L.Mageswary Dietitian

Hospital Selayang

14 – 15 AUG ASMIC 2015

Learning Objectives

1. To understand the importance of nutrition support in ICU

2. To know the right time to feed

3. To understand the indications for enteral formulas

4. To know how much feeding is adequate

5. To appreciate good feeding practices

Starvation

• Lack of nutrient intake & caloric demand

• Minimal loss of protein

• Reduced protein

catabolism to preserve lean body mass

• Mobilization of fat for energy

Hypermetabolism

• Activated state, REE • Increased lean body mass

wasting • Accelerated protein

catabolism for energy & protein synthesis

• Protein (muscle &visceral)

for energy and glucose formation (Gluconeogenesis)

Critically lll

Hypercatabolic & Hypermetabolic

Impaired immunological functions Impaired ventilatory drive Weaken respiratory muscles

Malnutrition

(Reported as being as high as 40% in ICU)

Giner M et al. Nutrition 12:23–29, 1996

prolonged ventilatory dependence infection morbidity mortality Dark D et al, Journal of Intensive Care Medicine 1993

CAN PATIENT EAT NORMALLY ?

YES

No Special Support Needed

NO

Specialized Nutritional Support Needed

IS GIT FUNTIONAL ?

YES

Naso-Gasrric or Naso-Enteral Tube Feeding

NO

Total Parenteral Nutrition(TPN) Needed

FULL AMOUNT TOLERATED ?

YES

Tube- feeding Alone Sufficient

NO

Supplement as Needed with Peripheral Parenteral Nutrition

(PPN)

IS PATIENT AT HIGH-RISK FOR

ASPIRATION ?

IS PATIENT AT HIGHER RISK

FOR ASPIRATION ?

YES

Use Post-Pyloric Feeding

NO

May Use Intra-Gastric Feeding

YES

Use Post-Pyloric Feeding

NO

May Use Intra-Gastric Feeding

ENTERAL NUTRITION

1. Promotes gut mucosal growth & development

2. Helps maintain the barrier function and may help prevent translocation of bacteria & toxins

3. Support the immune system

4. Results in better nutrient use with fewer metabolic disturbances

5. Less expensive

…comparing cost of PN versus En, estimated EN saves $425 per day over

Chellis MJ et al (JPEN 1996)

14 – 15 AUG ASMIC 2015

When to Initiate Feeding ?

Critically ill patients who are hemodynamically stable with functioning GIT & adequately resuscitated

All appropriate patients will have enteral nutrition initiated by 24 - 48 hours

Following hospitalisation, trauma, injury or admission to ICU

Caloric goal to be reached

by

48 - 72 hours after initiation

Why Early Feeding ?

Early use of the enteral route may play a significant role in preventing

• GI mucosal atrophy

• Development of the systemic inflammatory syndrome (SIRS)

• Multiple organ failure (MOF)

• Multiple organ dysfunction (MOD)

Time Required To Regain Post Operative GI Propulsion

Stomach

Liquid: 3 – 8 hrs

Solids: 24 -48 hrs

Small Bowel

12 – 24 hours

Colon

48 -72 hours

Early Enteral Feeding

Meta-analysis of RCT

Outcome

Anastomotic dehiscence

Infection: Any type

Wound Infection

Pneumonia

Intra-abdominal abscess

Vomiting

Death

NO TRIAL

Favours Early Feeding Favours NBM

5

6

5

7

6

9

8

Relative Risk

14 – 15 AUG ASMIC 2015

• As little as 10ml/H of feed of enteral feeding may be

sufficient to provide the desired `GI protective effect`

(Level B)

Early feeding with 55 to 60% goals target

Maintain gut integrity and gut barrier function

Provide immune benefit

McClave. J of critical illness. 2001:16:198-202;

Dose –dependent Effect of EN

•

These changes are time dependent; the longer they are left NPO, the greater the complications.

Objective

• Objective: To describe current nutrition practices in intensive care units and determine “best achievable” practice relative to evidence-based Critical Care Nutrition Clinical Practice Guidelines.

Research Design

• An international, prospective, observational, cohort study conducted January to June 2007.

