Practical Approach on Feeding the Critically Ill of COVID ... · Parenteral nutrisi. Practical...
Transcript of Practical Approach on Feeding the Critically Ill of COVID ... · Parenteral nutrisi. Practical...
Practical Approach on Feeding theCritically Ill of COVID-19: focus ICU
STOP COVID - 19SAVE LIVES
Frans JV PangalilaJakarta
Disease spectrum of COVID-19
Zunjou Wu et al. JAMA 2020
81% were mild statuso no pneumonia or mild pneumonia
5% were severe statuso dyspnea or respiratory rate ≥ 30/min or
SpO2 < 93% or PaO2 /FiO2 < 300 mmHg
14% were critical ill statuso needs mechanical ventilationo shocko multi-organ failure→ require ICU admission
Penyakit Kritis: COVID-19
Injury / Sepsis-COVID-19
Acute Stress Response
Immune Response NeuroendocrineResponse
Metabolic response
Release mediator and reaction Stress hormon release
ditandai:o peningkatan “ resting energy expenditure “ (REE) atau
hipermetabolik: meningkatkan kebutuhan energi-kalorio akselerasi “ whole body proteolysis “ atau hiperkatabolik
dan lipolisis
Tampilan ditemukan:- Klinis: demam, takikardi, takipnea
- Laktat darah - asidosis (hipoperfusi)
- Hiperglikemia- Negative Nitrogen balance : ekskresi N urin- C reactive protein (CRP) meningkat - hipoalbumin
Autophagy and Nutrient in Critically ill
Endothel
Pro
tein
me
tab
olis
mLi
pid
me
tab
olis
m
Amino Acid Lipid / Fat Glucose
Glu
cose
me
tabo
lism
Lysosome
Protein synthesis
Lipid droplets
Fatty Acid
Energy Glycogen
Energy
Energy
Autophagy• trigger : starvation• suppress : overfeeding /hyperglycemia and insulin
Airway managementBreathing control
Tissue oxygenationFluid managementCirculatory support
AntibioticNutrition delivery
Old Paradigm : Nutrition as a Supporthad been shift to
New Paradigm : Nutrition as a Therapy
Step 1: who are the patients requiring nutritionalsupport ?
“ all patients ICU are at risk of MALNUTRITION if stay > 2 days “
→ Nutrition assessment: identified malnutrition
ICU: NUTRIC Score and Subjective Global Assessment (SGA) more reliable
NUTRIC Score
Nutric Score without IL-6
Step 2: estimate Energy (calories) requirements
o tools: • Indirect calorimetry (ideal)• Harris- Benedict equation with longs modification
(time consuming and not validated in ICU)• etc
“ Rule of Thumb “ : 25 – 30 kcal/kg IBW meet patientsneeds, start: 8 – 10 kcal/kg/day
ESPEN: 27 kcal/kg/day in polymorbid older adult (> 65 yrs)30 kcal/kg/day , severely underweight polymorbid
ASPEN/SCCM: 15 – 20 kcal/kg ABW/day ≈ 70 – 80% ofcaloric requirements
o nutrition requirements should take into consideration the useof Propofol in terms of lipid calories and total calories needed
Step 3: estimate Protein (nitrogen) requirements
“ Rule of Thumb “ : 1.5 – 2 g /kg IBW meet patients needs
ESPEN: 1.0 gr/kg/day in older adults→progressive deliveryof 1.3 gr/kg in polymorbid COVID-19
ASPEN/SCCM: 1.2 – 2.0 kcal/kg ABW/day
- During ACUTE PHASE : 0.7 – 0.8 gr/kg protein (to avoid suppressingAUTOPHAGY)
o protein intake should not be calculated as calorie sourceo non protein calorie (NPC): nitrogen ratio
- 150 cal (NPC) : 1 g nitrogen- 6.25 g of protein = 1 g nitrogen
Step 4: estimate Fluid, Electrolyte requirementand supplement Micronutrient
o Rule of the “ thumbs “ 1 ml/kcal is the minimum requirement of fluid to deliver isocaloric feed BUT avoiding fluid balance ++
o electrolyte should be tailored to individuals requirement
ESPEN Recommendation:
➢ provision of vitamins and trace elements is required to maximize anti –infection nutritional defense• Vitamins A, D, E, B6 and B12
• Micronutrients zinc, selenium and iron• Omega-3 fatty acids with Enteral or Parenteral Nutrition
- metabolites of Arachidonic acid (AA) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are known to suppress inflammation, ↓ microbial load,augment phagocytosis of macrophages /other immunocytes , ↑ woundhealing (based on case reports)
Step 5: when should we start and which route ?
