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IN ICU NUTRITION?

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WHAT S NEW IN ICU NUTRITION? Outdated surgical practices Outdated surgical practices Intake in HDU Calorific and Protein Targets 25kcl/kg/day up to 30 in recovery ... – PowerPoint PPT presentation

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Title: IN ICU NUTRITION?


1
WHATS NEW
IN ICU NUTRITION?
2
A slender and restricted diet is always
dangerous in chronic and in acute diseases Let
food be thy medicine
  • Hippocrates 400 B.C.

3
SICS Nutrition Network
  • Set up in June 2006
  • Links 30 dietitians, 6 pharmacists, 10 ICU
    Nutrition nurses, and 17 doctors. Meets 3x/year
    at QMH. Around 12-18/meeting
  • Guidelines on practical issues planned
  • Website with protocols/guidelines/teaching
  • Educational meetings
  • Current projects on assessment/weighing
  • Encouraging projects in nutrition

4
SICS Nutrition Network
  • Meetings videoconferencing
  • Presentations of local projects/audits
  • Ideas for new projects discussed
  • Reports on conferences/equipment
  • Discussion on topical issues e.g. nutrition
    teams, education, weighing, screening
  • Reviews of topics planned e.g. pre-and post-op
    feeding
  • Article circulation planned

5
Best Practice statements
  • Starting and stopping feed
  • Adding water to feeds
  • Use of MUAC
  • Use of different weights (ideal, actual etc)
  • Nasal bridles

6
Education
  • Module on SICS website
  • Teaching powerpoint on website
  • Junior doctors induction
  • FY2 teaching by nutrition nurse
  • Consultants mandatory training
  • Chapter for ABC of Intensive Care
  • Website

7
Audits
  • Nutrition audit of Scottish Units 2006 widely
    diverse practice and knowledge
  • HDU feeding Fife, Forth Valley
  • International Nutrition QI audit 9 units last 2
    years
  • Helped to inform changes in practice
  • Nutrition Audit form on website

8
patients receiving PN/year
9
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10
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11
The Downward Spiral of Malnutrition in Severe
Illness
Morbidity / Mortality
12
Current Projects Nutritional Screening
  • Required by QIS and NICE for
  • All patients on admission to hospital and
    regularly thereafter
  • MUST introduced by BAPEN - being widely
    implemented
  • Not helpful in ICU all high risk
  • Need to identify the severely malnourished
  • Improves feeding of these patients

13
Nutritional State and Complications in SHDU, WGH
2003
14
SNACC 3 phases
  • Few ICU nutrition studies have looked at
    nutritional status probably crucial
  • Fife ICU nutritional screening tool
  • 1. Pilot study completed to repeat in WGH
    external validity study.
  • 2. Systematic review started (funded)
  • 3. Larger study 2010-11 - will need funding
    nutritional state and outcomes
  • Aim to focus nutritional intervention

15
Whats New in IC
Weighing ICU patients
16
Weighing Patients
  • Essential for nutrition screening
  • Nutritional requirement calculations
  • Indirect calorimetry
  • Drug dosages
  • Cardiac output monitoring LIDCO, PAFC, PICCO
  • Fluid balance
  • ARDS tidal volumes

17
Weighing Patients
  • Estimation of weight can be up to 20 out
  • i.e. 80 kg instead of 100kg and vice versa
  • Estimation of height also inaccurate but
    measuring height with tape fairly accurate
  • We need to weigh patients in ICU

18
Weighing Patients
  • Craig Hurnauth ICU S/N at SJH
  • Audit of 13/14 NHS trusts in Scotland
  • 12 trusts do not weigh patients in ICU on
    admission - use estimate/notes/family
  • 1 weighs every day with hoist weekly
  • 5 use MUST
  • 7 do not screen, 1 adapted screening tool
  • 7 units in England similar results

19
Methods of Weighing
  • Hoist time consuming, needs several nurses,
    risky for unstable patients or trauma patients
  • Weigh beds 16000 each
  • Digital bed scales scales for each wheel of
    the bed weighs bed patient, mobile, minimal
    manpower, no disruption to patient

