Nutrition Supports/Final.60.PaulWong.9.13.pdfa) Critically ill patients generally have decreased metabolic needs and do not require specialized nutrition support therapy b) Increases

Nutrition SupportA Review of Updated Guideline Recommendations

Paul Wong, PharmD, BCCCPCritical Care Clinical Pharmacist

Cedars-Sinai Medical [email protected]

mailto:[email protected]

The author of this presentation has no conflicts of interest to disclose.

Disclosure

• Describe the role of nutrition therapy in the management of critically ill patients

• Highlight changes made from the 2009 to the 2016 ASPEN/SCCM Nutrition Support Guidelines

• Discuss recent literature supporting guideline changes

• Incorporate updated guideline recommendations into routine care

Learning Objectives

Which of the following statements is true regarding the metabolic state of critically ill patients?

a) Critically ill patients generally have decreased metabolic needs and do not require specialized nutrition support therapy

b) Increases in inflammatory mediators during critical illness stimulate lipolysis, requiring fat supplementation

c) Metabolic demands do not change in critical illness and no specialized nutrition therapy is required

d) Critically ill patients are hypermetabolic and may require specialized nutrition therapy to meet these increased needs

Test Question #1

The SCCM/ASPEN Guidelines include all except which of the following recommendations regarding nutrition support in the critically ill patient?

a) Feeding via the enteral route is preferred over the parenteral route.

b) Enteral nutrition should routinely be supplemented with parenteral nutrition in all patients when nutrition support is initiated.

c) Exclusive parenteral nutrition should be held in patients at low nutrition risk during the first week of hospitalization.

d) Enteral nutrition should be started within 24-48 hours of admission in patients at high nutrition risk and unable to maintain volitional intake.

Test Question #2

Which of the following is the correct statement regarding gastric residual volumes?

a) Gastric residual volumes should be routinely monitored in all patients receiving enteral nutrition.

b) Gastric residual volumes should be routinely monitored and enteral nutrition should be immediately held for a gastric residual volume >100 mL over 4 hours.

c) Gastric residual volumes may be monitored and a gastric residual volume of >250 mL over 4 hours should raise concern.

d) Gastric residual volumes do not need to be routinely monitored in patients receiving enteral nutrition.

Test Question #3

• Committee of physicians, nurses, pharmacists, and dieticians addressing key clinical questions in nutrition therapy

• Reviewed literature through December 31, 2013◦ Randomized controlled trials (RCTs) were given preference

◦ Included nonrandomized cohort trials, prospective observational trials, and retrospective case series

◦ In absence of RCTs and observational studies, recommendations made on expert consensus

Formulating the Guidelines

Taylor BE, et al. Crit Care Med 2016;44:390-438.

Grading Recommendations2016 Guidelines

• GRADE system◦ High (H)

◦ Moderate (M)

◦ Low (L)

◦ Very Low (VL)

• RCTs and observational studies have High and Low GRADEs, respectively◦ Can be downgraded through Very Low

• Expert consensus (E) where evidence is limited

2009 Guidelines

• Grade of recommendation◦ A through E based on amount and quality of

literature available

• Level of evidence◦ I: large RCTs with clear results

◦ II: small RCTs with uncertain results

◦ III: nonrandomized, contemporaneous controls

◦ IV: nonrandomized, historical controls

◦ V: case series, uncontrolled studies, expert opinion

McClave SA, et al. J Parenter Enteral Nutr 2009; 33:277-316.Taylor BE, et al. Crit Care Med 2016;44:390-438.

Bundle Statements

• Assess patients on admission to the ICU for nutrition risk, and calculate both energy and protein requirements to determine goals of nutrition therapy.

• Initiate enteral nutrition (EN) within 24-48 hours following onset of critical illness and admission to the ICU and increase to goal over the first week of ICU stay.

• Take steps as needed to reduce the risk of aspiration or improve tolerance to gastric feeding.

Bundle Statements


• Implement enteral feeding protocols with institution-specific strategies to promote delivery of EN.

• Do not use gastric residual volumes as part of routine care to monitor ICU patients on EN.

