Proteintargetsincriticalillness

DanielleBearHEE/NIHRClinicalDoctoralFellow&CriticalCareDietitianGuy’sandStThomas’NHSFoundationTrust,London,UK

@danni_dietitian

CONFLICTS

Conferencefees,advisoryboard,consultingandhonorariafrom:

• Nutricia• NestleNutrition• Baxter• FreseniusKabi• AbbottNutrition

OBJECTIVES1. Tounderstandcurrentliteraturesupporting

recommendedproteintargetsincriticalillness

2. Todiscussthecurrentcontroversiessurroundingrecommendedproteintargetsincriticalillness

3. Tounderstandfactorswhichmayimpactproteintargetsincriticalillness

4. Tocalculateproteintargetsforvariouspatientgroupsofcriticallyillpatients

Clinical Nutrition (2006) 25, 210–223

ESPEN GUIDELINES

ESPEN Guidelines on Enteral Nutrition:Intensive care$

K.G. Kreymanna,!, M.M. Bergerb, N.E.P. Deutzc, M. Hiesmayrd, P. Jolliete,G. Kazandjievf, G. Nitenbergg, G. van den Bergheh, J. Wernermani,DGEM:$$ C. Ebner, W. Hartl, C. Heymann, C. Spies

aDepartment of Intensive Care Medicine, University Hospital Eppendorf, Hamburg, GermanybSoins Intensifs Chirurgicaux et Centre des Brules, Centre Hospitalier Universitaire Vaudois (CHUV)-BH08.660, Lausanne, SwitzerlandcDepartment of Surgery, Maastricht University, Maastricht, The NetherlandsdDepartment of Anaesthesiology and Intensive Care, Medical University of Vienna, Vienna, AustriaeDepartment of Intensive Care, University Hospital Geneva, Geneva, SwitzerlandfDepartment of Anaesthesiology and Intensive Care, Military Medical University, Sofia, BulgariagDepartment of Anaesthesia, Intensive Care and Infectious Diseases, Institut Gustave-Roussy,Villejuif, FrancehDepartment of Intensive Care Medicine, University Hospital Gasthuisberg, Leuven, BelgiumiDepartment of Anaesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge,Stockholm, Sweden

Received 20 January 2006; accepted 20 January 2006

KEYWORDSGuideline;Clinical practice;Evidence-based;Enteral nutrition;Tube feeding;Oral nutritional sup-plements;Parenteral nutrition;Immune-modulatingnutrition;

Summary Enteral nutrition (EN) via tube feeding is, today, the preferred way offeeding the critically ill patient and an important means of counteracting for thecatabolic state induced by severe diseases. These guidelines are intended to giveevidence-based recommendations for the use of EN in patients who have acomplicated course during their ICU stay, focusing particularly on those who developa severe inflammatory response, i.e. patients who have failure of at least one organduring their ICU stay.

These guidelines were developed by an interdisciplinary expert group inaccordance with officially accepted standards and are based on all relevant publica-tions since 1985. They were discussed and accepted in a consensus conference.

EN should be given to all ICU patients who are not expected to be taking a full oraldiet within three days. It should have begun during the first 24 h using a standard

ARTICLE IN PRESS

http://intl.elsevierhealth.com/journals/clnu

0261-5614/$ - see front matter & 2006 European Society for Clinical Nutrition and Metabolism. All rights reserved.doi:10.1016/j.clnu.2006.01.021

$For further information on methodology see Schutz et al. 69 For further information on definition of terms see Lochs et al. 70

!Corresponding author. Tel.: +49 40 42803 7010; fax: +49 40 42803 7020.E-mail address: kreymann@uke.uni-hamburg.de (K.G. Kreymann).

$$The authors of the DGEM (German Society for Nutritional Medicine) guidelines on enteral nutrition in intensive care areacknowledged for their contribution to this article.

Special Interest

The following article is one of two articles offered for continuing education credit in thisissue. Please see page 382 for details.

Canadian Clinical Practice Guidelines for Nutrition Support inMechanically Ventilated, Critically Ill Adult Patients*

Daren K. Heyland, MD, FRCPC, MSc*; Rupinder Dhaliwal, RD*; John W. Drover, MD, FRCSC, FACS†;Leah Gramlich, MD, FRCPC‡; Peter Dodek, MD, MHSc§; and the Canadian Critical Care

Clinical Practice Guidelines Committee

From the *Department of Medicine and the †Department of Surgery, Queen’s University, Kingston, Ontario; ‡Department of Medicine, Division ofGastroenterology, University of Alberta, Edmonton; and §St. Paul’s Hospital, Center for Health Evaluation and Outcome Sciences,

