Transcript malnutrition in the ICU comprehensive 50 min mar 24 12

Learning Objectives
• Define iatrogenic malnutrition
• Describe the nature of the evidence related
to optimal amount of calories/protein
• List key variables to consider in assessing
nutritional risk in ICU patients
• List strategies to improve nutritional
adequacy in the critical care setting.
A different form of
malnutrition?
Health Care Associated
Malnutrition
Nutrition deficiencies associated with
physiological derangement and organ
dysfunction that occurs in a health care facility
Patients who will benefit the most from nutrition
therapy and who will be harmed the most from
by iatrogenic malnutrition (underfeeding)
Early and Adequate Nutrition is therapy that
modulates the underlying disease process
and impacts patient outcomes
Adjunctive
Supportive
Care
Proactive
Primary
Therapy
Early Feeding Supports Gastrointestinal
Structure and Function
•
Maintenance of gut barrier function
• Increased secretion of mucus, bile, IgA
• Maintenance of peristalsis and blood flow
•Attenuates oxidative stress and inflammation
•Supports GALT
•Improves glucose absorption
Alverdy (CCM 2003;31:598)
Kotzampassi Mol Nutr Food Research 2009
Nguyen CCM 2011
Early vs. Delayed EN:
Effect on Infectious Complications
Updated 2009
www.criticalcarenutrition.com
Early vs. Delayed EN:
Effect on Mortality
Updated 2009
www.criticalcarenutrition.com
Feeding the Hypotensive Patient?
Prospectively collected multi-institutional ICU database of 1,174 patients
who required mechanical ventilation for more than two days and were on
vasopressor agents to support blood pressure.
The beneficial effect of early feeding is more
evident in the sickest patients, i.e, those on
multiple vasopressor agents.
DiGiovine et al. AJCC 2010
Early EN (within 24-48 hrs of
admission) is recommended!
Optimal Amount of Protein and
Calories for Critically Ill Patients?
Adequacy
of EN
kcal
Increasing Calorie Debt Associated with worse Outcomes
Prescribed Engergy
2000
1800
1600
1400
1200
1000
800
600
400
200
0
Energy Received From Enteral Feed
Caloric Debt
1
3
5
7
9
11
13
15
17
19
21
Days
 Caloric debt associated with:
 Longer ICU stay
 Days on mechanical ventilation
 Complications
  Mortality
Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006
• Point prevalence survey of nutrition
practices in ICU’s around the world
conducted Jan. 27, 2007
• Enrolled 2772 patients from 158 ICU’s over
5 continents
• Included ventilated adult patients who
remained in ICU >72 hours
Relationship of Caloric Intake, 60 day Mortality and BMI
60
BMI
All Patients
< 20
20-25
25-30
30-35
35-40
>40
Mortality (%)
50
40
30
20
10
0
0
500
1000
1500
Calories Delivered
2000
Effect of Increasing Amounts of Calories
from EN on Infectious Complications
Multicenter observational study of 207 patients >72 hrs in ICU
followed prospectively for development of infection
for increase of 1000 cal/day, OR of infection at 28 days
Heyland Clinical Nutrition 2010
Relationship between increased nutrition intake and
physical function (as defined by SF-36 scores)
following critical illness
Multicenter RCT of glutamine and antioxidants (REDOXS Study)
First 364 patients with SF 36 at 3 months and/or 6 months
Model *
Estimate (CI)
P values
PHYSICAL FUNCTIONING (PF) at 3 months
3.2 (-1.0, 7.3)
P=0.14
ROLE PHYSICAL (RP) at 3 months
4.2 (-0.0, 8.5)
P=0.05
(A) Increased energy intake
for
STANDARDIZED PHYSICAL COMPONENT
1.8 (0.3, 3.4)
SCALE (PCS) at 3 months
P=0.02
PHYSICAL FUNCTIONING (PF) at 6 months
0.8 (-3.6, 5.1)
P=0.73
ROLE PHYSICAL (RP) at 6 months
2.0 (-2.5, 6.5)
P=0.38
STANDARDIZED PHYSICAL COMPONENT
0.70 (-1.0, 2.4)
P=0.41
SCALE (PCS)
at 6gram/day,
months
increase
of 30
OR of infection at 28 days
Heyland Unpublished Data
Mechancially Vent’d patients >7days
(average ICU LOS 28 days)
Faisy BJN 2009;101:1079
More (and Earlier) is Better!
