FEEDING CRITICALLY ILL PATIENTS: DOES AMOUNT OF NUTRITION - - PowerPoint PPT Presentation

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

• Pts in the ICU often fail to meet kcal prescription
• 49-70% of calculated goal

attenuate acute phase response Provide early EN Improve

• utcomes

Why patients often fail to meet goals

http://www.sciencekids.co.nz/pictures/humanbody/gastrointestinaltract.html, the leanbody.com,

 highest risk = longer term critically ill patients  most effective strategy is prevention

How much to administer?

• the optimal amount is still debated
• New studies
• Purpose of this review

www.mappery.com, www.uniquetravelsblog.blogspot.com

50-65%

• ver first

week 20-25 kcals/kg initial & 25-30 kcals/kg during recovery

Let’s examine a possible future patient and compare how our nutrition provision could impact her care according to the findings of research studies.

A Hypothetical Case Study

Our patient

70 y/o Female 75 kg 150 cm BMI 33.3

Studies that show that achieving goal kcals of at least 50% can improve mortality

Benefit of Approaching Goal

Singh et al 30 kcals/kg 1.2 g/kg PRO

2250 kcals 90 gm PRO <1125 kcals/ day = higher risk of hospital mortality

Tsai et al Harris-Benedict (1.4 SF, 1.05 AF) v. 25-30 kcals/kg

H-B: 1944 kcals

• v. 1875-2250

kcals, AVG ~2000 kcals <1200 kcals/ day associated with ICU mortality

Heyland et al not standardized- will use 30 kcals/ kg as example

2250 kcals <1500 kcals/ day = increased risk 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.

Singh et al 30 kcals/kg 1.2 g/kg PRO

2250 kcals 90 gm PRO <1125 kcals/ day = higher risk of hospital mortality

Tsai et al Harris-Benedict (1.4 SF, 1.05 AF) v. 25-30 kcals/kg

H-B: 1944 kcals

• v. 1875-2250

kcals, AVG ~2000 kcals <1200 kcals/ day 2.43x greater risk of ICU mortality

Heyland et al not standardized- will use 30 kcals/ kg as example

2250 kcals <1500 kcals/ day = increased risk for mortality

Singh et al 30 kcals/kg 1.2 g/kg PRO

2250 kcals 90 gm PRO <1125 kcals/ day = higher risk of hospital mortality

Tsai et al Harris-Benedict (1.4 SF, 1.05 AF) v. 25-30 kcals/kg

H-B: 1944 kcals

• v. 1875-2250

kcals, AVG ~2000 kcals <1200 kcals/ day associated with ICU mortality

Heyland et al not standardized- will use 30 kcals/ kg as example

2250 kcals <1500 kcals/ day = increased risk 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.

Alberda et al not standardized

looked at benefit

• f an additional

1000 kcals daily Additional 1000 kcals/day would not impact her because BMI isn’t <25 or >35

Strack van Schijndel et al Harris-Benedict x 1.3 & 1.2 g/kg PRO

1720 kcals & 90 gm PRO 1550 kcals & 81 gm PRO = 92% lower chance of 28 day mortality b/c female

Faisy et al 30 kcals/kg

2250 kcals <1050 kcals/ day would predict death after 14 days

Alberda et al not standardized

looked at benefit

• f an additional

1000 kcals daily Additional 1000 kcals/day would not impact her because BMI isn’t <25 or >35

Strack van Schijndel et al Harris-Benedict x 1.3 & 1.2 g/kg PRO

1720 kcals & 90 gm PRO 1550 kcals & 81 gm PRO = 92% lower chance of 28 day mortality b/c female

Faisy et al 30 kcals/kg

2250 kcals <1050 kcals/ day would predict death after 14 days

Hazard Ratios for Women

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

According to energy goal reached and protein goal reached or not

Alberda et al not standardized

looked at benefit

• f an additional

1000 kcals daily Additional 1000 kcals/day would not impact her because BMI isn’t <25 or >35

Strack van Schijndel et al Harris-Benedict x 1.3 & 1.2 g/kg PRO

1720 kcals & 90 gm PRO 1550 kcals & 81 gm PRO = 92% lower chance of 28 day mortality b/c female

Faisy et al 30 kcals/kg

2250 kcals <1050 kcals/ day would predict death after 14 days

Indirect Calorimetry

Autho hor # p pts lo location Kcal g l goals ls mo mortali lity y reducti reduction

• n

Weijs et al 866 Holland Indirect calorimetry & 1.2-1.5 g/kg protein both goals = 50% decrease in 28 day mortality Heyland et al 7,872 352 ICUs in 33 countries varied >2/3

Indirect Calorimetry

Autho hor # p pts lo location Kcal g l goals ls mo mortali lity y reducti reduction

• n

Weijs et al 866 Holland Indirect calorimetry & 1.2-1.5 g/kg protein both goals = 50% decrease in 28 day mortality Singer et al 112 Israel Indirect calorimetry = treatment group 25 kcals/kg= control lower hospital mortality in treatment group (2086 kcals v. 1480 kcals)

