Nutrition on the ICU

Zsolt Molnár

AITI

Basics

• Artificial nutrition

• Energy requirement:• 25-30 kcal/kg/day• Carbo-hydrates: 50-70%• Fat: 15-30 %• Proteins: 10-20% (1.2-1.5 g/kg/day amino acids)• Vitamins, trace elements

• Routes• Enteral• Parenteral

Routes

Patient satisfaction

„That tube went all the way to my stomach - and they put it in while I was conscious - nice! Made me feel better though ;-)”

What’s new? – 25 years of experience

• Better tools

• „All-in-one” preparations

• Glutamin

• Blood sugar controll

Wernerman J. In: 25 Years of Progress and Innovation in Intensive Care Medicine 2007

After 4 weeks of MSOF…

Blame/self blame?

≠

Introduction

• Feeding phylosophy 25 years ago• „Bigger is better” - „hyper-alimentation”

Wernerman J. In: 25 Years of Progress and Innovation in Intensive Care Medicine 2007

• Theoretical basis• Nitrogen balance

Munro HN, et al. Biochemical aspects of protein metablism, New York and London. Academic Press 1963

• Practical proof• High measured energy expenditure

Wilmore DW. The Metabolic Management of the Critically Ill. New York and London: Plenum Medical Books 1977

„Under-”, and „Overfeeding”

• Under feeding: – Prolonged ICU stay– Prolonged ventilation– Higher incidence of infection

Villet S, et al. Clin Nutr 2005; 24: 502-9Rubinson L, et al. Crit Care Med 2004; 32: 350-7

• Over feeding:– Prolonged ICU and hospital stay– Nausea, vomiting– Hyperlipidaemia, hyperglicaemia

Stapleton RD, et al. Proc AmThorac Soc 2006; 3: A737

PN - indications

• Not functioning or severely disabled GI-tractASPEN Task Force. J Parenter Enteral Nutr 2002; 26: 1SA–138SA

• EN contraindicated or <40% energy/5 days• Ethically acceptable: life expectancy ≥14 days

Nardo P, et al. Clin Nutr 2008; 27: 858-64

• Timing• ASAP: EN + PN after admission/surgery

Heidegger CP, et al. Curr Opin Crit Care. 2008; 14: 408-414

PN + adjuvant treatment

• Immuno-nutrition (glutamin)• Improved survival

Goeters C, et al. Crit Care Med 2002; 30: 2032-2037Griffiths R, et al. Nutrition 1997; 13: 295-302

• SafeBerg A, et al. In: Yearbook of ICEM 2009; pp: 705-715

• Water-, and lipid-soluble vitamins: 1 amp/day• Trace elements: 1 amp/day

Nardo P, et al. Clin Nutr 2008; 27: 858-64

Calory intake

How much?

Assessment

• Harris-Benedict formula• Gender, age, weight, height• Compensation factor

Long CL et al. JPEN 1979; 3: 452–6

• Ireton-Jones • Age, weight, gender, + burn + trauma

Ireton-Jones CS, et al. J Burn Care Rehabil 1992;13:330–3

• Frankenfield• Minute ventilation, Hb, Sepsis

Frankenfield DC, et al. J Trauma 1994;18:398–403

• Fusco• Age, height, weight

Fusco MA, et al. JPEN 1995;19(suppl):18S

Measurements

• Indirect calorimetry• O2 uptake/ CO2 production• „Gold standard”

Feurer I, et al. Nutr Clin Pract 1986;1:43–9

• Fick’s principle • PA-catheter• CO, Ca-vO2

Liggett SB, et al. Chest 1987;91:562–6

Assessment – shortcomings

• Harris-Benedict, Ireton-Jones, Frankenfield, Fusco• EE increases:

– Fever, shivering– Work of breathing– Pain, stress, physio, „realtives”, stb– Sepsis– Catecholamines

