Nutrition support in the critically ill patients

Nutrition support in critically ill patients Luisito O. Llido MD, FPCS Nutrition Support Team St. Luke’s Medical Center Main areas for discussion • Malnutrition detection – nutritional assessment • How much and how soon to feed? – energy and nutrient requirements; computation issues and what variables to use • Access and delivery – enteral and parenteral nutrition • Nutrient modifiers – glutamine, omega-3- fatty acids, cysteine, arginine, vitamins and trace elements • Nutrition support team Malnutrition in critically ill patients Prevalence of malnutrition in critically ill patients, SLMC, 2000-2004 Malnutrition in the ICU Prevalence of malnutrition in critically ill patients, SLMC, 2000-2004 Malnutrition in the hospital Prevalence of malnutrition in hospitalized patients, SLMC, 2000-2004 Low albumin in critically ill patients Prevalence of malnutrition in critically ill patients, SLMC, 2000-2004 Underweight with low albumin in critically ill patients Prevalence of malnutrition in critically ill patients, SLMC, 2000-2004 Implications • Calorie reserves – strained • Protein reserves – on the “empty” level • Substrates that are involved in inflammatory processes, infection, injury healing and tissue repair – on the dangerously low to empty status • Processes involved in oxygenation and tissue perfusion – slowed or impaired Implications Cardiac function Intake Microcirculation environment • extracellullar • intracellular Energy provision Protein synthesis Pulmonary function FOOD Carbohydrates, fats, protein, electrolytes, trace elements, vitamins, special substrates Renal function Body reserves (adequate fed) Body reserves (malnourished) Inflammation and organ failure in the ICU SIRS Inflammatory balance TNF, IL-1, IL-6, IL-12, IFN, IL-3 Tissue inflammation, Early organ failure and death days IL-10, IL-4, IL-1ra, Monocyte HLA-DR suppression weeks Immunosuppression 2nd Infections Delayed MOF and death CARS Insult (trauma, sepsis) Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle Nutrition Workshop Series Survival in and from ICU • ICU is about preventing death from organ failure • Patients die early from single organ failure – Due to primary pathology/ insult/ infection (brain, or heart, or liver or lung) • Patients die later from multi-organ failure – Due to secondary infections (combined organ failure (e.g. lung, liver, and kidney) Griffiths, R. ICU nutrition. Bangkok 2002 Malnutrition detection • Nutritional assessment – Nutrition screening (within 24 hours) • Body mass index – Subjective global assessment or mininutritional assessment • Weight loss > 10% • Intake accounting (<70%, chronic) Malnutrition detection – whose responsibility? Attending physician Dietitian Nurse Best option – nutrition support team Department or section heads – presentors and main proponents • Administration – has the biggest role in providing for both suitable environment and manpower • • • • • Do we really have to feed these patients? • “inadequacy of recent dietary intake rather than the absolute nutritional status determines injury response and healing.” (Windsor JA, Knight GS, Hill GL. Wound healing in surgical patients: recent food intake is more important than nutritional status. Br J Surg, 1988; 27:1252) • “achieving a higher intake with parenteral nutrition supplementation led to a faster recovery of plasma protein markers” (Bauer P, Charpentier C, et al. Parenteral with enteral nutrition in the critically ill. Intens Care Med, 2000; 26:893) Are we feeding these patients adequately? Enteral feeding of critically ill patients Author Adams McClave Montejo Braga Woodcock De Jonge Kozar Heyland Journal/year Int Care Med/ 97 CCM/ 99 CCM/ 99 CCM/ 01 Nutr/ 01 CCM/ 01 J Surg Res/ 02 CCM/ 04 Approx % pts reach goal 51 52 63 80 53 86 65-85 1.8-76.6 Are we feeding these patients adequately? • Even on day 3 after ICU admission, intake is still at 72% (minimum adequate = 75%), Intake of geriatric ICU patients; Umali et al (SLMC, 2002) How much to give? Category Surgical Oncology Mixed Studies 7 5 2 Patient number 637 269 200 Kcal range 1300-1900 1300-1500 