Timing of Nutrition Therapy - American College of...

Stephen A. McClave, MD


Louisville, Kentucky

Nutritional Management of the Hospitalized Patient:

Insight from the Guidelines

Timing of Nutrition TherapyFirst week

Argument to AVOID feeding

Height dz process, inflam, insulin resist, intolerance

Evidence that full feeds may be harmful

Importance of preserving autophagy

Teleologic argument disrupting fight/fright/flight response

Opposing argument to PROVIDE feeding

Window of opportunity to attenuate disease severity, SIRS

Provide non-nutritional benefits of nutrition Rx

Second week

Change in priorities, less controversial

Need for nutritional benefits, impact of increasing caloric deficit

Catabolism to anabolism

ICU

SA McClave, JK DiBaise. GE Mullin, RG Martindale (Amer J Gastroent 2016;111:315)

ACG 2016 Southern Regional Postgraduate Course Copyright 2016 American College of Gastroenterology

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Providing vs Not Providing Early EN

Early EN vs No Early EN (p=0.01)

Mortality 14.1%→8.7%, p=0.05

Early EN vs No Early EN (p=0.05)

SA McClave, BE Taylor(JPEN 2016;40:159-211)

Infection 51.7%→36.3%, p=0.03

Controls: Do nothing (STD)Intentional delay

What are the Benefits of Early EN?

• Non-Nutrition benefits – Seen in all patients (trophic feeds OK)

Gastrointestinal responsesTrophic on gut integrity Commensal bacteriaGut/lung axis of inflamm Secretory IgA, GALT tissueReduced bact virulence

Immune responsesModulate regulatory cells Promote Th-2 >Th-1 lymphocytes Maintain MALT tissue

Metabolic responsesIncretin to insulin sens Reduce hyperglycemia (AGES)

• Nutrition benefits – Seen in high risk patients (need full feeds)

Protein, calories Micronutrients, anti-oxidants

Maintain LBM Stimulate protein synthesis

• Non-Nutrition benefits – Seen in all patients (trophic feeds OK)

Gastrointestinal responsesTrophic on gut integrity Commensal bacteriaGut/lung axis of inflamm Secretory IgA, GALT tissueReduced bact virulence

Immune responsesModulate regulatory cells Promote Th-2 >Th-1 lymphocytes Maintain MALT tissue

Metabolic responsesIncretin to insulin sens Reduce hyperglycemia (AGES)

• Nutrition benefits – Seen in high risk patients (need full feeds)

Protein, calories Micronutrients, anti-oxidants

Maintain LBM Stimulate protein synthesis

S McClave, R Martindale (CCM 2014;42:2600) S McClave (Amer J Gastroent 2016;111:315)


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What is the OptimumDose for Feeding in ICU?

• Proposed strategies:

Starvation (Van den Berghe, Marik) - Autophagy

Trophic feeding (Rice) – ARDSNet Trial, Surviving Sepsis

Permissive underfeeding – Charles, Arabi, Petros

Full dose aggressive feeding (Heyland) - Pep Up

• Best option: High protein hypocaloric feeding (first week)

Advance by slower ramp-up

• Proposed strategies:

Starvation (Van den Berghe, Marik) - Autophagy

Trophic feeding (Rice) – ARDSNet Trial, Surviving Sepsis

Permissive underfeeding – Charles, Arabi, Petros

Full dose aggressive feeding (Heyland) - Pep Up

• Best option: High protein hypocaloric feeding (first week)

Advance by slower ramp-up

Trophic Feeds

Full Feeds

1CCM 2011;39:967 2JAMA 2012;307:795 3JPEN 2016;40:242 4Am J Clin Nutr 2014;100:1337 5NEJM 2015;372:2398

80% Goal calories

25% Goal calories

• Trophic feeds vs full feeds (ARDS pts)Rice Single center (n=200) 1

Outcomes same (Full Rx to home)ARDSNet Multicenter (n=1000) 2

Outcomes no different (12 mos) • Permissive underfeeding

Half vs full calories/protein - Petros Med ICU pts (n=100) 3

Infections less in full feeds (11.1 vs 26.1%, p=0.04)Half vs full calories, full protein both

Charles Trauma pts (n=83) 4 Outcomes no differentArabi Mix ICU pts (n=1350) 5 Outcomes no different (3 mos)

Is Trophic Feeding OK to Start?


