RISKS AND BENEFITS OF NUTRITIONAL SUPPORT DURING CRITICAL ILLNESS Part II

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RISKS AND BENEFITS OF NUTRITIONAL SUPPORTDURING
CRITICAL ILLNESSPart II

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Is Enteral Nutrition Without Risks?

• altered gastric emptying and decreased intestinal
  motility ? critical illness ,MV , sedatives,
  opiates, and catecholamines ? high gastric
  residues ? inadequate nutritional intake, reflux,
  emesis, and aspiration
• abdominal distention, diarrhea, constipation,
  and, rarely, mesenteric ischemia.

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• Mechanical complications ? misplacement or
  dislodgment of feeding tube or luminal blockage
• both gastric enteral feeding and feeding in
  supine position, as opposed to semirecumbent
  position, are independent risk factors for
  nosocomial pneumonia in MV patients --------
  Drakulovic MB, 1999. Supine body position as a
  risk factor for nosocomial pneumonia in
  mechanically ventilated patients a randomised
  trial. Lancet 354185158
  

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• postpyloric feeding may result in an improved
  tolerance of enterally delivered nutrition and
  concomitant faster achievement of desired
  calories----- Kortbeek JB 1999.Duodenal versus
  gastric feeding in ventilated blunt trauma
  patients a randomized controlled trial. J.
  Trauma 4699296 discussion 99698
• no trial was able to reduce incidence of
  nosocomial pneumonia compared with NG
  feeding-------- one study in medical ICU even
  resulted in gastric way is better

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• feeding tube beyond gastric pylorus
  -----technically difficult, expensive, easy
  malposition and jejunal feeding is associated
  with risk of mesenteric ischemia
• strict attention to patient positioning and
  vigilant nursing care help to minimize rates of
  complications with enteral access and more
  important than location of enteral access

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• metoclopramide was able to postpone nosocomial
  pneumonia by one day in ICU setting, its use was
  unable to decrease the incidence of pneumonia and
  mortality----Yavagal DR, 2000. Metoclopramide for
  preventing pneumonia in critically ill patients
  receiving enteral tube feeding a randomized
  controlled trial. Crit. Care Med. 28140811
• promotility drugs have some beneficial effect on
  GI motility, no evidence affects any aspect of
  clinical outcome

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• IV erythromycin not only promoted gastric
  emptying but also significantly improved chances
  for successful early enteral feeding--- Reignier
  J, 2002. Erythromycin and early enteral
  nutrition in mechanically ventilated patients.
  Crit. Care Med. 30123741
• Diarrhea is a common complication associated with
  tube feeding ? consequences include infections ,
  skin care problems, loss of electrolytes,
  increased costs

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• soluble partly hydrolyzed guar as a source of
  fiber successfully ?incidence of diarrhea (from
  32 to 9) in mechanically ventilated septic
  patients ----- Spapen H, 2001. Soluble fiber
  reduces the incidence of diarrhea in septic
  patients receiving total enteral nutrition a
  prospective, doubleblind, randomized, and
  controlled trial. Clin. Nutr. 203015
• upper digestive intolerance to EN is a risk
  factor for unfavorable outcome ?pneumonia ,
  longer ICU and hospital stays , an increased
  risk of death

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• no difference in incidence of septic morbidity
  between nonrandomized groups of enterally and
  parenterally fed patients but a highly
  significant increase of non-septic
  feeding-related complications in the EN group ?a
  significant excess in mortality---------Woodcock
  N, 2002. Optimal nutrition support (and the
  demise of the enteral versus parenteral
  controversy). Nutrition 1852324
• choice of feeding route ?by clinical assessment
  of GI function ---- Woodcock, 2001. Enteral
  versus parenteral nutrition a pragmatic study.
  Nutrition 17112

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Combined Enteral/Parenteral Nutrition

• EN ?safer option in majority of patients when
  applied under close supervision but frequently
  hypocaloric feeding.
• actually no evidence that use of supplemental PN
  in ICU, when EN fails to reach adequate amounts
  of energy delivery, holds risks

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• recent prospective, double-blind, randomized,
  placebo-controlled study of 120 critically ill
  patients demonstrated 7 days of EN supplemented
  with PN led to a faster recovery of nutritional
  markers retinol-binding protein and prealbumin
  and reduced hospital stay by 2.5 days but no
  difference in terms of morbidity or day 90
  mortality--------Bauer P. 2000. Parenteral with
  enteral nutrition in the critically ill.
  Intensive Care Med. 26893900

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• a meta-analysis including five studies with
  combined EN and PN also did not document an
  increased mortality or infectious complication
  rate in comparison with EN alone----Dhaliwal R.
  2004. Combination enteral and parenteral
  nutrition in critically ill patients harmful or
  beneficial? A systematic reviewof the evidence.
  Intensive Care Med. 30166671
• combined nutritional support may provide a
  protective window necessary for EN to restore
  intestinal function, earlier assure adequate
  calories

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SPECIALIZED NUTRITIONAL SUPPORT

• nutritional support ?a way to provide energy
  under the form of carbohydrates (6080) and
  lipids (2040), protein (up to 1.5 g/kg/day),
  and essential micronutrients ? offset muscle
  wasting and prevent starvation-induced immune
  depletion

