critical care nutrition the right nutrient/nutritional strategy the right timing the right patient...

Improving the Practice of Nutrition Therapy in the Critically ill

Results of 2009 International Nutrition Survey

Daren K. HeylandProfessor of Medicine

Queen’s University, Kingston General HospitalKingston, ON Canada

Learning Objectives• Convince you that efforts to improve nutrition in the ICU

are worthwhile• Familiarize you with the recommendations of the

Canadian Critical Care Nutrition Clinical Practice Guidelines

• Make you aware of current nutrition practices in ICUs in your own geographic region and throughout the world

• Enable you to identify gaps between guideline recommendations and current practices in ICUs

• Provide tools to begin to narrow that GAP!

Underlying Pathophysiology Of Critical Illness

Caloric debt associated with: Longer ICU stay

Days on mechanical ventilation Complications

Mortality

EN Intake

Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006

0200

400600

8001000

12001400

16001800

2000

1 3 5 7 9 11 13 15 17 19 21

Days

kcal

Prescribed Engergy

Energy Received From Enteral Feed

Caloric Debt

• 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

Hypothesis

• There is a relationship between amount of energy and protein received and clinical outcomes (mortality and # of days on ventilator)

• The relationship is influenced by nutritional risk

• BMI is used to define chronic nutritional risk

What Study Patients Actually Rec’d

• Average Calories in all groups: – 1034 kcals and 47 gm of protein

Result: • Average caloric deficit in Lean Pts:

– 7500kcal/10days

• Average caloric deficit in Severely Obese:– 12000kcal/10days

Relationship Between Increased Calories and 60 day Mortality

BMI Group Odds Ratio

95% Confidence

Limits

P-value

Overall 0.76 0.61 0.95 0.014

<20 0.52 0.29 0.95 0.033

20-<25 0.62 0.44 0.88 0.007

25-<30 1.05 0.75 1.49 0.768

30-<35 1.04 0.64 1.68 0.889

35-<40 0.36 0.16 0.80 0.012

>=40 0.63 0.32 1.24 0.180

Legend: Odds of 60-day Mortality per 1000 kcals received per day adjusting for nutrition days, BMI, age, admission category, admission diagnosis and APACHE II score.

0 500 1000 1500 20000

10

20

30

40

50

60

All Patients< 2020-2525-3030-3535-40>40

Calories Delivered

Mo

rtal

ity

(%)

Relationship of Caloric Intake, 60 day Mortality and BMI

BMI

BMI Group

Adjusted

Estimate

95% CI P-value

LCL UCL

Overall 3.5 1.2 5.9 0.003

<20 2.8 -2.9 8.5 0.337

20-<25 4.7 1.5 7.8 0.004

25-<30 0.1 -3.0 3.2 0.958

30-<35 -1.5 -5.8 2.9 0.508

35-<40 8.7 2.0 15.3 0.011

>=40 6.4 -0.1 12.8 0.053

Relationship Between Increased Energy and Ventilator-Free days

Legend: # of VFD per 1000 kcals received per day adjusting for nutrition days, BMI, age, admission category, admission diagnosis and APACHE II score.

Effect of Increasing Amounts of Calories from EN on Infectious

Complications

Heyland Clinical Nutrition 2010

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

Effect of Increasing Amounts of Protein from EN on Infectious Complications

Multicenter observational study of 207 patients >72 hrs in ICU followed prospectively for development of infection

for increase of 30 gram/day, OR of infection at 28 days

Heyland Clinical Nutrition 2010

Relationship between increased nutrition intake and physical function (as defined by SF-36 scores)

following critical illness

Multicenter RCT of glutamine and antioxidants (REDOXS Study)First 364 patients with SF 36 at 3 months and/or 6 months

for increase of 30 gram/day, OR of infection at 28 days

Heyland Unpublished Data

Model *

Estimate (CI)P values

(A) Increased energy intake

PHYSICAL FUNCTIONING (PF) at 3 months 3.2 (-1.0, 7.3) P=0.14

ROLE PHYSICAL (RP) at 3 months 4.2 (-0.0, 8.5) P=0.05

STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 3 months

1.8 (0.3, 3.4) P=0.02

PHYSICAL FUNCTIONING (PF) at 6 months 0.8 (-3.6, 5.1) P=0.73

ROLE PHYSICAL (RP) at 6 months 2.0 (-2.5, 6.5) P=0.38

STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 6 months

0.70 (-1.0, 2.4) P=0.41

Faisy BJN 2009;101:1079

Mechancially Vent’d patients >7days (average ICU LOS 28 days)

Permissive Underfeeding(Starvation)?

