Nutrition Information Byte (NIBBLE) Brought to you by www.criticalcarenutrition.com and your ICU Dietitianwww.criticalcarenutrition.com Thanks for nibbling.

Slides:



Advertisements
Similar presentations
Iatrogenic Malnutrition in the ICU: Time for a Change!
Advertisements

Professor of Medicine Queen’s University, Kingston General Hospital Kingston, Ontario Daren K. Heyland, MD, MSc, FRCPC.
A Comparison of Early Versus Late Initiation of Renal Replacement Therapy in Critically III Patients with Acute Kidney Injury: A Systematic Review and.
The golden hour(s) for severe sepsis and septic shock treatment
The Inter-rater Reliability and Intra-rater Reliability of Bedside Ultrasounds of the Femoral Muscle Thickness Daren K. Heyland, MD, MSc, FRCPC Professor.
Foos et al, EASD, Lisbon, 13 September 2011 Comparison of ACCORD trial outcomes with outcomes estimated from modelled and meta- analysis studies Volker.
The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a multicenter observational study Rupinder Dhaliwal, RD Daren K. Heyland,
The Prevalence of Iatrogenic Underfeeding in the Nutritionally ‘At-Risk’ Critically ill Patient Rupinder Dhaliwal, RD Executive Director Nutrition & Rehabilitation.
CF Related Diabetes ADEU November Cystic Fibrosis Genetic disorder Exocrine pancreas dysfunction Autosomal recessive inheritance Several identified.
Feeding A Heterogeneous ICU Population: What is the Evidence?
Nutrition Information Byte (NIBBLE) Brought to you by and your ICU Dietitianwww.criticalcarenutrition.com Background: There.
1.A 33 year old female patient admitted to the ICU with confirmed pulmonary embolism. It was noted that she had elevated serum troponin level. Does this.
Periopperative nutritional support in GI surgery : Past, Present, and future on oncology perspective observation and evidence base Sirikan Yamada, MD Division.
Omega 3 Fatty Acids in Parenteral Nutrition Erin Buehler Lauryn Whitfield.
C-Reactive Protein: a Prognosis Factor for Septic Patients Systematic Review and Meta-analysis Introduction to Medicine – 1 st Semester Class 4, First.
Copyright restrictions may apply A Randomized Trial of Nebulized 3% Hypertonic Saline With Epinephrine in the Treatment of Acute Bronchiolitis in the Emergency.
Overview Importance of preserving muscle mass/function Optimal nutrition positively influences subsequent physical function Role of early rehabilition/mobilization.
Nutrition Screening and Assessment in Critically ill patients
Are the results valid? Was the validity of the included studies appraised?
Optimal Provision of EN Nutrition in the ICU
Objectives: To optimize the delivery of EN by implementing the PEP uP protocol in sites across North America. We provide practitioners the opportunity.
Queen’s University, Kingston General Hospital
INTRODUCTION Stress-induced hyperglycaemia is common in critical care 1 Hyperglycaemia worsens patient outcomes, increasing risk of infection 2, myocardial.
Sarah Struthers, MD March 19, 2015
Mr PS 76 years old COPD, no DM Severe CAP Day 1- intubated, sedated, high o2 requirements, vasopressor dependent Starting early EN Glucose 11.1 mmol/L.
Intensive versus Conventional Glucose Control in Critical Ill Patients N Engl J Med 2009; 360: 雙和醫院 劉慧萍藥師.
Surgical Nutrition Dr. Robert Mustard September 28, 2010.
Nutrition Information Byte (NIBBLE) Brought to you by and your ICU Dietitianwww.criticalcarenutrition.com There is a strong.
Optimizing Nutrition Therapy
Nutrition Information Byte (NIBBLE) Brought to you by and your ICU Dietitianwww.criticalcarenutrition.com Thanks for nibbling.
Improving Patient Outcomes GLYCEMIC CONTROL IN PERI-OPERATIVE PATIENTS UTILIZING INSULIN INFUSION PROTOCOLS.
A different form of malnutrition? Health Care Associated Malnutrition Nutrition deficiencies associated with physiological derangement and organ dysfunction.
Monthly Journal article review: Vimmi Kang PGY 2
Nutrition Information Byte (NIBBLE) Brought to you by and your ICU Dietitianwww.criticalcarenutrition.com Several observational.
Controversies in Nutrient-Specific Therapies: Effective or Ineffective? Daren K. Heyland MD Professor of Medicine Queen’s University, Kingston, ON Canada.
Meduri et all Chest 2007;131; Background  Inflammation in the first week of MV determines resolving vs un-resolving  Un-resolving ARDS LIS by.
International Critical Care Nutrition Survey 2009: Defining Gaps in Practice Naomi E Cahill, RD MSc Project Leader Queen’s University and Clinical Evaluation.
Barriers and Facilitators To making it Happen! Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada.
Gastrointestinal Symptoms and other Factors associated with Failure of Enteral Nutrition in Surgical Intensive Care Unit Session: Poster Poster No.: PP05.
Achieving Glycemic Control in the Hospital Setting Part 1 of 3
Surgical Nutrition Dr. Robert Mustard October 4, 2011.
Association of C-Reactive Protein and Acute Myocardial Infarction in HIV-Infected Patients Virginia A. Triant, MD, MPH, James B. Meigs, MD, MPH, and Steven.
Greg Gaines PA-S A RANDOMIZED TRIAL OF GLUTAMINE AND ANTIOXIDANTS IN CRITICALLY ILL PATIENTS.
Template provided by: “posters4research.com” Cross sectional, prospective study on 14 patients in an open 28-bed intensive care unit (ICU) at Virginia.
Objective Key Points Not all obese patients are the same Nutritional approach may need to vary Challenge to the prevailing dogma that hypocaloric feeding.
Statements like this are a problem! “Our results suggest that, irrespective of the route of administration, the amount of macronutrients administered.
Background There are 12 different types of medications to lower blood sugar levels in patients with type 2 diabetes. It is widely agreed upon that metformin.
Raghavan Murugan, MD, MS, FRCP Associate Professor of Critical Care Medicine, and Clinical & Translational Science Core Faculty, Center for Critical Care.
Early Enteral Nutrition in the ICU: The Clock is Ticking!
CAT 5: How to Read an Article about a Systematic Review Maribeth Chitkara, MD Rachel Boykan, MD.
Nutrition Information Byte (NIBBLE) Brought to you by and your ICU Dietitianwww.criticalcarenutrition.com Several observational.
I LOVE TURKEY Statements like this are a problem! “Our results suggest that, irrespective of the route of administration,
Queen’s University, Kingston General Hospital
The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a multicenter observational study Rupinder Dhaliwal, RD Daren K. Heyland,
Nutrition Information Byte (NIBBLE) Brought to you by and your ICU Dietitianwww.criticalcarenutrition.com Thanks for nibbling.
+ What to Do When Early Enteral Feeding is Not Possible in Critically Ill Patients? Results of a Multicenter Observational Study Naomi E Cahill RD MSc.
Nutrition Information Byte (NIBBLE) Brought to you by and your ICU Dietitianwww.criticalcarenutrition.com Thanks for nibbling.
Learning Objectives Review the evidentiary basis for the amount of macronutrients provided to critically ill patients List approaches for risk assessment.
Protein Delivery in the ICU: Optimal or Sub-optimal?
Determining the effects of peri-procedural fasting in Burn patients: are we meeting nutritional goals and does this affect patient outcomes? Stephanie.
Insert Objective 1 Insert Objective 2 Insert Objective 3.
REducing Deaths due to OXidative Stress: The REDOXS© Study: Can we provide adequate enteral nutrition to patients with Shock? Rupinder Dhaliwal John.
Nibble The Importance of Nutritional Adequacy
Nibble The Importance of Nutritional Adequacy
The PEP uP Trial Has Begun.
PPI prophylaxis for GI bleeding in ICU
Nibble Strategies to deal with GI Intolerance Issue 2
Nibble The North American vs. European Controversy Continues:
PEP uP Trial starts February 2009
Presentation transcript:

