Rupinder Dhaliwal RD Executive Director Nutrition amp Rehabilitation Investigators Consortium Clinical Evaluation Research Unit Queens University Kingston Canada
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Slide1
The Prevalence of Iatrogenic Underfeeding in the Nutritionally ‘At-Risk’ Critically ill Patient
Rupinder Dhaliwal, RDExecutive Director Nutrition & Rehabilitation Investigators ConsortiumClinical Evaluation Research UnitQueen’s University, Kingston, Canada
Slide2Introduction
Critically ill patients receive only 50% prescribed energy and protein needsThis “underfeeding”, considered to be IATROGENIC, could lead to
adverse consequences
However, not all critically ill patients seemed to be harmed more as a
consequence of iatrogenic underfeeding
Caloric debt
Slide3Who benefits from nutrition therapy in in the ICU?
Slide4Multicenter observational study, 2772 patients
For every increase of 1000 calories per day reduction in overall 60-day mortality (p=0.014) increase in ventilator-free days (p=0.003)Beneficial treatment effect of increased calories was only observed in:BMI<25 and >35 no benefit in BMI 25-<35 group
Slide5
NUTrition Risk in the Critically ill Score (NUTRIC Score)severity of the underlying illnessthe degree of acute markers of inflammation and starvation indicesthe degree of chronic markers of inflammation and starvation indicesHelps discriminate which ICU patients will benefit more (or less) from aggressive protein-energy provision
NUTRIC score ≥ 6 (out of 10) may benefit the most from nutrition
therapy
Slide6Mechanically ventilated > 7 days
Underfeeding in pts mechanically ventilated >7 days WORSE outcomes!Energy deficit of ~1200 kcals/day is associated with an independent likelihood of ICU death (Faisy et al British J Nutrition 2009)Recent randomized trials
FAIL to show a difference in
the group that received the most calories (Casaer et al NEJM 2011,
Rice et al
Crit
Care Med 2011)
Why so? 1. BMI mid ranges2. Patients young, few
comorbidities, so low NUTRIC3. short stays in ICU (<5 days on average)
Slide7What is optimal nutrition?
Heyland DK Crit Care Med 2011Analyzed patients who were mechanically ventilated and in the ICU for 96 hrs or > Receiving up to 80% of their prescribed energy requirements is
associated with a reduced mortality (>80-85% no added effect)
We posit that nutritionally ‘at-risk’ pts should receive at least
80% prescribed needs
Focus on patients that stayed in the ICU ≥ 96 hrs
Slide8Objective
describe the prevalence of “Iatrogenic Underfeeding” (receiving < 80% prescribed energy and protein) in ICUs across different Geographic areas in ‘high risk’ patients subgroups (those with > 7 days of mechanical ventilation)body mass index (BMI) of <25 and >35 those with a NUTRIC score of >6 compared to low risk patients
to determine those ICU and hospital characteristics associated with optimal nutrition practice (lowest rates of iatrogenic underfeeding)
Slide9Methods
Analysis of data from May 11, 2011 prospective, multi-institutional audit193 ICUs in 29 countries collected data ~20 pts per ICU, ICU LOS at least 96 hrs3174 mechanically ventilated patients
Geographical regions
Sites were divided approximately by continent
Canada, US separate as many ICUs
Sites from countries or continents with too few sites to comprise a unique region were compared to similar region of practice
Mexico & South Africa
Slide10
Data Collection
For each patientpatient characteristics and ICU admission information baseline nutrition assessmentmethod of calculation (e.g. indirect calorimetry
, predictive equations)
total calories and protein prescribeddaily nutrition data for first 12 days or IC d/c whatever first
Route i.e. EN or PN
total calories and protein prescribed
patient outcomes
ICU and hospital discharge
and mortality.Duration of mechanical ventilation
web-based electronic data capture system
Slide11Statistical Approach
