A Randomized Trial of Empiric Antibiotics and Invasive Diagnostic Techniques in the setting of Ventilator-Associated Pneumonia - PowerPoint PPT Presentation

About This Presentation
Title:

A Randomized Trial of Empiric Antibiotics and Invasive Diagnostic Techniques in the setting of Ventilator-Associated Pneumonia

Description:

* * What to do when early enteral feeding is not possible in critically ill patients: A multicenter observational study Adequacy of Calories from Total Nutrition (EN ... – PowerPoint PPT presentation

Number of Views:377
Avg rating:3.0/5.0

less

Transcript and Presenter's Notes

Title: A Randomized Trial of Empiric Antibiotics and Invasive Diagnostic Techniques in the setting of Ventilator-Associated Pneumonia


1
Early Parenteral Nutrition Should NOT be Used In
Critically ILL Patients
Daren K. Heyland Professor of Medicine Queens
University, Kingston General Hospital Kingston,
ON Canada
2
Consequences of Iatrogenic Malnutrition
Adequacy of EN
Adequacy of EN
  • ? Caloric debt associated with
  • ? Longer ICU stay
  • ? Days on mechanical ventilation
  • ? Complications
  • ? Mortality

Rubinson CCM 2004 Villet Clin Nutr 2005 Dvir
Clin Nutr 2006 Alberda ICM 2009
3
  • Point prevalence survey of nutrition practices in
    ICUs around the world conducted Jan. 27, 2007
  • Enrolled 2772 patients from 158 ICUs over 5
    continents
  • Included ventilated adult patients who remained
    in ICU gt72 hours
  • 60 medical 40 surgical
  • Average APACHE II 22 BMI 27

4
Hypothesis
  • There is a relationship between amount of energy
    and protein received and clinical outcomes
    (mortality and of days on ventilator)
  • The relationship is influenced by nutritional
    risk
  • BMI is used to define chronic nutritional risk

5
What Study Patients Actually Recd
  • Average Calories in all groups
  • 1034 kcals and 47 gm of protein
  • Result
  • Average caloric deficit in Lean Pts
  • 7500kcal/10days
  • Average caloric deficit in Severely Obese
  • 12000kcal/10days

6
Relationship Between Increased Calories and 60
day Mortality
BMI Group Odds Ratio 95 Confidence Limits 95 Confidence Limits P-value
Overall 0.76 0.61 0.95 0.014
lt20 0.52 0.29 0.95 0.033
20-lt25 0.62 0.44 0.88 0.007
25-lt30 1.05 0.75 1.49 0.768
30-lt35 1.04 0.64 1.68 0.889
35-lt40 0.36 0.16 0.80 0.012
gt40 0.63 0.32 1.24 0.180
Legend Odds of 60-day Mortality per 1000 kcals
received per day adjusting for nutrition days,
BMI, age, admission category, admission diagnosis
and APACHE II score.
7
(No Transcript)
8
More is Better!
Our Field of Dream
If you feed them (better!) They will leave
(sooner!)
9
2007 International Nutrition Practice Survey
Cahill NE CCM 2010 (in press)
10
ICU patients are not all created equalshould we
expect the impact of nutrition therapy to be the
same across all patients?
11
Results of 2008 International Surveyn156 ICUs
After so many years of trying to improve carewe
still cant feed adequately the enteral route!
12
  • What if you cant provide adequate early enteral
    nutrition?
  • to TPN or not to TPN,
  • that is the question!

13
Canadian RecommendationsEnteral vs. Parenteral
Nutrition
  • Based on one level 1 and 12 level 2 studies, when
    considering nutrition support for critically ill
    patients, we strongly recommend the use of
    Enteral Nutrition over Parenteral Nutrition.

www.criticalcarenutrition.com
14
Canadian RecommendationsCombined EN and PN
  • Based on 5 level 2 studies, for critically ill
    patients starting on enteral nutrition we
    recommend that parenteral nutrition not be
    started at the same time as enteral nutrition.

www.criticalcarenutrition.com
15
Canadian RecommendationsCombined EN and PN
  • Based on 5 level 2 studies, for critically ill
    patients starting on enteral nutrition we
    recommend that parenteral nutrition not be
    started at the same time as enteral nutrition.

www.criticalcarenutrition.com
16
ASPEN/SCCM ICU Nutrition CPGs
PN vs Standard Care
  • In the patient who was previously healthy prior
    to critical illness with no evidence of
    protein-calorie malnutrition, use of PN should be
    reserved and initiated only after the first 7
    days of hospitalization (when EN is not
    available).

