Critical Care – review of current practice
Emma Forsyth
Senior Specialist Dietitian - ICCU
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Overview
• Why me?
• Estimating requirements in critical care
• Feeding protocols
• Routes
• Prokinetics
• SB feeding
• EN and PN
• ‘specialist nutrition’
• Questions
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Why Me?
• CHS opened new combined HDU/ITU in 2000
• Full MDT involvement…… except dietetics
• Few tailored feeding regimens
• Feeding protocol out of date
• Nutrition ‘not always’ priority
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What Changed?
• Full time April 2009
• Integral part of the MDT
• Short listed for trust award for work on feeding on ICCU
• Submitting work to ESICM
• Clinical advisor NCEPOD PN Report 2010
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Excellence in Health putting People first
Excellence in Health putting People first
Why Feed?
• Early nutritional support beneficial
• Malnutrition
• Hypermetabolism
• Stress / inflammatory response……
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Stress!
Nutritional consequences are:
• An alteration in energy needs and production
• Preferential catabolism for protein stores
• Limitation of intake due to anorexia / inability to eat due to sedation / unconscious state
• Possible decreased intestinal absorption
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Why Feed?
• Muscle catabolism / weakness
• Weight loss
• Negative nitrogen balance
• Delay in mobilisation
• Average loss of 17% total body muscle stores after 21 days of critical illness
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Requirements
• Indirect calorimetry
• Equations
• Consideration of the stress response
• Under and overfeeding
Weight gain in critical care
= fat or fluid!!
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Excellence in Health putting People first
Feeding Protocol
• Timing
• Routes
• Rates
• Decrease use of parenteral nutrition
• Appropriate prokinetic prescription
• Assess tolerance issue
Well embedded feeding protocol improves overall nutrition practice
(Heyland et al 2010)
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GRV
• 200ml – ‘hinder administration’ – REGANE 2009
• 400-500ml (Currie 2010)
• Increased delivery of EN
• Decreased use of prokinetics without increased risk of aspiration
• Trends of aspirates should be used instead of a single large aspirate
• Return!
• 24 hour feeding – NICE SUGAR
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Excellence in Health putting People first
Contraindication to
enteral feeding
Initiate feed at
30ml/hr x 4hr then
aspirate
Is aspirate > 400ml?
Replace to max of
500ml, increase
feed by 30ml/hr x
4hr then aspirate
Is aspirate >
400ml?
Aspirate 4hrly and
increase rate by
30ml/hr until
desired rate
Consider parenteral
nutrition
Replace up to 500ml of
aspirate, maintain feed at
current rate and
considering initiating
prokinetics
If a second large aspirate,
hold feed for 1 hr and
restart at previous rate.
Aspirate after 4 hrs
If a third large aspirate
Reduce feed by 30ml/hr and
continue aspirate cycle. If
there are continued large
aspirates, consider post
pyloric feeding
Yes
No
No
No
Yes
Yes
Hurt and McClave 2010
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Routes
• Enteral preferred route of nutrition
• Decreases time on ventilator
• Decreases incidence of infection rates
• Decreases overall mortality
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Prokinetics
Metoclopramide
(Grant 2009)
Vs
Erythromycin
(Nguyen et al 2008)
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SB Feeding
• Gastric first line
• Gastric vs SB (Hsu 2009) (White et al 2009)
• Availability of placement of SB feeding tubes
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EN & PN
• Perseverance with troublesome EN can lead to increased risk of malnutrition
• Inclusion of PN can help meet calorie targets but does this actually improve outcome?
• Can appropriate PN deliver optimum nutrition?
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Specialist
EPA
GLA
Low CHO High Fat
Antioxidants
Arginine
Glutamine
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Summary
• Early nutrition (within 24-48hr)
• Preferable enteral nutrition
• Update feeding protocol (aim 400-500ml for aspirate level), prokinetics, SB feeding, 24hr feeding
• Metoclopramide 1st line
• Gastric 1st then SB if failed
• Use PN when indicated, eg. Failure / inability EN
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Summary
• Avoid over and underfeeding
• Consider omega 3 & 6 for ALI, ARDS
• Glutamine in PN
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Thank you for
listening
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