CCSG Spring/Summer Newsletter 2017
Feedback from the Nurse and AHP committee of the Intensive Care Society (ICS)
Provided by Ella Segaran (Chair of the NAHP committee)
ICS State of the Art Meeting: 4th - 6th Dec 2017, ACC Liverpool, UK
This year the Nutrition Support session will focus on emerging technologies that can help direct our nutrition support of critically ill patients. Agreed speakers so far are
- Elisabeth De Waele - European indirect calorimeter project. The role of IC to direct our nutritional treatment
- Peter Weijs – Protein intake, muscle wasting and CT scans;
- Danni Bear on USS and muscle wasting – can it be used in clinical practice
- Adam Deane – GI dysfunction and how to measure it and new ways to treat it.
Early Bird Discounted fee Deadline: 05 October 2017
Abstract Submission Deadline: 03 August 2017
We would really like to encourage dietitians to submit posters. It’s a wonderful chance to share your work and receive feedback.
Nurse and AHP Foundation Fellowship
This award aims primarily at promoting intensive care research led by nursing and allied health professions. The award of up to £3000 may be put towards costs associated with design, conduct and delivery of research projects covering any aspect relevant to critical care. Awards may also be used to support further applications to larger, more substantial grant-giving bodies. Grants are open to members (UK and international) and non-members (UK only) of the ICS.
The award will open on Monday 12th June, with a closing date for submission of Friday 11th August (8 weeks).
Feedback from Groups and Branches Day
A new service will be available for members in association with Unionline, which launched in 2014. Unionline is a ‘not for profit’ and ‘no deduction’ law firm.
BDA Legal will provide a range of services including personal injury, employment law, criminal & regulatory, family law as well as fixed or free legal services including free simple wills, fixed rate conveyancing, preferred rates for power of attorney, free motor legal services and a free legal advice line.
Outcomes Working Group
We are pleased to announce that the outcomes working group has now reformed and held their first meeting at the BDA offices in Birmingham at end of June. Results of the previous pilot project were reviewed and the group have made plans to produce some new tools and conduct a further pilot in the Autumn. The group is now being led by CCSG Development Officer Vicky Davies who will continue to provide updates on the progress of the group going forward.
Social Media Update
Are you on Twitter? If not …why not?
There are so many benefits to being on Twitter as a critical care Dietitian. I will argue until I’m blue in the face that you are mad not to have a Twitter account. I am biased though as your PR & Social Media officer.
Twitter is excellent [bias again, sorry]! It will help you to keep up to date with the latest research in critical care nutrition without even touching PubMed! It offers the opportunity to make global connections with Dietitians, clinicians, researchers and AHPs specialising in critical care medicine and beyond. Twitter offers the opportunity for everyone to learn together, educate together and share together.
Along with our Twitter account - @BdaCare - you will be instrumental in helping to help promote the work and role of critical care Dietitians. Of course you will also be able to stay up to date on the latest goings on from the CCSG. Did I forget to mention that Twitter will allow you can follow international conferences from the comfort of your own home? It almost feels like you are there!
If I have made you desperate to join Twitter but are not sure where to start, please check our quick reference infographic on basecamp ‘Thinking of Joining Twitter? The #Why #How #Who’. I will be posting more advice over the next few months to help you to get the most out of your twitter account. Keep your eyes peeled!
You are already on Twitter? Fantastic! Follow the CCSG Twitter Profile @BdaCare and join in the conversation today. Don’t forget to ‘mention’ @BdaCare in any post you would like us to share.
If you are still not sure if Twitter is for you but you already have a Facebook account, give our CCSG Facebook page a ‘like’ by searching for us using ‘BDA Critical Care Specialist Group’. You still get all the benefits of following @BdaCare but straight to your Facebook timeline.
If you want to find out more about social media for critical care Dietitians, you can contact me directly on firstname.lastname@example.org.
As you may have read in the previous newsletter, we are very excited to have been invited to be part of the Intensive Care Society/FICM working group whose aim is to produce a multi-professional core competency framework for all AHP’s working in critical care. This work will extend the structure and purpose of both the ICS Core Standards (2013) and GPICS (2014) through providing a standard framework to assess certain AHP professionals working with patients and families in adult critical care.
