The Prevalence of Iatrogenic Underfeeding in the Nutritionally ‘At-Risk’ Critically - PowerPoint Presentation

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The Prevalence of Iatrogenic Underfeeding in the Nutritionally ‘At-Risk’ Critically ill Patient

Rupinder Dhaliwal, RDExecutive Director Nutrition & Rehabilitation Investigators ConsortiumClinical Evaluation Research UnitQueen’s University, Kingston, Canada

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Introduction

Critically ill patients receive only 50% prescribed energy and protein needsThis “underfeeding”, considered to be IATROGENIC, could lead to

adverse consequences

However, not all critically ill patients seemed to be harmed more as a

consequence of iatrogenic underfeeding

Caloric debt

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Who benefits from nutrition therapy in in the ICU?

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Multicenter observational study, 2772 patients

For every increase of 1000 calories per day reduction in overall 60-day mortality (p=0.014) increase in ventilator-free days (p=0.003)Beneficial treatment effect of increased calories was only observed in:BMI<25 and >35 no benefit in BMI 25-<35 group

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NUTrition Risk in the Critically ill Score (NUTRIC Score)severity of the underlying illnessthe degree of acute markers of inflammation and starvation indicesthe degree of chronic markers of inflammation and starvation indicesHelps discriminate which ICU patients will benefit more (or less) from aggressive protein-energy provision

NUTRIC score ≥ 6 (out of 10) may benefit the most from nutrition

therapy

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Mechanically ventilated > 7 days

Underfeeding in pts mechanically ventilated >7 days WORSE outcomes!Energy deficit of ~1200 kcals/day is associated with an independent likelihood of ICU death (Faisy et al British J Nutrition 2009)Recent randomized trials

FAIL to show a difference in

the group that received the most calories (Casaer et al NEJM 2011,

Rice et al

Crit

Care Med 2011)

Why so? 1. BMI mid ranges2. Patients young, few

comorbidities, so low NUTRIC3. short stays in ICU (<5 days on average)

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What is optimal nutrition?

Heyland DK Crit Care Med 2011Analyzed patients who were mechanically ventilated and in the ICU for 96 hrs or > Receiving up to 80% of their prescribed energy requirements is

associated with a reduced mortality (>80-85% no added effect)

We posit that nutritionally ‘at-risk’ pts should receive at least

80% prescribed needs

Focus on patients that stayed in the ICU ≥ 96 hrs

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Objective

describe the prevalence of “Iatrogenic Underfeeding” (receiving < 80% prescribed energy and protein) in ICUs across different Geographic areas in ‘high risk’ patients subgroups (those with > 7 days of mechanical ventilation)body mass index (BMI) of <25 and >35 those with a NUTRIC score of >6 compared to low risk patients

to determine those ICU and hospital characteristics associated with optimal nutrition practice (lowest rates of iatrogenic underfeeding)

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Methods

Analysis of data from May 11, 2011 prospective, multi-institutional audit193 ICUs in 29 countries collected data ~20 pts per ICU, ICU LOS at least 96 hrs3174 mechanically ventilated patients

Geographical regions

Sites were divided approximately by continent

Canada, US separate as many ICUs

Sites from countries or continents with too few sites to comprise a unique region were compared to similar region of practice

Mexico & South Africa

 

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Data Collection

For each patientpatient characteristics and ICU admission information baseline nutrition assessmentmethod of calculation (e.g. indirect calorimetry

, predictive equations)

total calories and protein prescribeddaily nutrition data for first 12 days or IC d/c whatever first

Route i.e. EN or PN

total calories and protein prescribed

patient outcomes

ICU and hospital discharge

and mortality.Duration of mechanical ventilation

web-based electronic data capture system

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Statistical Approach

adequacy of total nutrition during the first 12 days in ICU% percent of caloric and protein prescriptions received from EN or PNSOFA score and IL-6 was dropped from the original NUTRIC score high vs. Low NUTRIC: according to median NUTRIC Score (i.e. patients with NUTRIC > median were classified as high risk subgroup)

multivariable analysis was performed

to examine the association between the prevalence of iatrogenic underfeeding repeated using three different sets of adjustments to account for# days in evaluation (first few days patients receive < 80%)

added covariates (ICU characteristics and patient characteristics)

simultaneously included high risk factors in addition to all covariates used

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Results

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Canada:

20 (20%)

USA: 45 (23%)

Australia & New Zealand:

39 (20%)

Europe and

South Africa

:

25 (13%)

Latin America:

24 (12%)

Asia:

41 (21%)

n = 193

ICUs, 29 countries, 3174 patients

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ICU Characteristics

Characteristics

Total (n=193)

Hospital Type

Teaching

149 (77.2%)

Non-teaching

44 (22.8%)

Size of Hospital (beds)

Mean (Range)

633

[100- 2600]

ICU Structure

Open

49 (25.4%)

Closed

140 (72.5%)

Other

4 (2.1%)

Size of ICU (beds)