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Alternative Lipid Solutions

• containing medium-chain triglycerides (MCTs) or
  structured triglycerides (STs) have been proposed
  for PN since they are oxidized more readily as
  compared with LCTs
• short-term administration of an ST emulsion
  results in an amelioration of nitrogen balance in
  ICU patients but no evidence results in a better
  clinical outcome

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Specialty Solutions

• Liver formulas ?branched-chain amino acids
  (BCAAs) and ?amount of aromatic and
  sulfur-containing amino acids for hepatic
  encephalopathy--------no convincing evidence
• Specialized pulmonary enteral solutions ?high
  fat-to-carbohydrate ratio.. But avoiding
  overfeeding is probably more important in
  decreasing ventilatory load

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• specialized formulation contains
  eicosapentaenoic acid, ?-linolenic acid, and
  antioxidants no proof for a survival benefit
• renal formulas ?low protein content BUT
  deleterious nutritional status and under
  continuous renal replacement therapy (CRRT)
  ?critically ill patients with acute renal failure
  should receive normal diets
• Diabetic EN solutions with lower carbohydrate and
  higher monounsaturated fat------ doubted under
  strict insulin control

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Immunonutrition

• Glutamine ?important fuel for rapidly dividing
  cells in gut and immune system and substrate for
  synthesis of endogenous antioxidant, glutathione
  ? beneficial fornot tolerate EN and dependent on
  PN for longer periods with glutamine or
  L-ananyl-L-glutamine ? improved six-month
  survival and lowered hospital costs..but A
  recent meta-analysis concluded no harm but also
  no benefit (Novak F, 2002. Glutamine
  supplementation in serious illness a systematic
  review of the evidence. Crit. Care Med. 302022
  29)

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• Arginine ? precursor of NO, is advocated to
  enhance immune function and wound healing
• Omega-3 fatty acids ? if fed before insult,
  influence cytokine production and target tissue
  responsiveness
• Nucleotides ?enhance host immune responses

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• enteral immunonutrition cocktails ? two largest
  studies addressed hospital mortality and
  intention-to-treat analysis divulged a
  significantly increased mortality in intervention
  group ? Until we understand the causes of these
  risks, generalized use of immune nutrient
  cocktails cannot be recommended for critically
  ill
• Atkinson S, 1998. A prospective, randomized,
  double-blind, controlled clinical trial of
  enteral immunonutrition in the critically ill.
  Guys Hospital Intensive Care Group. Crit. Care
  Med. 26116472
• Bower RH,. 1995. Early eNteral administration of
  a formula (Impact) supplemented with arginine,
  nucleotides, and fish oil in intensive care unit
  patients results of a multicenter, prospective,
  randomized, clinical trial. Crit. Care
  Med.2343649

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IMPORTANCE OF METABOLIC CONTROL

• Hyperglycemia and insulin resistance are common
  in critically ill patients, EVEN without a
  history of DM
• poor outcome after cardiac surgery, myocardial
  infarction and stroke
• an impaired leukocyte function contributing to an
  increased nosocomial infection rate
• reflection of severity of illness

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• Leuven study ? effect of strict maintenance of
  normoglycemia (blood glucose between 80 and 110
  mg/dl) by intensive insulin therapy ? reduced
  hospital mortality by 34
• a threshold level of 144 mg/dl would suffice
• ( Finney SJ, 2003. Glucose control and mortality
  in critically ill patients. JAMA 290204147)

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• parenterally fed patients required substantially
  more insulin in order to achieve normoglycemia
  than did those receiving EN ?effects of enteral
  nutrition on incretin-mediated endogenous insulin
  release
• potential risks of PN due to its higher
  hyperglycemic potential?insulin is titrated to
  achieve normoglycemia, this risk of PN disappears
• Van den Berghe G, et al. 2003. Outcome benefit of
  intensive insulin therapy in the critically ill
  insulin dose versus glycemic control. Crit. Care
  Med. 3135966

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• Dyslipidemia in critically ill ( high TG and low
  LDL, HDL) ?restored and reversed by
  intensive-insulin therapya significant part of
  beneficial effect on mortality and organ failure
  and may even surpass of glycemic control
• ? nonsurgical ICU patients with intensive
  insulin---- still beneficial by Van den Berghe
  et al. 2006. Intensive insulin therapy of medical
  intensive care patients. N. Engl. J. Med.
  35444961

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GENERAL CONCLUSIONS

• artificial nutrition carries risks that must be
  balanced against potential advantages
• Avoiding too few as well as too many calories but
  evidence is not available as to exact energy
  requirements
• Making use of a functional gut is always
  preferable
• Early adequate feeding
• patient-tailored combination of the two

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• Maintenance of normoglycemia with exogenous
  insulin in fed critically ill patients improves
  outcome
• overall metabolic control seems to surpass
  outcome benefit attributed to route of feeding
• special nutritional formulas may be promising in
  a variety of clinical settings, based on
  currently available data, it is not appropriate
  to recommend them for routine use

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Thank you for your attention