Ella Segaran (Chair of the N&AHP committee of ICS) and Lucy Morgan recently attended a meeting in London where discussions began regarding the format and possible content of this competency framework. The group also has representation from physio, SLT and OT so we think the end product will be a fantastic resource which will be of benefit for all AHP’s working in critical care. We are aiming to have the first draft written by December 2017 prior to the ICS State of the Art Meeting in Liverpool so look out for further updates soon!
As a result of the work currently being undertaken with ICS/FICM we have decided to put the current dietetic competency working group on hold until we are clear about which areas will be included in the generic competency framework. This will then allow us to identify any gaps and ensure that the dietetic competency framework complements the generic framework but also covers all the necessary elements for Dietitians working in critical care.
Events and Courses
CCSG Studay Day 2017
We are pleased to announce the opening of registration for the upcoming study day:
Friday 24th November 2017, Hilton London Olympia, 380 Kensington High Street
London W14 8NL. The day will explore up to date issues including presentations on the PROTINVENT study, the management of dysphagia in critical care and workshops on critical appraisal. The day is also an excellent opportunity to network with other dietitians specialising in critical care from across the UK. Further information about the study day agenda, travel information and details on how to register are available here. Follow us on Facebook and on Twitter @BdaCare where you can find out first about the latest programme for the day and further big speaker announcements!
Any queries please contact Karenfriend@nhs.uk
Look forward to seeing you there!
BACCN Annual Conference 2017
Due to the overwhelming success that was the 30th anniversary, this conference will yet again return to the City of London at the Park Plaza for the 32nd Annual BACCN Conference, taking place on 3rd-5th September 2017. Titled “Building Interprofessional Teams to Enhance Safer Critical Care”, a packed schedule of seminars, keynotes, simulation labs and workshops will be presented.
39th ESPEN Congress 2017
This event will be held for the 3rd time at the World Forum in the The Hague, Netherlands from 8th – 12th September 2017. A wealth of exciting topics are once again included in this year’s programme.
European Society of Intensive Care Medicine 30th Annual Congress 2017 (ESICM 2017)
Taking place from 23rd – 27th September 2017 at the Austria Center in Vienna the programme includes a number of sessions related to nutrition and metabolism. Abstract submissions are now closed.
RCN Critical Care Workshop 2017
Open to other healthcare professionals as well as nurses, this workshop takes place on Saturday 21st October 2017 in London and includes an array of topics which may be of interest to those who are both new to critical care as well as those who fancy an update. For more information about the workshop and programme visit the website.
Articles of Interest
Nutrition Day ICU: A 7 year worldwide prevalence study of nutrition practice in intensive care
Association of modified NUTRIC score with 28-day mortality in critically ill patients
Parenteral glutamine should not be routinely used in adult critically ill patients
ESPEN Guideline: Clinical nutrition in surgery
Indirect calorimetry in nutritional therapy. A position paper by the ICALIC study group
A randomised trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial
We are pleased to announce that we are launching the CCSG Award for 2017.
This year the winner of the CCSG Award will win £500 of prize money that they can put towards an ICU conference of their choice (this should be related to critical care e.g. ESPEN, ISICEM, ESICM). This fantastic prize also includes the opportunity to present at the CCSG study day in November this year!
Entries will be judged by CCSG Committee members using criteria taken from the BDA Awards Document (September 2008) Section 2, Appendix 1 (see attached). Submissions must be received by 5pm on Friday 29th of September. Please send all submissions and any queries to email@example.com.
37th International Symposium on Intensive Care and Emergency Medicine (ISICEM) 2017
The winner of last year’s competition was Mina Bharal, who impressed judges with her entry entitled ‘Is Volume-based Feeding the Way Forward for UK Critical Care Patients?‘. Mina was able to use her prize money to help fund her attendance at the fantastic ISICEM conference in Brussels and has kindly provided a summary of her experience for CCSG members.
“I would first like to thank CCSG for the award money which I put towards attending this ISICEM conference. It was a great experience and I would thoroughly recommend it.
