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WHAT’S NEW IN ICU NUTRITION? ‘A slender and restricted diet is always dangerous in chronic and in acute diseases’ ‘Let food be thy medicine’ Hippocrates 400 B.C. SICS Nutrition Network Set up in June 2006 Links 30 dietitians, 6 pharmacists, 10 ICU Nutrition nurses, and 17 doctors. Meets 3x/year at QMH. Around 12-18/meeting Guidelines on practical issues planned Website with protocols/guidelines/teaching Educational meetings Current projects on assessment/weighing Encouraging projects in nutrition SICS Nutrition Network Meetings – videoconferencing Presentations of local projects/audits Ideas for new projects discussed Reports on conferences/equipment Discussion on topical issues e.g. nutrition teams, education, weighing, screening Reviews of topics planned e.g. pre-and post-op feeding Article circulation planned ‘Best Practice’ statements Starting and stopping feed Adding water to feeds Use of MUAC Use of different weights (ideal, actual etc) Nasal bridles Education Module on SICS website Teaching powerpoint on website Junior doctors’ induction FY2 teaching by nutrition nurse Consultants’ mandatory training Chapter for ABC of Intensive Care Website Audits Nutrition audit of Scottish Units 2006 – widely diverse practice and knowledge HDU feeding – Fife, Forth Valley International Nutrition QI audit: 9 units last 2 years Helped to inform changes in practice Nutrition Audit form on website % patients receiving PN/year 30 25 20 15 Unit 10 5 0 E WD I F V M X A K N Q G S P H B C R The Downward Spiral of Malnutrition in Severe Illness Decreased energy and nutrient intake Serious complications e.g. pneumonia Muscle catabolism and weight loss Further decreased intake Morbidity / Mortality Depression and lethargy Delayed recovery Secondary infections Current Projects: Nutritional Screening Required by QIS and NICE for: All patients on admission to hospital and regularly thereafter MUST introduced by BAPEN - being widely implemented Not helpful in ICU – all high risk Need to identify the severely malnourished Improves feeding of these patients Nutritional State and Complications in SHDU, WGH 2003 25 20 15 10 5 0 Complications Poor No Complications Intermediate Good SNACC – 3 phases Few ICU nutrition studies have looked at nutritional status – probably crucial Fife ICU nutritional screening tool 1. Pilot study completed – to repeat in WGH + external validity study. 2. Systematic review started (funded) 3. Larger study 2010-11 - will need funding – nutritional state and outcomes Aim to focus nutritional intervention What’s New inWeighing IC ICU patients Weighing Patients Essential for nutrition screening Nutritional requirement calculations Indirect calorimetry Drug dosages Cardiac output monitoring – LIDCO, PAFC, PICCO Fluid balance ARDS tidal volumes Weighing Patients Estimation of weight can be up to 20% out: i.e. 80 kg instead of 100kg and vice versa Estimation of height also inaccurate but measuring height with tape fairly accurate We need to weigh patients in ICU Weighing Patients Craig Hurnauth: ICU S/N at SJH Audit of 13/14 NHS trusts in Scotland 12 trusts do not weigh patients in ICU on admission - use estimate/notes/family 1 weighs every day with hoist + weekly 5 use MUST 7 do not screen, 1 adapted screening tool 7 units in England – similar results Methods of Weighing Hoist: time consuming, needs several nurses, risky for unstable patients or trauma patients Weigh beds £16000 each Digital bed scales – scales for each wheel of the bed – weighs bed + patient, mobile, minimal manpower, no disruption to patient Methods of Weighing Progress since audit: 2 units have bought weigh beds 5 are considering bed scales Challenges in Critical Care Nutrition 1. Keeping up with evidence - guidelines 2. Screening/weighing 3. Prevention and treatment of complications 4. Outdated surgical practices/ Perioperative feeding 5. Achieving calorific and protein targets 6. Immunonutrition Guidelines Guidelines CCCTG Nutritional Support updated: 2009 www.criticalcarenutrition.com ESPEN Parenteral Nutrition guidelines 2009, EN 2006, (ASPEN guidelines) NICE guidelines on Nutrition Support in Adults QIS Standards MUST (BAPEN) Screening/Refeeding Syndrome Prisoners of war 1944-5, 1944: conscientious objectors in USA studied Starvation: early use of glycogen stores and gluconeogenesis from amino acids 72 hrs: fatty acid oxidation; use of fatty acids and ketones for energy source, low insulin levels Atrophy of organs, reduced lean body mass Refeeding syndrome Carbohydrate feeding: shift to CH metabolism Insulin release, Mg lost in urine Phosphate and potassium shift into cells. Magnesium, potassium and phosphate drop May get Lactic acidosis Sodium and water shift out of cells – oedema Insulin causes sodium retention Protein synthesis needs potassium and phosphate - these drop more Thiamine deficiency occurs (co-factor in CH metabolism): encephalopathy, weakness Refeeding Syndrome in ICU Unlikely to be a clear diagnosis Many effects: oedema, arrhythmias, pulmonary oedema, cardiac decompensation, respiratory weakness, fits, hypotension, leukocyte dysfunction, diarrhoea, coma, rhabdomyolysis, sudden death Screen: nutritional history and electrolytes Remember in HDU patients/malnourished ward patients Poor awareness among doctors! Risk of re-feeding syndrome Two or more of the following: BMI less than 18.5 kg/m2 (<16) unintentional weight loss greater than 10% within the last 3-6 months (>15%) little or no nutritional intake for more than 5 days (>10) Hx alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics Critically low levels of PO42-, K+ and Mg2+ NICE Guidelines for Nutrition Support in Adults 2006 Managing refeeding problems provide Thiamine (Pabrinex)/multivitamin/trace element supplementation start nutrition support at 10-15 kcal/kg/day increase levels over 3-5 days restore circulatory volume monitor fluid balance and clinical status replace phosphate, magnesium and K+ Reduce feeding rate if problems arise NICE Guidelines for Nutrition Support in Adults 2006 Complications Ileus- caused by: fluid overload, pain, hyperglycaemia, hypokalaemia, opioids, immobility, sepsis – trickle of feed if gut intact. Consider Neostigmine/prokinetics Constipation: avoid and treat; drugs Diarrhoea: exclude infections, optimise fluid balance and electrolytes, replace loss Intolerance: ? Sepsis, NJ feeding, PKs Feeding aids fluid and electrolyte balance Overfeeding Lactic acidosis Hyperglycaemia Increased infections Liver impairment (Alk phos, ALT, GGT, acalculous cholecystitis) Persistent pyrexia Underfeeding probably even more dangerous – studies starting to emerge – need to get the balance right Outdated surgical practices Outdated surgical practice Reluctance to feed at all Prolonged semi-starvation Sips of water/Over-IV hydration Incidence and treatment of ileus Nervous surgeon syndrome Evidence from ERAS – pre-op CH loading Benefits of early post-op feeding Over/under-use of PN Intake in HDU 60 50 40 30 20 10 0 Day 1 Day 2 Day 3 NBM Sips Fluids Day 4 Day 5 Oral TPN Day 6 NG Calorific and Protein Targets 25kcl/kg/day up to 30 in recovery phase Aim to provide energy as close as possible to target to avoid negative energy balance Protein 1.3 – 1.5g/kg/day (optimal prtn sparing) CVVH – lose AAs in filter – need to give 20% more using amino acid supplements Protein deficits may be very important Increasing evidence that patients with deficits in 1st 3-5 days do worse (?severely malnourished) Indirect calorimetry – the future? Maintaining enteral intake Follow a protocol; use prokinetics/NJs Gastric residuals: do not stop feed until you have 2 residuals of >250mls (check clinical signs) 400mls may be ok Starting and stopping feed: Extubations, fasting for theatre, scans, minor procedures Can catch up on feed that is missed ESPEN: PN in ICU All patients receiving less than their targeted enteral feeding after 2 days should be considered for supplementary PN All patients not able to receive EN within 2448 hours should be given PN CCCN: Inadequate enteral nutrition <80% of target after 3 days: PN Do not delay nutrition in malnourished Keep 10ml/hr EN if possible Immunonutrition The future: replacement of the body’s own ‘stress substrates’ and reduction of inflammation? ESPEN – new recommendations – glutamine in all PN 0.2-0.4g/kg/day ??? SIGNET/REDOXs glutamine in enteral nutrition for burns and trauma Polyunsaturated Fatty Acids Omega-6 ү-Linoleic acid (GLA) – borage oil Arachidonic Acid precursor Omega-3 Fish oils: Eicosapentanoic acid (EPA) and Docosahexanoic acid (DHA) Dietary Lipids Ratios in paleolithic diet ω6:ω-3 1:1 Current Western diet 16:1 Current UK PN Soybean oil base 7:1 New PN (‘SMOF’) 2.5:1 Cell membrane composition depends on balance AA, DHA and EPA are present in inflammatory cell membrane phospholipids Mechanisms of Action ω-3s EPA/DHA are incorporated quickly into cell membrane: inhibit ω-6 activity Promote synthesis of low activity PGs and LTs Decrease expression of adhesion molecules Inhibit monocyte prodn of pro-inflamm cytokines Decrease NFkB, increases lymphocyte apoptosis Decrease pro-inflammatory gene expression Lipoxins, resolvins and protectins 3 Studies: OXEPA Patients with ARDS fed with GLA, EPA and antioxidants had a reduction in pulmonary neutrophils Improvement in oxygenation Decrease in ventilator days Decrease in ICU and hospital days Gadek, Singer, Pontes-Arruda (sepsis) Recommended by ESPEN in ARDS ESPEN PN Guidelines PN for critically ill surgical patients should probably include ω-3 fatty acids. Fish oil enriched lipid emulsions probably reduce ICU LOS. The tolerance of MCT/LCT and olive oil emulsions is well established. These probably have advantages over LCT based lipid preparations – small studies so far. Anti-oxidants Normal state: reduction > oxidation Acute stress: injury/sepsis causes acute dysregulation: ROS/RNOS formed Mitochondria are both sources and targets Observational studies: anti-oxidant capacity inversely correlated with disease severity due to depletion during oxidative OXIDATION stress REDUCTION Antioxidants Glutathione, Vitamins A, C and E Zinc, copper, manganese, iron, selenium Already added to feeds Should we give extra? ESPEN: VitC/thiamine/Se/Zn in CVVH/burns Results of SIGNET and REDOXs awaited Oxidative stress in critically ill patients contributes to organ damage / malignant inflammation To conclude: Screen your patients Early enteral feeding is best Hyperglycaemia/overfeeding are bad Keep glucose down <10mmol/l (safely) Nutritional deficit a/w worse outcome Use EN and PN early to achieve goals Audit delivery of nutrition regularly Protocols improve delivery of feed Some nutrients show promising results: we should probably start using them now Please feed me enough and with the right stuff!