187 critically ill patients Tertiles according to ACCP recommended levels of

caloric intake Highest tertile (>66% recommended calories) vs.

Lowest tertile (<33% recommended calories) in hospital mortality Discharge from ICU breathing spontaneously

Middle tertile (33-65% recommended calories) vs. lowest tertile Discharge from ICU breathing spontaneously

Krishnan et al Chest 2003

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 administered 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 (in press)

Optimal Amount of Calories for Critically Ill Patients:

Depends on how you slice the cake!

• Sample restriction approaches have included limiting analyzed patients to those:

1. In the ICU for at least 96 hours,

2. In the ICU at least 96 hours prior to progression to exclusive oral feeding and

3. Eliminating days after progression to exclusive oral feeding from the calculation of nutrition intake.

• Statistical adjustment approaches have included using regression techniques to adjust for:

1. ICU length of stay (LOS),

2. Evaluable nutrition days and

3. Relevant baseline patient characteristics or some combination thereof.

Heyland Crit Care Med 2011 (in press)

0.4 0.6 0.8 1.0 1.2 1.4 1.6

UnadjustedAdjusted

Odds ratios with 95% confidence intervals

Association between 12 day average caloric adequacy and 60 day hospital mortality

>2/3 Unadjusted>2/3 Adjusted1/3-2/3 Unadjusted1/3-2/3 Adjusted

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.*

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.

Association Between 12-day Caloric Adequacy and 60-Day Hospital

Mortality

Quality Improvemen

t Target

More is Better!

If you feed them (better!)They will leave (sooner!)

ICU patients are not all created equal…should we expect the impact of nutrition

therapy to be the same across all patients?

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure

• Single center study of 200 mechanically ventilated patients• Trophic feeds: 10 ml/hr x 5 days

Rice CCM 2011;39:967


Rice CCM 2011;39:967

No difference between groups!Didn’t measure infection nor physical function


• Average age 51• Few comorbidities• Average BMI 29• 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!

Large multicenter trial of this concept (EDEN study) by ARDSNET just finished

ICU patients are not all created equal…should we expect the impact of nutrition

therapy to be the same across all patients?

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

survivalTaylor 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

More (and Earlier) is Better!

If you feed them (better!)They will leave (sooner!)

Objectives of International Survey

Quality Improvement• To determine current nutrition practice in the adult critical

care setting (overall and subgroups)• Illuminate gaps between best practice and current practice • To identify nutrition practices to target for quality

improvement initiativesGenerate New Knowledge• To determine factors associated with optimal provision of

nutrition • To determine what nutrition practices are associated with

best clinical outcomes

History of International Surveys

• 3 previous surveys in Canada– 2001, 2003, 2004– N > 50

• Extended to other countries – Focus on North America in 2007 (n=167)– Focus on Australasia in 2008 (n=169)– Focus back on North America in 2009 (n=172)

• 2011, Focus on Latin America

Methods

Eligibility Criteria• ICU Site

– >8 beds– Availability of individual with knowledge of clinical

nutrition to collect data• Patient

– In ICU > 72 hours– Mechanically ventilated within 48 hours

Methods• Prospective observational cohort study

• Start date: 16th September 2009

• Aim 20 consecutive patients– Min 8 pts

• Data included:– Hospital and ICU demographics– Patient baseline information (e.g. age, admission diagnosis, APACHE

II)– Baseline Nutrition Assessment– 12 days Daily Nutrition data (e.g. type of NS, amount NS received)– 60 day hospital outcomes (e.g. mortality, length of stay)

Web based Data Capture System

Benchmarking

Individual ICUs compared to:

•Canadian Clinical Practice Guidelines

•All ICUs

•ICUs from same geographic region

• Recommendations: Based on 8 level 2 studies, we recommend early enteral nutrition (within 24-48 hrs following resuscitation) in critically ill patients.