Other research has not shown an impact of increased nutrition provision on mortality

No Difference in Mortality

Rice et al 25-30 non-protein kcals and 1.2-1.6 g/ kg PRO

AVG pt: 1625 kcals = goal no difference in mortality between providing 400 and 1300 kcals in first 5 days

Heyland et al (c) 23 kcals/kg & 1g/kg PRO

1725 kcals and 75 gm PRO 725 kcals v. 1725 kcals would not change outcome since her BMI is >25 and <35

Doig et al assume varied by institution

guideline vs. control groups 1241 kcals would not improve mortality more than 1065 kcals

Rice et al 25-30 non-protein kcals and 1.2-1.6 g/ kg PRO

AVG pt: 1625 kcals = goal no difference in mortality between providing 400 and 1300 kcals in first 5 days

Heyland et al (c) 23 kcals/kg & 1g/kg PRO

1725 kcals and 75 gm PRO 725 kcals v. 1725 kcals would not change outcome since her BMI is >25 and <35

Doig et al assume varied by institution

guideline vs. control groups 1241 kcals would not improve mortality more than 1065 kcals

Rice et al 25-30 non-protein kcals and 1.2-1.6 g/ kg PRO

AVG pt: 1625 kcals = goal no difference in mortality between providing 400 and 1300 kcals in first 5 days

Heyland et al (c) 23 kcals/kg & 1g/kg PRO

1725 kcals and 75 gm PRO 725 kcals v. 1725 kcals would not change outcome since her BMI is >25 and <35

Doig et al assume varied by institution

guideline vs. control groups 1241 kcals would not improve mortality more than 1065 kcals

Rice et al 25-30 non-protein kcals and 1.2-1.6 g/ kg PRO

AVG pt: 1625 kcals = goal no difference in mortality between providing 400 and 1300 kcals in first 5 days

Heyland et al (c) 23 kcals/kg & 1g/kg PRO

1725 kcals and 75 gm PRO 725 kcals v. 1725 kcals would not change outcome since her BMI is >25 and <35

Doig et al assume varied by institution

guideline vs. control groups 1241 kcals would not improve mortality more than 1065 kcals

Jain et al varied by site, use 30 kcals/kg for example

2250 kcals going from 965 kcals to 1125 kcals would not impact risk of28- day mortality

Dvir et al indirect calorimetry

1972 kcals AVG goal Having only 1512 kcals daily (460 kcal AVG deficit) was not related to mortality

This controversy arose from research showing that achieving nutrition support closer to goal kcals was associated with mortality

The Detriment of Over-feeding

Krishnan et al 25 kcals/kg or 27.5 kcals/kg with SIRS

1875 kcals <620 or >1240 kcals = lower chance of hospital discharge alive

Arabi et al Harris-Benedict + appropriate stress factor

1944 kcals >1250 kcals would be associated with > 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

Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care 2011;15(6):R268. doi: cc10546 [pii]10.1186/ cc10546.

Limitations of the Current Evidence

EN v. PN

• manner in

which kcals were provided varies

• risks and

benefits must be weighed Prescriptions

• How nutrition

prescriptions are calculated varies greatly Protein

• Provision

varies greatly

• Importance
• f

combination

• f kcals and

protein shown

Analysis

 Feeding patients 60-90% of goal has a mortality benefit  Shown by prospective or retrospective studies  Dearth of randomized trials  1 of 3 show benefit  Optimal feeding is difficult

Conclusions

 ICU-based dietitian and ongoing use of nutrition protocol  80-90% of kcals is achievable  Future research

 energy and protein provision  maintain tight glucose control

 BWH should attempt to provide at least 60% of estimated

kcal needs, though with a goal of 80-90%

References



Alberda, C., Gramlich, L., Jones, N., Jeejeebhoy, K., Day, A. G., Dhaliwal, R. (2009). The relationship between nutritional intake and clinical

• utcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med, 35(10), 1728-1737. doi: 10.1007/

s00134-009-1567-4



Arabi,

• Y. M., Haddad, S. H., Tamim, H. M., Rishu, A. H., Sakkijha, M. H., Kahoul, S. H. (2010). Near-target caloric intake in critically ill medical-

surgical patients is associated with adverse outcomes. JPEN J Parenter Enteral Nutr, 34(3), 280-288. doi: 34/3/280 [pii]10.1177/0148607109353439



Biolo, G., Grimble, G., Preiser, J. C., Leverve, X., Jolliet, P ., Planas, M. (2002). Position paper of the ESICM Working Group on Nutrition and

• Metabolism. Metabolic basis of nutrition in intensive care unit patients: ten critical questions. Intensive Care Med, 28(11), 1512-1520. doi: 10.1007/

s00134-002-1512-2



Cahill, N. E., Dhaliwal, R., Day, A. G., Jiang, X., & Heyland, D. K. (2010). Nutrition therapy in the critical care setting: what is "best achievable" practice? An international multicenter observational study. Crit Care Med, 38(2), 395-401. doi: 10.1097/CCM.0b013e3181c0263d



