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Critical care board review
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Nutri&on)support)in)the)cri&cally)ill)pa&ent)
Brian)K.)Gehlbach,)MD)Division)of)Pulmonary,)Cri&cal)Care,)&)
)))Occupa&onal)Medicine)University)of)Iowa)
!!
Disclosures)None!
Objec&ves)1. Cite!evidence.based!strategies!for!the!
provision!of!enteral!nutri9on!in!the!ICU.!2. Describe!the!clinical!manifesta9ons!and!
preven9on!of!the!refeeding!syndrome.!3. Cite!the!differen9al!diagnosis!for!diarrhea!
in!the!cri9cally!ill!pa9ent.!
Cri&cal)illness)is)metabolically)costly)
Long!CL!et!al.!JPEN!1979.
Changes)in)res&ng)metabolic)
expenditure)with)&me)
The)intes&nal)microflora)is)altered)during)cri&cal)illness)
Adapted!from!Alverdy!JC!et!al.!J!Leukoc!Biol!2008.!
Use)of)vasoac&ve)drugs)=!!intes9nal!ischemia,!Δ!in!mucosal!pH,!CO2!and!O2!!!
Highly)processed)enteral)nutri&on)±)parenteral)nutri&on!=!distal!bowel!nutrient!deficiency!
Mul&ple)an&bio&c)use)=!predominance!of!virulent!&!resistant!organisms!
Long)term)opiate)use)=!intes9nal!iner9a!±!bacterial!overgrowth.organisms!trapped—cannot!jump!to!new!host!
Yet,)most)studies)of)specific)nutri&onal)strategies)have)been)nega&ve,)and)some)show)harm.))
Why?)• The!studies!aren’t!big!enough,!or!!
!good!enough?!• The!pa9ents!are!too!heterogeneous?!• Nutri9on!doesn’t!ma[er?!• We!don’t!know!enough!(yet)?!
– Ex.!nutri9on!&!autophagy!!
A)55)year)old)male)presents)with)pneumonia)and)ARDS.)Which)of)the)following)nutri&onal)strategies)is)best)supported)by)the)evidence?))A. Targe9ng!a!blood!glucose!level!of!81!to!108!mg/dl.!!B. The!administra9on!of!enteral!omega.3!fa[y!acid,!γ.
linolenic!acid,!and!an9oxidant!supplements.!C. The!provision!of!enteral!nutri9on!plus!early!
supplemental!parenteral!nutri9on!as!needed!to!meet!caloric!goals.!!
D. The!provision!of!trophic!enteral!feeds!for!the!first!6!days.!!
E. Holding!enteral!feeds!for!gastric!residual!volumes!>!300!ml.!!
NEJM 2009. • 6104!medical!pts!expected!to!require!ICU!tx!for!≥!3!days!
!• Intensive!(81!to!108)!vs!conven9onal!(≤!180)!control!
!• Lower!mortality!with!conven9onal!glucose!control!
• 272!adults!with!ALI!• No!benefit,!&!sugges9on!of!harm!!
Heyland!et!al.!NEJM!2013.!
• Background:↓!glutamine!levels!associated!with!↑!mortality;!evidence!of!oxida9ve!stress!in!cri9cal!illness!
• Result:!No!effect!of!an9oxidants;!glutamine!↑’d!mortality!
Rice!et!al.!ARDS!Network.!NEJM!2011.!
• PN!ini9ated!on!Day!3!as!needed!to!achieve!caloric!goal!(EN!+!PN!=!Calculated!caloric!goal)!&!adjusted!daily!
• Study!conducted!in!European!ICUs!following!European!guidelines.!Therefore,!“late!PN”!was!the!ac9ve!interven9on.!
• BG!target!80.110.!Casaer!et!al.!NEJM!2011.!
The)Early)group)received)far)more)energy)than)the)Late)group…)
Casaer!et!al.!NEJM!2011.!
Total)Ene
rgy)
(kcal/kg/day))
Total)Ene
rgy)
%)of)target)
…but)there)were)be\er)outcomes)with)delayed)PN)
• More!likely!to!be!“discharged!alive!earlier”!!
• ↓!ICU!infec9ons!&!cholestasis!
• ↓!MV!&!RRT!
Survival
Casaer!et!al.!NEJM!2011.!
In!a!post%hoc(analysis,!the!greatest!difference!occurred!in!pts!for!whom!early!EN!was!surgically!contraindicated!!(
Enteral)feeding)preserves)structure)&)func&on)of)GI)tract)
• Prevents!atrophy!of!small!intes9nal!villi!
• Maintains!gut!barrier!func9on!
• Preserves!IgA!secre9on!
Ohta!Am!J!Surgery!2003.!
Ini&al)trophic)vs)full)enteral)feeding)in)pts)with)ALI:)the)EDEN)trial)• Trophic!vs!full!enteral!
feeding!for!the!first!6!days!
• No)difference!in!ven9lator.free!days,!60.day!mortality,!or!infec9ous!complica9ons!
• Trophic!feeding!group!had!less!GI!intolerance!!
ARDSNetwork.!JAMA!2012.!
1000)adults)
Full)feeding)protocol)
Also)well)tolerated)!>)85%)of)pts)ini&ally)fed)using)a)gastric)tube)
ARDSNetwork.!JAMA!2012.!
“Doctor,)the)residual)is)(250,%300,%___,%etc)…should)we)hold)the)tube)feeds?)