• Start parenteral nutrition (PN) early when EN is not feasible or sufficient in high-risk or poorly nourished patients.

Bundle Statements


AA is a 54 year old male with a history of diabetes and HTN who presents with fevers, nausea, and abdominal pain. He is found to have a perforated appendix and is taken to the OR for an open appendectomy.

Post-operatively, the patient returns to the ICU intubated and NPO. During rounds, the patient fails to meet extubation criteria. The team asks, “What should we do for his nutrition?”

Patient Case

Assessment of Nutritional Requirements

• Acute critical illness associated with increase in metabolic demands

• Nutrition support provides means to meet the catabolic needs, prevent oxidative injury, and modulate immune response◦ Nutrition support is the enteral or parenteral provision of calories, protein,

electrolytes, minerals, vitamins, and fluid

• Delivery of early, appropriate nutrition therapy improves clinical outcomes

Importance of Nutrition


Nutritional Assessment

• Assess patients on admission to the ICU for nutrition risk◦ Determine nutrition risk using validated tools such as the Nutritional Risk

Score [NRS-2002] or NUTRIC score. High nutrition risk patients are most likely to benefit from early EN (E)◦ Both NUTRIC and NRS-2002 developed from retrospective data

◦ Validated in prospective trials

• Suggest against traditional nutrition indicators or surrogate markers, as they are not validated in critical care (E)

• Evaluate comorbid conditions, function of gastrointestinal (GI) tract, and risk of aspiration (E)

McClave SA, et al. J Parenter Enteral Nutr 2009; 33:277-316.Taylor BE, et al. Crit Care Med 2016;44:390-438.

NUTRIC ScoreVariable Range Points

Age <50 0

50 – 74 1

≥75 2

APACHE II <15 0

15 – 19 1

20 – 27 2

≥28 3

Heyland DK, et al. Crit Care 2011; 15:R268.

• NUTRIC score of 6 – 10 considered high risk◦ IL-6 shown to contribute minimally to prognostic value of score

◦ High risk score 5 – 9

NUTRIC ScoreVariable Range Points

SOFA <6 0

6 – 9 1

≥10 2

# of Comorbidities 0 – 1 0

≥2 1

Days from hospital to ICU admission

0 0

≥1 1

IL-6 0 – 399 0

≥400 1

NRS-2002Initial Screening Questions Present?

Is BMI < 20.5 kg/m2?Has the patient lost weight within the last 3 months?Has the patient had a reduced dietary intake in the last week?Is the patient severely ill?

Impaired Nutritional Status ScoreNormal nutritional status 0Wt loss >5% in 3 months or food intake 50-75% of normal requirement in

preceding week1

Wt loss >5% in 2 months or BMI 18.5 – 20.5 + impaired general condition or food intake 25-60% of normal requirement in preceding week

2

Wt loss >5% in 1 months (>15% in 3 months) or BMI <18.5 + impaired general condition or food intake 0-25% of normal requirement in preceding week

3

Severity of Disease ScoreNormal nutritional requirements 0Hip fracture; chronic hemodialysis; diabetes; oncology; chronic patients, in

particular with acute complications: cirrhosis, chronic obstructive pulmonary disease.

1

Major abdominal surgery, stroke, severe pneumonia, hematologic malignancy

2

Head injury, bone marrow transplant, ICU patients (APACHE II >10) 3

•Sum scores from nutritional status and disease severity •Add 1 point to total score if age ≥70

• Scores of ≥3 indicate nutritional risk and warrant specialized nutrition plan

Kondrup J, et al. Clin Nutr 2003; 22:415-21.

