5/9/2015

1

Annette Stralovich-Romani, RD, CNSC Adult Critical Care Nutritionist

UCSF Medical Center

NO DISCLOSURES

Incidence & consequences of malnutrition

Underfeeding in the ICU

◦ Causes/ consequences

Nutrition intervention

◦ What is the optimal amount of calories/protein in the

critically ill patient?

Strategies for improving enteral nutrient delivery

On hospital admission: 30-50%

On ICU admission: 50-55%

Malnutrition contributes to:

◦ Increased morbidity & mortality

◦ Decreased function & quality of life

◦ Increased frequency and length of hospital stay

◦ Higher healthcare cost

Nutritional status declines with length of stay

Early identification & intervention can lead to cost-

effective and beneficial outcomes

5/9/2015

2

Preexisting malnutrition / nutritional compromise Admission to hospital / ICU Stress / Inflammation ◦ Hormonal Response: Catecholamines, glucagon, cortisol ◦ Humeral Response: Cytokines (TNF, IL-1, IL-6)

Hypermetabolism (increased energy expenditure) Accelerated proteolysis (LBM breakdown) Insulin resistance

Nosocomial infections ◦ VAP, C.Difficile, Central line infection

UNDERFEEDING

Prevalence: 40-50% of prescribed EN received in

the first 2 weeks after ICU admission

Causes:

◦ GI Symptoms

◦ Underestimating nutrient needs (energy/protein)

◦ Feeding tube displacement / replacement

◦ Prematurely discontinuing EN

◦ Delayed administration

◦ Low volume TF infusion (trophic feeding)

◦ Interruptions in TF administration (avoidable vs.

unavoidable)

Prospective, observational study

Characterize EN interruptions (avoidable vs. unavoidable) &

determine impact on caloric deficits between patients ◦ Group 1: > 1 EN interruption

◦ Group 2: No interruptions

94 SICU patients (mean age 63yo, 71% male)

Gastric feeding

TF held for GRV > 500mL

Primary outcome: percentage of unavoidable interruptions

Secondary outcomes: 30-day mortality, surgical ICU LOS, hospital

LOS, VFDs and total complications per patient

Yeh, DD et al. JPEN. 2015

74%

26%

Avoidable • IR or surgical procedures

(if controlled airway & patient

in supine position)

• GRV < 500 mL

• Imaging studies (when

radiologist did not request

patient to be fasted) ✓

Unavoidable • PEG placement ✓

• IR or surgical procedures

(if no controlled airway or

patient not in supine position

• GI bleed

• Reintubation/extubation ✓

• GRV > 500mL

• Tracheostomy ✓

• GI surgery

Transient interruptions (lasting ten minutes or less) were not considered.

5/9/2015

3

RESULTS

◦ Group 1 compared to Group 2:

Accumulated double caloric deficit

Additional 1.5 days in ICU, 8 days longer in

hospital

NO statistical difference in 30-day VFDs,

in-hospital mortality, 30-day mortality 30day

BOTTOM LINE: Focus should be on how

to MAXIMIZE nutrient delivery rather than

trying to eradicate interruptions.

Yeh, DD et al. JPEN. 2015

Canadian Critical Care Clinical

Nutrition Practice Guidelines 2013

www.criticalcarenutrition.com.

Early Enteral Nutrition(24-48 hours)

• No difference in aspiration risk between gastric vs. small bowel feeding

• GRV threshold (250-500 mL)

Gastric Feeding

Aim for Goal Volume Feeding

Optimal amount of energy and protein required

to reduce morbidity and mortality is controversial

Few observational studies have shown

permissive underfeeding resulted in improved

clinical outcomes compared to full feeding

Several large observational studies have shown

a cumulative energy deficit or caloric debt is

associated with adverse clinical outcomes

5/9/2015

4

3 prospective randomized studies (EDEN, Rice, Arabi)

Compared trophic to full feeding

Results: ◦ No difference in long-term outcome (28 day mortality) between

two feeding strategies

◦ Reported more GI complications with the full EN feeding strategy

◦ Trend toward improved physical function in the full fed group

Recommend low dose EN for first week of ICU stay

Key Points: ◦ Relatively young (mean age = 52)

◦ Few co-morbidities

◦ Well-nourished (BMI 29-30)

◦ Average duration of study intervention 5 days

.

