14/02/15

Critical  Care  Nutrition

v Provision of nutritional
support recognised as
Critical  Care  Nutrition:  Improving  Patient   important aspect in the
Outcomes treatment of critically ill
patients

v Daniel L. Chan, DVM, DACVECC, DECVECC, DACVN,

FHEA, MRCVS
v Nutritional Support Service
v Section of Emergency and Critical Care

“Improving Patient Outcomes” v Do critical care patients actually need

nutrition?

What’s the evidence?? v Previous standards of care did not

consider the need for nutrition for at least
10 days of hospitalisation

“Nutrition improves
“Malnutrition worsensoutcome
outcomeinincritically
criticallyillill
patients” patients”

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Deleterious effects of malnutrition

Ø Poor surgical healing

Ø Immunosuppression
Ø Higher risk of infections
Ø Respiratory depression
Ø Delayed recovery
Ø Increased risk of mortality

What  about  veterinary  ICUs?

v Not much published

v Anecdotal reports cite inadequate food intake in
up to 66% of ICU patients

v Remillard R, et al,. An Investigation of the v Is there a relationship with outcome?

Relationship Between Calorie Intake and Outcome
in Hospitalized Dogs. Veterinary Therapeutics
2001, 2:4, 301-310
Ø Positive-energy balance was achieved in 220/821
(27%) dog-days

Nutrition  and  Critical  Illness

v Malnutrition during critical illness is detrimental

v Incidence of poor food intake in critically ill animals may

be as high as 66% in some ICUs

Energy intake (% Number of Percent of

MER) animals animals v There may be a direct relationship between food intake,
discharged from nutritional status and outcome in animals
hospital
0-33% 146 62.7%
34-66% 162 87% v What can we do to improve outcome??
67-100% 214 93.2

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Early  vs  Delayed  Nutritional  Support

Early  Enteral  Nutrition

v Does early feeding benefit patients? v Multitude of studies demonstrating improved

clinical outcome
v Are the risks of complications related to feeding v Biggest concerns:
worth the potential benefits of nutritional support?
Ø Tolerance
Ø  Metabolic complications
Ø  Infectious complications Ø Safety
Ø  GI dysfunction, vomiting, diarrhoea, aspiration Ø Feasibility
pneumonia

EEN:  Veterinary  Experience

Mohr AJ, et al. Effect of early enteral nutrition on intestinal
permeability, intestinal protein loss, and outcome in dogs v Liu et al. Early nutrition is associated with decreased
with severe parvoviral enteritis. J Vet Intern Med length of hospitalization in dogs with septic peritonitis. A
2003;17:791-8 retrospective study of 45 cases (2000-2009). J Vet
Emerg Crit Care 2012 (in press)
Will K, et al. Early enteral nutrition in dogs suffering from
haemorrhagic gastroenteritis. J Vet Med A Physiol Pathol Ø  Instituting nutritional support within 24 hr post-
Clin Med 2005;52:371-6. operatively was associated with 1.6 day shorter length of
hospitalisation
Mansfield et al. A pilot study to assess tolerability of early
enteral nutrition via esophagostomy tube feeding in dogs
with severe acute pancreatitis. JVIM 2011; 25(3):419-25

EEN:  Veterinary  Experience Early  Enteral  Feeding

v Place feeding tube as soon as it is feasible and safe
v Start feedings very gradually
v Conclusions from these studies suggest that Ø  Assess for tolerance
early enteral nutrition is not only feasible, but v Antiemetics and prokinetics may be good idea
not associated with serious complications Ø  Maropitant
Ø  Metoclopramide

v Not powered to comment on mortality

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Does  placing  feeding  tubes  make  a  difference? How  Much  to  Feed?

v Critical illness was thought to dramatically increase

energy expenditure
v Recommendations for nutritional support was to account
for such increases in energy requirement
v Illness Energy Requirement:
Ø Resting Energy Requirement x Illness Factor

Energy  Requirements Problems  with  Overfeeding

v Illness Factor
Ø Healthy animal, cage rest
Ø Trauma or major surgery
Ø Sepsis or major burns
v Not shown to be accurate
v Increase risk of complications
v Exacerbation of azotemia
v Fat-overload syndrome
= 1.25 X RER v Hepatic steatosis
= 1.3 – 1.6 x RER v Hypercapnia
= 1.5 – 2.0 x RER v Hyperglycemia
v Hypertonic dehydration
v Hypertriglyceridemia
v Refeeding Syndrome

