near-target caloric intake in critically ill medical-surgical patients
TRANSCRIPT
Near-Target Caloric Intake in Critically Ill Medical-
Surgical Patients Is Associated With Adverse
OutcomesYaseen M. Arabi, et.al.JPEN J Parenter Enteral Nutr 2010
34
MarniarPembimbing :
dr. Agussalim Bukhari, M.Med., Ph.D, SpGK
2
ABSTRACT
3
Background
The objective of this study was to determine whether caloric intake independently influences mortality and morbidity of critically ill patients.
4
MethodsThe study was conducted as a nested cohort study within a randomized controlled trial in a tertiary care intensive care unit (ICU). The main exposure in the study was average caloric intake/target for the first 7 ICU days.The primary outcomes were ICU and hospital mortality. Secondary outcomes included ICU-acquired infections, ventilator-associated pneumonia (VAP), duration of mechanical ventilation days, and ICU and hospital length of stay (LOS).
5
MethodsThe authors divided patients (n = 523) into 3 tertiles according to the percentage of caloric intake/ target: tertile I <33.4%, tertile II 33.4%–64.6%, and tertile III >64.6%.To adjust for potentially confounding variables, the authors assessed the association between caloric intake/target and the different outcomes using multivariate logistic regression for categorical outcomes (tertile I was used as reference) and multiple linear regression for continuous outcomes.
6
ResultsTertile III was associated with higher adjusted hospital mortality, higher risk of ICU-acquired infections, and a trend toward higher VAP rate.
Increasing caloric intake was independently associated with a significant increase in duration of mechanical ventilation, ICU LOS, and hospital LOS.
7
ConclusionsThe data demonstrate that near-target caloric intake is associated with significantly increased hospital mortality, ICU-acquired infections, mechanical ventilation duration, and ICU and hospital LOS.Further studies are needed to explore whether reducing caloric intake would improve the outcomes in critically ill patients.
8
INTRODUCTION
9
MALNUTRITIONcommon problem in ICU
patients
associated withincreased morbidity and
mortality
Nutrition support has become an
integral component of critical care
Several studies have demonstrated improved patient outcomes with early nutrition
support and with achieving the target caloric dose
10
On the other hand…CALORIC RESTRICTION
extends life span in a variety of species
improves biomarkers of longevity in humans
probably related to :• reduction in metabolic rate and oxidative stress • improvement in insulin sensitivity• modification of cardiovascular risk• alterations in neuroendocrine and sympathetic
nervous system function
11
hypercatabolic state
augmented oxidative stress
insulin
resistance
CRITICAL ILLNESS
Some researchers recommend the provision of reduced energy to avoid
accentuating these adaptive or maladaptive
responses to stress
supported by someevidence
12
Therefore…
it remains unclear what constitutes an appropriate dose of caloric intake for
critically ill patients
Professional societies recommended achieving
nutrition targets early in the course of critical illness,
although such a recommendation is not
based on strong evidence
The purpose of this study was to determine whether the dose of caloric intake independently influences
the mortality and morbidity of critically ill
patients
13
METHODS
14
Setting
a nested cohort study of all patients (n = 523)
who were enrolled in a RCT that compared intensive insulin therapy to conventional
insulin therapy
January 2004 - March 2006
15
Nutrition
•The caloric target was estimated by a dietitian using the Harris-Benedict equation and adjusting for stress factors.•Protein target was calculated as 0.8–1.5 g/kg based on the patient condition and underlying diseases
Prescribed by the treating intensivists
16
Data Collectionpatients’
demographicsAPACHE II score
admission category
vasopressor therapy
BG on admission
history of diabetes
mechanical ventilation
serumcreatinine
daily dose of insulin
average BG levels
daily total caloric intake
caloric intake/targ
et
17
Data Collection
•ICU mortality•Hospital mortality
primary endpoint
s
•Nosocomial infection•VAP•Duration of mechanical ventilation•ICU and hospital LOS
secondary endpoints
18
Statistical Analysis
SAS P values (x² test)
ANOVAmultivariate
logistic regression
multiple linear
regression
To discern whether there was a dose-effect relationship between the caloric intake/target and mortality, the
authors further stratified patients into 10 deciles and evaluated the association with the different outcomes
considered in this study.
