Nutrition Protocol in ICU-Dr Anupam.pptx

NUTRITION IN ICU

1. Nutrition Protocol in ICU Dr Anupam Patra

2. Introduction Medical nutrition therapy (MNT) is an essential part of the care for critically ill patients optimal feeding strategy for patients in the intensive care unit (ICU) is still debated and often remains a challenge for the ICU team in clinical practice

3. Terminology

4. How to define the energy expenditure (EE)? Indirect calorimetry is better Weir Equation for REE: REE = (3.94 x VO2) + (1.1 x VCO2) If indirect calorimetry is not available, (REE= VCO2 x 8.19) VCO2 only obtained from ventilators If both are not available we can use predicting equations REE(Kcal/day)=25 x BW(kg). Actual BW used unless it is 25% higher than IBW, Actual BW is mor than 125% of IBW then adjusted wt can be used.[(actual-IBW)x0.25]+IBW. Lambell et al. Critical Care (2020) 24:35

5. Indirect calorimetry vs predictive equation. has no effect on mortality. but associated with a significant reduction in hospital mortality. The use of indirect calorimetry compared to predictive equations may result in improved nutritional intake.

6. Why?—Nutritional Status as a Prognostic Factor Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review: Journal of parenteral and enteral nutrition,2017 case-control or cohort studies that recruited adults in the ICU; conducted the SGA, MNA, or used nutrition screening tools within 48 hours of ICU admission;  The prevalence of malnutrition 38% to 78%. Malnutrition diagnosed by nutrition assessments was independently associated with increased ICU LOS, ICU readmission, incidence of infection and the risk of hospital mortality. The SGA clearly had better predictive validity than the MNA. The association between malnutrition risk determined by nutrition screening was less consistent. Malnutrition is independently associated with poorer clinical outcomes in the ICU.

7. Who?”—Assessment of Nutritional Status Nutrition Risk Score (NRS 2002), the NUTRIC (Nutrition Risk in the Critically Ill) Score, the Subjective Global Assessment (SGA), or the Malnutrition Universal Screening Tool (MUST) No specific ICU nutritional score has been validated so far NRS,MUST scores not specifically for critically ill ASPEN and SCCM-recommends NRS,NUTRIC EPSN-not recommended any tools for assessing nutrition

8. There are no validated and recommended tools to estimate the nutritional status of a critically ill patient. In many of these tools, some of the following factors are included- Medical history: age, comorbidities, loss of physical function Nutrition history: weight loss, reduced food intake, loss of appetite Physical examination: BMI, edema, body composition Severity of disease: critically ill patients are severely ill by definition

9. The ESPEN guideline defines every patient who is in the ICU for more than 48 h to be at nutritional risk. The DGEM guideline recommends a combination of low BMI, unintended weight loss and lack of oral food intake, or the SGA for critically ill patients. Clinical Nutrition in Critical Care Medicine – Guideline of the German Society for Nutritional Medicine (DGEM), 2019

10. Nutric score

11. Comparison of Accuracy of NUTRIC and Modified NUTRIC Scores in Predicting 28-Day Mortality in Patients with Sepsis: A Single Center Retrospective Study. Nutrients.  2018 Jul; Population- 518 patients> 18 years old, admitted to the ICU with sepsis and had ICU stays of more than 24 hrs. Excluded who were discharged or died within 24 h, those for whom 28-day mortality could not be evaluated, and those from whom IL-6 levels from blood samples were not available. Intervention- demographics, height, body mass, comorbidities, diagnosis, length of stay (LOS) in the ICU, mechanical ventilation (MV), vasopressor use, and renal replacement therapy (RRT). The NUTRIC score (0–10) and modified NUTRIC score (0–9) were calculated using data from the first 24 h after ICU admission. NUTRIC and modified NUTRIC scores ≥6 and ≥5, respectively, were considered high Comparison- high and low nutritional risk using the NUTRIC and modified NUTRIC scores. Outcomes

12. Outcomes-28-day mortality increased with both higher NUTRIC score and higher modified NUTRIC score. 28-day mortality for the maximum NUTRIC score was 66.7% and for the maximum modified NUTRIC score was 62.5%.

