Metabolic monitoring in the ICU - WFSICCM2015ab.wfsiccm2015.com/WFSICCM_AB/1230PMJean-Daniel...
Transcript of Metabolic monitoring in the ICU - WFSICCM2015ab.wfsiccm2015.com/WFSICCM_AB/1230PMJean-Daniel...
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Jean-Daniel Chiche, MD PhD
Metabolic monitoring in the ICU
MICU & Dept of Host-Pathogen Interaction
Hôpital Cochin & Institut Cochin, Paris-F
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Conflicts of interest - Disclosure
GE Healthcare
Received honorarium for participation to
Medical Advisory Board for ventilation & CIS
activities (2009-2011)
Travel expenses Seoul 2015
Nestlé Healthcare
Received honorarium for participation to
Medical Advisory Board
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25 years of failed novel intervention trials
Being less pessimistic...
improved ICU outcomes (better general care,
less iatrogenic harm)
many positive outcome RCTs from doing less
(ventilation, sedation, Tx..)
excess reliance on protocols, guidelines?
Starting to understand what may be good
for populations .. but for the individual??
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It’s all about people!
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But we care for individuals
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Individuals are unique!
Photo credit: Kallel Koven
differing host
response to insult
different trajectory of
disease progression
different severity of
disease progression
affected not just by
genes but by age,
comorbidity, drugs...
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Interplay between critical ilness & chronic health
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ICU / Hospital Mortality
ARF
Shock
Infection
AKIOrgan
failure
Coma & Neuro
dysfunction
Nutrition
Sedation
Transfusio
n
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JAMA. 2014;311(13):1295-1297
JAMA. 2014;311(13):1295-
1297
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The global burden of critical illness
ARF
Shock
Infection
AKIOrgan
failure
Coma & Neuro
dysfunction
Nutrition
Sedation
Transfusio
n Patients &
Family
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ICU-acquired
weakness
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Try the ICU Diet…
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Impact of Systemic Aggression
Age and comorbidities predispose patients to
shock and critical illnesses
The normal response to aggression involves
simultaneous expression of genes involved in
the systemic inflammatory, innate immune, and
compensatory antiinflammatory responses, as
well as suppression of genes involved in
adaptive immunity
Differences in the magnitude and duration of
these changes are associated with complicated
outcomes
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Impact of Systemic Aggression
In addition to organ dysfunction taken into
account by SOFA scores, systemic aggression
triggers novel pathophenotypes
Critical illness neuromyopathy
Immune dysfunction
Heterotopic ossifications & joints abnormalities
Cognitive dysfunction
Depression
Acute cardiovascular events
Dementia
Tumor growth,…
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Individuals are unique…
Photo credit: Kallel Koven
Regardless of…
etiology
timing
severity
confirmed diagnosis
age
gender
co-morbidity
…
…and so are our treatment approaches!!!
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Frailty as an important determinant of critical illness
Syndrome of decreased reserve and resistance to
stressors, including sepsis
Results from cumulative declines across multiple
physiologic systems
Defined by ≥3 criteria
unintentional weight loss
self-reported exhaustion
weakness (as evidenced by
reduced grip strength)
slow walking speed
low physical activity
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J Am Geriatr Soc 54:991– 1001, 2006
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Male individuals, 2010 Female individuals, 2010.
Most ICU patients have some sort of comorbid state
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The complex ICU patient
Patients with complex multi-organ failure
have prolonged ICU stays – weeks to months
Some have prior nutritional deficits
Some (few) have clear contra-indications to
EN
But many of these develop gut dysfunction
during their episode:
Gut stasis
Constipation
Ileus
bleeding
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The complex ICU patient (2)
Prolonged ventilation & immobility:
Muscle loss
Continuous Renal Replacement Therapy
Nutrient loss
Underfeeding
Protein and calorie deficit
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The few things I know about nutrition…
Use enteral feeding every time it is possible
Use it early
Feed with whatever works…
Use some sort of glycemic control
Use common sense…
How much? Fortunately, smart people
publish guidelines…
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Body weight vs energy intake
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The problem of obesity
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Can we predict
energy expenditure?
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8070605040302010030
34
38
42
46
50
54
years
kc
al/
m2/
ho
ur
men
women
Fleisch A. Helv Med Acta 1951;1:23-44
73%
15%
12%
Basal metabolism
Thermogenesis
Physical activity
Energy expenditure in healthy subjects
• Disease states
• Temperature
• Stress
• Drugs, hormones
• Treatments
• Nutrition
• Physical activity
The surest things can change…
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Change in energy expenditure
Propacetamol External cooling
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weight & height
+ minute ventilation
+ temperatureREE (M) = 14 x kg + 5 x cm – 7 x years
REE (F) = 10 x kg + 1.8 x cm – 5 x years
weight & height
+ age (gender)
+hypermetabolism
weight & height
+ age (gender)
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Undernutrition vs Overnutrition
Autophagia?
Tissue repair?
Autophagia?
Tissue repair?
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Overnutrition & Lung Function
Nutrient intake & consumption
increase in metabolic rate
increase in CO2 production
increase in minute ventilation
High glucose intake induces lipogenesis
RQ > 1 + further increase in CO2 production
In case of weaning failure / high minute
ventilation (> 150 ml.kg-1.min-1) in otherwise
unstressed patient, consider the possibility
of overnutrition / high glucose intake
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Do We Have a problem?
Is it plausible that an initial nutritional deficit
may have a detrimental effect?
