Learning Objectives Define iatrogenic malnutrition Describe the nature of the evidence related to optimal amount of calories/protein List key variables

Learning Objectives

• Define iatrogenic malnutrition

• Describe the nature of the evidence related to optimal amount of calories/protein

• List key variables to consider in assessing nutritional risk in ICU patients

• List strategies to improve nutritional adequacy in the critical care setting.

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)

Adjunctive Supportive Care

ProactivePrimaryTherapy

Early and Adequate Nutrition is therapy that modulates the underlying disease process and impacts patient outcomes

Early Feeding Supports Gastrointestinal Structure and

Function• Maintenance of gut barrier function

• Increased secretion of mucus, bile, IgA• Maintenance of peristalsis and blood flow

•Attenuates oxidative stress and inflammation•Supports GALT

•Improves glucose absorption

Alverdy (CCM 2003;31:598)Kotzampassi Mol Nutr Food Research 2009 Nguyen CCM 2011

Early vs. Delayed EN: Effect on Infectious

Complications

Updated 2009www.criticalcarenutrition.com

Early vs. Delayed EN: Effect on Mortality

Updated 2009www.criticalcarenutrition.com

Feeding the Hypotensive Patient?

DiGiovine et al. AJCC 2010

The beneficial effect of early feeding is more evident in the sickest patients, i.e, those on

multiple vasopressor agents.

Prospectively collected multi-institutional ICU database of 1,174 patients who required mechanical ventilation for more than two days and were on

vasopressor agents to support blood pressure.

Optimal Amount of Protein and Calories for Critically Ill

Patients?

Early EN (within 24-48 hrs of admission) is recommended!

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

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

Faisy BJN 2009;101:1079

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

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!)

JAMA 1994;271:56

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

What other outcomes might be important?


“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

Rice et al. JAMA 2012;307


Still no measure of physical function!


Enrolled 12% of patients screened


• Average age 52

• Few comorbidities

• Average BMI 29-30

• 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!


Randomized Good follow up ITT No blinding

1. How representative are these patients to ALL the patients in your

ICU? May miss an important negative effect in ‘high risk’ patients

2. What about the physically recovery of underfed patients?

No benefit, potential harm, minimal cost advantage= Do not use routinely!

Internally valid

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?


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).

• % oral intake in the week prior was dichotomized into patients who reported less than 100% versus everyone else

• Weight loss was dichotomized as patients who reported any weight loss versus everyone else.

• BMI was dichotomized as <20 versus other

• Comorbidities was left as integer values range 0-5

• The remaining candidate variables were categorized into five equal sized groups (quintiles).


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)

Strategies to Maximize the Benefits and Minimize the Risks

of EN

• feeding protocols

• motility agents

• elevation of HOB

• small bowel feeds

weak evidence

stronger evidence

Canadian CPGs www.criticalcarenutrition.com

Use of Nurse-directed Feeding Protocols

Start feeds at 25 ml/hr

Check Residuals

q4h

> 250 ml

•hold feeds

•add motility agent

•reassess q 4h

< 250 ml

•advance rate by 25 ml

•reassess q 4h

2009 Canadian CPGs www.criticalcarenutrition.com

“Should be considered as a strategy to optimize delivery of enteral nutrition in critically ill adult patients.”

Characteristics Total

n=269

Feeding Protocol

Yes 208 (78%)

Gastric Residual Volume Tolerated in Protocol

Mean (range) 217 ml (50, 500)

Elements included in Protocol

Motility agents 68.5%

Small bowel feeding 55.2%

HOB Elevation 71.2 %

The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery:

Results of a multicenter observational study

Heyland JPEN 2010

15.2% using the recommended

threshold volume of 250 ml

The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery:

Results of a multicenter observational study

• Time to start EN from ICU admission 41.2 in protocolized sites vs 57.1 hours in those without a protocol

• Patients rec’ing motility agents 61.3% in protocolized sites vs 49.0% in those without

Heyland JPEN 2010

0

20

40

60

80

Calories from EN Total Calories

Protocol

No Protocol

P<0.05

P<0.05

Can we do better?

