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Iatrogenic Malnutrition in the ICU: Time for a Change!

Iatrogenic Malnutrition in the ICU: Time for a Change!. Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada. A different form of malnutrition?. Health Care Associated Malnutrition .

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Iatrogenic Malnutrition in the ICU: Time for a Change!

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  1. Iatrogenic Malnutrition in the ICU: Time for a Change! Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada

  2. A different form of malnutrition?

  3. 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)

  4. Increasing Calorie Debt Associated with worse Outcomes Adequacy of EN 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

  5. 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

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

  7. 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

  8. 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364 patients with SF 36 at 3 months and/or 6 months for increase of 30 gram/day, OR of infection at 28 days Heyland Unpublished Data

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

  10. 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

  11. 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

  12. 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 (Comparing patients rec’d >2/3 to those who rec’d <1/3) 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.

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

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

  15. 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

  16. Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Did not measure infection nor physical function! Rice CCM 2011;39:967

  17. Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure “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

  18. 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

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

  20. How do we figure out who will benefit the most from Nutrition Therapy?

  21. 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)

  22. All ICU patients treated the same

  23. 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

  24. Subjective Global Assessment?

  25. When training provided in advance, can produce reliable estimates of malnutrition • Note rates of missing data

  26. 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.

  27. “We must develop and validate diagnostic criteria for appropriate assignment of the described malnutrition syndromes to individual patients.”

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

  29. 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

  30. What are the nutritional risk factors associated with clinical outcomes?(validation of our candidate variables)

  31. What are the nutritional risk factors associated with clinical outcomes?(validation of our candidate variables)

  32. The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). For example, exact quintiles and logistic parameters for age

  33. The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). 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.

  34. The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).

  35. The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).

  36. The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score). Interaction between NUTRIC Score and nutritional adequacy (n=211)* P value for the interaction=0.01 Heyland Critical Care 2011, 15:R28

  37. Who might benefit the most from nutrition therapy? • High NUTRIC Score? • Clinical • BMI • Projected long length of stay • Others?

  38. Do we have a problem?

  39. Preliminary Results of INS 2011Overall Performance: Kcals 84% 56% 15% N=211

  40. Failure Rate% patients who failed to meet minimal quality targets (80% overall energy adequacy)

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

  42. 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

  43. 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!

  44. www.criticalcarenutrition.com

  45. Questions? www.criticalcarenutrition.com

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