(BQ) Part 1 book Nutrition support for the critically ill presents the following contents: An introduction to malnutrition in the intensive care unit, the immunological role of nutrition in the gut, assessment of the patient, timing and indications for enteral nutrition in the critically ill,...
Nutrition and Health Series Editor: Adrianne Bendich David S Seres Charles W Van Way, III Editors Nutrition Support for the Critically NUTRITION AND HEALTH Adrianne Bendich, PhD, FASN, FACN, Series Editor More information about this series at http://www.springer.com/series/7659 David S Seres • Charles W Van Way, III Editors Nutrition Support for the Critically Ill Editors David S Seres, MD, ScM, PNS Director of Medical Nutrition Associate Professor of Medicine in the Institute of Human Nutrition Department of Medicine Columbia University Medical Center New York, NY, USA Charles W Van Way, III, MD, FACS, FCCM, FCCP, FASPEN Emeritus Professor of Surgery Truman Medical Center Department of Surgery University of Missouri, Kansas City, School of Medicine Kansas City, MO, USA Nutrition and Health ISBN 978-3-319-21830-4 ISBN 978-3-319-21831-1 DOI 10.1007/978-3-319-21831-1 (eBook) Library of Congress Control Number: 2015952015 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2016 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper Humana Press is a brand of Springer Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com) Dedications To our patients, our students and trainees, and our colleagues And to our wives, Kesiah E Scully and Gail E Van Way, without whose love, support, and encouragement this work, and all we do, would not be possible Foreword Nutritional support in the critically ill patient is like mother’s milk, right? Indeed, there was a time, long ago and on a planet far away, when we felt we knew all the answers to feeding the critically ill At the end of the 1970s, when I was undertaking my Fellowship in Critical Care Medicine, it was assumed that total parenteral nutrition (TPN) would ultimately take care of our sick patients’ needs To underscore the naivety of this concept, soon after my graduation as a neophyte intensivist at a major university medical center, I was appointed Chair of the Hospital TPN Committee A classic case of the blind leading the blind! Today, the world of nutritional support of the critically ill patient is not only far more complex but also more discouraging, because we now realize how little we know As acute care physicians and surgeons, we continually search for evidence-based justification of our physiologically based theories In the field of nutrition, however, we are likely to be overwhelmed by an increasing array of large randomized control trials (RCTs) that are often mutually contradictory, not provide answers, and simply raise more questions Moreover, the practitioner is likely to be completely overwhelmed by an extraordinary jungle of mnemonics that at last count included TICACOS, EDEN, OMEGA, REGANE, NUTRIREA 1, EPaNIC, SPN, SIGNET, REDOXS, among others.1 And at the end of an extensive review of all the aforementioned RCTs in the New England Journal of Medicine, Casear and van den Bergh conclude, “These new insights limit the number of nutritional interventions that can be confidently recommended for daily critical care practice” [1] Many are the questions that remain to be definitively answered regarding nutritional intervention in the critically ill Should we attempt to assess nutritional status in preoperative patients undergoing major surgery (an opportunity that is obviously lacking in patients admitted to medical intensive care unit or after acute trauma)? Should we attempt to provide full feeding within the first 24 h of acute illness, trauma, or surgery? If yes, should we supplement enteral with parenteral nutrition? If no, is it A Neophyte’s Guide to Mnemonics in Nutritional RCTs: TICACOS, The Tight Caloric Control Study; EDEN, Trophic vs Full-Energy Enteral Nutrition in Mechanically Ventilated Patients with Acute Lung Injury; OMEGA, The Effect of Highly Purified Omega-3 Fatty Acids on Top of Modern Guideline-Adjusted Therapy after Myocardial Infarction; REGANE, The Gastric Residual Volume During Enteral Nutrition in ICU Patients; NUTRIREA 1, The Effect of Not Monitoring Residual Gastric Volume on the Risk of Ventilator-Associated Pneumonia In Adults Receiving Mechanical Ventilation and Early Enteral Feeding; EPaNIC, The Impact of Early Parenteral Nutrition Complementing Enteral Nutrition In Adult Critically Ill Patients; SPN, The Impact of Supplemental Parenteral Nutrition on Infection Rate, Duration of Mechanical Ventilation, and Rehabilitation in ICU Patients; EPN, Early Parenteral Nutrition; SIGNET, Scottish Intensive Care Glutamine or Selenium Evaluative Trial; REDOXS, Reducing Deaths Due to Oxidative Stress vii viii Foreword okay to allow hypocaloric enteral feedings for the first days of acute illness or injury? Should we provide prokinetic agents or postpyloric feeding to avoid aspiration? Should we perform daily indirect calorimetry to assess caloric need during different phases of acute illness? How we assess when the patient may be ready to transition from hypocaloric to full supplementation to reverse their accumulated nutritional deficit? Are there “magic bullets” that will enhance the success of nutritional support, such as glutamine, arginine, anti-inflammatory fatty acids, micronutrients, trace elements, fat-soluble vitamins or antioxidants such as selenium? In Nutrition Support for the Critically Ill, David Seres and Charles Van Way and their colleagues provide a state-of-the-art resource to address the physiology, pharmacology, and evidence basis underlying these questions This all-encompassing text addresses every conceivable aspect of nutritional support for the critically ill patient Cogent chapters address the pathogenesis, impact, and assessment of malnutrition in the acutely ill patient; the vital role of gut endothelium and the microbiome in the immunologic response to stress and trauma; and the timing, indications, and access for enteral and/or parenteral nutrition in the critically ill There are chapters that address nutritional support in specific situations, such as the patient admitted to a surgical intensive care unit following major trauma or surgery; the patient with severe sepsis; the patient who has developed single or multiple organ failure; or the patient with obesity Even the ethical stone is turned, in a thoughtful consideration of whether nutritional support should be discontinued when aggressive life-prolonging interventions are futile Practical considerations