A different form of malnutrition? Health Care Associated Malnutrition Nutrition deficiencies associated with physiological derangement and organ dysfunction

A different form of malnutrition?

Health Care Associated Malnutrition

Nutrition deficiencies associated with physiological derangement and organ

dysfunction that occurs in a health care facility

Patients who will benefit the most from nutrition therapy and who will be harmed the most from

by iatrogenic malnutrition (underfeeding)

Increasing Calorie Debt Associated with worse Outcomes

Caloric debt associated with: Longer ICU stay

Days on mechanical ventilation Complications

Mortality

Adequacy of EN

Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006

0200

400600

8001000

12001400

16001800

2000

1 3 5 7 9 11 13 15 17 19 21

Days

kcal

Prescribed Engergy

Energy Received From Enteral Feed

Caloric Debt

• Point prevalence survey of nutrition practices in ICU’s around the world conducted Jan. 27, 2007

• Enrolled 2772 patients from 158 ICU’s over 5 continents

• Included ventilated adult patients who remained in ICU >72 hours

Faisy BJN 2009;101:1079

Mechancially Vent’d patients >7days (average ICU LOS 28 days)

Effect of Increasing Amounts of Calories from EN on Infectious

Complications

Heyland Clinical Nutrition 2010

Multicenter observational study of 207 patients >72 hrs in ICU followed prospectively for development of infection

for increase of 1000 cal/day, OR of infection at 28 days

Relationship between increased nutrition intake and physical function (as defined by SF-36 scores)

following critical illness

Multicenter RCT of glutamine and antioxidants (REDOXS Study)First 364 patients with SF 36 at 3 months and/or 6 months

for increase of 30 gram/day, OR of infection at 28 days

Heyland Unpublished Data

Model *

Estimate (CI)P values

(A) Increased energy intake

PHYSICAL FUNCTIONING (PF) at 3 months 3.2 (-1.0, 7.3) P=0.14

ROLE PHYSICAL (RP) at 3 months 4.2 (-0.0, 8.5) P=0.05

STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 3 months

1.8 (0.3, 3.4) P=0.02

PHYSICAL FUNCTIONING (PF) at 6 months 0.8 (-3.6, 5.1) P=0.73

ROLE PHYSICAL (RP) at 6 months 2.0 (-2.5, 6.5) P=0.38

STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 6 months

0.70 (-1.0, 2.4) P=0.41

More (and Earlier) is Better!

If you feed them (better!)They will leave (sooner!)

Permissive Underfeeding(Starvation)?

187 critically ill patients Tertiles according to ACCP recommended levels of

caloric intake Highest tertile (>66% recommended calories) vs.

Lowest tertile (<33% recommended calories) in hospital mortality Discharge from ICU breathing spontaneously

Middle tertile (33-65% recommended calories) vs. lowest tertile Discharge from ICU breathing spontaneously

Krishnan et al Chest 2003

Optimal Amount of Calories for Critically Ill Patients:

Depends on how you slice the cake!

• Objective: To examine the relationship between the amount of calories recieved and mortality using various sample restriction and statistical adjustment techniques and demonstrate the influence of the analytic approach on the results.

• Design: Prospective, multi-institutional audit

• Setting: 352 Intensive Care Units (ICUs) from 33 countries.

• Patients: 7,872 mechanically ventilated, critically ill patients who remained in ICU for at least 96 hours.

Heyland Crit Care Med 2011

Association between 12 day average caloric adequacy and

60 day hospital mortality(Comparing patients rec’d >2/3 to those who rec’d

<1/3)A. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are included as zero calories*

B. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.*

C. In ICU for at least 4 days before permanent progression to exclusive oral feeding. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.*

D. In ICU at least 12 days prior to permanent progression to exclusive oral feeding*

*Adjusted for evaluable days and covariates,covariates include region (Canada, Australia and New Zealand, USA, Europe and South Africa, Latin America, Asia), admission category (medical, surgical), APACHE II score, age, gender and BMI.

0.4 0.6 0.8 1.0 1.2 1.4 1.6

UnadjustedAdjusted

Odds ratios with 95% confidence intervals

Association Between 12-day Caloric Adequacy and 60-Day Hospital

Mortality

Heyland CCM 2011

Optimal amount= 80-85%

More (and Earlier) is Better!

If you feed them (better!)They will leave (sooner!)

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure

• Single center study of 200 mechanically ventilated patients

• Trophic feeds: 10 ml/hr x 5 days

Rice CCM 2011;39:967


Rice CCM 2011;39:967

Did not measure infection nor physical function!


