1 / 50

Early Parenteral Nutrition Should NOT be Used In Critically ILL Patients

Early Parenteral Nutrition Should NOT be Used In Critically ILL Patients. Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada. Consequences of Iatrogenic Malnutrition. Caloric Debt. Adequacy of EN. Adequacy of EN.

hillcatherine
Download Presentation

Early Parenteral Nutrition Should NOT be Used In Critically ILL Patients

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Early Parenteral Nutrition Should NOT be Used In Critically ILL Patients Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada

  2. Consequences of Iatrogenic Malnutrition Caloric Debt Adequacy of EN Adequacy of EN •  Caloric debt associated with: •  Longer ICU stay •  Days on mechanical ventilation •  Complications •  Mortality Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Alberda ICM 2009

  3. 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 • 60% medical; 40% surgical • Average APACHE II 22; BMI 27

  4. 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

  5. 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

  6. 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.

  7. More is Better! Our Field of Dream If you feed them (better!) They will leave (sooner!)

  8. 2007 International Nutrition Practice Survey Cahill NE CCM 2010 (in press)

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

  10. After so many years of trying to improve care…we still can’t feed adequately the enteral route! Results of 2008 International Surveyn=156 ICUs

  11. What if you can’t provide adequate early enteral nutrition? … to TPN or not to TPN, that is the question!

  12. Canadian RecommendationsEnteral vs. Parenteral Nutrition • Based on one level 1 and 12 level 2 studies, when considering nutrition support for critically ill patients, we strongly recommend the use of Enteral Nutrition over Parenteral Nutrition. www.criticalcarenutrition.com

  13. Canadian RecommendationsCombined EN and PN • Based on 5 level 2 studies, for critically ill patients starting on enteral nutrition we recommend that parenteral nutrition not be started at the same time as enteral nutrition. www.criticalcarenutrition.com

  14. Canadian RecommendationsCombined EN and PN • Based on 5 level 2 studies, for critically ill patients starting on enteral nutrition we recommend that parenteral nutrition not be started at the same time as enteral nutrition. www.criticalcarenutrition.com

  15. ASPEN/SCCM ICU Nutrition CPGs PN vs Standard Care • In the patient who was previously healthy prior to critical illness with no evidence of protein-calorie malnutrition, use of PN should be reserved and initiated only after the first 7 days of hospitalization (when EN is not available). • 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. Supplemental PN McClave JPEN 2009;33:277

  16. Beth Taylorj • 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. Clinical Nutrition 2009

  17. A Leap of Faith?

  18. Significant decrease in mortality yet significant increase in infection Simpson Int Care Med 2005;31:12

  19. Beneficial Effect of Early PN? Simpson Int Care Med 2005;31:12

  20. Beneficial Effect of Early PN? • Flaws in this meta-analysis of early PN • Select studies were included (validity filter excluded trials with 4-21% lost to follow up) • Heterogeneous studies were included (elective surgical patients) • Used a fixed effects model rather than more conservative random effects model • Subgroup analysis at best is a hypothesis generating analysis • What is the biological rationale as to how PN causes increased infection and yet reduces mortality? Simpson Int Care Med 2005;31:12

  21. Beneficial Effect of Early PN? Simpson Int Care Med 2005;31:12

  22. The favorable effect of early parenteral feeding on survival in head-injured patients • RCT of 38 patients • EN vs PN • Methods score 6/14 • Patients prescribed 2600 cal • EN rec’d 26% vs PN 65% When study repeated years later, no difference in mortality Rapp J Neurosurg 1983:58:906

  23. Combined 2007 and 2008 International Nutrition Practice Survey Databases • Point prevalence survey of nutrition practices in ICU’s around the world conducted Jan. 25, 2007 and May 14, 2008. • Each site aimed to enroll 20 patient each • Included ventilated adult patients who remained in ICU >72 hours • Enrolled 5771 patients from 351 ICUs from >20 countries Heyland (unpublished data)

  24. What is the effect of supplemental PN in critically ill patients receiving early EN: Results of a multicenter observational study 2920 patients receiving early EN

  25. What is the effect of supplemental PN in critically ill patients receiving early EN: Results of a multicenter observational study Adequacy of Calories from Total Nutrition (EN+PN+propofol)

  26. What is the effect of supplemental PN in critically ill patients receiving early EN: Results of a multicenter observational study Adequacy of Calories from EN only

