FEEDING CRITICALLY ILL PATIENTS: DOES AMOUNT OF NUTRITION PROVISION IMPACT MORTALITY? A review by Shira Hirshberg, MS, Dietetic Intern
Response to Critical Illness stress-induced catabolic state systemic response gut barrier function, infection, immune function changes in macronutrient metabolism
The metabolic response • Provides • energy and substrates for wound healing • enhances organ function • Inflammatory cytokines • muscle proteolysis • Loss of lean body mass • Insulin Resistance and stress hyperglycemia
Goal of Nutrition Therapy attenuate Provide early Improve acute phase EN outcomes response • Pts in the ICU often fail to meet kcal prescription • 49-70% of calculated goal
Why patients often fail to meet goals highest risk = longer term critically ill patients most effective strategy is prevention http://www.sciencekids.co.nz/pictures/humanbody/gastrointestinaltract.html, the leanbody.com,
How much to administer? • the optimal amount is still debated 20-25 kcals/kg 50-65% initial & over first 25-30 kcals/kg week during recovery • New studies • Purpose of this review www.mappery.com, www.uniquetravelsblog.blogspot.com
A Hypothetical Case Study Let’s examine a possible future patient and compare how our nutrition provision could impact her care according to the findings of research studies.
Our patient 70 y/o Female 75 kg 150 cm BMI 33.3
Benefit of Approaching Goal Studies that show that achieving goal kcals of at least 50% can improve mortality
Tsai et al Heyland et al Singh et al Harris-Benedict not standardized- 30 kcals/kg (1.4 SF, 1.05 AF) v. will use 30 kcals/ 1.2 g/kg PRO 25-30 kcals/kg kg as example H-B: 1944 kcals 2250 kcals v. 1875-2250 2250 kcals 90 gm PRO kcals, AVG ~2000 kcals <1125 kcals/ <1200 kcals/ <1500 kcals/ day = higher day associated day = risk of hospital with ICU increased risk mortality mortality for mortality Singh, N., Gupta, D., Aggarwal, A. N., Agarwal, R., & Jindal, S. K. (2009). An assessment of nutritional support to critically ill patients and its correlation with outcomes in a respiratory intensive care unit. Respir Care, 54(12), 1688-1696.
Tsai et al Heyland et al Singh et al Harris-Benedict not standardized- 30 kcals/kg (1.4 SF, 1.05 AF) v. will use 30 kcals/ 1.2 g/kg PRO 25-30 kcals/kg kg as example H-B: 1944 kcals 2250 kcals v. 1875-2250 2250 kcals 90 gm PRO kcals, AVG ~2000 kcals <1125 kcals/ <1200 kcals/ <1500 kcals/ day = higher day 2.43x day = risk of hospital greater risk of increased risk mortality ICU mortality for mortality
Tsai et al Heyland et al Singh et al Harris-Benedict not standardized- 30 kcals/kg (1.4 SF, 1.05 AF) v. will use 30 kcals/ 1.2 g/kg PRO 25-30 kcals/kg kg as example H-B: 1944 kcals 2250 kcals v. 1875-2250 2250 kcals 90 gm PRO kcals, AVG ~2000 kcals <1125 kcals/ <1200 kcals/ <1500 kcals/ day = higher day associated day = risk of hospital with ICU increased risk mortality mortality for mortality
Heyland DK, Cahill N, Day AG. Optimal amount of calories for critically ill patients: depends on how you slice the cake! Crit Care Med 2011;39(12):2619-26. doi: 10.1097/CCM.0b013e318226641d.
