Download Nutrition Management in Critically Patients

Nutrition Management in
Critically Ill Patients
Lana Gettman, Pharm.D.
Harding University College of Pharmacy
AAHP Fall Seminar
September, 2016
Learning Objectives
• Describe metabolic and nutritional changes
during critical illness.
• Discuss nutrition assessment in the ICU
patients.
• Review current guidelines for provision of
nutrition support in adult critically ill patients.
Definition of a Critically Ill Patient
• American Association of Critical-Care Nurses
– “Critically ill patients are defined as those patients
who are at high risk for actual or potential lifethreatening health problems. The more critically ill
the patient is, the more likely he or she is to be
highly vulnerable, unstable and complex, thereby
requiring intense and vigilant nursing care”.
Nutrition and Malnutrition
in the Critically Ill Patient
• Nutrition plays a key role for recovery from illness
• Up to 50% of critically ill patients have preexisting
nutritional disorders
• Patients who are well nourished prior to ICU
admission, develop nutritional disorders rapidly
– Metabolic demands of illness and healing
– Rapid fluid shifts
– Loss of specific vitamins and trace elements
• Extent of muscle wasting and weight loss is
inversely correlated with long-term survival
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Physiological Changes During Critical
Illness
Imbalanced hormone
levels: catecholamines,
cortisol, glucagon,
growth hormone, insulin
Excess liver glucose
production
Excess catabolism
Insulin resistance
Increased production of
proinflammatory
cytokines
Catabolism and Urine Urea Nitrogen
• Protein breakdown
• Loss of nitrogen in the urine in the form of urea
16-24 g/day in critically ill vs 10-12 g/day in
healthy individuals
– Loss of 16 g N as urea = loss of 1 lb of skeletal
muscle/lean body mass per day
• Functional impairment
– Respiratory muscles  respiratory failure
– Heart muscles  heart failure
– GI mucosa muscles  diarrhea
• Rapid development of malnutrition
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Results and Manifestations of
Malnutrition in Critical Illness
Results
• Loss of body cell mass
• Changes in
fluid/electrolytes/mineral
homeostasis
• Organ dysfunction
Manifestations
• Impaired immune function
• Prolonged dependence on
mechanical ventilation
• Increased rates of infection
Terminology
Nutrition Support
• Adjunctive care to provide
exogenous fuels to preserve
lean body mass and support
the patient throughout the
stress response
Nutrition Therapy
• Help reduce the metabolic
response to stress, prevent
oxidative cellular injury, and
favorably modulate immune
response
• Achieved by
– Early enteral nutrition (EN),
appropriate macro-and
micronutrient delivery, “meticulous
glycemic control”
• Potential outcome
– Reduce disease severity, decrease
complications, decrease length of
stay (LOS) in the ICU, favorable
patient outcomes
Guidelines for the Provision and Assessment of Nutrition
Support Therapy in the Adult Critically Ill Patient: Society of
Critical Care Medicine (SCCM) and American Society for
Parenteral and Enteral Nutrition (A.S.P.E.N.)
• Target Patient Population
– Adult (>/=18 years) critically ill patient expected to
require length of stay greater than 2-3 days in
MICU or SICU who cannot sustain “volitional
intake”
– Patients with organ failure (lungs, liver, kidney),
acute pancreatitis, trauma, traumatic brain injury,
open abdomen, burns, sepsis, post-op major
surgery, chronic critically ill, and critically ill obese
Journal of Parenteral and Enteral Nutrition. 2016;40(2):159-211.
Addressed Criteria
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Nutrition assessment
Initiation of enteral nutrition (EN)
Dosing of EN
Monitoring tolerance and adequacy of EN
Selection of appropriate enteral formulation
Adjunctive therapy
When to use parenteral nutrition (PN)
When to maximize efficacy of PN
Addressed Criteria (Cont.)
