sccm/aspen critical care guidelines...

S C C M / A S P E N C R I T I C A L C A R E

G U I D E L I N E S W H A T ’ S N E W ?

Rebecca Stevenson RD Global Medical Affairs Nutricia

New SCCM & ASPEN Guidelines 2016

Content

The development of the guidelines Nutritional Assessment Initiate EN Dosing of EN Monitoring tolerance and adequacy of EN Selection of appropriate enteral form Other patient groups

SCCM & ASPEN Guidelines 2016

SCCM & ASPEN Guidelines 2016

GUIDELINES; Should never take priority over clinical judgement, they should be interpreted in context of the institutional setting importance. They are there to help you organize data, provide reference, a good start.

The evidence supporting the guidelines is GRADED mostly low to very low, as quality of studies are not comparable to pharmaceutical studies (budgets are much lower) and difficult feeding studies are difficult to blind.

(Prof Steve McClave, ASPEN 2016)

Introduction

Delivering early nutrition support therapy, primarily by the enteral route, is seen as a

proactive therapeutic strategy that may reduce disease severity, diminish complications,

decrease LOS in the ICU, and favorably impact patient outcomes

The target of these guidelines is intended to be the adult (≥18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical

ICU (MICU) or surgical ICU (SICU)

Historically see as a adjunctive care

Evolved to nutrition therapy

A. Nutritional Assessment

A2. We suggest not using nutrition indicators or surrogate markers and they are

not validated in the critical care setting.

ASPEN 2009 ASPEN 2016 Difference

No recommendation A1. Based on expert opinion Determine nutritional risk screening (e.g. using NRS 2002 or NUTRIC score) in those patients

admitted to ICU that can not take an adequate oral intake. High nutritional

risk identifies those patients most likely to benefit early EN therapy.

New recommendation

A3b. Indirect calorimetry (IC) used when available to measure energy

requirements, in the absence of IC use a simplistic weight based equation 25-

30kcal/kg/bwt

Very low grade of evidence

B. Initiate EN

B2. We suggest the use of EN over PN in critically

ill patients who require nutrition support therapy.


A4. EN should be started within 24-48 hours

following admission. The feedings should be

advanced towards goal over the next 48-72 hours

B1. We recommend that nutrition support is in the form of early EN initiated within 24-48 hours in the critically ill patient who is unable to maintain volitional intake

Similar

A3. EN is the preferred route of feeding over PN

for critically ill who requires nutrition support

therapy

B2. We suggest to use of EN over PN in critically ill patients who require nutrition support therapy

Similar

Early EN associated with reduced mortality

Updated meta-analysis of 21RCTs that met their criteria Early EN vs withholding early EN (delayed EN or STD) was associated with a significant reduction in mortality (RR = 0.70; 95% CI, 0.49–1.00; P = 0.05)

C. Dosing of EN


C2. >50-65% of goal calories should be provided in order to achieve the clinical benefit of EN over the first week of hospitalization (25-30kcal/kg)

C3. patients who are at high nutritional risk (e.g. NRS 2002≥5, or NUTRIC ≥5 should be advanced towards goal as quickly as tolerated over 24-48 hours while monitoring for refeeding. 80% goal energy & protein within 48-72 hours to achieve clinical benefits of EN over first week of hospitalization

Increase from 65% to 80% target should be met. Includes protein goal whereas, 2009 only specified energy

C4. Protein Requirements

Optimal protein and energy targeting

using measured energy expenditure and

1.2-1.5g protein per kg body weight was

associated with 50% reduction in

hospital mortality

Highest protein provision had highest

28-day survival

Importance of successful feeding

Allingstrup MJ, et al. Clin Nutr 2012;31:462–468; Weijs PJ, et al. JPEN J Parenter Enteral Nutr 2012;36:60–68.

This content may not be amended, modified or commercially exploited without prior written consent.

