1 in knowledge translation: the critical care experience

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InInKnowledge Translation: Knowledge Translation:

The Critical Care The Critical Care ExperienceExperience

Outline of SessionGuidelines for Nutrition Therapy in the ICU : How do they differ? Rupinder Dhaliwal, RD

WHAT SHOULD BE DONE?

Improving the practices of Nutrition Therapy in the Critically ill Naomi Cahill, RD

WHAT IS BEING DONE?

Bridging the Gap: Effective Dissemination Strategies for Improving Nutrition Practices in the ICUDaren Heyland, MD

HOW TO NARROW THE GAP?

Questions to be held at the end of the session

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Guidelines for Nutrition Therapy in the Guidelines for Nutrition Therapy in the ICU: How do they differ?ICU: How do they differ?

Rupinder Dhaliwal, RD

Team Leader/Project Leader

Clinical Evaluation Research Unit

Critical Care Nutrition

Kingston ON, Canada

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Conflict of interest

Co-author of Canadian Clinical Practice

Guidelines

Clinical practice guidelines are

“systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”

Best available evidence with integration of potential benefits, harm, feasibility, cost

Reduce variability in care, improve quality, reduce costs and can improve outcomes

Why bother with guidelines?Why bother with guidelines?

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Proliferation of guidelinesProliferation of guidelines

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The more guidelines they publish, the more confused I get!

Compare the content of recently published nutrition guidelines

Differences between the recommendations

Similarities in the recommendations

Highlight the need for harmonization

ObjectivesObjectives

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North American guidelinesNorth American guidelines

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www.criticalcarenutrition.com

Available Online

Population Levels of Evidence Grading used Time frames, outcomes Level of transparency between evidence and

recommendation

What differences? What differences?

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Differences Differences

Area Canadian ADA ASPEN/SCCM

Population Mechanically ventilated critically ill patients

no elective surgery

Critically ill patients needing EN

no burns

Medical and surgical critically ill patients

expected to stay in the ICU > 2-3 days

Level of evidence

RCTs, meta analyses

Level 1 or 2 based on validity of evidence

All levels of evidence

Grade 1-5 based on validity of evidence Minimum n>20

All levels of evidence

Level 1-5 based on validity of evidence

Time Frame 1980-2009 1993-20031993-20091996-2006

unclear

Outcomes clinical outcomes clinical and non clinical outcomes

clinical and non clinical outcomes

Grading Canadian ADA ASPEN/SCCM

Strongest

Weakest

“Strongly recommend”no reservations re: endorsement

(5%)

“Strong”benefits exceed harmhigh quality evidenceanticipated benefits (41%)

“A” supported by at least 2 Level 1 (RCT n > 100)(3%)

“Recommend”supportive evidence but minor uncertainties re: safety/feasibility or costs

“Fair”Same as above but quality of evidence is not as strong

“B” supported by 1 level 1

“Should be considered”Evidence was weak or major uncertainties re: safety/cost/feasibility

“Weak”Suspect quality of evidencelittle clear benefit

“C”Level 2 (RCTs <100)

“Insufficient data”Inadequate data or conflicting evidence(51%)

“Consensus”Expert opinion

“D”At least 2 Level 3(non RCT, contemporaneous controls)

“Insufficient evidence”No pertinent evidenceand harm/risk is ?(37%)

“E”Level 4 (non RCT, historical controls)Level 5 (case series), expert opinion (39%)

Criteria High Quality CPGs

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Rigor of development: Provide detailed information on the search strategy, the

inclusion/exclusion criteria, and methods used to formulate the recommendation (reproducible).

