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Nutritional Support

in the ICU
Sandra L Schoepfel MS RD RN CNSD
Karl D Pilson MD
Suresh Agarwal MD FACS
Boston Medical Center
Boston, MA

Rationale for Nutrition Support


Limit catabolism hypercatabolic state is driven by the
underlying disease process and is not reversed by
nutrition alone
Offset muscle wasting and starvation induced immune
depletion loss of 1% per day lean body mass = 2% per
day skeletal muscle
Substrate for healing and preserve immune function
Increase survival
Nutritional therapy in the ICU is at best supportive
cannot reverse hypermetabolism
Slide 3

Goals of Nutritional Support In The


ICU
Early intervention (after resuscitation)
Ensure adequate enteral access
Support the metabolic response to injury and
infection (bone marrow, acute phase proteins,
wound healing)
Correct fluid, metabolic and acid/base
abnormalities
Avoid overfeeding and hyperglycemia
? reduce ventilator dependency
Slide 4

Achieving Nutritional Goals in


the ICU is Difficult
1 year survey of ICU Nutritional Practice:
3526 record feeding days were evaluated

Desired intake was only achieved 52% of days


Ideal protein intake achieved in 54%
Ideal energy intake achieved in 66%
Ideal volume intake achieved in 75% of patients
Binnekade JM. Crit Care 2005. Jun;9(3):R216-25

Slide 5

Baseline Patient Assessment


No single test can be used as a completely
reliable indicator of nutritional status
Evaluation of weight loss and previous nutrient
intake before admission
Level of disease severity
Presence of comorbid conditions
Function of the gastrointestinal tract
Evaluation of biochemical indices
Measurement of body mass index
Slide 6

Nutritional Assessment A Difficult


Task in the ICU
Medical, surgical and dietary history may be hard to obtain
Physical assessment may be confounded by volume
resuscitation (surgery, burn, trauma, infection)
Problems with Nutritional Assessment in ICU Patients
Parameter

Invalidation

Weight (BMI)
Anthropometrics
Albumin, Pre-Albumin

Edema, fluids, diuretics


Edema, observer variability
Infection, inflammation, injury, renal failure

Nitrogen Balance

Drainage tubes, wounds, renal failure

Slide 7

Factors That Increase


Nutritional Risk
Involuntary loss or gain of > 10% of usual BW
within 6 months or > 5% of usual BW in 1 month,
or a weight of 20% over or under ideal BW
Presence of chronic disease
Increased metabolic requirements
Altered nutrient schedules (TFs, PN) because of
recent surgery, illness
Impaired ability to ingest or absorb food
adequately for > 7 days
Slide 8

Malnutrition
Recent surveys suggest that 33-53% of
hospitalized patients suffer from moderate to
severe malnutrition
Souba W. N. Eng J Med 1997;336-41
Atalay BG. JPEN 2008 Jul-Aug;32(4):454
Delgado AF. Clinics 2008;63(3):357

Assume some degree of malnutrition exists or


will develop in all patients
In the ICU: Malnutrition contributes to respiratory
weakness, failure to wean from the ventilator,
increased morbidity, mortality and hospital costs
Slide 9

Protein Markers in the ICU


Traditional protein markers (albumin,
prealbumin, transferrin, retinol binding protein)
and may also be a reflection of the acute phase
response and do not accurately represent
nutritional status
Improvement in hepatic protein levels indicate
recovery, although not necessarily nutritional
recovery

Slide 10

Stimuli for Stress Response

Loss of blood volume


Emotion/pain/fear
Temperature
Infection
Tissue injury

Slide 11

Goals of Stress Response


Maintain energy substrates (GLUCOSE)
Maintain oxygen delivery
Minimize further injury...

Slide 12

Slide 13

Greenfield
1997

Response to Stress/Injury
Neurohormonal - "Counterregulatory hormones"
Glucagon
Epinephrine
Glucocorticoids

Inflammatory mediators
IL-1, IL-2, IL-6
TNF-a
IFN-g

Slide 14

Metabolic Response During Sepsis


Carbohydrate Metabolism
Pro-inflammatory cytokines potentiate the release of
catabolic hormones (glucagon, catecholamines, and
cortisol) stimulating glycogenolysis and gluconeogenesis
to mobilize glucose
Following the onset of sepsis, glycogen stores are
depleted within hours, and endogenous lipid and protein
become the major source of oxidative energy substrate
As sepsis progresses, reduced splanchic blood flow and
severe hepatic dysfunction eventually lead to
hypoglycemia and decreased glucose production
Slide 15