adequacy of total nutrition during the first 12 days in ICU% percent of caloric and protein prescriptions received from EN or PNSOFA score and IL-6 was dropped from the original NUTRIC score high vs. Low NUTRIC: according to median NUTRIC Score (i.e. patients with NUTRIC > median were classified as high risk subgroup)
multivariable analysis was performed
to examine the association between the prevalence of iatrogenic underfeeding repeated using three different sets of adjustments to account for# days in evaluation (first few days patients receive < 80%)
added covariates (ICU characteristics and patient characteristics)
simultaneously included high risk factors in addition to all covariates used
Slide12Results
Slide13Canada:
20 (20%)
USA: 45 (23%)
Australia & New Zealand:
39 (20%)
Europe and
South Africa
:
25 (13%)
Latin America:
24 (12%)
Asia:
41 (21%)
n = 193
ICUs, 29 countries, 3174 patients
Slide14ICU Characteristics
Characteristics
Total (n=193)
Hospital Type
Teaching
149 (77.2%)
Non-teaching
44 (22.8%)
Size of Hospital (beds)
Mean (Range)
633
[100- 2600]
ICU Structure
Open
49 (25.4%)
Closed
140 (72.5%)
Other
4 (2.1%)
Size of ICU (beds)
Mean (Range)
17.7 [5
- 65]
Designated Medical Director
182 (94.3%)
Presence of Dietitian(s)
153 (79.3%)
FTE Dietitians (per 10 beds)
Mean (Range)
0.4 [0
-3.3]
Slide15Total used in analysis
3174
patients from
193
ICUs
29
countries
2011 International Nutrition Survey
3747
patients from
193
ICUs
29
countries
573 Excluded from analysis
378
in ICU <96 hours
195
nutritional adequacy not
available for at least 4 days
1812
patients
> 7 days of mechanical ventilation
350
patients
with BMI ≥ 35
1533
patients
with BMI <25
1013
p
atients
with NUTRIC > 4
Results
Patient
Flow Diagram
Slide16Patient Characteristics
Total
Canada
Australia and NZ
USA
Europe and South Africa
Latin America
Asia
p values†
N
3174
361
602
670
416
442
683
Age (years)
mean
(SD)
60.3(17.8)
64.6(16.0)
58.2(17.8)
61.5(17.2)
58.8(17.1)
56.7(19.4)
62.0(17.7)
<0.001
Sex
Male
(%)
1884 (59.4%)
191 (52.9%)
365 (60.6%)
353 (52.7%)
260 (62.5%)
257 (58.1%)
458 (67.1%)
<0.001
Admission
Medical
2031 (64.0%)
260 (72.0%)
370 (61.5%)
474 (70.7%)
224 (53.8%)
284 (64.3%)
419 (61.3%)
0.01
Elective surgery
361 (11.4%)
35 (9.7%)
74 (12.3%)
53 (7.9%)
56 (13.5%)
28 (6.3%)
115 (16.8%)
Emergent surgery
782 (24.6%)
66 (18.3%)
158 (26.2%)
143 (21.3%)
136 (32.7%)
130 (29.4%)
149 (21.8%)
Weight (kg)
mean
(SD)
76.3(24.5)
78.2(24.2)
81.1(25.2)
86.3(31.9)
77.9( 20.2)
71.3(16.3)
63.6(14.4)
< 0.001
BMI
mean
(SD)
26.9(7.5)
27.8(7.6)
27.9(7.7)
29.8(9.9)
26.8(6.5)
25.9(5.1)
23.7(4.7)
< 0.001
APACHE
II
mean
(SD)
21.9(7.7)
23.7(7.1)
22.2(7.9)
22.4(7.4)
21.5(8.2)
19.9(7.1)
21.9(7.7)
0.06
NUTRIC
>4
161 (44.6%)
173 (28.7%)
230 (34.3%)
139 (33.4%)
107 (24.2%)
203 (29.7%)
0.002
NUTRIC
<=
4
200 (55.4%)
429 (71.3%)
440 (65.7%)
277 (66.6%)
335 (75.8%)
480 (70.3%)
Slide17Nutrition Outcomes (all patients)
Total
Canada
Australia and NZ
USA
Europe and South Africa
Latin America
Asia
p values†
N
3174
361
602
670
416
442
683
Prescribed
kcal/kg/day
Mean (SD)
24.1(5.5)
23.3 (5.3
)
25.5(5)
21.5 (6.2
)
24.6(5)
24. 5(4.6
)
25.4 (5.2
)
<0.001
Adequacy
of
calories
%
Mean (SD)
56
(30.6
)
63.4(27.3 )
59.5(27.7 )
47.8(27.2 )
54.4(30.3 )
53.4(27.9 )
59.8(37.2 )
<0.001
Adequacy of
protein
%
Mean (SD)
51.5(29.2 )
59.7(27.2 )
53.9(27.3 )
44.1(27.0 )
49.5(29.6
)
51.1(28.1 )
53.9(32.7 )
<0.001
Prevalence of iatrogenic underfeeding
2467 (77.7
%)
255 (70.6
%)
450 (
74.8%)
599 (89.4
%)
309 (74.3
%)
372 (
84.2%)
482 (70.6
%)
<0.001
Time
to initiate EN from ICU admission in hours
Mean
(SD)
41.7 (43.6)
37.0 (42.8)
32.6 (39.9)
52.3 (43.8)
39.5 (41.7)
48.6 (42.3)
39.2 (46.4)
<0.001
78% of patients failed to meet ≥ 80% of energy target
Slide18Nutrition Outcomes: vented > 7 days
Total
MV
>7 days
<
7days
Nutritional adequacy
% mean (SD
)
Adequacy of calories
56
(30.6
)
62.8 (29.0)**
47.1 (30.5)
Adequacy of
protein
51.5
(
29.2 )
58.0 (27.7)**
42.9 (29.1)
Time to initiate EN from ICU admission in hours
Mean (SD)
41.7 (43.6 )
44.1 (46.9 )**
38.3 (38.0)
Prevalence of iatrogenic underfeeding
