ESPEN Congress Geneva 2014LLL LIVE COURSE: ICU NUTRITION AND PROBLEM SOLVING

More than choosing the route: enteral and parenteral nutritionP. Singer (IL)

Module 18.3

More than choosing a route: enteral and parenteral nutrition

Pierre Singer, MD

Module 18.3

Learning objectives

• Learn the possible routes of feeding• Understand the obstacles• Learn how to overcome the obstacles• Apply the proposed protocol to feed to

target

Which route?

ParenteralNutrition

Duodenal Jejunal Tube

SupplementalPN

ENTERAL

MessageParenteral Nutrition Enteral Nutrition

Message: this fight is wrong

Nutrition risk assessment• ICU-specific tool• Identify highest risk

patients

Benefit > Risk

Tight glycemic control• Avoidance of hypoglycemia• Minimize glycemic variability• Provide concurrently with

optimal nutrition support

Route of nutrition• Volume-based EN

when able (optimize tolerance)

• SPN to meet needs

• Timing depends on risk stratification

Amount of nutrition• Avoid underfeeding• Avoid overfeeding• Use indirect

calorimetry if available

Nutritional components• Energy• Protein• micronutrients

Monitoring• Daily reassessment

and adjustment• Laboratory data,

clinical status, fluid status

Nutrition risk assessment

Benefit > Risk

Tight glycemic control

Route of nutrition• oral• Volume-based EN

when able (optimize tolerance)

• SPN to meet needs

• Timing depends on risk stratificatio

• PN

Amount of nutrition

Nutritional components

Monitoring

© mh Nutrition Day 2009an

initiative supported by

Oral enteral parenteral

oral

0 1 2 4 6 8 14 21

0

20

40

60

80

20082007

day in ICU

perc

enta

ge

enteral

0 1 2 4 6 8 14 21

0

20

40

60

80

20082007

day in ICU

perc

enta

ge

parenteral

0 1 2 4 6 8 14 21

0

20

40

60

80 20072008

day in ICU

perc

enta

ge

Patient‘s nutrition control in ICU

Are you hungry?

Would you lik

e to eat?

Are you th

irsty?

Do you have

a dry mouth?

Do you have

nausea?

Do you have

abdominal pain?

01020304050

%

Guidelines ESPEN Guidelines

on Enteral

Nutrition:

Intensive Care

Kreymann K. G. et al.

Clin Nutr 2006, 25: 245-

59.

Free at: www.espen.org

Early enteral feeding is recommended

Enteral feeding, preferably as early as possible

Enteral Nutrition vs Standard Care (NPO or IV dextrose)

Kaplan‐Meier estimates of survival among critically ill medical patients in early feeding group and in the late feeding group. Early feeding was associated with a significantly higher rate of survival (p = 0.0005 by log‐rank test)

Effects of Early Enteral Feeding on the Outcome of ICU Mechanically Ventilated Medical Patients

Artinian et al, Chest 2006; 129:960

n=2,537

n=1,512

Indications for enteral feeding

• Normal peristaltism• No gastric residue > 500 mL• No severe diarrhea or ileus• No active upper GIT bleeding

Obstacles to enteral nutrition• Vomiting, aspiration and Increased gastric

residues• Severe diarrhea• Hemodynamic instability• Fear to induce intestinal complications, like

bowel ischemia • No protocol or Poor protocol application and

calorie deficit as a result• No possible use of duodenal feeding, PEG,

jejunostomy

• Hypoxemia, hypercapnia or acidosis are not contra indications

• No problem with muscle relaxants, hypothermia or small surgical procedures (open NGT)

• EN should be started early in abdominal trauma, after aortic aneuvrysm surgery

• EN should be given in pancratitis• EN should be administered in open

abdomen, in fistula if the tube is distal

The ischemic bowel……

EN should be delayed in• in case of abdominal distension, but not

in the absence of bowel sounds• in cases of ulcer bleeding with a high

risk of rebleeding• in Abdominal Compartment syndrome

and in bowel ischemia• in hemodynamic instability. Special

attention in increasing or persisting lactate levels (bowel ischemia).

Aspiration pneumonia

• Types of inhalation

– Micro-inhalations of saliva in case of swallowing disorders

– Massive inhalation massive in case of displacement of the feeding tube or emesis

– Silent and repeated inhalations of gastric juice

Aspiration pneumonia: how to prevent?