This busy four day programme included numerous nutrition sessions and invited inspiring speakers from across the world, providing an up to date review of the most recent research and clinical developments in the management of critically ill patients. The delegates represented a range of multidisciplinary professionals and there was a large scientific exhibition with a wide range of sponsors. I have summarised some points of interest from the conference.
Paul Wischmeyer (USA) opened the nutrition sessions by giving an energetic and comprehensive overview of nutrition in critical care. He stated that 60-80% of critically ill patients who stay in ICU longer than 1 week are functionally impaired and are likely to lose 1kg of body weight per day. Loss of lean body mass accelerates in critical illness, where weight gain is likely to be fat weight not muscle. He referred to the International Nutrition Surveys (2014/15) which revealed that patients on enteral nutrition (EN) were underfed by 50% of calories and equivalent to 0.6g/kg/d of protein. He explained that trials providing <1g/kg/d of protein, such as EPaNIC, EDEN Trial, PerMIT have shown no benefit, yet in contrast, extra protein reduces mortality. Nicolo et al (JPEN 2016), reported on a multicentre study ‘Clinical Outcomes related to Protein delivery in a Critically Ill population’, demonstrating that in 2800 ICU patients meeting >80% protein targets was associated with reduced 60 day mortality, independent of energy goals. Another study, looking at patients (n= 475) on mechanical ventilation for >8 days, showed an increased energy and protein delivery in the first ICU week improves survival in high risk patients (Wei et al, Crit Care Med. 2015).
Wischmeyer summarised key aspects of the ASPEN/SCCM guidelines (JPEN, 2016) targeted to nutrition delivery in critical illness. Aiming for protein requirements of 1.2-2.0g/kg/d, where every additional 30g/d protein reduces mortality (Alberda et al, Int Care Med 2009). Protein goals are vital compared to caloric goals. However, enteral feeding formulas have high calorie and low protein composition, impeding goal achievement. If underfeeding EN is likely, supplemental parenteral nutrition (SPN) or protein supplements should be considered. Hypocaloric PN (≤ 20kcal/kg/d or 80% of estimated energy needs) with adequate protein (≥1.2g protein/kg/day) should be considered in patients requiring PN, over first ICU week (Quality of evidence is low). In early sepsis, provision of trophic feeds (defined as 10-20 kcal/h or up to 500kcal/d) for initial phase of sepsis and advance as tolerated after 24-48h to >80% of target energy over the first week. Gastric residual volumes (GRVs) are not to be used as part of routine care to monitor ICU patients on EN. However, the quality of evidence is low and it is important to note that the evidence from the Reignier study (2013) were mainly medical patients.
The new ‘ESPEN Guidelines: Clinical Nutrition in Surgery’ (Weismann et al, 2017) recommend that all patients having major surgery should be screened pre-op using POET Pre-operative Nutrition Care Pathway nutrition screening tool (awaiting validation). A high score will result initially in postponement of surgery and a nutritional assessment, followed by nutrition advice and education. In the intensive care setting NUTRIC should be used for assessment.
In another session, Wischmeyer also discussed the obese patient, reporting that there is a higher mortality associated with underweight individuals compared with patients with a high BMI. Conversely, poor nutrition in the obese is increasing in the world and it receives minimal attention including in the ICU. Indirect calorimetry (IC) is gold standard for predicting caloric needs in the obese. However, there are many limitations to IC, including access to the equipment, lack of skilled operators/ validation, FiO2 needs to be <60% and inaccurate in patients on RRT and haemodynamically unstable patients. For predictive equations, the Penn State Equation is the most accurate in obese ICU patients. Based on metabolic cart REE studies for intubated obese ICU patients, 11-18kcal/kg of actual BW is a safe place to start (Port & Apovian, 2010).