Metabolic Response During Sepsis


Protein Metabolism
Amino acids released from skeletal muscle breakdown,
connective tissue, and unstimulated gut are shunted to
the liver, where they are used in gluconeogenesis and
for the synthesis of acute-phase reactants
The ureagenesis rate is increased, as well as the
synthesis rates of creatinine, uric acid, and ammonia
all get excreted in the urine
In an unfed, stressed patient, up to 250 g of lean body
mass will be broken down each day
The nitrogen loss of severe sepsis complicating recovery
from trauma may exceed 30g/d
Adequate nutrition support will not completely ablate the
catabolic effects and response
Slide 16

Greenfield
1997
Slide 17

Metabolic Response During Sepsis


Lipid Metabolism
Lipolysis under catecholamine regulation
In early sepsis, catabolic hormones outweigh the effects
of anabolic hormones such as insulin and result in the
breakdown of stored triglycerides to glycerol and free
fatty acids affecting intracellular transport metabolism
Sepsis impairs ketogenesis and the activity of lipoprotein
lipase is suppressed
Hyperlipidemia, hyperglycemia, hyperlactatemia, and
high levels of circulating -hydroxybutyrate often are
present in severe sepsis
Slide 18

Metabolic Needs - How Much?

Assessment of metabolic rate is an integral part of the nutrition care


of the ICU patient
Validity of multiple equations in this population has not been
systematically evaluated
Metabolic rate can be gauged by 3 methods:
Indirect calorimetry (gold standard)
Pulmonary artery catheter measurements using the Fick equation
VO=cardiac output X 10 (CaO-CvO) where VO is oxygen
consumption in mL/min, cardiac output is in L/min, CaO is
concentration of oxygen in arterial blood (mL/dL), and CvO is
concentration of oxygen in mixed venous blood (mL/dL)
Can be estimated using several predictive equations based on body
size, degree of injury/illness, or degree of inflammatory response

Given the limitations on the availability of indirect calorimetery,


predictive equations are the mainstay of energy expenditure
assessment in the ICU
Slide 19

Ideal Body Weight (IBW)


The Hamwi Method
Adult females
100 lb (45kg) for the first 60 inches (152 cm) + 5 lbs
(2.3 kg) for every inch > 60
Ex: Ht. 54 (165.1 cm) = IBW of 120 lb or 54.5 kg)

Adult males
106 lb (48 kg) for the first 60 inches (152 cm) = 6 lbs
(2.7 kg for every inch > 60
Ex: Ht. 510 (180.3 cm) = IBW of 166 lb or 75.4 kg)

Slide 20

Evaluation of Body Weight Data

Body Mass Index (BMI) - a weight-stature index, is use both as a


measure of obesity and malnutrition.
BMI = Weight (kg) Height (m)
Interpretation of BMI:

18.5 25 Normal weight


25-29.9 Overweight
30-34.9 Obesity grade I
35-39.9 Obesity II
40 Obesity grade III
17-18.4 Protein-energy malnutrition grade I
16-16.9 Protein-energy malnutrition grade II
<16 Protein-energy malnutrition grade III

Individual variation is large so patients should not be misclassified


as undernourished or obese using BMI alone
Slide 21

Goal Calculations - Harris-Benedict Equation

Estimates Basal Energy Expenditure (BEE):


Male BEE = 66 + (13.7 x Wt) + (5 x Ht) - (6.8 x age)
Female BEE = 665 + (9.6 x Wt) + (1.8 x Ht) - (4.7 x age)
Weight (Wt) in kilograms; Height (Ht) in centimeters
BEE X Stress Factor (see below); this prediction method can overestimate
or underestimate true resting metabolic rate and may be too unreliable for
clinical use in the ICU

Conditions

Energy Requirement

~ Kcal/kg/day

~Protein gm/kg/day

Elective Surgery

1.00-1.25 x BEE

25-30

1.0-1.2

Multiple Trauma

1.25-1.5 x BEE

25-35

1.4-1.5

Sepsis/Peritonitis

1.5 x BEE

25-35

1.4-2.0

1.75-2.0 x BEE

35-40

1.8-2.5

Massive Burns >50% TBSA

Slide 22

Goal Calculations Ireton-Jones


Equation 1992 vs 1997 Version
Developed for intubated patients

RMR=(W x 5) (A x 10) + (S x 281) + (T x 292) + (B x 851) +1925


for total calorie prescription where:

