L.Mageswary Dietitian Hospital Selayangmsic.org.my/filedownloader.asp?filename=asmic2015... ·...
Transcript of L.Mageswary Dietitian Hospital Selayangmsic.org.my/filedownloader.asp?filename=asmic2015... ·...
L.Mageswary Dietitian
Hospital Selayang
14 – 15 AUG ASMIC 2015
Learning Objectives
1. To understand the importance of nutrition support in ICU
2. To know the right time to feed
3. To understand the indications for enteral formulas
4. To know how much feeding is adequate
5. To appreciate good feeding practices
Starvation
• Lack of nutrient intake & caloric demand
• Minimal loss of protein
• Reduced protein
catabolism to preserve lean body mass
• Mobilization of fat for energy
Hypermetabolism
• Activated state, REE • Increased lean body mass
wasting • Accelerated protein
catabolism for energy & protein synthesis
• Protein (muscle &visceral)
for energy and glucose formation (Gluconeogenesis)
Critically lll
Hypercatabolic & Hypermetabolic
Impaired immunological functions Impaired ventilatory drive Weaken respiratory muscles
Malnutrition
(Reported as being as high as 40% in ICU)
Giner M et al. Nutrition 12:23–29, 1996
prolonged ventilatory dependence infection morbidity mortality Dark D et al, Journal of Intensive Care Medicine 1993
CAN PATIENT EAT NORMALLY ?
YES
No Special Support Needed
NO
Specialized Nutritional Support Needed
IS GIT FUNTIONAL ?
YES
Naso-Gasrric or Naso-Enteral Tube Feeding
NO
Total Parenteral Nutrition(TPN) Needed
FULL AMOUNT TOLERATED ?
YES
Tube- feeding Alone Sufficient
NO
Supplement as Needed with Peripheral Parenteral Nutrition
(PPN)
IS PATIENT AT HIGH-RISK FOR
ASPIRATION ?
IS PATIENT AT HIGHER RISK
FOR ASPIRATION ?
YES
Use Post-Pyloric Feeding
NO
May Use Intra-Gastric Feeding
YES
Use Post-Pyloric Feeding
NO
May Use Intra-Gastric Feeding
ENTERAL NUTRITION
1. Promotes gut mucosal growth & development
2. Helps maintain the barrier function and may help prevent translocation of bacteria & toxins
3. Support the immune system
4. Results in better nutrient use with fewer metabolic disturbances
5. Less expensive
…comparing cost of PN versus En, estimated EN saves $425 per day over
Chellis MJ et al (JPEN 1996)
14 – 15 AUG ASMIC 2015
When to Initiate Feeding ?
Critically ill patients who are hemodynamically stable with functioning GIT & adequately resuscitated
All appropriate patients will have enteral nutrition initiated by 24 - 48 hours
Following hospitalisation, trauma, injury or admission to ICU
Caloric goal to be reached
by
48 - 72 hours after initiation
Why Early Feeding ?
Early use of the enteral route may play a significant role in preventing
• GI mucosal atrophy
• Development of the systemic inflammatory syndrome (SIRS)
• Multiple organ failure (MOF)
• Multiple organ dysfunction (MOD)
Time Required To Regain Post Operative GI Propulsion
Stomach
Liquid: 3 – 8 hrs
Solids: 24 -48 hrs
Small Bowel
12 – 24 hours
Colon
48 -72 hours
Early Enteral Feeding
Meta-analysis of RCT
Outcome
Anastomotic dehiscence
Infection: Any type
Wound Infection
Pneumonia
Intra-abdominal abscess
Vomiting
Death
NO TRIAL
Favours Early Feeding Favours NBM
5
6
5
7
6
9
8
Relative Risk
14 – 15 AUG ASMIC 2015
• As little as 10ml/H of feed of enteral feeding may be
sufficient to provide the desired `GI protective effect`
(Level B)
Early feeding with 55 to 60% goals target
Maintain gut integrity and gut barrier function
Provide immune benefit
McClave. J of critical illness. 2001:16:198-202;
Dose –dependent Effect of EN
•
These changes are time dependent; the longer they are left NPO, the greater the complications.
