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Optimizing Nutrition Delivery in the Critically Ill

Optimizing Nutrition Delivery in the Critically Ill. Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada. Critical Care Nutrition. The right nutrient/nutritional strategy The right timing The right patient

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Optimizing Nutrition Delivery in the Critically Ill

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  1. Optimizing Nutrition Delivery in the Critically Ill Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada

  2. Critical Care Nutrition The right nutrient/nutritional strategy The right timing The right patient The right intensity (dose/duration) With the right outcome! www.criticalcarenutrition.com

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

  4. Underlying Pathophysiologyof Critical Illness Loss of Gut Epithelial Integrity Bacteria DISTAL ORGAN INJURY (Lung, Kidneys) INTESTINAL EPITHELIUM lymphocytes SIRS via thoracic duct

  5. Disuse Causes Loss of Functional and Stuctural IntegrityIncreased Gut Permeability Characteristics : Time dependent Correlation to disease severity Consequences: Risk of infection Risk of MOFS

  6. Feeding Supports Gastrointestinal Structure and Function • Maintenance of gut barrier function • Increased secretion of mucus, bile, IgA • Maintenance of peristalsis and blood flow • Attenuates oxidative stress and inflammation • Supports GALT • Improves glucose absorption Alverdy (CCM 2003;31:598) Kotzampassi Mol Nutr Food Research 2009 Nguyen CCM 2011

  7. Effect of Early Enteral Feeding on the Outcome of Critically ill Mechanically Ventilated Medical Patients • Retrospective analysis of multiinstitutional database • 4049 patients requiring mech vent > 2 days • Categorized as “Early EN” if rec’d feeds within 48 hours of admission (n=2537, 63%) P=0.007 P=0.02 P=0.0005 Artinian Chest 2006:129;960

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

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

  10. Optimal Amount of Protein and Calories for Critically Ill Patients

  11. Increasing Calorie Debt Associated with worse Outcomes Adequacy of EN Caloric Debt •  Caloric debt associated with: •  Longer ICU stay •  Days on mechanical ventilation •  Complications •  Mortality Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006

  12. Point prevalence survey of nutrition practices in ICU’s around the world conducted Jan. 27, 2007 • Enrolled 2772 patients from 158 ICU’s over 5 continents • Included ventilated adult patients who remained in ICU >72 hours

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

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

  15. Mechancially Vent’d patients >7days (average ICU LOS 28 days) Faisy BJN 2009;101:1079

  16. 113 select ICU patients with sepsis or burns • On average, receiving 1900 kcal/day and 84 grams of protein • No significant relationship with energy intake but…… Clinical Nutrition 2012

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

  18. 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 audit • Setting: 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

  19. A. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are included as zero calories* B. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.* C. In ICU for at least 4 days before permanent progression to exclusive oral feeding. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.* Association between 12 day average caloric adequacy and 60 day hospital mortality (Comparing patients rec’d >2/3 to those who rec’d <1/3) D. In ICU at least 12 days prior to permanent progression to exclusive oral feeding* *Adjusted for evaluable days and covariates,covariates include region (Canada, Australia and New Zealand, USA, Europe and South Africa, Latin America, Asia), admission category (medical, surgical), APACHE II score, age, gender and BMI.

  20. Association Between 12-day Caloric Adequacy and 60-Day Hospital Mortality Optimal amount= 80-85% Heyland CCM 2011

  21. RCT Level of Evidence that More EN= Improved Outcomes • RCTs of aggressive feeding protocols • Results in better protein-energy intake • Associated with reduced complications and improved survival • Taylor et al Crit Care Med 1999; Martin CMAJ 2004 • Meta-analysis of Early vs Delayed EN • Reduced infections: RR 0.76 (.59,0.98),p=0.04 • Reduced Mortality: RR 0.68 (0.46, 1.01) p=0.06 • www.criticalcarenutrition.com

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

  23. Rice et al. JAMA 2012;307

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

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

  26. Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure • Average age 52 • Few comorbidities • Average BMI 29-30 • All 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!

  27. ICU patients are not all created equal…should we expect the impact of nutrition therapy to be the same across all patients?

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

  29. A Conceptual Model for Nutrition Risk Assessment in the Critically Ill • Acute • Reduced po intake • pre ICU hospital stay • Acute • IL-6 • CRP • PCT • Chronic • Recent weight loss • BMI? • Chronic • Comorbid illness Starvation Nutrition Status micronutrient levels - immune markers - muscle mass Inflammation

  30. 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 patients • Historical po intake and weight loss only available in 171 patients • Outcome: 28 day vent-free days and mortality Heyland Critical Care 2011, 15:R28

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

  32. 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.

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

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

  35. 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

  36. Who might benefit the most from nutrition therapy? • High NUTRIC Score? • Clinical • BMI • Projected long length of stay • Others?

  37. Do we have a problem?

  38. Preliminary Results of INS 2011Overall Performance: Kcals 84% 56% 15% N=211

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

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

  41. “Use of a feeding protocol that incorporates motility agents and small bowel feeding tubes should be considered” www.criticalcarenutrition.com

  42. Use of Nurse-directed Feeding Protocols Start feeds at 25 ml/hr • < 250 ml • advance rate by 25 ml • reassess q 4h • > 250 ml • hold feeds • add motility agent • reassess q 4h Check Residuals q4h “Should be considered as a strategy to optimize delivery of enteral nutrition in critically ill adult patients.” 2009 Canadian CPGs www.criticalcarenutrition.com

  43. The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery:Results of a multicenter observational study • Time to start EN from ICU admission: • 41.2 in protocolized sites vs 57.1 hours in those without a protocol • Patients rec’ing motility agents: • 61.3% in protocolized sites vs 49.0% in those without P<0.05 P<0.05 Heyland JPEN Nov 2010

  44. Can we do better? The same thinking that got you into this mess won’t get you out of it!

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