A=age
W=wt in kg
S=sex (1=male, 0=female)
T=trauma (1=yes, 0=no)
B=burns (1= yes, 0 = no)
(This is the 1992 version)

The corrected 1997 version of this equation does


not perform as well as the 1992 version and is not
recommended for use
Slide 23

Goal Calculations Critically Obese


Permissive underfeeding or hypocaloric feeding
is recommended
CALORIES: When BMI is >30 provide 11-14
kcal/kg ACTUAL body weight/day or 22-25
kcal/kg ideal body weight per day
PROTEIN: When BMI is 30-40, provide 2.0
g/kg/ideal body weight per day and if BMI is 40,
provide 2.5 g/kg ideal body weight per day
Choban PS. Nutr Clin Pract. 2005;20:480-487.
Slide 24

Nitrogen Balance
Used to reflect the balance between exogenous nitrogen
intake and renal removal of nitrogen-containing
compounds through stool, urine, skin, fistulas, wounds,
etc.
Measurement of nitrogen balance is most accurate in
patient who receive a defined nutrient intake such as is
in the case in those receiving enteral or parenteral
nutrition
Urea nitrogen urine concentration increases dramatically
in the sickest of patients reflecting catabolism of protein
associated with systemic inflammation
Slide 25

Slide 26

Greenfield 1997

Calculating Nitrogen Balance

UUN excretion may differ from 3 to 5 grams

Slide 27

Problems With UUN


UUN will be invalid if creatinine clearance is <50 mL/min
One cannot assume that moving nitrogen in a positive
direction always means that protein catabolism has
decreased, particularly in inflammatory (disease and
trauma) conditions
Valid 24-hour urine collections are difficult to obtain
Alterations in renal function frequently occur in patient
with inflammatory metabolism, making standard nitrogen
balance calculations inaccurate
Slide 28

Metabolic Cart / Indirect


Calorimetry
Measurement of O2 consumption (VO2) and
CO2 production (VCO2) by a metabolic cart to
allow for a Measured Resting Energy
Expenditure (MREE) and Respiratory Quotient
(RQ) (VCO2/VO2)
RQ or respiratory quotient interpretation

0.6-0.7 starvation/underfeeding
0.84-0.86 desired range/mixed fuel utilization
0.9-1.0 carbohydrate metabolism
1.0+ overfeeding / lipogenesis
Slide 29

Clinical Indications for Indirect


Calorimetry
Factors causing predictive equations to be inaccurate
(ARDS, large open wounds or burns, MSOF, sepsis,
SIRS, ascites, multiple trauma, use of paralytic or
barbiturate agents, and malnutrition with altered body
composition like obesity or limb amputations)
When patients fail to respond to nutrition support based
on predictive equations during their clinical course (poor
wound healing, failure to wean from vent and protein
malnutrition) despite adequate support
To evaluate whether under- or overfeeding is contributing
to metabolic and respiratory derangements in ICU
patients
Slide 30

Technical Factors Decreasing


Indirect Calorimetry Accuracy
Mechanical ventilation with FIO 60
Mechanical ventilation with Positive End Expiratory
Pressure (PEEP) >12 cm H2O
Leak in the sampling system
Moisture in the system can affect the oxygen analyzer
Inability to collect all expired gases (leaking CTs or
broncho-pleural fistula)
Supplemental O2 in spontaneously breathing patient
Dialysis or continuous renal replacement therapy in
progress
Errors in calibration of indirect calorimeter
Wooley JA. Nutr Clin Pract. 2003;18:434-439.
Slide 31

Enteral vs. Parenteral?


Several studies have compared each mode of therapy
Traditionally its been said: Enteral is BETTER and If
the gut works, use it
Earlier studies did not adjust for overfeeding and various rates
of hyperglycemia increasing infectious complications
Earlier meta-analyses failed to show benefit of TPN over EN

PN use safer today with NST availability and tighter


glucose control decreasing overall infectious
complications
Bistrian BR. Crit Care Med 2006;34:1525-1531
Slide 32

Enteral vs. Parenteral?