2018
2016
Enteral Nutrition (EN) : technical and access
2016
2018
Algoritme Pilihan Akses Enteral Nutrisi (EN)
Indikasi EN (+)
Risiko Aspirasi
(+)Risiko Aspirasi
(-)Risiko Aspirasi
(-)Risiko Aspirasi
(+)
EN jangka pendek(< 4-6 minggu)
EN jangka panjang(> 4-6 minggu)
Nasoduodenalatau
Nasojejunal tubeNasogastric tube
Jejunostomi atauGastro-
jejunostomi tubeGastrotomi tube
Risiko Aspirasi
• riwayat aspirasi• kesadaran menurun• gangguan menelan• GERD *• gastroparesis• gastric outlet obstruc
tion
Calorie Targeted (%)
20
40
60
80
100
1 3 542 6 7 8 9
Days
Enteral Nutrisi
PN + EN
Caloric Debt
↑ Caloric debt associated with↑ ICU stay↑ days on MV↑ complications↑ mortality
Rubinson et al CCM 2004 Villet et al Clin Nutr 2005
Dvir et Clin Nutr 2006 Petros et al Clin Nutr 2006
Step 5: when we start to think to give ParenteralNutrition (PN)?
“ increased caloric debt associated with worseoutcome “
⓿ Consider PN if EN is not indicated or unable to reach targetcalories:- when GI symptoms is prominent (to reduce droplet aerosol)- hemodynamic instability requiring vasopressor at high or de escalation
dose or requiring high pressure respiratory support
ASPEN/SCCM Recommendation (2020):
⓿ Consider use of multi-chamber bag PN products, particularlyif standard PN components are in shortage
⓿ in case of Dysphagia after extubating consider temporary PN
⓿ Prone positioning (refractory hypoxemia)o to improve oxygenation and increase bronchial secretion clearanceo head of the bead elevated (reverse Trendelenburg) ≈10 - 25 degrees o delivered into stomach (post-pyloric placement)
Bagaimana PN diberikan ??
memerlukan PN > 5 hari dan atau > 1000 kalori
ya tidak
PN akses periferMemerlukan > 2 cairan dan atau obat / bahan iritan (vasopresor, kemoterapi)
Ya
Kateter multi-lumen
Tidak Kateter single lumen
Step 6: MONITORING ?
Pemantauan : identifikasi dini !!
Refeeding Syndrome (RFS)
• terjadi pergeseran cairan ,elektrolit (phosphat, magnesium, kalium) dan mineral akibat pemberian nutrisi yang aktif
• petanda khas : HYPHOPHOSPHATEMIA (prediktor hipoalbumin)• didasari : aktifitas hormon INSULIN dan GLUCAGON
Manifestasi Klinis
mual – muntahdeliriumgagal napasaritmiahipotensi - gagal jantungkoma - kematian
Risiko RFS
anoreksia nervosamalnutrisikronik alkoholismeusia lanjutNIDDM (poorly control)kristaloid berlebihan
Pemantauan : identifikasi dini !!
