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Feeding the Obese Critically Ill

Feeding the Obese Critically Ill. Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada. Objective. Key Points. Not all obese patients are the same Nutritional approach may need to vary

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Feeding the Obese Critically Ill

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  1. Feeding the Obese Critically Ill Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada

  2. Objective

  3. Key Points • Not all obese patients are the same • Nutritional approach may need to vary • Challenge to the prevailing dogma that hypocaloric feeding (undernourishment) is acceptable

  4. Obesity Trends* Among U.S. AdultsBRFSS,1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2000 1990 2010 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  5. What to do when the obese patient becomes critically ill?

  6. Feeding the Obese Critically Ill (BMI>30) Canadians • Insufficient evidence • Based on expert consensus, the goal should not exceed 65%–70% of target energy requirements as measured by IC. • If IC is unavailable, use weight-based equation 11–14 kcal/kg actual body weight per day for patients with BMI in the range of 30–50 and 22–25 kcal/kg ideal body weight per day for patients with BMI >50. • Protein should be provided in a range from 2.0 g/kg ideal body weight per day for patients with BMI of 30–40 up to 2.5 g/kg ideal body weight per day for patients with BMI ≥40. Americans* Europeans • (silent) *McClave CCM 2016

  7. RCTs of Hypocaloric Nutrition in Obesity (1) • 16 hospitalized obese patients requiring PN (? ICU, ‘mild-moderate stress’) • Defined obesity as >130% IBW • Goal was to show equal nitrogen balance in hypocaloric group (14 kcals/kg actual wt) vs control (25 kcals/kg actual wt) • Protein intake was the same (2.0g/kg IBW) • Outcomes: • No difference in % of patients achieving positive Nitrogen Balance • Weight change did not differ significantly between groups • Infections not measured • No difference in LOS or mortality Burge JPEN 1994

  8. RCTs of Hypocaloric Nutrition in Obesity (2) • 30 hospitalized obese patients (13 in the ICU) • Defined obesity as BMI >35 • Hypocaloric group -13.6kcals/kg actual wt • Control group – 22.5 kcals/kg actual wt • Protein intake was the same (2 g/kg IBW) • Outcomes: • No difference in % of patients achieving positive Nitrogen Balance • Weight change did not differ significantly between groups • Infections not measured • No difference in LOS or mortality Choban et al, Am J ClinNutr. 1997 Sep;66(3)

  9. Clinical Inferences to ICU Patients? • N=46 (13 ICU patients) • Focus was on patients requiring PN, says nothing about patients on EN • Focus was on NB, other outcomes not assessed or underpowered. Burge JPEN 1994 Choban et al, Am J Clin Nutr. 1997 Sep;66(3)

  10. Is there sufficient evidence that should inform one prescription on how ALL obese patients should be fed?

  11. Extreme Obesity and Outcomes in Critically Ill Patients Analysis of data from multicenter international observational study of ICU nutrition practices in 2007 and 2008 Increased obesity= increased risk of prolongation of stay Martino Chest 2011;140:1198

  12. Not all critically ill obese patients are the same: the influence of prior co-morbidities. Prospective observational study of 183 critically ill patients had a BMI ≥ 30 Raham ISRN Obesity 2012

  13. Not all critically ill obese patients are the same: the influence of prior co-morbidities. Raham ISRN Obesity 2012

  14. Not all critically ill obese patients are the same: the influence of prior co-morbidities. In the adjusted analysis, compared to patients with limited co-morbidities, obese patients with multiple co-morbidities were: • more likely to die at 28 days (OR 4.28, 95%CI, CI 0.92, 20.02, p=0.06) • tended to have longer ICU duration (3.06 days, standard error [SE] 2.28, p=0.18) and • had significantly fewer ICU free days in the first 28 days (-3.92 days, SE 1.83, p=0.03). Raham ISRN Obesity 2012

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

  16. Not all Obest ICU Patient 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 • 79 women • BMI 35 • PMHx COPD, poor functional status, frail • Admitted to hospital 1 week ago with CAP • Now presents in respiratory failure requiring intubation and ICU admission

  17. 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. Moisey Crit Care 2013 Sept;17(5):R206

