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Nutrition support in critically ill patients

Nutrition support in critically ill patients. Luisito O. Llido MD, FPCS Nutrition Support Team St. Luke’s Medical Center. Main areas for discussion. Malnutrition detection – nutritional assessment

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Nutrition support in critically ill patients

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  1. Nutrition support in critically ill patients Luisito O. Llido MD, FPCS Nutrition Support Team St. Luke’s Medical Center

  2. Main areas for discussion • Malnutrition detection – nutritional assessment • How much and how soon to feed? – energy and nutrient requirements; computation issues and what variables to use • Access and delivery – enteral and parenteral nutrition • Nutrient modifiers – glutamine, omega-3- fatty acids, cysteine, arginine, vitamins and trace elements • Nutrition support team

  3. Prevalence of malnutrition in critically ill patients, SLMC, 2000-2004 Malnutrition in critically ill patients

  4. Malnutrition in the ICU Prevalence of malnutrition in critically ill patients, SLMC, 2000-2004

  5. Malnutrition in the hospital Prevalence of malnutrition in hospitalized patients, SLMC, 2000-2004

  6. Low albumin in critically ill patients Prevalence of malnutrition in critically ill patients, SLMC, 2000-2004

  7. Underweight with low albumin in critically ill patients Prevalence of malnutrition in critically ill patients, SLMC, 2000-2004

  8. Implications • Calorie reserves – strained • Protein reserves – on the “empty” level • Substrates that are involved in inflammatory processes, infection, injury healing and tissue repair – on the dangerously low to empty status • Processes involved in oxygenation and tissue perfusion – slowed or impaired

  9. Cardiac function Pulmonary function Intake • Microcirculation environment • extracellullar • intracellular FOOD Energy provision Protein synthesis Renal function Carbohydrates, fats, protein, electrolytes, trace elements, vitamins, special substrates Body reserves (malnourished) Body reserves (adequate fed) Implications

  10. 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

  11. Survival in and from ICU • ICU is about preventing death from organ failure • Patients die early from single organ failure • Due to primary pathology/ insult/ infection (brain, or heart, or liver or lung) • Patients die later from multi-organ failure • Due to secondary infections (combined organ failure (e.g. lung, liver, and kidney) Griffiths, R. ICU nutrition. Bangkok 2002

  12. Malnutrition detection • Nutritional assessment • Nutrition screening (within 24 hours) • Body mass index • Subjective global assessment or mini-nutritional assessment • Weight loss > 10% • Intake accounting (<70%, chronic)

  13. Malnutrition detection – whose responsibility? • Attending physician • Dietitian • Nurse • Best option – nutrition support team • Department or section heads – presentors and main proponents • Administration – has the biggest role in providing for both suitable environment and manpower

  14. Do we really have to feed these patients? • “inadequacy of recent dietary intake rather than the absolute nutritional status determines injury response and healing.” (Windsor JA, Knight GS, Hill GL. Wound healing in surgical patients: recent food intake is more important than nutritional status. Br J Surg, 1988; 27:1252) • “achieving a higher intake with parenteral nutrition supplementation led to a faster recovery of plasma protein markers”(Bauer P, Charpentier C, et al. Parenteral with enteral nutrition in the critically ill. Intens Care Med, 2000; 26:893)

  15. Are we feeding these patients adequately?

  16. Are we feeding these patients adequately? • Even on day 3 after ICU admission, intake is still at 72% (minimum adequate = 75%), Intake of geriatric ICU patients; Umali et al (SLMC, 2002)

  17. 25-30 kcal/kg actual body weight On the first week then increase after • 20-25 kcal/kg ideal body weight • BEE x 1.5 or REE x 1.3-1.5 How much to give? Nordenstrom & Thorne, E. J. Clin Nutr, 1994; 48:531-537

  18. Suggested feeding: ICU • What is the caloric need? • Harris Benedict, 75% - 80% • Indirect calorimetry to settle the debate • Nitrogen – standard, add fiber • Additives? • Extra vitamins, trace elements, and zinc in parenteral nutrition • Magnesium or phosphate • Always give glutamine parenterally with enteral and/or parenteral nutrition Jan Wernermann, “ICU Cookbook”, Singapore, 2003