Nutrition Information Byte (NIBBLE) Brought to you by and your ICU Dietitianwww.criticalcarenutrition.com Thanks for nibbling on our NIBBLE. For more information go to or contact Lauren Murch at Issue 7 In a recent ARDSNET randomized trial published in JAMA, investigators compared the effects of trophic feeds (for the first 6 days, received only 25 % of goal calories) vs. full enteral feeding (up to goal rate as quickly as possible, received about 80% of goal calories) in 1000 critically ill patients with lung injury (1). This trial was part of a 2x2 factorial trial where patients were also randomized to omega 3 fatty acids or a control solution. The use of a calorie containing active ingredient and a protein containing control solution in the OMEGA trial confuses the interpretation of the EDEN trial, but nevertheless the investigators reported no difference between trophic vs. full feed patients in terms of ventilator-free days, infections, and 60-day mortality. How could that be? Particularly, since we have recently shown that better nutritional intake (>80% caloric intake) is associated with improved mortality in a large observational study (2). To properly interpret this study, one has to remember that not all critically ill patients are the same in terms of their nutritional risk or the benefit they receive from artificial nutrition. The evidence for this assertion comes from studies that demonstrate a differential treatment effect of artificial nutrition in different subgroups of ICU patients. In a recent analysis we observed that an increase of 1000 calories per day was associated with an overall reduction in mortality (Odds Ratio for 60 day mortality 0.76, 95% Confidence Intervals [CI] , p=0.014) (3). However, the beneficial treatment effect of increased calories on mortality was observed in patients with a BMI 35 with no benefit for patients in the BMI 25 to 7 days) may benefit the most from nutrition therapy, whereas patients in mid-range of BMI or who have short stays will not. In the EDEN trial (1), the patients were young (average 52 yrs), normo-well nourished (average BMI 30), and had a relatively short stay in the ICU (average duration of mechanical ventilation of 5 days). Furthermore, all patients received the benefits of early EN. Hence it is no surprise that the trial did not show a difference between trophic vs. full feeds. It is also important to note that functional endpoints, such as quality of life, physical function, return to work, etc. were not measured and one can postulate that trophic feed patients suffered more erosion of lean skeletal mass and poorer functional outcomes, particularly those older patients who are already sacropenic at the onset of their critical illness. What this study really speaks to is the need to have better tools that will help discriminate patients that benefit the most from aggressive nutrition therapy (or conversely, those that will be harmed the most by iatrogenic malnutrition). We recently developed a nutrition risk assessment tool validated specifically for the ICU patient population, the NUTrition Risk in the Critically ill Score (NUTRIC Score) (5). This score was based on a conceptual model that linked starvation, inflammation, nutrition status to clinical outcomes (Figure 1). We considered markers of acute starvation (i.e. decreased oral intake and pre-ICU stay in hospital) and chronic starvation (history of recent weight loss and a low BMI) (5). To represent acute inflammatory markers, we chose PCT, IL-6, and CRP and the presence of comorbid illnesses to reflect a measure of chronic inflammation. All of the variables selected based on the conceptual model were candidates for the inclusion in the NUTRIC score algorithm. We expected this model to explain additional mortality risk, above and beyond what would be derived from use of traditional measures of severity of illness (APACHE II score and baseline SOFA). Based on the statistical significance in the multivariable model, the final score used all candidate variables except BMI, CRP, PCT, estimated % oral intake and weight loss. As the score increased,