Traditional Biomarkers


Biomarker Normal Rangea Half-Life LimitationsAlbumin 3.5 – 5.5 g/dL 20 days • Negative acute phase reactant

• Long half life• Large endogenous pool

Transferrin 225 – 420 mcg/dL 7 days • Negative acute phase reactant• Increased in iron deficiency

Prealbumin 18 – 38 mg/dL 2 days • Negative acute phase reactant• Increased in CKD

a Ranges based on CSMC laboratory; CKD = chronic kidney disease

• Calculate both energy and protein requirements to determine goals of nutrition therapy◦ Carbohydrates and lipids provide calories

◦ Fat mobilization may be impaired in critical illness

◦ Protein is important in maintaining lean body mass, supporting immune function, and healing of wounds

Nutritional Requirements


Estimating Caloric Requirements• Indirect calorimetry (IC)

◦ Measured energy expenditure (MEE) based on O2 consumption and CO2 production

• Predictive equations◦ Calculates a basal energy expenditure (BEE) based on population data (i.e. Harris-Benedict)

◦ Applicable only to specific patient populations

• Weight-based estimations◦ Needs will vary based on acuity of patient, disease state, comorbidities

• Guideline recommendations◦ Use IC, where available (VL)

◦ 25 – 30 kcal/kg/day, where IC not available (E)


Disease State Specific Caloric RequirementsPatient Population Daily Caloric Needs (ABW unless otherwise indicated)

Burna • IC, if available

Hepatic Failure • Use dry weight

Obesitya • 65 – 70% of MEE, where IC available• BMI 30 – 50 kg/m2: 11 – 14 kcal/kg/day, using ABW• BMI > 50 kg/m2: 22 – 25 kcal/kg/day, using IBW

Renal failure (acute) • 25 – 30 kcal/kg/day

Renal failure (chronic) • 25 – 30 kcal/kg/day

Sepsis or minor surgery • 25 – 30 kcal/kg/day

Severe sepsis or major surgery • 30 – 35 kcal/kg/day

Trauma • 20 – 35 kcal/kg/day

Traumatic brain injury (TBI) • 140% of BEE

Cook AM, et al. Clin Nutr Pract 2008; 23:608-20.Taylor BE, et al. Crit Care Med 2016;44:390-438.

a = expert consensusABW = actual body weight, IBW = ideal body weight

Protein Requirements

• Normal, healthy patients: 0.6 – 0.8 g/kg/day

• Critically ill patients: 1.2 – 2 g/kg/day (VL)◦ Requirements may exceed 2 g/kg/day in specific patient populations

• Nitrogen balance is a surrogate marker for protein requirements◦ Difference between nitrogen intake and loss

◦ Nitrogen intake = protein (g/day) / 6.25 (assuming protein is 16% nitrogen)

◦ Nitrogen loss = urine urea nitrogen + 4g

◦ Limited utility in the critically ill

Hoffer LJ. J Parenter Enteral Nutr 2016; 40:460-74.Taylor BE, et al. Crit Care Med 2016;44:390-438.

Disease State Specific Protein RequirementsPatient Population Daily Protein Needs (ABW unless otherwise indicated)

Burna • 1.5 – 2 g/kg/day

Hepatic failure • 1 – 1.5 g/kg/day• If encephalopathic, 0.6 – 0.8 g/kg/day

Obesitya • 2 – 2.5 g/kg/day IBW

Renal failure (acute) • 1.2 – 2 g/kg/day• Additional 0.2 g/kg/day up to 2.5 g/kg/day when on CRRT

Renal failure (chronic) • Predialysis: 0.6 – 0.8 g/kg/day• On hemodialysis: 0.8 – 1 g/kg/day

Sepsis or minor surgery • 1.2 – 1.5 g/kg/day

Severe sepsis or major surgery • 2 – 2.5 g/kg/day

Traumatic brain injuryb • 1.5 – 2.5 g/kg/day

Cook AM, et al. Clin Nutr Pract 2008; 23:608-20Taylor BE, et al. Crit Care Med 2016;44:390-438.

a = expert consensus, b = recommendations varyABW = actual body weight, IBW = ideal body weight

AA is POD1 from an open appendectomy. He fails to meet criteria for extubation and the team asks your opinion on his nutrition plan.

• Assess his nutritional risk – NUTRIC score of 5

• Patient is high risk and would benefit from nutrition therapy

How should we initiate nutrition?

