Transcript Malnutrition in the ICU - Critical Care Nutrition

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 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
For every 1000 kcal/day received:
Model *
Estimate (CI)
P values
PHYSICAL FUNCTIONING
3.2 (-1.0, 7.3)
P=0.14
ROLE PHYSICAL
4.2 (-0.0, 8.5)
P=0.05
STANDARDIZED PHYSICAL COMPONENT SCALE
1.8 (0.3, 3.4)
P=0.02
PHYSICAL FUNCTIONING
0.8 (-3.6, 5.1)
P=0.73
ROLE PHYSICAL
2.0 (-2.5, 6.5)
P=0.38
STANDARDIZED PHYSICAL COMPONENT SCALE
0.70 (-1.0, 2.4)
P=0.41
At 3 months
At 6 months
for increase of 30 gram/day, OR of infection at 28 days
Unpublished data from Multicenter RCT of glutamine and antioxidants
(REDOXS Study); n=364
Mechancially Vent’d patients >7days
(average ICU LOS 28 days)
Faisy BJN 2009;101:1079
• 113 select ICU patients
with sepsis or burns
• On average, receiving
1900 kcal/day and 84
grams of protein
• No significant
relationship with
energy intake but……
Clinical Nutrition 2012
More (and Earlier) is Better!
If you feed them (better!)
They will leave (sooner!)
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!)
Rice et al. JAMA 2012;307
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!
Nutritional Management of ICU Patients:
Are these both the same?
• Low Risk
– 34 year former football
player,
– BMI 35
– otherwise healthy
– involved in motor
vehicle accident
– Mild head injury and
fractured R leg
requiring ORIF
• High Risk
– 72 women
– BMI 35
– PMHx COPD, poor
functional status
– Admitted to hospital 1
week ago with CAP
– Now presents in
respiratory failure
requiring intubation and
ICU admission
ICU-acquired Weakness
(ICUAW)
Muscle weakness develops in 25%-60% of patients who have
been mechanically ventilated for > 1 week1
Prolongs:1-4
– mechanical ventilation
– weaning from the ventilator
– ICU stay
• ICUAW main clinical manifestation of critical illness
neuromyopathy (CINM)5
1.
2.
3.
4.
5.
de Jonghe B, et al. Crit Care Med. 2004;30:1117-1121.
Garnacho-Montero J, et al. Crit Care Med. 2005;33:349-354.
van den Berghe G, et al. Crit Care Med. 2003;31:359-366.
Hermans G, et al. Am J Respir Crit Care Med. 2007;175:480-489.
de Jonghe B, et al. Crit Care Med. 2009;37(suppl.):S309-S315.
Determinants to Lean Body Mass
Muscle Matters!
Skeletal muscle mass predicts ventilator-free days, ICUfree days, and mortality in elderly ICU patients
• Patients > 65 years with an admission abdominal
computed tomography scan and requiring intensive care
unit stay at a Level I trauma center in 2009-2010 were
reviewed.
• Muscle cross-sectional area at the 3rd lumbar vertebra was
calculated and sarcopenia identified using sex-specific cutpoints.
• Muscle cross-sectional area was then related to clinical
parameters including ventilator-free days, ICU-free days,
and mortality.
Kozar (in submission)
Skeletal Muscle
Adipose Tissue
Physical Characteristics of
Patients
•
•
•
•
•
N=149 patients
Median age: 79 years old
57% males
ISS: 19
Prevalence of sarcopenia: 71%
BMI Characteristics
All Patients
Sarcopenic
Patients (n=106)
Non-sarcopenic
Patients (n=43)
25.8 (22.7, 28.2)
24.4 (21.7, 27.3)
27.6 (25.5, 30.4)
Underweight, %
7
9
2
Normal Weight, %
37
44
19
Overweight, %
42
38
51
Obese, %
15
9
28
BMI (kg/m2)
Low muscle mass associated
with mortality
Proportion of Deceased
Patients
Sarcopenic patients
32%
Non-sarcopenic patients
14%
P-value
0.018
Muscle mass is associated with
ventilator-free and ICU-free days
All Patients
Sarcopenic
Patients
NonSarcopenic
Patients
P-value
Ventilator-free
days
25 (0,28)
19 (0,28)
27 (18,28)
0.004
ICU-free days
19 (0,25)
16 (0,24)
23 (14,27)
0.002
• Prospective multicenter
observational trial of 136
patients requiring min 5
days of mechanical
ventilation
• After day 5, when
awake, performed muscle
testing
Am J Respir CCM 2008;178:261-268
PROTEIN REQUIREMENT IN CRITICAL ILLNESS
AT ADEQUATE ENERGY INTAKE
Wolfe et al., Ann Surg 1983; Ishibashi et al., Crit Care Med 1998
Hoffer Am J Clin Nutr 2003
g protein / kg IBW per day
Whole-body protein loss
(kg / 2 weeks)
 0.7
0
-0.5
-1
-1.5
-2
 1.0
 1.5
 2.2
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.
