benefit more from aggressive feeding (avoiding protein/calorie debt)BMI and/or NUTRIC Score is one way to quantify that riskNeed to do something to reduce iatrogenic malnutrition in your ICU!Audit your practice first!PEP uP protocol in allSelective use of small bowel feeds then sPN in high risk patients

Questions?

Add data from iatrogenic malnutrition slides*****Data evaluating the effect of n-3 FFAs on clinical outcomes is relatively sparse, and in this study, is confounded by the fact that they combined fish oils with antioxidants. ****glucose absorption (using 3-OMG as a marker; 3-OMG absorbed via same transporters as glucose, but renally excreted. Acccordingly, this OVERESTIMATES glucose absorption in the critically ill.

*Remove the 1/3-2/3 data**Need picture of malnourshed child******

Optimzing Nutrition Delivery in ICU

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