Optimal provision of en nutrition in the icu

Adjunctive
Supportive
Care
Proactive
Primary
Therapy
Early and Adequate Nutrition is therapy that
modulates the underlying disease process
and impacts patient outcomes

Increasing Calorie Debt Associated with worse Outcomes
↑ Caloric debt associated with:
↑ Longer ICU stay
↑ Days on mechanical ventilation
↑ Complications
 ↑ Mortality
Adequacy
of EN
Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006
0
200
400
600
800
1000
1200
1400
1600
1800
2000
1 3 5 7 9 11 13 15 17 19 21
Days
kcal
Prescribed Engergy
Energy Received From Enteral Feed
Caloric Debt

Early vs. Delayed EN:
Effect on Infectious
Complications
Updated 2009
www.criticalcarenutrition.com

Early vs. Delayed EN:
Effect on Mortality
Updated 2009

Feeding the Hypotensive Patient?
DiGiovine et al. AJCC 2010
The beneficial effect of early feeding is more
evident in the sickest patients, i.e, those on
multiple vasopressor agents.
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.

Optimal Amount of Protein and
Calories for Critically Ill Patients?
Early EN (within 24-48 hrs of
admission) is recommended!

• 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

Hypothesis
• There is a relationship between amount of
energy and protein received and clinical
outcomes (mortality and # of days on
ventilator)
• The relationship is influenced by nutritional
risk
• BMI is used to define chronic nutritional risk

What Study Patients Actually Rec’d
• Average Calories in all groups:
– 1034 kcals and 47 gm of protein
Result:
• Average caloric deficit in Lean Pts:
– 7500kcal/10days
• Average caloric deficit in Severely Obese:
– 12000kcal/10days

Relationship Between Increased
Calories and 60 day Mortality
BMI Group Odds
Ratio
95%
Confidence
Limits
P-value
Overall 0.76 0.61 0.95 0.014
<20 0.52 0.29 0.95 0.033
20-<25 0.62 0.44 0.88 0.007
25-<30 1.05 0.75 1.49 0.768
30-<35 1.04 0.64 1.68 0.889
35-<40 0.36 0.16 0.80 0.012
>=40 0.63 0.32 1.24 0.180
Legend: Odds of 60-day Mortality per 1000 kcals received per day adjusting for nutrition
days, BMI, age, admission category, admission diagnosis and APACHE II score.

BMI Group
Adjusted
Estimate
95% CI P-value
LCL UCL
Overall 3.5 1.2 5.9 0.003
<20 2.8 -2.9 8.5 0.337
20-<25 4.7 1.5 7.8 0.004
25-<30 0.1 -3.0 3.2 0.958
30-<35 -1.5 -5.8 2.9 0.508
35-<40 8.7 2.0 15.3 0.011
>=40 6.4 -0.1 12.8 0.053
Relationship Between Increased Energy
and Ventilator-Free days
Legend: # of VFD per 1000 kcals received per day adjusting for nutrition days, BMI, age,
admission category, admission diagnosis and APACHE II score.

Faisy BJN 2009;101:1079
Mechancially Vent’d patients >7days
(average ICU LOS 28 days)

Effect of Increasing Amounts of Protein
from EN on Infectious Complications
Multicenter observational study of 207 patients >72 hrs in ICU
followed prospectively for development of infection
for increase of 30 gram/day, OR of infection at 28 days
Heyland Clinical Nutrition 2010

Multicenter RCT of glutamine and antioxidants (REDOXS Study)
First 364 patients with SF 36 at 3 months and/or 6 months
for increase of 30 gram/day, OR of infection at 28 days
Heyland Unpublished Data
Model *
Estimate (CI)
P values
(B) Increased protein intake
PHYSICAL FUNCTIONING (PF) at 3 months 2.9 (-0.7, 6.6) P=0.11
ROLE PHYSICAL (RP) at 3 months 4.4 (0.7, 8.1) P=0.02
STANDARDIZED PHYSICAL COMPONENT
SCALE (PCS) at 3 months
1.9 (0.5, 3.2) P=0.007
PHYSICAL FUNCTIONING (PF) at 6 months 0.2 (-3.9, 4.3) P=0.92
ROLE PHYSICAL (RP) at 6 months 1.7 (-2.5, 5.9) P=0.43
STANDARDIZED PHYSICAL COMPONENT
SCALE (PCS) at 6 months
0.7 (-0.9, 2.2) P=0.39
Relationship between increased nutrition intake and
physical function (as defined by SF-36 scores)
following critical illness

