Nutrition Support of the Critically Ill

1
Nutrition Support of the Critically Ill

• Route and Timing
• Lori McCord Jordan, RD
• July 13, 2006

2
Route

• Parenteral vs. Enteral
• Parenteral associated with
• Gut atrophy
• Decreased gut blood flow that is worse with
  vasopressors
• Loss of gut barrier
• Increased bacterial adherences and microbe
  translocation

3
Route

• Parenteral associated with
• Liver dysfunction
• Cholestasis, gallstones
• Slower healing of anastomotic sites

4
Route

• Parenteral associated with
• Immune system dysfunction
• B and T cell dysfunction
• Macrophage dysfunction
• Loss of GALT system
• Increased infections
• Increased proinflammatory cytokines

5
Route

• Enteral vs. Parenteral Nutrition in Animal
  Studies
• Parenteral associated with negative outcomes by
• Kudsk in 1981, 1983
• Peterson in 1981
• Zaloga in 1991, 1993
• Shou in 1994
• Alverdy in 1990

6
Route

• Enteral vs. Parenteral in Human Studies
• Moore, et al. 1989. Journal of Trauma
  29(7)916-22
• RCPT of 75 patients with abdominal trauma
• Nutrition support within 12 hours post-op,
  randomized to enteral nutrition via NCJ or
  parenteral
• Fewer infections, and decreased septic morbidity
  in the enteral group

7
Route

• Enteral vs. Parenteral in Human Studies
• VA Co-op study in the NEJM 1991 325525-532
• Malnourished patients randomly assigned to TPN or
  standard care
• Rates of major complications were similar
• Mortality rates were similar
• Rates of infections higher in TPN group
• Use of pre-op TPN limited to patients who are
  severely malnourished.

8
Route

• Enteral vs. Parenteral in Human Studies
• Kudsk, et al. 1992. Annals of Surgery.
  215(5)503-11.
• PRCT of 98 patients after blunt and penetrating
  trauma
• Enteral or Parenteral feeding within 24 hours of
  injury

9
Route

• Enteral vs. Parenteral in Human Studies
• Kudsk, et al. 1992. Annals of Surgery.
  215(5)503-11.
• Enteral Nutrition resulted in
• Fewer pneumonias
• Fewer intra-abdominal abscess
• Less line infections

10
Route

• Enteral vs. Parenteral in Human Studies
• Kudsk, et al. 1992. Annals of Surgery.
  215(5)503-11.
• Overall conclusion
• Significantly lower incidence of septic
  morbidity in patients fed enterally after blunt
  and penetrating trauma with most of the
  significant changes occurring in the more
  severely injured patients.

11
Route

• Enteral vs. Parenteral in Human Studies
• Moore, et al. 1992 Annals of Surgery.
  216(2)172-183
• Meta analysis of 8 PRT to compare early enteral
  vs. parenteral in high risk surgical pts.
• Enteral pts
• experienced fewer septic complications
• Trauma Blunt trauma most significant reduction
• Slightly reduction in mortality and LOS

12
Route

• Enteral vs. Parenteral in Human Studies
• Braunschweig, C., et al. 2001 Am J Clin Nutr.
  74534-532
• Meta-analysis of PRCT consisting of 27 studies
  with 1828 patients
• Enteral, parenteral, standard care
• PEM in greater than 50 of the patients
• Enteral and standard care lower risk of infection
• Increased mortality and infection with standard
  care than parenteral in malnourished patients.

13
Route

• Enteral vs. Parenteral in Human Studies
• Marik Zaloga. 2004. BMJ 8(1)1407
• Meta-analysis of parenteral vs. enteral nutrition
  in acute pancreatitis 6 PRCT with 263 patients
• Enteral nutrition associated with
• Significant reduction in infections
• Reduced surgical interventions
• Reduced LOS
• Enteral Nutrition should be preferred route

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Route Summary

• Well nourished patients
• EnteralgtStandard CaregtTPN
• Malnourished patients
• EnteralgtTPNgtStandard Care
• Enteral Feeding is the preferred route of
  nutritional support.
• Zaloga. 2006. Lancet. 3671101-1111

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Timingearly enteral feeding

• Animal studiesImproved
• Survival after sepsis
• Survival after hemorrhagic shock
• Renal function after rhabdomyolysis
• Survival after burn injury

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Timingearly enteral feeding

• Mechanisms
• Improved GI blood flow
• Improved gut barrier function
• Decreased organ injury
• Improve anti-oxidant status

17
Timingearly enteral feeding

• Diminished proinflammatory responses
• Improved wound healing
• Diminished catabolic responses
• Improved immune function

18
Timingearly enteral feeding

• Moore. 1991 J Am Coll. Nutr. 10(6)633-48
• Randomized Controlled Trial
• Acutely injured population, well nourished PTA
• Early enteral (12 hours after lap) or TPN after
  POD 5

