VVKVM Symposium “Combinatie EN-PN” Boom, 14 december 2013

A surgeon’s view

on the use of EN/PN

in surgical patients on ICU

Dirk YSEBAERT

Antwerp University Hospital

Belgium

Disclosures

I have no disclosures related to this topic.

This presentation is a personal view,

not a systematic review of the evidence.

Surgical ICU patients

• Prolonged postop ICU stay after major GI surgery :

• Pancreatectomy - hepatectomy

• Esophagectomy

• Major GI resections – debulking surgery

• .......

• ICU admission of postop patients with postop

complications after initial uneventful recovery

• Polytraumatised patients

• ...

Trials in perioperatieve nutritional support or ICU patients

– Variations nutritional status of included patients

– Different underlying pathology in malnourished patients

– Different types and length of nutritional support

– Type II statistical error

– “surgical patients “, “critically ill patients”, “GI cancer patients”,.....

How to make solid conclusions ?

Critically ill patients

Surgical patients

GI Cancer patients

ICU

Re

stin

g M

eta

bo

lic E

xpe

nd

iture

EBB fase FLOW fase / katabole fase Anabole fase

1dag 5-50 dagen

Perioperative Nutritional Support

Attempts to preserve lean body mass following a surgical or traumatic stress

Efforts to - attenuate the hypermetabolic response

- reverse loss of lean body mass

- prevent oxidant stress

- favourably modulate the immune response with early enteral feeding

- attain meticulous glycemic control

- administer appropriate macro- and micronutrients

Shift of goals !

Surgical ICU patients...

How to deal with complicated surgery or surgery with

complications ?

- Are they different from “medical” ICU patients and how different ?

- Intestinal surgery complicates the “compromised gut” in critically-ill

patients...

- Where is the moment of the complication in the timeline of post-

traumatic metabolism ?

Issues to discuss

1. When to start nutrition?

2. What route to use: EN or PN?

3. How much to give and what ?

4. Who is at special risk ?

1.Timing of nutrition

2. Protein content

3. Micro- & macronutrients

Questions

The rationale for nutrition in ICU patients

a cumulated energy deficit is associated

with a higher mortality and morbidity

Krishnan et al. Chest 2003

jw12

• Prospective observational study

• n = 2772 ICU patients of 167 ICU from 37 countries

• During 12d: recording of nutritional intake:

– 68%EN & 8% PN & 17,6% EN+PN & 5,4% nihil

• 60d mortality and ventilator free days

• BMI = nutritional status

• 59,2% of energy prescribed & 56% of protein prescribed

<20(n=289)

20-25(n=937)

25-30(n=818)

30-35(n=395)

35-40(n=162)

>40(n=171)

BMI

0

500

1000

1500

2000

2500kcal/24h

prescribed kcal

received kcal

Alberda, ICM 2009

Alberda, ICM 2009

jw12

• Average 1034kcal/d & 47g prot/day

• Conclusions:

– > 1000 kcal/d: significant decrease of mortality when BMI<25 and BMI >=35

– > 30g proteins significant decrease of mortality when BMI<25 and BMI >=35

Villet, Clin Nutr 2005;24:502

Cumulated energy deficit v. infections

Villet, Clin Nutr 2005;24:502

Increasing Caloric Debt is associated with worse outcome

Caloric debt :

Longer ICU stay Days on MV Complications Mortality

Adequacy of EN ?

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1 3 5 7 9 11 13 15 17 19 21

Days

kcal

Prescribed Engergy

Energy Received From Enteral Feed

Caloric Debt

Villet, Clin Nutr 2005;24:502

TEN or TPN on ICU ?

No evidence for a mortality difference between patients

randomised to either enteral or parenteral nutrition, but

there may be a morbidity difference

Indirect evidence

1. Malnutrition is dangerous

2. Energy deficit is dangerous

3. EN & PN carries equal mortality

NEJM 2011;365:506-17

totalinfections

airwayinfections

bloodinfections

woundinfections

0

10

20

30

frac

tio

n in

fecte

d (

%)

**

early PN

late PN

**

***

early PN late PN

0

20

40

60

80

100

fractio

n d

isch

arg

ed

aliv

e o

n d

ay 8

(%

)