If you feed them (better!)
They will leave (sooner!)
Permissive Underfeeding
(Starvation)?
 187 critically ill patients
 Tertiles according to ACCP recommended levels of
caloric intake
 Highest tertile (>66% recommended calories) vs.
Lowest tertile (<33% recommended calories)
  in hospital mortality
  Discharge from ICU breathing spontaneously
 Middle tertile (33-65% recommended calories) vs.
lowest tertile
 Discharge from ICU breathing spontaneously
Krishnan et al Chest 2003
Optimal Amount of Calories for
Critically Ill Patients:
Depends on how you slice the cake!
• Objective: To examine the relationship between the
amount of calories recieved and mortality using various
sample restriction and statistical adjustment techniques and
demonstrate the influence of the analytic approach on the
results.
• Design: Prospective, multi-institutional audit
• Setting: 352 Intensive Care Units (ICUs) from 33
countries.
• Patients: 7,872 mechanically ventilated, critically ill
patients who remained in ICU for at least 96 hours.
Heyland Crit Care Med 2011
Association between 12 day average caloric adequacy and
60 day hospital mortality
(Comparing patients rec’d >2/3 to those who rec’d <1/3)
A. In ICU for at least 96 hours. Days
after permanent progression to
exclusive oral feeding are included as
zero calories*
B. In ICU for at least 96 hours. Days
after permanent progression to
exclusive oral feeding are excluded from
average adequacy calculation.*
C. In ICU for at least 4 days before
permanent progression to exclusive oral
feeding. Days after permanent progression
to exclusive oral feeding are excluded from
average adequacy calculation.*
Unadjusted
Adjusted
D. In ICU at least 12 days prior to
permanent progression to exclusive oral
feeding*
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Odds ratios with 95% confidence intervals
*Adjusted for evaluable days and covariates,covariates include region (Canada, Australia and New Zealand,
USA, Europe and South Africa, Latin America, Asia), admission category (medical, surgical), APACHE II score,
age, gender and BMI.
Association Between 12-day Caloric
Adequacy and 60-Day Hospital Mortality
Optimal
amount=
80-85%
Heyland CCM 2011
More (and Earlier) is Better!
If you feed them (better!)
They will leave (sooner!)
JAMA
1994;271:56
Trophic vs. Full enteral feeding in critically ill
patients with acute respiratory failure
• Single center study of 200 mechanically ventilated patients
• Trophic feeds: 10 ml/hr x 5 days
Rice CCM 2011;39:967
Trophic vs. Full enteral feeding in critically ill
patients with acute respiratory failure
What other outcomes might be important?
Rice CCM 2011;39:967
Trophic vs. Full enteral feeding in critically ill
patients with acute respiratory failure
“survivors who received
initial full-energy enteral
nutrition were more likely to
be discharged home with or
without help as compared to a
rehabilitation facility (68.3%
for the full-energy group vs.
51.3% for the trophic group;
p = .04).”
Rice CCM 2011;39:967
Rice et al. JAMA 2012;307
Still no measure of physical function!
Rice et al. JAMA 2012;307
Enrolled 12% of patients screened
Rice et al. JAMA 2012;307
Trophic vs. Full enteral feeding in critically ill
patients with acute respiratory failure
•
•
•
•
•
Average age 52
Few comorbidities
Average BMI 29-30
All fed within 24 hrs (benefits of early EN)
Average duration of study intervention 5 days
No effect in young, healthy,
overweight patients who
have short stays!
