CCSG Winter Newsletter 2017
New Committee Members
Following the announcement of some brand new committee roles at our AGM in November we are delighted to introduce the following members to our CCSG committee:
Regional Co-ordinator - Rowan Clemente
“Hello, I am one of the Critical Care Dietitians at North Bristol NHS Trust. North Bristol NHS Trust is a trauma centre and burns unit. Prior to having my family I provided inpatient services to neurosurgery and burns but as my hours have reduced I am now solely based on our mixed ITU seeing a whole variety of patients”.
Research Officer - Liesl Wandrag
"I'm the Principal Critical Care Dietitian for Guy's & St Thomas' NHS Foundation Trust. Although this is a clinical post I retain research links with the national working group 'Enhanced Recovery after Critical Illness' and the Centre for Altitude, Space & Extreme Environment Medicine (UCL) with research interests in muscle wasting, catabolism and recovery in hypoxic conditions. I completed my NIHR funded PhD at Imperial College in 2013."
PR Officer - Rob Cronin
“I've been a dietitian from some 8 years and my interest in critical care dietetics started when I was working for North Bristol Trust. A job opportunity closer to home at Gloucestershire NHS Foundation Trust allowed me to focus on this interest working as the critical care dietitian for Cheltenham General Hospital. I am currently covering maternity leave as the lead Dietitian for our Nutrition Support Team, with a focus on PN. I obviously still jump at any opportunity I get to help out and support our ICU dietitians.
I have interests in nutrition screening/risk screening on the ICU, nutrition support in the critically ill obese and I really enjoy providing updates and education to our ICU Drs, nurses and AHPs.
Please do follow @BdaCare if you are already on Twitter and like our Facebook page www.facebook.com/bdacriticalcarespecialistgroup/. It's a great forum to share the great work we do and to promote what a valuable role we can have to the health and outcomes of the critically unwell”.
CCSG Study Day 2016
The CCSG committee would like to take the opportunity to say a big thank you to all of the speakers, exhibitors and delegates who attended last year’s study day and AGM. It was another huge success with lots of interesting topics covered throughout the day. We appreciate that not all of our members are always able to attend and therefore we have provided a summary of the topics discussed in this newsletter, which will also feature in a future edition of CN magazine. You can also access our historic tweets from the day by visiting our Twitter page.
Critical Appraisal on Hypocaloric Feeding
Dr Elke an ICU consultant from Kiel University Hospital, Germany, kicked off the day with the first presentation. He discussed hypocaloric feeding, the “hibernation theory” and the worldwide issue of Post Intensive Care syndrome in ICU that affects up to 60% of critically ill patients. Both the nutritional and non-nutritional (e.g. maintaining functional integrity of the gut) benefits of enteral feeding and the concept of autophagy during the acute phase of illness were discussed. He stressed the importance of monitoring gastrointestinal and metabolic tolerance of nutrition support. In conclusion, he recommended early EN, and that hypocaloric feeding (EN & PN) may be safer and more beneficial within acute phase of illness (approx. 1st week of admission). He also highlighted the need for us to consider long term functional outcomes following discharge from the ICU.
Poster Competition: How well do we meet nitrogen requirements in parenterally fed patients?
Marta Alves presented on behalf of our poster award runner up Rachel Thomson, an Advanced Critical Care Dietitian at Addenbrookes Hospital to discuss an audit on meeting nitrogen (N) requirements in parenterally fed ICU patients. She concluded that their current PN bag options failed to meet N requirements in 94% of patients. She has submitted a business case to obtain an alternative bag with higher nitrogen: calorie ratio.
Parenteral Nutrition and Critical Care
Danni Bear, Critical Care Dietitian & NIHR Clinical Doctoral Fellow, Guy’s and St Thomas’ NHS Foundation Trust, London presented on Parenteral Nutrition. She highlighted a key issue in relation to inadequacy of nutritional provision on critical care. Her main take home messages were that early EN is preferable when possible, nutrition risk scores (eg. NUTRIC) should be used to determine which patients are suitable for early PN, decisions for PN should be individualised and to avoid overfeeding energy and meet protein requirements.
Poster Competition: How successful is gastric feeding in mechanically ventilated traumatic brain injury patients?
Our second runner up for the poster award Emma Service, an Advanced Major Trauma Dietitian at Addenbrooke’s Hospital (presented by Marta Alves), discussed findings from a retrospective service evaluation of gastric feeding in mechanically ventilated traumatic brain injury patients. Delayed gastric emptying, as indicated by high GRVs (>400ml), was the main barrier to meeting nutritional targets. The majority of patients were not prescribed laxatives until day 3 of admission and on average patients did not have a bowel movement until day 7. A correlation between high GRVs and decreased bowel movements was suggested. She concluded that gastric feeding failed to meet nutritional targets and recommended that if gastric feeding fails despite prokinetics, post pyloric feeding should be initiated before PN. Appropriate bowel care is also an important consideration.
