Tue, 17 January 2017
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN)This is an update and expansion of the previous nutrition guidelines and this is a summary of the some of the key points. I discussed this particular document at the Intensive Care Society State of the Art 2016 with Danielle Bear (@Danni_dietician), Ella Segaran (@ESegaran), Roger Harris (@RogerRdHarris) and Dr Todd Rice and that will be available as a podcast very soon so that you can listen to the discussion. When it is I will make sure I include the link on this page. Monitoring Tolerance and Adequacy of EN Selection of Appropriate Enteral Formulation and Adjunctive Therapy When to Use Parenteral Nutrition (PN). Nutrition Support in Particular Conditions.
Nutrition AssessmentThere is recommendation of the use of the Nutrition Risk Screening(NRS)/NUTRIC score for all patients who are expected not to be able to have sufficient volitional intake. Of all the other scores used these are the only ones that determine both nutrition status and disease severity. NRS score >3 is a patient at 'risk' and those at 'high risk' with an NRS score equal to or greater than 5. If interleukin 6 is measured this value would be greater than 6 in the NUTRIC score. However as there are rarely the facilities to measure this value then a value of 5 or greater indicates 'high risk in the NUTRIC score also. It is anticipated that ultrasound will emerge as a useful tool in measuring muscle mass and determine changes in muscle tissue and even CT scans of the skeletal muscle could be done. Both of these will not be too common currently due to cost and lack of trained personnel, however it is an aspiration towards the future. The same could be said of indirect calorimetry measurements which are also recommended. Where there is an absence of indirect calorimetry then energy requirements should be calculated using published predictive equations or simplistic weight based equations. Even where indirect calorimetry is available it is prone to error in the ICU due to presence of air leaks or chest tubes, supplemental oxygen, ventilator settings and renal replacement therapy. However calculated energy expenditure should be reevaluated at least once per week. There is also an emphasis on the provision of protein, being the most important macronutrient for healing wounds, supporting immune function and maintaining lean body mass. Initiating Enteral NutritionEnteral Nutrition (EN) should be initiated within 24-48 hours. The specific reasons for providing EN are to:
Studies have shown a significant reduction in mortality with the introduction of early EN. There is also a recommendation to use EN rather than parenteral nutrition (PN). Studies have shown a reduction in infectious morbidity and ICU LOS when comparing EN to PN. There is no need to wait for overt signs of bowel activity i.e. bowel sounds. These indicate only contractility and do not relate to mucosal integrity, barrier function or absorptive capacity. On most critically ill patients it is acceptable to initiate NG feeding whilst those at risk of aspiration should have feeding initiated lower down the GI tract. If small bowel access is difficult then feeding should be initiated in the stomach rather than wait. EN can be given to those stable patients on low dose vasopressors but should be withheld on patients who are hypotensive, have catecholamine agents or who are requiring escalating doses to maintain stability. For patients on vasopressors any sign of gut intolerance:
then the EN should be with held. Dosing of ENPatients at low risk with normal baseline nutrition and low disease severity (NRS less than or equal to 3 or NUTRIC less than or equal to 5) who cannot maintain volitional intake do not require specialised nutrition therapy. They should be offered oral intake and reassessed daily. Trophic or full EN is appropriate for patients with ALI or ARDS and those expected to have a ventilation period greater than 72 hours. In the high-risk patient, efforts should be made to provide greater than 80% of target within 48-72 hours. Studies have shown that greater than 50-60% of goal energy may be required to prevent increases in intestinal permeability and systemic infection in burn and bone marrow patients, promote faster cognitive return in head injury patients and to reduce mortality in high-risk hospitalised patients. Monitoring Tolerance and Adequacy of ENFor me, this is one of the main points to come out of this document. So some facts first!