Patient Case


Enteral Nutrition

• Preserves blood flow to gut, maintaining functional and structural integrity

• Supports gastric motility and regulates secretion of gastric hormones

• Stimulates release of IgA, which can generate a systemic anti-inflammatory effect

• Promotes commensal bacteria, providing a protective effect against pathogenic organisms

Benefits of Enteral Nutrition

Lewis SJ, et al. BMJ 2001; 323:773-6.McClave SA and Heyland DK. Nutr Clin Pract 2009;24:305-15.


Trial Patient Population Description Result

Lewis, et al. 2001

Elective surgery and surgical ICU patients

Meta-analysis of 11 prospective RCTs• Early aggressive feeding post-

operatively via enteral or oral routes

• Standard therapy

• Infections reduced by 28% (p = 0.036) and hospital length of stay reduced by 0.84 days (p = 0.001) in early feeding group

• Non-significant reduction in mortality• Increased risk of vomiting by 27% in early

feeding group (p = 0.046)

• Initiate EN within 24 – 48 hours in the patient unable to maintain volitional intake (VL)◦ Patients at low nutrition risk with normal baseline nutrition status and low disease

severity who cannot maintain volitional intake do not require specialized nutrition therapy over the first week of hospitalization (E)

◦ Patients at high nutrition risk or severely malnourished should be advanced towards goal over 24-48 hours with goal to provide >80% within 48-72 hours (E)

• Hold EN until patient is fully resuscitated (E)

Enteral Nutrition Recommendations


• Inconsistencies exist among the literature regarding timing of enteral nutrition relative to admission◦ Time points at 24, 36, and 48 hours after admission used to define “early”

initiation of nutrition

◦ Individual meta-analyses suggest benefits in terms of mortality, infectious morbidity, and/or hospital length of stay at these different time points

• A meta-analysis of early compared to delayed EN, using a 48 hour time point, showed decreased mortality and infectious morbidity

Timing of Enteral Nutrition


Enteral Nutrition Recommendations• Infusion should be diverted lower in

the GI tract in high aspiration risk patients or those with gastric intolerance (M to H)◦ In most patients, feeding the stomach is

acceptable (E)

• For the majority of patients, overt signs of contractility should not be required prior to initiation of EN (E)◦ GI contractility factors should still be

evaluated


Pyloric Sphincter

Monitoring Enteral Nutrition

• Monitor patients daily for EN tolerance (E)◦ Physical exams, abdominal radiographs, and clinical risk factors for aspiration can

be used

• EN should not be automatically stopped for diarrhea (E)◦ Assess cause, continuing EN throughout, until other causes of diarrhea ruled out

• Gastric residual volumes (GRVs) should not be routinely used to monitor tolerance (L)◦ Where GRVs are utilized, holding EN for GRVs <500mL in the absence of other signs

of intolerance should be avoided (L)


Gastric ResidualsTrial Patient

PopulationIntervention Result

Montejo, et al. 2010 (REGANE)

Medical/ surgical ICUpatients

Tolerable GRV set at 200 mL (control) or 500 mL (study)• All patients kept 30-45o

• Metoclopramide 10mg IV q8h given to all patients for 3 days

• No difference in GI symptoms or adverse clinical outcomes

• Increase in volume of EN received with higher GRV limit

Reignier, et al. 2013

Medical/ surgical ICUpatients

Monitoring vs. not monitoring GRVs in patients receiving EN• Monitoring group: EN held for GRV >250

mL or vomiting• Not monitoring: held only for vomiting

• Higher incidence of vomiting in intervention group (39.6% vs 27.0%)

• No difference in ventilator associated pneumonia, duration of ventilation, length of stay, or mortality

Montejo JC, et al. Intensive Care Med 2010; 36:1386-93.Reignier J, et al. JAMA 2013; 309:249-56.

AA was previously given a NUTRIC score of 5.

• He is determined to be a good candidate for early enteral nutrition. A Dobhoff tube is placed and tube feeds are started and advanced to goal.

The resident comes up to you after rounds and asks, “I thought that parenteral nutrition is better. Why aren’t we starting AA on TPN?”

