How to preserve muscle mass in the ICU patient - PowerPoint Presentation

1. How to preserve muscle mass in the ICU patient IrSPEN 2023 AVIVA STADIUM, DUBLINCarmel O’HanlonClinical Specialist Dietitian

2. Overview

3. Defining the problem

4. Muscle mass lossUpto 15% loss of muscle mass during first week in ICU Nearly 2% loss of skeletal muscle per day over 1st ICU weekWasting – associated with an elevated urea/creatinine ratioFazzini et al. Critical Care (2023) 27:2https://doi.org/10.1186/s13054-022-04253-0Loss in muscle mass from day 1 to day 14 of ICU admission.Rectus femoris: RF; cross-sectional area: CSA, thickness: Th, quadriceps muscle layer thickness: QMLT; biceps brachii: BB

5. Early and rapid muscle lossPuthucheary et al JAMA 2013;310(15):1591-160020% loss > 2 organ failure26% loss > 4 organ failure

6. ICU Acquired WeaknessDefinition:A bundle of neuromuscular disorders that develop due to ICU admission and severe illnessTriggered by critical illnessSeverity is independent of underlying primary condition

7. ICU Acquired Weakness: Hallmarks

8. Aetiology/risk factors for muscle loss & ICU-AW

9. Clinical consequences

10. IrSPEN 2023Measuring the problemHow do we measure muscle mass loss?

11. GLIM Guidance

12. Measurement techniquesPrado et al. Clinical Nutrition (2022) 41: 2244-2263

13. Methods used to measure muscle loss in ICUFazzini et al, 2023, 33 ICU studies85% used US15% used CTSmith et al, 2023, 47 studies in hospital, 9 ICU studies79% used BIA9 ICU studies:5 used BIA +/- anthropometry1 used US + DXA1 used CT + BIS + anthropometry1 used BIS + anthropometry1 used BIA + BIVA

14.

15.

16. IrSPEN 2023Treating the problemHow do we prevent/slow down muscle mass loss?

17. Attenuate muscle loss

18. Nutrition support Critical Care Nutrition Systematic ReviewsHeyland DK, Lee Z-Y, Lew CCH, Ortiz LA, Patel J, Stoppe C. Critical Care Nutrition.com

19. Preventing & treating muscle loss in ICU

20. Appropriate feeding

21. Energy ICALIC Position PaperClin Nutr. 2017;36(3):651-662“Indirect calorimetry is a tool of paramount importance, necessary to optimise the nutrition therapy of patients” ESPEN ICU Guidelines (2019)Rec 15: In critically ill mechanically ventilated patients, EE should be determined using indirect calorimetry (B)Singer, et al. Clinical Nutrition 38 (2019) 48-79

22. Singer et al. Clin Nutr 2019: 1.3g/kgCompher et al. JPEN 2022: 1.2-2g/kgPROTINVENT Clin Nutr 2019lower protein x 3d then increase

23. ProteinFurther investigation

24. ẞ-Hydroxy- ẞ-methylbutyrate (HMB)

25. Vitamin D & n-3 PUFAFurther research needed in ICU

26. Early active mobilisation in ICUIn theory – positiveIn practice – variable resultsSystematic review, Tipping et al., Int Car Med 2017: √TEAM/ANZICS trial NEJM 2022: XESPEN 2019 Statement 3 : Physical activity may improve the beneficial effects of nutritional therapy

27. Key considerationsEarly appropriate nutrition support is cornerstoneAdequate energy when stableindirect calorimetryConsider protein quantityHigher protein – progressively reachedCaution with very high dose in AKI & MOFConsider protein qualitySource & digestibilityAmino acid content: EAA/BCAAAdequate micronutrientsPhysical activity/rehabilitationMonitor body composition to detect muscle mass lossCT/USBIA/AnthropometryConsider functional assessmentMore research in ICU populationsLeucine & HMBN-3 PUFAVitamin DUS cut-off values for critically illEffects of feeding on muscle loss/ functionTiming of high protein provisionHigher protein + increased activity effects

28. ReferencesBarazzoni et al (2022) Guidance for assessment of muscle mass phenotypic criterion for GLIM diagnosis of malnutrition Clinical Nutrition 41, 1425-1433 Singer at al (2019) ESPEN guideline on clinical nutrition in the intensive care unit Clinical Nutrition 38, 48-79 Prado et al (2022) Advances in muscle health and nutrition: a toolkit for healthcare professionals Clinical Nutrition 41, 2244-2263Fazzini et al (2023) The rate and assessment of muscle wasting during critical illness Critical Care 27, 2Smith et al (2023) Clinical applications of body composition and functional status tools for nutrition assessment of hospitalized adults JPEN 47, 11-29Puthuceary et al (2013) Acute skeletal muscle wasting in critical illness. JAMA 310, 1591-1600Stellingwerf at al (2022) The predictive value of phase angle on long-term outcome after ICU admission Clinical Nutrition 41, 1256-1259Gonzalez et al (2021) Calf circumference: cutoff values from NHANES 1999-2006 Am J Clin Nutr 113, 1679-1687Heyland et al (2023) The effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein) Lancet 401, 568-576 Nakamura et al (2021) High protein versus medium protein delivery in critical care Clinical Nutrition 40, 796-803Koekkek et al (2019) The PROTINVENT retrospective study Clinical Nutrition 38, 883-890Nakamura et al (2020) HMB, arginine and glutamine complex on muscle volume loss in critically ill JPEN 44, 205-212Supinski et al (2021) RCT to determine whether HMB +/or EPA improves diaphragm and quadriceps strength in critically Ill Crit Care 25,308Viani et al (2021) Impact of HMB on muscle loss and protein metabolism in critically ill patients Clinical Nutrition 40, 4878-4887Bear et al (2019) HMB and its impact on skeletal muscle mass and physical function in clinical practice Am J Clin Nutr 109, 1119-1132TEAM Investigators and ANZICS Trial Group (2022) Early mobilization during mechanical ventilation in ICU NEJM 387, 1747-1756Tipping et al (2017) The effects of active mobilisation and rehabilitation in ICU on mortality and function Int Care Med 43, 171-183