**

Comments 1. Broad inclusion criteria

2. Overrepresentation of open hart surgery

3. High energy supply

4. High initial glucose supply

5. NO place for (dogmatic) protocol nutritional intervention

Lancet 2013;381:385-93

SPN 2012

Comments

1. Narrow inclusion criteria (10%)

2. MOF patients

3. Unorthodox primary endpoint

4. High energy supply (ESPEN Guidelines)

5. Indirect calorimetry (200-300 kcal lower)

JAMA 2013;309:2130-2138

Comments

1. Narrow inclusion criteria (27 units, 104 months)

2. Homogenous patient group

3. Pragmatic study

4. Not overfed

5. Result difficult to interpret

General conclusion on timing of PN supplementation

1. No mortality differences

2. No guidance which patients are at risk

3. Unclear if EE should be caloric target

4. Mechanistic studies rather than RCTs are needed

POSToperative nutritional support

Indication for TPN in patients with/who :

– Malnourished patients unable to have quick (48 h) adequate enteral nutrition

– Abnormal gut function

– Cannot consume adequate amounts of nutrients by enteral feeding

– Are anticipated to not be able to eat orally by 5-7 days

– Prognosis warrants aggressive nutritional support

= grade C

What about protein ? - wound repair

- muscle metabolism

-...

0 0.10 0.20 0.25 0.30

-100

-80

-60

-40

-20

0

Cu

mu

late

d n

itro

gen

bala

nce o

ver

1 w

(g

N)

daily nitrogen supply ( g/kg bw)

Larsson et al, Br J Surg 1990;77:413

Br J Surg 1990;77:413

jw12

• n = 113 mixed medical – surgical ICU patients

• 25-30 kcal/kg/d & 1.2-1.5g prot/kg/d until indirect calorimetry

• Indirect caloritmetry every day/2nd day (except WE)

• Daily N-balans (24h urea-N excretion + 2g+2g)

• EN within 24h + if needed PN

• Kcal from albumin, propofol included

• Patients were ranked in 3 groups according to protein/AA intake:

– Low (53,8g/d) – medium (84,3g/d) – high (114.9g/d)

Low – medium – high g prot/AA/kg/d

• Non-infectious complications occurred significantly earlier in the low prot/AA group

• Infectious complications: no sign diff in the time laps to the first infectious complication

• Variables predicting outcome:

• Age

• Apache II score

• Average SOFA

• Provision of prot/AA (persisted when corrected for these variables)

• Provision of energy, N- and energy-balance was not related to survival

Based on these results: 1,5g prot/AA /kg/d is recommended.

jw12 bFRANC Nov 30, 2012

Conclusions

1. Very poor evidence behind guidelines

2. A lot of religious beliefs out there

3. A modest attitude is recommended

4. Mechanistic studies are badly needed

?

?

?

From evidence to practice…

1. Optimize enteral feeding

2. Careful PN supplementation case-by-case

3. Avoid over- and underfeeding

4. Consider change of patient population profile

5. Optimize calculation of needs

6. Involve dietician on ICU

1. Optimize enteral nutrition

• Chirurgische plaatsing van sonde:

– Gastraal – meerdere lumen

– Jejunaal

• Prokinetica

• Maagresidu?

• Geconcentreerde sondevoeding?

2. PN supplementation

Weigh safety and benefits of PN initiation in patients not tolerating EN on an individual case-by-case basis - not dogmatic -

3. Avoid over- and underfeeding

4. Patient population is changing !

A. Baseline with expert developed bottom-down nutrition protocol

B. 3months after implementation of an interdisciplinary bottom up protocol

C. 1y later with dedicated ICU dietician

Thoughts & practise

• Respect ebb-phase / respect autophagy

• Respect surgical trauma metabolism

• Optimize EN from start

• If preop malnutrition : immediately EN+PN

but PN gradually (cave refeeding)

• Avoid deficit by liberal but careful PN addition with 4-5 days

(not dogmatic) target 25 Cal/kg

• Improve calculation of the needs : indirect calorimetry

• Target protein 1,2- 1,5 g/kg/d instead of calories

Take home message

1. Trials do not tell us the best moment of when

to supplement PN above EN

2. Trials do not tell us how and when to identify

the individual patient that will benefit most

from added calories

3. It is time for mechanistic studies

4. Individualize nutrition support