Nutrition Therapy in the ICU
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1 ICN, Bangkok, Oct 8, 2009 Nutrition Therapy in the ICU Jan Wernerman MD PhD Professor of Intensive Care Medicine Karolinska Huddinge Stockholm Sweden
2 Jan Wernerman Disclosure of potential conflicts of interest during thte last 2 years: Member of the Medical Advisory Board for Numico Invited speaker for Baxter, Fresenius-Kabi, Nestlé PI for Scandinavian multi-centre study of iv glutamine supplementation jw09 WFSICCM Firenze Sep 01, 2009
3 Strategies for nutrition in critical care Underfeeding in the ICU The patient at risk Cumulated energy deficit Combination of EN and PN jw09 ICN, Bangkok, Oct 8, 2009
4 Strategies for nutrition in critical care Underfeeding in the ICU The patient at risk Cumulated energy deficit Combination of EN and PN jw09 ICN, Bangkok, Oct 8, 2009
5 Krishnan et al. Chest124:297 (2003) jw09 ICN, Bangkok, Oct 8, 2009
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9 NICE-SUGAR, NEJM 2009;360:
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11 prescribed kcal 2500 receiv ed kcal 2000 kcal/24h < >40 (n=289) (n=937) (n=818) (n=395) (n=162) (n=171) Alberda et al, ICM 2009 BM I jw09 WFSICCM Firenze Sep 01, 2009
12 40 prescribed kcal 30 receiv ed kcal kc cal/kg/24h < >40 (n=289) (n=937) (n=818) (n=395) (n=162) (n=171) Alberda et al, ICM 2009 BM I jw09 WFSICCM Firenze Sep 01, 2009
13 Strategies for nutrition in critical care In summary Worldwide, underfeeding is the rule in the ICU, also in units with an interest in nutrition. jw09 ICN, Bangkok, Oct 8, 2009
14 Strategies for nutrition in critical care In summary Worldwide underfeeding is the rule in the ICU, also in units with an interest in nutrition. This mainly reflects a firm priority for enteral nutrition only. jw09 ICN, Bangkok, Oct 8, 2009
15 Strategies for nutrition in critical care Underfeeding in the ICU The patient at risk Cumulated energy deficit Combination of EN and PN jw09 ICN, Bangkok, Oct 8, 2009
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20 Aug 1, 2003 July 31, 2004 In total 844 pat 748 patients LOS < 5 days 96 patients LOS > 5 days 12 months mortality 8,4% 46,9%
21 Aug 1, 2003 July 31, 2004 In total 844 pat 748 patients LOS < 5 days 96 patients LOS > 5 days 12 months mortality 8,4% 46,9%
22 Strategies for nutrition in critical care In summary Mixing up ICU longstayers and shortstayers makes data from trials on nutrition uninterpretable. jw09 ICN, Bangkok, Oct 8, 2009
23 Strategies for nutrition in critical care In summary Mixing up ICU longstayers and shortstayers makes data from trials on nutrition uninterpretable. The two groups should be separated. jw09 ICN, Bangkok, Oct 8, 2009
24 Strategies for nutrition in critical care Underfeeding in the ICU The patient at risk Cumulated energy deficit Combination of EN and PN jw09 ICN, Bangkok, Oct 8, 2009
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26 Cumulated energy deficit v. infections Villet et al, Clin Nutr 24:502 (2005)
27 Cumulated energy deficit v. infections Villet et al, Clin Nutr 24:502 (2005)
28 Cumulated energy deficit v. infections Dvir et al, Clin Nutr 25:37 (2006)
29 Cumulated energy deficit v. infections Dvir et al, Clin Nutr 25:37 (2006)
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31 jw09 ICN, Bangkok, Oct 8, 2009
32 Alberda et al, ICM 2009 jw09 ICN, Bangkok, Oct 8, 2009
33 Strategies for nutrition in critical care Cumulated energy deficit is strongly associated with a worse outcome. jw09 ICN, Bangkok, Oct 8, 2009
34 Strategies for nutrition in critical care Cumulated energy deficit is strongly associated with a worse outcome. This generates the hypothesis that avoiding an energy deficit will bring about an improved outcome. jw09 ICN, Bangkok, Oct 8, 2009
35 Strategies for nutrition in critical care Cumulated energy deficit is strongly associated with a worse outcome. This generates the hypothesis that avoiding an energy deficit will bring about an improved outcome. This hypothesis is still not proven. jw09 ICN, Bangkok, Oct 8, 2009
36 Strategies for nutrition in critical care Underfeeding in the ICU The patient at risk Cumulated energy deficit Combination of EN and PN jw09 ICN, Bangkok, Oct 8, 2009
37 jw09 ICN, Bangkok, Oct 8, 2009
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39 jw09 ICN, Bangkok, Oct 8, 2009
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41 Adjuvant nutritional support indicated Inadequate oral intake for 7 days 562 patients Assessment of GI function Clinically certain 498 patients (88.6%) Clinically uncertain 64 patients (11.4%) Inadequate GI function Adequate GI function Randomised TPN 267 patients EN 231 patients rtpn 32 patients ren 32 patients Woodcock et al, Nutrition 2001;17:1-12
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46 Strategies for nutrition in critical care In summary Combining EN and PN gives the opportunity to avoid a cumulated energy deficit. jw09 ICN, Bangkok, Oct 8, 2009
47 Strategies for nutrition in critical care In summary Combining EN and PN gives the opportunity to avoid a cumulated energy deficit. There is no evidence whatsoever in terms of mortality for the superiority of EN over PN or the other way around. jw09 ICN, Bangkok, Oct 8, 2009
48 Strategies for nutrition in critical care In summary Combining EN and PN gives the opportunity to avoid a cumulated energy deficit. There is no evidence whatsoever in terms of mortality for the superiority of EN over PN or the other way around. However, feeding patients with PN who are possible to feed with EN is not a very good idea. jw09 ICN, Bangkok, Oct 8, 2009
49 Strategies for nutrition in critical care In summary Combining EN and PN gives the opportunity to avoid a cumulated energy deficit. There is no evidence whatsoever in terms of mortality for the superiority of EN over PN or the other way around. However, feeding patients with PN who are possible to feed with EN is not a very good idea. Among other things it probably increases infectious morbidity. jw09 ICN, Bangkok, Oct 8, 2009
50 Nutrition in critical care the importance of guidelines Local guidelines are instrumental for a successful feeding jw09 ICN, Bangkok, Oct 8, 2009
51 Nutrition in critical care the importance of guidelines Local guidelines are instrumental for a successful feeding A cumulated caloric deficit should be avoided. jw09 ICN, Bangkok, Oct 8, 2009
52 Nutrition in critical care the importance of guidelines Local guidelines are instrumental for a successful feeding A cumulated caloric deficit should be avoided. A combination of EN and PN may be a good idea. jw09 ICN, Bangkok, Oct 8, 2009
53 Nutrition in critical care the importance of guidelines Local guidelines are instrumental for a successful feeding A cumulated caloric deficit should be avoided. A combination of EN and PN may be a good idea. jw09 ICN, Bangkok, Oct 8, 2009
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