D.D. Monitoring Tolerance and Adequacy of EN


No recommendation D2a. GRVs NOT to be used as part of routine care to monitor ICU patients

receiving EN

New guidelines

D2. holding EN for GRV <500mls should

be avoided in absence of other signs of

intolerance

D2b. In ICUs where GRVs are still utilized, holding EN for GRV<500mls

in the absence of other signs of intolerance should be avoided

Same

Rationale: GRVs do not correlate with incidence of pneumonia, regurgitation, or aspiration.

Should GRV be measured?

Absence of gastric

volume monitoring

was not inferior to

routine gastric

residual volume

monitoring

This content may not be amended, modified or commercially exploited without prior written consent.

Reignier J, et al. JAMA 2013;309:249–256.

D. EN Protocol


D.3 Use EN protocol increases increases the

overall percentage of goal calories provided

and should be implemented

D3a. EN feeding protocols designed and implemented to increase the overall percentage of goal calories provided. D3b. suggest considering volume based feeding protocol or a top-down multi-strategy protocol.

New recommendation

E. Selection of appropriate enteral formula General immune-modulating enteral formulas (supplemented with arginine, glutamine, nucleic acid, omega 3 fatty acids and antioxidants)


E1. Immune modulating EN use in appropriate patients (major elective surgery, trauma, burns, head & neck cancer), & critically ill patients on mechanical ventilation, with caution in severe sepsis

E2. Should NOT be used routinely in the MICU. Consider in TBI & peri-operative patients in the SICU E.1 Standard polymeric formula, when initiating EN in the ICU setting. We suggest avoiding the routine use of all specialty formulas in critically ill patients in the medical ICU and disease specific formulas in the surgical ICU

Only recommended now for TBI and

peri-operative SICU


ARDs & severe ALI (acute lung injury)

should be on an EN formula with an anti-

inflammatory lipid profile (ie, omega 3 fish

oils, borage oils) & antioxidants

CAN NOT make a recommendation at this time (as per 2009) due to conflicting data.

cannot make a recommendation

• We suggest avoiding the routine use of all specialty formulas in critically ill patients in MICU and disease specific in the SICU

• IMN only in postoperative phase

• Pulmonary formulas with omega 6 may drive inflammation – no recommendation

E.3 Fish oils – specialty formulas

6 RCTS in ARDS, ALI and sepsis. Great heterogeneity of method of infusion. Aggregating studies showed no sig reduction ICU LOS, duration of mechanical ventilation. Rice study contained

additional 16g protein/day in control compared to 4g in study group.

Date of download: 2/25/2016 Copyright © 2016 American Medical

Association. All rights reserved.

From: Enteral Omega-3 Fatty Acid, γ-Linolenic Acid, and Antioxidant Supplementation in Acute Lung Injury

JAMA. 2011;306(14):1574-1581. doi:10.1001/jama.2011.1435

Bolus study and the control product had higher protein content Study stopped due to futility. Possible indication of harm in supplemented

patients with ALI

F4.Glutamine


Glutamine should be considered in burn,

trauma & mixed ICU patients

EN glutamine should NOT be added to an EN regimen routinely in critically ill patients

New recommendation

Metaplus


B.1 Start PN> 8 days in the case

enteral nutrition not

reaching calorie targets

G1. patient at low nutrition risk NRS≤3 or NUTRIC ≤5 exclusive PN

be withheld over the first 7 days following ICU admission if the

patient cannot maintain volitional intake and if early EN is not

feasible G2. if patient is determined to be

high nutrition risk (NRS≥5 or NUTRIC ≥5 or severely

malnourished, when EN is not feasible, we suggest initiating PN as soon as possible following ICU

admissions

New recommendation –

consider early PN in those malnourished

or high nutritional risk

G. When to use PN

EPaNIC primary endpoints Late PN Early PN P-value

Discharged alive within 8 days 75.2 % 71.7 % P = 0.007

ICU stay (days) median (IQR) 3 (2 – 7)

(mean 8)

4 (2 – 9)