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

Impaired motility Medications Metabolic, electrolyte abnormalities Underlying disease

Reasons for Inadequate Intake

Prophylactic use of motility agents

Slow starts and slow ramp ups Interruptions

Mostly related to procedures Not related to GI dysfunction

Can be overcome by better feeding

protocols

Protocol to Manage Interruptions to EN due to non-

GI Reasons

Can be downloaded from www.criticalcarenutrition.com

Enhanced Protein-Energy Provision

via the Enteral Routein Critically Ill Patients:

The PEP uP Protocol

• Different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds.

• 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 (250 ml or more)• Motility agents and protein supplements are started

immediately• Nurse reports daily on nutritional adequacy.

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 Enterally

Begin 24 hour volume-based feeds. After initial tube placement confirmed, start Pepatmen 1.5. Total volume to receive in 24 hours is 17ml x weight (kg)= <write in 24 target volume>. Determine initial rate as per Volume Based Feeding Schedule. Monitor gastric residual volumes as per Adult Gastric Flow Chart and Volume Based Feeding Schedule. OR Begin Peptamen 1.5 at 10 mL/h after initial tube placement confirmed. Hold if gastric residual volume >500 ml and ask Doctor to reassess. Reassess ability to transition to 24 hour volume-based feeds next day. {Intended for patient who is hemodynamically unstable (on high dose or escalating doses of vasopressors, or inadequately resuscitated) or not suitable for high volume enteral feeding (ruptured AAA, upper intestinal anastomosis, or impending intubation)}OR

NPO. Please write in reason: __________________ ______. (only if contraindication to EN present: bowel perforation, bowel obstruction, proximal high output fistula. Recent operation and high NG output not a contraindication to EN.) Reassess ability to transition to 24 hour volume-based feeds next day.

Stable patients should be able to tolerate goal rate

We use a concentrated solution to maximize

calories per ml

Drs need to justify why there are keeping patients

NPO

If unstable or unsuitable, just use

trophic feeds

We want to minimize the use of NPO but if selected, need to reassess next day

The PEP uP Protocol

Note, there are only a few absolute

contraindications to EN

Note indications for trophic feeds

It’s not just about calories...

Protein supplement Beneprotein® 14 grams mixed in 120 mls sterile water

administered bid via NG

So in order to minimize this, we order:

Loss of lean muscle mass

Inadequate protein intake

Immune dysfunction

WeakProlonged mechanical

ventilation

Other Strategies to Maximize the Benefits and Minimize the Risks of

EN

• Motility agents started at initiation of EN rather that waiting till problems with High GRV develop.– Maxeran 10 mg IV q 6h (halved in renal failure)

– If still develops high gastric residuals, add Erythromycin 200 mg q 12h.

– Can be used together for up to 7 days but should be discontinued when not needed any more

– Reassess need for motility agents daily

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

The PEP uP Protocol!

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 TotalP-value 0.08 0.0003 0.10 0.19 0.48 0.18 0.11 <0.0001

Adequacy of Calories from EN (Before Group vs. After Group on Full Volume Feeds)

Heyland Crit Care 2010

Change of nutritional intake from baseline to follow-up of all the study sites (all patients)

% calories received/prescribed

% c

alo

rie

s re

ceiv

ed

/pre

scri

be

d

326326

326326

331331

331331

360360

360360

371371

371371

372372372372

373373373373

374374

374374

375375

375375

390390

390390

Baseline Follow-up

20

30

40

50

60

70

80

p value <0.0001

Intervention sites

% c

alo

rie

s re

ceiv

ed

/pre

scri

be

d

p value=0.65

327327 327327

p value=0.65p value=0.65

359359

359359


362362

362362

p value=0.65p value=0.65p value=0.65p value=0.65p value=0.65p value=0.65

376376

376376

p value=0.65

377377

377377

p value=0.65

378378378378

p value=0.65

379379

379379

p value=0.65

380380

380380


404404

404404


Baseline Follow-up

20

30

40

50

60

70

80

Control sites

Change of nutritional intake from baseline to follow-up of all the study sites (all patients)