To what extent is the concept of relative
underfeeding merely an excuse for poor
performance?
If this is true, how might we address it?
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Energy deficit has significant
consequences on outcome
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ICU cumulated energy balance & outcome
0
5
10
15
20
25
30
Positive 0-10k negative > 10k negative
Nu
mb
er
of
pati
en
ts
Survived
Died
• Patients at risk of organ failure
• Indirect calorimetry determinations of target
27%
39%86%
Bartlett et al. Surgery, 92: 772, 1982
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Villet et al, Clin Nutr 2005
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Villet et al, Clin Nutr 2005
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Kyle et al, Clin Nutr 2006
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Predictive equations showed proportional bias
Overestimation of low REE values
Underestimation of high REE values
Correction by regression analysis did not
improve results
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Measuring energy
expenditure in the ICU
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Energy expenditure measurements
Living organisms consume O2 &
generate heat due to cellular respirationNutrients + O2 ATP + heat
Direct calorimetry
Body heat radiation is captured by circulatingwater in a highly isolated environment
EE= Water volume (ml/sec) x T (water in -out)
Precision± 1%
Indirect calorimetry
Expired vs. inspired O2 & CO2 EE
Precision ± 1-5%
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O2 (ml) CO2 (ml) RQ
Glucose
Lipids
Proteins
828.8
2019.3
966.3
828.8
1427.3
773.9
1.00
0.70
0.80
RQ = O2 consumption/CO2 production
Interpretation
0.7 - 0.85 lipolysis
0.7 - 0.95 glycolysis
≥ 1.0 lipogenesis
Indirect calorimetry: parameters
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Distribution of measured EE in 335 patients on MV as % of predicted EE (HB)
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Indirect calorimetry in practice…
Indications
Body weight ≤80 % or ≥130% IBW
Major stress
Hyperthyroidia, pheochromocytoma
Shivering, spasms, plegia, coma,
Long-term ICU stay & mechanical ventilation
Difficult weaning
Limitations
High pressure regimen leaks
Hyper / hypoventilation ∆ PH
Insufficient duration
Non-collaboration, agitation
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Indirect calorimetry in the ICU
The Tools
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Indirect calorimetry in the ICU
What can we do with it?
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Patients randomized to receive enteral nutrition with
an energy target determined repeated indirect calorimetry measurements; study group, n=56
according to 25 kcal/kg/day; control group, n=56)
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By Day3:
-3856±1311kcal
Day 4-8: 248±1479 kcal
Day 4-8: -2220±2478 kcal
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SUCCESS
FAILURE
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SUCCESS
Correlation between respiratory drive (expressed as P0.1) & VO2
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Metabolic monitoring
Any other use?
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Bedside measurement of FRC
N2 wash-out / wash-in
Volume and
concentration of
Nitrogen captured
Change Oxygen
concentration
Calculate
change
in Nitrogen
Calculate FRC
through
metabolic
monitoring
• FRC = VN2/N2%start – N2%end
• N2% = 1-EtO2–EtCO2
• VN2 = VTi x N2%in – VTe x N2%out, where;
– N2%in = 1-FiO2
– N2%out = 1-EtO2 – EtCO2
Metabolic stability is mandatory
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Bedside measurement of FRC
Establish a patient’s baseline FRC
Evaluate the progression of acute lung injury
Assess whether a specific therapy or a change in ventilation improves FRC
Evaluate the effect of recruitment maneuvers
Patient-tailored physiological determination of the “best PEEP”
What can we expect ?
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∆PEEPxCompl
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Recestim = -136 +
1.2xRecmes
P = 0.0002
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Decremental PEEP trials to set PEEP ?- a practical alternative -
Recruitment maneuver (RM)
FiO2= 1, Paw 40 cmH2O x40 sec, then
Pplat ≤ 30 cmH2O, PEEP 16 (20)
ABG 10 min after RMAdjust RR & VT for pH> 7.25
Wean FiO2 for SpO2 = 88-93 %
Decrease PEEP 2 cmH2O/5 minstop @ « PEEPdr », with SpO2 < target
Recruitment maneuver (RM)
Paw 40 cmH2O x40 sec, then
Pplat ≤ 30 cmH2O, PEEP= PEEPdr + 2
cmH2O
Maintenance
0
0,6
1
0,2
0,4
0,8
1,2
1,4
1,6
-5 0 5 10 15 20 25 30 35
Deflation
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Decremental PEEP trials
• Volume difference can
represent either recruited or
de-recruited volume.
• CRF measurements during a
decremental PEEP trial
following a recruitment
maneuver can identify:
the response to
recruitment manœuver
the level of PEEP where
de-recruitment occurs.
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FRC-guided PEEP setting in ALI -1
FRC (mL) SpO2 (%)
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FRC-guided PEEP setting in ALI -1
FRC (mL) CO (L/min)
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FRC-guided PEEP setting in ALI -2
FRC (mL) SpO2 (%)
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FRC-guided PEEP setting in ALI -2
Volume expansion
1500 mL saline serum
FRC (mL) CO (L/min)
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FRC-guided PEEP setting in ALI -2
FRC (mL) SpO2 (%)
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Summary
Metabolic monitoring can be implemented
in the ICU and has potential useful clinical
applications in the critically ill
Optimization of nutrition therapy
Weaning
Determination of FRC is potentially helpful to
Evaluate the progression of acute lung injury
Assess the efficiency of specific therapies or
changes in ventilation strategies (PEEP setting,
recruitment maneuvers, prone position, …)
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