Trophic vs. Full enteral feeding in critically ill
patients with acute respiratory failure




Randomized
Good follow up
ITT
No blinding
Internally
valid
1. How representative are these
patients to ALL the patients in your
ICU? May miss an important
negative effect in ‘high risk’ patients
2. What about the physically recovery
of underfed patients?
No benefit, potential harm, minimal cost advantage=
Do not use routinely!
ICU patients are not all created equal…should we
expect the impact of nutrition therapy to be the
same across all patients?
How do we figure out who will benefit
the most from Nutrition Therapy?
Health Care Associated
Malnutrition
Do Nutrition Screening tools help us
discriminate those ICU patients that will benefit
the most from artificial nutrition?
Patients who will benefit the most from nutrition
therapy and who will be harmed the most from
by iatrogenic malnutrition (underfeeding)
All ICU patients
treated the same
Albumin: a marker of malnutrition?
• Low levels very prevalent in critically ill patients
• Negative acute-phase reactant such that synthesis,
breakdown, and leakage out of the vascular
compartment with edema are influenced by
cytokine-mediated inflammatory responses
• Proxy for severity of underlying disease
(inflammation) not malnutrition
• Pre-albumin shorter half life but same limitation
Subjective Global Assessment?
• When training
provided in
advance, can
produce reliable
estimates of
malnutrition
• Note rates of
missing data
• mostly medical patients; not all ICU
• rate of missing data?
• no difference between well-nourished and malnourished
patients with regard to the serum protein values on
admission, LOS, and mortality rate.
“We must develop and validate
diagnostic criteria for appropriate
assignment of the
described malnutrition syndromes
to individual patients.”
A Conceptual Model for Nutrition Risk
Assessment in the Critically Ill
Acute
Chronic
-Reduced po intake
-pre ICU hospital stay
-Recent weight loss
-BMI?
Starvation
Nutrition Status
micronutrient levels - immune markers - muscle mass
Inflammation
Acute
-IL-6
-CRP
-PCT
Chronic
-Comorbid illness
The Development of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
• When adjusting for age, APACHE II, and
SOFA, what effect of nutritional risk factors
on clinical outcomes?
• Multi institutional data base of 598 patients
• Historical po intake and weight loss only
available in 171 patients
• Outcome: 28 day vent-free days and mortality
Heyland Critical Care 2011, 15:R28
What are the nutritional risk factors
associated with clinical outcomes?
(validation of our candidate variables)
Age
Baseline APACHE II score
Baseline SOFA
# of days in hospital prior to ICU admission
Baseline Body Mass Index
Body Mass Index
Non-survivors by day 28
(n=138)
Survivors by day 28
(n=460)
p values
71.7 [60.8 to 77.2]
61.7 [49.7 to 71.5]
<.001
26.0 [21.0 to 31.0]
20.0 [15.0 to 25.0]
<.001
9.0 [6.0 to 11.0]
6.0 [4.0 to 8.5]
<.001
0.9 [0.1 to 4.5]
0.3 [0.0 to 2.2]
<.001
26.0 [22.6 to 29.9]
26.8 [23.4 to 31.5]
0.13
0.66
<20
≥20
6 ( 4.3%)
122 ( 88.4%)
3.0 [2.0 to 4.0]
# of co-morbidities at baseline
Co-morbidity
Patients with 0-1 co-morbidity
20 (14.5%)
Patients with 2 or more co-morbidities
118 (85.5%)
¶
135.0 [73.0 to 214.0]
C-reactive protein
4.1 [1.2 to 21.3]
Procalcitionin¶
158.4 [39.2 to 1034.4]
Interleukin-6¶
171 patients had data of recent oral intake and weight loss
% Oral intake (food) in the week prior to enrolment
% of weight loss in the last 3 month
25 ( 5.4%)
414 ( 90.0%)
3.0 [1.0 to 4.0]
<0.001
<0.001
140 (30.5%)
319 (69.5%)
108.0 [59.0 to 192.0]
0.07
1.0 [0.3 to 5.1]
<.001
72.0 [30.2 to 189.9]
<.001
Non-survivors by day 28
(n=32)
Survivors by day 28
(n=139)
p values
4.0[ 1.0 to 70.0]
50.0[ 1.0 to 100.0]
0.10
0.0[ 0.0 to
2.5]
0.0[ 0.0 to
0.0]
0.06
What are the nutritional risk factors
associated with clinical outcomes?