2016 ASPEN/SCCM Guidelines recommendation for energy in obese ICU patients:
Energy goal ~65-70% of target energy needs as measured by IC. If IC is not available, use weight based on 11-14kcal/kg ABW/d for BMI 30-50 and 22-25kcal/kg IBW/d for BMI >50. There is currently no robust data supporting hypocaloric feeding in this patient group. A study by Kozar et al (2013), in N=149 (median age 78 years old, 57% males), prevalence of sarcopenia was 71% in these obese patients. Following trauma, lean patients use 61% of REE from free fatty acids (FFA) in comparison obese patients’ use their LBM as major energy source and only 39% of FFA as REE. Obese patients have large fat reserves but cannot utilise fat for energy in ICU. Thus obese patients lose their muscle mass faster than non-obese and as a result require more protein (2.0-2.5g protein/kg of IBW) to maintain nitrogen balance.
The patient on ECMO: Elisabeth De Waele (Brussels, Belgium)
De Waele presented her fascinating research of patients on ECMO, where nutritional implications and challenges of transplant patients undergoing extracorporeal membrane oxygenation (ECMO) therapy are being recognised. With an increasing number of patients on ECMO and staying on this for longer periods, the question was asked of how these patients should be fed and understanding the measurement of nutritional requirements. Both enteral and parenteral feeding is safe for ECMO patients. Providing adequate nutrition to these patients is challenging as there are no clear clinical guidelines for the adult population on ECMO unlike neonates. These guidelines only provide ‘best guidance’ as there remain controversies and few strategies have achieved consensus. Indirect calorimetry consistently remains the gold standard method for measuring REE in ICU patients; De Waele explained that it is possible to attach the ECMO machine to the IC, her team (2015) studied REE measurements during ECMO. No data exist on the use of IC in ECMO-treated patients as oxygen uptake and carbon dioxide elimination are divided between mechanical and the artificial lung. They report their preliminary clinical experience with a theoretical model that derives REE from IC measurements obtained separately on the ventilator and on the artificial lung. The REE (kcal/d) was variable but not very high, the mean energy expenditure per kg BW resulted in approximately 19kcal/kg; this has not been validated and requires more data. There is currently no data for measuring protein intakes in this group. Optimal protein intakes are still being debated, current recommendations are 1.2-1.5g/kg/day.
Our very own Dannielle Bear continues to raise dietetic profile within critical care nutrition. She had a hectic schedule at the conference as a member of expert panels, chairing sessions and presenting several of the nutrition sessions.
How to feed the Polytrauma Patient
Incidence of malnutrition on admission to ICU is low, trauma patients are less likely to be malnourished, with 85% considered to be well nourished, using a Subjective Global Assessment (SGA). Nutritional status declines over the course of hospital admission SGA 85% to 56% (Chapple et al, 2016). Completing NUTRIC score for all ICU pts is recommended in the 2016 ASPEN/SCCM guidelines. However, it is important to note NUTRIC does not have any variables related to nutritional status and it is only done on admission to the ICU and not frequently repeated or as the condition of the patient changes, therefore some that develop a high NRS may be missed. Puthucheary et al, 2013 reported a 26% muscle loss as nutrition score declines, highlighting that muscle wasting in these patients should be avoided. To date there are no published studies of muscle loss in trauma patients.
A meta-analysis carried out by Doig et al, suggested that the provision of early EN within 24 hours of injury was associated with a significant reduction in mortality (OR = 0.20, 95% confidence interval 0.04–0.91, I2 = 0). When managing patients with an open abdomen, Danni reassured that EN is safe and feasible, leading to early closure, fewer complications and reduced mortality (Burlew et al. J Trauma Acute Care 2012; Collier et al. JPEN 2007; Dissanake et al. J Am Coll Surg).
Energy expenditure is not static in the ICU trauma patient, we need to consider the degree of illness, medication (paralysing agents), sedation and now exercise. If IC is not available opt for the Penn State predictive equation. The ESPEN recommendation of 25kcal/kg is not as precise. Aim for protein requirements of 2.0g/kg including surgery and CRRT, or 2.5g/kg including burns (need to consider protein losses in exudate ~12-30g/L) and obesity (ASPEN/SCCM guidelines, 2016). There is currently no conclusive evidence for the use of glutamine or arginine in this patient group.