Use the GI tract whenever possible
Contraindications to GI feeds

Bowel obstruction / prolonged ileus > 7 day


High output fistula > 500 mL/d
Bowel ischemia
Intractable vomiting or diarrhea
Severe GI bleeding
Conditions precluding feeding tube placement (i.e. esophageal
tumor or tear)
Acute exacerbation of IBD with PO intolerance (malnutrition +
bowel rest > 7 days)
Failure of high risk, hypermetabolic patient to tolerate TF trials
Slide 33

ICU Enternal Feeding Algorithm

Slide 34

Nutrition Support Protocol For


Mechanically Vented Patients
Developed by multidisciplinary team approach

Timing of enteral nutrition


Identify high risk patients
Identify malnourished patients
Progression to minimal enteral nutrition goals (80%)
Monitor gastric residuals
Use of prokinetic agents or surgically placed jejeunal
tubes with gastric intolerance
Mackensiz SL. JPEN 2005;29(2):74-80

Slide 35

Results of Nutrition Support Protocol


in Mechanically Vented Patients
Percentage of patients receiving 80% of
nutritional goals rose from 20% to 60%
(p<0.001)
Goal achieved in just 5 days
TPN use declined from 13% to 1.6% (p<0.02)
Significant increase in delivered calories
No data on the effect on outcome
Mackensiz SL. JPEN 2005;29(2):74-80

Slide 36

Early Nutritional Support in the


Mechanically Vented Patient

4,049 ventilated (>2 days) patients were studied


2,537 (63%) labeled Early Feeding (<48 hours)
1,512 (37%) labeled Late Feeding Group
Patients with contraindication to enteral diet
were excluded
Control for disease severity using separate
models with:
APACHE II, SAPS II, MPM-0

Retrospective multi-institutional study


Artinian V, et al; Chest 2006;129(4):960-967
Slide 37

Effect of Early Feeding in Ventilated


Patients
Early

Late
Feeding

ICU Mortality

18.10%

21.40%

0.01

Hospital Mortality

28.70%

33.90%

0.001

ICU Length of Stay

10.9 8.1

10.2 7.7

NS

~58%

~52%

0.001

Outcomes

Survival (vented over 30 days)

p Value

Artinian V, et al; Chest 2006;129(4):960-967

Slide 38

Timing of Enteral Feeds


Many studies claim benefits to early EN
Meta-analysis that looked at 27 randomized,
prospective studies
Early EN had lower infections (RR 0.45)
Early EN had shorter LOS (2.2 days)
Marik PE, Zaloga GP. Crit Care Med. 2001;29:2264-2270

Slide 39

How Nutrition Support Goals Have


Shifted in the ICU
Goals have become more focused on nutrition
therapy
1. Attempt to attenuate the metabolic response to
stress
2. Prevent oxidative cellular injury
3. Modulate the immune response
Aim for early enteral nutrition, appropriate
macronutrient and micronutrient delivery and
meticulous glycemic control
Slide 40

Where to start?!
Determine number of calories needed
Use predetermined feeding weight whether actual, ideal,
adjusted or usual body weight first
Utilize predictive equations, indirect calorimetry

Determine normal or increased protein needs


Severity of injury, presence of wounds, fistulas, burns

Determine if contraindication to fats


Sepsis, hemodynamic instability, hypertriglyceridemia

Determine fluid needs


Determine mode of nutrition => use the GI tract
whenever feasible
Slide 41

ICU Nutrition Guidelines


Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient: Society of Critical Care
Medicine and American Society for Parenteral and Enteral Nutrition:
Executive Summary
Robert G. Martindale, MD, PhD; Stephen A. McClave, MD; Vincent W. Vanek, MD;
Mary McCarthy, RN, PhD;Pamela Roberts, MD; Beth Taylor, RD; Juan B. Ochoa,
MD; Lena Napolitano, MD; GailCresci, RD; American College of Critical Care
Medicine; and the A.S.P.E.N. Board of Directors
Crit Care Med 2009;37(5):1757-1761
JPEN 2009;33(3):277-316
Guidelines developed that provided recommendations supported by review and analysis of the
pertinent available current literature up to May 2008, by other national and international
guidelines, and by the blend of expert opinion and clinical practicality. A grading system was
used to help determine the level of evidence to support these recommendations.
Slide 42

Grading System Used for the


Guidelines
Grade of recommendation

A. Supported by at least two level I investigations


B. Supported by one level I investigation
C. Supported by level II investigations only
D. Supported by at least two level III investigations
E. Supported by level IV or level V evidence