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Pulmonary failure
Renal failure
Hepatic failure
Acute pancreatitis
Surgical subsets: trauma, traumatic brain injury, open
abdomen, burns
Sepsis
Postoperative major surgery (SICU admission expected)
Chronically critically ill
Obesity in critical illness
Nutrition therapy end-of-life situations
Guidelines Recommendations are
Based on the Data Derived From:
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Randomized controlled trials
Nonrandomized cohort trials
Prospective observational studies
Retrospective case series
Quality of evidence ranges from very low-lowmoderate-to high
Current Guidelines Limitations
• Data was obtained through December 31,
2013
• Other landmark studies published after this
date were not included in this guideline
Nutrition Assessment:
Determine Nutrition Risk for All
Patients Admitted to the ICU
Baseline
nutrition
status
Disease
severity
Use NRS 2002 or NUTRIC score.
Nutrition
risk
Nutritional Risk Screening (NRS 2002)
Nutrition Assessment (Cont.)
NRS 2002
• Risk
– NRS 2002 >3
• High risk
– NRS 2002 >/=5
NUTRIC
• High risk
– NUTRIC >/=5
Nutrition Assessment:
Energy Requirement
Method
Comments
Indirect calorimetry (IC)
(Quality of Evidence:
Very Low)
Simplistic formula:
25-30 kcal/kg/day
Accuracy affected by air leaks, chest tubes,
supplemental oxygen, ventilator settings,
CRRT, anesthesia, PT, excessive movement.
Use dry or usual body weight for normal
weight patients; use IBW for obese
patients.
Less accurate in obese and underweight
patients.
Predictive equations
Reevaluate energy expenditure more than once per week.
Account for dextrose-containing fluids and lipid-based medications.
Nutrition Assessment:
Protein Requirements
• Protein requirements are higher than energy
requirements
• Provision of protein is more closely correlated with
positive patient outcomes than provision of total
energy
• Not easily met by routine enteral formulations and
patients might benefit from protein supplementation
• Weight-based recommendation: 1.2-2 g/kg/day (actual
body weight) (Quality of Evidence: Very Low)
– May be higher in burn/trauma/CRRT patients
Nutrition Assessment:
Protein Requirements (Cont.)
Albumin
• T ½ = 21 days
• Indicates body protein
stores
• Good indicator of initial
nutritional status
• Not a good indicator of
early protein malnutrition
Pre-albumin
• T ½ = 2-3 days
• Responds more rapidly to
nutrition support
• Reflects improvements in
nutrition intake and status
• Renally eliminated  falsely
elevated in ARF/CRF
Do not use serum protein markers to determine
adequacy of protein provision.
Enteral Nutrition
Enteral Nutrition
• Supports structural integrity of the gut
• If structural integrity compromised
– Increased bacterial challenge
– Risk of systemic infections
– Risk of multiple-organ dysfunction
• Initiate within 24-48 hours (Quality of Evidence: Very Low)
• Use EN over PN (Quality of Evidence: Low to Very Low)
• Bowel sounds and evidence of bowel function are not required for
initiation of EN
– Safety data came from studies involving critically ill surgical patients
• Initiate EN in the stomach, unless
– High risk for aspiration
– Not able to tolerate gastric infusion
• Hold EN in hemodynamically unstable patients
– Use caution in patients undergoing withdrawal of vasopressor support
Figure 1. Early enteral nutrition (EN) vs delayed EN, mortality.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr
2016;40:159-211
Copyright © by The American Society for Parenteral and Enteral Nutrition
Figure 2. Early enteral nutrition (EN) vs delayed EN, infectious complications.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr
2016;40:159-211
Copyright © by The American Society for Parenteral and Enteral Nutrition
Figure 3. Enteral nutrition (EN) vs parenteral nutrition (PN), infectious complications.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr
2016;40:159-211
Copyright © by The American Society for Parenteral and Enteral Nutrition
Dosing/Amount of EN
• Patients with low nutrition risk and low disease
severity (NRS 2002 </=3 or NUTRIC </=5) do not
require nutrition therapy during the first week in the
ICU
– Reassess daily
• Patients with ARDS/acute lung injury and are on
mechanical ventilation, should receive either trophic
(10-20 kcal/hr or 10-20 ml/hr or up to 500 kcal/day) or
full EN during the first week in the ICU
• Patients at high nutrition risk (NRS 2002 >/=5 or
NUTRIC >/=5) should be advanced to goal over 24-48
hours
Monitoring Tolerance
and Adequacy of EN: Daily
Tolerance
• Normal physical
examination
• Passage of flatus and stool
• Absence of pain or
abdominal distension
• Normal radiologic
evaluation
Intolerance
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Vomiting
Diarrhea
Reduced passage of flatus and stool
Abdominal distension
Complaints of discomfort
Abnormal abdominal radiographs
High NG output
High gastric residual volume (GRV)
>500ml/24hrs
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GRV does not correlate with incidences of
PNA, regurgitation, or aspiration
Not recommended to do routine GRV
measurements in patients on EN
Not recommended to hold EN for GRV
<500ml/24hrs in the absence of other signs of
intolerance (Quality of Evidence: Very Low)
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GRV 200-500ml/24hrs, need to implement
measures to reduce risk of aspiration
Who is at Risk for Aspiration?
