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Improving the Practice of Nutrition Therapy in the Critically ill Results of 2009 International Nutrition Survey

Improving the Practice of Nutrition Therapy in the Critically ill Results of 2009 International Nutrition Survey. Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada. Learning Objectives.

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Improving the Practice of Nutrition Therapy in the Critically ill Results of 2009 International Nutrition Survey

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  1. Improving the Practice of Nutrition Therapy in the Critically ill Results of 2009 International Nutrition Survey Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada

  2. Learning Objectives • Convince you that efforts to improve nutrition in the ICU are worthwhile • Familiarize you with the recommendations of the Canadian Critical Care Nutrition Clinical Practice Guidelines • Make you aware of current nutrition practices in ICUs in your own geographic region and throughout the world • Enable you to identify gaps between guideline recommendations and current practices in ICUs • Provide tools to begin to narrow that GAP!

  3. Underlying PathophysiologyOf Critical Illness EN Intake Caloric Debt •  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

  4. 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

  5. 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

  6. 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

  7. Relationship Between Increased Calories and 60 day Mortality 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.

  8. 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.

  9. 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

  10. 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

  11. 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 for increase of 30 gram/day, OR of infection at 28 days HeylandUnpublished Data

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

  13. 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

  14. 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 administered 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 (in press)

  15. 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: • In the ICU for at least 96 hours, • In the ICU at least 96 hours prior to progression to exclusive oral feeding and • 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: • ICU length of stay (LOS), • Evaluable nutrition days and • Relevant baseline patient characteristics or some combination thereof. Heyland Crit Care Med 2011 (in press)

  16. 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.* Association between 12 day average caloric adequacy and 60 day hospital mortality 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.

  17. Association Between 12-day Caloric Adequacy and 60-Day Hospital Mortality Quality Improvement Target

  18. More is Better! If you feed them (better!) They will leave (sooner!)

  19. ICU patients are not all created equal…should we expect the impact of nutrition therapy to be the same across all patients?

  20. 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

  21. Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure No difference between groups! Didn’t measure infection nor physical function Rice CCM 2011;39:967

  22. Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure • 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

  23. ICU patients are not all created equal…should we expect the impact of nutrition therapy to be the same across all patients?

  24. RCT Level of Evidence that More EN= Improved Outcomes • RCTs of aggressive feeding protocols • Results in better protein-energy intake • Associated with reduced complications and improved survival • Taylor et al Crit Care Med 1999; Martin CMAJ 2004 • Meta-analysis of Early vs Delayed EN • Reduced infections: RR 0.76 (.59,0.98),p=0.04 • Reduced Mortality: RR 0.68 (0.46, 1.01) p=0.06 • www.criticalcarenutrition.com

  25. More (and Earlier) is Better! If you feed them (better!) They will leave (sooner!)

  26. Objectives of International Survey Quality Improvement • To determine current nutrition practice in the adult critical care setting (overall and subgroups) • Illuminate gaps between best practice and current practice • To identify nutrition practices to target for quality improvement initiatives Generate New Knowledge • To determine factors associated with optimal provision of nutrition • To determine what nutrition practices are associated with best clinical outcomes

  27. History of International Surveys • 3 previous surveys in Canada • 2001, 2003, 2004 • N > 50 • Extended to other countries • Focus on North America in 2007 (n=167) • Focus on Australasia in 2008 (n=169) • Focus back on North America in 2009 (n=172) • 2011, Focus on Latin America

  28. Methods Eligibility Criteria • ICU Site • >8 beds • Availability of individual with knowledge of clinical nutrition to collect data • Patient • In ICU > 72 hours • Mechanically ventilated within 48 hours

  29. Methods • Prospective observational cohort study • Start date: 16th September 2009 • Aim 20 consecutive patients • Min 8 pts • Data included: • Hospital and ICU demographics • Patient baseline information (e.g. age, admission diagnosis, APACHE II) • Baseline Nutrition Assessment • 12 days Daily Nutrition data (e.g. type of NS, amount NS received) • 60 day hospital outcomes (e.g. mortality, length of stay)

  30. Web based Data Capture System

  31. Benchmarking • Individual ICUs compared to: • Canadian Clinical Practice Guidelines • All ICUs • ICUs from same geographic region

  32. Recommendations: Based on 8 level 2 studies, we recommend early enteral nutrition (within 24-48 hrs following resuscitation) in critically ill patients. Early vs Delayed Nutrition Intake

  33. Who participated in 2009?: 157 ICUs Canada: 32 Asia: 16 Europe: 14 USA: 63 China: 1 Taiwan: 1 India: 10 Iran : 1 Japan: 1 Singapore: 2 Italy: 2 UK: 7 Ireland: 2 Norway: 1 Switzerland: 1 Czech Republic: 1 Mexico: 2 Brazil:1 Colombia:5 Peru:1 Venezuela:1 Latin America: 10 Australia & New Zealand: 22

  34. ICU Characteristics

  35. Patient Characteristics

  36. Outcomes at 60 days

  37. We strongly recommend the use of enteral nutrition over parenteral nutrition

  38. Type of Artificial Nutrition n=3028 patients

  39. Use of EN Only n=17567 patients days

  40. Use of PN Only n=2294 patients days

  41. Role of Supplemental PN We recommend that parenteral nutrition not be started at the same time as enteralnutrition. In the patient who is not tolerating adequate enteral nutrition, there are insufficient data to put forward a recommendation about when parenteral nutrition should be initiated.Practitioners will have to weigh the safety and benefits of initiating PN in patients not tolerating EN on an individual case-by-case basis.We recommend that PN not be started in critically ill patients until all strategies to maximize EN delivery (such as small bowel feeding tubes, motility agents) have been attempted.

  42. Use of EN + PN n=1157 patients days

  43. EN in Combination with PN % of patients received motility agents before PN started

  44. We recommend early enteral nutrition (within 24-48 hrs following admission) in critically ill patients

  45. Timing of Initiation of EN

  46. An evidence based feeding protocol should be considered as a strategy to optimize delivery of enteral nutrition

  47. Use of a Feeding Protocol

  48. In critically ill patients who experience feed intolerance (high gastric residual volumes, emesis) the use of a motility agent and small bowel feeding tubes are recommended

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