Level of evidence
Large, randomized trials with clear-cut results; low risk of falsepositive (alpha) error or false-negative (beta) error
Small, randomized trials with uncertain results; moderate to high
risk of false-positive (alpha) and/or false-negative (beta) error
Slide 43

Grading System Used for the


Guidelines
Nonrandomized, contemporaneous controls
Nonrandomized, historical controls
Case series, uncontrolled studies, and expert opinion

Large studies warranting level I evidence were defined


as those with 100 patients or those which fulfilled end
point criteria predetermined by power analysis. Metaanalyses were used to organize information and to draw
conclusions about overall treatment effect from multiple
studies on a particular subject. The grade of
recommendation, however, was based on the level of
evidence of the individual studies.
Dellinger RP. Crit Care Med. 2004;32(11)(suppl):S446
Slide 44

Guidelines: Enteral Feeding


Enteral Nutrition (EN) is the preferred route of feeding
over parenteral nutrition (PN) (Grade B)
EN should be started early within the first 24-48 hours
following admission (Grade C) and feedings should be
advanced toward goal over the next 48-72 hours (Grade
E)
EN should be withheld until the patient is fully
resuscitated and/or hemodynamically stable (Grade E)
Neither presence nor absence of bowel sounds, flatus,
and stool is required for the initiation of EN (Grade B)
Either gastric or small bowel feeding is acceptable
(Grade C)
Slide 45

Guidelines: When to Use


Parenteral Nutrition
If early EN is not feasible or available over the first 7
days following admission to the ICU, no nutrition support
(standard therapy) should be provided (Grade C)
If there is evidence of protein-calorie malnutrition at
admission and EN is not feasible, it is appropriate to
initiate PN as soon as possible following admission and
adequate resuscitation (Grade C)
If a patient is expected to undergo major upper GI
surgery and EN is not feasible, provide PN when:
Patient is malnourished. Initiate PN 5-7 days preoperatively and
continue into the postoperative period (Grade B)
The duration of therapy is anticipated to be 7 days (Grade B)
Slide 46

Guidelines: Dosing of Enteral


Feeding

The target goal of EN (defined by energy requirements) should be


determined and clearly identified at the time of initiation of nutrition
support therapy (Grade C)
Efforts to provide > 50%-65% of goal calories should be made to
achieve the clinical benefit of EN over the first week of
hospitalization (Grade C)
Initiating supplemental PN before 7-10 days when unable to meet
energy requirements with EN alone does not improve outcome and
may be detrimental to the patient (Grade C)
In patients with BMI <30, protein requirements should be in the
range of 1.2-2.0 g/kg/d actual body weight (Grade E)
Critically ill obese patients with BMI >30, give 11-14 kcal/kg actual
body weight/day or 22-25 kcal/kg IBW/d. Protein should be provided
in a range of 2.0 g/kg IBW/d for BMI 30-40 and 2.5 g/kg IBW/d for
BMI 40 (Grade D)
Slide 47

Guidelines: Selection of Appropriate


Enteral Formula
Immune-modulating formulations containing
arginine, glutamine, nucleic acid, omega-3 fatty
acids and antioxidants should be used for major
elective surgery, trauma, burns, head and neck
cancer, and critically ill patients on vents. Be
cautious with severe sepsis for SICU patients
(Grade A) and MICU patients (Grade B).
Patients with ARDS and severe acute lung injury
should receive a formula containing an antiinflammatory lipid profile containing omega-3
fish oils, borage oil and antioxidants (Grade A)
Slide 48

What is Immunonutrition (IMN)?


The term given to describe special enteral feeds
containing:

Arginine
Omega-3 fatty acids
Nucleotides
+ / - Glutamine
Antioxidants

Slide 49

Organs of the Immune System

Slide 50

Immunonutrition

Glutamine Most abundant AA in plasma and skeletal muscle; nonessential, but may be conditionally essential during catabolic stress. Has
shown to be of benefit in burn, and trauma patients, but evidence is lacking
in other critically ill patients.
Arginine conditionally essential amino acid thought to enhance the
depressed immune responses associated with trauma, sepsis, or
malnutrition.
Nucleotides precursor of DNA and RNA that are necessary for most cell
functions, including protein synthesis. Demands during catabolic stress may
exceed production.
Omega-3 FAs fish oil with beneficial effects in septic patients, including
modulating of leukocyte function and regulation of cytokine release through
nuclear signaling and gene expression. The enhance the production of
prostaglandin derivatives which play a role in accelerating the resolution of
the pro-inflammatory state. IV omega-3 fatty acids are currently unavailable
in parenteral emulsions in the United States.
Antioxidants thought to be of some benefit in severely stressed and septic
patients, but exact amounts and combinations have yet to be determined for
this population
Slide 51