20
Methods of Weighing
  • Progress since audit
  • 2 units have bought weigh beds
  • 5 are considering bed scales

21
Challenges in Critical Care Nutrition
  • 1. Keeping up with evidence - guidelines
  • 2. Screening/weighing
  • 3. Prevention and treatment of complications
  • 4. Outdated surgical practices/ Peri-operative
    feeding
  • 5. Achieving calorific and protein targets
  • 6. Immunonutrition

22
Guidelines
23
Guidelines
  • CCCTG Nutritional Support updated 2009
    www.criticalcarenutrition.com
  • ESPEN Parenteral Nutrition guidelines 2009, EN
    2006, (ASPEN guidelines)
  • NICE guidelines on Nutrition Support in Adults
  • QIS Standards
  • MUST (BAPEN)

24
Screening/Refeeding Syndrome
  • Prisoners of war 1944-5, 1944 conscientious
    objectors in USA studied
  • Starvation early use of glycogen stores and
    gluconeogenesis from amino acids
  • 72 hrs fatty acid oxidation use of fatty acids
    and ketones for energy source, low insulin levels
  • Atrophy of organs, reduced lean body mass

25
Refeeding syndrome
  • Carbohydrate feeding shift to CH metabolism
  • Insulin release, Mg lost in urine
  • Phosphate and potassium shift into cells.
  • Magnesium, potassium and phosphate drop
  • May get Lactic acidosis
  • Sodium and water shift out of cells oedema
  • Insulin causes sodium retention
  • Protein synthesis needs potassium and phosphate
    - these drop more
  • Thiamine deficiency occurs (co-factor in CH
    metabolism) encephalopathy, weakness

26
Refeeding Syndrome in ICU
  • Unlikely to be a clear diagnosis
  • Many effects oedema, arrhythmias, pulmonary
    oedema, cardiac decompensation, respiratory
    weakness, fits, hypotension, leukocyte
    dysfunction, diarrhoea, coma, rhabdomyolysis,
    sudden death
  • Screen nutritional history and electrolytes
  • Remember in HDU patients/malnourished ward
    patients
  • Poor awareness among doctors!

27
Risk of re-feeding syndrome
  • Two or more of the following
  • BMI less than 18.5 kg/m2 (lt16)
  • unintentional weight loss greater than 10 within
    the last 3-6 months (gt15)
  • little or no nutritional intake for more than 5
    days (gt10)
  • Hx alcohol abuse or drugs including insulin,
    chemotherapy, antacids or diuretics
  • Critically low levels of PO42-, K and Mg2
  • NICE Guidelines for Nutrition Support in Adults
    2006

28
Managing refeeding problems
  • provide Thiamine (Pabrinex)/multivitamin/trace
    element supplementation
  • start nutrition support at 10-15 kcal/kg/day
  • increase levels over 3-5 days
  • restore circulatory volume
  • monitor fluid balance and clinical status
  • replace phosphate, magnesium and K
  • Reduce feeding rate if problems arise

NICE Guidelines for Nutrition Support in Adults
2006
29
Complications
  • Ileus- caused by fluid overload, pain,
    hyperglycaemia, hypokalaemia, opioids,
    immobility, sepsis trickle of feed if gut
    intact. Consider Neostigmine/prokinetics
  • Constipation avoid and treat drugs
  • Diarrhoea exclude infections, optimise fluid
    balance and electrolytes, replace loss
  • Intolerance ? Sepsis, NJ feeding, PKs
  • Feeding aids fluid and electrolyte balance

30
Overfeeding
  • Lactic acidosis
  • Hyperglycaemia
  • Increased infections
  • Liver impairment (Alk phos, ALT, GGT, acalculous
    cholecystitis)
  • Persistent pyrexia
  • Underfeeding probably even more dangerous
    studies starting to emerge need to get the
    balance right

31
Outdated surgical practices
32
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33
Outdated surgical practice
  • Reluctance to feed at all
  • Prolonged semi-starvation
  • Sips of water/Over-IV hydration
  • Incidence and treatment of ileus
  • Nervous surgeon syndrome
  • Evidence from ERAS pre-op CH loading
  • Benefits of early post-op feeding
  • Over/under-use of PN

34
Intake in HDU
35
Calorific and Protein Targets
  • 25kcl/kg/day up to 30 in recovery phase
  • Aim to provide energy as close as possible to
    target to avoid negative energy balance
  • Protein 1.3 1.5g/kg/day (optimal prtn sparing)
  • CVVH lose AAs in filter need to give 20 more
    using amino acid supplements
  • Protein deficits may be very important
  • Increasing evidence that patients with deficits
    in 1st 3-5 days do worse (?severely malnourished)
  • Indirect calorimetry the future?

