IN ICU NUTRITION

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WHATS NEW
IN ICU NUTRITION?
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A slender and restricted diet is always
dangerous in chronic and in acute diseasesLet
food be thy medicine

• Hippocrates 400 B.C.

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SICS Nutrition Network

• Set up in June 2006
• Links 30 dietitians, 6 pharmacists, 10 ICU
  Nutrition nurses, and 17 doctors. Meets 3x/year
  at QMH. Around 12-18/meeting
• Guidelines on practical issues planned
• Website with protocols/guidelines/teaching
• Educational meetings
• Current projects on assessment/weighing
• Encouraging projects in nutrition

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SICS Nutrition Network

• Meetings videoconferencing
• Presentations of local projects/audits
• Ideas for new projects discussed
• Reports on conferences/equipment
• Discussion on topical issues e.g. nutrition
  teams, education, weighing, screening
• Reviews of topics planned e.g. pre-and post-op
  feeding
• Article circulation planned

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Best Practice statements

• Starting and stopping feed
• Adding water to feeds
• Use of MUAC
• Use of different weights (ideal, actual etc)
• Nasal bridles

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Education

• Module on SICS website
• Teaching powerpoint on website
• Junior doctors induction
• FY2 teaching by nutrition nurse
• Consultants mandatory training
• Chapter for ABC of Intensive Care
• Website

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Audits

• Nutrition audit of Scottish Units 2006 widely
  diverse practice and knowledge
• HDU feeding Fife, Forth Valley
• International Nutrition QI audit 9 units last 2
  years
• Helped to inform changes in practice
• Nutrition Audit form on website

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patients receiving PN/year
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The Downward Spiral of Malnutrition in Severe
Illness
Morbidity / Mortality
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Current ProjectsNutritional Screening

• Required by QIS and NICE for
• All patients on admission to hospital and
  regularly thereafter
• MUST introduced by BAPEN - being widely
  implemented
• Not helpful in ICU all high risk
• Need to identify the severely malnourished
• Improves feeding of these patients

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Nutritional State and Complications in SHDU, WGH
2003
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SNACC 3 phases

• Few ICU nutrition studies have looked at
  nutritional status probably crucial
• Fife ICU nutritional screening tool
• 1. Pilot study completed to repeat in WGH
  external validity study.
• 2. Systematic review started (funded)
• 3. Larger study 2010-11 - will need funding
  nutritional state and outcomes
• Aim to focus nutritional intervention

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Whats New in IC
Weighing ICU patients
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Weighing Patients

• Essential for nutrition screening
• Nutritional requirement calculations
• Indirect calorimetry
• Drug dosages
• Cardiac output monitoring LIDCO, PAFC, PICCO
• Fluid balance
• ARDS tidal volumes

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Weighing Patients

• Estimation of weight can be up to 20 out
• i.e. 80 kg instead of 100kg and vice versa
• Estimation of height also inaccurate but
  measuring height with tape fairly accurate
• We need to weigh patients in ICU

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Weighing Patients

• Craig Hurnauth ICU S/N at SJH
• Audit of 13/14 NHS trusts in Scotland
• 12 trusts do not weigh patients in ICU on
  admission - use estimate/notes/family
• 1 weighs every day with hoist weekly
• 5 use MUST
• 7 do not screen, 1 adapted screening tool
• 7 units in England similar results

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Methods of Weighing

• Hoist time consuming, needs several nurses,
  risky for unstable patients or trauma patients
• Weigh beds 16000 each
• Digital bed scales scales for each wheel of
  the bed weighs bed patient, mobile, minimal
  manpower, no disruption to patient

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Methods of Weighing

• Progress since audit
• 2 units have bought weigh beds
• 5 are considering bed scales

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Challenges in Critical Care Nutrition

• 1. Keeping up with evidence - guidelines
• 2. Screening/weighing
• 3. Prevention and treatment of complications
• 4. Outdated surgical practices/ Peri-operative
  feeding
• 5. Achieving calorific and protein targets
• 6. Immunonutrition