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

Optimal Amount of Calories for
Critically Ill Patients:
Depends on how you slice the cake!
• Sample restriction approaches have included limiting
analyzed patients to those:
1. In the ICU for at least 96 hours,
2. In the ICU at least 96 hours prior to progression to exclusive oral feeding and
3. Eliminating days after progression to exclusive oral feeding from the calculation
of nutrition intake.
• Statistical adjustment approaches have included using
regression techniques to adjust for:
1. ICU length of stay (LOS),
2. Evaluable nutrition days and
3. Relevant baseline patient characteristics or some combination thereof.
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.*
D. In ICU at least 12 days prior to
permanent progression to exclusive oral
feeding*
*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.
0.4 0.6 0.8 1.0 1.2 1.4 1.6
Unadjusted
Adjusted
Odds ratios with 95% confidence intervals

Association Between 12-day Caloric
Adequacy and 60-Day Hospital Mortality
Heyland CCM 2011
Optimal
amount=
80-85%

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

Rice CCM 2011;39:967
Did not measure infection nor physical function!

“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

• Average age 51
• Few comorbidities
• Average BMI 29
• 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!
Large multicenter trial of this concept
(EDEN study) by ARDSNET just finished

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?

Nutrition Status
micronutrient levels - immune markers - muscle mass
Starvation
Acute
-Reduced po intake
-pre ICU hospital stay
Chronic
-Recent weight loss
-BMI?
Inflammation
Acute
-IL-6
-CRP
-PCT
Chronic
-Comorbid illness
A Conceptual Model for Nutrition Risk
Assessment in the Critically Ill

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)
Non-survivors by day 28
(n=138)
Survivors by day 28
(n=460)
p values
Age 71.7 [60.8 to 77.2] 61.7 [49.7 to 71.5] <.001
Baseline APACHE II score 26.0 [21.0 to 31.0] 20.0 [15.0 to 25.0] <.001
Baseline SOFA 9.0 [6.0 to 11.0] 6.0 [4.0 to 8.5] <.001
# of days in hospital prior to ICU admission 0.9 [0.1 to 4.5] 0.3 [0.0 to 2.2] <.001
Baseline Body Mass Index 26.0 [22.6 to 29.9] 26.8 [23.4 to 31.5] 0.13
Body Mass Index 0.66
<20 6 ( 4.3%) 25 ( 5.4%)
≥20 122 ( 88.4%) 414 ( 90.0%)
# of co-morbidities at baseline 3.0 [2.0 to 4.0] 3.0 [1.0 to 4.0] <0.001
Co-morbidity <0.001
Patients with 0-1 co-morbidity 20 (14.5%) 140 (30.5%)
Patients with 2 or more co-morbidities 118 (85.5%) 319 (69.5%)
C-reactive protein¶ 135.0 [73.0 to 214.0] 108.0 [59.0 to 192.0] 0.07
Procalcitionin¶ 4.1 [1.2 to 21.3] 1.0 [0.3 to 5.1] <.001
Interleukin-6¶ 158.4 [39.2 to 1034.4] 72.0 [30.2 to 189.9] <.001
171 patients had data of recent oral intake and weight loss
Non-survivors by day 28
(n=32)
Survivors by day 28
(n=139)
p values
% Oral intake (food) in the week prior to enrolment 4.0[ 1.0 to 70.0] 50.0[ 1.0 to 100.0] 0.10
% of weight loss in the last 3 month 0.0[ 0.0 to 2.5] 0.0[ 0.0 to 0.0] 0.06

Variable
Spearman
correlation with
VFD within 28
days
p values
Number of
observations
Age -0.1891 <.0001 598
Baseline APACHE II score -0.3914 <.0001 598
Baseline SOFA -0.3857 <.0001 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 -0.1828 0.0130 184
Baseline BMI 0.0581 0.1671 567
# of co-morbidities at baseline -0.0832 0.0420 598
Baseline CRP -0.1539 0.0002 589
Baseline Procalcitionin -0.3189 <.0001 582
Baseline IL-6 -0.2908 <.0001 581
What are the nutritional risk factors
associated with clinical outcomes?
(validation of our candidate variables)

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

Variable Range Points
Age <50 0
50-<75 1
>=75 2
APACHE II <15 0
15-<20 1
20-28 2
>=28 3
SOFA <6 0
6-<10 1
>=10 2
# Comorbidities 0-1 0
2+ 1
Days from hospital to ICU admit 0-<1 0
1+ 1
IL6 0-<400 0
400+ 1
AUC 0.783
Gen R-Squared 0.169
Gen Max-rescaled R-Squared 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.

