Critical Care – review of current practice

Emma Forsyth

Senior Specialist Dietitian - ICCU

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Overview

• Why me?

• Estimating requirements in critical care

• Feeding protocols

• Routes

• Prokinetics

• SB feeding

• EN and PN

• ‘specialist nutrition’

• Questions

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Why Me?

• CHS opened new combined HDU/ITU in 2000

• Full MDT involvement…… except dietetics

• Few tailored feeding regimens

• Feeding protocol out of date

• Nutrition ‘not always’ priority

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What Changed?

• Full time April 2009

• Integral part of the MDT

• Short listed for trust award for work on feeding on ICCU

• Submitting work to ESICM

• Clinical advisor NCEPOD PN Report 2010

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Excellence in Health putting People first

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Why Feed?

• Early nutritional support beneficial

• Malnutrition

• Hypermetabolism

• Stress / inflammatory response……

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Stress!

Nutritional consequences are:

• An alteration in energy needs and production

• Preferential catabolism for protein stores

• Limitation of intake due to anorexia / inability to eat due to sedation / unconscious state

• Possible decreased intestinal absorption

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Why Feed?

• Muscle catabolism / weakness

• Weight loss

• Negative nitrogen balance

• Delay in mobilisation

• Average loss of 17% total body muscle stores after 21 days of critical illness

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Requirements

• Indirect calorimetry

• Equations

• Consideration of the stress response

• Under and overfeeding

Weight gain in critical care

= fat or fluid!!

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Feeding Protocol

• Timing

• Routes

• Rates

• Decrease use of parenteral nutrition

• Appropriate prokinetic prescription

• Assess tolerance issue

Well embedded feeding protocol improves overall nutrition practice

(Heyland et al 2010)

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GRV

• 200ml – ‘hinder administration’ – REGANE 2009

• 400-500ml (Currie 2010)

• Increased delivery of EN

• Decreased use of prokinetics without increased risk of aspiration

• Trends of aspirates should be used instead of a single large aspirate

• Return!

• 24 hour feeding – NICE SUGAR

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Excellence in Health putting People first

Contraindication to

enteral feeding

Initiate feed at

30ml/hr x 4hr then

aspirate

Is aspirate > 400ml?

Replace to max of

500ml, increase

feed by 30ml/hr x

4hr then aspirate

Is aspirate >

400ml?

Aspirate 4hrly and

increase rate by

30ml/hr until

desired rate

Consider parenteral

nutrition

Replace up to 500ml of

aspirate, maintain feed at

current rate and

considering initiating

prokinetics

If a second large aspirate,

hold feed for 1 hr and

restart at previous rate.

Aspirate after 4 hrs

If a third large aspirate

Reduce feed by 30ml/hr and

continue aspirate cycle. If

there are continued large

aspirates, consider post

pyloric feeding

Yes

No

No

No

Yes

Yes

Hurt and McClave 2010

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Routes

• Enteral preferred route of nutrition

• Decreases time on ventilator

• Decreases incidence of infection rates

• Decreases overall mortality

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Prokinetics

Metoclopramide

(Grant 2009)

Vs

Erythromycin

(Nguyen et al 2008)

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SB Feeding

• Gastric first line

• Gastric vs SB (Hsu 2009) (White et al 2009)

• Availability of placement of SB feeding tubes

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EN & PN

• Perseverance with troublesome EN can lead to increased risk of malnutrition

• Inclusion of PN can help meet calorie targets but does this actually improve outcome?

• Can appropriate PN deliver optimum nutrition?

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Specialist

EPA

GLA

Low CHO High Fat

Antioxidants

Arginine

Glutamine

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Summary

• Early nutrition (within 24-48hr)

• Preferable enteral nutrition

• Update feeding protocol (aim 400-500ml for aspirate level), prokinetics, SB feeding, 24hr feeding

• Metoclopramide 1st line

• Gastric 1st then SB if failed

• Use PN when indicated, eg. Failure / inability EN

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Summary

• Avoid over and underfeeding

• Consider omega 3 & 6 for ALI, ARDS

• Glutamine in PN

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Thank you for

listening

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