“survivors who received initial full-energy enteral nutrition were more likely to be discharged home with or without help as compared to a rehabilitation facility (68.3% for the full-energy group vs. 51.3% for the trophic group; p = .04).”

Rice CCM 2011;39:967


• Average age 51

• Few comorbidities

• Average BMI 29

• All fed within 24 hrs (benefits of early EN)

• Average duration of study intervention 5 days

No effect in young, healthy, overweight patients who

have short stays!

Large multicenter trial of this concept (EDEN study) by ARDSNET just finished

ICU patients are not all created equal…should we expect the impact of nutrition

therapy to be the same across all patients?

How do we figure out who will benefit the most from Nutrition

Therapy?

Health Care Associated Malnutrition

Do Nutrition Screening tools help us discriminate those ICU patients that will benefit the most from artificial nutrition?

Patients who will benefit the most from nutrition therapy and who will be harmed the most from

by iatrogenic malnutrition (underfeeding)

All ICU patients treated the same

Albumin: a marker of malnutrition?

• Low levels very prevalent in critically ill patients• Negative acute-phase reactant such that synthesis,

breakdown, and leakage out of the vascular compartment with edema are influenced by cytokine-mediated inflammatory responses

• Proxy for severity of underlying disease (inflammation) not malnutrition

• Pre-albumin shorter half life but same limitation

Subjective Global Assessment?

• When training provided in advance, can produce reliable estimates of malnutrition

• Note rates of missing data

• mostly medical patients; not all ICU• rate of missing data?• no difference between well-nourished and malnourished patients with regard to the serum protein values on admission, LOS, and mortality rate.

“We must develop and validatediagnostic criteria for appropriate

assignment of thedescribed malnutrition syndromes

to individual patients.”

Nutrition Statusmicronutrient levels - immune markers - muscle mass

Starvation

Acute-Reduced po intake

-pre ICU hospital stay

Chronic-Recent weight loss

-BMI?

InflammationAcute

-IL-6-CRP-PCT

Chronic-Comorbid illness

A Conceptual Model for Nutrition Risk Assessment in the Critically Ill

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC

Score).

• When adjusting for age, APACHE II, and SOFA, what effect of nutritional risk factors on clinical outcomes?

• Multi institutional data base of 598 patients

• Historical po intake and weight loss only available in 171 patients

• Outcome: 28 day vent-free days and mortality

Heyland Critical Care 2011, 15:R28

What are the nutritional risk factors associated with clinical outcomes?

(validation of our candidate variables)Non-survivors by day 28

(n=138) Survivors by day 28

(n=460) p values

Age 71.7 [60.8 to 77.2] 61.7 [49.7 to 71.5] <.001

Baseline APACHE II score 26.0 [21.0 to 31.0] 20.0 [15.0 to 25.0] <.001

Baseline SOFA 9.0 [6.0 to 11.0] 6.0 [4.0 to 8.5] <.001

# of days in hospital prior to ICU admission 0.9 [0.1 to 4.5] 0.3 [0.0 to 2.2] <.001

Baseline Body Mass Index 26.0 [22.6 to 29.9] 26.8 [23.4 to 31.5] 0.13

Body Mass Index 0.66

<20 6 ( 4.3%) 25 ( 5.4%)≥20 122 ( 88.4%) 414 ( 90.0%)

# of co-morbidities at baseline 3.0 [2.0 to 4.0] 3.0 [1.0 to 4.0] <0.001

Co-morbidity <0.001

Patients with 0-1 co-morbidity 20 (14.5%) 140 (30.5%)Patients with 2 or more co-morbidities 118 (85.5%) 319 (69.5%)

C-reactive protein¶ 135.0 [73.0 to 214.0] 108.0 [59.0 to 192.0] 0.07

Procalcitionin¶ 4.1 [1.2 to 21.3] 1.0 [0.3 to 5.1] <.001

Interleukin-6¶ 158.4 [39.2 to 1034.4] 72.0 [30.2 to 189.9] <.001

171 patients had data of recent oral intake and weight loss Non-survivors by day 28

(n=32) Survivors by day 28

(n=139) p values

% Oral intake (food) in the week prior to enrolment 4.0[ 1.0 to 70.0] 50.0[ 1.0 to 100.0] 0.10

