Iatrogenic Malnutrition in the ICU: Time for a Change!

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. Learning Objectives • Define iatrogenic malnutrition • Describe the nature of the evidence related to optimal amount of calories/protein • List key variables to consider in assessing nutritional risk in ICU patients • List strategies to improve nutritional adequacy in the critical care setting.

3. A different form of malnutrition?

4. 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)

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

6. 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

7. 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

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. Relationship between increased nutrition intake and physical function (as defined by SF-36 scores) following critical illness For every 1000 kcal/day received: for increase of 30 gram/day, OR of infection at 28 days Unpublished data from Multicenter RCT of glutamine and antioxidants (REDOXS Study); n=364

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

12. 113 select ICU patients with sepsis or burns • On average, receiving 1900 kcal/day and 84 grams of protein • No significant relationship with energy intake but…… Clinical Nutrition 2012

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

15. 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

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 (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.

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

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

20. Rice et al. JAMA 2012;307

21. Rice et al. JAMA 2012;307

22. Enrolled 12% of patients screened Rice et al. JAMA 2012;307

23. Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure • Average age 52 • Few comorbidities • Average BMI 29-30 • 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!

24. Nutritional Management of ICU Patients: Are these both the same? • Low Risk • 34 year former football player, • BMI 35 • otherwise healthy • involved in motor vehicle accident • Mild head injury and fractured R leg requiring ORIF • High Risk • 72 women • BMI 35 • PMHx COPD, poor functional status • Admitted to hospital 1 week ago with CAP • Now presents in respiratory failure requiring intubation and ICU admission

25. ICU-acquired Weakness (ICUAW) Muscle weakness develops in 25%-60% of patients who have been mechanically ventilated for > 1 week1 Prolongs:1-4 • mechanical ventilation • weaning from the ventilator • ICU stay • ICUAW main clinical manifestation of critical illness neuromyopathy (CINM)5 • de Jonghe B, et al. Crit Care Med. 2004;30:1117-1121. • Garnacho-Montero J, et al. Crit Care Med. 2005;33:349-354. • van den Berghe G, et al. Crit Care Med. 2003;31:359-366. • Hermans G, et al. Am J Respir Crit Care Med. 2007;175:480-489. • de Jonghe B, et al. Crit Care Med. 2009;37(suppl.):S309-S315.

26. Determinants to Lean Body Mass

27. Muscle Matters!Skeletal muscle mass predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients • Patients > 65 years with an admission abdominal computed tomography scan and requiring intensive care unit stay at a Level I trauma center in 2009-2010 were reviewed. • Muscle cross-sectional area at the 3rd lumbar vertebra was calculated and sarcopenia identified using sex-specific cut-points. • Muscle cross-sectional area was then related to clinical parameters including ventilator-free days, ICU-free days, and mortality. Kozar (in submission)

28. Body Composition Lab CT Imaging Analysis Skeletal Muscle Adipose Tissue

29. Physical Characteristics of Patients • N=149 patients • Median age: 79 years old • 57% males • ISS: 19 • Prevalence of sarcopenia: 71%

30. BMI Characteristics

31. Low muscle mass associated with mortality

32. Muscle mass is associated with ventilator-free and ICU-free days

34. Prospective multicenter observational trial of 136 patients requiring min 5 days of mechanical ventilation • After day 5, when awake, performed muscle testing Am J Respir CCM 2008;178:261-268

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

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

38. 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)

40. All ICU patients treated the same

41. 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

42. Subjective Global Assessment?

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

44. 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.

45. Mostly surgical patients; 100% data available for SGA

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

48. 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

49. 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.

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