The Validation of the NUTrition Risk in the
0 1 2 3 4 5 6 7 8 9 10
Nutrition Risk Score
MortalityRate(%)
020406080
Observed
Model-based
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
Nutrition Risk Score
DaysonMechanicalVentilator
02468101214
Observed
Model-based
n=12 n=33 n=55 n=75 n=90 n=114 n=82 n=72 n=46 n=17 n=2

0 50 100 150
0.00.20.40.60.81.0
Nutrition Adequacy Levles (%)
28DayMortality
11
11
1
1
1
11
2
2
2
2
2 2
2
2
2
3
3
3
33
3
3
3
3
33
3
3
3
3
3
3
3
444
4
44
4444
4
44
4
44 44
44
4
4
4
4
4
4 4
44 4 44
4
4
4
55 5555 5 5
5 5 5 5 5 5
5 55
555 5
5
5
5
555 55 555
55
5
5
5
555 5
55
66 66 66
666
66
6 6
6
6
66
6 666 66 6
6
6
6
6
6
6 6
6
66
6 6
6
6
6
7
7
7
7
7
7
7
7
7
7
7
7
7
7
77
7
7
7
7
7
7
7 7
7
8
8
8
8
8
8
8
8
88
8
8
8
88
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
9
1010
Interaction between NUTRIC Score and nutritional adequacy (n=211)*
P value for the
interaction=0.01
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?

Can we do better?
The same thinking that got you into
this mess won’t get you out of it!

Aggressive Gastric Feeding
may be a BAD THING!
Observational study of 153 medical/surgical
ICU patients receiving EN in stomach
Intolerance= residual volume>500ml,
vomiting, or residual volume 150-500x2.
Patients followed for development of VAP
(diagnosed invasively)
Mentec CCM 2001;29:1955

Incidence of
Intolerance= 46%
Statistically associated
with worse clinical
outcomes!
Risk factors for
Intolerance
 Sedation
 Catecholamines
 High residuals before and
during EN
43
23
41
24
15
25
Pneumonia ICU LOS
(days)
%Mortality
Intolerance none
Aggressive Gastric Feeding
may be a BAD THING!

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 a feeding protocol that incorporates motility
agents and small bowel feeding tubes should be
considered”

Use of Nurse-directed Feeding Protocols
Start feeds at 25
ml/hr
Check
Residuals
q4h
> 250 ml
•hold feeds
•add motility
agent
•reassess q 4h
< 250 ml
•advance rate by 25 ml
•reassess q 4h
2009 Canadian CPGs www.criticalcarenutrition.com
“Should be considered as a strategy to optimize delivery of
enteral nutrition in critically ill adult patients.”

Characteristics Total
n=269
Feeding Protocol
Yes 208 (78%)
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 %
The Impact of Enteral Feeding Protocols
on Enteral Nutrition Delivery:
Results of a multicenter observational study
Heyland JPEN Nov 2010
15.2% using the
recommended
threshold volume
of 250 ml

The Impact of Enteral Feeding Protocols
on Enteral Nutrition Delivery:
Results of a multicenter observational study
• 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
Heyland JPEN 2010
0
20
40
60
80
Caloriesfrom EN TotalCalories
Protocol
No Protocol
P<0.05
P<0.05

 Impaired motility
 Medications
 Metabolic, electrolyte abnormalities
 Underlying disease
Reasons for Inadequate Intake
Prophylactic
use of motility
agents
 Slow starts and slow ramp ups
 Interruptions
 Mostly related to procedures
 Not related to GI dysfunction
Can be overcome
by better feeding
protocols

Initial Efficacy and Tolerability of Early Enteral
Nutrition with Immediate or Gradual
Introduction in Intubated Patients
Desachy ICM 2008;34:1054
• This study randomized 100
mechanically ventilated patients
(not in shock) to Immediate goal
rate vs gradual ramp up (our usual
standard).
• The immediate goal group rec’d
more calories with no increase in
complications

Initial Efficacy and Tolerability of Early Enteral
Nutrition with Immediate or Gradual
Introduction in Intubated Patients
Desachy ICM 2008;34:1054

• 329 patients randomized
to GRV 200 vs. 500
• >80% Medical
• Average APACHE II 18
• Similar nutritional
adequacy:
• 85 vs 88% goal
calories
What Gastric Residual Volume Threshold Should I use?

