1、Daren K. Heyland Professor of Medicine Queens University, Kingston General Hospital Kingston, ON Canada,Second Generation Enteral Nutrition Feeding Protocols:Taking us the the next level of performance,Mr CD 47 renal transplant Severe CAP Septic shock, ARDS, MODs Requires vasopressors for days Day 3
2、- trickle feeds (20 cc/hr) Feeds on and off again for whole first week Nurses notes gastric residual volume of 60cc Ask resident what to do Resident says wait till rounds,Case Scenario,Cahill N Crit Care Med 2010 (in press),In patients with high gastric residual volumes: use of motility agents 58.7%
3、 (site average range: 0-100%) use of small bowel feeding 14.7% (range: 0-100%),Cahill NE CCM 2010 (in press),Average time to start of EN was 46.5 hours(site average range: 8.2-149.1 hours),Consequences of Iatrogenic Malnutrition, Caloric debt associated with: Longer ICU stay Days on mechanical venti
4、lation Complications Mortality,Adequacy of EN,Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Alberda ICM 2009,Adequacy of EN,RCT Level of Evidence that More EN= Improved Outcomes,RCTs of aggressive feeding protocols Results in better protein-energy intake Associated with reduced comp
5、lications and improved survival,Taylor et al Crit Care Med 1999; Martin CMAJ 2004,Meta-analysis of Early vs Delayed EN Reduced infections: RR 0.76 (.59,0.98),p=0.04 Reduced Mortality: RR 0.68 (0.46, 1.01) p=0.06,,More is Better!,Our Field of Dream,If you feed them (better!) They will leave (sooner!)
6、,,Updated January 2009Summarizes 191 trials studying 15000 patients 34 topics 18 recommendations,,“Use of a feeding protocol that incorporates motility agents and small bowel feeding tubes should be considered”,The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a multi
7、center observational study,International, prospective, observational, cohort studies conducted in 2007 and 2008 from 269 Intensive Care Units (ICUs) in 28 countries Included 5497 mechanically ventilated adult patients 3 days in ICU Sites recorded the presence or absence of a feeding protocol Sites p
8、rovided nutritional data on enrolled patients from ICU admission to ICU discharge for a max of 12 days.,Heyland JPEN 2010 ( in press),The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a multicenter observational study,Heyland JPEN 2010 ( in press),The Impact of Entera
9、l Feeding Protocols on Enteral Nutrition Delivery: Results of a multicenter observational study,Time to start EN from ICU admission 41.2 in protocolized sites vs 57.1 hours in those without a protocol Patients recing motility agents 61.3% in protocolized sites vs 49.0% in those without,Heyland JPEN
10、2010 ( in press),P0.05,P0.05,Does One Size Fit All?,Resuscitation is the priority No sense in feeding someone dying of progressive circulatory failure However, if on stable or declining doses of vasopressors:,What About Feeding the Hypotensive Patient?,Purcell Am J Surg 1993;165:188,Dog Model with I
11、V oleic acid lung injury,9 patients day 1 Post-op following CPB requiring inotropes and vasopressors Feed enterally; metabolic response consistent with substrates being utilized,Prospectively collected multi-institutional medical intensive care unit (ICU) database. 1,174 patients were identified who
12、 required mechanical ventilation for more than two days and were placed on vasopressor agents to support blood pressure. Patients divided according to whether or not they received enteral nutrition within 48 hours of mechanical ventilation onset. 707 patients (60%) who did were labeled as the “early
13、 enteral nutrition group” and the remaining 467 patients (40%) were labeled as “late enteral nutrition group”. The primary endpoints were overall ICU and hospital mortality. Data also analyzed after controlling for confounding by matching for propensity score,Feeding the Hypotensive Patient?,DiGiovi
14、ne et al. AJCC 2009 (in press),Feeding the Hypotensive Patient?,DiGiovine et al. AJCC 2009 (in press),The beneficial effect of early feeding is more evident in the sickest patients, i.e, those on multiple vasopressor agents.,“Trophic Feeds”,Progressive atrophy of villous height and Crypt depth in ab
15、sence of ENLeads to increased permeability and decreased IgA secretion Can be preserved by a minimum of 10-15% of goal calories. Observational study of xx critically ill patients suggests TPN+trophic feeds associated with reduced infection and mortality compared to TPN alone,A= No EN; B = 100% EN,Oh
16、ta Am J Surgery 2003;185:79-85,Marik Crit Care 5:1-10,Initial Efficacy and Tolerability of Early Enteral Nutrition with Immediate or Gradual Introduction in Intubated Patients,Desachy ICM 2008;34:1054,This study randomized 100 mechanically ventilated patients (not in shock) to Immediate goal rate vs
17、 gradual ramp up (our usual standard).The immediate goal group recd more calories with no increase in complications,Daren K. Heyland Professor of Medicine Queens University, Kingston General Hospital Kingston, ON Canada,Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Criticall
18、y Ill Patients: The PEP uP ProtocolA Single center feasibility trial,Not all critically ill patients are the same; we have different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds. In select patients, we start the EN immediately at goal rate, not at
19、 25 ml/hr. We target a 24 hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume. Tolerate higher GRV threshold (250 ml or more) Motility agents and protein supplements are started immediately, rather than starte
20、d when there is a problem.,The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!,A Major Paradigm Shift in How we Feed Enterally,Begin 24 hour volume-based feeds. After initital tube placement confirmed, start Pepatmen 1.5. Totlal vo