Energy  Expenditure  in  Critically  Ill  Dogs

Overfeeding  and  complications
Energy expenditure in 104 postoperative and Paper Species Energy Complications Mortality

traumatically injured dogs with indirect calorimetry. Reuter – TPN Dogs (209) 1.2-1.5 RER 0.52 complications per 48%
Walton RS, Wingfield WE, Ogilvie GK, et al. J Vet TPN day
Emerg Crit Care 1996; 6(2):71-79 Lippert – TPN Dogs (72) 1.25-2.0 RER 0.42 complications per 30%
Cats (12) TPN day

Pyle – TPN* Cats (75) 1.1-1.4 RER 0.62 complications per 52%
v Critically ill, post-operative, and traumatized dogs TPN day
did not differ from controls in energy requirements Crabb – TPN** Cats (40) 0.7-1.4 RER 0.29 complication per 40 %
v Energy expenditure in critically ill dogs may be TPN day
overestimated by the IER method Chan – PPN Dogs (80) 0.5 - 0.75 RER 0.16 complication per 27%
Cats (47) PPN day

*Hyperglycemia statistically related to mortality

** Illness factor related to development of hyperglycemia

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How  to  avoid  overfeeding? How  much  is  enough?

v Should target RER
v However, in more severely affected patients - target may be
75% - 80% RER
v Calculate RER
v RER = 70(body weight kg)0.75
v RER = 30(body weight kg) + 70

v Avoid use of illness factors

v Adjust therapy based on frequent monitoring

Is  TPN  really  that  bad? Importance  of  Route  of  Feeding

Total parenteral nutrition: Potion or Poison? Jeejeebhoy
KN. Am J Clin Nutr 2001; 74(2):160-3.
Is parenteral nutrition really that risky in the intensive
care unit? Griffiths RD. Curr Opin Clin Nutr Metab
Care 2004; 7(2): 175-81
v Current ICU doctrine is that enteral is always better than
parenteral nutrition
v Early studies of TPN showed high rates of infection
Ø Overfeeding
Ø Hyperglycemia
v Experimental models claimed lower rates of bacterial
translocation with enteral nutrition

Parenteral  Nutrition  in  ICU Is  Enteral  Really  that  Much  BeOer?

Parenteral vs enteral nutrition in the critically ill
patient: A meta-analysis of trials using the
intention to treat principle. Simpson F, Doig GS.
Intensive Care Med 2005;31:12-23
v Screened and excluded poor quality studies
v Significant mortality benefit for TPN over enteral
v Still demonstrated higher rates of infection
v Prevention of mucosal atrophy
Ø Data comes from rodent studies
Ø Studies have shown no gut atrophy after 1 month of TPN and
bowel rest
Ø Only when TPN was given for several months were lesions
seen
v Prevents bacterial translocation
Ø Physiological reasoning
Ø Rates of translocation equal in TPN vs EN patients
Ø Questionable evidence that this is a true phenomenon

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Who  benefits  from  TPN? Nutritional  Support  and  Hyperglycaemia

v Patients with gut failure

v Overtly malnourished patients
v Most common complication associated with nutritional
v Benefits of PN apparent: support in critically ill animals is hyperglycaemia
Ø Avoid overfeeding Ø Up to 60% of patients in older studies evaluating total
Ø Control hyperglycaemia parenteral nutrition

Hyperglycaemia  and  Nutrition Hyperglycemia  and  Nutrition

v Pyle SC et al.
Evaluation of complications and prognostic factors associated Ø Development of hyperglycaemia within 24 hrs of
with administration of total parenteral nutrition in cats: 75 commencing TPN associated with poor outcome
cats (1994-2001). Pyle SC, Marks SL, Kass PH. J Am Vet
v Crabb SE et al.
Med Assoc 2004; 225(2):242-50.
Ø Use of illness energy requirements associated with
higher incidence of hyperglycaemia
Retrospective evaluation of total parenteral nutrition in cats: 40
cases (1991-2003). Crabb SE, Freeman LM, Chan DL,
Labato MA. J Vet Emerg Crit Care 2006;16(S1):S21-S26