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Dual Aspect of Nutritional Risk

Components: Impaired nutrition status and disease severityJ Kondrup (Curr Opin Clin Nutr Metab Care 2014;17:177)

NutritionalStatus

Disease Severity

Increased risk of complications, adverse outcome

Kondrup J (Clin Nutr 2002)

Age >70 yrs : Add 1 point Score >3 Consider EN/PNScore >5 High risk

Concept of Nutritional Risk: NRS-2002 Score


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Concept of Nutritional Risk: Nutric Score

Heyland DK (Crit Care 2011;6:1)

Six factors for Nutric Score: Disease severity:

AgeInitial APACHE II scoreInitial SOFA scoreInterleukin-6Comorbidities

Poor nutritional status:Hosp LOS prior to ICU

Nutritional Risk May Predict Benefit from Rx

1 ClinNutr 2012 2 Clin Nutr 2015 Jan 3 Amer J Resp Crit Care 2016

• Jie Study NRS-2002 1 - High Risk patients (n=120)with NRS Score >5Insufficient (n=77) Sufficient Nutr Rx (n=43)

Overall complications 51% 26% *Nosocomial infection 34% 16% *

No benefit (sufficient vs insufficient ) Low Risk pts (n=965) NRS <5

• Heyland Study Nutric Score 2

Observational Trial (n=1199)

• Arabi Trial Post Hoc Analysis 3

Nutric score did not predictbetter response to Rx

(both full protein, 46 vs 71% kcal)

EN Rx Effect onHigh Risk Pts (p<0.0001)

Low Risk (p=NS)


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Should We Push to Goal Quickly?Endogenous Glucose Production

• Endogenous glucose production

Greater early in ICU

Cannot be suppressed

• Energy requirements not same as

energy needs

• Hypocaloric feeding

Avoids overfeeding

Better tolerance

Better outcome

More appropriateV Fraipont, JC Prieser (JPEN 2016;37:705-13)

Endogenous

Exogenous

GS Doig (Lancet Respir Med 2015; 3: 943–52) Heymsfield (Amer J Cardiol 1987;60:75G)

• Patient candidatesNPO x 7-10d, low BMI, wght lossCHF, mech vent, hypercapnea

• Spectrum of changes with feedingCHF, underlying cardiomyopathy Electrolyte, fluids, gas exchange abnsInsulin resistence, poor WBC fxn, infection, respir failure

• RCT ICU Multicenter (n=339) phos <0.65 mmol/LSlow ramp-up over 4 days vs standard (STD)

Results: Mortality worse in STDInfection: Slow 8% vs STD 16% (p=0.01)

No different: MOF, Durat MVOther signs: ↓K+ (27%) ↑gluc (52%)

Resp fail (91%) Diuretic need (30%)

Calories Phosphate

Survival

Should We Push to Goal Quickly?Refeeding Syndrome


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Monitor Tolerance and Adequacy• GRVs should not be used as part of routine care1

Montejo Multicenter RCT 2 GI Complic %Goal 500cc GRV (n=160) 47.8% * 89% *200cc GRV (n=169) 63.6% 83%

Reignier Multicenter RCT 3 VAP Infect Mortality DeficitNo GRV used (n=227) 16.7% 26.4% 27.8% 319 kcalRoutine GRV (n=222) 15.8% 27.0% 27.5% 509 kcal

• Implementation plan – Announce new policy of No GRVs in 1 year

Use GRVs on initiating EN x 3days only, d/c EN for 2nd 500 cc

No GRVs: Awake/alert pts, tube in SB

• Focus instead on:

Phys exam Passing stool, gas Tracking I&Os

Aspirat risk Access site Protein calorie goals1McClave (JPEN 2016;40:159) 2Montejo (ICM 2010;36:1386) 3Reignier (JAMA 2013;309:249)

Which Formula Should Be Used?

• Most patients - Start with standard polymeric formula • Elective Surgery, SICU – Use arg/fish oil formula 1

Infection ↓ 41% (OR=0.59)Hosp LOS ↓2.38 days

• Crit Care MICU – Don’t recommend arg/FO formulaNo difference mortality, infection, LOS

• ALI/ARDS – No recommendation anti-inflammatory lipid profile formula 2-8

Gadek, Singer, Pontes-Arruda, Grau-CarmonaAll benefit

Rice ARDSNet, Stapleton, MetaPlusHarm or no benefit

Elective Surg

Critical ICU

ARDS or ALI

1 JW Drover (JACS 2011;212(3);385) 2 JE Gadek (CCM 1999;27:1409) 3 P Singer (CCM 2006;34:1033) 4 A Pontes-Arruda (CCM 2006;34:2325)5 T Grau-Carmona (Clin Nutr 2011;30:578) 6 T Rice (JAMA 2012;307:795)7 R Stapleton (CCM 2011;39:1655) 8 A Van Zanten (JAMA 2014;312:514)


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Multicenter Trial in EnglandEN vs PN in 2400 ICU pts

High risk (mortality 34%)Each provided 80% goal feedsNo difference in outcomes

Impact: Under controlled conditions, high risk patients, PN can = ENEN still preferred over PN, but should lower threshold to use PN

SE Harvey CALORIES Trial Group [NEJM 2014; 371(18):1673]

What is the Role of Parenteral Nutrition?