19
RESULTS
20
Patient Characteristics
40% of patients were diabetic
83% were admitted for medical indications
85% were mechanically ventilated
APACHE II score was 22.8 ± 8.1
85% were mechanically ventilated
83% were admitted for medical indications
40% of patients were diabetic
APACHE II score was 22.8 ± 8.1
21
Patient Characteristics
BMI, blood glucose on admission, and calculated caloric targets were
similar in the 3 tertiles
patients in tertile III required higher doses of insulin to maintain
target blood glucose level
22
Outcomes
patients in tertile III had increased ICU mortality, hospital
mortality, ICU-acquired infections, VAP, mechanical
ventilation duration, and ICU and hospital LOS
23
Outcomes
24
Outcomes
25
Outcomes
26
Outcomes
27
Tabel 4
Tertile III
↑ hospital mortality
↑ ICU LOS↑ ICU-acq.inf
↑ hospital LOS
↑ VAP↑ duration
of mech.vent
28
29
30
DISCUSSION
31
THE MAIN FINDING : near-target caloric intake in critically ill
medical-surgical patients is associated with increased mortality as well as morbidity, including ICU-acquired infections, VAP
rate, duration of mechanical ventilation, and ICU and hospital LOS
Although there was universal agreement about the
importance of nutrition support to critically ill patients, considerable controversy exists
over the appropriate caloric dose, as different studies have yielded different
results
32
Studies suggested that low caloric intake may
be detrimental and that higher caloric intake may be associated with improved
outcomes :• cumulative energy deficit was associated with longer ICU LOS, longer mechanical ventilation
duration, and more complications
Villet et al
• patients receiving <25% of prescribed energy requirements had higher risk for bloodstream
infection than other patients
Rubinson et al
33
Studies suggested that low caloric intake may
be detrimental and that higher caloric intake may be associated with improved
outcomes :• Patients in the enhanced nutrition group had a trend
toward better neurologic outcome 3 months postinjury and fewer
overall complications, including infections
Taylor et al
• Patients in the intervention hospitals had a significantly
shorter hospital LOS and a trend toward reduced mortality
ACCEPT
34
Evidence to support lowerthan-target :
• Moderate caloric intake was associated with better outcomes
in terms of mechanical ventilation duration, ICU LOS, and hospital mortality than higher levels of
caloric intake
Krishnan et al
• Patients who received lower calories had decreased ICU LOS, reduced duration of antibiotic therapy, and a trend toward
decreased mechanical ventilation duration
Dickerson et al
35
Evidence to support lowerthan-target :
• Patients in the early feeding group had higher incidences of VAP and Clostridium difficile– associated diarrhea and longer
ICU and hospital LOS
Ibrahim et
al
36
This study :
within this population, increasing caloric intake closer to target was associated with increasing mortality
and morbidity
37
Several potential mechanisms :
nutrition support
hyperglycemia
requires
higher insuli
n dosin
gASSOCIATED WITH
WORSE OUTCOME
38
Several potential mechanisms : ↑↑
enteral
feeding
↑↑ gastric
residuals
↑↑ risk of
aspiration
39
Several potential mechanisms :
reduces oxidative stress
attenuatesinflammatory response
affects the cardiovascular risk profile
alters several neuroendocrine and sympathetic nervous system functions
CALORIC RESTRIC
TION
THESE MECHANISMS DURING CRITICAL
ILLNESS ISUNCLEAR AT
PRESENT
40
The strengths & weaknesses of this study :
• the data extraction from an original prospective RCT
• the setting of a closed ICU with continuous coverage by critical care board-certified intensivists
• the nutrition assessment by full-time board-certified clinical dietician
STRENGTHS
• its being conducted in a single center• this study could not answer whether
patients should be “underfed” for a defined period of time or for the entire ICU stay
• the 3 tertile groups were different in their baseline characteristics
WEAKNESSE
S
41
CONCLUSIONThis study demonstrated that near-target
caloric intake is ASSOCIATED with significantly increased hospital mortality,
ICU-acquired infections, mechanical ventilation duration,
and ICU and hospital LOSThere is a need for a large RCT to examine the effects of permissive underfeeding vs
eucaloric/hypercaloric diet and also to identify the appropriate caloric needs
for critically ill patients
42
43
TELAAH KRITIS JURNAL
Near-Target Caloric Intake in Critically Ill Medical-Surgical Patients Is Associated
With Adverse Outcomes
Yaseen M. Arabi, Samir H. Haddad, Hani M. Tamim, Asgar H. Rishu, Maram H. Sakkijha, Salim H. Kahoul and
Riette J.BrittsJPEN J Parenter Enteral Nutr 2010 34: 280
44
1. UMUMHAL YANGDINILAI
CHECK LIST PENILAIAN YA TIDAK
JudulMakalah
a. Apakah judul tidak terlalu panjang atau terlalu pendek ?
b. Apakah judul menggambarkan isi utama penelitian ?
c. Apakah judul cukup menarik ?d. Apakah judul menggunakan singkatan
selain yang baku ?
√
√
√Tdk ada singk.
Abstrak a. Apakah merupakan abstrak satu paragraf atau abstrak terstruktur ?
b. Apakah sudah tercakup komponen IMRAC (Introduction, Methods, Result, Conclusion) ?
c. Apakah secara keseluruhan abstrak informatif ?
d. Apakah abstrak lebih dari 200 kata dan kurang dari 250 kata?
Terstruktur
√
√
√ 241
45
Pendahuluan a. Apakah mengemukakan alasan dilakukannya penelitian ?
b. Apakah menyatakan hipotesis atau tujuan penelitian ?
c. Apakah pendahuluan didukung oleh pustaka yang kuat dan relevan ?
