A different form of malnutrition?

Health Care Associated Malnutrition Nutrition deficiencies associated with physiological derangement and organ dysfunction that occurs in a health care facility Patients who will benefit the most from nutrition therapy and who will be harmed the most from by iatrogenic malnutrition (underfeeding)

Increasing Calorie Debt Associated with worse Outcomes   Caloric debt associated with:   Longer ICU stay   Days on mechanical ventilation   Complications   Mortality Adequacy of EN Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006 Caloric Debt

Point prevalence survey of nutrition practices in ICU’s around the world conducted Jan. 27, 2007 Enrolled 2772 patients from 158 ICU’s over 5 continents Included ventilated adult patients who remained in ICU >72 hours

Faisy BJN 2009;101:1079 Mechancially Vent’d patients >7days (average ICU LOS 28 days)

Effect of Increasing Amounts of Calories from EN on Infectious Complications Heyland Clinical Nutrition 2010 Multicenter observational study of 207 patients >72 hrs in ICU followed prospectively for development of infection for increase of 1000 cal/day, OR of infection at 28 days

Relationship between increased nutrition intake and physical function (as defined by SF-36 scores) following critical illness Multicenter RCT of glutamine and antioxidants (REDOXS Study) First 364 patients with SF 36 at 3 months and/or 6 months for increase of 30 gram/day, OR of infection at 28 days Heyland Unpublished Data Model * Estimate (CI) P values (A) Increased energy intake PHYSICAL FUNCTIONING (PF) at 3 months3.2 (-1.0, 7.3) P=0.14 ROLE PHYSICAL (RP) at 3 months4.2 (-0.0, 8.5)P=0.05 STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 3 months 1.8 (0.3, 3.4)P=0.02 PHYSICAL FUNCTIONING (PF) at 6 months0.8 (-3.6, 5.1)P=0.73 ROLE PHYSICAL (RP) at 6 months2.0 (-2.5, 6.5)P=0.38 STANDARDIZED PHYSICAL COMPONENT SCALE (PCS) at 6 months 0.70 (-1.0, 2.4) P=0.41

More (and Earlier) is Better! If you feed them (better!) They will leave (sooner!)

Permissive Underfeeding (Starvation)?  187 critically ill patients  Tertiles according to ACCP recommended levels of caloric intake  Highest tertile (>66% recommended calories) vs. Lowest tertile (<33% recommended calories)   in hospital mortality   Discharge from ICU breathing spontaneously  Middle tertile (33-65% recommended calories) vs. lowest tertile   Discharge from ICU breathing spontaneously Krishnan et al Chest 2003

Optimal Amount of Calories for Critically Ill Patients: Depends on how you slice the cake! Objective: To examine the relationship between the amount of calories recieved and mortality using various sample restriction and statistical adjustment techniques and demonstrate the influence of the analytic approach on the results. Design: Prospective, multi-institutional audit Setting: 352 Intensive Care Units (ICUs) from 33 countries. Patients: 7,872 mechanically ventilated, critically ill patients who remained in ICU for at least 96 hours. Heyland Crit Care Med 2011

Association between 12 day average caloric adequacy and 60 day hospital mortality (Comparing patients rec’d >2/3 to those who rec’d <1/3) A. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are included as zero calories* B. In ICU for at least 96 hours. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.* C. In ICU for at least 4 days before permanent progression to exclusive oral feeding. Days after permanent progression to exclusive oral feeding are excluded from average adequacy calculation.* D. In ICU at least 12 days prior to permanent progression to exclusive oral feeding* *Adjusted for evaluable days and covariates,covariates include region (Canada, Australia and New Zealand, USA, Europe and South Africa, Latin America, Asia), admission category (medical, surgical), APACHE II score, age, gender and BMI.

Association Between 12-day Caloric Adequacy and 60-Day Hospital Mortality Heyland CCM 2011 Optimal amount= 80-85%

More (and Earlier) is Better! If you feed them (better!) They will leave (sooner!)

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Single center study of 200 mechanically ventilated patients Trophic feeds: 10 ml/hr x 5 days Rice CCM 2011;39:967

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Rice CCM 2011;39:967 Did not measure infection nor physical function!

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure “survivors who received initial full-energy enteral nutrition were more likely to be discharged home with or without help as compared to a rehabilitation facility (68.3% for the full-energy group vs. 51.3% for the trophic group; p =.04).” Rice CCM 2011;39:967

Trophic vs. Full enteral feeding in critically ill patients with acute respiratory failure Average age 51 Few comorbidities Average BMI 29 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! Large multicenter trial of this concept (EDEN study) by ARDSNET just finished

ICU patients are not all created equal…should we expect the impact of nutrition therapy to be the same across all patients?

How do we figure out who will benefit the most from Nutrition Therapy?

Health Care Associated Malnutrition Do Nutrition Screening tools help us discriminate those ICU patients that will benefit the most from artificial nutrition? Patients who will benefit the most from nutrition therapy and who will be harmed the most from by iatrogenic malnutrition (underfeeding)

All ICU patients treated the same

Albumin: a marker of malnutrition ? Low levels very prevalent in critically ill patients Negative acute-phase reactant such that synthesis, breakdown, and leakage out of the vascular compartment with edema are influenced by cytokine-mediated inflammatory responses Proxy for severity of underlying disease (inflammation) not malnutrition Pre-albumin shorter half life but same limitation

Subjective Global Assessment?