Patient Case


Parenteral Nutrition

Enteral vs Parenteral Nutrition

Harvey SE, et al. N Engl J Med. 2014; 371:1673-84.Simpson F and Doig GS. Intens Care Med 2005; 31:12-23.


Trial Patient Population Description Result

Peter, et al. 2005

Mixed medical, surgical, and trauma ICU patients

Meta-analysis of 30 RCTs• Early EN vs. early PN (within 96

hours)

• Increased infectious complications (risk difference 7.9%, p = 0.001) and longer hospital LOS (1.2 days, p = 0.004) with early PN

• No effect on mortality

Simpson and Doig2005

Mixed medical, surgical, and trauma ICU patients

Meta-analysis of 11 RCTs• EN vs. PN• Included only intention to treat

• PN associated with increased infections (OR 1.66, p = 0.02), but reduced mortality (OR 0.51, p = 0.04)

Harvey, et al. 2014 (CALORIES)

Mixed medical and surgical ICU patients expected to need ≥2 days of nutrition support

Nutrition support within 36 hours of admission• EN or PN exclusively for 5 days• Targeted 25 kcal/kg/day

• No difference in 30-day mortality (RR 0.97, p = 0.57), infectious complications (mean difference 0.01, p = 0.72), or ICU length of stay (p = 0.15)

• More hypoglycemia and vomiting with EN

Enteral vs Parenteral Nutrition• Use EN rather than PN in critically ill patients who require nutrition support

therapy (L to VL)

• Conflicting evidence regarding benefits of each route relative to the other◦ Most meta-analyses seem to suggest an overall benefit of EN over PN

◦ Reduction in infectious complications

◦ Possible reduction in length of stay

◦ No change in mortality

◦ Differences in outcome arise from findings from older studies

• PN does not induce physiologic benefits of EN◦ Use of supplemental intravenous pharmaconutrients may close the gap, but clinical

evidence is lacking


• For patients at low nutrition risk, withheld exclusive PN over the first 7 days if patient cannot maintain volitional intake or if early EN is not feasible (VL)◦ Supplemental PN should be considered after 7-10 days if unable to meet >60% of

goal intake by EN alone (M)

• Patients at high nutrition risk or severely malnourished, for whom EN is not feasible, should be started on exclusive PN as soon as possible (E)◦ Hypocaloric PN (≤20 kcal/kg/day or 80% of estimated energy needs) with adequate

protein (≥1.2 g/kd/day) should be considered over the first week (L)

• Continue PN until EN meets >60% of goal intake (E)

Parenteral Nutrition Recommendations


• Optimal timing of supplemental PN is unclear and should be evaluated on a case-by-case basis

Supplemental Parenteral Nutrition

Casaer MP, et al. New Engl J Med 2011; 365:506-17.Kutsogiannis J, et al. Crit Care Med 2011; 39:2691-9.


Trial Patient Population

Description Result

Kutsogiannis, et al. 2011

Mixed medicaland surgical ICU patients

Multicenter observational study• Early EN alone• EN + early supplemental PN• EN + late supplemental PN

• PN associated with improved adequacy of calorie and protein delivery (p < 0.001)

• 60-day mortality rate higher in early PN (34.6%) and late PN (35.3%) compared to early EN (27.8%, p = 0.02)

Casaer, et al. 2011 (EPaNIC)

Mixed medicaland surgical ICU patients

Early vs. late PN• Early PN started on day 1• Late PN withheld until day 8• EN started in all patients and

advanced as tolerated

• Early PN increased ICU length of stay by 1 day (p = 0.02) and infectious complications by 3.4% (p = 0.008)

• Mortality rates similar between groups

Hypocaloric Feeding

Ahrens CL, et al. Crit Care Med 2005; 33:2507-12.McCowen KC, et al. Crit Care Med 2000; 28:2606-11.



