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The Prevalence of Iatrogenic Underfeeding in the Nutritionally ‘At-Risk’ Critically ill Patient. Rupinder Dhaliwal, RD Executive Director Nutrition & Rehabilitation Investigators Consortium Clinical Evaluation Research Unit Queen’s University, Kingston, Canada. Introduction.

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the prevalence of iatrogenic underfeeding in the nutritionally at risk critically ill patient

The Prevalence of Iatrogenic Underfeeding in the Nutritionally ‘At-Risk’ Critically ill Patient

Rupinder Dhaliwal, RD

Executive Director

Nutrition & Rehabilitation Investigators Consortium

Clinical Evaluation Research Unit

Queen’s University, Kingston, Canada

introduction
Introduction

Critically ill patients receive only 50% prescribed energy and

protein needs

This “underfeeding”, considered to be IATROGENIC, could lead to

adverse consequences

However, not all critically ill patients seemed to be harmed more as a

consequence of iatrogenic underfeeding

Caloric debt

slide4

Multicenter observational study, 2772 patients

  • For every increase of 1000 calories per day
    • reduction in overall 60-day mortality (p=0.014)
    • increase in ventilator-free days (p=0.003)
  • Beneficial treatment effect of increased calories was only observed in:
    • BMI<25 and >35
    • no benefit in BMI 25-<35 group
slide5

NUTrition Risk in the Critically ill Score (NUTRIC Score)

  • severity of the underlying illness
  • the degree of acute markers of inflammation and starvation indices
  • the degree of chronic markers of inflammation and starvation indices

Helps discriminate which ICU patients will benefit more (or less)

from aggressive protein-energy provision

NUTRIC score ≥ 6 (out of 10) may benefit the most from nutrition

therapy

mechanically ventilated 7 days
Mechanically ventilated > 7 days

Underfeeding in pts mechanically ventilated >7 days WORSE outcomes!

Energy deficit of ~1200 kcals/day is associated with an independent likelihood

of ICU death (Faisy et al British J Nutrition 2009)

Recent randomized trials FAIL to show a difference in

the group that received the most calories

(Casaer et al NEJM 2011, Rice et al Crit Care Med 2011)

Why so?

1. BMI mid ranges

2. Patients young, few comorbidities, so low NUTRIC

3. short stays in ICU (<5 days on average)

what is optimal nutrition
What is optimal nutrition?

Heyland DK Crit Care Med 2011

Analyzed patients who were mechanically

ventilated and in the ICU for 96 hrs or >

Receiving up to 80% of their prescribed energy requirements is

associated with a reduced mortality (>80-85% no added effect)

We posit that nutritionally ‘at-risk’ pts should receive at least

80% prescribed needs

Focus on patients that stayed in the ICU ≥ 96 hrs

objective
Objective
  • describe the prevalence of “Iatrogenic Underfeeding” (receiving < 80% prescribed energy and protein) in ICUs across different Geographic areas
  • in ‘high risk’ patients subgroups
    • (those with > 7 days of mechanical ventilation)
    • body mass index (BMI) of <25 and >35
    • those with a NUTRIC score of >6 compared to low risk patients
  • to determine those ICU and hospital characteristics associated with optimal nutrition practice (lowest rates of iatrogenic underfeeding)
methods
Methods

Analysis of data from

  • May 11, 2011 prospective, multi-institutional audit
  • 193 ICUs in 29 countries collected data
  • ~20 pts per ICU, ICU LOS at least 96 hrs
  • 3174 mechanically ventilated patients
  • Geographical regions
  • Sites were divided approximately by continent
    • Canada, US separate as many ICUs
  • Sites from countries or continents with too few sites to comprise a unique region were compared to similar region of practice
    • Mexico & South Africa
data collection
Data Collection

For each patient

  • patient characteristics and ICU admission information
  • baseline nutrition assessment
    • method of calculation (e.g. indirect calorimetry, predictive equations)
    • total calories and protein prescribed
  • daily nutrition data for first 12 days or IC d/c whatever first
    • Route i.e. EN or PN
    • total calories and protein prescribed
  • patient outcomes
    • ICU and hospital discharge
    • and mortality.
    • Duration of mechanical ventilation

web-based electronic data capture system

statistical approach
Statistical Approach
  • adequacy of total nutrition during the first 12 days in ICU