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

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

  20. BMI Characteristics Almost half the sarcopenic patients were overweight

  21. Low muscle mass associated with mortality

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

  23. What does Nutrition Risk Assessment look like for the obese critically ill? Acute Starvation (Reduced po intake, pre ICU hospital stay) Functional Impairment (reduced mobility and strength) Pre-existing Co-morbidities (Metabolic consequences) Severity of Illness (APACHE, SOFA, IL-6) Chronic Malnutrition (?Sarcopenia) Degree of Obesity (BMI) Nutrition Status micronutrient levels - immune markers - muscle mass Risk Status High risk= high risk of death and greater likelihood of benefit from Nutrition

  24. A Proposed Clinical Staging System for Obesity(non-critically ill) Increasing complications Increasing aggressiveness We need to adapt this way of thinking to the ICU setting! Sharma Int J of Obesity 2009;33:289

  25. Start EN within 24-48 hrs of admission to ICU Optimal Amount of Protein and Calories for Critically Ill Patients

  26. Bias and accuracy of common estimation methods for resting metabolic rate in mechanically ventilated critically ill patients Penn State or modified Penn State if >60 recommended by experts* Curr Opin Crit Care 2012, 18:174–177 *Choban JPEN 2013

  27. 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

  28. 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

  29. How are Obese Patients Actually Being Fed?

  30. 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

  31. How do we increase nutrition delivery in the Obese Patient? • Enterally • High protein (low NPC:N ratio solutions) • Protein supplements • PEP uP protocol • Parenterally • IV amino acids • Supplemental PN?

  32. The TOP UP Trial PN for 7 days Primary Outcome High-risk ICU patients Stratified by: • Site • BMI • Med vs Surg R BMI <25 60-day mortality BMI >35 EN Alone

  33. HYPOTHESIS Increased early energy and protein delivery with PN+EN to underweight (BMI < 25) and obese (BMI> 35) critically ill patients will result in improved survival at 60 day versus standard EN alone

  34. Objectives of the Pilot Study • Not powered to look at clinical outcomes • Primary Aim: • Difference in the calories and protein received between the control and intervention groups • Secondary Aims • Confirm the feasibility of the trial (estimate recruitment rate) • Confirm feasibility of the intervention. • Tertiary Aim • explore the effect of differential effects of calorie and protein delivery on muscle mass and physical function

  35. Eligibility Criteria Inclusion Criteria • Critically ill adult patients (>18 years old) • Expected to require mechanical ventilation > 48 hrs • Expected ICU dependency of 5 or more days • Are on enteral nutrition or are to be initiated on enteral nutrition within 7 days of ICU admission and • Have a BMI < 25 or >35, based on pre-ICU actual or estimated dry weight.

  36. Study Intervention • Olimel N9 in 3 Chamber bag • 1000 ml size • 20% lipid emulsion containing a mixture of refined olive oil (80%) and refined soya oil (20%). • High nitrogen concentration (14% AA) • 27.5% glucose solution • 1.1 cal/ml

  37. Study Intervention • Both groups fed enterally started as early as possible (as per standard care) • EN solution will be 1.2 + 0.2 cal/ml • EN started at 25 ml/hr and increased by at least 25 mls q 4 hrs until goal achieved • Upon enrollment, study dietitians calculated the total volume/24 hours of either EN or PN required to receive goal calories and protein. • The PN solution was started at 25 ml/hr and increase by 25ml/hr increments every 4 hours as tolerated (monitoring blood glucose every 4 hours and electrolytes every twelve hours) till 100% of goal calories are reached. • As PN rate increased, EN rate decreased (paired feeding)

  38. Results

  39. Patient Demographics, BMI >35

  40. Primary Outcome Nutritional Adequacy* (%), BMI >35 *refers to % prescribed volume received

  41. Clinical Outcomes

  42. Performance-based Measures

  43. Other Outcomes

  44. Conclusions of TOP uP study • Topping UP obese critically ill patient feasible • Possible signals of benefit • Hand grip strength • SF 36 PF need to reduce missing data

  45. In Conclusion • Not all Obese ICU patients are the same in terms of ‘risk’- need to develop and validate risk assessment tools in this population • Iatrogenic underfeeding is harmful to some Obese ICU patients or some will benefit more from aggressive feeding (avoiding protein/calorie debt) • Aggressive use of EN (high protein diets) and protein supplements indicated • Supplemental PN may be beneficial in some

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