Description Result

Ahrens, et al. 2005

Surgical and trauma patients

Hypocaloric vs. standard PN formulas• Hypocaloric: 20 kcal/kg/day• Standard: 30 kcal/kg/day• Included only non-protein calories

• Significantly less hyperglycemia associated with hypocaloric PN (p < 0.001)

• No change in infectious complication rate

Jiang, et al. 2011

Surgical andtrauma ICU patients

Meta-analysis of five RCTs• Hypocaloric PN (≤20 kcal/kg/day)

or standard PN (>25 kcal/kg/day)

• Hypocaloric PN associated with fewer infectious complications (RR 0.60, p = 0.02), shorter length of stay (2.49 days, p = 0.0004)

• No difference in mortality

Taylor, et al. 2016

Surgical andtrauma ICU patients

Meta-analysis of four RCTs• Hypocaloric PN (≤20 kcal/kg/day)

or standard PN (>25 kcal/kg/day)

• Decreased incidence of hyperglycemia with hypocaloric PN (0% vs. 33.1%, p = 0.001)

• No effect on mortality or infectious complications

• Withhold or limit soy-based IV fat emulsions (IVFE) during the first week of PN to a maximum of 100 g/week if there is a concern for fatty acid deficiency (VL)

Intravenous Lipids

Arrazcaeta J, et al. Nutr Clin Pract 2014; 29:355-9.Battistella F, et al. J Trauma 1997; 43:52-60.



Description Result

Battistella, et al. 1997

Trauma ICU patients

Early vs. delayed IVFE usage• IVFE started on day 5 or day 10• TPN standard for all patients• Goal 30 kcal/kg/day including IVFE

• Increased pneumonia (73.3% vs. 48.1%, p = 0.05) and catheter-related sepsis (43.3% vs. 18.5%, p = 0.04) with early IVFE

• Longer duration of mechanical ventilation (p = 0.01), ICU length of stay (p = 0.02), and hospital length of stay (p = 0.03)

Arrazcaeta, et al. 2014

Mixed medical and surgical ICU patients

Early vs. delayed IVFE usage• Use of IVFE within or after 7 days• Pre- and post-implementation

study

• Infection rates similar between groups (40.9% vs. 55.2%, p = 0.264)

• No difference in ICU and hospital length of stay or mortality

AA has been started on EN via a newly placed Dobhoff tube, titrated to goal caloric intake. You advise the resident that EN is preferred in this patient at this time.

On POD2, the patient’s respiratory status worsens with progressive hypoxia on increasing FiO2, concerning for ARDS. The team asks, “Should we change his tube feed formulation to an ω-3 fatty acids rich formula?”

Patient Case

Pharmaconutrition

Pharmaconutrition

• Augmentation of nutrition therapy with supplemental metabolic substrates◦ Glutamine

◦ Arginine

◦ ω-3 fatty acids

◦ Antioxidants

• Several enteral formulations contain specific amounts of various macro-and micronutrients◦ Immune-modulating formulations

Pierre JF, et al. JPEN 2013; 37:51S-65S.Taylor BE, et al. Crit Care Med 2016;44:390-438.

Guideline Recommendations• Immune-modulating formulations should not be routinely used in the MICU

(VL)◦ Consider using immune-modulating formulations and fish oil in patients with severe

trauma (VL) and TBI patients (E)

• No recommendation can be made for the routine use of EN high in anti-inflammatory lipids in acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) (L to VL)

• Antioxidants and trace minerals may be provided to patients that require specialized nutrition therapy (L)


Glutamine

• Amino acid that serves a variety of metabolic functions◦ Improves glucose metabolism

◦ Substrate in gut-associated immune cell activation and proliferation

◦ Precursor to GABA, providing potential neurologic benefit

◦ Precursor to antioxidant glutathione, which promotes heat shock protein responses and modulates apoptosis


Glutamine

• Meta-analyses suggest glutamine is associated with decreased mortality, shorter length of stay, and less infectious complications◦ Variations in dosing, formulation, and delivery

◦ Benefits derived from older studies, specifically with IV formulation

• One recent large RCT (REDOXS) showed a trend towards increased 28-day mortality with glutamine◦ In-hospital and 6 month mortality significantly higher with glutamine

• Supplemental enteral or parenteral glutamine should not be routinely added for critically ill patients (M)

Heyland D, et al. N Engl J Med 2013; 368:1489-97.Pierre JF, et al. JPEN 2013; 37:51S-65S.