Early vs Delayed Nutrition Intake

0

20

40

60

80

100

120

Tim

e t

o In

itia

tio

n o

f E

N (

hrs

)

Site

Maximum

Minimum

Median

Your site All sites Sister sites

Canada: 32

USA: 63

Australia & New Zealand: 22

Europe: 14

Latin America: 10

Asia: 16

Mexico: 2 Brazil:1Colombia:5Peru:1Venezuela:1

Italy: 2UK: 7

Ireland: 2Norway: 1

Switzerland: 1Czech Republic: 1

China: 1Taiwan: 1India: 10Iran : 1Japan: 1

Singapore: 2

Who participated in 2009? : 157 ICUs

ICU CharacteristicsCharacteristics Total (n=157)

Hospital Type

Teaching 116 (73.9%) Non-teaching 41 (26.1%)

Size of Hospital (beds) Mean (Range) 503 (50, 1500)

ICU Structure Open 49 (31.2%)

Closed 104 (66.2%)Other 4 (2.6%)

Size of ICU (beds) Mean (Range) 19 (6, 64)

Designated Medical Director 149 (94.9%)Presence of Dietitian(s) 145 (92.4%)FTE Dietitians (per 10 beds)

Mean (Range) 0.4 (0.0, 1.7)

Patient CharacteristicsCharacteristics Total n=3028

Age (years) Median [Q1,Q3] 61 [48, 73]

Sex

Female 1215 (40.1%)Male 1813 (59.9%)

Admission Category

Medical 1952 (64.5%)Surgical: Elective 366 (12.1%)

Surgical: Emergency 710 (23.4%)BMI (kg|m2)

Median [Q1, Q3] 26.0 [22.8, 30.8]Apache II Score

Median [Q1, Q3] 22 [17, 28]Presence of ARDS

Yes 413 (13.6%)

Outcomes at 60 days

Characteristics Total

n=2948Length of Mechanical Ventilation (days)

Median [Q1, Q3] 7.2 [3.3, 15.2] Length of ICU Stay (days)

Median [Q1, Q3] 10.3 [5.9, 19.8]Length of Hospital Stay (days)

Median [Q1,Q3] 18.9[10.4, 36.7]Patient Died (within 60 days)

Yes 738(24.7%)

We strongly recommend the use of enteral nutrition over parenteral nutrition

Type of Artificial Nutrition

EN Only71%

PN Only6%

EN+PN13%

None10%

n=3028 patients

Use of EN Only

n=17567 patients days

73.6%

66.7%62.2%

93.9%

9.8%

0

10

20

30

40

50

60

70

80

90

100

Canada Australia andNew Zealand

USA Europe Latin America Asia Total

% IC

U d

ays

Use of PN Only


6.6%10.0% 8.7%

38.6%

0.6%0

5

10

15

20

25

30

35

40

45

50



% IC

U d

ays

We recommend that parenteral nutrition not be started at the same time as enteral nutrition.

In the patient who is not tolerating adequate enteral nutrition, there are insufficient data to put forward a recommendation about when parenteral nutrition should be initiated.

Practitioners will have to weigh the safety and benefits of initiating PN in patients not tolerating EN on an individual case-by-case basis.

We recommend that PN not be started in critically ill patients until all strategies to maximize EN delivery (such as small bowel feeding tubes, motility agents) have been attempted.

Role of Supplemental PN

Use of EN + PN


4.4%

11.7%

2.7%

72.2%

0.3%0

10

20

30

40

50

60

70

80



% IC

U d

ay

s

EN in Combination with PN% of patients received motility agents before PN started

34.6

21.4

63.2

0

10

20

30

40

50

60

70

80

90

100



% r

ece

ive

d m

otil

ity a

ge

nts

be

fore

PN

sta

rte

d

We recommend early enteral nutrition (within

24-48 hrs following admission) in critically ill

patients

Timing of Initiation of EN

30hrs

50hrs

41hrs

144hrs

9hrs0

24

48

72

96

120

144

168

Canada Australia andNew

Zealand

USA Europe LatinAmerica

Asia Total

Tim

e t

o In

itia

tio

n o

f E

N (

ho

urs

)

An evidence based feeding protocol should be

considered as a strategy to optimize delivery of enteral

nutrition

Use of a Feeding Protocol

Characteristics Total n=157

Feeding Protocol Yes 129 (82.2%)

Gastric Residual VolumeThresholdMean (range) 240 (50, 500)

Algorithms included in Protocol Motility agents 90 (72.6%)

Small bowel feeding 69 (55.6%) Withholding for procedures 69 (55.6%)

HOB Elevation 117 (94.4%)Other 19 (15.3%)

In critically ill patients who experience feed intolerance

(high gastric residual volumes, emesis) the use of a motility agent and small

bowel feeding tubes are recommended

Strategies to Optimize EN Delivery:Motility Agents

67%

46%

86%

100.0

0.00

10

20

30

40

50

60

70

80

90

100



% p

atie

nts

with

HG

RV

12%

2%

44%

100

00

10

20

30

40

50

60

70

80

90

100

Canada Australia andNew

Zealand


Asia Total

% p

atie

nts

with

HG

RV

Strategies to Optimize EN Delivery:

Small Bowel Feeding

Composition of EN and Pharmaconutrient Supplementation

recommendations

Arginine-supplemented formulas Recommend NOT be used

Glutamine supplementation

Enteral should be considered in burn and traumaParenteral strongly recommended in PN pts

Fish oil enriched formula Recommended in ARDS

Combined vitamins and trace elements

Should be considered

Polymeric Recommend

Use of EN Formula and Pharmaconutrients

Arginine-supplemented formulas 8.2%(0.0%-94.7%)

Glutamine supplementation (All) 5.9%(0.0%-95%)

Fish oil enriched formula (ARDS) 18.9% (0.0%-100%)

Selenium Supplementation (All) 3.1% (0.0%-100%)

Polymeric 85.9% (0.0%-100.%)

We recommend that hyperglycemia

(blood sugars >10mmol/l) be avoided

Blood Glucose >10 mmol/l

8.7

15.213.1

0

5

10

15

20

25

30

35

40



Asia Total

% p

atie

nt-

da

ys

Overall Performance

Adequacy of Nutrition Support =

Calories received from EN + appropriate PN+Propofol Calories prescribed

Overall Performance: Kcals

87%

58%

6.8%

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12

ICU Day

% r

ec

eiv

ed

/pre

sc

rib

ed

Mean of All Sites Best Performing Site Worst Performing Site

Failure Rate% patients who failed to meet minimal quality targets (80% overall energy

adequacy)

Canada Australia and New Zealand

USA Europe Latin America Asia Total0

10

20

30

40

50

60

70

80

90

100

81.1 79.4

89.0

78.283.8

77.883.6

% p

atie

nts

no

t ach

ieve

min

imu

m o

f 80

% o

ver

sta

y in

ICU

Where can we do better?• Inadequate EN delivery

– timing of initiation of EN– feeding protocols– small bowel feeding and motility agents

• Optimize Pharmaconutrition– use of glutamine, antioxidants, omega-3 FFA.

• Tighten (not tight) glycemic control

How to Change?

CPGs to bedsideGuidelines

Bedside

Dissemination and Implementation Strategies

Special JPEN Issue Dedicated to KT

• Knowledge Translation (KT) – describes the process of moving evidence learned from

clinical research and summarized in CPGs to its incorporation into clinical and policy decision-making.

– defined as “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of patients, provide more effective health services and products and strengthen the health care system.”

– Knowledge transfer, knowledge exchange, research utilization, implementation science, dissemination, and diffusion are other terms that have been used interchangeably to describe the same concept.

Nov 2010, Available online at www.criticalcarenutrition.com

http://www.cihr-irsc.gc.ca/e/29418.html#Synthesis

http://www.cihr-irsc.gc.ca/e/29418.html#Dissemination

http://www.cihr-irsc.gc.ca/e/29418.html#Exchange

http://www.cihr-irsc.gc.ca/e/29418.html#Ethically-sound

Understanding Adherence to Guidelines in the ICU:

Development of a Comprehensive Framework

Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK

CPGCharacteristics

ADHERENCE

Implementation Process Institutional Factors Provider Intent

Hospital characteristics

-Structure- Processes-Resources-Patient Case-mix Knowledge Attitudes

Familiarity

AwarenessMotivation Self-efficacy

Outcomeexpectancy

Agreement

ICU characteristics

-Structure- Processes-Resources- Patient Case-mix-Culture

Provider Characteristics- Profession -Critical care expertise-Educational background-Personality

Patient Characteristics

Lack of agreement among ICU team on the best nutrition plan of care for the patient.

Current scientific evidence supporting some nutrition interventions is inadequate to inform practice.

Current feeding protocol is outdated.

Not enough nursing staff to deliver adequate nutrition.

Not enough dietitian time dedicated to the ICU during regular weekday hours.

Not enough time dedicated to education and training on how to optimally feed patients.

Nurses failing to progress feeds as per the feeding protocol.

The language of the recommendations of the current national guidelines for nutrition are not easy to understand.

Fear of adverse events due to aggressively feeding patients.

No feeding protocol in place to guide the initiation and progression of enteral nutrition.

Feeding being held too far in advance of procedures or operating room visits.

Waiting for the dietitian to assess the patient.

The current national guidelines for nutrition are not readily accessible.