(validation of our candidate variables)
Spearman
correlation with
VFD within 28
days
p values
Number of
observations
Age
Baseline APACHE II score
Baseline SOFA
-0.1891
-0.3914
-0.3857
<.0001
<.0001
<.0001
598
598
594
% Oral intake (food) in the week prior to enrollment
0.1676
0.0234
183
number of days in hospital prior to ICU admission
-0.1387
0.0007
598
% of weight loss in the last 3 month
Baseline BMI
# of co-morbidities at baseline
Baseline CRP
Baseline Procalcitionin
Baseline IL-6
-0.1828
0.0581
-0.0832
-0.1539
-0.3189
-0.2908
0.0130
0.1671
0.0420
0.0002
<.0001
<.0001
184
567
598
589
582
581
Variable
The Development of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
• % oral intake in the week prior was dichotomized into patients
who reported less than 100% versus everyone else
• Weight loss was dichotomized as patients who reported any
weight loss versus everyone else.
• BMI was dichotomized as <20 versus other
• Comorbidities was left as integer values range 0-5
• The remaining candidate variables were categorized into five
equal sized groups (quintiles).
The Development of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
For example, exact quintiles and logistic parameters for age
Exact Quintile
Parameter
Points
19.3-48.8
referent
0
48.9-59.7
0.780
1
59.7-67.4
0.949
1
67.5-75.3
1.272
1
75.4-89.4
1.907
2
The Development of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
Variable
Age
APACHE II
SOFA
# Comorbidities
Range
<50
50-<75
>=75
<15
15-<20
20-28
>=28
<6
6-<10
>=10
0-1
2+
Points
0
1
2
0
1
2
3
0
1
2
0
1
Days from hospital to ICU admit
0-<1
1+
0
1
IL6
0-<400
400+
0
1
AUC
Gen R-Squared
Gen Max-rescaled R-Squared
0.783
0.169
0.256
BMI, CRP, PCT, weight loss, and oral intake were excluded because they were not significantly
associated with mortality or their inclusion did not improve the fit of the final model.
Observed
Model-based
40
20
n=12
n=33
0
1
n=55
n=75
n=90
n=114
n=82
n=72
n=46
n=17
2
3
4
5
6
7
8
9
n=2
0
Mortality Rate (%)
60
80
The Validation of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
Nutrition Risk Score
10
Observed
Model-based
10
8
6
4
2
n=12
n=33
n=55
n=75
n=90
n=114
n=82
n=72
n=46
n=17
n=2
0
1
2
3
4
5
6
7
8
9
10
0
Days on Mechanical Ventilator
12
14
The Validation of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
Nutrition Risk Score
The Validation of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
1.0
Interaction between NUTRIC Score and nutritional adequacy (n=211)*
9
0.8
9
9
0.6
8 88
0.2
0.4
77 7
2
0
9
9
7
4
0.0
28 Day Mortality
P value for the
interaction=0.01
9
8888
7 7
7
8888
8
9
10
10
888
77
88
77 7
77 7
88
7
77
6
7
7777
6 66666 6
9
66666 6 6 66
6 666666666
666 6 6 66
7
5
555
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
4 4 3
5 55 555 55 555 55
5
5 5
44 4 43
4
4
4
2
4
4
4
3
44444444
33
444 4444
3
4
3
4
1
4
22
3
4 4
3 3 33 2 22 2 1
3
11
33 3
2
1 11 1 1
50
100
3
3
5
9
8
150
Nutrition Adequacy Levles (%)
Heyland Critical Care 2011, 15:R28
Who might benefit the most from
nutrition therapy?