Vancouver, British Columbia, Canada

ABSTRACT. Objective: This study was conducted to developevidence-based clinical practice guidelines for nutrition sup-port (ie, enteral and parenteral nutrition) in mechanicallyventilated critically ill adults. Options: The following inter-ventions were systematically reviewed for inclusion in theguidelines: enteral nutrition (EN) versus parenteral nutri-tion (PN), early versus late EN, dose of EN, composition ofEN (protein, carbohydrates, lipids, immune-enhancing addi-tives), strategies to optimize delivery of EN and minimizerisks (ie, rate of advancement, checking residuals, use ofbedside algorithms, motility agents, small bowel versus gas-tric feedings, elevation of the head of the bed, closed deliverysystems, probiotics, bolus administration), enteral nutritionin combination with supplemental PN, use of PN versusstandard care in patients with an intact gastrointestinaltract, dose of PN and composition of PN (protein, carbohy-drates, IV lipids, additives, vitamins, trace elements,immune enhancing substances), and the use of intensiveinsulin therapy. Outcomes: The outcomes considered weremortality (intensive care unit [ICU], hospital, and long-

term), length of stay (ICU and hospital), quality of life, andspecific complications. Evidence: We systematically searchedMEDLINE and CINAHL (cumulative index to nursing andallied health), EMBASE, and the Cochrane Library for ran-domized controlled trials and meta-analyses of randomizedcontrolled trials that evaluated any form of nutrition supportin critically ill adults. We also searched reference lists andpersonal files, considering all articles published or unpub-lished available by August 2002. Each included study wascritically appraised in duplicate using a standard scoringsystem. Values: For each intervention, we considered thevalidity of the randomized trials or meta-analyses, the effectsize and its associated confidence intervals, the homogeneityof trial results, safety, feasibility, and the economic conse-quences. The context for discussion was mechanically venti-lated patients in Canadian ICUs. Benefits, Harms, and Costs:The major potential benefit from implementing these guide-lines is improved clinical outcomes of critically ill patients(reduced mortality and ICU stay). Potential harms of imple-menting these guidelines include increased complicationsand costs related to the suggested interventions. Summaries ofEvidence and Recommendations: When considering nutritionsupport in critically ill patients, we strongly recommend thatEN be used in preference to PN. We recommend the use of astandard, polymeric enteral formula that is initiated within24 to 48 hours after admission to ICU, that patients be caredfor in the semirecumbent position, and that arginine-contain-ing enteral products not be used. Strategies to optimize deliv-ery of EN (starting at the target rate, use of a feeding protocolusing a higher threshold of gastric residuals volumes, use ofmotility agents, and use of small bowel feeding) and mini-mize the risks of EN (elevation of the head of the bed) shouldbe considered. Use of products with fish oils, borage oils, and

Received for publication January 31, 2003.Accepted for publication May 28, 2003.Correspondence: Daren Heyland, MD, FRCPC, MSc, Kingston Gen-eral Hospital, Kingston, Ontario, Canada K7L 2V7. Electronic mailmay be sent to dkh2@post.queensu.ca.

†This guideline was funded by unrestricted grants from the Cana-dian Institute of Health Research, The Canadian Critical Care Soci-ety, and The Canadian Society for Clinical Nutrition.‡Dr. Heyland is a Career Scientist of the Ontario Ministry of Health.

*This study was the work of the Canadian Critical Care Practice Guidelines Committee, a broadly representative committee of Canadianphysicians and nutritional authorities with representation from United States and Canadian nutritional organizations, and externaladvisors from the nutritional industry. The membership of the Committee is listed in Appendix I. The recommendations contained inthis report do not represent official policy of A.S.P.E.N., nor has there been any explicit endorsement by A.S.P.E.N., nor isthere an endorsement implied by the publication of this report in the Journal of Parenteral and Enteral Nutrition. The findingsand recommendations contained in this report are to be used to assist in the care of patients only as the result of the professional judgmentof the attending health professional.

0148-6071/03/2705-0355$03.00/0 Vol. 27, No. 5JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Printed in U.S.A.Copyright © 2003 by the American Society for Parenteral and Enteral Nutrition

355

CRITICALCARENUTRITIONGUIDELINES

PROTEINTARGETS1.2g/kg 2.0g/kg 2.5g/kg

GeneralICU

Trauma

Burns

Obesity

1.5g/kg

Trauma

CRRT

SurgicalProteinlossesinexudate(12-30g/L)

SYSTEMATICREVIEW• Clinicaltrialsinvestigatingdifferentproteinintakesincriticalillness• 12investigatingnitrogenbalance• 3investigatingwhole-bodyproteinturnover• 1investigatingchangeinbodycomposition

Hoffer&Bistrian.AJCN2012;96:591–600

• Allshowedimprovementswithincreasedproteinintakes• Plasmaaminoacidprofile• Nitrogenbalance• Proteinturnover• Clinicaloutcomes

Higherproteinisassociatedwithreducedmortality

PROTEINTRACERSANDMUSCLEBIOPSY

• Observationalstudyinvestigatingequivalentof1g/kg/dayparenteralaminoacidson3-hourwholebodyproteinturnover.