Targeting muscle wasting
There are significant physical and functional disabilities in 1-5years post ICU, Puthucheary (2013) demonstrated that at the end of 7 days patients are not in a catabolic balance. Higher total protein delivery is associated with increased muscle wasting.
A study by Ferrie et al (JPEN, 2016), ‘Protein requirements in the critically ill: A RCT using PN’, showed higher levels of amino acids were associated with small improvements in a number of different measures, supporting guideline recommendations for ICU patients; including a slight improvement in hand grip strength in ICU and on hospital discharge, improved fatigue score and reduced muscle wasting.
Danni highlighted that we currently know very little of the impact on muscle wasting. We assume that our current methods of feed delivery are adequate, including method of delivery e.g. continuous superior to bolus, but what about intermittent feeding? A simple over-provision of amino acids does not lead to continued increase in muscle protein synthesis (MPS) (Atherton et al; Am J Clin Nutr, 2010). She described her hypothesis for her impending study, investigating the effect of β-Hydroxy β-Methylbutyrate (HMB) on skeletal muscle wasting in early critical illness. Explaining that the provision of nutrition support is based on several assumptions, gut plasma and plasma-muscle uptake of nutrients is sufficient. Timing of nutrition is likely to be key factor, concluding that nutrition interventions to reduce skeletal muscle wasting and enhance recovery are urgently required across the continuum of critical illness. Intermittent feeding, specific amino acids (leucine) and their metabolites HMB may reduce muscle wasting during critical illness and improve strength and function.
Nutrition Rehabilitation: what happens after the first week?
Danni explained that there is a dearth of guidance and evidence for patients post first week of ICU. Rehabilitation should include nutrition support based on recommendations in NICE 2009, Nutrition Support in Adults. Long term outcomes from nutrition trials are variable. A RCT trial by Jones et al (2010) suggested that supplementation of an essential amino acid and physiotherapy classes improved rehabilitation. Nutritional support over the continuum of critical illness has the potential to positively influence (physical, functional and quality of life) outcomes.
Nutritional status declines over the course of hospital admission (Chapple et al, 2017) and patients may not regain muscle (Reid et al, 2008). Oral intake is poor following extubation, as little as <50% on each day for 7 days (Peterson et al, J Am Diet Assoc, 2010). Oral energy and protein targets are not met post ICU. A study by Rowles (2016) revealed that enteral feeding did not reduce oral intake or appetite. Changes in appetite could be related to gut hormone levels such as ghrelin, which are lower in ICU patients than in controls and took 4 weeks to recover to normal levels.
A qualitative study by Merriweather et al, J Clin Nurs 2014, suggested that organisational factors influenced nutritional intake, such as ward culture and system-centred and disjointed delivery of care. Reduced oral intake is multifactorial and can be due to early removal of NGT, meal specific issues, dysphagia, low mood and physiological changes. Concluding that poor appetite and oral intake persists post ICU stay, this is likely to influence long term outcomes in trials of an ICU nutrition interventions.
Hypocaloric, Goal directed or no nutrition at all in the acute phase of critical illness (Gunner Elke, Kiel, Germany)
Elke opened his session describing a study by Doig et al (2008) suggesting that the implementation of evidence based feeding guidelines to improve feeding practices and reduce mortality in ICU patients; promoting earlier feeding and greater nutritional adequacy did not improve clinical outcomes. He explained the ‘Hibernation (black bear) theory “Half of the year not eating or drinking, urinating or defecating and when the bear awakes and leaves his sleeping berth, he is in full possession of his muscle strength!” Metabolism is on a “low flame”, comparing it to MOF in its adaptive, endocrine-mediated, metabolic response to overwhelming systemic inflammation. It is possible that the metabolic “downregulation” (hibernation), metabolic shutdown decreases nutrient requirements, reduces substrate use and lowers energy expenditure.
Indirect calorimetry informs us the REE at the time of measurement but does not inform us how many calories we should give or the patient may tolerate, respectively. Both overfeeding and underfeeding appears to be harmful to patients, achieving an adjusted calorie intake / REE of 70% had a survival advantage (Zusman et al, Critical care 2016). High quality RCTs had different effects on morbidity due to non-comparable nutrition strategies, patient population and methodological criteria. There was no effect on mortality and long term functional outcomes were not reported.