The  importance  of  hyperglycaemic  

v Avoidance of hyperglycaemia perhaps most
appropriate
v Future studies should focus on mechanism driving
hyperglycaemia in animals
v Investigate whether hyperglycaemia has causal
relationship with morbidity or mortality
How  else  can  we  improve  outcome?  Role  of  
nutrient  content
v Major focus of critical care nutrition today now focuses in
the modulation of disease via supplementation of nutrients
v As pathophysiological processes afflicting critical ill patients
are uncovered provide potential targets for therapy

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Role  of  nutrition  during  critical  illness

Inflammation

v Inflammation
v Oxidative injury
v Manipulation of the inflammatory
v Immunological dysfunction/failure cascade
Ø Changing the composition of precursors
v Provision of Omega-3 fatty acids
yields less inflammatory eicosanoids
and leukotrienes

Inflammatory  Cascade Oxidative  Stress

N-6 series N-3 series v Depletion of normal antioxidant defences via consumption
Linoleic acid α-linolenic acid
v Host vulnerable:
Ø  Free radicals
Ø  Membrane damage
Arachidonic acid Eicosapentaenoic acid
Ø  DNA, mitochondrial injury
Ø  Activation of apoptosis
Eicosanoids Leukotrienes Eicosanoids Leukotrienes Ø  Contributes to pathogenesis of MODS
2 series 4 series 3 series 5 series
Less inflammatory

Oxidative  Stress Immunomodulation

v Enzymatic and Non-enzymatic systems
Ø Glutathione peroxidase
Ø  Selenium
Ø  S-adenosylmethionine (SAMe)
Ø  Acetylcysteine
Ø  Vitamin C and E, betacarotene
v Replenishment of antioxidant defenses touted as key
components of many diseases
v Some nutrients can have pharmacological affects
beyond their role in nutrition
v Some work in a dose-depended fashion in the
absence of a deficient state
v Immune-enhancing diets

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Immune-­‐‑enhancing  diets Glutamine

v Represents 30% of amino acids released by muscle during

stress
v Cocktails containing: v Major fuel for rapidly proliferating cells
Ø Glutamine Ø  Immune cells
Ø Arginine Ø  Enterocytes
Ø Omega-3 fatty acids v Beneficial effects in the structure and function of the
Ø Antioxidants gastrointestinal tract
Ø  Especially if given parenterally
Ø Nucleotides
Ø  Tremendous enterocyte uptake
v Supplied as easily dissolved powders

Six-­‐‑month  outcome  of  critically  ill  patients  given  glutamine-­‐‑

Effect  of  glutamine-­‐‑enriched  TPN  in  patients  with  
supplemented  parenteral  nutrition.  Griffiths  RD,  et  al.  
Nutrition  13:  295,  1997 acute  pancreatitis.  Ockenga  J,  et  al.  Clin  Nutr  21(5):
409,  2002
v Compared glutamine-enriched PN with
isonitrogenous, isocaloric PN
v Randomized to receive standard TPN or TPN
v Six-month mortality reduced supplemented with glutamine
v Decreased associated costs v Assessed for nutritional and inflammatory
v No specific analyses of septic patients parameters, LOH, overall cost
v Small study

Effect  of  glutamine-­‐‑enriched  TPN  in  patients  with   Can  we  improve  outcome  with  nutritional  
acute  pancreatitis.  Ockenga  J,  et  al.  Clin  Nutr  21(5):409,   support?
2002
v How are we defining “outcome” ?
v Mortality vs Morbidity
v Findings
Ø Improved serum albumin, lymphocyte counts v Important aims:
Ø Decreased C-Reactive Protein levels Ø  Reversal of malnutrition
Ø Reduction in TPN days
Ø  Reducing nutritional and overall complications
Ø Trend towards decreased LOH Ø  Intervene earlier
Ø No difference in cost Ø  Avoidance of overfeeding and hyperglycaemia
Ø  Investigate potential of certain nutrients to further
improve outcome

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“Nutritional support does

improve patient outcomes in
critically ill patients”