• EE decreases:– Hypothermia– Sedation, anaesthesia– IPPV/CPAP– MOF

McClave SA, et al. Nut Pract 1992; 9: 61-8

Only the patient is missing

Measurements – shortcomings

• Indirect calorimetry• Complicated, time consuming, expensive• Seal, FiO2<60%, „steady state” 60-120 minutes (!)• Snapshot only

Browning JA, et al. Crit Care Med 1982; 10: 82–5Hennenberg S, et al. Crit Care Med 1987; 15: 8–13

• Fick’s principle • P-A catheterisation• SvO2<60%, „flow-dependent O2 supply” (ARDS,sepsis) • „Mathematical coupling”

Vincent JL, et al. Am Rev Respir Dis 1990; 142: 2–7Tuchschmidt J, et al. Crit Care Med 1991; 19: 664–71

Caloric Intake in Medical ICU Patients: consistency of care with guidelines and relationship to clinical outcomes.

Krishnan JA, et al. Chest 2003; 124: 297-305

9-18 kcal/kg/day

Caloric Intake in Medical ICU Patients: consistency of care with guidelines and relationship to clinical outcomes.

• 33-66% (II) vs >66% (III)• Significantly better OR:

- Hospital survival- Spontaneous breathing – on discharge- No sepsis – on discharge

Krishnan JA, et al. Chest 2003; 124: 297-305

• 25% >• Significantly more:

- Nosocomial infectionRubinson L et al. CCM 2004; 32: 350

Sepsis, immobilisation

Fredriksson K, et al. Crit Care Med 2007; 35: S449-S453

Mitochondrial function in sepsis: Respiratory versus leg muscle

Mitochondrial function in sepsis: Respiratory versus leg muscle

Fredriksson K, et al. Crit Care Med 2007; 35: S449-S453

Black: sepsis+MOFGrey: control (elective surgical patients)

Atrophy and Impaired Muscle Protein Synthesis during Prolonged Inactivity and Stress

Paddon-Jones D, et al. J Clin Endocrinol Metab. 2006 Dec;91(12):4836-41

Atrophy and Impaired Muscle Protein Synthesis during Prolonged Inactivity and Stress

Variable Value

Age (yr) 27 ± 1Height (cm) 180 ± 3Body mass (prebed rest) (kg) 82.8 ± 4.0Body mass change (kg) –2.8 ± 0.6Upper body lean mass change (g) –679.8 ± 165.71

Lean leg mass change (g)2 –1325.4 ± 183.01

Body fat mass change (g) –95.6 ± 288.11RM leg ext strength change (%) –28.4 ± 4.41

1 Significant pre- to postbed rest change (P < 0.05).2 Loss of lean muscle mass (dual-energy x-ray absorptiometry) from both legs.

Paddon-Jones D, et al. J Clin Endocrinol Metab. 2006 Dec;91(12):4836-41

The way I did it till 2009…

• Supportive therapy• „Best standard care”• DO2/VO2 • Regular blood gases (arterial, central venous)• Tight blood sugar control 6-8 mmol/l

• Early, controlled enteral nutrition• 30 ml/h: NG aspirate 3-4 hours later• 50-60 ml/h ~ 1500 kcal/day

• Early tracheostomy• No sedation, active moving• Communication

• „Agressive” weaning• Passive moving: avoids contractures• Muscle strength: active excercise

…the way I will carry on

• Same, but…• Early EN +/- TPN

• 30 ml/h: NG aspirate 3-4 h later• 50-60 ml/h ~ 1500 kcal/day

• Blood sugar control• Target: 8-10 mmol/l (instead of 6-8 mmol/l)

Finfer S, et al. N Engl J Med 2009; 360: 1283-97

• Every patient on TPN will get:• Trace elements + vitamins (1amp/day)• Glutamin

• Chronic fasting ≠ critical illness muscle wasting• We treat patients differently now than 25 years ago

– ICU is more comfortable for patients

• Less often means more– 25-60% of calculated calory intake – not harmful, the opposite!– PRCTs are required

• Active moving is invaluable

Summary

Patients are always right:

if they are not hungry I don’t feed them.

Motto