  19. Caution - Re-feeding syndrome • Severe fluid and electrolyte shifts in malnourished patients undergoing re-feeding • Consequences: • Hypophosphatemia • Hypokalemia • Hypomagnesemia • Effects: altered myocardial function, arrhythmia, respiratory failure, liver dysfunction, seizures, confusion, coma, tetany

  20. Suggested feeding: ICU • Who to feed? • All malnourished • All at risk of becoming long-stayers • What are the contraindications? • Unstable circulation (relative) • Non-functioning gut (enteral nutrition) Jan Wernermann, “ICU Cookbook”,Singapore, 2003

  21. The route - enteral or parenteral nutrition? Clinically certain on GI function Clinically uncertain on GI function GI inadequate GI adequate Randomized EN (2) TPN (3) EN (4) TPN (1) 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 17: 1-12, 2001

  22. Suggested feeding: ICU CALORIE COUNT!!! • When to start? • The sooner, the better • How much? • Patients adapted to undernutrition or with a circulatory instability may benefit with a slow start, lower target with stepwise increase • What to give? • Balanced nutrition • Enteral route, parenteral as supplementation Jan Wernermann, “ICU Cookbook”.Franc-, 2003

  23. Feeding method CALORIE COUNT!!! • Enteral nutrition • Enteral pump • Small amounts, frequent feedings (no pump) • Gastric retention • <200 ml – give back and continue • >200 ml – dispose • Motility stimulators • Parenteral nutrition Jan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003

  24. Monitoring? Calorie balance Gastric retention for enteral nutrition Blood tests: BUN high – dialyze High triglycerides – lower lipid flow Hyperglycemia – insulin CALORIE COUNT!!! Jan Wernermann, “ICU Cookbook”, Singapore, 2003

  25. 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

  26. Glutamine - supplementation will make a difference: • Reduces mortality rate by one half in ICU patients (Griffiths, R et al. Six months outcome of critically ill patients given glutamine. Nutrition 1997; 13:295-302). • Improves 6 month outcome in surgical and trauma patients (Goeters C, et al, Crit Care Med 2002; 30:2022) • Meta-analysis: Glutamine supplementation reduces infectious complications and mortality in serious illness (Novak F et al. Glutamine supplementation in serious illness: a systematic review of the evidence; Crit Care Med 2002; 30(9):2022-29)

  27. A B A - Griffiths, RD, et al. Six Month Outcome of Critically Ill Patients Given Glutamine-Supplemented Parenteral Nutrition; Nutrition 1997;13:4 B - Schultzki C et al: Supplemental Alanyl Glutamine Dipeptide improves nitrogen balance and reduces length of hospitalization in patients with severe operative injury. ASPEN Congress 1999. Glutamine: Survival and Hospital Costs

  28. Jiang Hua, The clinical efficacy of glutamine: evidence from systematic review and clinical trials; 11/01/03 Comparison: mortality Outcome: glutamine vs. control Glutamine n/N Control n/N RR 95% C.I. fixed Weight % RR 95% C.I. fixed Study 28/42 Griffiths 18/42 38.3 0.64 (0.43, 0.97) 2/39 Houdijk 2/41 2.8 0.95 (0.14, 6.43) 10/24 12/26 14.2 1.11 (0.59, 2.08) Jones 20/85 Powell-Tuck 14/83 27.1 0.72 (0.39, 1.32) 1/13 3/16 1.5 2.44 (0.29, 20.75) Schloerb 1993 Schloerb 1999 6/31 8/35 8.7 1.18 (0.46, 3.03) Wischmeyer 4/16 1/15 5.3 0.27 (0.03, 2.12) Zhu J 1/24 0/24 2.1 0.33 (0.01, 7.80) Total (95% CI) 72/274 58/282 100 0.79 (0.59, 1.04) 1 2 5 10 Favors treatment Favors control Glutamine vs standard nutritional support on mortality

