5/30/2014 Disclosures NONE Nutrition in the ICU Lee-lynn Chen - PDF document

5/30/2014 Disclosures • NONE Nutrition in the ICU Lee-lynn Chen May 30, 2014 Objectives Health Care Associated Malnutrition • Define health care associated malnutrition • Occurs in a health care facility • Review evidence related to optimal nutrition • Nutritional deficiencies that are iatrogenic • List strategies to improve nutritional adequacy • Subsequent physiological derangement and/or in the ICU setting organ dysfunction • Caveat – – Early and adequate nutrition can modulate the underlying disease process and improve patient outcomes 1

5/30/2014 Scope of Issue NUTRIC Variables • Incidence of malnutrition ranges 25-75% • Malnutrition contributes to morbidity/mortality • Nutritional status declines with length of stay • Early identification and intervention can lead to cost-effect and beneficial outcomes Relationship between nutritional intake and mortality NUTRIC Scoring System 2

5/30/2014 Metabolic Response to Stress Hormonal Response • Glucagon • Nutrition supplies substrate for metabolic needs • Acute critical illness – Stimulates gluconeogenesis – Catabolism exceeds anabolism • Cortisol – Fat mobilization is impaired – Carbohydrates are preferred fuel source – Increases net protein catabolism – Goal is to mitigate muscle protein breakdown • Catecholamines • Hormones – Glucose intolerance / insulin resistance • Protein Messengers/Cytokines Overall Metabolic Effect on Stress Role of Cytokines Response • TNF, IL-1, IL-6 • Increased energy expenditure • Weight loss – Fever, hypotension, inflammation • Anorexia – Accelerate skeletal muscle proteolysis • Increased Urinary Nitrogen Losses – Increase metabolic rate – 20-30 grams nitrogen / day – Stimulate & release acute phase reactants • Profound reduction in lean body mass ( CRP, ferritin, ceruloplasmin ) – Depress hepatic protein synthesis (albumin, pre- albumin, transferrin) 3

5/30/2014 Importance of Appropriate Nutrition Goals of Nutrition Therapy • Reduce infectious complications • Well-balanced fuel mix – Maintain immunocompetence – 30% fat, 20% protein, 50% carbohydrate – Enhance wound healing process • Maintain lean body mass – Prevent bacterial translocation • Provide substrates for tissue repair • Decrease length of stay & healthcare cost • Support hepatic protein synthesis • Decrease mortality •  morbidity and mortality • Optimize outcomes (cost and length of stay) Who should not be fed? Feeding Patients on Vasopressors • Non-functioning GI tract • Controversial • Shock Liver • MAP > 60 • Hemodynamic instability • Shock - induced gastroparesis may limit effectiveness of gastric feeding • Aggressive therapy not warranted • Evidence supports feasibility of EN • ? Enteral administration of glutamine in setting of gut hypoperfusion 4

5/30/2014 ICU patients on pressors and MV Timing of Feeding • Timing significantly affects degree to which GI integrity protected or maintained • Bowel sounds should not be used to indicate feasiblity of enteral feeding • Numerous studies comparing early (within 24- 36 hours) vs. delayed (>48 hours) feeding showing positive clinical outcomes DiGiovine et al. AJCC 2010 Calculations Protein • Anthropometrics • RDA=.8 gm pro / Kg ideal body weight (IBW) – Usual body weight versus ideal body weight • Critical illness: 1.5-2.0 gm / Kg – 25-40 Kcal/kg • Moderate protein provision with ARF – Predictive equations for resting energy expenditure – No dialysis (.8-1.2 gm / Kg IBW) (i.e. Harris-Benedict Equation) – ARF/CRF(hemodialysis)=1.2-1.5 gm/Kg • Provide greater protein with CRRT • Other adjustments – CAVHD/CVVHD=1.6-1.8 gm /Kg – Multiply REE by stress factors • Protein restriction with liver failure • Elective Surgery 1.2 – Moderate restriction 1.0-1.2 gm / kg • Sepsis 1.2 – 1.4 – No major benefit of limiting protein intake • Burns 1.8 – 2.5 – Low protein diet did not have consequence on liver function or ammonia levels 5