• High NUTRIC Score?
• Clinical
– BMI
– Projected long length of stay
• Others?
Do we have a problem?
Preliminary Results of INS 2011
Overall Performance: Kcals
120
% received/prescribed
100
84%
56%
80
60
40
15%
20
0
1
2
3
4
5
6
7
8
9
10
11
12
ICU Day
Mean of All Sites
Best Performing Site
Worst Performing Site
N=211
Failure Rate
% patients who failed to meet minimal quality targets (80% overall energy adequacy)
Strategies to Maximize the Benefits and
Minimize the Risks of EN
•
•
•
•
feeding protocols
motility agents
elevation of HOB
small bowel feeds
weak evidence
stronger evidence
Canadian CPGs www.criticalcarenutrition.com
Use of Nurse-directed Feeding Protocols
Start feeds at 25
ml/hr
> 250 ml
•hold feeds
•add motility
agent
Check
Residuals
q4h
< 250 ml
•advance rate by 25 ml
•reassess q 4h
•reassess q 4h
“Should be considered as a strategy to optimize delivery of
enteral nutrition in critically ill adult patients.”
2009 Canadian CPGs www.criticalcarenutrition.com
The Impact of Enteral Feeding Protocols
on Enteral Nutrition Delivery:
Results of a multicenter observational study
Characteristics
Total
n=269
Feeding Protocol
Yes 208 (78%)
15.2% using the
recommended
threshold volume
of 250 ml
Gastric Residual Volume
Tolerated in Protocol
Mean (range) 217 ml (50, 500)
Elements included in Protocol
Motility agents 68.5%
Small bowel feeding 55.2%
HOB Elevation 71.2 %
Heyland JPEN 2010
The Impact of Enteral Feeding Protocols
on Enteral Nutrition Delivery:
Results of a multicenter observational study
80
60
40
Protocol
20
No Protocol
0
Calories from EN Total Calories
P<0.05
• Time to start EN from ICU admission 41.2 in protocolized
sites vs 57.1 hours in those without a protocol
• Patients rec’ing motility agents 61.3% in protocolized sites
vs 49.0% in those without
P<0.05
Heyland JPEN 2010
Can we do better?
The same thinking that got you into
this mess won’t get you out of it!
Reasons for Inadequate Intake


Slow starts and slow ramp ups
Interruptions
Mostly related to procedures
Not related to GI dysfunction


Can be overcome
by better feeding
protocols

Impaired motility



Medications
Metabolic, electrolyte abnormalities
Underlying disease
Prophylactic
use of motility
agents
Protocol to Manage Interruptions
to EN due to non-GI Reasons
Can be downloaded from www.criticalcarenutrition.com
Enhanced Protein-Energy Provision
via the Enteral Route
in Critically Ill Patients:
The PEP uP Protocol
The Efficacy of Enhanced Protein-Energy Provision via the
Enteral Route in Critically Ill Patients:
The PEP uP Protocol!
•
•
•
•
•
•
•
Different feeding options based on hemodynamic
stability and suitability for high volume intragastric
feeds.
In select patients, we start the EN immediately at goal
rate, not at 25 ml/hr.
We target a 24 hour volume of EN rather than an hourly
rate and provide the nurse with the latitude to increase
the hourly rate to make up the 24 hour volume.
Start with a semi elemental solution, progress to
polymeric
Tolerate higher GRV threshold (250 ml or more)
Motility agents and protein supplements are started
immediately
Nurse reports daily on nutritional adequacy.
