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Adjunctive
Supportive
Care
Proactive
Primary
Therapy
Caloric Debt
Adequacy
of EN
Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006
Updated 2009
www.criticalcarenutrition.com
Updated 2009
www.criticalcarenutrition.com
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
Result:
Average caloric deficit in Lean Pts:
7500kcal/10days
Odds
Ratio
95%
Confidence
Limits
P-value
Overall
0.76
0.61
0.95
0.014
<20
0.52
0.29
0.95
0.033
20-<25
0.62
0.44
0.88
0.007
25-<30
1.05
0.75
1.49
0.768
30-<35
1.04
0.64
1.68
0.889
35-<40
0.36
0.16
0.80
0.012
>=40
0.63
0.32
1.24
0.180
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.
95% CI
P-value
Estimate
LCL
UCL
Overall
3.5
1.2
5.9
0.003
<20
2.8
-2.9
8.5
0.337
20-<25
4.7
1.5
7.8
0.004
25-<30
0.1
-3.0
3.2
0.958
30-<35
-1.5
-5.8
2.9
0.508
35-<40
8.7
2.0
15.3
0.011
>=40
6.4
-0.1
12.8
0.053
Legend: # of VFD per 1000 kcals received per day adjusting for nutrition days, BMI, age,
admission category, admission diagnosis and APACHE II score.
P values
P=0.11
P=0.02
for
P=0.007
P=0.92
P=0.43
Permissive Underfeeding
(Starvation)?
187 critically ill patients
Tertiles according to ACCP recommended levels of
caloric intake
Highest tertile (>66% recommended calories) vs.
Lowest tertile (<33% recommended calories)
in hospital mortality
Discharge from ICU breathing spontaneously
0.4
Unadjusted
Adjusted
0.6
0.8
1.0
1.2
1.4
1.6
Optimal
amount=
80-85%
Average age 51
Few comorbidities
Average BMI 29
All fed within 24 hrs (benefits of early EN)
Average duration of study intervention 5 days
No effect in young, healthy,
overweight patients who
have short stays!
Large multicenter trial of this concept
(EDEN study) by ARDSNET just finished
Chronic
-Reduced po intake
-pre ICU hospital stay
Starvation
Nutrition Status
micronutrient levels - immune markers - muscle mass
Acute
-IL-6
-CRP
-PCT
Inflammation
Chronic
-Comorbid illness
Non-survivors by day 28
(n=138)
Survivors by day 28
(n=460)
p values
<.001
<.001
<.001
<.001
0.13
0.66
<20
20
6 ( 4.3%)
122 ( 88.4%)
3.0 [2.0 to 4.0]
# of co-morbidities at baseline
Co-morbidity
Patients with 0-1 co-morbidity
20 (14.5%)
Patients with 2 or more co-morbidities
118 (85.5%)
25 ( 5.4%)
414 ( 90.0%)
3.0 [1.0 to 4.0]
<0.001
<0.001
140 (30.5%)
319 (69.5%)
108.0 [59.0 to 192.0]
0.07
<.001
<.001
Non-survivors by day 28
(n=32)
Survivors by day 28
(n=139)
p values
0.10
0.0[ 0.0 to
0.0]
0.06
p values
Number of
observations
Age
Baseline APACHE II score
Baseline SOFA
-0.1891
-0.3914
-0.3857
<.0001
<.0001
<.0001
598
598
594
0.1676
0.0234
183
-0.1387
0.0007
598
-0.1828
0.0581
-0.0832
-0.1539
-0.3189
-0.2908
0.0130
0.1671
0.0420
0.0002
<.0001
<.0001
184
567
598
589
582
581
Variable
Parameter
Points
19.3-48.8
referent
48.9-59.7
0.780
59.7-67.4
0.949
67.5-75.3
1.272
75.4-89.4
1.907
<50
50-<75
>=75
<15
15-<20
20-28
>=28
<6
6-<10
>=10
0-1
2+
0
1
2
0
1
2
3
0
1
2
0
1
0-<1
1+
0
1
IL6
0-<400
400+
0
1
APACHE II
SOFA
# Comorbidities
AUC
Gen R-Squared
Gen Max-rescaled R-Squared
0.783
0.169
0.256
BMI, CRP, PCT, weight loss, and oral intake were excluded because they were not significantly
associated with mortality or their inclusion did not improve the fit of the final model.