5/30/2014 Assessment Pre-Albumin • Short half-life; small protein pool • Normal protein levels – Albumin (3.5-5 gm/dL) • Sensitive indicator of refeeding – Pre-albumin (20-40 mg/dL) • Not greatly affected by fluid shifts – Transferrin (200-400 mg/dL) •  in acute stress or infection • Trend CRP & Prealbumin Effectiveness of Therapy Critical Care Nutrition Guidelines 2013 • Serum visceral proteins (track • The Canadian Critical Care/ASPEN Guidelines • Reviewed 120 new RCT trend) • Updated recommendations – Albumin, prealbumin, CRP • Nitrogen balance studies • Indirect calorimetry studies 6

5/30/2014 Trophic Feeding Targets • Is there a minimum feeding rate needed? • Caloric goals • Maybe in animal studies • Protein goals • No definitive human studies • PEP UP study demonstrated decreased mortality in patients who were fed with more • Likely need approximately 60% of goal feedings calories and more protein to obtain desired effect • New initiatives to target 24 hour totals • Recent study showing no worse outcome – Targeting volume based feeding protocol now • Recommendations are to avoid trophic feeding as the initial strategy • More information to come Enteral vs Parenteral Route Basic guidelines • Enteral feeding preferred over parenteral • EN superior to PN nutrition • Start EN early within 24-48 hours –  infectious complications • Indirect calorimetry vs predictive equations – – Maintenance of more “ physiologic ” state of the insufficient data GI tract • Consider polymeric formulas – Reduce or contain stress response • Prokinetic agents (metoclopramide) may be – Nitrogen sparing &  weight loss helpful and tolerating higher residual volumes – Higher visceral protein levels • HOB elevated to 45 degrees when possible – Less expensive 7

5/30/2014 Gastric vs Small Bowel Feedings Small bowel feedings • Best method of delivery remains controversial • Recommend small bowel feedings when feasible • Several studies suggesting gastric feedings • Consider for patients at high risk for intolerance safe in ICU patients to EN (on inotropes or sedative, high NG tube • Several studies showing safer to administer drainage or nursed in the supine position) enteral feeds past the pylorus • Most recent studies show no significant difference in aspiration but small bowel feedings provided more nutrient intake Infectious Complications of Parenteral PN Nutrition • Increase in hyperglycemia • Strongly recommend against the use of PN and high IV glucose • Increased permeability of GI mucosa to bacteria • Should only be started after all enteral options and enteral toxins have been exhausted • Reduction in mucosa immunity • Utility of supplementing inadequate enteral nutrition with PN is still in question 8

5/30/2014 Pharmaconutrition Glutamine • Variety of specialized formulas available for • Central to cellular energy, cell proliferation and acid/base regulation isolated organ failure or specific disease processes • May be beneficial • Expensive – Preferred fuel source in enterocytes • Limited data to support impact on patient – Promotes protein synthesis in gut mucosa outcome preclude use – Precursor for glutathione • Standard formulas usually acceptable – Intraluminal gln reverses shock-induced splanchnic vasoconstriction Glutamine Arginine • When PN is prescribed for critically ill patients, • Essential amino acid glutamine should be considered (especially • Precursor for nitric oxide burn and trauma) • Stimulates processes (regulates) • Insufficient evidence supporting IV glutamine – Collagen synthesis supplementation to critically ill patients receiving EN – Glucose clearance • REDOX Study - strongly recommends against – Lymphocyte function glutamine (EN and PN) use in critically ill • Should not be used not be used for critically ill patients with shock and MOF patients (4 level 1 and 22 level 2) 9

5/30/2014 Use of enteral formula with fish oils Selenium borage oils and antioxidants • Essential trace mineral with antioxidant and anti- • Fatty acids converted to eicosanoids during inflammatory effects stress (i.e. pro-inflammatory) – Glutathione • w-3 promote less inflammatory eicosanoids – Iodine • 2 level 1 studies and 5 level 2 studies – Thyroid Metabolism • Considered in ALI and ARDS patients • Decrease mortality – no difference • Potential reduction in pressure ulcer in LOS • Insufficient data to support supplementation • Use of IV/PN selenium alone in critically ill patients supplementation alone or in combination with other antioxidants should be considered in critically ill patients Take Home Messages • Audit your nutrition practice • Standardize Care • Identify Barriers to feeding patients • Improve Nutrition Knowledge QUESTIONS? • Be a Nutrition Champion 10