% protein received/prescribed

% p

rote

in r

ece

ive

d/p

resc

rib

ed

326326

326326

331331

331331

360360

360360

371371

371371

372372

372372

373373 373373

374374

374374

375375

375375390390

390390

Baseline Follow-up

20

30

40

50

60

70

80

p value <0.0001

Intervention sites

% p

rote

in r

ece

ive

d/p

resc

rib

ed

p value=0.78

327327 327327


359359

359359


362362 362362

p value=0.78p value=0.78p value=0.78p value=0.78p value=0.78p value=0.78

376376

376376

p value=0.78

377377

377377

p value=0.78

378378

378378

p value=0.78

379379

379379

p value=0.78

380380

380380


404404

404404


Baseline Follow-up

20

30

40

50

60

70

80

Control sites

Effect on VAP

Updated 2011,www.criticalcarenutrition.com

Small Bowel vs. Gastric Feeding: A meta-analysis

Other Strategies to Maximize the Benefits and Minimize the Risks of

EN

Does Postpyloric Feeding Reduce Risk of GER and Aspiration?

Tube Position

# of patients

% positive for GER

% positive for

Aspiration

Stomach 21 32 5.8

D1 8 27 4.1

D2 3 11 1.8

D4 1 5 0

Total 33 75 11.7

P=0.004 P=0.09

Heyland CCM 2001;29:1495-1501

FRICTIONAL ENTERAL FEEDING TUBE(TIGER TUBETM)

Flaps to allow peristalsis to pull tube passively forward

Sucessful jejunal placement >95%

CORTRAK® A new paradigm in feeding tube placement

– Aid to placement of feeding tubes into the stomach or small bowel

– The tip of the stylet is a transmitter.

– Signal is picked up by an external receiver unit.

– Signal is fed to an attached Monitor unit.

– Provides user with a real-time, graphic display that represents the path of the feeding tube.

A Change to Nursing Report

Adequacy of Nutrition Support =

24 hour volume of EN receivedVolume prescribed to meet caloric

requirements in 24 hours

Please report this % on rounds as

part of the GI systems report

When performance is measured, performance improves.

When performance is measured and

reported back, the rate of improvement

accelerates. Thomas Monson

What if you can’t provide adequate nutrition enterally?

… to add PN or not to add PN,

that is the question!


Early vs. Late Parenteral Nutrition in Critically ill Adults

• 4620 critically ill patients

• Randomized to early PN

– Rec’d 20% glucose 20 ml/hr then PN on day 3

• OR late PN

– D5W IV then PN on day 8

• All patients standard EN plus ‘tight’ glycemic control

Cesaer NEJM 2011

• Results:

Late PN associated with

• 6.3% likelihood of early discharge alive from ICU and hospital

• Shorter ICU length of stay (3 vs 4 days)

• Fewer infections (22.8 vs 26.2 %)

• No mortality difference

Early vs. Late Parenteral Nutrition in Critically ill Adults

• ? Applicability of data– No one give so much IV glucose in first few days– No one practice tight glycemic control

• Right patient population?– Majority (90%) surgical patients (mostly cardiac-60%)– Short stay in ICU (3-4 days)– Low mortality (8% ICU, 11% hospital)– >70% normal to slightly overweight

• Not an indictment of PN– Early group only rec’d PN for 1-2 days on average– Late group –only ¼ rec’d any PN

Cesaer NEJM 2011

What if you can’t provide adequate nutrition enterally?

… to TPN or not to TPN,

that is the question!

•Case by case decision•Maximize EN delivery

prior to initiating PN•Use early in high risk

cases

ICU patientsBMI <25 R

PN for 7 days

Control

The TOP UP Trial

Fed enterally

Primary Outcome

60-day mortality

BMI >35

Stratified by:SiteBMI

Med vs Surg

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!– PEP uP protocol in all– Selective use of small bowel feeds then sPN in high risk patients

Yes

YES

Day 3

>80% of Goal

CaloriesNo

NO

No problem

Anticipated Long Stay?

Yes No

Maximize EN with motility agents and small bowel feeding

Yes

YES Not tolerating

EN at 96 hrs? No

NO

Supplemental PN?

Start PEP UP

High Risk?

Carry on!

www.criticalcarenutrition.com

Questions?

Documents

Learning Objectives Define iatrogenic malnutrition Describe the nature of the evidence related to optimal amount of calories/protein List key variables