% percent of caloric and protein prescriptions received from EN or PN

  • SOFA score and IL-6 was dropped from the original NUTRIC score
  • high vs. Low NUTRIC: according to median NUTRIC Score (i.e. patients with NUTRIC > median were classified as high risk subgroup)
  • multivariable analysis was performed
    • to examine the association between the prevalence of iatrogenic underfeeding
    • repeated using three different sets of adjustments to account for
      • # days in evaluation (first few days patients receive < 80%)
      • added covariates (ICU characteristics and patient characteristics)
      • simultaneously included high risk factors in addition to all covariates used
slide13

n = 193 ICUs, 29 countries, 3174 patients

Canada: 20 (20%)

Asia: 41 (21%)

USA: 45 (23%)

Europe and South Africa: 25 (13%)

Latin America: 24 (12%)

Australia & New Zealand: 39 (20%)

slide15

2011 International Nutrition Survey

3747 patients from 193 ICUs

29 countries

ResultsPatient Flow Diagram

573 Excluded from analysis

    • 378 in ICU <96 hours
  • 195 nutritional adequacy not
  • available for at least 4 days

Total used in analysis

3174 patients from 193 ICUs

29 countries

350 patients

with BMI ≥ 35

1013patients

with NUTRIC > 4

1812 patients > 7 days of mechanical ventilation

1533 patients

with BMI <25

nutrition outcomes all patients
Nutrition Outcomes (all patients)

78% of patients failed to meet ≥ 80% of energy target

nutrition outcomes vented 7 days
Nutrition Outcomes: vented > 7 days

> 7 d mechanical ventilation

Better calorie adequacy

Better protein adequacy

Longer to start EN

Lower prevalence underfeeding

(all values p<0.01)

nutrition outcomes bmi
Nutrition Outcomes (BMI)

BMI ≥ 35 vs. 25-34

Better calorie adequacy

(p 0.01-0.05)

No difference

No difference

No difference

BMI < 25 vs. 25-34

Better calorie adequacy

Better protein adequacy

Shorter time to EN

Lower prevalence underfeeding

all values p<0.01

nutrition outcomes nutric score
Nutrition Outcomes (NUTRIC score)

NUTRIC Score > 4

No difference

No difference

No difference

No difference

slide21

Multivariate analysis (odds of receiving <80% of prescription)

  • being mechanically ventilated for more than 7 days
  • having a BMI <25 and
  • having a BMI ≥35 were all associated with about a one third reduction in the odds of receiving <80% of energy prescription
conclusions
Conclusions

Worldwide, the majority of critically ill patients fail to receive adequate nutritional intake

This rate of failure varies across geographic regions

High risk patients are less likely to be underfed than low

risk patients but still experience significant underfeeding

acknowledgements
Acknowledgements

Daren K. Heyland MD, MSc Lauren MurchMSc

Xuran Jiang MSc Andrew G. Day MSc

Clinical Evaluation Research Unit, Kingston General Hospital

Department of Community Health and Epidemiology, Queen’s University

Department of Medicine, Queen’s University

Kingston, ON, Canada

slide24

References

  • Alberda C, Gramlich L, Jones NE, Jeejeebhoy K, Day A, Dhaliwal R, Heyland DK. The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observation study. Intensive Care Med 2009;35(10):1728-37.  
  • Faisy C, Lerolle N, Dachraoui F, Savard JF, About I, Tadie JM, Fagon JY. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. British J Nutrition 2009;101:1079-1087.
  • Heyland DK, Dhaliwal R, Jiang X, Day A. Quantifying nutrition risk in the critically ill patient: The development and initial validation of a novel risk assessment tool. Critical Care 2011
  • Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011;June 29 (epub).
  • Rice T, Morgan S, Hays MA, Bernard GR, Jensen GL, Wheeler AP. Randomized trial of initial trophic versus full-energy nutrition in mechanically ventilated patients with acute respiratory failure. Crit Care Med 2011;39;967-974.
  • Heyland DK, Cahill N, Day A. Optimal amount of calories for critically ill patients: Depends on how you slice the cake! Crit Care Med 2011 Jun 23 (epub).