Observational studies examining various doses of enteral feeding have yielded conflicting results. The PermiT trial tested a moderate amount of calories to critically ill adults in the presence of full protein intake which was not associated with lower mortality than a strategy aimed at providing a full amount of calories. However, when analysing these results, the following points such as, pseudo multicentre (70% of pts recruited at 1 site), selected patient cohort (75% medical, mean age 51yrs, BMI 29.3) and low caloric intakes in both groups (10 vs 16kcal/kg/d) need to be considered.
A recent meta-analyses of treatment effects of nutrition (Elke et al, Crit Care 2016), suggested no differences in ICU and hospital LOS, duration of MV, and infectious complications between lower vs higher calorie nutrition strategy. The recent study by Charlene Compher et al (2017), demonstrated that greater nutritional intake is associated with lower mortality and faster time to discharge alive in high risk longer stay patients but not in nutritionally low risk patients.
Elke recommended hypocaloric (500kcal = hypocaloric feeding from day 1 and advance as tolerated during the first week), goal directed or no nutrition at all in the acute phase of critical illness and to start trophic EN early after resuscitation within 6-12h, using a ramp up approach towards target of 25kcal/kg. Targeted (not forced) approach is safer and more beneficial (hypocaloric> isocaloric within the acute phase of illness ~1st week) as hyperalimentation worsens outcome. The same holds true when using (total or supplemental) PN.
Elke reported what is still unclear; tolerable lower limit of energy intake in patients with high nutrition risk and true impact on long term functional outcomes, the clinical role of autophagy in the absence of overfeeding and is high protein the magic bullet?
The controversy around protein intake continues and a whole afternoon was dedicated to recent protein studies, many of which suggested that optimal protein requirements in ICU patients remains inconclusive. Studies showed that intakes of between 1.2-1.5g.kg.day of protein with 25-30kcal/kg/d (using indirect calorimetry) had higher percentage survival rates, with the least negative nitrogen balance. Energy may not be as relevant as adequate protein. Kenneth Christopher (USA) highlighted that not many studies use high protein and compare low protein intakes to 1.2g/kg and clinical outcomes and calorie intakes may vary alongside other confounding variables not controlled. There is a need for robust trials on Elevated vs Standard protein delivery in critically ill patients.
Timing of Higher protein intake is important: protein intake is important – Arthur Van Zanten (Netherlands).
Van Zanten opened with an introduction to Metabolic and Nutritional support of critical care patients: consensus and controversies (Jean-Charles Preiser). Normal vs low intakes of protein, where low intakes are associated with increased mortality, 25% muscle loss within 10 days in MOF. Increased protein requirements are related to the need for a greater amount of amino acid to achieve the same muscular synthesis as a result of the anabolic resistance and the need for amino acids for synthesis of acute phase response proteins.
A study by Weijs, (Crit Care 2014) looked at low skeletal muscle area (assessed by LBM CT scan during the early stage of critical illness), as a risk factor for mortality in the MV critically ill patients independent of sex and APACHE II score. Muscle wasting occurred early and rapidly during the first week of critical illness and this was more severe among those patients with MOF compared with patients with the single organ failure.
The EPaNIC trial (Casaer, 2013) suggests protein had a deleterious effect and not glucose as part of the nutrition therapy. There is currently a surge in debate around autophagy. An article by McClave & Weijs (Current Opin Crit & Metab Care, 2015), on ‘Preservation of autophagy should not direct nutritional therapy’ explaining that “Autophagy is a well-recognised physiologic process that serves a housekeeping role for the cell to eliminate large protein aggregates and as a survival mechanism in starvation for generating energy (ATP) and promoting protein synthesis to maintain cell structure. In the critical care setting, autophagy may have important roles in modulating immune function, fighting infection, and preventing organ failure. The effect of feeding on autophagy is complex, poorly understood, and difficult to predict”. Therefore, the argument to withhold feeding to preserve autophagy is poorly substantiated and should not interfere with the delivery of early enteral nutrition to the critically ill patient in that first week following admission to the ICU.