Transparent link between evidence, values, and resulting recommendation

External review

Procedure for updating the CPG

AGREE Qual Saf Health Care 2003;12:18

Integration of values

Validity Homogeneity

SafetyFeasibility

Cost

evidence integration of values+

practiceguidelines

Indirect calorimetry vs. predictive equations

Differences: recommendationsDifferences: recommendations

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Canadian ADA ASPEN/SCCM

Insufficient data

1 small RCT burn patients

Strong

Use indirect calorimetry

Non RCTs, no clinical outcomes

Grade E

Use either, caution with equations

Narrative review article

Dose of enteral nutrition and target range


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Should be considered

Use strategies to optimize EN i.e. goal rate start, 250 mls GRVs, m. agents, small bowel feeding

No threshold

1 RCT and 2 Cluster RCTs

Fair

Give at least 60-70% energy within first week

2 RCTs and 2 non RCTs

Grade C

Provide >50-65% goal calories in first week

Specifics for Obese (Grade E and D)

1 RCT and 1 non RCT

Gastric Residual Volumes & Motility agents


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GRVs Should be considered 250 mls

1 RCT and 2 Cluster RCTs

Consensus

250 mls

Grade B

500 mls

4 RCTs

Motility agents Recommendmetoclopromide

Strongmetoclopromide

Grade CMetoclopromideErythromycinOpiod antagonists

Arginine


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Recommend NOT be used

Meta-analyses of 22 RCTs3 RCTs harm

FairNot be used

11 RCTs2 RCTS harm

Grade A SurgicalGrade B MedicalCautious in severe sepsisVolume use 50-65% goal

earlier meta-analyses showing no benefitRCT showing benefit

Grade A: based on elective surgery patients

Enteral Glutamine


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Burns: Recommended

Trauma: Should be considered

Other ICU: Insufficient data

9 RCTS

-------- Grade B

Burns, Trauma and mixed ICU patients

1 RCT

Peptides


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Recommendpolymeric (since no benefit for peptides)

4 RCTs

---------Grade E Use small peptides in diarrhea

1 non RCT

zzzz…….

Fibre


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Insufficient data

6 RCTs

---------Grade E Use soluble fibre3 RCTs

Grade CAvoid soluble and insoluble fibre for bowel ischemia/severe dysmotility2 non RCTs

Probiotics


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Insufficient data

No benefit in outcomes, potential for harm

12 RCTs

---------Grade CUse in transplant, major abd surgery, severe trauma

Not in necrotizing pancreatitis

5 RCTs

Intensive Insulin Therapy


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RecommendTarget 8.0 mmol/LRange 7-9 mmol/L

Most recent meta- analyses

Strong Medical: 4.4-6.1 mmol/L

Grade BModerate strict control

Grade E6.1-8.3 mmol/L

Similarities?

Topic Canadian ADA ASPEN/SCCM

Use of EN over PN

Start EN within 24-48 hr

EN Fish Oils -----

CHO/Fat Insufficient ----- Insufficient

Body position (45) (45)

Small bowel vs. gastric

Continuous vs. other insufficient ---- High risk (D)

PN vs std care Not be used ---- Not for 7 days

Type of IV lipids No soy based ---- No soy based

PN Glutamine ----

Low dose of PN ----

AOX/vits/minerals ----

ADOPT NOW!

Slight difference in strengthSlight difference in strength

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Enteral Nutrition over Parenteral NutritionCanadians and ADA: StrongestASPEN/SCCM: second strongest

Feeding ProtocolsCanadians and ASPEN/SCCM: weaker recommendationADA: none for feeding protocol per se, but for GRV : expert opinion

EN plus PNCanadian: recommend NOT be usedASPEN/SCCM: not be started for 7 -10 days (grade C)

Blue DyeASPEN/SCCM : not recommendADA : do not recommend but highest level of evidence

Differences exist between the guidelines: Populations, levels of evidence, time frames, etc Recommendations: due to interpretation of the evidence, lack of

transparency

Similarities in many of the recommendations

Highlight the need for harmonization across North American Societies

SummarySummary

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Similarities should be adopted without hesitation

Differences

Harmonize between societiesDefine critically ill patientTransparency needed (websites)

Practitioner: right recommendation for the right person

ImplicationsImplications

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Upcoming in JPEN Upcoming in JPEN

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Available onlineKnowledge

Translation issue Fall 2010

Ahhh…..Harmonized Guidelines!

1 in knowledge translation: the critical care experience

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