13. The area under the curves (AUCs) of the NUTRIC Score and modified NUTRIC Score for predicting 28-day mortality were 0.762 (95% confidence interval (CI): 0.718–0.806) and 0.757 (95% CI: 0.713–0.801), respectively (Figure 2). There was no significant difference in ROC curves between the two scores (p = 0.45). In the ROC curve of modified NUTRIC score, the best cutoff was at 6 (sensitivity 75% and specificity 65%), and the Youden index was 0.401.

14. the modified NUTRIC score was a good prognostic substitute for the NUTRIC score in patients with sepsis. The baseline components of the two scores are similar, except for IL-6 level. There is no significant difference between the two tools in the ability to predict 28-day mortality. Therefore, IL-6 level may not be a critical item in a nutritional risk scoring system of septic patients. A cutoff score of 6 for the modified NUTRIC score (versus a cutoff of 5) was better in predicting 28-day mortality.

15. There is no single “golden bullet” to diagnose malnutrition, but many helpful tools and criteria are available. All ICU patients should be regularly screened for risk of malnutrition.

16. “How?”—The Route of Nutrition EN PEN Combined

17. Trial of the Route of Early Nutritional Support in Critically Ill Adults. The NEJM; October 30, 2014. Background: Uncertainty exists about the most effective route for delivery of early nutritional support in critically ill adults. Hypothesis: delivery through the parenteral route is superior to that through the enteral route.

18. Design: pragmatic, open, multicenter, parallel-group, randomized, controlled trial. 33 English intensive care units.

19. Populations Included: >18 years of age expected to require nutritional support for at least 2 days, as determined by a clinician within 36 hours after an unplanned ICU admission that was expected to last at least 3 days. Excluded those could not be fed through either the parenteral or the enteral route, received nutritional support in the past 7 days, had a gastrostomy or jejunostomy in situ, pregnant

20. Using a 24-hour telephone randomization system, we assigned patients in a 1:1 ratio to receive early nutritional support through the parenteral route or the enteral route. Intervention: Nutritional support was initiated as soon as possible after randomization (within 36 hours after admission) and used exclusively for 5 days (120 hours) or until transition to exclusive oral feeding, discharge from the ICU, or death (termed the intervention period).

21. Primary outcome-at 30 d mortality- no significant diff Secondary outcomes: decrease hypoglycaemia and vomiting in PEN group.

22. Conclusion: No significant difference in 30-day mortality associated with the route of delivery of early nutritional support in critically ill adults.

23. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2) The Lancet, Nov, 2017 Background: Whether the route of early feeding affects outcomes of patients with severe critical illnesses is controversial. Hypothesis-outcomes were better with early first-line enteral nutrition than with early first-line parenteral nutrition. Design: Randomized controlled, multicenter, open-label, parallel-group study (NUTRIREA-2 trial) done at 44 French intensive-care units (ICUs). Population: Inclusion criteria adults (18 years or older) receiving invasive mechanical ventilation and vasopressor support for shock

24. Intervention: were randomly assigned (1:1) to either parenteral nutrition or enteral nutrition targeting normo-caloric goals (20–25 kcal/kg per day), within 24 h after intubation. Randomization was stratified by center using permutation blocks of variable sizes. Given that route of nutrition cannot be masked, blinding of the physicians and nurses was not feasible Patients receiving parenteral nutrition could be switched to enteral nutrition after at least 72 h in the event of shock resolution (no vasopressor support for 24 consecutive hours and arterial lactate <2 mmol/L)

25. outcomes mortality on day 28 after randomization in the intention-to-treat-population. between March 22, 2013, and June 30, 2015, 2410 patients were enrolled and randomly assigned; 1202 to the enteral group and 1208 to the parenteral group. Paramters EN PEN 28 d mortality 443(37%) 422(35%) No significant difference ICU infections 173(14%) 194(16%) HR-0.89, p=0.25 (not significant) vomiting 406(34%) 246(20%) HR=1.89,p<0.0001 diarrhoea 432(36%) 393(33%) HR=1.2,p<0.009 Bowel ischemia 19(2%) 5(<1%) P<0.007 Acute colonic pseudo-obstruction 11(1%) 3(<1%) P<0.04 Conclusion: In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of GI complications compared with early isocaloric parenteral nutrition.

