5/9/2015 NO DISCLOSURES Annette Stralovich-Romani, RD, CNSC Adult Critical Care Nutritionist UCSF Medical Center Incidence & consequences of malnutrition On hospital admission: 30-50% On ICU admission: 50-55% Underfeeding in the ICU ◦ Causes/ consequences Malnutrition contributes to: ◦ Increased morbidity & mortality Nutrition intervention ◦ Decreased function & quality of life ◦ What is the optimal amount of calories/protein in the ◦ Increased frequency and length of hospital stay critically ill patient? ◦ Higher healthcare cost Strategies for improving enteral nutrient delivery Nutritional status declines with length of stay Early identification & intervention can lead to cost- effective and beneficial outcomes 1
5/9/2015 Preexisting malnutrition / nutritional compromise Prevalence: 40-50% of prescribed EN received in Admission to hospital / ICU the first 2 weeks after ICU admission Stress / Inflammation Causes: ◦ Hormonal Response: Catecholamines, glucagon, cortisol ◦ Humeral Response: Cytokines (TNF, IL-1, IL-6) ◦ GI Symptoms Hypermetabolism (increased energy expenditure) ◦ Underestimating nutrient needs (energy/protein) Accelerated proteolysis (LBM breakdown) ◦ Feeding tube displacement / replacement Insulin resistance ◦ Prematurely discontinuing EN Nosocomial infections ◦ Delayed administration ◦ VAP, C.Difficile, Central line infection ◦ Low volume TF infusion (trophic feeding) ◦ Interruptions in TF administration (avoidable vs. UNDERFEEDING unavoidable) Prospective, observational study Unavoidable Avoidable Characterize EN interruptions (avoidable vs. unavoidable) & • IR or surgical procedures 26% • PEG placement ✓ determine impact on caloric deficits between patients (if controlled airway & patient • IR or surgical procedures in supine position ) ◦ Group 1: > 1 EN interruption (if no controlled airway or ◦ Group 2: No interruptions • GRV < 500 mL patient not in supine position 74% 94 SICU patients (mean age 63yo, 71% male) • GI bleed • Imaging studies ( when radiologist did not request patient to be fasted) ✓ Gastric feeding • Reintubation/extubation ✓ TF held for GRV > 500mL • GRV > 500mL • Tracheostomy ✓ Primary outcome: percentage of unavoidable interruptions • GI surgery Secondary outcomes: 30-day mortality, surgical ICU LOS, hospital LOS, VFDs and total complications per patient Transient interruptions (lasting ten minutes or less) were not considered. Yeh, DD et al. JPEN. 2015 2
5/9/2015 Early Enteral Nutrition(24-48 hours) RESULTS ◦ Group 1 compared to Group 2: Accumulated double caloric deficit Gastric Feeding Additional 1.5 days in ICU, 8 days longer in hospital • No difference in aspiration risk between gastric vs. small NO statistical difference in 30-day VFDs, bowel feeding in-hospital mortality, 30-day mortality 30 day • GRV threshold (250-500 mL) BOTTOM LINE: Focus should be on how Aim for Goal Volume Feeding to MAXIMIZE nutrient delivery rather than trying to eradicate interruptions. Canadian Critical Care Clinical Yeh, DD et al. JPEN. 2015 Nutrition Practice Guidelines 2013 www.criticalcarenutrition.com. Optimal amount of energy and protein required to reduce morbidity and mortality is controversial Few observational studies have shown permissive underfeeding resulted in improved clinical outcomes compared to full feeding Several large observational studies have shown a cumulative energy deficit or caloric debt is associated with adverse clinical outcomes 3
