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Bridging the Guideline-Practice Gap: The Critical Care Experience
Rupinder Dhaliwal, RD
Daren Heyland, MD
Guidelines for Nutrition Therapy in the ICU
Rupinder Dhaliwal, RD
Operations Manager
Clinical Evaluation Research Unit
Kingston, Ontario
Disclosure
Canadian Clinical Practice Guidelines for Nutrition Support for the Mechanically Ventilated Critically ill• Co-Author
Rupinder Dhaliwal
Critical Care Nutrition
The right nutrient/nutritional strategyThe right timingThe right patientThe right intensity (dose/duration)With the right outcome!
www.criticalcarenutrition.com
www.criticalcarenutrition.com
A Continuous Quality Improvement Effort
What is done?
What ought to be done?
What do we need to do differently?
“Gaps” - site reports
How to change? “KT strategies”
RCTs, Systematic Reviews, and Evidence-based practice guidelines
Survey resultswww.criticalcarenutrition.comWhat is done?
To identify the similarities and the differences between the recommendations of three North American Clinical Practice Guidelines
Understand why these differences occur
Need for harmonization across guidelines
Objectives
Why bother with 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
The more guidelines they publish, the more confused I get!
Review of guidelines needed
A review of the content and the evidence used to formulate the
recommendations
What is neededAssesses the process of development
Which Guidelines to compare?
Critically ill populations
Developed by North American professional/national organization
Published/online 1999-2009
Addressed more than one single topic
Were not consensus statements (i.e. immunonutrition )
Were original work vs. part of cluster RCTs
• Population
• Levels of Evidence
• Grading used
• Time frames, outcomes
• Level of transparency between evidence and recommendation
What differences?
Differences Area Canadian ADA ASPEN/SCCM
Population Mechanically ventilated critically ill patients
no elective surgery
Critically ill patients eligible for 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 (2009)
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 CPGsRigor 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 CPGAGREE 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: recommendations
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 EN/Achieving target range
Differences: recommendations
Canadian ADA ASPEN/SCCM
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
Differences: recommendations
Canadian ADA ASPEN/SCCM
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
Differences: recommendations
Canadian ADA ASPEN/SCCM
Recommend NOT be used
Meta-analyses of 22 RCTs3 RCTs harm(Bower. Bertolini, Dent)
FairNot be used
11 RCTs2 RCTS harm(Bower, Bertolini)
Grade A SurgicalGrade B MedicalCautious in severe sepsisVolume use 50-65% goal
earlier meta-analyses showing no benefitRCT showing benefit (Galban)
Grade A: based on elective surgery patients
Enteral Glutamine
Differences: recommendations
Canadian ADA ASPEN/SCCM
Burns & Trauma: Should be considered
Other ICU: Insufficient data
9 RCTS
-------- Grade B
Burns, Trauma and mixed ICU patients
1 RCT (Jones mixed ICU pts)
Peptides
Differences: recommendations
Canadian ADA ASPEN/SCCM
Recommendpolymeric (since no benefit for peptides)
4 RCTs
---------Grade E Use small peptides in diarrhea
1 non RCT
Fibre
Differences: recommendations
Canadian ADA ASPEN/SCCM
Insufficient data
6 RCTs
---------Grade E Use soluble fibre3 RCTs
Grade CAvoid soluble and insoluble fibre for bowel ischemia/severe dysmotility
2 non RCTs (review, case study)
Probiotics
Differences: recommendations
Canadian ADA ASPEN/SCCM
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 (elective sx)
Intensive Insulin Therapy
Differences: recommendations
Canadian ADA ASPEN/SCCM
RecommendTarget around 144 mg/dl (8.0 mmol/L)
Range 120-160 mg/dL(7-9 mmol/L)
Keep < 180 mg/dL (10 mmol/L) in all
Most recent meta- analyses includes NICE SUGAR
Strong Medical: 80-110 mg/dL (4.4-6.1 mmol/L)
BEING UPDATED 2009
Grade BModerate strict control
Grade E110-150 mg/dL(6.1-8.3 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 strength
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 used until strategies to maximize EN adoptedASPEN/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: not enough RCTs so tendency to make a recommendation
– Time frames of literature searches and updates
– Recommendations: due to interpretation of the evidence, lack of transparency
Similarities in many of the recommendations
Conclusions
Similarities should be adopted without hesitation
Differences
Define critically ill patient
Transparency needed (websites)
Harmonize between societies
Practitioner: right recommendation for the right person
Implications
JPEN Nov 2010:625-643
Ahhh…..Harmonized Guidelines!
Thank You!