(mean 9) P = 0.02

Time to alive discharge from ICU

Hazard ratio (95%CI) Adjusted cox proportional hazard analysis

1.063 (1.002 – 1.128) P = 0.04

G. When to start PN: data influencing

M. Surgical


E1. IMN recommended in trauma

M1a. We suggest that, similar to other critically ill patients, early enteral feeding with a high protein polymeric diet be initiated in the immediate post trauma period (within 24-48 hours of injury) once the patient is haemodynamically stable . Energy in the ranges of 20-35kcal/kg depending on phase, lower energy provision in resuscitative phase, higher in rehabilitation phase. 1.2 – 2g/kg/bwt /day protein May benefit from volume based feeding approach

New recommendation Also mention M1b. IMN containing arginine and

fish oil considered in patients with severe

trauma (very low quality of evidence)

AM2b. expert consensus arginine IMN in TBI

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwisp7qdsO3KAhXsF5oKHVHYDS4QjRwIBw&url=http://www.canstockphoto.com/illustration/trauma.html&psig=AFQjCNHOBRKe0n-bFXOZGaFP-ObtyIABRQ&ust=1455199874406758


No equivalent recommendations

Expert consensus, EEN (24-48 hours post-injury) in patients treated with OA in the absense of a bowel injury. Suggest providing 15-30g per liter of exudate lost for patients with OA Energy needs determined same for other ICU patients

New recommendation

Multicentred, restrospective data of n-597 patients with OA 307 with no bowel injury showed that use of EN assoss with sign. Reduction in abdominal fascial closure, pneumonia,

compllications and mortality (Burlew et al 2012). EEN restrospective review found early fascial closure and less fistula formation (Collier et al 2007)

M3a.Open Abdomen


No recommendation

M4a. Based on expert consensus, EN should be provided to burn patients whose GI tracts are functional and for whom volitional intake is inadequate to meet estimated energy needs. M4b. IC be used when available to assess energy need in burn patients with weekly repeated measures. M4c. Protein 1.5g to 2g/kg/d (supported by ESPEN and 2001 American burn association

New recommendation

M4. Burns

M4d. Early initiation within 4-6 hours of injury.

Predictive equations poor accuracy in estimating energy needs in burns >20% total body surface area. Small protein turnover study in 6 adults with mean 70% total body surface area burn, 1.4 /g/kg versus 2.5g/kg

showed increase catabolism with highest dose 2.5g/kg/bwt Wolfe 1983


No equivalent recommendations

Expert consensus, we suggest the provision of trophic feeding (defined as 10-20g kcal/h or up to 500 kcal/d for the initial phase of sepsis, advancing as tolerated after 24-48 hours to >80% of target goal over the first week. We suggest delivery of 1.2-2g protein /kg /d

New recommendation

Restoring effective circulating volume takes priority in shock states, particularly septic and hypovolemic shock.

Early enteral nutrition can be safely provided to patients on vasopressor support in septic shock

N1. Sepsis


Q4. Based on expert consensus we suggest that high protein hypocaloric feeding be implemented in the care of the obese patient to preserve lean mass, mobilize stores and minimize the metabolic complications. Use IC and if unavailable use weight based equation 11-14kcal/kg actual body weight BMI 30-50 and 22-25kcal/kg IBW BMI>50. Protein should be provided 2/g/kg IBW with BMI 30-40 up to 2.5g/kg IBW BMI>40.

New recommendation

Q. Obesity

Q1. Early EN initiation within 24-48 hours.

Key take home messages

• Determine nutritional risk in all patients

• Avoid routine use of IMN in the MICU

• Avoid routinely adding glutamine to EN regimen

• IMN only in post-operative phase SICU

• Avoid specialty formulas in SICU

• High protein 1.5 – 2g/kg/bwt/day

• Aim for 80% nutritional target for energy and protein 24-48 hrs

• Use indirect calorimetry if available

• No routine measurement of GRVs

• EEN in sepsis is safe, advance 48-72 hours to >80% target as tolerated

THANK YOU

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