Mostly surgical patients; 100% data available for SGA
“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).
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
• Multicenter prospective study of
nutrition practice in abdominal
surgery
• All patients had nutrition
screening, not all patients had
peri op nutrition support
• Benefit of nutrition support seen
in NRS>5 compared to controls,
no benefit seen in low risk
patients (NRS<5).
P=0.008
P=0.04 P=0.04
Patients with
NRS >5
Who might benefit the most from
nutrition therapy in the ICU?
• 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
Nutritional
Adequacy of
High Risk
Patients
compared to
Low Risk
Patients
Failure Rate
% high risk patients who failed to meet minimal
quality targets (80% overall energy adequacy)
91.2
75.6
78.1
87.0
79.9
75.1
69.8
Unpublished observations.
Results of 2011 International Nutrition Survey (INS).
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
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!
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 (300 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 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
100
100
Change of nutritional intake from baseline to followup of all the study sites (intervention group only)
n ITT
n Efficacy
n FVF
n E@Base
90
80
70
60
50
40
30
20
% protein received/prescribed
60
50
40
30
20
10
ITT
Efficacy
Full volume feeds
Baseline intervention
0
10
ITT
Efficacy
Full volume feeds
Baseline intervention
0
% calories received/prescribed
70
80
90
% calories
received/prescribed
243
113
57
260
219
113
57
236
194
113
57
209
171
108
54
175
153
105
52
152
138
96
46
136
118
83
40
113
107
75
35
102
83
59
26
90
76
52
23
80
1
2
3
4
5
6
7
8
9
10
59
40
17
71
52
35
14
62
12
n ITT
n Efficacy
n FVF
n E@Base
243
113
57
260
219
113
57
236
194
113
57
209
171
108
54
175
153
105
52
152
138
96
46
136
118
83
40
113
107
75
35
102
83
59
26
90
76
52
23
80
1
2
3
4
5
6
7
8
9
10
59
40
17
71
52
35
14
62
12
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
Lancet Dec 2012
Lancet Dec 2012
Lancet Dec
2012
Adult patients were eligible for enrollment within 24
hours of ICU admission if they were expected to
remain in the ICU on the calendar day after
enrollment, were considered ineligible for enteral
nutrition by the attending clinician due to a shortterm relative contraindication and were not
expected to PN or oral nutrition
Doig, ANZICS, JAMA May 2013
Who were these patients?
Overall, standard
care group
remained unfed for
2.8 days after
randomization
40% of standard
care group never
rec’d any artificial
nutrition; remained
in ICU 3.5 days
Intervention not intense enough?
• 40% of both groups got EN (delayed)
• 40% of standard care group got PN for an
average of 3.0 days
• Average PN use in early PN group was 6.0 days
•
Main inference: No harm by early PN
(in contrast to EPaNIC)
Doig, ANZICS, JAMA May 2013
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
Start PEP UP within 24-48 hrs
At 72 hrs
YES
>80% of Goal
Calories?
NO
No
Yes
Anticipated
Long Stay?
High Risk?
Carry on!
Yes
No
Maximize EN with
motility agents and
small bowel feeding
YES
No
Supplemental PN?
Tolerating
EN at 96
hrs?
No problem
NO
Yes
No problem
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
Muscle Outcome Assessments
in TOP UP
• Measures of muscle mass and function
–
–
–
–
–
mitochondrial complex I activity
US of femoral quad (baseline and follow up CTs when available)
Hand grip strength
6 min walk test
SF 36 (RP and PCS)
Reliability of US measure of
Quad Muscle Layer Thickness
• 46 pairs of within operator measurements with an ICC of .98
• 73 pairs of operator 1 to operator 2 measurements with an ICC of .94.
•There was a small but statistically significant difference between the
operator 1 and 2 results Mean (operator 1-2) (95% CI) = -0.061 cm (0.100 to -0.022), p= 0.0028.
Lancet 2009;273:
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! (JOIN International Critical Care Nutrition
Survey in 2013)
– PEP uP protocol in all
– Selective use of small bowel feeds then sPN in high risk patients
Questions?