1300-1400 Nordenstrom & Thorne, E. J. Clin Nutr, 1994; 48:531-537 • 25-30 kcal/kg actual body weight • 20-25 kcal/kg ideal body weight • BEE x 1.5 or REE x 1.3-1.5 On the first week then increase after Suggested feeding: ICU • What is the caloric need? – Harris Benedict, 75% - 80% – Indirect calorimetry to settle the debate • Nitrogen – standard, add fiber • Additives? – Extra vitamins, trace elements, and zinc in parenteral nutrition – Magnesium or phosphate – Always give glutamine parenterally with enteral and/or parenteral nutrition Jan Wernermann, “ICU Cookbook”, Singapore, 2003 Caution - Re-feeding syndrome • Severe fluid and electrolyte shifts in malnourished patients undergoing re-feeding • Consequences: – Hypophosphatemia – Hypokalemia – Hypomagnesemia • Effects: altered myocardial function, arrhythmia, respiratory failure, liver dysfunction, seizures, confusion, coma, tetany Suggested feeding: ICU • Who to feed? – All malnourished – All at risk of becoming long-stayers • What are the contraindications? – Unstable circulation (relative) – Non-functioning gut (enteral nutrition) Jan Wernermann, “ICU Cookbook”,Singapore, 2003 The route - enteral or parenteral nutrition? Clinically certain on GI function GI inadequate TPN (1) Clinically uncertain on GI function Randomized TPN (3) 94.7% EN (4) 37.5% GI adequate EN (2) 68% Reached 80% of computed requirement 91.8% Failed to reach 80% 8.2% 32% 6.3% 62.5% Woodcock NP et al, Enteral vs parenteral nutrition: a pragmatic study; Nutrition 17: 1-12, 2001 Suggested feeding: ICU CALORIE COUNT!!! • When to start? – The sooner, the better • How much? – Patients adapted to undernutrition or with a circulatory instability may benefit with a slow start, lower target with stepwise increase • What to give? – Balanced nutrition – Enteral route, parenteral as supplementation Jan Wernermann, “ICU Cookbook”.Franc-, 2003 Feeding method • Enteral nutrition • Gastric retention – – – – <200 ml – give back and continue >200 ml – dispose Motility stimulators Parenteral nutrition Jan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003 CALORIE COUNT!!! – Enteral pump – Small amounts, frequent feedings (no pump) Monitoring? • Calorie balance • Gastric retention for enteral nutrition • Blood tests: – BUN high – dialyze – High triglycerides – lower lipid flow – Hyperglycemia – insulin CALORIE COUNT!!! Jan Wernermann, “ICU Cookbook”, Singapore, 2003 Insulin in critically ill patients 100 100 Intensive treatment 96 Survival in the ICU (%) In-Hospital Survival (%) 96 Intensive treatment 92 92 Conventional treatment 88 88 Conventional treatment 84 intens conv am_glucose 103 mg% 150 mg% insulin_given 103 173 84 0 40 80 120 Days after admission 160 0 65 130 195 Days after admission 260 Van den Berghe, G et al. Intensive insulin therapy in critically ill patients. NEJM 2001; 345:1359-1367 Glutamine - supplementation will make a difference: • Reduces mortality rate by one half in ICU patients (Griffiths, R et al. Six months outcome of critically ill patients given glutamine. Nutrition 1997; 13:295-302). • Improves 6 month outcome in surgical and trauma patients (Goeters C, et al, Crit Care Med 2002; 30:2022) • Meta-analysis: Glutamine supplementation reduces infectious complications and mortality in serious illness (Novak F et al. Glutamine supplementation in serious illness: a systematic review of the evidence; Crit Care Med 2002; 30(9):2022-29) Glutamine: Survival and Hospital Costs B A A - Griffiths, RD, et al. Six Month Outcome of Critically Ill Patients Given Glutamine-Supplemented Parenteral Nutrition; Nutrition 1997;13:4 B - Schultzki C et al: Supplemental Alanyl Glutamine Dipeptide improves nitrogen balance and reduces length of hospitalization in patients with severe operative injury. ASPEN Congress 1999. Glutamine vs standard nutritional support on mortality Comparison: mortality Outcome: glutamine vs. control Study Glutamine Control n/N n/N 18/42 2/41 12/26 14/83 3/16 8/35 1/15 0/24 58/282 28/42 2/39 10/24 20/85 1/13 6/31 4/16 1/24 72/274 1 2 Favors treatment RR 95% C.I. fixed Weight % Jiang Hua, The clinical efficacy of glutamine: evidence from systematic review