davies - nutrition in intensive care

Nutrition in Intensive Care

Three contemporaryclinical questions

Andrew Davies

Frankston Hospital & Baxter Healthcare

Nutrition in Intensive Care

Three important questions that might help our patients

Andrew Davies

Frankston Hospital & Baxter Healthcare

The Modern Rationale for Nutrition

Nutrition therapy is important because it improves clinical outcomes

The choice of methodAND

The choice of nutrient matter to our patientsAND

The timing of administration

Nutrition is not just support but a powerful critical care intervention

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Simply

““Feed the Prisoners” Feed the Prisoners” in our ICUsin our ICUs

Optimising Enteral Nutrition

Overall PerformanceThe proportion of prescribed calories received

62%

Suboptimal Nutritional Delivery% patients did not meet overall energy adequacy of 80%

69

Clinical Question Number 1

Should we really try to meet our patient’s nutrition target?

Arguments from the literature

More is better

Arguments from the literature

More is better

Less is better

Arguments from the literature

More is better

Less is better

There’s a sweetspot (and it is <

100%)

Doig G, Simpson F. www.evidencebased.net 2005 and JAMA 2008

Doig G, Simpson F. www.evidencebased.net 2005 and JAMA 2008

Placing nasojejunal feeding tubes

Placing nasojejunal feeding tubes

ARDSnet. JAMA 2012; 307(8):795

NEJM 2015; 372(25):2398

So

Less might be OK (if both are less than 80%)

But what if we actually deliver 100% in one of the arms?

Effect on mortality of full predicted energy (10 trials, 3155 participants)

Random effects analysis: OR 1.02, 95%CI 0.74-1.41

Systematic Review: 80-120% vs < 80% of target

Effect on hospital length of stay of full predicted energy (5 studies, 389 patients)

MD 4.71 days, 95%CI -0.33 - 9.75

Systematic Review: 80-120% vs < 80% of target

Clinical Question Number 1

Should we really try to meet our patient’s nutrition target?

Overall PerformanceThe proportion of prescribed calories received

62%

2014;100:616-625

TARGET Feasibility Study

FRESUBIN 1000

FRESUBIN 2250

Calories, kcal/ml

Carbohydrates, g

Fat, g

Protein, g

Fibre, g

Osmolality mosm/kg H2O

1.0

12.5

2.7

5.5

2.0

360

1.5

18.0

5.8

5.6

1.5

430

2014;100:616-625

Aim to determine if substitution of 1.0 kcal/ml with 1.5kcal/ml EN

delivers more calories when delivered at same rate

Peake S, et al. Am J Clin Nutr 2014;100:616

2014;100:616-625

Mean (SD) kcal/day Mean (SD) kcal/kg IBW/day

Peake S, et al. Am J Clin Nutr 2014;100:616

Daily calorie delivery over first 10 feeding days

2014;100:616-625

Peake S, et al. Am J Clin Nutr 2014;100:616

1.0 kcal/ml 1.5 kcal/ml P value

Volume delivered, ml/day (mean, SD) 1259 (428) 1221 (381) 0.63

Calories delivered, kcal/day (mean, SD) 1259 (428) 1832 (571) < 0.001

Calories delivered, kcal/kg IBW /day (mean, SD) 19.0 (6.0) 27.3 (7.4) < 0.001

Goal CALORIES achieved, (%)* 72 102 < 0.001

46% increase in calorie delivery with 1.5 kcal/ml EN

Peake S, et al. Am J Clin Nutr 2014;100:616

Survival

P = 0.06 log-rank test

The Augmented versus Routine approach to Giving Energy Trial

(TARGET)

FundingNational Health and Medical Research Council

Health Research Council of New Zealand

EndorsementANZICS Clinical Trials Group

Coordinating Centre ANZIC Research Centre, Monash University

Medical Research Institute of NZ

SupportNHMRC Centre for Research Excellence in Nutrition, Adelaide Australia

Fresenius Kabi Deutschland GmbH

4000 patient study in 51 ICUs in ANZ

Aims

Primary

To determine if augmentation of calorie delivery using energy dense EN

in mechanically ventilated patients improves 90-day survival compared to

routine care

Secondary

To determine if augmentation of calorie delivery using energy dense EN

in mechanically ventilated patients improves functional outcomes

compared to routine care

Clinical Question Number 2

Is there a role for supplemental PN in ICU patients?

Overall PerformanceThe proportion of prescribed calories received

62%

PN has now entered a new era

NEJM 2014 Oct 30; 371(18):1673-84. Epub 2014 Oct 1.

JAMA 2013 309 (20): 2130.

JAMA 2013 309 (20): 2130.

So what do we know aboutSupplemental PN?

A subsequent Supplemental PN study:In Australia and NZ

• In a more severely unwell critical care population than EPANIC

• With NICE-SUGAR control (< 10mmol)

• No IV dextrose

• Standard ANZ energy targets

• With an intervention designed to avoid overnutrition

Research Question - wider program

“Does a supplemental PN strategy improve short and longer term clinical outcomes in critically ill patients with at least 1 organ system failure compared to a

standard strategy”

Pilot Study Design

• Study Design– Prospective, concealed, randomized, multi-centre trial – Feasibility study aiming at a program of research

• Sites– 2 in Australia, 4 in New Zealand

• Sample size:– 100 patients

Clinical Question Number 3

Should intensivists be interested in diet and lifestyle

interventions that might reverse heart disease?

Is plant-based nutrition therapeutic?

Lancet 1990; 336:129

Lifestyle program

In patients with 1-3 vessel IHD and EF >25% Low fat vegetarian diet (no caloric restriction) with no animal products except egg white and low fat yoghurt

No caffeine, maximum of 2 units alcohol per day

Moderate aerobic exercise (3 hrs/week at target HR zones)

Stress management training (1 hr/day) – meditation and visualisation

Group support (2 meetings a week)

Lancet 1990; 336:129

Lancet 1990; 336:129

Angiographic lesions

Lifestyle group 40.0% to 37.8% at 1 year

Control group 42.7% to 46.1% at 1 year

Lancet 1990; 336:129

Angiographic lesions at 5 years

Lifestyle Overall progression -3.1%

Control Overall progression 11.8%

JAMA 1998; 280:2001

Courtesy of Dr Caldwell Esselstyn

Strict plant-based diet

Plant-based diets can improve outcomes in

- Diabetes

- Hypertension

- Cancer

- Inflammatory bowel disease

- Parkinson’s & Alzheimers