Mean (Range)

17.7 [5

- 65]

Designated Medical Director

182 (94.3%)

Presence of Dietitian(s)

153 (79.3%)

FTE Dietitians (per 10 beds)

Mean (Range)

0.4 [0

-3.3]

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Total used in analysis

3174

patients from

193

ICUs

29

countries

2011 International Nutrition Survey

3747

patients from

193

ICUs

29

countries

573 Excluded from analysis

378

in ICU <96 hours

195

nutritional adequacy not

available for at least 4 days

 

1812

patients

> 7 days of mechanical ventilation

 

350

patients

with BMI ≥ 35

 

1533

patients

with BMI <25

 

1013

p

atients

with NUTRIC > 4

Results

Patient

Flow Diagram

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Patient Characteristics

Total

Canada

Australia and NZ

USA

Europe and South Africa

Latin America

Asia

p values†

N

3174

361

602

670

416

442

683

Age (years)

mean

(SD)

60.3(17.8)

64.6(16.0)

58.2(17.8)

61.5(17.2)

58.8(17.1)

56.7(19.4)

62.0(17.7)

<0.001

Sex

Male

(%)

1884 (59.4%)

191 (52.9%)

365 (60.6%)

353 (52.7%)

260 (62.5%)

257 (58.1%)

458 (67.1%)

<0.001

Admission

Medical

2031 (64.0%)

260 (72.0%)

370 (61.5%)

474 (70.7%)

224 (53.8%)

284 (64.3%)

419 (61.3%)

0.01

Elective surgery

361 (11.4%)

35 (9.7%)

74 (12.3%)

53 (7.9%)

56 (13.5%)

28 (6.3%)

115 (16.8%)

Emergent surgery

782 (24.6%)

66 (18.3%)

158 (26.2%)

143 (21.3%)

136 (32.7%)

130 (29.4%)

149 (21.8%)

Weight (kg)

mean

(SD)

76.3(24.5)

78.2(24.2)

81.1(25.2)

86.3(31.9)

77.9( 20.2)

71.3(16.3)

63.6(14.4)

< 0.001

BMI

mean

(SD)

26.9(7.5)

27.8(7.6)

27.9(7.7)

29.8(9.9)

26.8(6.5)

25.9(5.1)

23.7(4.7)

< 0.001

APACHE

II

mean

(SD)

21.9(7.7)

23.7(7.1)

22.2(7.9)

22.4(7.4)

21.5(8.2)

19.9(7.1)

21.9(7.7)

0.06

NUTRIC

>4

161 (44.6%)

173 (28.7%)

230 (34.3%)

139 (33.4%)

107 (24.2%)

203 (29.7%)

0.002

NUTRIC

<=

4

200 (55.4%)

429 (71.3%)

440 (65.7%)

277 (66.6%)

335 (75.8%)

480 (70.3%)

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Nutrition Outcomes (all patients)

Total

Canada

Australia and NZ

USA

Europe and South Africa

Latin America

Asia

p values†

N

3174

361

602

670

416

442

683

Prescribed

kcal/kg/day

Mean (SD)

24.1(5.5)

23.3 (5.3

)

25.5(5)

21.5 (6.2

)

24.6(5)

24. 5(4.6

)

25.4 (5.2

)

<0.001

Adequacy

of

calories

%

Mean (SD)

56

(30.6

)

63.4(27.3 )

59.5(27.7 )

47.8(27.2 )

54.4(30.3 )

53.4(27.9 )

59.8(37.2 )

<0.001

Adequacy of

protein

%

Mean (SD)

51.5(29.2 )

59.7(27.2 )

53.9(27.3 )

44.1(27.0 )

49.5(29.6

)

51.1(28.1 )

53.9(32.7 )

<0.001

Prevalence of iatrogenic underfeeding

2467 (77.7

%)

255 (70.6

%)

450 (

74.8%)

599 (89.4

%)

309 (74.3

%)

372 (

84.2%)

482 (70.6

%)

<0.001

Time

to initiate EN from ICU admission in hours

Mean

(SD)

41.7 (43.6)

37.0 (42.8)

32.6 (39.9)

52.3 (43.8)

39.5 (41.7)

48.6 (42.3)

39.2 (46.4)

<0.001

78% of patients failed to meet ≥ 80% of energy target

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Nutrition Outcomes: vented > 7 days

Total

MV

>7 days

<

7days

Nutritional adequacy

% mean (SD

)

Adequacy of calories

56

(30.6

)

62.8 (29.0)**

47.1 (30.5)

Adequacy of

protein

51.5

(

29.2 )

58.0 (27.7)**

42.9 (29.1)

Time to initiate EN from ICU admission in hours

Mean (SD)

41.7 (43.6 )

44.1 (46.9 )**

38.3 (38.0)

Prevalence of iatrogenic underfeeding

N (%)

2467 (77.7%)

1295 (71.5%)**

1172 (86.1%)