• n=13studiedonce&n=7twice

• Wholebodyproteinbalanceincreasedonbothoccasions• Duetoincreasedproteinsynthesis• Aminoacidoxidationnotincreased

MUSCLEULTRASOUND

Higherparenteralaminoacidintake(0.9g/kg/dayvs1.1g/kg/day)

ü Improvedhandgripstrength(ICUandhospitaldischarge)ü ImprovedFatiguescoreü Reducedmusclewasting

Ferrieetal.JPEN2016;40:795-805

ComputedTomography• LowMusclemassassociatedwith• Mortality• Ventilator-freedaysandLOS• 63-70%ofpatientshavelowmusclemass

PoulsenCCM2011,MoiseyCritcare2013,WeijsCritCare2014,BraunschweigJPEN2014

PROTEIN INTAKES IN PATIENTS WITH LOW MUSCLE MASS

VARSNOMINATIONLooijaardetal,2017,Unpublished

Higher protein intake associated with reduced mortality (28 day, hospital and 6-month) in patients with LOW muscle mass

AssociationBetweenNutritionalAdequacyandSF-36Scores

*Every25%increaseinnutritionaladequacy;adjustedforage,APACHEIIscore,baselineSOFA,FunctionalComorbidityIndex,admissioncategory,primaryICUdiagnosis,bodymassindex,andregion

Weietal,2015CCM.

SF-36 AdjustedEstimate*(95%CI) p-value

PhysicalFunctioning 3-month(n=179)

7.29(1.43,13.15) 0.02

6-month(n=202)

4.16(-1.32,9.64) 0.14

RolePhysical 3-month(n=178)

8.30(2.65,13.95) 0.004

6-month(n=202)

3.15(-2.25,8.54) 0.25

PhysicalComponentScale

3-month(n=175)

1.82(-0.18,3.81) 0.07

6-month(n=200)

1.33(-0.65,3.31) 0.19

Study Intervention ResultsEPaNIC EarlyvslatePN êMusclequalityinearlyPN

groupéWeaknessinearlyPNgroup(MRC-sumscore)

FasterrecoveryinlatePNgroup

MUSCLE-UK Nil- observational é Proteinintakewithémusclewasting

Higherproteinleadstoworseoutcome

HOWDOESITWORKINPRACTICE?

üWHO isthepatient?

üIF youshouldfeed(safetyandfeasibility)

üWHEN youshouldfeed(timing)

üHOW youshouldfeed(route)

üWHAT youshouldFEED(typeandamount)

üWHAT youaretryingtoachieve

NUTRITIONALSTATUS&ASSESSMENT

Parameter LIMITATIONWeight Calibrationofbedscales

Fluidshifts

Height UnabletostandDemispan/Ulnalengthinaccurate

BMI Asabove

WeightHistory Canaskfamily(?notasaccurate)Medicalnotesifuptodate

DietHistory Asabove

Biochemicalparameters Oftenassociatedwithinflammation

VARIABLE RANGE POINTS

Age <5050- <75≥75

012

APACHEII <1515- <2020– 28≥28

0123

SOFA <66- <10≥10

012

Numberofco-morbidities 0– 1≥2

01

DaysfromhospitaltoICUadmission

0- <1≥1

01

NUTRICScore• Developedbasedonacuteandchronicfactorsthataffectnutritionalstatus

• Patientsareconsidered‘highnutritionrisk’withascoreof≥5

http://www.scymed.com/enmi/smnxpw/pwfbd770_m.htmFerreiraetal.JAMA2001;286(14):17541758

TheAPACHEIIandSOFAScoresarerequiredforcalculationtheNUTRICscore

NRS2002

NutritionalRiskScreening(NRS2002)

Table1:Initialscreening Yes No

1 IsBMI<20?

2 Hasthepatientlostweightwithinthelast3months?

3 Hasthepatienthadareduceddietaryintakeinthelastweek?

4 Isthepatientseverelyill?(e.g.inintensivetherapy)

Yes: Iftheansweris'Yes'toanyquestion,thescreeninginTable2isperformed.No: Iftheansweris'No'toallquestions,thepatientisre-screeningatweeklyintervals.Ifthepatiente.g.isscheduledfora majoroperation,apreventivenutritionalcareplanisconsideredtoavoidtheassociatedriskstatus.

Kondrupetal.ClinNutr2003;22(4):415-421

NRSisatwo-stepscreeningtool.PatientsintheICUautomaticallyprogresstostep2.

Table2:Finalscreening

Impairednutritionalstatus Severityofdisease(» increaseinrequirements)

AbsentScore0

Normalnutritionalstatus AbsentScore0

Normalnutritionalrequirements

MildScore1

Wtloss>5%in3mthsorFoodintakebelow50-75%ofnormalrequirementinpreceding

week.