A Major Paradigm Shift in How we Feed Enterally
The PEP uP Protocol
Stable patients should be able
to tolerate goal rate
Begin 24 hour volume-based feeds. After initial tube placement confirmed, start Pepatmen
1.5. Total volume to receive in 24 hours is 17ml x weight (kg)= <write in 24 target volume>.
Determine initial rate as per Volume Based Feeding Schedule. Monitor gastric residual
volumes as per Adult Gastric Flow Chart and Volume Based Feeding Schedule.
OR
Begin Peptamen 1.5 at 10 mL/h after initial tube placement confirmed. Hold if gastric
residual volume >500 ml and ask Doctor to reassess. Reassess ability to transition to 24
hour volume-based feeds next day. {Intended for patient who is hemodynamically unstable
(on high dose or escalating doses of vasopressors, or inadequately resuscitated) or not
suitable for high volume enteral feeding (ruptured AAA, upper intestinal anastomosis, or
impending intubation)}
OR
NPO. Please write in reason: __________________
______.
(only if contraindication
to EN present: bowel perforation, bowel obstruction, proximal high output fistula. Recent
operation and high NG output not a contraindication to EN.) Reassess ability to transition
to 24 hour volume-based feeds next day.
We want to minimize the
use of NPO but if selected,
need to reassess next day
We use a concentrated
solution to maximize
calories per ml
If unstable or
unsuitable, just use
trophic feeds
Note indications
for trophic feeds
Drs need to justify why
there are keeping patients
NPO
Note, there are only a
few absolute
contraindications to
EN
It’s not just about calories...
Inadequate protein intake
Loss of lean muscle mass
Immune dysfunction
Weak
Prolonged mechanical
ventilation
So in order to minimize this, we order:
 Protein supplement Beneprotein® 14 grams mixed in 120 mls sterile water
administered bid via NG
Other Strategies to Maximize the Benefits
and Minimize the Risks of EN
• Motility agents started at initiation of EN
rather that waiting till problems with High
GRV develop.
– Maxeran 10 mg IV q 6h (halved in renal failure)
– If still develops high gastric residuals, add
Erythromycin 200 mg q 12h.
– Can be used together for up to 7 days but should
be discontinued when not needed any more
– Reassess need for motility agents daily
The Efficacy of Enhanced Protein-Energy Provision via the
Enteral Route in Critically Ill Patients:
The PEP uP Protocol!
Adequacy of Calories from EN
(Before Group vs. After Group on Full Volume Feeds)
P-value
Day 1
0.08
Day 2
0.0003
Day 3
0.10
Day 4
0.19
Day 5
0.48
Day 6
0.18
Day 7
0.11
Total
<0.0001
Heyland Crit Care 2010
Change of nutritional intake from baseline to
follow-up of all the study sites (all patients)
80
80
% calories
received/prescribedControl sites
Intervention sites
p value <0.0001
30
373
360
390
371
375
60
70
373
50
372
360
372
379
376
404
40
40
374
374
331
378
359
378
379
404
380
362
380
390
331
371
20
362
377
375
Baseline
376
30
326
% calories received/prescribed
60
50
326
20
% calories received/prescribed
70
p value=0.65
Follow-up
Baseline
327
359
377
Follow-up
327
Change of nutritional intake from baseline to
follow-up of all the study sites (all patients)
80
80
% protein
received/prescribedControl sites
Intervention sites
70
p value=0.78
70
p value <0.0001
390
373
390
375
371
60
50
360
373
404
376
40
372
376
379
378
30
40
30
374
331
360
% protein received/prescribed
60
50
326
372
374
359
378
379
404
380
331
371
375
Baseline
20
20
% protein received/prescribed
326
Follow-up
377
362
Baseline
327
380
362
359
377
327
Follow-up
Other Strategies to Maximize the Benefits
and Minimize the Risks of EN
Small Bowel vs. Gastric Feeding: A meta-analysis
Effect on VAP
Updated 2011,www.criticalcarenutrition.com
Does Postpyloric Feeding Reduce
Risk of GER and Aspiration?