When training provided in advance, can produce reliable estimates of malnutrition Note rates of missing data

mostly medical patients; not all ICU rate of missing data? no difference between well-nourished and malnourished patients with regard to the serum protein values on admission, LOS, and mortality rate.

“We must develop and validate diagnostic criteria for appropriate assignment of the described malnutrition syndromes to individual patients.”

Nutrition Status micronutrient levels - immune markers - muscle mass Starvation Acute -Reduced po intake -pre ICU hospital stay Chronic -Recent weight loss -BMI? Inflammation Acute -IL-6 -CRP -PCT Chronic -Comorbid illness A Conceptual Model for Nutrition Risk Assessment in the Critically Ill

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). When adjusting for age, APACHE II, and SOFA, what effect of nutritional risk factors on clinical outcomes? Multi institutional data base of 598 patients Historical po intake and weight loss only available in 171 patients Outcome: 28 day vent-free days and mortality Heyland Critical Care 2011, 15:R28

What are the nutritional risk factors associated with clinical outcomes? (validation of our candidate variables) Non-survivors by day 28 (n=138) Survivors by day 28 (n=460) p values Age 71.7 [60.8 to 77.2]61.7 [49.7 to 71.5]<.001 Baseline APACHE II score 26.0 [21.0 to 31.0]20.0 [15.0 to 25.0]<.001 Baseline SOFA 9.0 [6.0 to 11.0]6.0 [4.0 to 8.5]<.001 # of days in hospital prior to ICU admission 0.9 [0.1 to 4.5]0.3 [0.0 to 2.2]<.001 Baseline Body Mass Index 26.0 [22.6 to 29.9]26.8 [23.4 to 31.5]0.13 Body Mass Index 0.66 <20 6 ( 4.3%) 25 ( 5.4%) ≥ ( 88.4%) 414 ( 90.0%) # of co-morbidities at baseline 3.0 [2.0 to 4.0]3.0 [1.0 to 4.0]<0.001 Co-morbidity <0.001 Patients with 0-1 co-morbidity 20 (14.5%) 140 (30.5%) Patients with 2 or more co-morbidities 118 (85.5%) 319 (69.5%) C-reactive protein ¶ [73.0 to 214.0]108.0 [59.0 to 192.0]0.07 Procalcitionin ¶ 4.1 [1.2 to 21.3]1.0 [0.3 to 5.1]<.001 Interleukin-6 ¶ [39.2 to ]72.0 [30.2 to 189.9]< patients had data of recent oral intake and weight loss Non-survivors by day 28 (n=32) Survivors by day 28 (n=139) p values % Oral intake (food) in the week prior to enrolment 4.0[ 1.0 to 70.0]50.0[ 1.0 to 100.0]0.10 % of weight loss in the last 3 month 0.0[ 0.0 to 2.5]0.0[ 0.0 to 0.0]0.06

Variable Spearman correlation with VFD within 28 days p values Number of observations Age < Baseline APACHE II score < Baseline SOFA < % Oral intake (food) in the week prior to enrollment number of days in hospital prior to ICU admission % of weight loss in the last 3 month Baseline BMI # of co-morbidities at baseline Baseline CRP Baseline Procalcitionin < Baseline IL < What are the nutritional risk factors associated with clinical outcomes? (validation of our candidate variables)

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). % oral intake in the week prior was dichotomized into patients who reported less than 100% versus everyone else Weight loss was dichotomized as patients who reported any weight loss versus everyone else. BMI was dichotomized as <20 versus other Comorbidities was left as integer values range 0-5 The remaining candidate variables were categorized into five equal sized groups (quintiles).

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). For example, exact quintiles and logistic parameters for age Exact QuintileParameterPoints referent

The Development of the NUTrition Risk in the Critically ill Score (NUTRIC Score). VariableRangePoints Age< <751 >=752 APACHE II< < >=283 SOFA<60 6-<101 >=102 # Comorbidities Days from hospital to ICU admit0-< IL60-< AUC0.783 Gen R-Squared0.169 Gen Max-rescaled R-Squared 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.

The Validation of the NUTrition Risk in the Critically ill Score (NUTRIC Score).

Interaction between NUTRIC Score and nutritional adequacy (n=211) * P value for the interaction=0.01 Heyland Critical Care 2011, 15:R28

Who might benefit the most from nutrition therapy? High NUTRIC Score? Clinical –BMI –Projected long length of stay Others?

Do we have a problem?

Preliminary Results of INS 2011 Overall Performance: Kcals 84% 56% 15% N=211

Failure Rate % patients who failed to meet minimal quality targets (80% overall energy adequacy)

Can we do better? The same thinking that got you into this mess won’t get you out of it!

In select patients, we start the EN immediately at goal rate, not at 25 ml/hr. We target a 24 hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume. Start with a semi elemental solution, progress to polymeric Tolerate higher GRV threshold (300 ml or more) Motility agents and protein supplements are started immediately, rather than started when there is a problem. The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol! A Major Paradigm Shift in How we Feed Enterally Heyland Crit Care 2010

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!

Questions?