2. Bridging the Guideline-Practice Gap: The Critical Care Experience Rupinder Dhaliwal, RD Daren Heyland, MD Rupinder Dhaliwal, RD Daren Heyland, MD

3. Guidelines for Nutrition Therapy in the ICU Rupinder Dhaliwal, RD Operations Manager Clinical Evaluation Research Unit Kingston, Ontario Rupinder Dhaliwal, RD Operations Manager Clinical Evaluation Research Unit Kingston, Ontario

4. DisclosureDisclosure Canadian Clinical Practice Guidelines for Nutrition Support for the Mechanically Ventilated Critically ill Co-Author Rupinder Dhaliwal

5. Critical Care Nutrition The right nutrient/nutritional strategy The right timing The right patient The right intensity (dose/duration) With the right outcome! www.criticalcarenutrition.com

7. A Continuous Quality Improvement Effort What is done? What ought to be done ? What do we need to do differently? “Gaps” - site reports How to change? “KT strategies” RCTs, Systematic Reviews, and Evidence-based practice guidelines Survey results www.criticalcarenutrition.com What is done?

8.  To identify the similarities and the differences between the recommendations of three North American Clinical Practice Guidelines  Understand why these differences occur  Need for harmonization across guidelines Objectives Objectives

9. Why bother with 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

10. Proliferation of guidelines

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

12. Review of guidelines needed A review of the content and the evidence used to formulate the recommendations Assesses the process of development

13. Which Guidelines to compare? Critically ill populations Developed by North American professional/national organization Published/online 1999-2009 Addressed more than one single topic Were not consensus statements (i.e. immunonutrition ) Were original work vs. part of cluster RCTs

14. North American Guidelines www.criticalcarenutrition.com

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

16. Differences AreaCanadianADAASPEN/SCCM PopulationMechanically ventilated critically ill patients no elective surgery Critically ill patients eligible for 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 1980-20091993-2003 1993-2009 1996-2006 (2009) unclear Outcomes clinical outcomesclinical and non clinical outcomes

17. 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%)

18. Criteria High Quality CPGs 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

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

20. Indirect calorimetry vs. predictive equations Differences: recommendations 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

21. Dose of EN/Achieving target range Differences: recommendations 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

22. Gastric Residual Volumes & Motility agents Differences: recommendations 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

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

24. Enteral Glutamine Differences: recommendations CanadianADAASPEN/SCCM Burns & Trauma: Should be considered Other ICU: Insufficient data 9 RCTS --------Grade B Burns, Trauma and mixed ICU patients 1 RCT (Jones mixed ICU pts)

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

27. Fibre Differences: recommendations 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 (review, case study)

28. Probiotics Differences: recommendations 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 (elective sx)

29. Intensive Insulin Therapy Differences: recommendations CanadianADAASPEN/SCCM Recommend Target around 144 mg/dl (8.0 mmol/L) Range 120-160 mg/dL (7-9 mmol/L) Keep < 180 mg/dL (10 mmol/L) in all Most recent meta- analyses includes NICE SUGAR Strong Medical: 80-110 mg/dL (4.4-6.1 mmol/L) BEING UPDATED 2009 Grade B Moderate strict control Grade E 110-150 mg/dL (6.1-8.3 mmol/L)

30. Similarities?

31. TopicCanadianADAASPEN/SCCM Use of EN over PN  Start EN within 24-48 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!

32. Slight difference in strength 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 until strategies to maximize EN adopted ASPEN/SCCM: not be started for 7 -10 days (grade C) Blue Dye ASPEN/SCCM : not recommend ADA : do not recommend but highest level of evidence

33. Differences exist between the guidelines: – Populations – Levels of evidence: not enough RCTs so tendency to make a recommendation – Time frames of literature searches and updates – Recommendations: due to interpretation of the evidence, lack of transparency Similarities in many of the recommendations Conclusions

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

35. JPEN Nov 2010:625-643

36. Ahhh…..Harmonized Guidelines!

37. Thank You!