A study recently submitted by van Sethan & van Zanten et al, PROTINVENT a retrospective study on PROtein INtakes and critical outcome in adult critically ill patients on prolonged mechanical VENTilation > 7 days, primary endpoints > 6 month mortality. Early (< 3 days) high protein intake associated with higher mortality, after day 3, a high intake is better. Patients that receive more than 0.8g/kg /day during day 1-3 have a higher risk of 6 month adjusted mortality compared with patients with lower intake (P=0.055). More protein intake during these initial days is associated with increased adjusted mortality. Patients that receive less than 0.8g/kg /day during day 1-3 and more than 0.8g/kg/d during day 4-7 have a lower risk of 6 month adjusted mortality compared with continuous lower or higher intake.
Conclusions: This may suggest that gradually increasing protein intake over 3 days like caloric intake is recommended. It is speculative that autophagy deficiency plays a role only during early critical illness.
Optimal composition: Pietro Vecchiarelli (Italy)
Puthucheary et al (2013) reported a 20% loss in rectus femoris cross sectional area in > 2 ‘organ failure’ patients after 10 days and 26% loss in rectus femoris cross sectional area in > 4 organ ‘failure patients’ after 10 days.
Can early optimal nutritional support reduce proteolysis, prevent muscle loss, prevent skeletal mass quality and improve clinical outcome? The ASPEN/SCCM and ESPEN 2009 guidelines do not explain how to select an individual patient’s dose within the wide range of 25-30kcal/kg and 1.2-2.5g protein/kg/day.
In the 5 RCTs (EDEN Trial, Early PN Trial, EPaNIC Trial, SPN Trial and TICACOS Trial) of macronutrient intake and outcomes, it was concluded that there are no benefits with respect to mortality with enhanced EN or PN early in a critical illness. A reduced energy intake shows a beneficial effect on morbidity and ICU stay. In the EPaNIC study, early PN (more aggressive feeding) did not prevent wasting of skeletal muscle and induced lipogenesis. When estimating energy expenditure, indirect calorimetry does not take into account endogenous production of calories (Fraipont & Preiser, JPEN 2013). During the early phase of critical illness inadvertent overfeeding can occur every day when totalling exogenous and endogenous (non-inhibitable production) energy sources.
The inhibition of autophagy exacerbates muscle loss and degeneration in catabolic conditions. Early PN via the suppression of autophagy may impair clearance of damaged organelles and protein aggregates, thereby threatening muscle function and aggravating ICU-acquired weakness in humans (Hermans et al, Lancet 2013)
Hoffman and Bristran (2014 & 2016) state that so many recent RCTs of nutrition support in the ICU have been disappointing. The amount of protein provided was dramatically less than what was the best available evidence suggested it ought to be. Protein not calories, is the crucial macronutrient in catabolic illness. In Doig et al’s (Int Care Med, 2015) nephroprotective RCT trial (n=474 patients) of intravenous amino acid therapy for kidney function in critically ill patients, a higher dose of amino acids did not lead to a clinically relevant benefit, led to increased ureagenesis with a trend towards more RRT, however, there was no data on muscle weakness.
In the 3 successive phases..
Phase 1 (Early): there is a misuse of caloric intake and nutrition cannot inhibit gluconeogenesis and proteolysis. Protein appears more harmful than glucose in the first days and there are currently no specific methods to measure protein requirements. Phase 2-3 (Delayed(2): days and weeks; Recovery(3): weeks and months): caloric intake should match energy expenditure plus increased protein supplementation for muscle protein synthesis.
Conclusions: Vecchiarelli recommends that, during the first week in ICU, administer the dose of enteral nutrition that is tolerated, and supplement with micronutrients from admission. Still need to understand whether the target is 70%, 80% or 100% of requirements.
Early full PN as a strategy to reduce muscle catabolism, may actually damage cellular function by impairing autophagy. Protein appears to be more harmful than glucose. After the acute phase, caloric intake should match energy expenditure plus increased protein supplementation to stimulate anabolism".
Thank you Mina for an excellent summary!