Strack van Schijndel Alberda et al et al Faisy et al not standardized Harris-Benedict x 30 kcals/kg 1.3 & 1.2 g/kg PRO looked at benefit 1720 kcals & of an additional 2250 kcals 90 gm PRO 1000 kcals daily Additional 1000 1550 kcals & 81 <1050 kcals/ kcals/day would gm PRO = 92% day would not impact her lower chance of predict death because BMI isn’t 28 day mortality after 14 days <25 or >35 b/c female
Strack van Schijndel Alberda et al et al Faisy et al not standardized Harris-Benedict x 30 kcals/kg 1.3 & 1.2 g/kg PRO looked at benefit 1720 kcals & of an additional 2250 kcals 90 gm PRO 1000 kcals daily Additional 1000 1550 kcals & 81 <1050 kcals/ kcals/day gm PRO = 92% day would would not impact lower chance of predict death her because BMI 28 day mortality after 14 days isn’t <25 or >35 b/c female
Hazard Ratios for Women According to energy goal reached and protein goal reached or not Strack van Schijndel, R. J., Weijs, P. J., Koopmans, R. H., Sauerwein, H. P., Beishuizen, A., & Girbes, A. R. (2009). Optimal nutrition during the period of mechanical ventilation decreases mortality in critically ill, long-term acute female patients: a prospective observational cohort study. Crit Care, 13(4), R132. doi: cc7993 [pii]10.1186/cc7993
Strack van Schijndel Alberda et al et al Faisy et al not standardized Harris-Benedict x 30 kcals/kg 1.3 & 1.2 g/kg PRO looked at benefit 1720 kcals & of an additional 2250 kcals 90 gm PRO 1000 kcals daily Additional 1000 1550 kcals & 81 <1050 kcals/ kcals/day would gm PRO = 92% day would not impact her lower chance of predict death because BMI isn’t 28 day mortality after 14 days <25 or >35 b/c female
Indirect Calorimetry mo mortali lity y Autho hor # p pts location lo Kcal g l goals ls reducti reduction on Indirect both goals = calorimetry & 50% decrease Weijs et al 866 Holland 1.2-1.5 g/kg in 28 day protein mortality 352 ICUs in 33 Heyland et al 7,872 varied >2/3 countries
Indirect Calorimetry mo mortali lity y Autho hor # p pts lo location Kcal g l goals ls reducti reduction on Indirect both goals = calorimetry & 50% decrease Weijs et al 866 Holland 1.2-1.5 g/kg in 28 day protein mortality Indirect lower hospital calorimetry = mortality in Singer et al 112 Israel treatment group treatment group 25 kcals/kg= (2086 kcals v. control 1480 kcals)
No Difference in Mortality Other research has not shown an impact of increased nutrition provision on mortality
Doig et al Rice et al Heyland et al (c) assume varied by 25-30 non-protein 23 kcals/kg & 1g/kg institution kcals and 1.2-1.6 g/ PRO kg PRO AVG pt: 1625 1725 kcals and 75 guideline vs. kcals = goal gm PRO control groups no difference in 725 kcals v. 1725 1241 kcals would mortality between kcals would not not improve providing 400 change outcome mortality more and 1300 kcals since her BMI is than 1065 kcals in first 5 days >25 and <35
Doig et al Rice et al Heyland et al (c) assume varied by 25-30 non-protein 23 kcals/kg & 1g/kg institution kcals and 1.2-1.6 g/ PRO kg PRO AVG pt: 1625 1725 kcals and 75 guideline vs. kcals = goal gm PRO control groups no difference in 725 kcals v. 1725 1241 kcals would mortality between kcals would not not improve providing 400 change outcome mortality more and 1300 kcals since her BMI is than 1065 kcals in first 5 days >25 and <35
Doig et al Rice et al Heyland et al (c) assume varied by 25-30 non-protein 23 kcals/kg & 1g/kg institution kcals and 1.2-1.6 g/ PRO kg PRO AVG pt: 1625 1725 kcals and 75 guideline vs. kcals = goal gm PRO control groups no difference in 725 kcals v. 1725 1241 kcals would mortality between kcals would not not improve providing 400 change outcome mortality more and 1300 kcals since her BMI is than 1065 kcals in first 5 days >25 and <35
Doig et al Rice et al Heyland et al (c) assume varied by 25-30 non-protein 23 kcals/kg & 1g/kg institution kcals and 1.2-1.6 g/ PRO kg PRO AVG pt: 1625 1725 kcals and 75 guideline vs. kcals = goal gm PRO control groups no difference in 725 kcals v. 1725 1241 kcals would mortality between kcals would not not improve providing 400 change outcome mortality more and 1300 kcals since her BMI is than 1065 kcals in first 5 days >25 and <35
Jain et al Dvir et al varied by site, use 30 indirect calorimetry kcals/kg for example 1972 kcals AVG 2250 kcals goal going from Having only 1512 kcals daily (460 kcal 965 kcals to 1125 AVG deficit) was kcals would not not related to impact risk of28- mortality day mortality
The Detriment of Over-feeding This controversy arose from research showing that achieving nutrition support closer to goal kcals was associated with mortality
Krishnan et al Arabi et al 25 kcals/kg or 27.5 Harris-Benedict + kcals/kg with SIRS appropriate stress factor 1875 kcals 1944 kcals <620 or >1240 >1250 kcals kcals = lower would be chance of hospital associated with > discharge alive hospital mortality
Methodological Differences Results may appear discordant Difference in methodology Demonstrated difference with analysis of largest critical care nutrition database in the world If researchers fail to exclude certain patients quickly progress to oral feeding do not adjust for number of days before oral intake begins short-term pts with good outcomes are confounders
Methodological Differences Analyses suggest relationship between caloric intake and risk of mortality longer length of stay = more time to reach goal Exclude pts progressing to oral intake Base 12-day adequacy average only on days before oral intake progression Increased caloric intake associated with lower mortality
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