Raising the cutoff value for GRVs from a lower number of 50-150ml to a higher number of 250-500ml DOES NOT increase the incidence of regurgitation, aspiration or pneumonia. Use of GRVs leads to:
So the recommendation is that GRVs should NOT be used and, if they are used, the cut off should be 500mls. The patient should be monitored for other signs of intolerance (see above). Another area which drew my attention especially was the recommendation that there should be a volume based feeding protocol which should be ICU or nurse-driven. These protocols would:
Such strategies have been shown to increase the overall percentage of energy provided. These are the free to access references that are used....go have a read and see what you think... The aim of these protocols is to empower nurses to increase feeding rates to make up for volume lost while EN is held. Aspiration is always of great concern in the Intensive Care patient and the guidelines acknowledge this. Patients should be assessed for risk of aspiration which may be identified by a number of factors:
....phew! That covers a lot of my patients! Where there is a risk of aspiration the patient should be feed beyond the pylorus, so NJ feeding, they should not be fed by bolus EN and there should be the use of prokinetics, and those prokinetics would include metoclopramide and erythromycin. Whilst not improving long-term ICU outcomes these drugs have been shown to improve gastric emptying. Nursing measures, such as head elevation between 30-45 degrees and the use of chlorhexedine mouth washes, are recommended. Other steps to decrease aspiration risk include reducing the level of sedation/analgesia when possible and minimising transport out of the ICU for diagnostic tests and procedures (although I think we only ever take patients for these tests when absolutely necessary). Enteral feeding should not be discontinued due to the presence of diarrhoea until other causes have also been investigated. These could include:
Assessment of diarrhoea should then include abdominal examination, quantification of stool, stool culture for C Diff, serum electrolytes and review of medications. Selection of Appropriate Enteral Formulation and Adjunctive TherapyThere is a recommendation to start with standard feed when initiating EN as there has been no clear benefit shown to using speciality formulas in areas such as the surgical ICU or medical ICU. They also do not recommend the use of immune modulation formulations. They make no recommendations around the use of fish oils, borage oil and antioxidants in patients with ARDS and ALI due to conflicting data. Consideration needs to be given to the use of a mixed fibre formulation in those patients with persistent diarrhoea. Such a formulation is not recommended for routine use in the patient to promote bowel regularity. There is no recommendation as to the use of probiotics in the general ICU population. The use of probiotics would seem theoretically sound but there has not been a consistent benefit demonstrated. Antioxidants (vitamin E and C) and trace minerals might be useful especially in burns, trauma and critical illness requiring mechanical ventilation. Finally, they recommend that glutamine is not added routinely- outcomes from the use of glutamine showed no significant benefit on mortality, infections or hospital LOS. When to Use Parenteral Nutrition (PN).In the low nutrition risk patient, where early EN is not feasible, then PN should be witheld for the first seven days whereas in the patient at high nutrition risk in the same circumstances then PN should be started as early as possible. In the patient where EN is not meeting greater than 60% of their needs then PN should be started after 7-10 days. Nutrition Support in Particular Conditions.Pulmonary FailureSpeciality high fat/low carbohydrate formulations designed to manipulate the respiratory quotient and reduce carbon dioxide production are not recommended in ICU patients with acute respiratory failure. Renal and Hepatic FailurePatients in ARF or AKI should be put onto a standard formula. If significant electrolyte disturbances occur then formulations designed for renal failure should be considered. Those patients on CRRT should receive increased protein as significant amino acid loss is associated with CRRT. A dry weight should be used instead of actual weight in the patient in hepatic failure when determining energy and protein requirements. This then accounts for the possibly significant ascites and oedema they may be suffering. EN should be used in preference to PN in the patient with liver failure and a standard formulation should be used. Acute PancreatitisDisease state may change quickly in this condition so frequent reassessment is needed. For those patients with a mild acute pancreatitis specialised nutritional therapy is not recommended but an effort to work towards normal oral intake instead. For those with moderate to severe pancreatitis an NG tube should be inserted and there should be efforts made to advance to goal within 24-48 hours after admission. Standard formula should be used in the severe pancreatitis patient and EN is preferred to PN as it has been shown in several studies and meta-analysis to reduce mortality, LOS and surgical interventions. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. In moderate to severe patients who have an intolerance to EN measures should be taken to reduce the intolerance such as:
Probiotics should be added for this type of patient. SepsisEN therapy should be introduced within 48 hours from diagnosis when resuscitation is complete and the patient is haemodynamically stable. In the acute phase, where possible, EN should be used exclusively. There is no recommendation regarding selenium, zinc and antioxidant supplementation. A recommendation is made for trophic feeding for the initial phase of sepsis advancing to 80% within the first week and there should be delivery of 1.2-2g protein/kg/day. Chronically Critically IllDefined as those with persistent organ dysfunction requiring ICU LOS greater than 21 days. They should be managed with aggressive high protein EN therapy. In a series of studies, patients demonstrated chronic inflammation and a maladaptive immune response that contributed to secondary nosocomial infections and severe protein catabolism. Obesity in Critical IllnessEarly EN should start within 24-48 hrs. There is no difference between this type of patient and those that are not obese. 57% of hospitalised patients with a BMI of greater than 25 show signs of malnutrition! A couple of quotes are needed here I feel to reinforce a couple of key points:
This section of the paper highlights a number of the problem the obese patient will have in the ICU such as:
As a consequence of all of these factors there is a recommendation for the nutrition assessment of the obese patient to focus on evidence of central adiposity, metabolic syndrome, sarcopenia (loss of skeletal muscle mass), SIRS and other comorbidities that correlate with higher obesity-related risk for cardiovascular disease and mortality. There is a recommendation for high protein hypocaloric feeding to preserve lean body mass, mobilise adipose stores and minimise the metabolic complications of overfeeding. Promotion of weight loss is achieved by aiming for 60-70% of target energy requirements. Some degree of weight loss may increase insulin sensitivity, facilitate nursing care and reduce risks of comorbidities. Due to the intentional permissive underfeeding of the obese patient, there should be additional monitoring to assess for worsening of:
It is very important to restate that these are guidelines only. Each patient should be assessed individually and care should be taken to take account of the units they are being nursed in and the resources that are available, both financial and personnel. These are very extensive guidelines and if you want to read more or see the many references then go to this site here. If you have any views on any of the above then please feel free to get in touch or leave a comment on the site. |
Tue, 10 January 2017
Desarmenien. The chronic critical illness: a new disease in intensive care. Swiss Med Wkly 2016;146:w14336This paper is one from the Swiss Medical Weekly 2016 and is a description of the efforts to develop what they call a multi modal care management approach to those patients at risk of chronic critical illness. They call these patients PLS from the french term 'Patient Long Sejour'. In 2006 there was a realisation that this kind of patient needs to be managed differently from those in the acute phase and the formation of an interdisciplinary team helped in the development of a new approach. They defined the chronically critically ill (CCI) as those with a length of stay in the ICU of greater than seven days with a second criterion being the necessity for support by sophisticated means available only in the ICU. This group of patients;
Their problems are many but some of the ones worthy of note are;
Caregivers need to be able to have great skill in human relationships. There may be much conflict for these patients amongst them and their family or their carers or even their family and their carers. These conflicts are associated with burnout of their carers. An attempt to pool this kind of patient between 2006 and 2009 resulted in exhaustion of the team members. It failed for several reasons;
One of the learning points from this attempt was that a specialist nurse should be used in the future to help be a resource for this type of patient and their family and to assist in training the carers in looking after this type of patient. They did identify some specific actions to be taken to ensure that the PLS patient is identified and helped as early as possible;
After implementing these changes re admissions have decreased between 2014-2015. They are presently training carers in the use of massage to decrease the anxiety and pain of the patients as well as their sleep quality and sleep is the subject of their next research project. Marchioni. Chronic critical illness: the price of survival. Eur J Clin Invest 2015;epublished November 9thThis paper addresses some of the pathophysiological aspects related to the development of Chronic Critical Illness. It first acknowledges that an absolute definition of CCI is not available but speculates that prolonged mechanical ventilation might be one of the factors. Prolonged in this instance is quoted as being 21 days of ventilation for a minimum of 6 hours per day. This population is growing with some studies reporting up 5-10% of patients admitted to ICU requiring prolonged mechanical ventilation. Only 10% of CCI patients achieve functional autonomy and live in their own home at 1 year after the onset of the acute condition requiring admission to ICU. Whilst respiratory failure is the main feature of CCI there are other features which are often present which include:
There are no biomarkers that can assist in predicting the development of CCI but risk factors include old age, comorbidities, sepsis and ARDS. CCI is associated with persistent systemic inflammation and those patients presenting with higher inflammation levels at disease onset show worse progress and higher incidence of multiple organ failure. Those older patients have a chronic increase of some of the inflammatory markers putting them more at risk as a consequence. There is some impairment of the regulation of the processes aimed at limiting damage associated with inflammation which might be involved in the progression from the acute to the chronic phase and even a low inflammatory state may play a role. Endocrine abnormalities play a large part in the development of the acutely critically ill patient but have not been recognised for the chronically critically ill patient. Some of these processes are complex and perhaps merit more study in depth but to summarise the patients cortisol levels are very important in their attempts to fight disease. Cortisol causes a positive haemodynamic effect through intravascular fluid retention and increase in inotropic and vasopressor response to catecholamines and angiotensin II. It also has an anti-inflammatory effect. During sepsis, due to relative adrenal insufficiency, cortisol production is insufficient to maintain haemodynamic stability. Another endocrine impairment is hyperglyceamia secondary to the response to acute stress. Once hyperglyceamia is present, it may even persist. Some of the problems are best summed up by this quote from the paper:
Macintyre. Chronic critical illness: the growing challenge to health care. Respir Care 2012;57(6):1021-7Like many other papers on this subject it starts with an attempt to pin down a definition. The main part of the definition it works with is the presence of prolonged mechanical ventilation discussing the length of this PMV as being 21 days of mechanical ventilation whilst also acknowledging that it could be as little as 14 or as much as 28 days ventilation. There is also the need to ensure that this population requires a different mindset to the acutely ill patient in ITU. Unlike the acutely ill patient the CCI patient is characterised by:
Caregivers with unique skills are needed and because outcomes are poor a culture of care that has a heavy palliative care influence is critical. In general yearly mortality is 40-50%. ProVent score:
If none of these factors present then survival was over 80%. However if all 4 were present there was virtually 100% mortality at one year. CCI is a persistent ongoing inflammatory state following an initial inflammatory insult. There is persistent elevations of cytokines and a failure of anti inflammatory processes to modulate and repair. Organ dysfunction may have left the patient with:
These can be combined with inappropriate clinician responses such as:
Discussion then moves onto the venues of care with proponents of the long-term acute care hospital (LTAC) arguing that the culture of care is more rehab oriented with an emphasis on physical therapy, occupational therapy and respiratory therapy that is better suited to the patients long term needs. Issues of mechanical ventilation are covered. The injured lung has abnormal mechanics, abnormal dead space and impaired gas exchange that can overload the neuromuscular capabilities of the patient with CCI. Ventilator settings should be lung protective and there is no clear consensus on how best to remove/reduce ventilator support in this population. Spontaneous breathing trails should not be attempted until the support has been reduced to an appropriate level e.g. pressure support 10-15 cm, PEEP <5 and oxygen 0.5 or below. In those patients with a tracheostomy care should be taken when decannulating the patient with secretion issues or obstructive apnoeas. It is important to acknowledge that some patients will never be weaned off the ventilator- the literature indicates that 90% or more of those patients who eventually are weaned have the weaning complete by 90 days of mechanical ventilation. Supportive evidence for NIV in CCI is lacking. Nutritional support is important as many of the features of the CCI patient involve persistent catabolism, malnutrition and neuro-endocrine imbalance. Hypoglyceamia is a common problem as is bone resorption, vitamin B deficiency and anasarca. Bone dysfunction requires multiple strategies, including calcium replacement, vitamin D replacement and biphosphonates. They are at increased risk of infections because of multiple invasive devices, malnutrition, hyperglyceamia and immune exhaustion. Device associated infections can be limited by using appropriate care bundles. VAP would include head of bed elevation, minimised sedation, oral care, subglottic suctioning,peptic ulcer disease prophylaxis and DVT prophylaxis. Infection care bundles would include hand hygiene, complete barriers for central line insertion, chlorhexedine use, proper site selection and daily assessment for continued need of catheter. Neuromyopathies commonly occur in the critically ill