5/9/2015 3 prospective randomized studies (EDEN, Rice, Arabi) Compared trophic to full feeding SSC (Surviving Sepsis Campaign) recommends Results: avoiding mandatory full caloric feeding and using low ◦ No difference in long-term outcome (28 day mortality) between dose EN the first week in the ICU two feeding strategies ◦ Reported more GI complications with the full EN feeding strategy ◦ Trend toward improved physical function in the full fed group The 2013 Canadian Critical Care Nutrition Practice Guidelines (based on multiple randomized trials and Recommend low dose EN for first week of ICU stay large scale observational studies) recommend: Key Points: Optimizing the dose of EN ◦ Relatively young (mean age = 52) No effect in young, healthy, NOT use intentional underfeeding in those first 5 ◦ Few co-morbidities overweight patients who have short stays! ◦ Well-nourished (BMI 29-30) ICU days (all patients) ◦ Average duration of study intervention 5 days . Prospective, multicenter observational study Determine: ◦ Effect of energy & protein intake on outcome ◦ Whether patients with pre-existing malnutrition or lack of nutritional reserve benefit more from aggressive EN provision 2772 patients (158 ICU’s over 5 continents) Included ventilated patients in ICU >72 hours BMI used as marker of nutritional status prior to admission Average daily nutrient intake: 1034 kcal; 47gm protein 4
5/9/2015 Relationship of Caloric Intake, 60 day Mortality and BMI 60 BMI All Patients 50 < 20 Secondary analysis of large nutrition database 20-25 40 25-30 2270 mechanically ventilated patients with sepsis and / Mortality (%) 30-35 or pneumonia 35-40 ICU stay > 3 days receiving EN ONLY 30 >40 Older (mean age 62) ; low to normal BMI Nutrition intervention 11 days 20 Average daily nutrient intake: 1057 kcal; 49gm protein 10 Results: ◦ Increasing 1000 kcal & 30 gm protein daily more VFDs and lower mortality in septic patients 0 0 500 1000 1500 2000 Calories Delivered Elke, G et al. Crit Care 2014 Objective: To examine the relationship between the amount of prescribed calories received and 60-day hospital mortality Prospective, multi-institutional audit 352 ICUs (33 countries) 7872 mechanically ventilated patients (> 96 hrs in ICU) Heyland et al CCM, 2011 5
5/9/2015 RESULTS: Optimal target = 80-85% of prescribed amount (best clinical outcome) No additional benefit attaining 100% prescribed amount Conclusions: ◦ Regardless of BMI, practice of permissive underfeeding is not advised (including the obese critically ill) ◦ Recommended 80-85% target should be feasible goal for ALL ICUs world wide Heyland DK, et al. Crit Care Med . 2011 . Protein-Energy Provision via the Enteral Route in Critically Ill Patients (PEP up ) 1 • Designed by Heyland et al to “make up” for lost EN infusion time 1 • Shift from “traditional” rate -based to volume-based feeding approach • RN to adjust hourly rate to reach goal EN volume • Trial included 18 mixed med/surg ICUs (80-85% MICU) • Implementation of protocol resulted in increased calorie & protein delivery Feed Early Enteral Diet Adequately for Maximum Effect (FEED ME) 2 • Designed by Taylor et al 2 • Surgical / Trauma ICU patients • Modified version of PEP up • Protocol resulted in increased delivery of EN volume, calories & protein • No significant increases in GRV, emesis and only minimal increase in diarrhea 1. Heyland et al. CCM 2013 2. Taylor et al. Nutr Clin Prac 2014 6
5/9/2015 Pilot in Neuro ICUs 28 beds Collect baseline data % prescribed amount received, GRVs, interruptions (number, time held, reason) Enteral Product (up to RD discretion) “Ramp Up” to goal infusion rate 24-h clock (07:00-07:00) Makeup rate calculation: (FEED ME protocol) GRV threshold: 350 mL No routine use of promotility agents 120 mL / hr (maximum hourly infusion rate) NO bolus feeding Post implementation data collection identify barriers Taylor B et al, Nutri Clin Prac 2014 Increased risk for nutrition depletion due to acute illness Early nutrition intervention improves outcomes Intentional underfeeding is not recommended Maximize nutrient delivery (80-85% goal) but further randomized trials needed Consider 24 hour volume based feeding strategy Teamwork is key to successful nutrition delivery THANK YOU! 7
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