• 158 adult intensive care units from 20 countries.

• Total subjects = 2946

Result

• Average adequacy of total calories and protein over the 12 days of observation

• Calorie adequacy = 59.0% (site range, 20.5%–94.4%)

• Protein adequacy = 60.3% (site range, 18.6%–152.5%)

Calorie Debt

• Increase days on mechanical ventilation

• Longer ICU stay

• Increase mortality

Increasing caloric debt is

associated with

EN

Inta

ke

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1 3 5 7 9 11 13 15 17 19 21

kcal

Days

Prescribed Engergy

Energy Received From Enteral Feed

Caloric Debt

Villet et al Clinical Nutrition 2005; Faisy et al British Journal of Nutrition 2009; Tsai et al Clinical Nutrition 2011

21.9% patients remain NPO ≥ 3 days mean duration 5.2 days (range 0 – 16 days)

• Physician order 65% of goal volume

• Only 15% of patients reach goal feeds within 3 days

Problem initiating feeding

• Only 80% of ordered volume is given

• Cessation of EN in 80% patients (diagnostic, procedures, high GRV ect.)

• Net effect – only average 50% of goal volume

• Slow advancement

Problems delivering feeding

Fanklin, McClave (JPEN 2006;30:S32)

McClave (CCM 1999;27:1252)

Heyland (JPEN 2003;27:74)

Jones (J Crit Care 2008;23:301)

Underfeeding

Overfeeding

Hyperglycemia Hyperlipidemia Fat

deposition (bedridden)

Neuromuscular disease

patients, loss muscle mass & gain fat mass

Increased metabolic rate,

cardiac demand, respiration & CO2

Monitor with Respiratory

quotient (RQ) > 1.0

Overfeeding CHO

COPD

Retain CO2

• Accurate initial assessment of calorie requirement & periodic reassessment prevents overfeeding

• Reducing excessive calorie is far more therapeutic than reducing CHO

• Acute and initial phase

• Exogenous energy supply > 20 – 25 kcal/kg BW/day may be associated with a less favorable outcome (C)

• Recovery (anabolic flow phase)

• Aim to provide 25 – 30 kcal/kg BW/day

• Severe under nutrition should receive up to 25 -30 kcal/kg BW/day

• If these target not reached, supplementary PN should be given.

How much EN?

ESPEN Guidelines on Enteral Nutrition: Intensive Care. Clinical Nutrition (2006) 25, 210-223

How Much to Feed ?

Protein: 1.2 to 2.0 gm/ Actual Body Weight

• In the critically ill obese patient, permissive underfeeding or hypocaloric feeding with EN is recommended.

• For all classes of obesity where BMI is > 30 kg/m2, the goal of the EN regimen should not exceed 60%-70% of target energy requirements or 11-14 kcal/kg actual body weight per day or 22-25 kcal/kg ideal body weight per day

• Protein should be provided in a range

≥ 2.0 g/kg ideal body weight per day for Class I and II patients (BMI 30-40),

≥ 2.5 g/kg ideal body weight per day for Class III (BMI ≥ 40).

ASPEN Recommendation 2009

Feeding the Obese Patients

Tropic or trickle feeding

• Whenever full feeding is not possible

– 10 to 30 ml/hour should be given

• To prevent gut mucosa atrophy

McClave et al. 2009

14 – 15 AUG ASMIC 2015

YES

YES

YES

YES

Does the patient have impaired digestion or absorption ?

Does the patient require electrolyte restriction ?

Does the patient require fluid restriction ? OR have high energy

needs ?

Does the patient have protein needs ?

Does the patient have hyperglycemia ?

Standard Formula (1.0 – 1.2 kcal/mL)

Elemental or semi-elemental formula

Renal Formula

High Energy Formula

High Protein standard formula OR modular

Low CHO, High fiber formula

NO

NO

NO

NO

NO

YES

Does the patient have impaired digestion or absorption ?

Does the patient require electrolyte restriction ?

Does the patient require fluid restriction ? OR have high

energy needs ?

Does the patient have protein needs ?

Does the patient have hyperglycemia ?

