Beruflich Dokumente
Kultur Dokumente
Role of Supplemental PN
Underlying Pathophysiology
of Critical Illness
Loss of Gut Epithelial Integrity
Bacteria
INTESTINAL EPITHELIUM
DISTAL ORGAN
INJURY
(Lung, Kidneys)
lymphocytes
SIRS
Feeding Supports
Gastrointestinal Structure and
Function
Retrospective analysis of
multiinstitutional database
Categorized as Early EN if
recd feeds within 48 hours of
admission (n=2537, 63%)
P=0.007
P=0.02
P=0.0005
Caloric Debt
Adequacy
of EN
Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006
P values
PHYSICAL FUNCTIONING
P=0.14
ROLE PHYSICAL
P=0.05
P=0.02
PHYSICAL FUNCTIONING
P=0.73
ROLE PHYSICAL
P=0.38
P=0.41
At 3 months
At 6 months
0.4
Unadjusted
Adjusted
0.6
0.8
1.0
1.2
1.4
1.6
Optimal
amount=
80-85%
Average age 52
Few comorbidities
Average BMI 29-30
All fed within 24 hrs (benefits of early EN)
Average duration of study intervention 5 days
No effect in young, healthy,
overweight patients who
have short stays!
Chronic
-Reduced po intake
-pre ICU hospital stay
Starvation
Nutrition Status
micronutrient levels - immune markers - muscle mass
Acute
-IL-6
-CRP
-PCT
Inflammation
Chronic
-Comorbid illness
Non-survivors by day 28
(n=138)
Survivors by day 28
(n=460)
p values
<.001
<.001
<.001
<.001
0.13
0.66
<20
20
6 ( 4.3%)
122 ( 88.4%)
3.0 [2.0 to 4.0]
# of co-morbidities at baseline
Co-morbidity
Patients with 0-1 co-morbidity
20 (14.5%)
Patients with 2 or more co-morbidities
118 (85.5%)
25 ( 5.4%)
414 ( 90.0%)
3.0 [1.0 to 4.0]
<0.001
<0.001
140 (30.5%)
319 (69.5%)
108.0 [59.0 to 192.0]
0.07
<.001
<.001
Non-survivors by day 28
(n=32)
Survivors by day 28
(n=139)
p values
0.10
0.0[ 0.0 to
0.0]
0.06
<50
50-<75
>=75
<15
15-<20
20-28
>=28
<6
6-<10
>=10
0-1
2+
0
1
2
0
1
2
3
0
1
2
0
1
0-<1
1+
0
1
IL6
0-<400
400+
0
1
APACHE II
SOFA
# Comorbidities
AUC
Gen R-Squared
Gen Max-rescaled R-Squared
0.783
0.169
0.256
BMI, CRP, PCT, weight loss, and oral intake were excluded because they were not significantly
associated with mortality or their inclusion did not improve the fit of the final model.
Observed
Model-based
40
20
n=12
n=33
n=55
n=75
n=90
n=114
n=82
n=72
n=46
n=17
n=2
60
80
10
Observed
Model-based
10
8
6
4
2
n=12
n=33
n=55
n=75
n=90
n=114
n=82
n=72
n=46
n=17
n=2
10
12
14
0.8
8 88
0.6
77 7
9
9
8888
7 7
8888
0.2
0.4
77
4
0.0
28 Day Mortality
2
0
9
8
10
10
888
8
77 7
8
77 7
88
7
77
6
7
7777
6 66666 6
9
66666 6 6 6
66 666666666
666 6 6 66
7
5
555
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
4 4 3
5 55 555 55 555 55
5
5 5
444 4 43
4
4
2
4
4
4
3
44444444
33
444 4444
3
4
3
1
4 4
22
3
4 4
3 3 33 2 22 2 1
3
11
33 3
2
1 11 1 1
50
100
3
3
5
150
Others?
Do we have a problem?
N=211
Failure Rate
% high risk patients who failed to meet minimal
quality targets (80% overall energy adequacy)
Check
Residuals
q4h
< 250 ml
advance rate by 25 ml
reassess q 4h
reassess q 4h
P<0.05
Can we do better?
Enhanced Protein-Energy
Provision
via the Enteral Route
in Critically Ill Patients:
The PEP uP Protocol
P-value
Day 1
0.08
Day 2
0.0003
Day 3
0.10
Day 4
0.19
Day 5
0.48
Day 6
0.18
Day 7
0.11
Total
<0.0001
100
100
n
n
n
n
ITT
Ef ficacy
FVF
E@Base
70
60
50
40
30
10
ITT
Efficacy
Full volume feeds
Baseline intervention
10
ITT
Efficacy
Full volume feeds
Baseline intervention
20
% protein received/prescribed
20
30
40
50
60
% calories received/prescribed
70
80
80
90
90
% calories
received/prescribed
243
113
57
260
219
113
57
236
194
113
57
209
171
108
54
175
153
105
52
152
138
96
46
136
118
83
40
113
107
75
35
102
83
59
26
90
76
52
23
80
10
59
40
17
71
52
35
14
62
12
n ITT
n Eff icacy
n FVF
n E@Base
243
113
57
260
219
113
57
236
194
113
57
209
171
108
54
175
153
105
52
152
138
96
46
136
118
83
40
113
107
75
35
102
83
59
26
90
76
52
23
80
10
59
40
17
71
52
35
14
62
12
Results:
Late PN associated with
6.3% likelihood of early
discharge alive from ICU
and hospital
Shorter ICU length of
stay (3 vs 4 days)
Fewer infections (22.8 vs
26.2 %)
No mortality difference
Cesaer NEJM 2011
Not an indictment of PN
Early group only recd PN for 1-2 days on average
Late group only recd any PN
YES
>80% of Goal
Calories?
NO
No
Yes
Anticipated
Long Stay?
High Risk?
Carry on!
Yes
No
Maximize EN with
motility agents and
small bowel feeding
YES
No
Supplemental PN?
Tolerating
EN at 96
hrs?
No problem
NO
Yes
No problem
In Conclusion
Health Care Associate Malnutrition is rampant
Not all ICU patients are the same in terms of risk
Iatrogenic underfeeding is harmful in some ICU patients or
some will benefit more from aggressive feeding (avoiding
protein/calorie debt)
BMI and/or NUTRIC Score is one way to quantify that risk
Need to do something to reduce iatrogenic malnutrition in
your ICU!
Audit your practice first!
PEP uP protocol in all
Selective use of small bowel feeds then sPN in high risk patients
Questions?