% of weight loss in the last 3 month 0.0[ 0.0 to 2.5] 0.0[ 0.0 to 0.0] 0.06

Variable

Spearman correlation with VFD within 28

days

p valuesNumber of

observations

Age -0.1891 <.0001 598

Baseline APACHE II score -0.3914 <.0001 598

Baseline SOFA -0.3857 <.0001 594

% Oral intake (food) in the week prior to enrollment 0.1676 0.0234 183

number of days in hospital prior to ICU admission -0.1387 0.0007 598

% of weight loss in the last 3 month -0.1828 0.0130 184

Baseline BMI 0.0581 0.1671 567

# of co-morbidities at baseline -0.0832 0.0420 598

Baseline CRP -0.1539 0.0002 589

Baseline Procalcitionin -0.3189 <.0001 582

Baseline IL-6 -0.2908 <.0001 581

What are the nutritional risk factors associated with clinical outcomes?

(validation of our candidate variables)


Score).

For example, exact quintiles and logistic parameters for age

Exact Quintile Parameter Points

19.3-48.8 referent 0

48.9-59.7 0.780 1

59.7-67.4 0.949 1

67.5-75.3 1.272 1

75.4-89.4 1.907 2


Score). Variable Range PointsAge <50 0

50-<75 1>=75 2

APACHE II <15 015-<20 120-28 2>=28 3

SOFA <6 06-<10 1>=10 2

# Comorbidities 0-1 02+ 1

Days from hospital to ICU admit 0-<1 01+ 1

IL6 0-<400 0400+ 1

AUC 0.783Gen R-Squared 0.169Gen Max-rescaled R-Squared 0.256

BMI, CRP, PCT, weight loss, and oral intake were excluded because they were not significantly associated with mortality or their inclusion did not improve the fit of the final model.

The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).

0 1 2 3 4 5 6 7 8 9 10

Nutrition Risk Score

Mo

rta

lity

Ra

te (

%)

02

04

06

08

0

ObservedModel-based

n=12 n=33 n=55 n=75 n=90 n=114 n=82 n=72 n=46 n=17 n=2


0 1 2 3 4 5 6 7 8 9 10

Nutrition Risk Score

Da

ys o

n M

ech

an

ica

l Ve

ntil

ato

r

02

46

81

01

21

4 ObservedModel-based

n=12 n=33 n=55 n=75 n=90 n=114 n=82 n=72 n=46 n=17 n=2


0 50 100 150

0.0

0.2

0.4

0.6

0.8

1.0

Nutrition Adequacy Levles (%)

28

Da

y M

ort

alit

y

11 111

1

111

22

2

22 2

22

2

33

333

33

3

3

333

3

3

33

33

444444

4444

4

444

44 4444

44

4

44

4 444 4 44

44

4

55 5555 5 55 5 5 5 5 5

5 55555 5

5

55

555 55 55555

55

5 555 555

66 66 6666666

6 66

6

666 666 66 6

6

66

66

6 6

666

6 66

66

77

7

77

7

7

7

7

7

7

7

7

7

77

7

7

77

7

7

7 7

7

88

8

8

8

8

8

8

88

88

8

88

8

8

88

8

8

8

99

9

9

9

9

9

9

9

1010

Interaction between NUTRIC Score and nutritional adequacy (n=211)*

P value for the interaction=0.01

Heyland Critical Care 2011, 15:R28

Who might benefit the most from nutrition therapy?

• High NUTRIC Score?

• Clinical– BMI– Projected long length of stay

• Others?

Do we have a problem?

Preliminary Results of INS 2011

Overall Performance: Kcals

84%56%

15%

N=211

Failure Rate% patients who failed to meet minimal quality targets (80% overall energy

adequacy)

Can we do better?

The same thinking that got you into this mess won’t get you out of it!

• 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.

• Start with a semi elemental solution, progress to polymeric

• Tolerate higher GRV threshold (300 ml or more)• Motility agents and protein supplements are started

immediately, rather than started when there is a problem.

The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients:

The PEP uP Protocol!

A Major Paradigm Shift in How we Feed EnterallyHeyland Crit Care 2010

In Conclusion• Health Care Associate Malnutrition is rampant• Not all ICU patients are the same in terms of ‘risk’• Iatrogenic underfeeding is harmful in some ICU

patients or some will benefit more from aggressive feeding (avoiding protein/calorie debt)

• BMI and/or NUTRIC Score is one way to quantify that risk

• Need to do something to reduce iatrogenic malnutrition in your ICU!– Audit your practice first!

www.criticalcarenutrition.com

Questions?

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Documents

A different form of malnutrition? Health Care Associated Malnutrition Nutrition deficiencies associated with physiological derangement and organ dysfunction