21、lume to receive in 24 hours is 17ml x weight (kg)= . Determine initial rate as per Volume Based Feeding Schedule. Monitor gastric residual volumes as per Adult Gastric Flow Chart and Volume Based Feeding Schedule.ORBegin Peptamen 1.5 at 10 mL/h after initial tube placement confirmed. Hold if gastric
22、 residual volume 500 ml and ask Doctor to reassess. Reassess ability to transition to 24 hour volume-based feeds next day. Intended for patient who is hemodynamically unstable (on high dose or escalating doses of vasopressors, or inadequately resuscitated) or not suitable for high volume enteral fee
23、ding (ruptured AAA, upper intestinal anastomosis, or impending intubation) ORNPO. Please write in reason: _ _. (only if contraindication to EN present: bowel perforation, bowel obstruction, proximal high output fistula. Recent operation and high NG output not a contraindication to EN.) Reassess abil
24、ity to transition to 24 hour volume-based feeds next day.,The PEP uP Protocol,Note indications for trophic feeds,Rather than hourly goal rate, we changed to a 24 hour volume-based goal Nurse has responsibility to administer than volume over the 24 period with the following guidelines:,Order for volu
25、me based enteral feeding will be total volume goal for 24 hours. 24 hour period goes from 7 am to 7 am each day. If the total volume ordered is 1800 mL the hourly amount to feed is 75 mL/hour. If patient was fed 450 mL of feeding (6 hours) and the tube feeding is on “hold” for 5 hours, then subtract
26、 from goal volume the amount of feeding patient has already received. Volume Ordered per 24 hours 1800 mL Tube feeding in (current day) 450 = Volume of feeding remaining in day to feed. 1800- 450= 1350 mL remaining to feed Patient now has 13 hours left in the day to receive 1350 mL of tube feeding.
27、Divide remaining volume over remaining hours (1350ml/13 hrs) to determine new hourly goal rate Round up so new rate would be 105 ml/hr for 13 hours. The following day, at shift change, the rate drops back to 75 ml/hour. A chart is provided to help with the calculations,As a consequence, our bedside
28、feeding algorithm has changed.,Adult ICU Gastric Feeding Flow Chart,No,Its not just about calories.,Protein supplement Beneprotein 14 grams mixed in 120 mls sterile water administered bid via NG,So in order to minimize this, we order:,Aggressive feeding in patients who havent been eating much or in
29、skinny patients, may cause problems with electrolyte and Phos balance.,Thats why we check the lytes, Phos, Mg and Ca at least twice a day for the first 3 days, and then if no problem, back to usual ICU blood work. If there are problems then at rate of feeding needs to be decreased or not accelerated
30、 until the lytes etc. are corrected.,Potential for refeeding syndrome,Other Strategies to Maximize the Benefits and Minimize the Risks of EN,Head of Bed elevation to 45 (or at least 30 if the patient doesnt tolerate 45) This will reduce regurgitation, aspiration and subsequent Pneumonia,List of Cont
31、raindications to HOB Elevation,unstable c-spinehemodynamically unstablePelvic fractures with instability Prone position Intra-aortic ballon pump Procedures Unable because of obesity,Other Strategies to Maximize the Benefits and Minimize the Risks of EN,Motility agents started at initiation of EN rat
32、her that waiting till problems with High GRV develop. Maxeran 10 mg IV q 6h (halved in renal failure) If still develops high gastric residuals, add Erythromycin 200 mg q 12h. Can be used together for up to 7 days but should be discontinued when not needed any more Reassess need for motility agents d
33、aily,Other Strategies to Maximize the Benefits and Minimize the Risks of EN,If intragastric feeds not tolerated, problems with high GRVs refractory to motility agents, we recommend small bowel feeding tube,Hey Dr.can we get that small bowel tube in place so I can get their volume of EN in asap!,They
34、 may need a gentle reminder to get the small bowel feeding tube in place,A Change to Nursing Report,Adequacy of Nutrition Support =24 hour volume of EN receivedVolume prescribed to meet caloric requirements in 24 hours,Please report this % on rounds as part of the GI systems report,Evaluation Plan,P
35、urpose: to evaluate the safety and acceptibility of this new protocol Before (n=20) and after (n=30) study Consecutive eligible mechanically ventilated patients 3days Compared nutritional outcomes At the end of each nursing shift, will ask the nurse the following 4 questions:,Evaluation Questions,We
36、re you exposed to the educational interventions and if so, how useful did you find them? Did you encounter any situation or event that in your opinion, compromised the patients safety? Overall, how acceptable was this new protocol (1-totally unacceptable; 10- totally acceptable) Any suggestions for
37、improving the protocol?,RESULTS,Nurses Ratings of Acceptability,1=totally unacceptable and 10=totally acceptable,No adverse events noted by Nurses,Results,The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!,Heyland (in submission),
38、Effect on Caloric Adequacy,The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!,Heyland (in submission),Effect on Protein Adequacy,Conclusions,Significant iatrogenic malnutrition occurs worldwide. In an attempt to maximize EN safely, feeding protocols should be part of standard of care Through optimization of different aspects of the standard feeding protocol, we can further optimize EN delivery The PEP uP protocol is acceptable and safe and warrants further investigation,