Supplemental PN
  • If unable to meet energy requirements after 7-10
    days by the enteral route, consider initiating
    PN.
  • Initiating PN prior to this 7-10 day period does
    not improve outcome and may be detrimental to the
    patient.

McClave JPEN 200933277
17
Beth Taylorj
  • All patient who are not expected to be on normal
    nutrition within 3 days should receive PN within
    24-48 hours if EN is contraindicated or if they
    can not tolerate adequate amounts of EN.

Clinical Nutrition 2009
18
A Leap of Faith?
19
Significant decrease in mortality yet significant
increase in infection
Simpson Int Care Med 20053112
20
Beneficial Effect of Early PN?
Simpson Int Care Med 20053112
21
Beneficial Effect of Early PN?
  • Flaws in this meta-analysis of early PN
  • Select studies were included (validity filter
    excluded trials with 4-21 lost to follow up)
  • Heterogeneous studies were included (elective
    surgical patients)
  • Used a fixed effects model rather than more
    conservative random effects model
  • Subgroup analysis at best is a hypothesis
    generating analysis
  • What is the biological rationale as to how PN
    causes increased infection and yet reduces
    mortality?

Simpson Int Care Med 20053112
22
Beneficial Effect of Early PN?
Simpson Int Care Med 20053112
23
The favorable effect of early parenteral feeding
on survival in head-injured patients
  • RCT of 38 patients
  • EN vs PN
  • Methods score 6/14
  • Patients prescribed 2600 cal
  • EN recd 26 vs PN 65

When study repeated years later, no difference in
mortality
Rapp J Neurosurg 198358906
24
Combined 2007 and 2008 International Nutrition
Practice Survey Databases
  • Point prevalence survey of nutrition practices in
    ICUs around the world conducted Jan. 25, 2007
    and May 14, 2008.
  • Each site aimed to enroll 20 patient each
  • Included ventilated adult patients who remained
    in ICU gt72 hours
  • Enrolled 5771 patients from 351 ICUs from gt20
    countries

Heyland (unpublished data)
25
What is the effect of supplemental PN in
critically ill patients receiving early EN
Results of a multicenter observational study
2920 patients receiving early EN
26
What is the effect of supplemental PN in
critically ill patients receiving early EN
Results of a multicenter observational study
Adequacy of Calories from Total Nutrition
(ENPNpropofol)
27
What is the effect of supplemental PN in
critically ill patients receiving early EN
Results of a multicenter observational study
Adequacy of Calories from EN only
28
What is the effect of supplemental PN in
critically ill patients receiving early EN
Results of a multicenter observational study
Clinical Outcomes All Patients Proportion dead
or remaining in hospital
P0.0003
Regression model Time to Discharge Alive
Multiple Predictor
Single Predictor
29
What is the effect of supplemental PN in
critically ill patients receiving early EN
Results of a multicenter observational study
Clinical Outcomes Patients with low BMI
(lt20) Proportion dead or remaining in hospital
P0.43
30
What is the effect of supplemental PN in
critically ill patients receiving early EN
Results of a multicenter observational study
Clinical Outcomes Patients with GI admission
diagnosis Proportion dead or remaining in hospital
P0.06
31
What is the effect of supplemental PN in
critically ill patients receiving early EN
Results of a multicenter observational study
Clinical Outcomes Patients with persistent early
GI dysfunction Proportion dead or remaining in
hospital
P0.04
32
What is the effect of supplemental PN in
critically ill patients receiving early EN
Results of a multicenter observational study
Conclusions
  • In mechanically ventilated ICU patients
    receiving early EN, supplemental PN is associated
    with greater provision of calories and protein
    but no beneficial effect on clinical outcomes,
    even in high risk patients (low BMI, GI admission
    diagnosis, persistent early GI dysfunction)

33
What to do when early enteral feeding is not
possible in critically ill patients A
multicenter observational study
  • Focus in medical ICU patients only
  • Excluded all those who recd early EN