26. ESPEN guideline on clinical nutrition in the intensive care unit. P. Singer et al. Clinical Nutrition, 2018 Oral diet shall be preferred over EN or PN in critically ill patients who are able to eat. If oral intake is not possible, early EN (within 48 h) in critically ill adult patients should be performed/initiated rather than delaying EN. If oral intake is not possible, early EN (within 48 h) shall be performed/initiated in critically ill adult patients rather than early PN. In case of contraindications to oral and EN, PN should be implemented within three to seven days. Early and progressive PN can be provided instead of no nutrition in case of contraindications for EN in severely malnourished patients.

27. comparing early EN vs early PN (meta-analysis) Decrease infections and ICU stay in early EN Mortality was not different. EEN Vs EPN

28. EEN Vs DEN Six studies in ICU patients on meta-analysis shows- reduction of infectious complications in early EN (RR 0.76, CI 0.59, 0.97, p < 0.03).

29. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive care medicine, March,2017 compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery did not detect any evidence of superiority for early PN or delayed EN over EEN

30. Forest plots (a mortality; b infections) early EN (EEN) vs. delayed EN (DEN) in unselected critically ill patients Forest plots (a mortality; b infections) early EN (EEN) vs. early PN (EPN) in unselected critically ill patients 12 RCTs, 662 pts 11 RCTS, 597 pts

31. EEN in the majority of critically ill pts. delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

32. Combination of EN with Parenteral Nutrition (PN) Often calorie/protein target not achieved by EN alone. Thus, first ICU week, EN alone may lead to macronutrient deficiency. To avoid large cumulative energy and protein deficits, EN and PN may be combined, either early during the patient’s ICU course (combined EN+PN), or after several days once EN is proven to be insufficient.

33. The PubMed (June 30st, 2018), EMBASE (June 30st, 2018), and Cochrane library databases (June 30st, 2018) were searched systematically. Randomized controlled trials (RCTs) of comparing combined PN and EN with EN alone were eligible.

34. No statistically significant difference was observed on hospital mortality compared PN + EN with EN alone for adult critically ill patients (RR, 0.91 [95% CI 0.74–1.12]).

35. Fewer patients in EN alone group acquired the respiratory infections (RR, 1.13 [95% CI 1.01–1.25])

36. Length of days at hospital (MD, 1.83 [95% CI 1.05–2.62]) were shorter in EN alone group (Fig. 5C). The data showed no significant differences on length of days in ICU and duration of ventilatory support (Fig. 5A and B) 1.83[1.05-2.62]

37. Receiving EN alone decreased the respiratory infections and length of days at hospital for critically ill patients. Combined PN and EN did not add up the potential risk from PN and EN on hospital mortality, length of days in ICU, duration of ventilatory support.

38. A recent meta-analysis by Hill et al. including 12 RCTs with 5543 patients found that treatment with combined EN and PN led to increased delivery of macronutrients in severely ill ICU patients. No statistically significant effect of a combination of EN with PN vs. EN alone on any of the analyzed endpoints were observed: mortality (Risk Ratio [RR] 1.0, 95% Confidence Interval [CI], 0.79 to 1.28 p = 0.99), hospital LOS (Mean Difference [MD]-1.44, CI −5.59 to 2.71, p = 0.50), ICU LOS and ventilation days.

39. The ESPEN guideline recommends as good practice point: “PN should not be started until all strategies to maximize EN tolerance have been attempted”. “In patients who do not tolerate full dose EN during the first week in the ICU, the safety and benefits of initiating should be weighed on a case-by-case basis

40. EN may be preferred in almost all ICU patients Macronutrient targets may not be reached with EN alone in the acute phase The addition of PN or the use of total PN (in the acute phase) needs to be considered on a case-by-case basis.

