Nutrition support in the ICU setting

1. Nutrition support in the ICU setting It is what you don’t see that really matters Luisito O. Llido, MD,FPCS St. Luke’s Medical Center Philippine Society of Parenteral and Enteral Nutrition

2. Profile of problems in the ICU • Inadequate intake due to multiple etiologies • Chronic illness • Cardiac problems • Pulmonary problems • Gastrointestinal problems • Stroke • Depressed • Geriatric patients • Common Features: • No appetite • Swallowing problems • Malabsorption

3. Cardiopulmonary failure Gastrointestinal dysfunction Renal failure Microcirculation dysfunction Acid base imbalance Microcirculation collapse Organ failure Pathophysiology

4. nucleus • oxygen • macronutrients • micronutrients • substrates • hormones • cytokines • CO2 • breakdown products • micronutrients • substrates • hormones • cytokines • energy production • substrate utilization • substrate synthesis • protein / complex subs synthesis LOCAL EFFECTS Endothelium interaction • Interaction with clotting mechanism • interaction with inflammation process SYSTEMIC EFFECTS Capillary arterial side Capillary venous side The microcirculatory environment

5. DNA Stimulus • nutrient • microbe • cell debris • physical agent • chemical agent • hostile environment PROTEIN SYNTHESIS Response • defense • offense • repair • suicide Current Concept Stimulus and cell response

6. Tissue inflammation, Early organ failure and death SIRS TNF, IL-1, IL-6, IL-12, IFN, IL-3 PRO days weeks Inflammatory balance ANTI IL-10, IL-4, IL-1ra, Monocyte HLA-DR suppression Immunosuppression Delayed MOF and death 2nd Infections 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 Inflammation and organ failure in the ICU

7. Alternate pathway activators: C3bBb C4b2a C3 Classical pathway activators C4 C3a C4a C1qr2s2 C1qr2s2 C3b B C4b C2 MBL MASP1, MASP2 MBL MASP1, MASP2 C3bB C4b2 D Ba C3 C2b Lectin pathway activators C3bBb C4b2a C3a C3b C8 C9 C6 C7 C5 C5b C5a C3b C5b-9 C5b67 Surface site Complement System Antigen/ antibody complexes (adaptive Microorganisms (innate)

10. How about cancer patients? Stage 3-4

11. 100 100 Intensive treatment 96 96 Intensive treatment 92 92 Conventional treatment In-Hospital Survival (%) Survival in the ICU (%) 88 88 Conventional treatment 84 84 0 40 80 120 160 0 65 130 195 260 Days after admission Days after admission Insulin in critically ill patients Van den Berghe, G et al. Intensive insulin therapy in critically ill patients. NEJM 2001; 345:1359-1367

12. Nutrition issues in critical care • Adequate and complete nutrient intakes • “NPO” mind set • Type of nutrient and route of delivery • Development of immune reactions (e.g. allergy) • Parenteral nutrition • Antibiotics • Effect on normal flora • Preventive measures • Stressful or injurious environment (e.g. oxidative stress) • Use of special nutrients that become conditionally essential

13. Nutrition intake in critically ill

14. Umali et al. Recommended and actual calorie intakes of intensive care unit patients in a tertiary care hospital in the Philippines. Nutrition 2006. Nutrition intake in critically ill

15. Are we feeding these patients adequately?

17. cytochrome • dehydrogenase Oxidation Energy Iron Protein synthesis Wound healing Zinc • DNA processes Copper • SO dismutase Immunity Phagocytosis Selenium • Glutathione Antioxidants Inflammation Trace elements and life processes

18. Lecuit M, Sonnenburg J. Host-microbial relationship in the intestine: sensing commensal and pathogenic bacteria: Nutrition, immune functions and health; Euroconferences, Paris; June 9-10, 2005 Host-microbial interaction

19. Gut – inductive and effector sites Per Brandtzaeg, Mucosal adaptive immunity: impact of exogenous stimuli and feeding; Nutrition, immune functions and health; Euroconferences, Paris; June 9-10, 2005

20. 20% energy (keys) Complete starvation Injury + Starvation 0 Decision Box 5 Maastricht trial 1992 10 Veterans trial 1990 15 Nottingham trial 1983 20 Lincoping trial 1990 Studley 1930 % WEIGHT LOSS 25 Keys 1953 30 Warsaw Ghetto 1942 35 30% Mortality 40 45 DAYS 0 10 20 30 40 50 60 70 80 90 100 Allison SP. The uses and limitations of nutrition support. Arvid Wretlind lecture given at 14th ESPEN Congress in Vienna. Clinical Nutrition (1992) 11: 319-330. What to do?

21. Ability to withstand starvation - effects of age and size 2500 2000 2 kg prem adult 1500 Calorie reserve (kcal/kg) term 1000 1 year old 500 1 kg prem 0 10 20 30 40 50 60 70 80 90 100 Duration of starvation (days) Pediatric patients: priorities

22. 200 Lymphoid type 180 Neural type 160 140 General type 120 Percent Genital type 100 80 60 40 20 B 2 4 6 8 10 12 14 16 18 20 Age in years Pediatric patients: priorities • Brain growth is pre-programmed; especially high in the first 2 years • Myelinization is completed by 6 to 12 months and in some nerves up to 2 years

23. Principal areas to address • Adequacy of microcirculation: • Accurate fluid balance • Adequate oxygenation • Adequacy of nutrients (macro and micro) • Appropriate access • Accurate calorie count • Differentiation between infection and SIRS • Appropriate antibiotic use

24. Clinically certain on GI function Clinically uncertain on GI function GI inadequate GI adequate Randomized EN TPN EN TPN Reached 80% of computed requirement 91.8% 68% 94.7% 37.5% Failed to reach 80% 8.2% 32% 6.3% 62.5% Woodcock NP et al. Enteral vs parenteral nutrition: a pragmatic study; Nutrition 2001; 17: 1-12 Approach to feeding