Use of Parenteral Nutrition

• Exclusive PN (EN not feasible)

Low Risk - Withhold exclusive PN

(NRS 2002 ≤3, Nutric Score ≤5)

High Risk - Initiate exclusive PN ASAP (esp malnourished)

(NRS 2002 ≥5, Nutric Score ≥6)

• Supplemental PN (on EN) - Add at 7-10d if <60% goal high or low risk 1

• Maximize efficacy of PN

Use Multidisciplinary Nutrition Team, protocols in place

Moderate glucose control (140-180 mg/dL)

High protein hypocaloric (80%) dosing first week 2

Transition off PN when EN provides >60% goal

1Heiddeger (Lancet 2012 Dec 3) 2 Jiang (Clin Nutrit 2011;30:730)


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Determining Caloric Requirements

G Yost (NCP 2015;30:690-697)

Caloric requirements25-30 kcal/kg/dEquations no more accurateIndirect calorimetry

CHF pts prior to LVAD (n=98)All poor estimate of REE

HB Owen

Mifflin Livingston

BrandiSwinanmer

Faisy PSU

Schofield Henry

Determining Protein Requirements

Protein requirements

Greater emphasis

Higher doses

1.2–2.0 gm/kg/d

Fewer restrictions

MJ Allingstrup (Clin Nutr 2012;31:462)1

P Weijs (JPEN 2012;36:60)2

28-Day Mortality2

Survival1

PET ET

Protein


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Initiation of EN: Adjustments for Obesity• Adjustment for obesity – high protein hypocaloric feeds

Push protein to 2.0 (Class I, II) to 2.5 (Class III) gm prot/kg IBW/day

Reduce calories to 65-70% of requirements (IC)

• Beware of paradox of obesity 1

Effect of central adiposity - ICU mortality 25%→44% 2

Effect of sarcopenia - Mortality 14→32% 3

• Adjustment for obesity – high protein hypocaloric feeds

Push protein to 2.0 (Class I, II) to 2.5 (Class III) gm prot/kg IBW/day

Reduce calories to 65-70% of requirements (IC)

• Beware of paradox of obesity 1

Effect of central adiposity - ICU mortality 25%→44% 2

Effect of sarcopenia - Mortality 14→32% 3

1 NCP 2008;23:16-34 2 CCM 2010;38:1308 3 Crit Care 2013;17:R206

Avoid common mistakes:Don’t need to feed (reserves)Feed to maintain fat mass

Drag Tube Drag Wire Untethered EndoscopyTube

NJ

PEGJ

Prioritizing Techniques for Enteral Access


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Modify Site for all PEG Placements

Facilitate conversion to PEGJ if needed

SA McClave (Amer J Gastroent 2016;111:315)

When Do You Pull the Trigger on SB Feeding?

• It is a soft call: No difference MOF, hosp LOS, durat MV, mortality 1,2

• SB feeding involves: Expertise, timing, availability, delays, cost

• Usual reasons: Frequent cessation due to high GRVs, pancreatitis

Recurrent cessation for Dx tests, Rx procedures

Difficulty advancing feeds due to intolerance

• Consider when: Intolerant to gastric feeds, high risk aspiration 2

1 criticalcarenutrition.com (Feb 2014) 2 SA McClave (Amer J Gastroent 2016;111:315)

Pneumonia 1


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Take Time to Secure Enteral Access Device

Hollister (Vertical) Clamp

Magnetic Nasal BridleSA McClave (Amer J Gastroent 2016;111:315)

Conclusions

• The benefit of early nutrition Rx is due primarily to EN• The risk/benefit ratio of PN is narrower, use in high risk

patients when EN insufficient

• Manner of delivery shifting

Trophic feeding initially with slower ramp up

High protein hypocaloric feeding may be best option first week

• Assess risk, monitor tolerance - Important, prognostic, directs Rx


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