Arginine• Essential amino acid that regulates physiological processes

◦ May stimulate wound repair

◦ Influences β-cell insulin release and peripheral glucose uptake

◦ Improves T-cell mediated immune response

• Precursor to nitric oxide◦ Potent vasodilator with cytotoxic effects

◦ Directly bactericidal

• Withhold supplemental arginine in septic patients (M)

• Formulations with arginine may be considered in patients with severe trauma (VL) and TBI (E)

• Consider holding in hemodynamically unstable patients


ω-3 Fatty Acids• Polyunsaturated fatty acids that cannot be synthesized by mammals

◦ Linolenic acid (LA), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA)

• Number of proposed physiological benefits◦ Role in cognitive function

◦ Released from cell membranes during cellular stress and converted to eicosanoids, mediating tissue response to injury

◦ Precursors to both pro- and anti-inflammatory compounds

◦ Limits activity of iNOS

• No recommendation can be made for the routine use of EN high in anti-inflammatory lipids in ARDS and ALI (L to VL)


ω-3 Fatty Acids in ARDS

Cook DJ and Heyland DK. JAMA 2011; 306:1599-1600.Pontes-Arruda A, et al. 2008; 32:596-605.Rice TW, et al. JAMA 2011; 306:1574-81.



Intervention Result

Pontes-Arruda, et al. 2008

ARDS and ALI patients on mechanical ventilation

Meta-analysis of three RCTs• Study diet enriched with EPA + GLA +

antioxidants (Oxepa)• Control diet without fatty acids

(Pulmocare)

• Study diet associated with 60% reduction in 28-day hospital mortality (p = 0.001), 4.9 day reduction in ventilator days (p < 0.0001), and 56% reduction in organ failure (p < 0.0001)

Rice, et al. 2011 (OMEGA)

ALI patients on mechanical ventilation

Supplemental pharmaconutrition vs. placebo• Twice daily supplemental ω-3 fatty acids,

LA, antioxidants• Isocaloric, isovolemic carbohydrate

control• Administered outside of EN

Stopped early for futility

• Fewer ventilator-free days (14.0 vs. 17.2, p = 0.02), ICU-free days (14.0 vs. 16.7, p = 0.02), nonpulmonaryorgan failure-free days (12.3 vs. 15.5, p = 0.02) in intervention group

• Trend towards increased 60-day hospital mortality (26.6% vs 16.3%, p = 0.054)

Antioxidants• Antioxidants and trace minerals may be provided to patients that require

specialized nutrition therapy (L)◦ Vitamins E and C, selenium, zinc, copper

• Aggregated results suggest a significant reduction in mortality (RR 0.8, 95% CI 0.7 – 0.92, p = 0.001)◦ No difference in infectious complications, ICU or hospital LOS, and duration of mechanical

ventilation

• No standard for dosage, frequency, duration, and route of therapy has been established


AA is continued on his current tube feed formula, at goal and tolerating. His respiratory status is improving and by POD5, he is extubated and stable for transfer.

Patient Case

Test Questions

Which of the following statements is true regarding the metabolic state of critically ill patients?

a) Critically ill patients generally have decreased metabolic needs and do not require specialized nutrition support therapy

b) Increases in inflammatory mediators during critical illness stimulate lipolysis, requiring fat supplementation

c) Metabolic demands do not change in critical illness and no specialized nutrition therapy is required

d) Critically ill patients are hypermetabolic and may require specialized nutrition therapy to meet these increased needs

Test Question #1

The SCCM/ASPEN Guidelines include all except which of the following recommendations regarding nutrition support in the critically ill patient?

a) Feeding via the enteral route is preferred over the parenteral route.

b) Enteral nutrition should routinely be supplemented with parenteral nutrition in all patients when nutrition support is initiated.

c) Exclusive parenteral nutrition should be held in patients at low nutrition risk during the first week of hospitalization.

d) Enteral nutrition should be started within 24-48 hours of admission in patients at high nutrition risk and unable to maintain volitional intake.