  27. What is the effect of supplemental PN in critically ill patients receiving early EN: Results of a multicenter observational study Clinical Outcomes: All Patients Proportion dead or remaining in hospital P=0.0003 Regression model: Time to Discharge Alive Multiple Predictor Single Predictor

  28. What is the effect of supplemental PN in critically ill patients receiving early EN: Results of a multicenter observational study Clinical Outcomes: Patients with low BMI (<20) Proportion dead or remaining in hospital P=0.43

  29. What is the effect of supplemental PN in critically ill patients receiving early EN: Results of a multicenter observational study Clinical Outcomes: Patients with GI admission diagnosis Proportion dead or remaining in hospital P=0.06

  30. What is the effect of supplemental PN in critically ill patients receiving early EN: Results of a multicenter observational study Clinical Outcomes: Patients with persistent early GI dysfunction Proportion dead or remaining in hospital P=0.04

  31. What is the effect of supplemental PN in critically ill patients receiving early EN: Results of a multicenter observational study Conclusions In mechanically ventilated ICU patients receiving early EN, supplemental PN is associated with greater provision of calories and protein but no beneficial effect on clinical outcomes, even in high risk patients (low BMI, GI admission diagnosis, persistent early GI dysfunction)

  32. What to do when early enteral feeding is not possible in critically ill patients: A multicenter observational study • Focus in medical ICU patients only • Excluded all those who rec’d early EN

  33. What to do when early enteral feeding is not possible in critically ill patients: A multicenter observational study Adequacy of Calories from Total Nutrition (EN+PN+propofol)

  34. What to do when early enteral feeding is not possible in critically ill patients: A multicenter observational study Adequacy of Calories from EN only

  35. What to do when early enteral feeding is not possible in critically ill patients: A multicenter observational study Clinical Outcomes: All Patients Proportion dead or remaining in hospital P=0.01 Multivariable regression model: No effect of timing of nutrition on outcome

  36. What to do when early enteral feeding is not possible in critically ill patients: A multicenter observational study Clinical Outcomes: Only Patients with low BMI (<25) Proportion dead or remaining in hospital P=0.01

  37. What to do when early enteral feeding is not possible in critically ill patients: A multicenter observational study Conclusions In medical ICU patients, when early EN is not possible, early PN is associated with greater provision of calories and protein but no beneficial effect on clinical outcomes, even in high risk patients (low BMI)

  38. Current Evidence for use of PN in critically ill patients:Results of prospective, observational multicenter German Study Point prevalence study 454 ICUs from 310 hospitals in Germany 399 patients septic patients included Median APACHE II 26 68% had no GI pathology 46% in shock Overall mortality 55.2% Elke CCM 2008;36:1762

  39. Point prevalence study 454 ICUs from 310 hospitals in Germany 399 patients septic patients included Median APACHE II 26 68% had no GI pathology 46% in shock Overall mortality 55.2% Current Evidence for use of PN in critically ill patients:Results of prospective, observational multicenter German Study P=0.005 Multivariate analysis: PN independent predictor for mortality (OR 2.09, 95% CI 1.29-3.37)

  40. Current Evidence for use of PN in critically ill patients: Observational study in Critically Ill Trauma Patients • Retrospective, multicenter, cohort study of 597 severely injured patients • Compared those that rec’d PN within 7 to those who did not. • Also compared early PN group to subgroup of ‘EN tolerant’ (tolerated 1000 kcal any day during first week) • Adjusted for differences in key baseline demographics Sena J Am Coll Surg 2008;207:459

  41. Early Supplemental PN is Associated with Increased Infection in Critically Ill Trauma Patients Differences not due to differences in glycemic control

  42. International Multicenter Observational Study of Nutrition Practices • 351 ICUs around the world • 5771 mechanically ventilated patients > 3days in ICU 5.1% Heyland (unpublished data)

  43. What if you can’t provide adequate early enteral nutrition? … to TPN or not to TPN, that is the question!

  44. Consider a newer, second generation feeding protocol...

  45. Not all critically ill patients are the same; we have different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds. 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. 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

  46. The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol! Heyland (in submission)

  47. The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol! Heyland (in submission)

  48. Conclusions • More EN is better • Currently no role for routine use of PN in early setting • Potential for harm • Need RCT level of evidence to establish role

  49. Questions?

More Related