Tube
Position
# of
patients
% positive
for GER
Stomach
21
32
% positive
for
Aspiration
5.8
D1
8
27
4.1
D2
3
11
1.8
D4
1
5
0
Total
33
75
11.7
P=0.004
P=0.09
Heyland CCM 2001;29:1495-1501
FRICTIONAL ENTERAL FEEDING TUBE
(TIGER TUBETM)
Flaps to allow
peristalsis to
pull tube
passively
forward
Sucessful jejunal placement >95%
CORTRAK®
A new paradigm in feeding tube placement
– Aid to placement of feeding
tubes into the stomach or
small bowel
– The tip of the stylet is a
transmitter.
– Signal is picked up by an
external receiver unit.
– Signal is fed to an attached
Monitor unit.
– Provides user with a realtime, graphic display that
represents the path of the
feeding tube.
A Change to Nursing Report
Please report this
% on rounds as
part of the GI
systems report
Adequacy of Nutrition Support =
24 hour volume of EN received
Volume prescribed to meet caloric requirements
in 24 hours
When performance is measured,
performance improves.
When performance is measured
and reported back, the rate of
improvement accelerates.
Thomas Monson
Health Care Associated
Malnutrition
What if you can’t provide
adequate nutrition enterally?
… to add PN or not to add PN,
that is the question!
Early vs. Late Parenteral
Nutrition in Critically ill Adults
• 4620 critically ill patients
• Results:
• Randomized to early PN
Late PN associated with
– Rec’d 20% glucose 20
• 6.3% likelihood of early
ml/hr then PN on day 3
discharge alive from ICU
and hospital
• OR late PN
• Shorter ICU length of
– D5W IV then PN on day
stay (3 vs 4 days)
8
• Fewer infections (22.8 vs
• All patients standard EN plus
26.2 %)
‘tight’ glycemic control
• No mortality difference
Cesaer NEJM 2011
Early vs. Late Parenteral
Nutrition in Critically ill Adults
• ? Applicability of data
– No one give so much IV glucose in first few days
– No one practice tight glycemic control
• Right patient population?
–
–
–
–
Majority (90%) surgical patients (mostly cardiac-60%)
Short stay in ICU (3-4 days)
Low mortality (8% ICU, 11% hospital)
>70% normal to slightly overweight
• Not an indictment of PN
– Early group only rec’d PN for 1-2 days on average
– Late group –only ¼ rec’d any PN
Cesaer NEJM 2011
What if you can’t provide
adequate nutrition
enterally?
… to TPN or not to TPN,
that is the question!
•Case by case decision
•Maximize EN delivery
prior to initiating PN
•Use early in high risk
cases
The TOP UP Trial
PN for 7 days
Primary
Outcome
ICU patients
BMI <25
BMI >35
Fed enterally
R
Stratified by:
Site
BMI
Med vs Surg
Control
60-day
mortality
In Conclusion
• Health Care Associate Malnutrition is rampant
• Not all ICU patients are the same in terms of ‘risk’
• Iatrogenic underfeeding is harmful in some ICU
patients or some will benefit more from aggressive
feeding (avoiding protein/calorie debt)
• BMI and/or NUTRIC Score is one way to quantify
that risk
• Need to do something to reduce iatrogenic
malnutrition in your ICU!
– Audit your practice first!
– PEP uP protocol in all
– Selective use of small bowel feeds then sPN in high risk patients
Start PEP UP
Day 3
>80% of
Goal
Calories
YES
NO
No
Yes
Anticipated
Long Stay?
High Risk?
Carry on!
Yes
No
Maximize EN with
motility agents and
small bowel feeding
YES
Yes
Supplemental PN?
Not
tolerating
EN at 96
hrs?
No problem
NO
No
www.criticalcarenutrition.com
Questions?