Observed
Model-based
40
20
n=12
n=33
n=55
n=75
n=90
n=114
n=82
n=72
n=46
n=17
n=2
60
80
10
Observed
Model-based
10
8
6
4
2
n=12
n=33
n=55
n=75
n=90
n=114
n=82
n=72
n=46
n=17
n=2
10
12
14
0.8
8 88
0.6
77 7
9
9
8888
7 7
8888
0.2
0.4
77
4
0.0
28 Day Mortality
2
0
9
8
10
10
888
8
77 7
8
77 7
88
7
77
6
7
7777
6 66666 6
9
66666 6 6 6
66 666666666
666 6 6 66
7
5
555
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
4 4 3
5 55 555 55 555 55
5
5 5
444 4 43
4
4
2
4
4
4
3
44444444
33
444 4444
3
4
3
1
4 4
22
3
4 4
3 3 33 2 22 2 1
3
11
33 3
2
1 11 1 1
50
100
3
3
5
150
Others?
Can we do better?
Sedation
Catecholamines
High residuals before and
feeding protocols
motility agents
elevation of HOB
small bowel feeds
weak evidence
stronger evidence
Canadian CPGs www.criticalcarenutrition.com
Check
Residuals
q4h
< 250 ml
advance rate by 25 ml
reassess q 4h
reassess q 4h
Total
15.2% using the
recommended
threshold volume
of 250 ml
n=269
Feeding Protocol
Yes 208 (78%)
Gastric Residual Volume
Tolerated in Protocol
Mean (range)
Elements included in Protocol
Motility agents
Small bowel feeding
HOB Elevation
P<0.05
Can be overcome
by better feeding
protocols
Impaired motility
Medications
Metabolic, electrolyte abnormalities
Underlying disease
Prophylactic
use of motility
agents
Protocol to Manage
Interruptions to EN due to nonGI Reasons
80
% calories
Intervention
sites
Control sites
received/prescribed
371
331
60
376
378
50
390
404
359
379
40
40
374
373
360
375
% calories received/prescribed
60
326
372
50
70
Academic
Community
380
30
30
362
Baseline
377
327
p value for Academic sites=0.20
p value for Community sites=0.78
20
20
% calories received/prescribed
70
Academic
Community
Follow-up
Baseline
Follow-up
Control sites
80
80
326
331
371
60
376
378
50
360
374
373
404
359
379
40
375
% protein received/prescribed
390
40
50
60
372
380
30
30
362
Baseline
377
327
p value for Academic sites=0.15
p value for Community sites=0828
20
20
% protein received/prescribed
70
Academic
Community
70
Academic
Community
Follow-up
Baseline
Follow-up
Updated 2011,www.criticalcarenutrition.com
# of
patients
% positive
for GER
% positive
for
Aspiration
Stomach
21
32
5.8
D1
27
4.1
D2
11
1.8
D4
Total
33
75
11.7
P=0.004
P=0.09
Results:
Late PN associated with
6.3% likelihood of early
discharge alive from ICU
and hospital
Shorter ICU length of
stay (3 vs 4 days)
Fewer infections (22.8 vs
26.2 %)
No mortality difference
Cesaer NEJM 2011
Not an indictment of PN
Early group only recd PN for 1-2 days on average
Late group only recd any PN
ICU patients
BMI <25
BMI >35
Fed enterally
Stratified by:
Site
BMI
Med vs Surg
Control
Primary
Outcome
60-day
mortality
In Conclusion
Health Care Associate Malnutrition is rampant
Not all ICU patients are the same in terms of risk
Iatrogenic underfeeding is harmful in some ICU patients or
some will benefit more from aggressive feeding (avoiding
protein/calorie debt)
BMI and/or NUTRIC Score is one way to quantify that risk
Need to do something to reduce iatrogenic malnutrition in
your ICU!
Audit your practice first!
Consider updating your feeding protocol!
www.criticalcarenutrition.com
Questions?
www.criticalcarenutrition.com