Protocol to Manage Interruptions
to EN due to non-GI Reasons
Can be downloaded from www.criticalcarenutrition.com

• 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, rather than started when there is a
problem.
The Efficacy of Enhanced Protein-Energy Provision via the
Enteral Route in Critically Ill Patients:
The PEP uP Protocol!
A Major Paradigm Shift in How we Feed Enterally
Heyland Crit Care 2010

Change of nutritional intake from baseline to
follow-up of all the study sites
(Efficacy Analysis)
% calories received/prescribed
%caloriesreceived/prescribed
326326
331331
360360
371371
372372
373373
374374
375375
390390
Baseline Follow-up
20304050607080
p value for Community sites=0.07
p value for Academic sites=0.001
Academic
Community
Intervention sites
%caloriesreceived/prescribed
327327
359359
362362
376376
377377
378378
379379
380380
404404
Baseline Follow-up
20304050607080
Academic
Community
Control sites

% protein received/prescribed
Change of nutritional intake from
baseline to follow-up of all the study sites
(Efficacy Analysis)%proteinreceived/prescribed
326326
331331
360360
371371
372372
373373
374374
375375
390390
Baseline Follow-up
20304050607080
Academic
Community
Intervention sites
%proteinreceived/prescribed
p value for Community sites=0828
327327
359359
362362
376376
377377
378378
379379
380380
404404
Baseline Follow-up
20304050607080
Academic
Community
Control sites

Effect on VAP
Updated 2011,www.criticalcarenutrition.com
Small Bowel vs. Gastric Feeding: A meta-analysis
Other Strategies to Maximize the
Benefits and Minimize the Risks of EN

Does Postpyloric Feeding Reduce
Risk of GER and Aspiration?
Tube
Position
# of
patients
% positive
for GER
% positive
for
Aspiration
Stomach 21 32 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

What if you can’t provide
adequate nutrition enterally?
… to add PN or not to add PN,
that is the question!
Health Care Associated
Malnutrition

Critical Care Nutrition CPGs
• If unable to meet energy requirements after 7-10 days
by the enteral route, consider initiating PN.
• Initiating PN prior to this 7-10 day period does not
improve outcome and may be detrimental to the patient.
Americans
• Maximize EN (motility agents, small bowel feeds, etc.)
prior to starting PN.
Canadians
• All patient who are not expected to be on normal
nutrition within 3 days should receive PN within 24-48
hours if EN is contraindicated or if they can not tolerate
adequate amounts of EN.
Europeans

Early vs. Late Parenteral
Nutrition in Critically ill Adults
• 4620 critically ill patients
• Randomized to early PN
– Rec’d 20% glucose 20
ml/hr then PN on day 3
• OR late PN
– D5W IV then PN on day
8
• All patients standard EN
plus ‘tight’ glycemic control
Cesaer NEJM 2011
• Results:
Late PN associated with
• 6.3% likelihood of early
discharge alive from ICU
and hospital
• Shorter ICU length of
stay (3 vs 4 days)
• Fewer infections (22.8 vs
26.2 %)
• No mortality difference

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

ICU patients
BMI <25 R
PN for 7 days
Control
The TOP UP Trial
Fed enterally
Primary
Outcome
60-day
mortality
BMI >35
Stratified by:
Site
BMI
Med vs Surg

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!
– Consider updating your feeding protocol!

Questions?

Optimal provision of en nutrition in the icu

More Related Content

What's hot (20)

Viewers also liked (6)

Similar to Optimal provision of en nutrition in the icu (20)

More from Mario Sanchez (20)

Recently uploaded (20)

Optimal provision of en nutrition in the icu

Editor's Notes