Test Question #2

Which of the following is the correct statement regarding gastric residual volumes?

a) Gastric residual volumes should be routinely monitored in all patients receiving enteral nutrition.

b) Gastric residual volumes should be routinely monitored and enteral nutrition should be immediately held for a gastric residual volume >100 mL over 4 hours.

c) Gastric residual volumes may be monitored and a gastric residual volume of >250 mL over 4 hours should raise concern.

d) Gastric residual volumes do not need to be routinely monitored in patients receiving enteral nutrition.

Test Question #3

Ahrens CL, Barletta JF, Kanji S, et al. Effect of low-calorie parenteral nutrition on the incidence and severity of hyperglycemia in surgical patients: a randomized, controlled trial. Crit Care Med 2005; 33:2507-12.Arrazcaeta J and Lemon S. Evaluating the significance of delaying intravenous lipid therapy during the first week of hospitalization in the intensive care unit. Nutr Clin Pract 2014; 29:355-9.Battistella FD, Widergren JT, Anderson JT, Siepler JK, Weber JC, and MacColl K. A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition. J Trauma 1997; 43:52-8.Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365:506-17.Cook AM, Peppard A, and Magnuson B. Nutrition considerations in traumatic brain injury. Nutr Clin Pract 2008; 23:608-20.Cook DJ and Heyland DK. Pharmaconutrition in acute lung injury. JAMA 2011; 306:1599-600.Harvey SE, Parrott F, Harrison DA, et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med 2014; 371:1673-84.Heyland DK, Dhaliwal R, Jiang X, and Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care 2011; 15:R268.Heyland D, Muscedere J, Wischmeyer PE, et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med 2013; 368-1489-97.Hoffer LJ. Human Protein and Amino Acid Requirements. J Parenter Enteral Nutr 2016; 40:460-74.Kondrup J, Allison SP, Elia M, Vellas B, and Plauth M. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003; 22:415-21.Kutsogiannis J, Alberda C, Gramlich L, et al. Early use of supplemental parenteral nutrition in critically ill patients: Results of an international multicenter observational study. Crit Care Med 2011; 39:2691-9.Lewis SJ, Egger M, Sylvester PA, and Thomas S. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ 2001; 323:773-6.McClave SA, and Heyland DK. The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract 2009; 24:305-15.McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN).

J Parenter Enteral Nutr 2009; 33:277-316.McCowen KC, Friel C, Sternberg J, et al. Hypocaloric total parenteral nutrition: effectiveness in prevention of hyperglycemia and infectious complications—a randomized clinical trial. Crit Care Med 2000; 28:3606-11.Montejo JC, Minambres E, Bordeje L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med 2010; 36:1386-93.Pierre JF, Heneghan AF, Lawson CM, Wischmeyer PE, Kozar RA, and Kudsk KA. Pharmaconutrition review: physiological mechanisms. J Parenter Enteral Nutr 2013; 37:51S-65S.Pontes-Arruda A, Demichele S, Seth A, and Singer P. The use of an inflammation-modulating diet in patients with acute lung injury or acute respiratory distress syndrome: a meta-analysis of outcome data. J Parenter Enteral Nutr 2008; 32:596-605.Reignier J, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA 2013; 309:249-56.Rice TW, Wheeler AP, deBoisblanc BP, Steingrub J, and Rock P. Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury. JAMA 2011; 306:1574-81.Taylor BE, McClave SA, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN).

Crit Care Med 2016; 44:390-438.Simpson F and Doig GS. Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive Care Med 2005; 31:12-23.

References

Nutrition SupportA Review of Updated Guideline Recommendations

Paul Wong, PharmD, BCCCP

Critical Care Clinical Pharmacist

Cedars-Sinai Medical Center

[email protected]

mailto:[email protected]

1. Write down the course code. Space has been provided in the daily program-at-a-glance sections of your program book.

2. To claim credit: Go to www.cshp.org/cpe before December 1, 2016.

Session Code:

Documents

Nutrition Supports/Final.60.PaulWong.9.13.pdfa) Critically ill patients generally have decreased metabolic needs and do not require specialized nutrition support therapy b) Increases