Precise Nutrition with Precision - PowerPoint Presentation

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Precise Nutrition with Precision

ISCCM Day

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Precise Nutrition with Precision

Assessment:

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Nutritional Screening

Rapid and simple evaluation

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Screening tools

SGA-

Subjective Global Assessment

NRS- Nutrition Risk Screening

MUST- Malnutrition Universal Screening

Tool

MNA- Mini Nutritional Assessment

NUTRIC score

Nutritional Assessment tools

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Precise Nutrition with Precision

Diagnosis:

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GLIM criteria

To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present.

Phenotypic metrics for grading severity are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes.

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Precise Nutrition with Precision

Intervention:

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Hemodynamically stable

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Early feeding reduces mortality in ICU

2

1

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Enteral nutrition

“

If the gut works, use it”

Maintains GI tract function and integrity

Stimulates GI contractility and trophic substance release

Supports gut and mucosa associated lymphoid tissues

Preserves gut

microbiotaMcClave SA, Heyland DK. The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract 2009;24:305-315.

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Nutritional adequacy is associated with

improved outcomes in critical illness

Nutritional adequacy

(% of requirement

)

>80%

50-<80%

0-<50%

Improved 6-mo survival & physical recovery 3 mos post-ICU discharge per 25% increase in nutritional adequacy

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Inadequate Delivery of Enteral

Nutrition Is Common

Frequent problems are associated with the delivery and tolerance of EN

Discrepancies exist between the delivered vs. prescribed EN

1.

Krishnan JA, Parce PB, Martinez A, et al. Chest. 2003;124:297-305.

; 2 .

Elpern

EH, Stutz L, Peterson S, et al.

Am J

Crit

Care

. 2004;13:221-227.; 3.

Rice

TW,

Swope

T, Bozeman S, et al.

Nutrition

. 2005;21:786-792.

; 4. O'Leary-Kelley CM, Puntillo KA, Barr J, et al.

Am J

Crit

Care

. 2005;14:222-231.; 5. Higgins PA, Daly BJ, Lipson AR, et al.

Am J

Crit

Care

. 2006;15:166-176.; 6.

Hise

ME,

Halterman

K,

Gajewski

BJ, et al.

J Am

Diet

Assoc

. 2007;107:458-465.

; 7. O'Meara D, Mireles-

Cabodevila

E, Frame F, et al.

Am J

Crit

Care

. 2008;17:53-61.

% of Nutritional Goal* Met by

Enterally

Fed Patients

Cleveland, OH

7

Nashville, TN

3

Chicago, IL

2

Baltimore. MD

1

Study Site

52%

129

59

55

39

# Patients

50-70%

64%

50%

% of Goal

*

Methods of nutrition goal determination varied amongst studies

Kansas City, KS

6

Cleveland, OH

5

Palo Alto, CA

4

Study Site

77

360

60

# Patients

44-50%

14%

32%

% Patients

%

Enterally

Fed Patients Meeting Nutritional Goal*

*Methods of nutrition goal determination varied amongst studies.

5

EN fed to 85% patients.

6

PN fed to 28.5% of patients.

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Early EN is the preferred route, but is often poorly tolerated in ICU patients with

GI dysfunction.

Therefore,

early supplemental PN

must be promptly initiated,

so as to prevent underfeeding and

the resulting energy-protein gap

associated complications.

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Preliminary discussion from SPN study

Early EN within 24 hours in ICU patients on mechanical ventilation reduces energy deficit & maintains gut function

However, poor EN tolerance indicates gut dysfunction–

this sign of a “sick gut” is an important warning signal

Persistent GI intolerance on day 3 automatically selects patients who will require supplemental PN

Early EN with early supplemental PN improves outcomes:

Significant reduction in new infections

Increase in antibiotic-free days

Reduced time on mechanical ventilation

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Energy requirements in critical illness

Energy deficits accumulate quickly during the 1st

wk

in ICU and are not completely preventable.

It is necessary to identify safe minimal and maximal amounts. The

best approach is indirect

calorimetry

. If not available, provide 20-25 kcal/kg (early acute phase), and increase to 25-30 kcal/kg in stabilized patients.

The target for total energy intake (PN + ON/EN) should be within 23-27 kcal (including energy from proteins) per kg ABW or IBW (whatever applies) per day. In severely stressed patients, up to 30 kcal/kg ABW/d may be given temporarily Braga et al: ClinNutr 2009; 28: 378–86 Mohandas et al. Nat Med J India 2003; 16: 29-33Singer et al. Intensive care. Clin Nutr 2009; 28: 387–400 Chowdary et al. Indian J Anaesth 2010; 54: 95–103

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Protein requirements in critical illness

A

high protein intake (1.5 g/kg/d)

is recommended during the early phase of ICU stay, regardless of calorie intake

Later on during the ICU stay, a high protein intake remains recommended, but it should be combined with a sufficient amount of energy to avoid proteolysis due to fuel energy deficit

Observational studies suggest patients may benefit from ‘more’ protein (regardless of BMI levels)

Daily protein targets between 1.2–2.0 g/kg are reasonable

There is no compelling evidence for 1.2 g/kg as minimal dose, while patients with unstable renal function in ICU may not benefit from 2.0 g/kg

Protein dosing is a hot topic and may lead to reduced mortality, but more well done multi-centre RCTs are needed to define target range

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Better control of hyperglycemia (lipids + glucose)

Improved lipid formulations (less pro- inflammatory)

Higher protein delivery- closer to requirements

3-chamber bags (Pre-filled AIOs)

Vigilant central line care

P

Wischmeyer

,

Future of Critical Care Medicine, Hong Kong, Apr 2016Implementation of PN in current practice (2016)

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Optimizing PN delivery with all-in-one bags

For administration of PN an all-in-one (3CB) should be preferred

instead of

multibottle

system (B)

Clinical Nutrition 36 (April 2017) 623-650

doi

: 10.1016/j.clnu.2017.02.013.

The use of standardized commercially available PN may be considered in ICU patients when the formulation meets the metabolic needs of the patient. PN admixtures should be administered as a complete all-in-one bag

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Precise Nutrition with Precision

Monitoring/Evaluation:

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Clinical data monitored daily

History:

fever, h/s/o fluid overload or glucose and electrolyte imbalance.

Vital signs

: Temp., HR, BP, RR

Fluid balance

: input/output chart, weight

Local care: inspection and dressing of site of vascular access.Delivery system: inspection of solution for contamination and functioning of infusion pump.

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Laboratory data

Fingerstick

glucose test

3 times daily until pt. stable

Blood glucose, Na, K,

Cl

, HCO₃, BUN

Daily until glucose infusion load and pt. stable, then twice weeklyLFT, S.Creatinine

, albumin, PO₄, Ca, Mg, Hb/Hct, WBCBaseline, then twice weeklyClotting, INRBaseline, then weeklyMicronutrient testAs indicatedMonitoring response to nutritional therapy:Improvement in clinical status, Protein concentrations(Albumin,

prealbumin

, transferrin)

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To summarize nutrition therapy….

Patients admitted in

ICU

should be screened for

pre-existing malnutrition

or

nutrition risk

(for nutrition related complications).When nutrition risk is identified, it should be optimized by provision of appropriate nutrition therapy.Early EN provides both nutritional benefits as well as non-nutritional benefits, but may be associated with poor tolerance due to the gut dysfunction associated with critical illness.Early supplemental PN assures adequate delivery of energy, protein & nutrients to

minimize risk and improve clinical outcomes.Enhance nutrition with specialized substrates like Immunonutrients