34
What to do when early enteral feeding is not
possible in critically ill patients A
multicenter observational study
Adequacy of Calories from Total Nutrition
(ENPNpropofol)
35
What to do when early enteral feeding is not
possible in critically ill patients A
multicenter observational study
Adequacy of Calories from EN only
36
What to do when early enteral feeding is not
possible in critically ill patients A
multicenter observational study
Clinical Outcomes All Patients Proportion dead
or remaining in hospital
P0.01
Multivariable regression model No effect of
timing of nutrition on outcome
37
What to do when early enteral feeding is not
possible in critically ill patients A
multicenter observational study
Clinical Outcomes Only Patients with low BMI
(lt25) Proportion dead or remaining in hospital
P0.01
38
What to do when early enteral feeding is not
possible in critically ill patients A
multicenter observational study
Conclusions
  • In medical ICU patients, when early EN is not
    possible, early PN is associated with greater
    provision of calories and protein but no
    beneficial effect on clinical outcomes, even in
    high risk patients (low BMI)

39
Current Evidence for use of PN in critically ill
patientsResults of prospective, observational
multicenter German Study
  • Point prevalence study
  • 454 ICUs from 310 hospitals in Germany
  • 399 patients septic patients included
  • Median APACHE II 26
  • 68 had no GI pathology
  • 46 in shock
  • Overall mortality 55.2

Elke CCM 2008361762
40
Current Evidence for use of PN in critically ill
patientsResults of prospective, observational
multicenter German Study
P0.005
  • Point prevalence study
  • 454 ICUs from 310 hospitals in Germany
  • 399 patients septic patients included
  • Median APACHE II 26
  • 68 had no GI pathology
  • 46 in shock
  • Overall mortality 55.2

Multivariate analysis PN independent predictor
for mortality (OR 2.09, 95 CI 1.29-3.37)
41
Current Evidence for use of PN in critically ill
patients Observational study in Critically Ill
Trauma Patients
  • Retrospective, multicenter, cohort study of 597
    severely injured patients
  • Compared those that recd PN within 7 to those
    who did not.
  • Also compared early PN group to subgroup of EN
    tolerant (tolerated 1000 kcal any day during
    first week)
  • Adjusted for differences in key baseline
    demographics

Sena J Am Coll Surg 2008207459
42
Early Supplemental PN is Associated with
Increased Infection in Critically Ill Trauma
Patients
No Early PN Early PN Odds Ratio P value
Overall Adjusted
Nosocomial Infections 27 56 2.1 (1.3-3.5) P0.003
Late ARDS 1 8 3.4 (1.0-11.0) P0.04
Death 8 23 1.5 (0.8-3.0) P0.24
EN tolerant analysis
Nosocomial Infections 42 69 2.5 (1.1-5.9) P0.03
Late ARDS 2 9 5.4 (1.1-27.4) P0.04
Death 8 19 2.7 (0.8-9.3) P0.10
Differences not due to differences in glycemic
control
43
International Multicenter Observational Study of
Nutrition Practices
  • 351 ICUs around the world
  • 5771 mechanically ventilated patients gt 3days in
    ICU

5.1
Heyland (unpublished data)
44
  • What if you cant provide adequate early enteral
    nutrition?
  • to TPN or not to TPN,
  • that is the question!

45
(No Transcript)
46
The Efficacy of Enhanced Protein-Energy Provision
via the Enteral Route in Critically Ill Patients
The PEP uP Protocol!
  • Not all critically ill patients are the same we
    have different feeding options based on
    hemodynamic stability and suitability for high
    volume intragastric feeds.
  • In select patients, we start the EN immediately
    at goal rate, not at 25 ml/hr.
  • We target a 24 hour volume of EN rather than an
    hourly rate and provide the nurse with the
    latitude to increase the hourly rate to make up
    the 24 hour volume.
  • Tolerate higher GRV threshold (300 ml or more)
  • Motility agents and protein supplements are
    started immediately, rather than started when
    there is a problem.

A Major Paradigm Shift in How we Feed Enterally
47
The Efficacy of Enhanced Protein-Energy Provision
via the Enteral Route in Critically Ill Patients
The PEP uP Protocol!
Heyland (in submission)
48
The Efficacy of Enhanced Protein-Energy Provision
via the Enteral Route in Critically Ill Patients
The PEP uP Protocol!
Heyland (in submission)
49
Conclusions
  • More EN is better
  • Currently no role for routine use of PN in early
    setting
  • Potential for harm
  • Need RCT level of evidence to establish role

50
Questions?
Write a Comment
User Comments (0)
About PowerShow.com