on the use of en/pn in surgical patients on icu · 2014-02-11 · vvkvm symposium “combinatie...
TRANSCRIPT
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VVKVM Symposium “Combinatie EN-PN” Boom, 14 december 2013
A surgeon’s view
on the use of EN/PN
in surgical patients on ICU
Dirk YSEBAERT
Antwerp University Hospital
Belgium
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Disclosures
I have no disclosures related to this topic.
This presentation is a personal view,
not a systematic review of the evidence.
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Surgical ICU patients
• Prolonged postop ICU stay after major GI surgery :
• Pancreatectomy - hepatectomy
• Esophagectomy
• Major GI resections – debulking surgery
• .......
• ICU admission of postop patients with postop
complications after initial uneventful recovery
• Polytraumatised patients
• ...
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Trials in perioperatieve nutritional support or ICU patients
– Variations nutritional status of included patients
– Different underlying pathology in malnourished patients
– Different types and length of nutritional support
– Type II statistical error
– “surgical patients “, “critically ill patients”, “GI cancer patients”,.....
How to make solid conclusions ?
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Critically ill patients
Surgical patients
GI Cancer patients
ICU
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Re
stin
g M
eta
bo
lic E
xpe
nd
iture
EBB fase FLOW fase / katabole fase Anabole fase
1dag 5-50 dagen
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Perioperative Nutritional Support
Attempts to preserve lean body mass following a surgical or traumatic stress
Efforts to - attenuate the hypermetabolic response
- reverse loss of lean body mass
- prevent oxidant stress
- favourably modulate the immune response with early enteral feeding
- attain meticulous glycemic control
- administer appropriate macro- and micronutrients
Shift of goals !
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Surgical ICU patients...
How to deal with complicated surgery or surgery with
complications ?
- Are they different from “medical” ICU patients and how different ?
- Intestinal surgery complicates the “compromised gut” in critically-ill
patients...
- Where is the moment of the complication in the timeline of post-
traumatic metabolism ?
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Issues to discuss
1. When to start nutrition?
2. What route to use: EN or PN?
3. How much to give and what ?
4. Who is at special risk ?
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1.Timing of nutrition
2. Protein content
3. Micro- & macronutrients
Questions
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The rationale for nutrition in ICU patients
a cumulated energy deficit is associated
with a higher mortality and morbidity
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Krishnan et al. Chest 2003
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jw12
• Prospective observational study
• n = 2772 ICU patients of 167 ICU from 37 countries
• During 12d: recording of nutritional intake:
– 68%EN & 8% PN & 17,6% EN+PN & 5,4% nihil
• 60d mortality and ventilator free days
• BMI = nutritional status
• 59,2% of energy prescribed & 56% of protein prescribed
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<20(n=289)
20-25(n=937)
25-30(n=818)
30-35(n=395)
35-40(n=162)
>40(n=171)
BMI
0
500
1000
1500
2000
2500kcal/24h
prescribed kcal
received kcal
Alberda, ICM 2009
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Alberda, ICM 2009
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jw12
• Average 1034kcal/d & 47g prot/day
• Conclusions:
– > 1000 kcal/d: significant decrease of mortality when BMI<25 and BMI >=35
– > 30g proteins significant decrease of mortality when BMI<25 and BMI >=35
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Villet, Clin Nutr 2005;24:502
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Cumulated energy deficit v. infections
Villet, Clin Nutr 2005;24:502
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Increasing Caloric Debt is associated with worse outcome
Caloric debt :
Longer ICU stay Days on MV Complications Mortality
Adequacy of EN ?
0
200
400
600
800
1000
1200
1400
1600
1800
2000
1 3 5 7 9 11 13 15 17 19 21
Days
kcal
Prescribed Engergy
Energy Received From Enteral Feed
Caloric Debt
Villet, Clin Nutr 2005;24:502
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TEN or TPN on ICU ?