Standard Formula (1.0 – 1.2 kcal/mL)

Protein Type

Casein protein Forms curd in stomach

Delays gastric emptying

Whey protein

Whey protein remains in

liquid state in stomach

Facilitate gastric emptying

Soluble non-curdling property

Reduces risk of reflux and

aspiration pneumonia

Greater patient comfort

Fiber Type

• Soluble fiber may be beneficial – fully resuscitated

– hemodynamically stable critically ill pts receiving EN who develops diarrhea

• Insoluble fiber should be avoided in all critically ills

• Both soluble and insoluble fiber should be avoided in pts at high risk for bowel ischemia or severe dysmotility (Grade C)

Guidelines for the provision and assessment of nutrition support therapy in adult critically ill pts: Society of Critical Care Medicine and ASPEN (2009)

Avoid Immune Enhancing formulas in

actively sepsis patients.

• Reserved for critically – ill surgical/ trauma/ burn patients

• Duration of formula is for up to 10 days or > if pt remains at significant risk of infectious complications

PN 0.2 – 0.4 gm/kg/day EN 0.3 – 0.5 gm/kg/day

Glutamine

• NO BENEFIT if total calories intake < 700 kcal/day • For therapeutic benefit : 50 to 60% energy should be delivered

Immune modulating Formula

14 – 15 AUG ASMIC 2015

Giving enteral feed into the stomach rather than the small intestine permits the use of hypertonic feeds, higher feeding rates, and bolus feeding (grade A).

- Starter regimens using reduced initial feed volumes are unnecessary in patients who have had reasonable nutritional intake in the last week (grade A).

- Diluting feeds risks infection and osmolality difficulties.

Both inadequate or excessive feeding may be harmful.

Dietitians or other experts should be consulted on feed prescription

(grade C).

Nutrition Support Practices

Method Of Administration

Bolus feeding • Administered using a syringe • High incidence of complications

Intermittent • Administered by gravity flow or pump • Each feeding is given over 30 minutes every 3 - 6 hours

Continuous • Pump assisted • Utilized in patients who are critically ill or with small

bowel feeding • Restricts patient ambulation

Continuous pump feeding can reduce gastrointestinal

discomfort and may maximise levels of nutrition

support when absorptive capacity is diminished.

However, intermittent infusion should be initiated as soon

as possible (grade A).

Bolus feeds are discouraged in a critical care setting and

contraindicated with jejunal feeding.

Feeding Initiation

Standard Formula

Gastric administration

• Begin full strength 25 – 50 ml/hour

• Advance by 25 ml/hr every 4 – 8 hours until goal rate is met

Post Pyloric administration

• Begin full strength at 25 ml/hr for first 12 hours

• Advance by 25 ml/hr every 6 – 12 hours until goal rate is met

• Bolus administration is not recommended

Concentrated/ elemental formula

Gastric or Post Pyloric

Infusion

• Begin full strength at 25 ml/hr for first 12 hours

• Advance by 25 ml/hr every 6 – 12 hours until goal rate is met

• Bolus administration is not recommended

**Head of bed to be elevated ≥ 30 to 45 degrees at all times**

Feeding Transition

WEANING TPN or TEN • Wean TPN or TEN off once patient consuming ½ to 2/3 of

nutritional needs

Abrupt cessation of tube feeding is not recommended, as nutritional status may be compromised.

Ceasing feeds during meal times

• Aims to improve the patient’s appetite and oral intake at mealtimes

• Stop tube feed 1-2 hours before each main meal

• Feeds can resume when the patient has finished eating, or 1-2 hours

afterwards

Nocturnal Feeding

• Overnight feeding (8-16 hours) to encourage oral intake during day

• More energy-dense formula (1.5 – 2.0 kcal/ml) can be used for meeting

need using lower feed rate

• Administer bolus feeds separate from meals to minimise on appetite

What happen to patients post-extubation?

Journal of American Dietetic Association 2010

Energy = 40-60% Protein = 20-40%

“Window of Opportunity”

“Window of Opportunity”

Early Enteral Nutrition Provide Adequate Feeding

Apply Good Nutrition Support Practices