> 7 d mechanical ventilation

Better calorie adequacy

Better protein adequacy

Longer to start EN

Lower prevalence underfeeding

(all values p<0.01)

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BMI ≥ 35 vs. 25-34

Better calorie adequacy (p 0.01-0.05)No differenceNo differenceNo difference

Nutrition Outcomes (BMI)

Total

BMI

<25

25-34

≥35

Nutritional adequacy

% mean (SD

)

Adequacy of calories

56

(30.6

)

57.8 (32.4)**

54.0 (28.7)

55.6 (29.6)*

Adequacy of

protein

51.5

(

29.2 )

53.5 (30.2)**

50.1 (28.3)

47.9 (27.7)

Time to initiate EN from ICU admission in hours

Mean (SD)

41.7 (43.6 )

38.6

(

41.0 )**

44.8 (45.6)

44.4 (46.2)

Prevalence of iatrogenic underfeeding

N (%)

2467 (77.7%)

1136 (74.1%)**

1058 (82.0%)

273 (78.0%)

BMI < 25 vs. 25-34

Better calorie adequacy

Better protein adequacy

Shorter time to EN

Lower prevalence underfeeding

all values p<0.01

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Nutrition Outcomes (NUTRIC score)

Total

NUTRIC score

>4

<

4

Nutritional adequacy

% mean (SD

)

Adequacy of calories

56

(30.6

)

55.3 (29.8)

56.4 (31.0)

Adequacy of

protein

51.5

(

29.2 )

51.3 (29.1)

51.2 (29.3

)

Time to initiate EN from ICU admission in hours

Mean (SD)

41.7 (43.6 )

43.6 (45.0)

40.8 (42.9)

Prevalence of iatrogenic underfeeding

N (%)

2467 (77.7%)

788 (77.8%)

1679 (77.7%)

NUTRIC Score > 4

No difference

No difference

No difference

No difference

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Adjusting for number of days included in nutrition assessment

Adjusting for all covariates* but not other risk factors of interest

Adjusting for all covariates* and other risk factors of interest.

Risk Factors of Interest

OR (95% CI)

p-value

OR (95% CI)

p-value

OR (95% CI)

p-value

MV> 7 days (vs. MV ≤ 7 days)

0.67 (0.50-0.90)

0.0077

0.69 (0.51-0.93)

0.016

0.68

(

0.51-0.92)

0.013

BMI < 25 (vs. BMI between 25 and 35)

0.65 (0.54-0.80)

<0.0001

0.67 (0.54-0.83)

0.0002

0.66

(

0.54-0.82)

0.0001

BMI > 35 (vs. BMI between 25 and 35)

0.64 (0.49-0.84)

0.0014

0.64 (0.47-0.86)

0.0036

0.64

(

0.47-0.86)

0.0038

NUTRIC > 4 (vs. NUTRIC ≤ 4)

1.06 (0.88-1.27)

0.55

1.02 (0.78-1.35)

0.86

1.04

(

0.79-1.38)

0.75

Multivariate analysis

(

odds of receiving <80% of prescription)

being mechanically ventilated for more than 7 days

having a BMI <25 and

having a BMI ≥35 were all associated with about a one third

reduction

in the odds of receiving <80% of energy prescription

Slide22

Conclusions

Worldwide, the majority of critically ill patients fail to receive adequate nutritional intake This rate of failure varies across geographic regionsHigh risk patients are less likely to be underfed than low risk patients but still experience significant underfeeding

Slide23

Acknowledgements

Daren K. Heyland MD, MSc Lauren Murch MScXuran Jiang MSc Andrew G. Day MSc Clinical Evaluation Research Unit, Kingston General Hospital

Department of Community Health and Epidemiology, Queen’s University

Department of Medicine, Queen’s UniversityKingston, ON, Canada

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References

Alberda C, Gramlich L, Jones NE, Jeejeebhoy K, Day A, Dhaliwal R, Heyland DK. The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observation study. Intensive Care Med 2009;35(10):1728-37.  Faisy C, Lerolle N,

Dachraoui F,

Savard JF, About I, Tadie JM, Fagon JY. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. British J Nutrition 2009;101:1079-1087.

Heyland

DK, Dhaliwal R, Jiang X, Day A. Quantifying nutrition risk in the critically ill patient: The development and initial validation of a novel risk assessment tool. Critical Care 2011

Casaer

MP,

Mesotten D, Hermans G, et al. Early versus late parenteral

nutrition in critically ill adults. N Engl J Med 2011;June 29 (

epub).

Rice T, Morgan S, Hays MA, Bernard GR, Jensen GL, Wheeler AP. Randomized trial of initial trophic versus full-energy nutrition in mechanically ventilated patients with acute respiratory failure. Crit

Care Med 2011;39;967-974.

 

Heyland

DK, Cahill N, Day A. Optimal amount of calories for critically ill patients: Depends on how you slice the cake!

Crit

Care Med 2011 Jun 23 (

epub

).

 

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Questions?