• Mul9center!RCT!of!no!gastric!residual!volume!monitoring!vs!250!ml!trigger!
• Clinical!intolerance!=!regurgita9on!+/.!vomi9ng!
• No)differences)in)VAP)rates)or)outcomes)
Development)of)VAP)
Reignier!et!al.!NEJM!2013.!
The)clinical)bo\om)line)for)monitoring)tolerance)of)enteral)feeding)
It!is!reasonable!to!rely!on!clinical!signs!for!evidence!of!feeding!intolerance.!At!a!
minimum,!a!higher!gastric!residual!volume!trigger—say,!400!cc–is!
warranted!
A)43)year)old)male)with)severe)obesity)(BMI)45))presents)with)respiratory)failure)requiring)intuba&on)&)MV.)Which)of)the)following)is)true)regarding)his)nutri&onal)support?)A. Feeding!should!be!withheld!for!the!first!week.!!B. The!presence!of!increased!nutrient!reserves!in!obesity!
will!confer!protec9on!against!the!loss!of!lean!body!mass.!
C. He!should!receive!parenteral!nutri9on!in!order!to!reduce!the!risk!of!aspira9on.!
D. The!use!of!a!hypocaloric!regimen!(60.70%!target!energy!requirements)!may!improve!insulin!sensi9vity.!
E. His!dietary!plan!should!include!protein!restric9on!(e.g.!≤!1.5!g/kg!IBW/day).!
Considera&ons)for)the)cri&cally)ill)obese)pa&ent)• The!“obesity!paradox”:!mild!to!moderate!obesity!(class!I!
and!II)!may!be!somewhat!protec9ve!in!CI!
• Controlled!hypocaloric!regimens!may!reduce!fat!stores,!preserve!lean!body!mass,!and!increase!insulin!sensi9vity.!(ASPEN!guidelines).!– 60.70%!target!energy!requirements,!or!22.25!kcal/kg!ideal!body!weight/day.!
• A[en9on!to!protein!!!– BMI!30.40:!≥!2!g/kg!IBW/day!– BMI!≥!40:!≥!2.5!g/kg!IBW/day!! McClave!JPEN!2011.!
A)65)year)old)homeless)man)with)a)history)of)alcohol)abuse,)chronic)pancrea&&s,)weight)loss,)and)severe)COPD)is)intubated)for)respiratory)failure.)A)feeding)tube)is)placed)and)full)enteral)feeding)is)ini&ated.))
Which)of)the)following)is)true?)A. In!the!short!term,!full!enteral!feeding!may!impair!efforts!
at!discon9nuing!mechanical!ven9latory!support.!!B. The!pa9ent!is!at!risk!for!volume!deple9on!caused!by!
hyperinsulinemia,!which!increases!the!renal!excre9on!of!Na.!
C. The!pa9ent!is!at!risk!for!hyperkalemia!caused!by!transcellular!shiy!of!potassium.!
D. Diarrhea!may!occur!as!the!result!of!longstanding!mucosal!hypertrophy.!
E. The!presence!of!a!prolonged!PR!interval!may!indicate!the!presence!of!magnesium!deficiency.!
The)refeeding)syndrome)At)risk)Alcoholism!Ac9ve!cancer!+/.!tx!Malabsorp9on!!Poorly!controlled!diabetes!Chronic!liver!disease!COPD!AIDS!Ea9ng!disorders!Food!insecurity!!!!!
Manifesta&ons)• Onset!usually!within!
several!days!of!↑!feeding!• ↑!!insulin!&!synthesis!of!
glycogen,!protein,!&!fat!leading!to!↓!potassium,!phosphorus,!magnesium!
• Cardiac!arrhythmias!&!CHF!• Respiratory!muscle!
weakness!• Convulsions!!
Preven&on:)Recognize)atkrisk)scenarios,)ini&ate)feeding)at)50%)of)energy)requirements)(permissive)underfeeding),)&)monitor)electrolytes)closely)
Malnutrii&on)warning)signs)• Uninten9onal!weight!loss!>!10%!within!1.3!months!!• Prolonged!fas9ng!or!NPO!status!>!7.10!days!• Inadequate!nutri9onal!intake!>!10!days!• <!70.80%!ideal!body!weight!• Muscle!was9ng!• Chronic!dysphagia!• Persistent!N/V/D!!!Byrnes.!Curr!Opin!Clin!Nutr!Metab!Care!2011.!
Approach)to)diarrhea)Differen&al)diagnosis)
– C.(difficile(– Hyperosmolar!agents!(hypertonic!elixirs,!sorbitol.containing!meds)!
– An9bio9cs,!other!medica9ons!– Mucosal!atrophy!!
Can)try)• con9nuous!instead!of!bolus!feeding!• a!formula!with!lower!osmolality!• soluble!fiber.containing!formula9ons!(avoid!if!at!high!risk!for!
bowel!ischemia!or!severe!dysmo9lity)!
Summary)• Use!the!gut!(the!corollary:!Avoid!TPN)!• Use!“regular”!feeding!tubes!in!most!instances!• The!op9mal!dose!of!nutri9on!is!not!known.!!• Monitoring!of!enteral!feeding!should!be!based!primarily!on!clinical!criteria!
• Iden9fy!pa9ents!at!risk!for!refeeding!syndrome!• Diarrhea!can!be!from!C.(difficile,!meds,!mucosal!atrophy,!formula9on!