N (%)
2467 (77.7%)
1295 (71.5%)**
1172 (86.1%)
> 7 d mechanical ventilation
Better calorie adequacy
Better protein adequacy
Longer to start EN
Lower prevalence underfeeding
(all values p<0.01)
Slide19BMI ≥ 35 vs. 25-34
Better calorie adequacy (p 0.01-0.05)No differenceNo differenceNo difference
Nutrition Outcomes (BMI)
Total
BMI
<25
25-34
≥35
Nutritional adequacy
% mean (SD
)
Adequacy of calories
56
(30.6
)
57.8 (32.4)**
54.0 (28.7)
55.6 (29.6)*
Adequacy of
protein
51.5
(
29.2 )
53.5 (30.2)**
50.1 (28.3)
47.9 (27.7)
Time to initiate EN from ICU admission in hours
Mean (SD)
41.7 (43.6 )
38.6
(
41.0 )**
44.8 (45.6)
44.4 (46.2)
Prevalence of iatrogenic underfeeding
N (%)
2467 (77.7%)
1136 (74.1%)**
1058 (82.0%)
273 (78.0%)
BMI < 25 vs. 25-34
Better calorie adequacy
Better protein adequacy
Shorter time to EN
Lower prevalence underfeeding
all values p<0.01
Slide20Nutrition Outcomes (NUTRIC score)
Total
NUTRIC score
>4
<
4
Nutritional adequacy
% mean (SD
)
Adequacy of calories
56
(30.6
)
55.3 (29.8)
56.4 (31.0)
Adequacy of
protein
51.5
(
29.2 )
51.3 (29.1)
51.2 (29.3
)
Time to initiate EN from ICU admission in hours
Mean (SD)
41.7 (43.6 )
43.6 (45.0)
40.8 (42.9)
Prevalence of iatrogenic underfeeding
N (%)
2467 (77.7%)
788 (77.8%)
1679 (77.7%)
NUTRIC Score > 4
No difference
No difference
No difference
No difference
Slide21
Adjusting for number of days included in nutrition assessment
Adjusting for all covariates* but not other risk factors of interest
Adjusting for all covariates* and other risk factors of interest.
Risk Factors of Interest
OR (95% CI)
p-value
OR (95% CI)
p-value
OR (95% CI)
p-value
MV> 7 days (vs. MV ≤ 7 days)
0.67 (0.50-0.90)
0.0077
0.69 (0.51-0.93)
0.016
0.68
(
0.51-0.92)
0.013
BMI < 25 (vs. BMI between 25 and 35)
0.65 (0.54-0.80)
<0.0001
0.67 (0.54-0.83)
0.0002
0.66
(
0.54-0.82)
0.0001
BMI > 35 (vs. BMI between 25 and 35)
0.64 (0.49-0.84)
0.0014
0.64 (0.47-0.86)
0.0036
0.64
(
0.47-0.86)
0.0038
NUTRIC > 4 (vs. NUTRIC ≤ 4)
1.06 (0.88-1.27)
0.55
1.02 (0.78-1.35)
0.86
1.04
(
0.79-1.38)
0.75
Multivariate analysis
(
odds of receiving <80% of prescription)
being mechanically ventilated for more than 7 days
having a BMI <25 and
having a BMI ≥35 were all associated with about a one third
reduction
in the odds of receiving <80% of energy prescription
Slide22Conclusions
Worldwide, the majority of critically ill patients fail to receive adequate nutritional intake This rate of failure varies across geographic regionsHigh risk patients are less likely to be underfed than low risk patients but still experience significant underfeeding
Slide23Acknowledgements
Daren K. Heyland MD, MSc Lauren Murch MScXuran Jiang MSc Andrew G. Day MSc Clinical Evaluation Research Unit, Kingston General Hospital
Department of Community Health and Epidemiology, Queen’s University
Department of Medicine, Queen’s UniversityKingston, ON, Canada
Slide24References
Alberda C, Gramlich L, Jones NE, Jeejeebhoy K, Day A, Dhaliwal R, Heyland DK. The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observation study. Intensive Care Med 2009;35(10):1728-37. Faisy C, Lerolle N,
Dachraoui F,
Savard JF, About I, Tadie JM, Fagon JY. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. British J Nutrition 2009;101:1079-1087.
Heyland
DK, Dhaliwal R, Jiang X, Day A. Quantifying nutrition risk in the critically ill patient: The development and initial validation of a novel risk assessment tool. Critical Care 2011
Casaer
MP,
Mesotten D, Hermans G, et al. Early versus late parenteral
nutrition in critically ill adults. N Engl J Med 2011;June 29 (
epub).
Rice T, Morgan S, Hays MA, Bernard GR, Jensen GL, Wheeler AP. Randomized trial of initial trophic versus full-energy nutrition in mechanically ventilated patients with acute respiratory failure. Crit
Care Med 2011;39;967-974.
Heyland
DK, Cahill N, Day A. Optimal amount of calories for critically ill patients: Depends on how you slice the cake!
Crit
Care Med 2011 Jun 23 (
epub
).
Slide25
Questions?