What Is An Appropriate
Gastric Residual Volume (GRV)?
Threshold level of GRV tolerated by clinicians is
of great debate!
No clinical significance of GRV < 200 ml
Stomach is a distensible container in which GRV
measurements dont account for
Aspiration of TFs is associated with a low morbidity
and an even lower mortality risk
Patients with high GRV >400 ml or who demonstrate
GI intolerance => consider NJT

Slide 52

EN Associated Bowel Necrosis


Considered a very RARE complication < 1%
Most often reported with SB feeds
Exact cause is unclear - ? related to mucosal
perfusion, underlying bowel injury, excessive
vasoconstriction or bacterial toxins
No prospective randomized studies for TFs w/
hypotension

Slide 53

Hemodynamic Instability
High risk guidelines for a hypoperfused GI
tract:

FiO2 >60
PEEP >5
Mean Arterial Pressure 75 mmHg
? high dose pressors

Levophed >8 mcg/min


Neosynephrine >40 mcg/min
Dopamine >15 mcg/kg/min
Slide 54

Recommendations For Feeding


The Hypotensive Patient
Hold feeds in hypotension:

Initiating pressor therapy


Increasing dose of pressors
Adding a second or third agent
Lactic acidosis

OK to feed in hypotension on pressors:


Stable (24-48 hrs) or ing doses
MAP 75 mm/hg
Avoid fiber; stomach may be better than SB

Hold feeds (on pressors) for any sign of intolerance:

NG output increases
New abdominal pain
Abdominal distention
Cessation of flatus, stool
Slide 55

Refeeding Syndrome
Metabolic response caused by either enteral or
parenteral nutrition
Shift from stored body fat to CHO as primary fuel after
prolonged NPO status
Feeding causes insulin levels to rise creating intracellular
movement of electrolytes
Mg, K, PO4 levels may fall; can lead to arrhythmias,
respiratory and cardiac failure, and death
Prevention and therapy:
Correct electrolyte abnormalities BEFORE initiating nutrition
support, avoid overfeeding, and provide appropriate vitamin
supplementation
Slide 56

Basic Parenteral Nutrition Calculations

Amino Acids
Dextrose
Fat
10% Lipids
20% Lipids
30% Lipids

4 kcal / g
3.4 kcal / g
10 kcals / g
1.1 kcal / mL
2 kcal / mL
3 kcal / mL

Slide 57

Basic Parenteral Nutrition Calculations

Amino Acids
Dextrose
Lipids
Total Volume

4%
15%
2%
2000 mL

Grams AA = 4 grams X 2000 mL = 80 g X 4 kcal/g = 320 kcal


100 mL
Grams CHO = 15 grams X 2000 mL = 300 g X 3.4 kcal/g = 1020 kcal
100 mL
Grams Lipid = 2 grams X 2000 mL = 40 g X 10 kcal/g = 400 kcal
100 mL

TOTAL CALORIES = 1740


Slide 58

Parenteral Nutrition Formulation


Additives
Vitamins
Folate, Thiamine, Vitamin C, Zinc, Vitamin B12

Trace Elements
Chromium, Copper, Zinc, Manganese, Selenium, Iron

Electrolytes
Usually in the form of NaCl, NaAc, NaPO4, KCL, KAc,
KPO4, MgSO4, CaGluc

Miscellaneous
H2 blockers, Heparin, Insulin, Glutamine
Slide 59

When Initiating PN Therapy

CHO* - Start conservatively with 100-150 grams of dextrose per day


advancing only when electrolytes and blood sugars are stable and repleted.

Protein* - Amino acids should be limited initially to 1-1.2 gm/kg feeding


weight due to their potential refeeding effects.

Lipids** Limit to ~1 gm/kg/d. Soy-based lipids have been shown to be


immunosuppressive with proinflammatory characteristics so may have some
benefit to withhold lipids or use with caution for the first 7 days in the ICU.
Keep in mind that Propofol, is lipid based, and provides 1.1 kcal/mL.