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Guidelines
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Guidelines

• CCCTG Nutritional Support updated 2009
  www.criticalcarenutrition.com
• ESPEN Parenteral Nutrition guidelines 2009, EN
  2006, (ASPEN guidelines)
• NICE guidelines on Nutrition Support in Adults
• QIS Standards
• MUST (BAPEN)

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Screening/Refeeding Syndrome

• Prisoners of war 1944-5, 1944 conscientious
  objectors in USA studied
• Starvation early use of glycogen stores and
  gluconeogenesis from amino acids
• 72 hrs fatty acid oxidation use of fatty acids
  and ketones for energy source, low insulin levels
• Atrophy of organs, reduced lean body mass

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Refeeding syndrome

• Carbohydrate feeding shift to CH metabolism
• Insulin release, Mg lost in urine
• Phosphate and potassium shift into cells.
• Magnesium, potassium and phosphate drop
• May get Lactic acidosis
• Sodium and water shift out of cells oedema
• Insulin causes sodium retention
• Protein synthesis needs potassium and phosphate
  - these drop more
• Thiamine deficiency occurs (co-factor in CH
  metabolism) encephalopathy, weakness

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Refeeding Syndrome in ICU

• Unlikely to be a clear diagnosis
• Many effects oedema, arrhythmias, pulmonary
  oedema, cardiac decompensation, respiratory
  weakness, fits, hypotension, leukocyte
  dysfunction, diarrhoea, coma, rhabdomyolysis,
  sudden death
• Screen nutritional history and electrolytes
• Remember in HDU patients/malnourished ward
  patients
• Poor awareness among doctors!

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Risk of re-feeding syndrome

• Two or more of the following
• BMI less than 18.5 kg/m2 (lt16)
• unintentional weight loss greater than 10 within
  the last 3-6 months (gt15)
• little or no nutritional intake for more than 5
  days (gt10)
• Hx alcohol abuse or drugs including insulin,
  chemotherapy, antacids or diuretics
• Critically low levels of PO42-, K and Mg2
• NICE Guidelines for Nutrition Support in Adults
  2006

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Managing refeeding problems

• provide Thiamine (Pabrinex)/multivitamin/trace
  element supplementation
• start nutrition support at 10-15 kcal/kg/day
• increase levels over 3-5 days
• restore circulatory volume
• monitor fluid balance and clinical status
• replace phosphate, magnesium and K
• Reduce feeding rate if problems arise

NICE Guidelines for Nutrition Support in Adults
2006
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Complications

• Ileus- caused by fluid overload, pain,
  hyperglycaemia, hypokalaemia, opioids,
  immobility, sepsis trickle of feed if gut
  intact. Consider Neostigmine/prokinetics
• Constipation avoid and treat drugs
• Diarrhoea exclude infections, optimise fluid
  balance and electrolytes, replace loss
• Intolerance ? Sepsis, NJ feeding, PKs
• Feeding aids fluid and electrolyte balance

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Overfeeding

• Lactic acidosis
• Hyperglycaemia
• Increased infections
• Liver impairment (Alk phos, ALT, GGT, acalculous
  cholecystitis)
• Persistent pyrexia
• Underfeeding probably even more dangerous
  studies starting to emerge need to get the
  balance right

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Outdated surgical practices
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Outdated surgical practice

• Reluctance to feed at all
• Prolonged semi-starvation
• Sips of water/Over-IV hydration
• Incidence and treatment of ileus
• Nervous surgeon syndrome
• Evidence from ERAS pre-op CH loading
• Benefits of early post-op feeding
• Over/under-use of PN

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Intake in HDU
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Calorific and Protein Targets

• 25kcl/kg/day up to 30 in recovery phase
• Aim to provide energy as close as possible to
  target to avoid negative energy balance
• Protein 1.3 1.5g/kg/day (optimal prtn sparing)
• CVVH lose AAs in filter need to give 20 more
  using amino acid supplements
• Protein deficits may be very important
• Increasing evidence that patients with deficits
  in 1st 3-5 days do worse (?severely malnourished)
• Indirect calorimetry the future?