No effect in young, healthy,

overweight patients who have short

stays!

SSC (Surviving Sepsis Campaign) recommends

avoiding mandatory full caloric feeding and using low

dose EN the first week in the ICU

The 2013 Canadian Critical Care Nutrition Practice

Guidelines (based on multiple randomized trials and

large scale observational studies) recommend:

Optimizing the dose of EN

NOT use intentional underfeeding in those first 5

ICU days (all patients)

Prospective, multicenter observational study

Determine:

◦ Effect of energy & protein intake on outcome

◦ Whether patients with pre-existing malnutrition or lack of nutritional reserve benefit more from aggressive EN provision

2772 patients (158 ICU’s over 5 continents)

Included ventilated patients in ICU >72 hours

BMI used as marker of nutritional status prior to admission

Average daily nutrient intake: 1034 kcal; 47gm protein

5/9/2015

5

0

10

20

30

40

50

60

0 500 1000 1500 2000

All Patients

< 20

20-25

25-30

30-35

35-40

>40

Calories Delivered

Mo

rta

lity

(%

)

Relationship of Caloric Intake, 60 day Mortality and BMI

BMI

Secondary analysis of large nutrition database

2270 mechanically ventilated patients with sepsis and / or pneumonia

ICU stay > 3 days receiving EN ONLY

Older (mean age 62); low to normal BMI

Nutrition intervention 11 days

Average daily nutrient intake: 1057 kcal; 49gm protein

Results: ◦ Increasing 1000 kcal & 30 gm protein daily more

VFDs and lower mortality in septic patients

Elke, G et al. Crit Care 2014

Objective: To examine the relationship between the

amount of prescribed calories received and 60-day

hospital mortality

Prospective, multi-institutional audit

352 ICUs (33 countries)

7872 mechanically ventilated patients (> 96 hrs in ICU)

Heyland et al CCM, 2011

5/9/2015

6

RESULTS: Optimal target = 80-85% of prescribed amount (best

clinical outcome)

No additional benefit attaining 100% prescribed amount

Conclusions: ◦ Regardless of BMI, practice of permissive underfeeding is not

advised (including the obese critically ill) ◦ Recommended 80-85% target should be feasible goal for ALL

ICUs world wide

Heyland DK, et al. Crit Care Med. 2011 .

Protein-Energy Provision via the Enteral Route in Critically Ill Patients (PEPup)

1

• Designed by Heyland et al to “make up” for lost EN infusion time1

• Shift from “traditional” rate-based to volume-based feeding approach

• RN to adjust hourly rate to reach goal EN volume

• Trial included 18 mixed med/surg ICUs (80-85% MICU)

• Implementation of protocol resulted in increased calorie & protein delivery

Feed Early Enteral Diet Adequately for Maximum Effect (FEED ME)2

• Designed by Taylor et al2

• Surgical / Trauma ICU patients

• Modified version of PEPup

• Protocol resulted in increased delivery of EN volume, calories & protein

• No significant increases in GRV, emesis and only minimal increase in diarrhea

1. Heyland et al. CCM 2013

2. Taylor et al. Nutr Clin Prac 2014

5/9/2015

7

Taylor B et al, Nutri Clin Prac 2014

Pilot in Neuro ICUs 28 beds Collect baseline data% prescribed amount received, GRVs,

interruptions (number, time held, reason)

Enteral Product (up to RD discretion)

“Ramp Up” to goal infusion rate 24-h clock (07:00-07:00) Makeup rate calculation: (FEED ME protocol)

GRV threshold: 350 mL No routine use of promotility agents 120 mL / hr (maximum hourly infusion rate)

NO bolus feeding Post implementation data collectionidentify barriers

Increased risk for nutrition depletion due to acute illness

Early nutrition intervention improves outcomes

Intentional underfeeding is not recommended

Maximize nutrient delivery (80-85% goal) but further

randomized trials needed

Consider 24 hour volume based feeding strategy

Teamwork is key to successful nutrition delivery

THANK YOU!