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Inability to protect the airway
Presence of nasoenteric enteral access device
Mechanical ventilation
Age >70 years
Reduced level of consciousness
Poor oral care
Inadequate nurse:patient ratio
Supine position
Neurologic deficit
Gastroesophageal reflux
Transport out of the ICU
Bolus intermittent EN infusion
If at Risk for Aspiration
• Deliver EN to the small bowel instead of stomach OR
• Use prokinetic agents IV or PO (Quality of Evidence: Low)
– Metoclopramide 10 mg QID for normal renal function
– Erythromycin 3-7 mg/kg/day
• Intubated patients receiving EN – head of bed to be
elevated 30°-45° and use chlorhexidine mouthwash BID
• Reduce level of sedation/analgesia when possible
• Minimize transport out of the ICU for diagnostic tests and
procedures
Figure 7. Motility agents vs placebo, outcome lower gastric residual volume.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr
2016;40:159-211
Copyright © by The American Society for Parenteral and Enteral Nutrition
Selection of Enteral Formulation
• Use standard polymeric formula
• Avoid routine use of specialty or diseasespecific formulas
– Exception: immune-modulating formula in post-op
patient in SICU setting (Quality of Evidence: Very
Low)
• Rationale for use of pulmonary formulas (high
fat:carbohydrate ratio) “has shown to be
erroneous”
Adjunctive Therapy
Fermentable soluble
fiber additive
-To be considered in all hemodynamically stable ICU
patients on standard EN.
-10-20 g/24 hrs of a fermentable soluble fiber in patients
with diarrhea.
Probiotics
Recommendation cannot be made at this time with
regards to routine use across all types of ICU patients.
(Quality of Evidence: Very Low)
• Probiotics MOA: competitive inhibition of pathogenic
bacterial growth and epithelial attachment of invasive
pathogens, elimination of pathogenic toxins,
enhancement of intestinal epithelial barrier, favorable
modulation of host inflammatory response.
• Documented safety and outcome benefit in selective
patient populations: liver transplantation, trauma,
pancreatectomy.
Antioxidant vitamins and -To be provided in patients with burns, trauma, and on
trace minerals
mechanical ventilation. (Quality of Evidence: Very Low)
Parenteral Nutrition
When to Use PN
Patient at low nutritional risk
(NRS 2002 </=3 or NUTRIC
score </=5)
If early EN not feasible,
recommend to withhold PN
over the first 7 days following
ICU admission, unless PN
dependent. (Quality of
Evidence: Very Low)
Patient at high nutritional risk
(NRS 2002 >/=5 or NUTRIC
score >/=5) or severely
malnourished
If early EN not feasible,
recommend to initiate PN as
soon as possible following ICU
admission.
In patients at low or high nutrition risk who are on EN but unable to
meet >60% of energy and protein requirements, recommend use of
supplemental PN after 7-10 days. Once patient is able to receive
>60% of their goal via EN, recommend to d/c PN.
Risks Associated with PN
Hyperglycemia
Electrolyte
imbalances
Oxidative
stress
Immune
suppression
Infections
Risk Factors for Refeeding Syndrome
Alcoholism
Weight
loss
Low BMI
Prolonged
NPO
Advance to goal over 3-4 days.