√
√
√
Metode a. Apakah disebutkan desain, tempat dan waktu penelitian ?
b. Apakah disebutkan populasi sumber (populasi terjangkau) ?
c. Apakah kriteria pemilihan (inklusi dan eksklusi) dijelaskan ?
d. Apakah cara pemilihan subyek (teknik sampling) disebutkan ?
e. Apakah perkiraan besar sampel disebutkan dan disebut pula alasannya?
f. Apakah perkiraan sampel dihitung dengan rumus yang sesuai ?
√d/w
√
√
√
√
√
46
g. Apakah observasi, pengukuran serta intervensi dirinci sehingga orang lain dapat mengulanginya ?
h. Apakah defenisi istilah dan variabel penting dikemukakan ?
i. Apakah ethical clearance diperoleh ?
j. Apakah disebutkan rencana analisis, batas kemaknaan dan power penelitian ?
√
√Tdk
dijelaskan
√
Hasil a. Apakah disertakan tabel deskripsi subyek penelitian ?
b. Apakah karakteristik subyek yang penting (data awal) dibandingkan kesetaraannya ?
c. Apakah dilakukan uji hipotesis untuk kesetaraan ini ?
d. Apakah disebutkan jumlah subyek yang diteliti ?
√
√
√
√
47
e. Apakah dijelaskan subyek yang drop out dengan alasannya ?
f. Apakah semua hasil di dalam tabel disebutkan dalam naskah ?
g. Apakah semua outcome yang penting disebutkan dalam hasil ?
h. Apakah disertakan hasil uji statistik (x2,t) derajat kebebasan (degree of freedom), dan nilai p ?
i. Apakah dalam hasil disertakan komentar dan pendapat ?
√
√
√
√
Tidak ada DO
Diskusi a. Apakah semua hal yang relevan dibahas ?
b. Apakah dibahas keterbatasan penelitian dan kemungkinan dampaknya terhadap hasil ?
c. Apakah disebutkan kesulitan penelitian, penyimpangan dari protokol dan kemungkinan dampaknya terhadap hasil ?
√
√
√
48
d. Apakah pembahasan dilakukan dengan menghubungkannya dengan teori dan hasil penelitian terdahulu ?
e. Apakah dibahas hubungan hasil dengan praktek klinis ?
f. Apakah disertakan kesimpulan utama penelitian ?
g. Apakah kesimpulan didasarkan pada data penelitian ?
h. Apakah disebutkan hasil tambahan selama diobservasi ?
i. Apakah disebutkan generalisasi hasil penelitian ?
j. Apakah disertakan saran penelitian selanjutnya, dengan anjuran metodologis yang tepat ?
√
√
√
√
√
√√
49
KHUSUSValidity
Apakah awal penelitian didefenisikan dengan jelas ?
Ya. “…was conducted between January 2004 and March 2006…”
Apakah desain penelitian dinyatakan dengan jelas ?
Ya. ”This was a nested cohort study…”
Apakah ada pembanding yang jelas ?
Ya. ” The authors divided patients (n = 523) into 3 tertiles according to the percentage of caloric intake/target: tertile I <33.4%, tertile II 33.4%–64.6%, and tertile III >64.6%..”
Apakah follow up pasien dilakukan cukup panjang dan lengkap ?
Ya. “…was conducted between January 2004 and March 2006…”
50
Apakah faktor kausal dikemukakan ?
Ya. “…Therefore, it remains unclear what constitutes an appropriate dose of caloric intake for critically ill patients…”
Apakah kelompok-kelompok yang dibandingkan sebanding pada tahap awal ?
Tidak. “BMI, blood glucose on admission, and calculated caloric targets were similar in the 3 tertiles. Patients in tertile III had higher APACHE II scores and were more likely to be admitted for nonoperative reasons and to bemechanically ventilated. Although there was no significant difference in average blood glucose, patients in tertile III required higher doses of insulin to maintain target blood glucose level. Patients in tertile I received fewer calories from enteral feeding and propofol and more calories from intravenous glucose as compared to tertiles II and III.”
51
ImportantApakah outcome/hasil dipaparkan secara jelas (hasil uji statistik dengan nilai p) ?
Ya, sebagaimana yang telah ditampilkan pada Tabel 2, 3 dan 4, dan Figure 1 dan 2.
ApplicabilityApakah pasien kita mirip dengan subyek yang diteliti ?
Ya, pada pasien yang di rawat di ICU.
Apakah bukti ini akan mempunyai pengaruh yang penting secara klinis terhadap kesembuhan pasien kita tentang apa yang telah ditawarkan/diberikan kepada pasien kita ?
Ya, pemberian kalori yang tepat pada pasien-pasien ICU akan menurunkan morbiditas dan mortalitas.
52
53
Outcomes
54
Lancet 2009; 373: 1798–807
55
In the hospital setting, a combination of factors aff ect the development of stress hyperglycaemia (fi gure 2). The mechanisms for this disorder probably vary with the patients’ underlying glucose tolerance, type and severity of disease, and stage of illness. The cause of hyperglycaemia in type 2 diabetes is a combination of insulin resistance and β-cell secretory defects. However, the development of stress hyperglycaemia is caused by a highly complex interplay of counter-regulatory hormones such as catecholamines, growth hormone, cortisol, and cytokines (fi gure 3).
56
HPA axis
57