  29. Jiang Hua, The clinical efficacy of glutamine: evidence from systematic review and clinical trials; 11/01/03 Comparison: infectious complications Outcome: glutamine vs. control Glutamine n/N Control n/N RR 95% C.I. fixed Weight % RR 95% C.I. fixed Study 16/39 Houdijk 6/41 12.9 0.36 (0.16, 0.82) 4/17 Neri 1/16 3.1 0.27 (0.03, 2.13) 2/11 1/11 1.6 0.50 (0.05, 4.75) O’Riordan 38/85 37/83 29.6 1.00 (0.71, 1.40) Powell-Tuck 5/10 0/10 4.3 0.09 (0.01, 1.45) Schettinga Schloerb 1993 5/13 6/16 4.3 0.97 (0.38, 2.48) Schloerb 1999 4/31 5/35 3.3 1.11 (0.33, 3.76) Wischmeyer 9/16 7/15 6.9 0.83 (0.42, 1.65) Young 4/10 1/13 3.6 0.19 (0.03, 1.46) Ziegler 1992 9/21 3/24 7.6 0.29 (0.09, 0.94) Ziegler 1998 5/11 0/9 3.9 0.11 (0.01, 1.74) Chen SL 2/15 1/15 1.6 0.50 (0.05, 4.94) Jiang ZM 3/30 0/30 2.8 0.14 (0.01, 2.71) Liang CH 3/12 1/12 2.4 0.33 (0.04, 2.77) Yao GX 2/14 0/14 2.0 0.20 (0.01, 3.82) Zhu J 10/24 5/24 7.9 0.50 (0.20, 1.25) Zhu MW 3/15 1/15 2.4 0.33 (0.04, 2.85) Total (95% CI) 124/404 75/413 100 0.60 (0.48, 0.76) 1 2 5 10 Favors treatment Favors control Glutamine vs standard nutritional support on infectious complications

  30. Tissue inflammation, Early organ failure and death SIRS TNF, IL-1, IL-6, IL-12, IFN, IL-3 PRO glutamine 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

  31. Immunonutrition Galban C. et al. An immune enhancing diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients. Crit Care Med 2000; 28: 643-648.

  32. Immunonutrition Gadek et al. Effect of enteral feeding with EPA, GLA, and antioxidants in patients with ARDS. Crit Care Med 1999; 27:1409-1420

  33. Comparison: mortality Heyland et al. JAMA, 2001 Outcome: early enteral nutrition vs. control Treatment n/N Control n/N Study 1/11 1/9 Cerra et al 1990 2/17 1/14 Gottschlich et al, 1990 0/19 Brown et al, 1994 0/18 1/51 Moore et al, 1994 2/47 24/163 12/143 Bower et al, 1996 1/16 Kudsk et al, 1996 1/17 20/87 Ross Products, 1996 8/83 7/18 Engel et al, 1997 5/18 1/22 Mendez et al, 1997 1/21 2/16 Rodrigo et al, 1997 2/13 2/16 Weimann et al, 1998 4/13 96/197 86/193 Atkinson et al, 1998 17/89 Galban et al, 2000 28/87 Pooled Risk Ratio 0.01 0.1 1 10 100 Higher for control Higher for treatment Early enteral nutrition vs standard nutritional support on mortality

  34. Tissue inflammation, Early organ failure and death SIRS TNF, IL-1, IL-6, IL-12, IFN, IL-3 Immunonutrients PRO glutamine 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

  35. Early enteral nutrition in severe sepsis (critical care patients) Bertolini et al. Early enteral nutrition in patients with severe sepsis, ICM 2003; 327 recruited patients; 39 with severe sepsis or septic shock; 21 received EN; feeding started within 48 hours

  36. Increased referrals and workload to clinical dietitians 1997-98 vs. 2000-03, SLMC Do we need a nutrition support team?

  37. Comparison with another center which has been fully utilizing parenteral nutrition (McFie J, England) Nutrition team fully implemented (SLMC, 2004) Do we need a nutrition support team?

  38. * *p < 0.05 y2001 < y2000A Do we need a nutrition support team? Days of inadequate intake in stroke tube fed patients were decreasing from 43% to 20% while improvement in adequate intake increased from 57% to 80% (SLMC, 2000-2001)

  39. Do we need a nutrition support team?

  40. Thank you

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