How to Maximize Efficacy of PN in High
Risk/Severely Malnourished Patients
• During first week (Quality of Evidence: Low)
– Hypocaloric PN: </=20 kcal/kg/day or 80% of estimated
energy
– Adequate protein: >/= 1.2 g/kg/day
• Once patient is stable, advance to 100% of estimated
goal
• Withhold or limit soy-based IV fat emulsion during the
first week of PN to maximum of 100 g/wk (divided in 2
doses/wk) if there is concern for essential fatty acid
deficiency (Quality of Evidence: Very Low)
• Target BG 140 or 150-180 mg/dL
EN/PN Recommendations
for
Organ Dysfunctions
Organ Dysfunctions
Pulmonary
failure
Renal failure
(AKI/ARF)
-Do not recommend use of high-fat/low CHO
formulations to reduce CO2 production in patients
with acute respiratory failure. (Quality of Evidence:
Very Low)
-Avoid rapid infusion of IVFE.
-Use fluid-restricted energy-dense EN formulations.
-Close serum phosphate monitoring and
appropriate replacement.
-Use standard enteral formulation.
-Energy provision: 25-30 kcal/kg/day.
-Protein provision: 1.2-2 g/kg/day (actual body
weight); up to 2.5 g/kg/day if on HD or CRRT
(Quality of Evidence: Very Low).
-Consider specialty formulations (low in phosphate
and potassium) with appropriate electrolyte profile.
Organ Dysfunctions (Cont.)
Hepatic
failure
(cirrhosis)
-Use dry weight or usual weight to determine energy and protein
requirements.
-Avoid restricting protein.
-EN is preferred route.
-Use standard EN formulation (there is no evidence of benefit of
branched-chain amino acids formulations on coma grade in patients
with encephalopathy).
Acute
pancreatitis
Mild pancreatitis: specialized nutrition is not recommended;
advance to oral diet as tolerated. If not able to advance to oral diet
within 7 days, then consider specialized nutrition. (Quality of
Evidence: Very Low)
Moderate to severe pancreatitis: start EN (preferred over PN) at a
low-volume rate within 24-48 hrs of admission and advance to goal
as tolerated. (Quality of Evidence: Very Low)
• Consider use of probiotics with severe pancreatitis in patients
on EN. (Quality of Evidence: Low)
• If EN not feasible, use PN after 1 week from the onset of
symptoms.
Figure 12. Parenteral nutrition (PN) vs enteral nutrition (EN) in severe acute pancreatitis,
mortality.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr
2016;40:159-211
Copyright © by The American Society for Parenteral and Enteral Nutrition
Figure 13. Parenteral nutrition (PN) vs enteral nutrition (EN) in severe acute pancreatitis,
infections.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr
2016;40:159-211
Copyright © by The American Society for Parenteral and Enteral Nutrition
Recommendations
for
Surgical Subsets
Surgical Subsets
Trauma
-Early EN within 24-48 hrs of injury with high protein.
(Quality of Evidence: Very Low)
-Energy requirements: 20-35 kcal/kg/day. Less energy in early
phase and more energy in rehabilitation phase.
-Protein requirements: 1.2-2 g/kg/day, target higher end of
range.
-In severe trauma: consider immune-modulating
formulations. (Quality of Evidence: Very Low)
Traumatic brain
injury
-Early EN within 24-48 hrs of injury. (Quality of Evidence: Very
Low)
-Energy requirements: vary depending on use of paralytics
and/or coma-inducing agents.
-Protein requirements: 1.5-2.5 g/kg/day.
-Suggest arginine-containing immune-modulating formulation
or EPA/DHA supplement with EN formulation.
Surgical Subsets
Open abdomen
-Early EN within 24-48 hrs post-injury in the
absence of a bowel injury.
-Determine energy needs similar to other
patients in surgical or trauma ICU.
-Protein requirements: suggest additional 1530 g of protein/liter of exudate lost.
Burns
-EN should be provided if GI tract is functional
and be initiated within 4-6 hrs of injury.
-PN reserved if EN not feasible or not
tolerated.
-Suggest IC to assess energy needs, repeat
weekly.
-Protein requirements: 1.5-2 g/kg/day.
