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Nutrition on the ICU Zsolt Molnár AITI

Nutrition on the ICU Zsolt Molnár AITI. Basics. Artificial nutrition Energy requirement: 25-30 kcal/kg/day Carbo-hydrates: 50-70% Fat: 15-30 % Proteins: 10-20% (1.2-1.5 g/kg/day amino acids) Vitamins, trace elements Routes Enteral Parenteral. Routes. Patient satisfaction.

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Nutrition on the ICU Zsolt Molnár AITI

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  1. Nutrition on the ICUZsolt MolnárAITI

  2. Basics • Artificial nutrition • Energy requirement: • 25-30 kcal/kg/day • Carbo-hydrates: 50-70% • Fat: 15-30 % • Proteins: 10-20% (1.2-1.5 g/kg/day amino acids) • Vitamins, trace elements • Routes • Enteral • Parenteral

  3. Routes

  4. Patient satisfaction „That tube went all the way to my stomach - and they put it in while I was conscious - nice! Made me feel better though ;-)”

  5. What’s new? – 25 years of experience • Better tools • „All-in-one” preparations • Glutamin • Blood sugar controll Wernerman J.In: 25 Years of Progress and Innovation in Intensive Care Medicine2007

  6. After 4 weeks of MSOF…

  7. Blame/selfblame? ≠

  8. Introduction • Feeding phylosophy 25 years ago • „Bigger is better” - „hyper-alimentation” Wernerman J.In: 25 Years of Progress and Innovation in Intensive Care Medicine2007 • Theoretical basis • Nitrogen balance Munro HN, et al. Biochemical aspects of protein metablism, New York and London. Academic Press 1963 • Practical proof • High measured energy expenditure Wilmore DW. The Metabolic Management of the Critically Ill. New York and London: Plenum Medical Books 1977

  9. „Under-”, and „Overfeeding” • Under feeding: • Prolonged ICU stay • Prolonged ventilation • Higher incidence of infection Villet S, et al. Clin Nutr 2005; 24: 502-9 Rubinson L, et al. Crit Care Med 2004; 32: 350-7 • Over feeding: • Prolonged ICU and hospital stay • Nausea, vomiting • Hyperlipidaemia, hyperglicaemia Stapleton RD, et al. Proc AmThorac Soc 2006; 3: A737

  10. PN - indications • NotfunctioningorseverelydisabledGI-tract ASPEN TaskForce. J ParenterEnteralNutr2002;26: 1SA–138SA • EN contraindicatedor <40% energy/5 days • Ethicallyacceptable: life expectancy ≥14 days Nardo P, et al. ClinNutr2008; 27: 858-64 • Timing • ASAP: EN + PN afteradmission/surgery Heidegger CP, et al. CurrOpinCrit Care. 2008;14:408-414

  11. PN + adjuvant treatment • Immuno-nutrition (glutamin) • Improvedsurvival Goeters C, et al. CritCareMed2002; 30: 2032-2037 Griffiths R, et al. Nutrition 1997; 13: 295-302 • Safe Berg A, et al. In: Yearbook of ICEM 2009; pp: 705-715 • Water-, and lipid-solublevitamins: 1 amp/day • Traceelements: 1 amp/day Nardo P, et al. ClinNutr2008; 27: 858-64

  12. Calory intake • How much?

  13. Assessment • Harris-Benedict formula • Gender, age, weight, height • Compensation factor Long CL et al. JPEN 1979; 3: 452–6 • Ireton-Jones • Age, weight, gender, + burn + trauma Ireton-Jones CS, et al.J Burn Care Rehabil 1992;13:330–3 • Frankenfield • Minute ventilation, Hb, Sepsis Frankenfield DC, et al. J Trauma 1994;18:398–403 • Fusco • Age, height, weight Fusco MA, et al. JPEN 1995;19(suppl):18S

  14. Measurements • Indirect calorimetry • O2 uptake/ CO2 production • „Gold standard” Feurer I, et al. Nutr Clin Pract 1986;1:43–9 • Fick’s principle • PA-catheter • CO, Ca-vO2 Liggett SB, et al.Chest 1987;91:562–6