MildScore1

Hipfracture*Chronicpatients,inparticularwithacutecomplications:cirrhosis*,COPD*.Chronichemodialysis,diabetes,oncology.

ModerateScore2

Wtloss>5%in2mthsorBMI18.5- 20.5+impairedgeneralconditionorFoodintake25-50%ofnormalrequirementinprecedingweek

ModerateScore2

Majorabdominalsurgery*Stroke*Severepneumonia,hematologicmalignancy.

SevereScore3

Wtloss>5%in1mth(>15%in3mths)orBMI<18.5+impairedgeneralconditionorFoodintake0-25%ofnormalrequirementinprecedingweekin

precedingweek.

SevereScore3

Headinjury*Bonemarrowtransplantation*Intensivecarepatients(APACHE>10).

Score + Score: =Totalscore:

Age if³ 70years:add1tototalscoreabove = age-adjusted total score:

Score³3:the patient is nutritionally at-risk and a nutritional care plan is initiatedScore < 3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status.

NRS2002

Kondrupetal.ClinNutr2003;22(4):415-421

NRS2002maynotbespecificenoughasitclassifiesallcriticallyillpatientsas‘highrisk’whichmaynotbethecase

• Age• BodyMassIndex• Musclemass• Severityofillness• Admissioncategory• Lengthofstay(LOS)inhospitalpriortoICU• PredictedICULOS• Co-morbidities

NOTALLICUPATIENTSARETHESAME!

ButwhichweightdoIuse?• Idealoractualbodyweightwillleadtounderfeedinginsome

patientsandoverfeedinginothers

• ShouldbebasedonFatFreeMass(FFM),butnoreliablebedsidetool• MightbeaplaceforBIAorCTinthefuture

ProteinTarget(BMI_20_30formula)

BMI20–30 1.2g/kgactualbodyweight(ABW)

BMI<20 1.2gxheight(m2)x20

BMI>30 1.2gxheight(m2)x27.5

Weijsetal,ClinNutr;2011

WhatdoIdoinpractice?• Underweight(BMI<18.5kg/m2)• Useactualbodyweight

• Normalweight(BMI19-25kg/m2 )• Useactualbodyweight

• Overweightandobese• Useidealbodyweight(adjustedtoBMI23kg/m2)

HOWDOYOUMEETTHETARGETSINPRACTICE?

HOWDOYOUMONITORTHESEPATIENTSINPRACTICE?

CASESTUDIES• Whatwouldyouconsiderinyournutritionassessment?

• Doesthispatienthaveanyadditionalconsiderationswhichmayaffecttheirproteintarget?

• Whichweightwouldyouusetocalculatetheproteintarget?

• Whatproteintargetwouldyouaimfor?

CASESTUDY171yearold♀ admittedwithtype2respiratoryfailureduetoexacerbationofCOPD.

PMHxCOPD,hypertension

Intubatedandventilated,propofolforsedation,butweaningoff

AnthropometryWeight73kg;Height161cm;BMI28kg/m2

Youreviewher72hoursintoherICUadmission.

CASESTUDY276yearold♂ admfromtheatrefollowingbowelresectionandwashoutforfourquadrantfaecalperitonitiswithmultipleperforationsaroundanastomosis.Abdomenleftopen

2/52ago,hadanteriorresectionforColonCa(shortICUstay,butmanagedontheward)

Intubatedandventilated,propofolforsedation

AnthropometryWeight62kg;Height178cm;BMI19.5kg/m2

4kgweightlosssinceadmissionwith5%weightlossin3monthspriortosurgery

ReferralforPNonday1post-op

CASESTUDY319yearold♂ admfollowinghighspeedroadtrafficaccident

•Leftsubduralhaemorrhageanddiffusebrainswelling•MultipleC-Spinefractures•Complexbilateralfacialandbasalskullfractures•Largebilaterallungcontusions

Intubatedandventilated,sedatedandparalysed

AnthropometryWeight120kg;Height178cm;BMI38kg/m2

Youreviewwithin72hoursofadmissiontotheICU

CONCLUSIONS• Higherproteinintakesincriticalillnessmayimproveoutcome

• Individualised nutritionassessmentisrequiredtodetermineappropriateproteinintakesandmethodsofdeliveryforeachpatient

• Monitoringisessential!

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McClaveetal.JPEN2016;40(2):159-211

Singeretal.ClinNutr2014;33;246-251

Chobanetal.JPEN2013;37;714-44

Ishibashietal.CritCareMed1998;26;1529-35

Diazetal.JTrauma.2010;68(6):1425-1438

Cheathametal.CritCareMed.2007;35(1):127-131.

Houriganetal.NutrClinPract.2010;25(5):510-516.