Sepsis
• EN to be initiated within 24-48 hrs of diagnosis of severe sepsis/septic
shock as soon as resuscitation is complete and patient is hemodynamically
stable
– Hemodynamically stable: adequate perfusion pressure, stable doses of
vasoactive drugs, stabilized or decreasing levels of lactate and
metabolic acidosis, MAP >/=60 mmHg
• Regardless of patients’ nutrition risk, do not recommend use of exclusive
PN or supplemental PN in conjunction with EN early in the acute phase of
severe sepsis/septic shock (Quality of Evidence: Very Low)
• Energy requirements: up to 500 kcal/day during first 24-48 hrs of initial
phase, then advance to >80% of goal energy (25 kcal/kg/day) over the
first week
• Protein requirements: 1.2-2 g/kg/day
• Cannot make recommendation regarding selenium, zinc, and antioxidant
supplementation due to conflicting results
Postoperative Major Surgery
(SICU Admission Expected)
• Provide EN within 24 hrs postoperatively
– Exceptions: GI obstruction, bowel discontinuity, increased
risk of bowel ischemia, ongoing peritonitis
• Recommend immune-modulating formulas for post-op
patients on EN
• EN is suggested in patients with prolonged ileus, intestinal
anastomosis, open abdomen, on vasopressors (Quality of
Evidence: Low to Very Low)
• In patients s/p major upper GI surgery and EN not feasible,
initiate PN only if duration of therapy is anticipated >/=7 days
and be initiated post-op day 5-7
– Exception: in patients at high nutrition risk may initiate it
earlier
• Post-op diet to be advanced to solid food and not clear liquids
Chronically Critically Ill
• Persistent organ dysfunction requiring ICU LOS
>21 days
• “Persistent inflammation,
immunosuppression, and catabolism
syndrome”
• Recommend
– Aggressive high-protein EN therapy
– Glycemic control
Obesity in Critical Illness
• EN within 24-48 hrs of ICU admission
• Determine actual, usual, and ideal weight
– Adjusted body weight is not recommended
• Calculate BMI, identify class of obesity, measure waist
circumference (if possible)
• Evaluate biomarkers of metabolic syndrome: BG, TG,
cholesterol
• Assess preexisting conditions
• In patients with history of bariatric surgery, supplement
thiamine prior to initiating dextrose-containing IV fluids or
nutrition therapy
– Evaluate for micronutrient and trace minerals deficiency
• Implement high-protein hypocaloric feeding
Obesity in Critical Illness (Cont.)
BMI
30-50
>50
Weight-based energy requirements
11-14 kcal/kg actual body weight/day
22-25 kcal/kg ideal body weight/day
-Energy goal should not exceed 65-70% of goal as
measured by IC.
-Weight-based equations represent 65-70% of
measured energy expenditure.
Obesity in Critical Illness (Cont.)
BMI
30-40
>/=40
Protein requirements
2 g/kg ideal body weight/day
Up to 2.5 g/kg ideal body weight/day
Nutrition and Hydration Therapy
in End-of-Life Situations
• Not obligatory
• Cultural, ethnic, religious, or individual patient
issues may necessitate delivery of nutrition
and hydration
• Should be communicated to patients, family
members, or decision makers
• Respect for dignity and patient autonomy
Table 2. Bundle Statements.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr
2016;40:159-211
Copyright © by The American Society for Parenteral and Enteral Nutrition
Question #1
• You do NOT use serum protein markers to
determine adequacy or protein provision.
A. True
B. False
Question #2
• When should admitted patients be required
for initial nutrition screening?
A.
B.
C.
D.
No later than 24 hours
Within 48 hours of admission
At admission
None of the above
References
• Bongard F.S., Sue D.Y., Vintch J.E. Current Diagnosis &
Treatment Critical Care, 3rd edition, McGraw Hill 2008, Ch.6.
• Gastroenterology and Nutrition. ACCP PSAP, 6th edition,
book 9, pp.119-128.
• Kondrup J., et al. Nutritional Risk Screening (NRS 2002): a
New Method Based on an Analysis of Controlled Clinical
Trials. Clinical Nutrition 2003; 22(3):321-336.
• McClave S.A., et al. Guidelines for the Provision and
Assessment of Nutrition Support Therapy in the Adult
Critically Ill Patient: Society of Critical Care Medicine
(SCCM) and American Society for Parenteral and Enteral
Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral
Nutrition 2016; 40(2):159-211.
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