Poster Competition: Is volume-based feeding the way forward for critical care?
Our poster award winner Mina Bharal, an Advanced Specialist Dietitian at Northwick Park Hospital spoke about a service evaluation project in which Volume-Based Feeding (VBF) was compared to the rate based feeding regimen in an ICU setting. She concluded that VBF may allow for significantly greater provision of recommended energy and protein with little effect on glycaemic control and GI tolerance. However, this strategy did not show any effect on clinical outcome.
Dietetic Outcomes in Critical Care
Sarah Airey (Specialist Dietitian at Papworth Hospital) spoke about Dietetic Outcomes in Critical Care. This project was previously discussed at our study day in 2014 and has been supported by the Critical Care Specialist Group. Dietitians from 10 critical care units from NHS hospital Trusts participated in the pilot and data was collected on between 4-20 patients per unit between June and August 2015.The Pilot study report is on critical care specialist groups discussion forum with full details of the preliminary dietetic outcomes developed by CCSG. Further work on this is planned for 2017.
GRV Management on Critical Care
After lunch Ella Segaran, Advanced Dietitian for Critical Care at St Mary’s hospital, spoke about management of Gastric Residual Volumes. Her take home messages were that there is varied practice in ICU’s across the UK, much is historically based and not all ICU patients are equal. Therefore one approach may not suit all. Thresholds of between 200-500ml should be used and monitored every 4-8 hours and whether the aspirate should be replaced or discarded is down to clinical judgement. Other symptoms of GI dysfunction should be used in conjunction with GRV to assess feeding tolerance.
Meeting Protein Requirements in Critical Care
Our last presentation of the day was by Dr Stephen Taylor, Specialist Critical Care Dieitian and Research Lead Southmead Hospital, North Bristol NHS Trust. He presented on achieving protein adequacy without overfeeding. He explained why protein requirements may increase during critical illness and discussed the difficulties faced in meeting them. He discussed an audit completed by himself and his team in 2016 looking at protein adequacy compared with local and international guidelines. He concluded that feed, plus a protein/glucose supplement met 82-100% of goal. He concluded that we also need to look at the type of protein supplement we use; they need to be soluble and contain essential amino acids.
At the end of the day we held two workshops on Nutrition Screening and Dietetic Competencies. These interactive sessions generated much discussion amongst delegates and enabled each group to identify and target future developments.
Following on from the competencies workshop a small working group, led by Sarah Ashley, has now been established to take this work forward. The aim of the group is to create a dietetic competency framework for those working in critical care. Following its most recent meeting the group are now planning to write competencies based on the knowledge and skills that were identified in the workshops. FICM and ICS have also invited CCSG to be part of a working group that is aiming to create a generic competency framework for allied health professionals working in critical care. Ella Segaran will be our representative on this group to ensure that the work being undertaken by both groups will complement each other. Watch this space for further updates!!
Our annual general meeting took place during the lunch break where the committee updated members on our annual report and forward plan. It was with great sadness that we announced the cessation of the burns subgroup and Natasha Kershaw and Tig Howells were both thanked for the hard work and commitment they have shown in supporting those working within this clinical speciality. Both dietitians will continue to be available through Basecamp to support members working with burns patients.
Events & Courses
The 37th International Symposium on Intensive Care and Emergency Medicine takes place in Brussels from 21st – 24th March 2017. If any of our members are able to attend this event we are offering the chance to be awarded a £50 voucher by submitting a summary of the experience for our next newsletter. More details about the programme can be found online.
Trauma and Critical Care
The 3rd Annual Congress and Medicare Expo on Trauma and Critical Care takes place in London from 13th-14th March 2017. Visit the event website for more details about the programme and how to register.
Trauma Critical Care for Nurses and AHP Conference
This study day will take place on 15th March 2017 in Stone, Staffordshire and includes topics on traumatic brain injury, trauma rehabilitation and nutrition. More information can be found online.
Critical Care Symposium
The 14th Annual Critical Care Symposium takes place in Manchester from 27th – 28th April 2017. Gut integrity in sepsis, dysphagia and skeletal muscle wasting are just some of the topics featured in the programme. For more information please visit the event website.
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, sim labs and workshops will be presented.
The new ‘Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock’ are now available. It’s fantastic to see that Nutrition has been granted its own section and as such we have put together a short summary of the key recommendations. The full article can be accessed via the above link and we recommend that all dietitians working in critical care should take some time to review the guidelines in full.