Objective
• Objective: To describe current nutrition practices in intensive care units and determine “best achievable” practice relative to evidence-based Critical Care Nutrition Clinical Practice Guidelines.
Research Design
• An international, prospective, observational, cohort study conducted January to June 2007.
• 158 adult intensive care units from 20 countries.
• Total subjects = 2946
Result
• Average adequacy of total calories and protein over the 12 days of observation
• Calorie adequacy = 59.0% (site range, 20.5%–94.4%)
• Protein adequacy = 60.3% (site range, 18.6%–152.5%)
Calorie Debt
• Increase days on mechanical ventilation
• Longer ICU stay
• Increase mortality
Increasing caloric debt is
associated with
EN
Inta
ke
0
200
400
600
800
1000
1200
1400
1600
1800
2000
1 3 5 7 9 11 13 15 17 19 21
kcal
Days
Prescribed Engergy
Energy Received From Enteral Feed
Caloric Debt
Villet et al Clinical Nutrition 2005; Faisy et al British Journal of Nutrition 2009; Tsai et al Clinical Nutrition 2011
21.9% patients remain NPO ≥ 3 days mean duration 5.2 days (range 0 – 16 days)
• Physician order 65% of goal volume
• Only 15% of patients reach goal feeds within 3 days
Problem initiating feeding
• Only 80% of ordered volume is given
• Cessation of EN in 80% patients (diagnostic, procedures, high GRV ect.)
• Net effect – only average 50% of goal volume
• Slow advancement
Problems delivering feeding
Fanklin, McClave (JPEN 2006;30:S32)
McClave (CCM 1999;27:1252)
Heyland (JPEN 2003;27:74)
Jones (J Crit Care 2008;23:301)
Underfeeding
Overfeeding
Hyperglycemia Hyperlipidemia Fat
deposition (bedridden)
Neuromuscular disease
patients, loss muscle mass & gain fat mass
Increased metabolic rate,
cardiac demand, respiration & CO2
Monitor with Respiratory
quotient (RQ) > 1.0
Overfeeding CHO
COPD
Retain CO2
• Accurate initial assessment of calorie requirement & periodic reassessment prevents overfeeding
• Reducing excessive calorie is far more therapeutic than reducing CHO
• Acute and initial phase
• Exogenous energy supply > 20 – 25 kcal/kg BW/day may be associated with a less favorable outcome (C)
• Recovery (anabolic flow phase)
• Aim to provide 25 – 30 kcal/kg BW/day
• Severe under nutrition should receive up to 25 -30 kcal/kg BW/day
• If these target not reached, supplementary PN should be given.
How much EN?
ESPEN Guidelines on Enteral Nutrition: Intensive Care. Clinical Nutrition (2006) 25, 210-223
How Much to Feed ?
Protein: 1.2 to 2.0 gm/ Actual Body Weight
• In the critically ill obese patient, permissive underfeeding or hypocaloric feeding with EN is recommended.
• For all classes of obesity where BMI is > 30 kg/m2, the goal of the EN regimen should not exceed 60%-70% of target energy requirements or 11-14 kcal/kg actual body weight per day or 22-25 kcal/kg ideal body weight per day
• Protein should be provided in a range
≥ 2.0 g/kg ideal body weight per day for Class I and II patients (BMI 30-40),
≥ 2.5 g/kg ideal body weight per day for Class III (BMI ≥ 40).
ASPEN Recommendation 2009
Feeding the Obese Patients
Tropic or trickle feeding
• Whenever full feeding is not possible
– 10 to 30 ml/hour should be given
• To prevent gut mucosa atrophy
McClave et al. 2009
14 – 15 AUG ASMIC 2015
YES
YES
YES
YES
Does the patient have impaired digestion or absorption ?
Does the patient require electrolyte restriction ?
Does the patient require fluid restriction ? OR have high energy
needs ?
Does the patient have protein needs ?
Does the patient have hyperglycemia ?
Standard Formula (1.0 – 1.2 kcal/mL)
Elemental or semi-elemental formula
Renal Formula
High Energy Formula
High Protein standard formula OR modular
Low CHO, High fiber formula
NO
NO
NO
NO
NO
YES
Does the patient have impaired digestion or absorption ?
Does the patient require electrolyte restriction ?
Does the patient require fluid restriction ? OR have high
energy needs ?