*Patients should be monitored closely for refeeding syndrome for the first week
of PN therapy.
**Essential Fatty Acid Deficiency (EFAD) may develop when no source of fatty
acid is supplied for > 14 days. Minimum lipid requirements to prevent EFAD
is 500 mL of a 20% fat emulsion (100 grams) over 24 hours given once a
week
Slide 60

Overfeeding Consequences - 1
Azotemia Patients >65 years and patients given >2 gm/kg
protein are at risk.
Fat-overload syndrome Recommended maximum is 1 gm
lipid/kg/d. Infuse IV lipid slowly over 24 hours.
Hepatic steatosis Patients receiving chronic highcarbohydrate, very low fat TPN are at risk.
Hypercapnia Makes weaning difficult.
Hyperglycemia Increases risk of infection. Intake should
not exceed 5 mg CHO/kg/min (4 mg/kg/min for diabetics).
Slide 61

Overfeeding Consequences - 2
Hypertonic dehydration Can be caused by
high-protein formula with inadequate fluid
provision.
Hypertriglyceridemia Propofol, high TPN lipid
loads, and sepsis increase the risk. If the
patient is hypertriglyceridemic, decrease lipid to
an amount to prevent EFAD and monitor.

Slide 62

Consequences of Overfeeding-3
Metabolic acidosis Patients receiving low
ratios of energy to nitrogen are at risk. Acidosis
can cause muscle catabolism and negative
nitrogen balance.
Refeeding syndrome Common in
malnourished patients or those held NPO prior
to initiation of feeding. Start feedings
conservatively, advance gradually, and monitor
Mg, Ph, and K closely.
Slide 63

Intensive Insulin Therapy


in the Critically Ill
PRCT, SICU ventilated pts (n=1548)
Intensive insulin therapy (BG 80-110mg/dl)
versus SSI (BG>215 mg/dl)
Results
5 day ICU stay (10 vs 20%)
Hospital mortality x 34%
Blood infections x 46%
ARF requiring therapy x 41%
Van den Berghe G, et al. N. Engl J Med 001;345:1359-1367
Slide 64

Intensive Glycemic Control and


Survival in SICU Patients
100

Intensive treatment

96
92

Conventional treatment
ONLY REACHED
SIGNIFICANCE for patients
in the SICU for
5 days or longer

88

42.5% reduction in
mortality with
intensive treatment;
P<.04

84
80
0

20 40 60 80 100 120 140


160
Days After

A
Admission

In-Hospital Survival (%)

Survival in ICU (%)

100

96

Intensive treatment

92
Conventional treatment

88

34% reduction in
mortality with
intensive treatment;
P<.01

84
80
0

50

100

B
Days
250 After
Admission
Slide 65

Van den Berghe G et al. N Engl J Med. 2001;345:1359-1367.

150

200

Not so NICE (study) to follow


Hypothesis: There is no difference in the relative risk of death between
patient assigned a glucose range of 4.5 6.0 mmol/L (81-108 mg/dl) and
those assigned a glucose range of 10.0 mmol/L, or less (180 mg/dl, or
less). The primary end point would be defined as death from any cause
within 90 days after randomization.

International multi-center
6104 ICU patients were randomized
Conventional insulin group (n = 3054 assigned => 3010 after 90 days)
Maintain 80-110 mg/dL
Intensive insulin group (n = 3050 assigned => 3012 after 90 days)
Maintain < 180 mg/dL
The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-97
Slide 66

NICE-SUGAR RESULTS
No difference

ICU LOS
Hospital LOS
Ventilator days
Renal replacement
therapy

The NICE study showed no difference in ICU


length of stay, hospital length of stay, days on
the ventilator or need for renal replacement
therapy. There was a significant incidence of
severe hypoglycemia in the intensive therapy
group combined with an increase in mortality of
27.5% vs 24.9% in the conventionally treated
group.

Severe hypoglycemia
Conventional insulin group 0.5%
Intensive insulin group 6.8%

90-day mortality
in conventional insulin group
Slide 67

Insulin Study Discrepancies


Van den Berghe
Majority PN
Did not account exact
amount of EN
Majority CV surgery

NICE-SUGAR
> 70% nutrition received
from EN
Larger sample size
Mixed medical / surgical

Slide 68

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Slide 69

References

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References

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