Summary of Recommendations
- Insulin therapy should be commenced when two consecutive blood glucose levels are >180 mg/dL (10.0 mmol/L) to target an upper blood glucose level of ≤180 mg/dL rather than an upper target blood glucose level ≤110 mg/dL (6.1 mmol/L). Blood glucose levels should be monitored every 1-2 hours until glucose values and insulin infusion are stable, then every 4 hours in those continuing to receive insulin therapy. Arterial blood rather than capillary blood should be used to test glucose levels if an arterial catheter is in situ. Capillary blood for point-of-care testing should be interpreted with caution.
- Renal replacement therapy (RRT) may be used continuously or intermittently in septic patients with acute kidney injury but continuous therapy should be used to support fluid management in haemodynamically unstable septic patients.
- In patients who can be fed enterally, early PN (either alone or in addition to EN) is not recommended in critically ill patients with sepsis or septic shock. Of 10 trials with 2888 patients, early PN was associated with increased length of ICU stay and no benefit on mortality or infection risk. Use of PN alone or in combination with EN should not be used over the first 7 days in critically ill patients with sepsis or septic shock where early EN is not feasible. Initiation of IV glucose and advancing EN as tolerated is suggested instead. A total of 4 trials of 6087 patients found that early PN either alone or supplementary was not associated with reduced mortality but was associated with increased risk of infection. Future research needs to focus on characterising subgroups of patients who may benefit from early PN (e.g. malnourished patients).
- Early initiation of EN rather than complete fast or IV glucose is recommended in patients with sepsis or septic shock. This may be trophic/hypocaloric (≤70% standard caloric targets) or full enteral feeding with trophic/hypocaloric feeds being advanced according to patient tolerance. The benefits of early EN are suggested to be physiological with reduced gut permeability, inflammation and infection risk being noted. Patients with sepsis or septic shock who do not tolerate EN may benefit from trophic/hypocaloric feeding that is titrated as tolerated but there is insufficient evidence to confirm that a trophic/hypocaloric feeding strategy is effective and safe in patients who are malnourished (BMI ≤18.5).
- Omega -3 fatty acids should not be used as an immune supplement in critically ill patients with sepsis or septic shock. In a total of 16 trials with 1216 patients there were no significant reductions in death but ICU length of stay was reduced in the omega-3 group. However, the overall quality of the evidence was graded low and other studies have raised the potential of harm with uncertainty of benefit.
- In nonsurgical critically ill patients with sepsis or septic shock, routine measurement of gastric residual volumes (GRVs) is not recommended. However, these may be monitored in those with feeding intolerance (e.g. vomiting, reflux of feeds into the oral cavity) or who are considered to be at high risk of aspiration. Vomiting may be more frequent when GRVs are not monitored but studies to date do not show a benefit in relation to ventilator-associated pneumonia or mortality. Prokinetic agents may be used in patients with feed intolerance but future studies are needed to determine efficacy and safety. Placement of post-pyloric feeding tubes is recommended in those with feeding intolerance or considered high risk of aspiration and is associated with a reduced risk of pneumonia.
- The use of IV selenium is not recommended to treat sepsis or septic shock. Although there may be a reduction in selenium levels in septic patients the trials available do not show any benefit for infection rates, length of ICU stay or mortality. The panel advise against the use of arginine or glutamine due to the disparity in study findings to date. Larger trials are also needed to determine the benefits of carnitine supplementation.
Articles of Interest
Can calculation of energy expenditure based on CO2 measurements replace indirect calorimetry?
Insulin and the brain
Identification of malnutrition in critically ill patients via the subjective global assessment tool
ESPEN Guideline: Clinical nutrition in inflammatory bowel disease
We would like to remind all members to look out for the CCSG on both Facebook and Twitter for useful updates in critical care nutrition throughout the year.
To keep up to date with the latest critical care nutrition journal publications; podcasts and international conferences follow us on Twitter @BdaCare and like our Facebook page www.facebook.com/bdacriticalcarespecialistgroup/ .
Twitter is also a great way to connect with critical care Dietitians, Doctors, Nurses, Physios and AHPs from all over the world. Sign up today to join the conversation and promote the great work we do!
There is also a mobile app available for Basecamp which may be helpful for members to access our discussion forum with ease.
Intensive Care Society
We would like to take the opportunity to congratulate Ella Segaran (former CCSG Chair) on her recent appointment to Chair of the ICS N/AHP Committee. Ella has always worked hard to maintain strong links between the CCSG and ICS and we wish her every success in her new role.