journal club nutrition in critically ill

Presenter: Dr. Venugopalan.G

Preceptor: Dr. Navinath.M

Department of Geriatric Medicine, AIIMS

Critical illness is typically associated with a catabolic

stress state in which patients commonly demonstrate a

systemic inflammatory response

Proper nutrition is mandatory to…

Preserve lean body mass,

Maintain immune function, and

Avert metabolic complications

EN is the preferred route of feeding over parenteral

nutrition (PN) for the critically ill patient who requires

nutrition support therapy (Grade B)

EN started early within the first 24–48 hours following

admission (Grade C)

Robert G. Martindale et al. Crit Care Med 2009 Vol. 37, No. 5

If there is evidence of PEM at admission and EN is not

feasible, initiate PN as soon as possible (Grade C)

PN should be delayed for 7 days for patients without

evidence of PEM and EN not feasible (Grade E)

PN provided for a duration of 5–7 days would be

expected to have no outcome effect and may result in

increased risk.


Can GIT be used safely and

effectively?

Support for >6 weeks is

required?

Tube Enterostomy

Nasoenteric

Nasoduodenal Nasogastric

Parenteral Nutrition

Central Line PICC

Yes

Yes

No

No

Resting energy expenditure:

REE (kcal/min) = (3.6*VO2)+(1.1*VCO2)-16

REE (kcal/day) = (25 to 30) * Body weight (Kg)

Indirect calorimetry vs Predictive equation

> 200 predictive equations

Nitrogen Balance= Nitrogen Intake – Nitrogen Excretion

Nitrogen Balance= Protein Intake/6.25 – [UUN+(4-6)]

The ICU book-4th ed. Paul L. Marino

Daily energy should be provided by non-protein calories

Protein intake is for essential enzymatic and structural

protein

Goal for Positive N2 balance of 4 to 6 gm

Calories from non-nutritional source should be

considered along with supplement (e.g. propofol in 10%

lipid emulsion gives 1.1 kcal/mL)

Carbohydrate 70% of REE 3.7 kcal/g

Lipid 30% of REE 9.1 kcal/g

Protein 1.2 to 1.6 g/kg --- (4.0 kcal/g)

Standard Enteral Nutrition

AIIMS Feed(Special Feed)

Calories 1 kcal/ml 1.4 kcal/ml

Protein 20 g/500 ml 30 g/500 ml (0.06 g/ml)

Feed Contents

Special Feed Milk + Corn starch + High Protein + oil + egg + sugar

Coma feed Only calories, no protein

Diabetic feed Less carbs

Renal feed Less protein (38.75/ 1 L)

Curd feed

Dal feed

Half and full strength milk feed

Start within 24 to 48 hours

Gastric feeding: begin at target rate

Small bowel feed: start low (10 – 20 ml/hr) and gradually

increase to target rate in 4 to 6 hours

Absolute Contraindications:

Complete bowel obstruction

Bowel ischemia

Ileus

Circulatory shock with high dose vasopressors

1. Calculate REE (kcal/day) and protein requirement(1.2

to 1.6 g/kg/day)

2. Select feeding formula (1 kcal/mL to 1.5 kcal/mL)

3. Infusion rate= feeding volume/ feeding time

Feeding volume= Calorie required(kcal/day)

Feeding formula(kcal/mL)

4. Adjust protein intake

Start at rate of 10-30 ml/hr infusion for first few

days and titrate to reach target infusion rate

within a week


Head of the bed should be elevated 30°– 45° (Grade C).

For high-risk patients/ intolerant to gastric feeding, delivery of

EN should be continuous infusion (Grade D).

Agents promoting motility (prokinetics, narcotic antagonists)

initiated where clinically feasible (Grade C).

Post-pyloric tube placement (Grade C).

Chlorhexidine mouthwash bid to reduce risk of VAP (Grade C)


No benefits in mortality or complications for routine

use of…

Arginine

Glutamine

Omega 3 fatty acids

Antioxidants

Fibres

Prokinetics

1. Calculate REE

2. Standard mixture of 10% amino acids (A10)-500 ml

and 50% Dextrose (D50)-500 ml

Calculate Volume of A10D50 and Infusioin rate

3. Determine Non-protein calories and correct deficit

with lipid emulsion

Final TPN order for 60 kg male will look like this:

• A10D50 to run at 80 ml/hr

• 10% intralipid, 150 ml over 3 hours

• Add standard electrolytes, multivitamins and

trace elements

• Dedicated line, infusion pump, in-line filters


Total volume 1000 ml

Total Energy (kcal) 1022

Non protein energy 9kcal) 862

Dextrose (g) 120

Lipids (g) 40

Nitrogen (g) 5.4

Aminoacids (g) 40

Osmolarity 1158

Catheter related:

CLABSI, misdirection, thrombosis, pneumothorax..…

Metabolic:

Hyperglycemia, hypophosphatemia, hypokalemia

Hypercapnia, hyperosmolar dehydration

Metabolic acidosis

Hepatic steatosis, cholestasis

Bowel ischemia

Early initiation of parenteral nutrition (European Guidelines)-

initiated within 48 hours after ICU admission - In 2312

patients

Late initiation of parenteral nutrition (ASPEN and Canadian

guidelines)- not initiated before day 8- In 2328 patients

Casaer MP et al. NEJM 2011

Late initiation of parenteral nutrition was associated with faster recovery and fewer

complications, as compared with early initiation

Casaer MP et al. NEJM 2011

Heidegger CP et al. Lancet 2013;381:385-93

Heidegger CP et al. Lancet 2013;381:385-93

Individually optimised energy supplementation with SPN starting 4 days after ICU

admission could reduce nosocomial infections and should be considered as a

strategy to improve clinical outcome for whom EN is insufficient

Early PN (started within 24 hours) and to achieve target by

day 3 vs standard nutrition (according to ICU protocols)

686 to standard care, 686 to early PN

The provision of early PN to critically ill adults with relative contraindications to early EN,

compared with standard care, did not result in a difference in day-60 mortality.

The early PN strategy resulted in significantly fewer days of invasive ventilation but not

significantly shorter ICU or hospital stays

Nutrition in the Acute Phase of Critical Illness. N Engl J Med 2014;370:1227-36

No consensus on timing, route, duration and type of

nutrition supplementation in critically ill

Meta analysis have varying results and affected by

small sample size and inconsistent study methods

Need of time to know whether Parenteral nutrition

(PN) is superior to enteral nutrition

Open

Multi-center (33 ICU)

Parallel-group

Randomized controlled trial

North West London Research Ethics Committee

approved the study protocol

Grant from the Health Technology Assessment

Program of the United Kingdom National Institute for

Health Research (project no. 07/52/03)

At least 18 years of age

Unplanned admission

Expected to require nutritional support for at least 2

days, as determined by a clinician within 36 hours after

an unplanned ICU admission

Not expected discharge in at least 3 days

Could not be fed through either PN or EN/ contraindications

Received nutritional support in the past 7 days

Had a gastrostomy/PEG or jejunostomy in situ

Pregnant

Not expected to be in the UK for next 6 months

Previously randomised into CALORIES

In ICU for > 36 hours

Patients admitted to ICU for treatment of thermal injury/ palliative care

Nutrition initiated as soon as possible after

randomization (within 36 hours)

Used exclusively for 5 days (120hours) or until

transition to exclusive oral feeding, discharge from

ICU, or death

Oral feeding could be initiated if clinically indicated

during the intervention period

Energy targets : 25 kcal/kg/day

Goal of reaching the target within 48 to 72 hours

Protein or AA targets were set according to local practice.

Glycemic control: <180 mg/dl

Enteral Nutrition according to local hospital supply

Total volume of EN and PN adjusted according to fluid

status

Calories from non-nutritional sources (e.g., Propofol)

were included in calculation.

All other treatments and nutritional support were

provided according to local practice guidelines

Constituent of PN Per standard bag Per ml

Energy (total kcal) 1365 – 2540 0.9 – 1.1

Nitrogen (g) 7.2 – 16.0 0.005 – 0.007

Primary outcome: (at 30 days)

All-cause mortality at 30 days.

Secondary outcomes: (at 90 days)

Duration of organ support,

Treated infectious and non infectious complications,

Length of stay in the ICU and hospital,

Duration of survival, and

Mortality at the time of discharge from the ICU and from the

hospital, at 90 days, and at 1 year.

Adverse events were monitored for 30 days

Estimated to enrol 2400 patients

With a power of 90% to detect a 20% relative risk

reduction (absolute risk reduction, 6.4 percentage

points) in the parenteral group

With a two sided alpha level of 0.05

Assuming that 2% of patients would cross over to the other

group or have a protocol violation and that 2% of patients

would be lost to follow-up or withdraw from the study

All analyses using the intention-to-treat principle on the

basis of a pre specified statistical analysis plan

Fisher’s exact test to compare b/w group difference in

primary outcome

For secondary outcomes: Fisher’s exact test, t-test,

Wilcoxon rank-sum (Mann-Whitney) test were used

Primary outcome: 33.1 % in PN vs 34.2% in EN

(p=0.57)

No significant difference in infectious complications,

90 day mortality, mechanical ventilation

Hypoglycemia: 3.7% in PN vs 6.2% in EN (p=0.006)

Vomiting: 8.4% in PN vs 16.2% in EN (p<0.001)

No significant difference in outcome between the two

study groups

No significant difference in effective nutritional

delivery, since patients in the two groups did not

receive the caloric targets

Suggest that early nutritional support through the

parenteral route is neither more harmful nor more

beneficial than such support through the enteral route

Start EN as early as possible

Use PN only when EN is contraindicated

Try to achieve target energy level within pre-specified

time (according to local ICU policy)

Individualize treatment choices

journal club nutrition in critically ill

Health & Medicine