  15. Assessment – shortcomings • Harris-Benedict, Ireton-Jones, Frankenfield, Fusco • EE increases: • Fever, shivering • Work of breathing • Pain, stress, physio, „realtives”, stb • Sepsis • Catecholamines • EE decreases: • Hypothermia • Sedation, anaesthesia • IPPV/CPAP • MOF McClave SA, et al. Nut Pract 1992; 9: 61-8 • Only the patient is missing

  16. Measurements – shortcomings • Indirect calorimetry • Complicated, time consuming, expensive • Seal, FiO2<60%, „steady state” 60-120 minutes (!) • Snapshot only Browning JA, et al. Crit Care Med 1982; 10: 82–5 Hennenberg S, et al. Crit Care Med 1987; 15: 8–13 • Fick’s principle • P-A catheterisation • SvO2<60%, „flow-dependent O2 supply” (ARDS,sepsis) • „Mathematical coupling” Vincent JL, et al. Am Rev Respir Dis1990;142:2–7 Tuchschmidt J, et al. Crit Care Med 1991;19:664–71

  17. Caloric Intake in Medical ICU Patients: consistency of care with guidelines and relationship to clinical outcomes. Krishnan JA, et al. Chest2003; 124: 297-305 9-18 kcal/kg/day

  18. Caloric Intake in Medical ICU Patients: consistency of care with guidelines and relationship to clinical outcomes. Krishnan JA, et al. Chest2003; 124: 297-305 • 33-66% (II) vs >66% (III) • Significantlybetter OR: • Hospitalsurvival • Spontaneousbreathing – ondischarge • No sepsis – ondischarge • 25% > • Significantly more: • Nosocomialinfection • Rubinson L et al. CCM 2004; 32: 350

  19. Sepsis, immobilisation

  20. Mitochondrial function in sepsis: Respiratory versus leg muscle Fredriksson K, et al. CritCareMed 2007; 35: S449-S453

  21. Mitochondrial function in sepsis: Respiratory versus leg muscle Fredriksson K, et al. CritCareMed 2007; 35: S449-S453 Black: sepsis+MOF Grey: control (electivesurgicalpatients)

  22. Atrophy and Impaired Muscle Protein Synthesis during Prolonged Inactivity and Stress Paddon-Jones D, et al. J Clin Endocrinol Metab. 2006 Dec;91(12):4836-41

  23. Atrophy and Impaired Muscle Protein Synthesis during Prolonged Inactivity and Stress Paddon-Jones D, et al. J Clin Endocrinol Metab. 2006 Dec;91(12):4836-41 1 Significant pre- to postbed rest change (P < 0.05). 2 Loss of lean muscle mass (dual-energy x-ray absorptiometry) from both legs.

  24. The way I did it till 2009… • Supportive therapy • „Best standard care” • DO2/VO2 • Regular blood gases (arterial, central venous) • Tight blood sugar control 6-8 mmol/l • Early, controlled enteral nutrition • 30 ml/h: NG aspirate 3-4 hours later • 50-60 ml/h ~ 1500 kcal/day • Early tracheostomy • No sedation, active moving • Communication • „Agressive” weaning • Passive moving: avoids contractures • Muscle strength: active excercise

  25. …the way I will carry on • Same, but… • Early EN +/- TPN • 30 ml/h: NG aspirate 3-4 h later • 50-60 ml/h ~ 1500 kcal/day • Blood sugar control • Target: 8-10 mmol/l (instead of 6-8 mmol/l) Finfer S, et al. N Engl J Med 2009; 360: 1283-97 • Every patient on TPN will get: • Trace elements + vitamins (1amp/day) • Glutamin

  26. Summary • Chronic fasting ≠ critical illness muscle wasting • We treat patients differently now than 25 years ago • ICU is more comfortable for patients • Less often means more • 25-60% of calculated calory intake – not harmful, the opposite! • PRCTs are required • Active moving is invaluable

  27. Motto Patients are always right: if they are not hungry I don’t feed them.

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