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Timingearly enteral feeding

• Moore. 1991 J Am Coll Nutr. 10(6)633-48
• Enteral
• Improved nitrogen balance
• Less septic complications
• higher constitutive protein and lower acute-phase
  protein

20
Timingearly enteral feeding

• Tucker, et al. 1996 Nutr. Rev 54111-121
• Malnutrition is still prevalent in hospitals
• Degree of malnutrition increases LOS
• Average institution saves gt1mil/yr by early
  feeding
• LOS decreased with early enteral feeding

21
Timingearly enteral feeding

• Kudsk, et al. 1996 Ann Surg 24(4)531-540
• Trauma population and early immune vs. delayed
  standard
• LOS, infectious complications, costs and
  antibiotic use highest in unfed group
• Early enteral nutrition with immune formula
  resulted in decreased LOS and decreased costs

22
Timingearly enteral feeding

• Beier-Holgerson. 1996 Gut 39833-835
• Abdominal surgery population
• Initiated day of surgery and advanced slowly
• Resulted in
• Decreased LOS
• Decreased infections
• Decreased cost

23
Timingearly enteral feeding

• Marik Zaloga. 2001 Crit. Care Med 292264-70
• Early enteral nutrition in acutely ill patients
  A systematic review
• Meta-analysis of PRCT 15 studies with 753
  patients
• Early(36hrs of admission/surgery) with delayed
  enteral nutrition

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Timingearly enteral feeding

• Marik Zaloga. 2001 Crit. Care Med 292264-70
• Outcome measures included
• Infectionsless with early enteral nutr.
• Noninfectious complicationsdifference was not
  significant
• LOSsignificantly shorter
• Mortalitynot significant

25
Timingearly enteral feeding

• Lewis, et al. 2001 BMJ 323(6)1-5.
• Meta-analysis of RCT comparing any type of
  enteral feeding started within 24 hours of
  elective GI surgery
• Eleven studies with 837 patients
• 6 studies with small bowel feedings
• 5 studies with po feeding

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Timingearly enteral feeding

• Lewis, et al. 2001 BMJ 323(6)1-5.
• Outcomes
• Anastomotic dehiscence
• Infection of any typereduced
• Wound infection
• Pneumonia
• Intra-abdominal abscess
• LOSreduced
• Mortality

27
Timingearly enteral feeding

• Heyland JPEN 200327355-73
• Canadian Clinical Practice Guidelines
• Enteral nutrition is preferred
• Standard formula24-48 hours after admission to
  the ICU
• Optimize delivery
• Minimize risks

28
Timingearly enteral feeding

• Artinian, V., et al. 2006. Chest 129(4)960-967
• Retrospective analysis of a prospectively
  collected large multi institutional ICU database
• 4049 patients
• Early feeding is within 48 hours of intubation

29
Timingearly enteral feeding

• Artinian, V., et al. 2006. Chest 129(4)960-967
• Early enteral feeding resulted in
• Decreased ICU and hospital mortality
• Most evident in the sickest
• Associated with increased risk of VAP

30
Timingearly enteral feeding

• Hip Fracture
• Delmi, et al. 1990 Lancet 3351013-16
• Tkatch, et al. 1992 J Am Coll Nutr 11(5)519-25
  
• Schurch, et al. 1998 Ann Intern Med
  128(10)801-09

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Timingearly enteral feeding

• Hip fractureearly enteral nutrition results in
• Decreased LOS
• Decreased Costs
• Decreased Mortality
• Improve outcome

32
Timingearly enteral feeding

• Kudsk, et al. JPEN 2003271-9
• Preoperative Albumin and Surgical Site Identify
  Surgical Risk for Major Postoperative
  Complications
• Degree of malnutrition prior to surgery along
  with location of the surgery affects outcome

33
Timingearly enteral feeding

• Demling J Burn Care Rehabil 20052694-100
• The incidence and impact of pre-existing protein
  energy malnutrition on outcome in the elderly
  burn patient population
• 123 patients 65 or older with burns from 1-30
• 61 with PEM

34
Timingearly enteral feeding

• Demling J Burn Care Rehabil 20052694-100
• PEM
• Increased infection rate
• Decreased rate of healing of donor site
• Increased LOS
• Increased mortality

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Conclusions

• Enteral nutrition is preferred in patients with
  functioning GI tracts
• Early enteral nutrition is beneficial
• Malnutrition still exists in hospitalized
  patients and increases complications and costs

36
Nutrition Support with the TBE Service

• What do we do here?
• Enteral nutrition is preferred
• Early enteral nutrition
• within 24 hours of less for burns, trauma,
• 24-48 hours for general surgery
• Post-pyloric and aspiration precautions
• For burns we continue tube feeds during the OR