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Maintaining enteral intake

• Follow a protocol use prokinetics/NJs
• Gastric residuals do not stop feed until you
  have 2 residuals of gt250mls (check clinical
  signs) 400mls may be ok
• Starting and stopping feed
• Extubations, fasting for theatre, scans, minor
  procedures
• Can catch up on feed that is missed

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ESPEN PN in ICU

• All patients receiving less than their targeted
  enteral feeding after 2 days should be considered
  for supplementary PN
• All patients not able to receive EN within 24-48
  hours should be given PN
• CCCN Inadequate enteral nutrition lt80 of target
  after 3 days PN
• Do not delay nutrition in malnourished
• Keep 10ml/hr EN if possible

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Immunonutrition

• The future replacement of the bodys own stress
  substrates and reduction of inflammation?
• ESPEN new recommendations glutamine in all PN
  0.2-0.4g/kg/day
• ??? SIGNET/REDOXs
• glutamine in enteral nutrition for burns and
  trauma

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Polyunsaturated Fatty Acids
Omega-6 ?-Linoleic acid (GLA) borage oil
Arachidonic Acid precursor Omega-3 Fish oils
Eicosapentanoic acid (EPA) and Docosahexanoic
acid (DHA)
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Dietary Lipids

• Ratios in paleolithic diet ?6?-3 11
• Current Western diet 161
• Current UK PN Soybean oil base 71
• New PN (SMOF) 2.51
• Cell membrane composition depends on balance
• AA, DHA and EPA are present in inflammatory cell
  membrane phospholipids

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Mechanisms of Action

• ?-3s EPA/DHA are incorporated quickly into cell
  membrane inhibit ?-6 activity
• Promote synthesis of low activity PGs and LTs
• Decrease expression of adhesion molecules
• Inhibit monocyte prodn of pro-inflamm cytokines
• Decrease NFkB, increases lymphocyte apoptosis
• Decrease pro-inflammatory gene expression
• Lipoxins, resolvins and protectins

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3 Studies OXEPA

• Patients with ARDS fed with GLA, EPA and
  antioxidants had a reduction in pulmonary
  neutrophils
• Improvement in oxygenation
• Decrease in ventilator days
• Decrease in ICU and hospital days
• Gadek, Singer, Pontes-Arruda (sepsis)
• Recommended by ESPEN in ARDS

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ESPEN PN Guidelines

• PN for critically ill surgical patients should
  probably include ?-3 fatty acids. Fish oil
  enriched lipid emulsions probably reduce ICU LOS.
• The tolerance of MCT/LCT and olive oil emulsions
  is well established. These probably have
  advantages over LCT based lipid preparations
  small studies so far.

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Anti-oxidants

• Normal state reduction gt oxidation
• Acute stress injury/sepsis causes acute
  dysregulation ROS/RNOS formed
• Mitochondria are both sources and targets
• Observational studies anti-oxidant capacity
  inversely correlated with disease severity due to
  depletion during oxidative stress

OXIDATION
REDUCTION
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Antioxidants

• Glutathione, Vitamins A, C and E
• Zinc, copper, manganese, iron, selenium
• Already added to feeds
• Should we give extra? ESPEN VitC/thiamine/Se/Zn
  in CVVH/burns
• Results of SIGNET and REDOXs awaited
• Oxidative stress in critically ill patients
  contributes to organ damage / malignant
  inflammation

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To conclude

• Screen your patients
• Early enteral feeding is best
• Hyperglycaemia/overfeeding are bad
• Keep glucose down lt10mmol/l (safely)
• Nutritional deficit a/w worse outcome
• Use EN and PN early to achieve goals
• Audit delivery of nutrition regularly
• Protocols improve delivery of feed
• Some nutrients show promising results we should
  probably start using them now

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Please feed me enough and with the right stuff!