36
Maintaining enteral intake
  • Follow a protocol use prokinetics/NJs
  • Gastric residuals do not stop feed until you
    have 2 residuals of gt250mls (check clinical
    signs) 400mls may be ok
  • Starting and stopping feed
  • Extubations, fasting for theatre, scans, minor
    procedures
  • Can catch up on feed that is missed

37
ESPEN PN in ICU
  • All patients receiving less than their targeted
    enteral feeding after 2 days should be considered
    for supplementary PN
  • All patients not able to receive EN within 24-48
    hours should be given PN
  • CCCN Inadequate enteral nutrition lt80 of target
    after 3 days PN
  • Do not delay nutrition in malnourished
  • Keep 10ml/hr EN if possible

38
Immunonutrition
  • The future replacement of the bodys own stress
    substrates and reduction of inflammation?
  • ESPEN new recommendations glutamine in all PN
    0.2-0.4g/kg/day
  • ??? SIGNET/REDOXs
  • glutamine in enteral nutrition for burns and
    trauma

39
Polyunsaturated Fatty Acids
Omega-6 ?-Linoleic acid (GLA) borage oil
Arachidonic Acid precursor Omega-3 Fish oils
Eicosapentanoic acid (EPA) and Docosahexanoic
acid (DHA)
40
Dietary Lipids
  • Ratios in paleolithic diet ?6?-3 11
  • Current Western diet 161
  • Current UK PN Soybean oil base 71
  • New PN (SMOF) 2.51
  • Cell membrane composition depends on balance
  • AA, DHA and EPA are present in inflammatory cell
    membrane phospholipids

41
Mechanisms of Action
  • ?-3s EPA/DHA are incorporated quickly into cell
    membrane inhibit ?-6 activity
  • Promote synthesis of low activity PGs and LTs
  • Decrease expression of adhesion molecules
  • Inhibit monocyte prodn of pro-inflamm cytokines
  • Decrease NFkB, increases lymphocyte apoptosis
  • Decrease pro-inflammatory gene expression
  • Lipoxins, resolvins and protectins

42
3 Studies OXEPA
  • Patients with ARDS fed with GLA, EPA and
    antioxidants had a reduction in pulmonary
    neutrophils
  • Improvement in oxygenation
  • Decrease in ventilator days
  • Decrease in ICU and hospital days
  • Gadek, Singer, Pontes-Arruda (sepsis)
  • Recommended by ESPEN in ARDS

43
ESPEN PN Guidelines
  • PN for critically ill surgical patients should
    probably include ?-3 fatty acids. Fish oil
    enriched lipid emulsions probably reduce ICU LOS.
  • The tolerance of MCT/LCT and olive oil emulsions
    is well established. These probably have
    advantages over LCT based lipid preparations
    small studies so far.

44
Anti-oxidants
  • Normal state reduction gt oxidation
  • Acute stress injury/sepsis causes acute
    dysregulation ROS/RNOS formed
  • Mitochondria are both sources and targets
  • Observational studies anti-oxidant capacity
    inversely correlated with disease severity due to
    depletion during oxidative stress

OXIDATION
REDUCTION
45
Antioxidants
  • Glutathione, Vitamins A, C and E
  • Zinc, copper, manganese, iron, selenium
  • Already added to feeds
  • Should we give extra? ESPEN VitC/thiamine/Se/Zn
    in CVVH/burns
  • Results of SIGNET and REDOXs awaited
  • Oxidative stress in critically ill patients
    contributes to organ damage / malignant
    inflammation

46
To conclude
  • Screen your patients
  • Early enteral feeding is best
  • Hyperglycaemia/overfeeding are bad
  • Keep glucose down lt10mmol/l (safely)
  • Nutritional deficit a/w worse outcome
  • Use EN and PN early to achieve goals
  • Audit delivery of nutrition regularly
  • Protocols improve delivery of feed
  • Some nutrients show promising results we should
    probably start using them now

47
Please feed me enough and with the right stuff!
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