RISKS AND BENEFITS OF NUTRITIONAL SUPPORT DURING CRITICAL ILLNESS Yves Debaveye and Greet Van den Berghe Annual Review of Nutrition Vol. 26: 513-538, August 2006

1
RISKS AND BENEFITS OF NUTRITIONAL SUPPORT DURING
CRITICAL ILLNESSYves Debaveye and Greet Van den
BergheAnnual Review of Nutrition Vol. 26
513-538, August 2006

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2
Introduction

• Anorexia and intolerance of oral feeds lead to
  starvation, multifactorial hormonal and immune
  response to stress, results in hypercatabolism of
  the critically ill.
• Liberates necessary fuel substrates for vital
  organs and systems.

3
Introduction

• Wasting syndrome is a major clinical problem
  because it hampers the recovery process.
• Prolonged dependency on intensive care, exposing
  patients to potentially lethal complications and
  carrying a high risk of death.

4
Introduction

• Quarter of the adult patients requiring intensive
  care for more than three weeks do not survive the
  intensive care phase, and up to 50 do not leave
  the hospital alive.
• The survival often need institutional care for a
  long time after hospital discharge.

5
Introduction

• Studies in the area of nutritional support are
  difficult because of the heterogeneous nature of
  the patient populations.
• Most nutritional strategies in the ICU are
  deduced from data obtained in noncritically ill.

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SimpleMalnutrition Versus Hypercatabolism of the
Critically Ill

• Malnutrition is a disorder evoked by inadequate
  nutritional intake.
• Resulting in reduced body mass, abnormal body
  composition, reduced organ function, and
  abnormalities in blood chemistry.

7
Malnutrition

• Malnutrition affects outcome of a superimposed
  stress or disease was already noted in 1936 by
  Studley.
• Malnourished patients undergoing ulcer surgery
  had a tenfold higher risk of death.
• Malnutrition are exposed to a higher risk of
  complications, such as nosocomial infections, and
  an increased risk of death.

8
Hypercatabolism of the Critically Ill

• Changes in substrate metabolism and leads to
  clinically obvious alterations in body
  composition.
• Metabolic status of critically ill patients is
  fundamentally different.
• Resting energy expenditure (REE) is depressed
  during simple starvation, during critical illness
  it rises proportionally to the amount of stress.
• Not reversed by nutrition alone.

9
Nutritional Support Versus Starvation or
Standard Care

• Most of the clinical studies evaluating
  nutritional support focused on patients
  recovering from acute and self-limiting insults
  (e.g., surgery and trauma) instead of those with
  ongoing or progressive disease (e.g., shock and
  multiorgan failure).
• Standard care ? oral diet plus intravenous
  dextrose critically ill patients receive glucose
  infusion because they are unable to eat.

10
Nutritional support in critically ill

• Parenteral nutrition of the critically ill may
  increase rather than reduce mortality1.
• Nutritional support in critically ill patients is
  not beneficial2,3.
• Heyland DK, MacDonald S, Keefe L, Drover JW.
  1998. Total parenteral nutrition in the
  critically ill patient a metaanalysis. JAMA
  280201319.
• Koretz RL. 1995. Nutritional supplementationin
  the ICU. How critical is nutritionfor the
  critically ill? Am. J. Respir. Crit. Care Med.
  15157073
• Marino PL, Finnegan MJ. 1996. Nutrition support
  is not beneficial and can be harmful in
  critically ill patients. Crit. Care
  Clin.1266776

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Nutritional support in critically ill

• Only severely malnourished patients benefit from
  nutritional intervention before surgery1.
• The use of PN in malnourished patients may be
  able to reduce complication rates and decrease
  mortality in comparison with standard care2,3.
• The Veteran Affairs Total Parenteral Nutrition
  Cooperative Study Group. 1991. Perioperative
  total parenteral nutrition in surgical patients.
  The Veterans Affairs Total Parenteral Nutrition
  Cooperative Study Group. N. Engl. J. Med.
  32552532.
• Braunschweig CL, Levy P, Sheean PM, Wang X. 2001.
  Enteral compared with parenteral nutrition a
  meta-analysis. Am. J. Clin. Nutr. 7453442
• Heyland DK, MacDonald S, Keefe L, Drover JW.
  1998. Total parenteral nutrition in the
  critically ill patient a metaanalysis. JAMA
  280201319

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What Is Sufficient Energy Intake?