being both myopathys (direct muscle injury) and polyneuropathy (diffuse axonal injury) both secondary to impaired oxygen delivery/uptake. Prevention and management of this would include good glucose control, reduction of neuromuscular blockers and steroids, optimisation of electrolytes and early mobilisation. Delirium should be managed taking care of the risk factors such as inflammation, hypotension, electrolyte shifts. sleep deprivation, hypoxeamia and drugs. There should be a more palliative care mindset which focuses on symptom relief , align treatment of patient and family wishes and provision of patient and family support. Maguire. Strategies to combat chronic critical illness. Curr Opin Crit Care 2013;19(5):480-7This starts by attempting to define what is meant by CCI. Initially they say it is those who have survived acute critical illness or injury, but have a persistent organ dysfunction leading to prolonged intensive care needs. Many of the definitions include the need for prolonged mechanical ventilation (PMV) but the length of that seems to vary greatly from 96 hours to 21 days. CCI is a syndrome which also includes profound weakness, malnutrition, anasarca (generalised oedema), prolonged brain dysfunction and extreme symptom burden. They feel that the presence of a tracheostomy might also make the patient inclusive in the CCI category, but they do conclude by saying that recognition is perhaps more important than any rigid definition. Depending on the definition, of the mechanically ventilated patients in the ICU 5-10% develop CCI and this number is projected to double in the next ten years. Based upon some cohort studies one-year survival for CCI is between 40-50%. The article then moves on to prevention and management of CCI and starts this by looking at mechanical ventilation. ARDS is most associated with CCI and some of the strategies concerned with this problem are highlighted. These include protective lung ventilation, conservative fluid management, sepsis bundles, daily awakening trials and spontaneous breathing trials. With the spontaneous breathing trial (SBT) they go on to compare tracheostomy collar groups with the pressure support based weaning protocol. In a trial of patients those with the tracheostomy collar weaned in 15 days compared to 19 days with pressure support. They go on to say that the optimal approach to weaning is not necessarily clear but there should be a more aggressive search for the causes of failure. ICU acquired weakness (ICUAW) is acknowledged as a well-recognised complication of critical illness. Perhaps one of the most interesting points in the paper and certainly one that should always be borne in mind is this;
The risk factors which contribute to ICUAW include prolonged immobility, hyperglycaemia, systemic infection and multiple organ dysfunction. Possibly mitochondrial dysfunction, contributing to diaphragmatic weakness adds to the ICUAW and the role of systemic corticosteroids is unclear. One of the main recommendations under this heading is the early mobilisation of the patients being key to improving their outcomes. Malnutrition is reported in 43% of ICU patients and this is associated with increased morbidity, mortality, infection rates, ICU length of stay, poor wound healing and muscle weakness. Data still supports the use of enteral feeding in those patients with a functioning GI tract. Mean physical function and survival at 12 months in the ARDS patient were not affected by initial trophic versus full feed. The data is not conclusive when looking at adding parenteral to enteral feed but there is an observation that over feeding rather than underfeeding may be more common and this can lead to increased infectious complications, liver dysfunction and increased mortality. Cognitive impairment is a feature of this type of patient and affects a large number of them one year after ICU and there is possibly some relationship between acute delirium and long-term impairment. The most important way to manage this is to evaluate for any modifiable cause such as infection, hypotension, electrolyte imbalance, hypoxia and the use of sedatives. The ICU patients have a lot of invasive lines and some of the infections these produce may add to their potential to become a chronically critically ill patient. They speculate that 'immune exhaustion' is another mechanism that puts the patient at risk. So there should be basic infection control measures, a minimization of catheters and possibly decontamination using intranasal mupicirin and chlorhexedine cloths to reduce the incidence of MRSA. It is also noted that the patient and family wishes should also play a major part in the care of the critically ill. There should be frequent discussions about this covering areas such as thresholds for continuation or discontinuation of therapies, open and honest communication about eventual location of discharge and preparedness planning for upcoming therapies. The venue of care is also something which needs to be considered. Is it appropriate for this type of patient to be cared for in the acute ICU. We need to consider other centres which will particularly address their special needs. In summary, there needs to be prevention measures including:
and then management strategies of the CCI which will include:
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