41. EN vs PN – summary of evidences • No benefit in mortality. • Increase in number of infectious complication with use of PN • EN associated with significant reduction hospital length of stay. • But no difference in in ICU days compared to PN or ventilator days • EN associated with increased vomiting.

42. Parenteral Nutrition-When should we start?

43. In conclusion- in early initiation group Fewer discharges Long ICU LOS More new infections More time on vent More renal failure Cost more money

44. “When?”—The Timing of Nutrition

45. EEN EEN within 24–48 h is uniformly recommended EN should be started at a low feeding rate (e.g. 5–10 mL) and increased carefully and individually adapted to hemodynamic stability and tolerance.

46. Early Enteral Nutrition Provided Within 24 Hours of ICU Admission: A Meta-Analysis of Randomized Controlled Trials. Tian F et al. Crit Care Med. 2018 Background-whether early enteral nutrition alters patient outcomes from critical illness. Data source-Medline and Embase were searched. The close out date was November 20, 2017. Populations-Sixteen RCTs enrolling 3,225 critically ill participants were included. Intervention-Early enteral nutrition was defined as a standard formula commenced within 24 hours of ICU admission. Comparators -included any form of nutrition support "except" early enteral nutrition. Outcomes-The primary outcome was mortality. Secondary outcomes included pneumonia, duration of mechanical ventilation, and ICU and hospital stay.

47. EEN (within 24 hrs )-no reduction in mortality (odds ratio, 1.01; 95% CI, 0.86-1.18; p = 0.91; I = 32%). However, there was a differential treatment effect between a priori identified subgroups (p = 0.032): early enteral nutrition reduced mortality compared with delayed enteral intake (odds ratio, 0.45; 95% CI, 0.21-0.95; p = 0.038; I = 0%), whereas a mortality difference was not detected between early enteral nutrition and parenteral nutrition (odds ratio, 1.04; 95% CI, 0.89-1.22; p = 0.58; I = 30%). overall, patients who were randomized to receive early enteral nutrition were less likely to develop pneumonia (odds ratio, 0.75; 95% CI, 0.60-0.94; p = 0.012; I = 48%).

48. Early enteral nutrition (within 48 hours) versus delayed enteral nutrition (after 48 hours) with or without supplemental parenteral nutrition in critically ill adults. Cochrane Database Syst Rev. 2019 Patient or population: critically ill adults Setting: ICUs in university teaching hospitals, tertiary care hospitals, and general hospitals from the USA (2), Australia (1), Greece (1), India (1), and Russia (1) Intervention: early enteral nutrition (initiated within 48 hours of initial injury or ICU admission) Comparison: delayed enteral nutrition (initiated later than 48 hours after initial injury or ICU admission)

49. Trophic vs full nutrition

50. If indirect calorimetry is used, isocaloric nutrition rather than hypocaloric nutrition can be progressively implemented after the early phase of acute illness. Hypocaloric nutrition (not exceeding 70% of EE) should be administered in the early phase of acute illness. After day 3, caloric delivery can be increased up to 80-100% of measured EE. If predictive equations are used to estimate the energy need, hypocaloric nutrition (below 70% estimated needs) should be preferred over isocaloric nutrition for the first week of ICU stay ESPN guidelines-2019

51. Continuous rather than bolus EN should be used.

52. Gastric Vs Post Pyloric feeding( ESPN-2019 Guidelines)

53. Postpyloric EN has been associated with a decrease in VAP, but this benefit did not translate into decreases in length of ventilation, ICU or hospital stay, or mortality. Post pyloric feeding is better in patients with a high risk for aspiration (Inability to protect the airway, mechanical ventilation, age >70 years, reduced level of consciousness, poor oral care, supine positioning, neurologic deficits, gastroesophageal reflux, transport out of the ICU).

54. Thank you