Overfeeding Syndrome
❑ KARBOHIDRAT : > 5 mg/kg/menit
❑ LEMAK : > 2 gr/kg/hari
❑ PROTEIN : > 2 gr/kg/hari
Gagal Napas - hipercapnea
Hiperglikemia
Hiperinsulinemia
Gangguan fagositosis
Perlemakan hati
Hipertrigliseridemia
Ureagenesis – gangguanfungsi ginjal
Enteral Nutrition (EN) : monitoringPulmonary Aspiration is potentially lethal
o don’t discontinue enteral feeding for GRV < 500 ml
o GRV > 500 ml: withhold feeding GRV > 250 ml: use prokinetic agent
Enteral Nutrition( 20 – 40 ml/hour )
“ aspirate at 6 hours “
Aspirate < 250
↑ rate by 20 ml/hour or continue until maximal
Aspirate > 250
↓ rate half or minimum 20 ml /hour but don’t STOP to feed and use prokineticagent
⓿ Head of the Bed 30○ to 45○
⓿ Monitoring Gastric Residual Volume (GRV)
Pasien Dalam Pemantauan (PDP) atau konfirmasi “COVID 19”
“ Risiko tinggi “o Usia lanjut (≥ 50 thn)o laki lakio co morbid: hipertensi, diabeteso temperatur ≥ 37.8○Co lama keluhan ≥ 6 hario netrofil-limfosit rasio > 5o CRP > 50o d dimer ≥ 0.7µg/ml atau > 3 kali
nilai awalo CT thoraks: pneumonia (+)
(+)
suplemen oksigen• simpel mask atau NRM
(pemantauan ketat)
(-)
standar oksigen• nasal kanul (02 NK 2-3 l)(pemantauan 2 x perhari)
RR > 30/menit SpO2 < 93% HR > 120/menit
Intensive Care Unit (ICU)
Rawat bangsal(PDP)
Diet oral atauSuplemen nutrisi oral danatau Parenteral nutrisi dini
Intensive Care Unit (ICU)
o nilai SOFA ≥ 5 atau ∆ > 2atau
o disertai satu gagal organatau
o P/f rasio < 200
RR > 30 / menit SpO2 < 93 % HR > 120 /menit
(+)(-)
• Non Invasive Ventilation• High Flow Nasal Cannula
Oxygen
• awake prone position• restriksi cairan
Sp02 < 95% 3 - 5 jam Invasive ventilation
Rawat ICU
Enteral nutrisi dan atauParenteral nutrisi
Practical approach nutrition during the phase Critical illness and Convalescence
Acute phaseDay 1 - 4
Post Acute ICU phase> Day 5
Post ICU phase
Day 125%
Day 480 - 85%Day 3
75%
Target 1
ICU discharge
Post ICU
Target 2Progressive feeding(avoid overfeeding)
• monitor phosphate (P)• stay at 25% of caloric target for 48 hour
if phosphate drop• prevent very early high protein intake
protein: 0.7 – 0.8 g/kg
Target 1o calories 85% of calculated targetso proteins 1.3 g/kg/day
Target 2o calories 30 – 35 kcal / kg/dayo proteins 1.5 – 2.5 g/kg
• patients are at risk for reductionsin caloric and protein intake aftercessation of enteral nutrition(after feeding tube removal)
Cal
ori
es
kcal
/ d
ay
Pro
tein
s g
/kg
/ d
ay
Zanten AR et al Crit Care 2019 (modified)
Take Home Point
⓿ Identifikasi dini : MALNUTRISI
⓿ Fase Akut penyakit kritis: HINDARI sindroma Re-Feedingdan Over-feeding
⓿ Unit Rawat Intesif: multidisiplin-multispesialis perlunya:→ Penyusunan/konsensus penatalaksanaan bersama
NUTRISI
⓿ Nutrisi Enteral berikan secara dini → simptom GI ++nutrisi Parenteral dini dipertimbangkan
⓿ Integrated post discharge hospital center COVID-19- post ICU discharge- usia lanjut- pendataan