• Elevate the bed 30-45 O• Consider prokinetics• Give continuously the enteral feeding

Determination of the gastric volume containedduring nutrition

useful during the first 24-48 h of enteralnutrition / to be checked q4-6h

threshold 150-500 ml (expert opinion)Reinfusion of aspirated volume?

Gastric residual volumes

From Dr Christian Wunder

Gastric Residual Volume:Should we look at it?

In case of « high » residual volume?

• Check electrolytes (K, Mg)

• Promotility agents (gastric residue between 150 and 500 mL)– métoclopramide 10 mg x 3/j – erythromycine 3 mg/kg x 3/j

• In case of failure or gastric residue >500mL : duodenal/jejunal site or TPN

Duodenal tube

Complications of postpyloric feeding

• 1-2% have serious complications• Mechanical complications: dislodgement,

intraperitoneal migration, occlusion, volvulus

• Diarrhea: 22 to 50% of the patients• Cramping, abdominal distension• 13% never tolerate and convert to TPN• Bowel necrosis

Recommendations

Recommandations ESPEN 2006 Clin Nutr 2006; 25: 210-223

Percutaneous Endoscopic Gastrostomy: advantages

• No surgery• Bedside• Minimal sedation• Short procedure• Low costs

Rigid Flexible

Minard G. Nutr Clin Prac 1994;9:172-182

When should we proposed PEG?

• PEG is considered in the ICU only in patients after head trauma, CVA, long term ventilation and long ICU stay.

• Consider after 2 weeks for patients requiring enteral feeding for more than 8 weeks

• PEG is a safe procedure • Increases comfort but do not decrease

morbidity or mortality

TPN the good choice?

Parenteral nutrition indication

• If enteral nutrition contraindicated• If enteral nutrition does not reach

energy requirements

Acute Intestinal failure = Non absorption of nutrients

• Gut mass below the minimum amount required for adequate digestion and absorption of nutrients

• Intestinal obstruction or paralytic ileus: abdominal distension, vomiting and constipation and radiological findings of dilated small intestine

Complications

• Insertion (pneumothorax, arterial puncture)• Mechanical: Rupture, occlusion, embolus,

thrombosis, poor placement• Infection: Catheter site, subcatenous

tunnel, colonization, bacteremia, sepsis• Metabolic: Hyperglycemia, electrolyte

inbalance, refeeding syndrome• Liver function disorder

Recommendations

• Starvation or underfeeding in ICU is associated with increased morbidity and mortality Grade B

• All the patients who are not expected to be on an oral nutrition within 3 days should receive PN if EN is contraindicated or if they do not tolerate EN Grade C

Is this the appropriate target?

Cardiac surgery

Non Malnourished patients

High Target

Regulation of energy balance

SPN Study (Supplemental PN)

C. Heidegger et al. As presented at ESPEN 2011

C. Heidegger et al. As presented at ESPEN 20111

SPN Study (Supplemental PN)

Developing a protocol• Based on current recommendations• Adapted to meet local constraints

– Available formulas, tubes– Type of patients– Local habits

• Includes Frequently Asked Questions– complications (high residual volume, diarrhoea,

constipation) – daily concerns (access, planned extubation or exams,

insulin therapy,…)• Involvement of each healthcare professional

caring for the patient

Avoiding underfeeding in severely ill patientsLancet 2013 A Weimann and P Singer

Requirements• Starvation or underfeeding in ICU is

associated with increased morbidity and mortality Grade B

• ICU patients receiving PN should receive a formulation to cover their needs Grade C

• Provide energy as close as possible to the measured energy expenditure to decrease negative energy balance. Grade B

• All the patients receiving less than targeted enteral feeding after 3 days should receive complementary PN Grade C

Parenteral Nutrition

• Should be considered after 48 hours for patients staying in the ICU, and not reaching the energy target, mainly if malnourished.

• Is not increasing mortality but may increasing infection rate

• Should also be considered as complementary therapy to enteral feeding

Conclusions

• If possible use the gut through nasogastric or nasoduodenal tube

• If the gut is not accessible, use parenteral nutrition (subclaviar access)

• If required calories not achieved, complete with parenteral nutrition after 3 or 7 days?