Does the patient have protein needs ?
Does the patient have hyperglycemia ?
Standard Formula (1.0 – 1.2 kcal/mL)
Protein Type
Casein protein Forms curd in stomach
Delays gastric emptying
Whey protein
Whey protein remains in
liquid state in stomach
Facilitate gastric emptying
Soluble non-curdling property
Reduces risk of reflux and
aspiration pneumonia
Greater patient comfort
Fiber Type
• Soluble fiber may be beneficial – fully resuscitated
– hemodynamically stable critically ill pts receiving EN who develops diarrhea
• Insoluble fiber should be avoided in all critically ills
• Both soluble and insoluble fiber should be avoided in pts at high risk for bowel ischemia or severe dysmotility (Grade C)
Guidelines for the provision and assessment of nutrition support therapy in adult critically ill pts: Society of Critical Care Medicine and ASPEN (2009)
Avoid Immune Enhancing formulas in
actively sepsis patients.
• Reserved for critically – ill surgical/ trauma/ burn patients
• Duration of formula is for up to 10 days or > if pt remains at significant risk of infectious complications
PN 0.2 – 0.4 gm/kg/day EN 0.3 – 0.5 gm/kg/day
Glutamine
• NO BENEFIT if total calories intake < 700 kcal/day • For therapeutic benefit : 50 to 60% energy should be delivered
Immune modulating Formula
14 – 15 AUG ASMIC 2015
Giving enteral feed into the stomach rather than the small intestine permits the use of hypertonic feeds, higher feeding rates, and bolus feeding (grade A).
- Starter regimens using reduced initial feed volumes are unnecessary in patients who have had reasonable nutritional intake in the last week (grade A).
- Diluting feeds risks infection and osmolality difficulties.
Both inadequate or excessive feeding may be harmful.
Dietitians or other experts should be consulted on feed prescription
(grade C).
Nutrition Support Practices
Method Of Administration
Bolus feeding • Administered using a syringe • High incidence of complications
Intermittent • Administered by gravity flow or pump • Each feeding is given over 30 minutes every 3 - 6 hours
Continuous • Pump assisted • Utilized in patients who are critically ill or with small
bowel feeding • Restricts patient ambulation
Continuous pump feeding can reduce gastrointestinal
discomfort and may maximise levels of nutrition
support when absorptive capacity is diminished.
However, intermittent infusion should be initiated as soon
as possible (grade A).
Bolus feeds are discouraged in a critical care setting and
contraindicated with jejunal feeding.
Feeding Initiation
Standard Formula
Gastric administration
• Begin full strength 25 – 50 ml/hour
• Advance by 25 ml/hr every 4 – 8 hours until goal rate is met
Post Pyloric administration
• Begin full strength at 25 ml/hr for first 12 hours
• Advance by 25 ml/hr every 6 – 12 hours until goal rate is met
• Bolus administration is not recommended
Concentrated/ elemental formula
Gastric or Post Pyloric
Infusion
• Begin full strength at 25 ml/hr for first 12 hours
• Advance by 25 ml/hr every 6 – 12 hours until goal rate is met
• Bolus administration is not recommended
**Head of bed to be elevated ≥ 30 to 45 degrees at all times**
Feeding Transition
WEANING TPN or TEN • Wean TPN or TEN off once patient consuming ½ to 2/3 of
nutritional needs
Abrupt cessation of tube feeding is not recommended, as nutritional status may be compromised.
Ceasing feeds during meal times
• Aims to improve the patient’s appetite and oral intake at mealtimes
• Stop tube feed 1-2 hours before each main meal
• Feeds can resume when the patient has finished eating, or 1-2 hours
afterwards
Nocturnal Feeding
• Overnight feeding (8-16 hours) to encourage oral intake during day
• More energy-dense formula (1.5 – 2.0 kcal/ml) can be used for meeting
need using lower feed rate
• Administer bolus feeds separate from meals to minimise on appetite
What happen to patients post-extubation?
Journal of American Dietetic Association 2010
Energy = 40-60% Protein = 20-40%
“Window of Opportunity”
“Window of Opportunity”
Early Enteral Nutrition Provide Adequate Feeding
Apply Good Nutrition Support Practices