Thanks for nibbling on our NIBBLE. For more information go to or contact Lauren Murch at Issue 7 so did mortality rate and duration of mechanical ventilation. Most importantly, in a subgroup of patients who stayed in ICU more than 3 days, we observed that patients with a high NUTRIC score benefit the most from aggressive provision of protein-energy requirements, towards meeting their estimated requirements. On the other hand, patients with a low score may even be harmed by such an approach. In summary, the NUTRIC score may be used to help determine which patients receive supplemental parenteral nutrition or strategies to enhance EN delivery (such as motility agents, small bowel feeding tubes, and aggressive feeding protocols, such as the PEP uP protocol (6)). The NUTRIC score, or the concepts contained therein, may have utility in the design and interpretation of clinical trials of nutrition therapies in the ICU setting. Studies that include heterogeneous ICU patients, some at high nutritional risk, some at low nutritional risk, are more likely to be negative than those who focus on treating only high risk patients. We believe this to be the case for the EDEN Study as well as for the EPaNIC study of supplemental PN (7) recently published in the New England Journal of Medicine. References: 1.Rice TW, Mogan S, Hays MA, Bernard GR, Jensen GL, Wheeler AP. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Crit Care Med 2011;29(5): Heyland DK, Cahill N, Day A. Optimal amount of calories for critically ill patients: Depends on how you slice the cake! Crit Care Med 2011 Jun 23 (epub). 3.Alberda C, Gramlich L, Jones NE, Jeejeebhoy K, Day A, Dhaliwal R, Heyland DK. The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observation study. Intensive Care Med 2009;35(10): Faisy C, Lerolle N, Dachraoui F, Savard JF, About I, Tadie JM, Fagon JY. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. British J Nutrition 2009;101: Heyland DK, Dhaliwal R, Jiang X, Day A. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Critical Care 2011 Nov 15;15(6):R268 (Epub). 6.Heyland DK, Cahill NE, Dhaliwal R, Wang M, Day AG, Alenzi A, Aris F, Muscedere J, Drover JW, McClave SA. Enhanced protein-energy provision via the enteral route in critically ill patients: a single center feasibility trial of the PEP uP protocol. Crit Care 2010;14(2):R78. 7.Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med DOI: /NEJMoa Nutritional Status Micronutrient deficiency Erosion of Lean Body Mass Immune Dysfunction Age APACHE II SOFA Outcomes 28 day mortality Ventilator Free Days within 28 days Acute starvation Decreased oral intake over the last week Pre ICU Hospital Admission Chronic starvation Weight loss over the last 6 months BMI<20 Acute inflammation IL-6, PCT, and CRP Chronic inflammation Co-morbid illnesses Figure 1. Conceptual Model For Nutrition Risk Assessment in the Critically Ill