No evidence for a mortality difference between patients
randomised to either enteral or parenteral nutrition, but
there may be a morbidity difference
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Indirect evidence
1. Malnutrition is dangerous
2. Energy deficit is dangerous
3. EN & PN carries equal mortality
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NEJM 2011;365:506-17
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totalinfections
airwayinfections
bloodinfections
woundinfections
0
10
20
30
frac
tio
n in
fecte
d (
%)
**
early PN
late PN
**
***
early PN late PN
0
20
40
60
80
100
fractio
n d
isch
arg
ed
aliv
e o
n d
ay 8
(%
)
**
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Comments 1. Broad inclusion criteria
2. Overrepresentation of open hart surgery
3. High energy supply
4. High initial glucose supply
5. NO place for (dogmatic) protocol nutritional intervention
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Lancet 2013;381:385-93
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SPN 2012
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Comments
1. Narrow inclusion criteria (10%)
2. MOF patients
3. Unorthodox primary endpoint
4. High energy supply (ESPEN Guidelines)
5. Indirect calorimetry (200-300 kcal lower)
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JAMA 2013;309:2130-2138
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Comments
1. Narrow inclusion criteria (27 units, 104 months)
2. Homogenous patient group
3. Pragmatic study
4. Not overfed
5. Result difficult to interpret
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General conclusion on timing of PN supplementation
1. No mortality differences
2. No guidance which patients are at risk
3. Unclear if EE should be caloric target
4. Mechanistic studies rather than RCTs are needed
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POSToperative nutritional support
Indication for TPN in patients with/who :
– Malnourished patients unable to have quick (48 h) adequate enteral nutrition
– Abnormal gut function
– Cannot consume adequate amounts of nutrients by enteral feeding
– Are anticipated to not be able to eat orally by 5-7 days
– Prognosis warrants aggressive nutritional support
= grade C
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What about protein ? - wound repair
- muscle metabolism
-...
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0 0.10 0.20 0.25 0.30
-100
-80
-60
-40
-20
0
Cu
mu
late
d n
itro
gen
bala
nce o
ver
1 w
(g
N)
daily nitrogen supply ( g/kg bw)
Larsson et al, Br J Surg 1990;77:413
Br J Surg 1990;77:413
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jw12
• n = 113 mixed medical – surgical ICU patients
• 25-30 kcal/kg/d & 1.2-1.5g prot/kg/d until indirect calorimetry
• Indirect caloritmetry every day/2nd day (except WE)
• Daily N-balans (24h urea-N excretion + 2g+2g)
• EN within 24h + if needed PN
• Kcal from albumin, propofol included
• Patients were ranked in 3 groups according to protein/AA intake:
– Low (53,8g/d) – medium (84,3g/d) – high (114.9g/d)
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Low – medium – high g prot/AA/kg/d
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• Non-infectious complications occurred significantly earlier in the low prot/AA group
• Infectious complications: no sign diff in the time laps to the first infectious complication
• Variables predicting outcome:
• Age
• Apache II score
• Average SOFA
• Provision of prot/AA (persisted when corrected for these variables)
• Provision of energy, N- and energy-balance was not related to survival
Based on these results: 1,5g prot/AA /kg/d is recommended.
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jw12 bFRANC Nov 30, 2012
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Conclusions
1. Very poor evidence behind guidelines
2. A lot of religious beliefs out there
3. A modest attitude is recommended
4. Mechanistic studies are badly needed
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?
?
?
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From evidence to practice…
1. Optimize enteral feeding
2. Careful PN supplementation case-by-case
3. Avoid over- and underfeeding
4. Consider change of patient population profile
5. Optimize calculation of needs
6. Involve dietician on ICU
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1. Optimize enteral nutrition
• Chirurgische plaatsing van sonde:
– Gastraal – meerdere lumen
– Jejunaal
• Prokinetica
• Maagresidu?
• Geconcentreerde sondevoeding?
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2. PN supplementation
Weigh safety and benefits of PN initiation in patients not tolerating EN on an individual case-by-case basis - not dogmatic -
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3. Avoid over- and underfeeding
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4. Patient population is changing !
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A. Baseline with expert developed bottom-down nutrition protocol
B. 3months after implementation of an interdisciplinary bottom up protocol
C. 1y later with dedicated ICU dietician
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Thoughts & practise
• Respect ebb-phase / respect autophagy
• Respect surgical trauma metabolism
• Optimize EN from start
• If preop malnutrition : immediately EN+PN
but PN gradually (cave refeeding)
• Avoid deficit by liberal but careful PN addition with 4-5 days
(not dogmatic) target 25 Cal/kg
• Improve calculation of the needs : indirect calorimetry
• Target protein 1,2- 1,5 g/kg/d instead of calories
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Take home message
1. Trials do not tell us the best moment of when
to supplement PN above EN
2. Trials do not tell us how and when to identify
the individual patient that will benefit most
from added calories
3. It is time for mechanistic studies
4. Individualize nutrition support