• Indirect calorimetry
• In sepsis and trauma the total energy expenditure
  (TEE) of critically ill patients rises from 30
  kcal/kg/d in the first week to 5060 kcal/kg/d in
  the second week1.
• American College of Chest Physicians guidelines
  recommending 25 kcal/kg/d as caloric content of
  nutrition for the critically ill2.
• Uehara M, Plank LD, Hill GL. 1999. Components of
  energy expenditure in patients with severe sepsis
  and major trauma a basis for clinical care.
  Crit. Care Med. 271295302
• Cerra FB, Benitez MR, Blackburn GL, Irwin RS,
  Jeejeebhoy K, et al. 1997. Applied nutrition in
  ICU patients. A consensus statement of the
  American College of Chest Physicians. Chest
  11176978

13
Sufficient Energy Intake?

• No evidence to suggest that failure to match
  energy intake to energy expenditure adversely
  affects clinical outcome.
• A recent prospective observational study of
  medical ICU patients even suggested that the
  classical caloric target of 25 kcal/kg/day may
  overestimate the needs, since caloric intake
  exceeding the mid-tertile of 918 kcal/kg/day
  resulted in a poorer hospital survival1.
• 1. Krishnan JA, Parce PB, Martinez A, Diette
  GB, Brower RG. 2003. Caloric intake in medical
  ICU patients consistency of care with guidelines
  and relationship to clinical outcomes. Chest
  124297305

14
Sufficient Energy Intake?

• Enterally fed patients had significantly worse
  neurological outcome than did those receiving
  PN1.
• Faster neurological recovery occurred with a
  higher amount of nutritional support in both
  trials1,2.
• Rapp RP, Young B, Twyman D, Bivins BA, Haack D,
  et al. 1983. The favorable effect of early
  parenteral feeding on survival in head-injured
  patients. J. Neurosurg. 5890612
• Young B, Ott L, Twyman D, Norton J, Rapp R, et
  al. 1987. The effect of nutritional support on
  outcome from severe head injury. J. Neurosurg.
  6766876

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Is Early Feeding Beneficial?

• Inadequate early nutrient intake in head-injured
  patients has been associated with prolongation of
  the acute-phase response and an increased
  incidence of septic morbidity.
• Animal studies also suggest a benefit of early EN
  versus starvation in protecting against oxidative
  organ injury through attenuation of lipid
  peroxidation.
• Poor evidence that early EN or PN has clinical
  advantages over brief starvation.

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Is Early Feeding Beneficial?

• There was no benefit from the use of PN when EN
  was initiated early (lt24 h), a significant
  survival benefit from the use of PN was found
  only in the trials where EN was delayed.
• 1. Simpson F, Doig GS. 2005. Parenteral vs.
  enteral nutrition in the critically ill patient
  a meta-analysis of trials using the intention to
  treat principle. Intensive Care Med. 311223

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Parenteral Nutrition Really Dangerous?

• PN has been defined as an intravenous solution
  containing protein and a source of nonprotein
  energy with or without lipids.
• Hyperalimentation was coined and practiced in the
  surgical community.
• Infectious complications and metabolic
  disturbances.

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Parenteral Nutrition Really Dangerous?

• PN is nowadays considered by many to be a
  dangerous and risky venture in the critically
  ill1.
• The use of PN in critically ill patients may
  result in significantly increased mortality2.
• Inclusion of noncritically ill patients,overfeedin
  g in the PN group, combined enteral and
  parenteral feeding.
• Griffiths RD. 2004. Is parenteral nutrition
  really that risky in the intensive care unit?
  Curr. Opin. Clin. Nutr. Metab. Care717581
• Heyland DK, MacDonald S, Keefe L, Drover JW.
  1998. Total parenteral nutrition in the
  critically ill patient a metaanalysis. JAMA
  280201319

19
Parenteral Nutrition Really Dangerous?

• Septic morbidity that is often attributed to PN.
• Vascular access, an altered gut barrier,
  translocation of enteric bacteria.
• Animal studies demonstrating that PN adversely
  affects villus architecture and intestinal
  permeability.

20
Overfeeding

• Severe metabolic disorders
• Hyperglycemia
• Hypertriglyceridemia
• Azotemia to hepatic steatosis
• Fat-overload syndrome
• Hypertonic dehydration

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Parenteral Nutrition Really Dangerous?

• Use of PN in surgical and critically ill patients
  is safe and is not associated with an excess
  morbidity or mortality.
• Use of PN may even be associated with a
  significant survival benefit over EN1.
• 1. Simpson F, Doig GS. 2005. Parenteral vs.
  enteral nutrition in the critically ill patient
  a meta-analysis of trials using the intention to
  treat principle. Intensive Care Med. 311223

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Potential Advantages of Enteral Nutrition

• More physiological
• To promote gastrointestinal tract function and
  integrity
• To prevent bacterial translocation
• To reduce nosocomial infections
• To be more cost-effective than PN.

23
Potential Advantages of Enteral Nutrition

• Early EN in critically ill patients may be
  associated with a significantly lower incidence
  of infections and a reduced hospital stay of two
  days1.
• The proportion of nutrients adequately delivered
  was only 75 with EN versus 88 with PN2.
• Gut dysfunction, setting targets that are too
  low, initiating the feeding too late, elective
  interruption of the feeding for procedures, not
  using feeding protocols, and a tendency to stop
  enteral feeding too readily.
• Marik PE, Zaloga GP. 2001. Early enteral
  nutrition in acutely ill patients a systematic
  review. Crit. Care Med. 292264 70
• Berger MM, Chiolero RL, Pannatier A, Cayeux MC,
  Tappy L. 1997. A 10-year survey of nutritional
  support in a surgical ICU 19861995. Nutrition
  1387077