Doig, G. S., Simpson, F., Finfer, S., Delaney, A., Davies, A. R., Mitchell, I. (2008). Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA, 300(23), 2731-2741. doi: 300/23/2731 [pii]10.1001/jama.2008.826



Dvir, D., Cohen, J., & Singer, P . (2006). Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr, 25 (1), 37-44. doi: S0261-5614(05)00187-1 [pii]10.1016/j.clnu.2005.10.010



Faisy, C., Lerolle, N., Dachraoui, F., Savard, J. F., Abboud, I., Tadie, J. M. (2009). Impact of energy deficit calculated by a predictive method on

• utcome in medical patients requiring prolonged acute mechanical ventilation. Br J Nutr, 101(7), 1079-1087. doi: S0007114508055669 [pii]

10.1017/S0007114508055669



Heyland, D. K., Cahill, N., & Day, A. G. (2011a). Optimal amount of calories for critically ill patients: depends on how you slice the cake! Crit Care Med, 39(12), 2619-2626. doi: 10.1097/CCM.0b013e318226641d



Heyland, D. K., Dhaliwal, R., Jiang, X., & Day, A. G. (2011b). Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care, 15(6), R268. doi: cc10546 [pii]10.1186/cc10546



Heyland, D. K., Stephens, K. E., Day, A. G., & McClave, S. A. (2011c). The success of enteral nutrition and ICU-acquired infections: a multicenter

• bservational study. Clin Nutr, 30(2), 148-155. doi: S0261-5614(10)00184-6 [pii]10.1016/j.clnu.2010.09.011



Jain, M. K., Heyland, D., Dhaliwal, R., Day, A. G., Drover, J., Keefe, L. (2006). Dissemination of the Canadian clinical practice guidelines for nutrition support: results of a cluster randomized controlled trial. Crit Care Med, 34(9), 2362-2369. doi: 10.1097/01.CCM.0000234044.91893.9C



Kreymann, K. G., Berger, M. M., Deutz, N. E., Hiesmayr, M., Jolliet, P ., Kazandjiev, G. (2006). ESPEN Guidelines on Enteral Nutrition: Intensive

• care. Clin Nutr, 25(2), 210-223. doi: S0261-5614(06)00041-0 [pii] 10.1016/j.clnu.2006.01.021

References



Krishnan, J. A., Parce, P . B., Martinez, A., Diette, G. B., & Brower, R. G. (2003). Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes. Chest, 124(1), 297-305.



McClave, S. A., Martindale, R. G., Vanek, V . W ., McCarthy, M., Roberts, P ., Taylor, B. (2009). Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P .E.N.). JPEN J Parenter Enteral Nutr, 33(3), 277-316. doi: 33/3/277 [pii]10.1177/0148607109335234



Rice, T. W ., Wheeler, A. P ., Thompson, B. T., Steingrub, J., Hite, R. D., Moss, M. (2012). Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA, 307(8), 795-803. doi: jama.2012.137 [pii]10.1001/jama.2012.137



Schulman, R. C., & Mechanick, J. I. (2013). Can nutrition support interfere with recovery from acute critical illness? World Rev Nutr Diet, 105, 69-81. doi: 000341272 [pii]10.1159/000341272



Singer, P ., Anbar, R., Cohen, J., Shapiro, H., Shalita-Chesner, M., Lev, S. (2011). The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients. Intensive Care Med, 37(4), 601-609. doi: 10.1007/ s00134-011-2146-z



Singer, P ., Berger, M. M., Van den Berghe, G., Biolo, G., Calder, P ., Forbes, A. (2009). ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr, 28(4), 387-400. doi: S0261-5614(09)00098-3 [pii]10.1016/j.clnu.2009.04.024



Singer, P ., Pichard, C., Heidegger, C. P ., & Wernerman, J. (2010). Considering energy deficit in the intensive care unit. Curr Opin Clin Nutr Metab Care, 13(2), 170-176. doi: 10.1097/MCO.0b013e3283357535



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.



Soguel, L., Revelly, J. P ., Schaller, M. D., Longchamp, C., & Berger, M. M. (2012). Energy deficit and length of hospital stay can be reduced by a two-step quality improvement of nutrition therapy: the intensive care unit dietitian can make the difference. Crit Care Med, 40(2), 412-419. doi: 10.1097/CCM.0b013e31822f0ad7



Stapleton, R. D., Jones, N., & Heyland, D. K. (2007). Feeding critically ill patients: what is the optimal amount of energy? Crit Care Med, 35(9 Suppl), S535-540. doi: 10.1097/01.CCM.0000279204.24648.4400003246-200709001-00017 [pii]



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

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

Tsai, J. R., Chang, W . T., Sheu, C. C., Wu,

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

Weijs, P . J., Stapel, S. N., de Groot, S. D., Driessen, R. H., de Jong, E., Girbes, A. R. (2012). Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study. JPEN J Parenter Enteral Nutr, 36(1), 60-68. doi: 0148607111415109 [pii]10.1177/0148607111415109

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