and clinical trials; 11/01/03 RR 95% C.I. fixed 0.64 (0.43, 0.97) 0.95 (0.14, 6.43) 1.11 (0.59, 2.08) 0.72 (0.39, 1.32) 2.44 (0.29, 20.75) 1.18 (0.46, 3.03) 0.27 (0.03, 2.12) 0.33 (0.01, 7.80) 0.79 (0.59, 1.04) Griffiths Houdijk Jones Powell-Tuck Schloerb 1993 Schloerb 1999 Wischmeyer Zhu J Total (95% CI) 38.3 2.8 14.2 27.1 1.5 8.7 5.3 2.1 100 5 10 Favors control Glutamine vs standard nutritional support on infectious complications Comparison: infectious complications Outcome: glutamine vs. control Study Houdijk Neri O’Riordan Powell-Tuck Schettinga Schloerb 1993 Schloerb 1999 Wischmeyer Young Ziegler 1992 Ziegler 1998 Chen SL Jiang ZM Liang CH Yao GX Zhu J Zhu MW Total (95% CI) Jiang Hua, The clinical efficacy of glutamine: evidence from systematic review and clinical trials; 11/01/03 RR 95% C.I. fixed Weight % 12.9 3.1 1.6 29.6 4.3 4.3 3.3 6.9 3.6 7.6 3.9 1.6 2.8 2.4 2.0 7.9 2.4 100 Glutamine n/N 6/41 1/16 1/11 37/83 0/10 6/16 5/35 7/15 1/13 3/24 0/9 1/15 0/30 1/12 0/14 5/24 1/15 75/413 Control n/N 16/39 4/17 2/11 38/85 5/10 5/13 4/31 9/16 4/10 9/21 5/11 2/15 3/30 3/12 2/14 10/24 3/15 124/404 RR 95% C.I. fixed 0.36 (0.16, 0.82) 0.27 (0.03, 2.13) 0.50 (0.05, 4.75) 1.00 (0.71, 1.40) 0.09 (0.01, 1.45) 0.97 (0.38, 2.48) 1.11 (0.33, 3.76) 0.83 (0.42, 1.65) 0.19 (0.03, 1.46) 0.29 (0.09, 0.94) 0.11 (0.01, 1.74) 0.50 (0.05, 4.94) 0.14 (0.01, 2.71) 0.33 (0.04, 2.77) 0.20 (0.01, 3.82) 0.50 (0.20, 1.25) 0.33 (0.04, 2.85) 0.60 (0.48, 0.76) 1 2 Favors treatment 5 10 Favors control Inflammation and organ failure in the ICU SIRS Inflammatory balance TNF, IL-1, IL-6, IL-12, IFN, IL-3 Tissue inflammation, Early organ failure and death glutamine days IL-10, IL-4, IL-1ra, Monocyte HLA-DR suppression weeks Immunosuppression 2nd Infections Delayed MOF and death CARS Insult (trauma, sepsis) Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle Nutrition Workshop Series Immunonutrition Galban C. et al. An immune enhancing diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients. Crit Care Med 2000; 28: 643-648. Immunonutrition Gadek et al. Effect of enteral feeding with EPA, GLA, and antioxidants in patients with ARDS. Crit Care Med 1999; 27:1409-1420 Early enteral nutrition vs standard nutritional support on mortality Comparison: mortality Outcome: early enteral nutrition vs. control Study Cerra et al 1990 Gottschlich et al, 1990 Brown et al, 1994 Moore et al, 1994 Bower et al, 1996 Kudsk et al, 1996 Ross Products, 1996 Engel et al, 1997 Mendez et al, 1997 Rodrigo et al, 1997 Weimann et al, 1998 Atkinson et al, 1998 Galban et al, 2000 Pooled Risk Ratio 0.01 0.1 Higher for control 1 10 100 Higher for treatment Heyland et al. JAMA, 2001 Treatment n/N 1/11 2/17 Control n/N 1/9 1/14 0/18 2/47 12/143 1/17 8/83 5/18 1/21 2/13 4/13 86/193 28/87 0/19 1/51 24/163 1/16 20/87 7/18 1/22 2/16 2/16 96/197 17/89 Inflammation and organ failure in the ICU SIRS Inflammatory balance TNF, IL-1, IL-6, IL-12, IFN, IL-3 Tissue inflammation, Early organ failure and death Immunonutrients glutamine days IL-10, IL-4, IL-1ra, Monocyte HLA-DR suppression weeks Immunosuppression 2nd Infections Delayed MOF and death CARS Insult (trauma, sepsis) Griffiths, R. “Specialized nutrition support in the critically ill: For whom and when? Clinical Nutrition: Early Intervention; Nestle Nutrition Workshop Series Early enteral nutrition in severe sepsis (critical care patients) Bertolini et al. Early enteral nutrition in patients with severe sepsis, ICM 2003; 327 recruited patients; 39 with severe sepsis or septic shock; 21 received EN; feeding started within 48 hours Do we need a nutrition support team? Increased referrals and workload to clinical dietitians 1997-98 vs. 2000-03, SLMC Do we need a nutrition support team? Comparison with another center which has been fully utilizing parenteral nutrition (McFie J, England) Nutrition team fully implemented (SLMC, 2004) Do we need a nutrition support team? * * p < 0.05 y2001 < y2000A Days of inadequate intake in stroke tube fed patients were decreasing from 43% to 20% while improvement in adequate intake increased from 57% to 80% (SLMC, 2000-2001) Do we need a nutrition support team? Thank you