Delays in initiating motility agents in patients not tolerating enteral nutrition.

Non-ICU physicians (i.e. surgeons, gastroenterologists) requesting patients not be fed enterally.

Delay in physicians ordering the initiation of EN.

No feeding tube in place to start feeding.

No or not enough dietitian coverage during weekends and holidays.

Delays and difficulties in obtaining small bowel access in patients not tolerating enteral nutrition.

Enteral formula not available on the unit.

No or not enough feeding pumps on the unit.

In resuscitated, hemodynamically stable patients, other aspects of patient care take priority over nutrition.

10.015.0

20.025.0

30.035.0

40.045.0

50.055.0

60.065.0

70.075.0

80.085.0

90.0

19.3

21.3

23.4

23.4

27.8

28.0

29.0

29.0

29.9

31.0

31.3

34.0

35.2

37.2

37.8

40.7

41.4

42.4

43.1

46.9

48.6

50.0

Proportion that responded "important" or "very important"

• Different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds.

• In select patients, we start the EN immediately at goal rate, not at 25 ml/hr.

• We target a 24 hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume.

• Start with a semi elemental solution, progress to polymeric

• Tolerate higher GRV threshold (300 ml or more)• Motility agents and protein supplements are started

immediately, rather than started when there is a problem.

The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients:

The PEP uP Protocol!

A Major Paradigm Shift in How we Feed EnterallyHeyland Crit Care 2010

Creating a Culture of Clinical Excellence in Critical Care

Nutrition:

The ‘Best of the Best’ Award

Heyland DK, Heyland R, Jones N, Dhaliwal R, Day A

Recognition and Reward

Recognition a powerful motivator of human performance

Determining the Best of the BestDeterminant WeightingOverall Adequacy of EN plus appropriate PN 10% patients receiving EN 5% of patients with EN initiated within 48 hours 3% of patients with high gastric residual volumes (HGRV) receiving motility agents

1

% of patients with HGRV receiving small bowel tubes 1% of patient glucose measurements greater than 10 mmol/L (excluding day 1; fewest is best)

3

Rank all eligible ICUs by determinantsMultiply ranking by weightingICU with highest score is crowned ‘Best of the Best’

Best of the Best Award

• Eligible sites: Data on 20 critically ill patients Complete baseline nutrition assessment Presence of feeding protocol No missing data or outstanding queries Permit source verification by CCN

• Awarded to ICU that demonstrate: Highest ranking nutritional performance

BEST OF THE BEST

KGH

2008

Last year, 156 ICUs participated in an international audit of nutrition practices in critically ill patients. This year we want to take part.

Please help us to improve our performance as it relates to nutrition in our ICU. Better nutrition therapy translates into reduced

morbidity and improved survival.

For more information, contact____________________

ADD HOSPLOGO

2009 Best of the BestOf >200 ICUS competing Internationally

1. Instituto Neurologico de Antioquia, Medellin, Colombia

1. Royal Prince Alfred Hospital, Sydney, Australia

1. The Alfred, Melbourne, Australia

TOP Performers

Determinants to Top PerformanceWhat site and hospital characteristics are associated with top BOB ranking?

Hospital/ICU characteristics** Ranking p values

Region

Australia and New Zealand vs. Canada -3.0 0.61

China vs. Canada +30.4 0.008

Europe and South Africa vs. Canada -7.9 0.22

India vs. Canada +32.7 0.08

Latin America vs. Canada 0.17 0.98

USA vs. Canada +30.4 <0.0001

Hospital size (per 100 beds) -0.24 0.78

ICU structure

Closed vs. open or other -0.89 0.89

Presence of Dietitian(s)

Yes vs. No -23.5 0.005

(Best Rank=1rst thus a negative number is associated with a better ranking)

Heyland JPEN 2010

International Nutrition Survey 2011

Participate on May 11th 2011 Data on min 20 critically ill patients Complete baseline nutrition assessment No missing data or outstanding queries Permit source verification

Benchmarked Site Report Compare your performance to other ICUs Compare your performance to the Canadian CPGs Highlight gaps in practice and barriers to improving

BEST OF THE BEST

KGH

2008





ADD HOSPLOGO

International Nutrition Survey 2011

Debriefing session with INS participants and other interested parties

Today, 5 pm, SOLANA (1rst Floor, South Tower)

BEST OF THE BEST

KGH

2008





ADD HOSPLOGO

critical care nutrition the right nutrient/nutritional strategy the right timing the right patient...

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