1 In Knowledge Translation: The Critical Care Experience

Outline of Session Guidelines for Nutrition Therapy in the ICU : How do they differ? Rupinder Dhaliwal, RD WHAT SHOULD BE DONE? Improving the practices of Nutrition Therapy in the Critically ill Naomi Cahill, RD WHAT IS BEING DONE? Bridging the Gap: Effective Dissemination Strategies for Improving Nutrition Practices in the ICU Daren Heyland, MD HOW TO NARROW THE GAP?

Questions to be held at the end of the session 1

Guidelines for Nutrition Therapy in the ICU: How do they differ? Rupinder Dhaliwal, RD Team Leader/Project Leader Clinical Evaluation Research Unit Critical Care Nutrition Kingston ON, Canada 1

Conflict of interest Co-author of Canadian Clinical Practice Guidelines

Clinical practice guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Best available evidence with integration of potential benefits, harm, feasibility, cost Reduce variability in care, improve quality, reduce costs and can improve outcomes Why bother with guidelines? 1

Proliferation of guidelines 1

The more guidelines they publish, the more confused I get!

Compare the content of recently published nutrition guidelines Differences between the recommendations Similarities in the recommendations Highlight the need for harmonization Objectives 1

North American guidelines 1 Available Online

Population Levels of Evidence Grading used Time frames, outcomes Level of transparency between evidence and recommendation What differences? 1

Differences AreaCanadianADAASPEN/SCCM PopulationMechanically ventilated critically ill patients no elective surgery Critically ill patients needing EN no burns Medical and surgical critically ill patients expected to stay in the ICU > 2-3 days Level of evidence RCTs, meta analyses Level 1 or 2 based on validity of evidence All levels of evidence Grade 1-5 based on validity of evidence Minimum n>20 All levels of evidence Level 1-5 based on validity of evidence Time Frame unclear Outcomes clinical outcomesclinical and non clinical outcomes

GradingCanadianADAASPEN/SCCM Strongest Weakest “Strongly recommend” no reservations re: endorsement (5%) “Strong” benefits exceed harm high quality evidence anticipated benefits (41%) “A” supported by at least 2 Level 1 (RCT n > 100) (3%) “Recommend” supportive evidence but minor uncertainties re: safety/feasibility or costs “Fair” Same as above but quality of evidence is not as strong “B” supported by 1 level 1 “Should be considered” Evidence was weak or major uncertainties re: safety/cost/feasibility “Weak” Suspect quality of evidence little clear benefit “C” Level 2 (RCTs <100) “Insufficient data” Inadequate data or conflicting evidence (51%) “Consensus” Expert opinion “D” At least 2 Level 3 (non RCT, contemporaneous controls) “Insufficient evidence” No pertinent evidence and harm/risk is ? (37%) “E” Level 4 (non RCT, historical controls) Level 5 (case series), expert opinion (39%)

Criteria High Quality CPGs 1 Rigor of development: Provide detailed information on the search strategy, the inclusion/exclusion criteria, and methods used to formulate the recommendation (reproducible). Transparent link between evidence, values, and resulting recommendation External review Procedure for updating the CPG AGREE Qual Saf Health Care 2003;12:18

Integration of values Validity Homogeneity Safety Feasibility Cost evidenceintegration of values + practice guidelines

Indirect calorimetry vs. predictive equations Differences: recommendations 1 CanadianADAASPEN/SCCM Insufficient data 1 small RCT burn patients Strong Use indirect calorimetry Non RCTs, no clinical outcomes Grade E Use either, caution with equations Narrative review article

Dose of enteral nutrition and target range Differences: recommendations 1 CanadianADAASPEN/SCCM Should be considered Use strategies to optimize EN i.e. goal rate start, 250 mls GRVs, m. agents, small bowel feeding No threshold 1 RCT and 2 Cluster RCTs Fair Give at least 60-70% energy within first week 2 RCTs and 2 non RCTs Grade C Provide >50-65% goal calories in first week Specifics for Obese (Grade E and D) 1 RCT and 1 non RCT

Gastric Residual Volumes & Motility agents Differences: recommendations 1 CanadianADAASPEN/SCCM GRVsShould be considered 250 mls 1 RCT and 2 Cluster RCTs Consensus 250 mls Grade B 500 mls 4 RCTs Motility agentsRecommend metoclopromide Strong metoclopromide Grade C Metoclopromide Erythromycin Opiod antagonists

Arginine Differences: recommendations 1 CanadianADAASPEN/SCCM Recommend NOT be used Meta-analyses of 22 RCTs 3 RCTs harm Fair Not be used 11 RCTs 2 RCTS harm Grade A Surgical Grade B Medical Cautious in severe sepsis Volume use 50-65% goal earlier meta-analyses showing no benefit RCT showing benefit Grade A: based on elective surgery patients

Enteral Glutamine Differences: recommendations 1 CanadianADAASPEN/SCCM Burns: Recommended Trauma: Should be considered Other ICU: Insufficient data 9 RCTS Grade B Burns, Trauma and mixed ICU patients 1 RCT

Peptides Differences: recommendations 1 CanadianADAASPEN/SCCM Recommend polymeric (since no benefit for peptides) 4 RCTs Grade E Use small peptides in diarrhea 1 non RCT

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Fibre Differences: recommendations 1 CanadianADAASPEN/SCCM Insufficient data 6 RCTs Grade E Use soluble fibre 3 RCTs Grade C Avoid soluble and insoluble fibre for bowel ischemia/severe dysmotility 2 non RCTs

Probiotics Differences: recommendations 1 CanadianADAASPEN/SCCM Insufficient data No benefit in outcomes, potential for harm 12 RCTs Grade C Use in transplant, major abd surgery, severe trauma Not in necrotizing pancreatitis 5 RCTs

Intensive Insulin Therapy Differences: recommendations 1 CanadianADAASPEN/SCCM Recommend Target 8.0 mmol/L Range 7-9 mmol/L Most recent meta- analyses Strong Medical: mmol/L Grade B Moderate strict control Grade E mmol/L

Similarities?

TopicCanadianADAASPEN/SCCM Use of EN over PN  Start EN within hr  EN Fish Oils   CHO/FatInsufficient -----Insufficient Body position  (45)  Small bowel vs. gastric  Continuous vs. otherinsufficient----High risk (D) PN vs std careNot be used----Not for 7 days Type of IV lipidsNo soy based----No soy based PN Glutamine  ----  Low dose of PN  ----  AOX/vits/minerals  ----  ADOPT NOW!

Slight difference in strength 1 Enteral Nutrition over Parenteral Nutrition Canadians and ADA: Strongest ASPEN/SCCM: second strongest Feeding Protocols Canadians and ASPEN/SCCM: weaker recommendation ADA: none for feeding protocol per se, but for GRV : expert opinion EN plus PN Canadian: recommend NOT be used ASPEN/SCCM: not be started for days (grade C) Blue Dye ASPEN/SCCM : not recommend ADA : do not recommend but highest level of evidence

Differences exist between the guidelines: Populations, levels of evidence, time frames, etc Recommendations: due to interpretation of the evidence, lack of transparency Similarities in many of the recommendations Highlight the need for harmonization across North American Societies Summary 1

Similarities should be adopted without hesitation Differences Harmonize between societies Define critically ill patient Transparency needed (websites) Practitioner: right recommendation for the right person Implications 1

Upcoming in JPEN 1 Available online Knowledge Translation issue Fall 2010

Ahhh…..Harmonized Guidelines!