are not ignored either There is emphasis on safe practice in enteral and parenteral nutrition; the economic impact of nutritional support; and the importance of a multidisciplinary approach to enhance patient management and outcome In a perfectly timed denouement, Drs Seres and Van Way posit the many questions that remain to be fully answered by future research Not surprisingly, these are questions that we have been asking for many years Are there reliable markers of malnutrition and its impact on the systemic response to acute injury and sepsis? What are the important biologic interactions between the patient’s nutritional status and their immunologic response to acute illness or injury? How will we settle the great areas of controversy that remain with regard to the timing and nature of nutritional support in the acute phase of illness, especially in the face of accelerated metabolism? When does the benefit of parenteral nutrition outweigh its potential computations? Today, in-depth training in nutritional support appears to have been confined to a tiny cul de sac in the critical care curriculum of our students, residents, and fellows We are focused on all the exciting aspects of acute care, such as invasive monitoring and inotropic agents, the latest cure for acute respiratory distress syndrome, or increasingly miniaturized mechanical circulatory support systems Unfortunately, this is achieved to the detriment of our understanding of the physiology, pharmacology, and evidence basis for nutritional support As long as a feeding tube is in place and enteral feeds are started, we’re okay, right? If not, we’ll get a nutritional consult—at our institution, Dr Seres, of course! I am convinced that this remarkable textbook will go a long way to restore the rightful place of nutritional support as an integral component of our daily management, right up there with our shortterm focus on hemodynamics, antibacterial therapy, and organ system support Nutrition Support for the Critically Ill re-emphasizes the inestimable role that appropriate nutrition plays in long-term outcome in the critically ill It enhances our knowledge and understanding of the current concepts in this essential aspect of intensive care As such, it should be required reading for every intensivist There should be no excuse that “there’s no way that I can digest such a big textbook” (so to speak) Nutrition Support for the Critically Ill has a modular approach that allows the reader to focus on individual Foreword ix aspects of the theoretic, empiric, evidence-based, and practical considerations that should guide our approach today As such, Drs Seres and van Way and their collaborators should be lauded on their timely and much-needed contribution to the nutritional support—and overall care—of our critically ill patients And I am honored to have been asked to be their flag-bearer! Division of Critical Care, Department of Anesthesiology, PH 527-B, CTICU and SICU, College of Physicians & Surgeons of Columbia University, 630 West 168th Street, New York, NY 10032, USA Robert N Sladen, MBChB, FCCM rs543@cumc.columbia.edu Reference Casaer MP, Van den Berghe G Nutrition in the acute phase of critical illness N Engl J Med 2014;370:1227–36 Timing and Indication for Parenteral Nutrition in the Critically Ill 83 The early administration of supplemental PN, as advocated by European guidelines, was intended to prevent the accumulation of caloric and protein deficit Indeed, buildup of such a deficit has been associated with adverse outcome in several large observations In an international multicenter observational analysis, every 1000 kcal increase in average daily energy intake was associated with a shorter duration of mechanical ventilation and a 25 % relative reduction in 60 days mortality [9] Likewise, the incidence of new infections was found to be lower in patients with a lower energy debt [11] However, the observational nature of these studies precludes an estimation whether these associations were causal or casual Indeed, the adequacy of feeding, especially the adequacy of EN, depends on the severity of illness The buildup of a caloric deficit may to some extent reflect a higher disease severity rather than being detrimental by itself Moreover, a number of observational analyses of the relation between nutrient intake and outcome were flawed by time bias and/or informative censoring [12] A reliable estimation of the impact of early, full nutritional support including early administration of supplemental parenteral nutrition requires an adequately powered methodologically sound randomized controlled trial [13, 14] In contrast to the European guidelines, the American guidelines recommended withholding parenteral nutrition until week after ICU admission This policy allows accumulation of energy deficit in a considerable number of patients, as EN is often insufficient to meet the caloric requirements, especially in the acute phase of illness In the absence of RCTs, this approach was justifiable Compared with EN, administration of PN has been associated with an increased risk of complications, such as hyperglycemia, infectious complications and hyperbilirubinemia Theoretically, administration of supplemental PN could offset potential benefits of more energy and protein delivery with increased complications Another factor contributing to the difference in the American versus the European approach with regard to timing of supplemental PN may have been the long-standing unavailability of newer PN preparations containing less inflammatory lipids in the USA Indeed, for decades, only soybean oil based preparations were approved by the American Food and Drug Administration (FDA) The feared delayed hypersensitivity reactions reported with the cottonseed oil emulsions of the early 1960s are very uncommon with soybean oil-based preparations [15] In any case, the clinical superiority of different lipid compositions in PN remains to be established [16] In summary, an important discrepancy between European and American PN practices has existed for decades Recently, both strategies have been compared in several high quality randomized controlled trials [17–19] In the following section we will provide a balanced overview of the published RCTs in order to put the results in a broader perspective Results from Recent RCTs Studying the Time of PN Initiation in the ICU Over the last years, three (large) RCTs have studied the timing of supplemental parenteral nutrition, the EPaNIC, SPN and Early PN trial respectively The study design varied among the different studies, with different inclusion criteria and different interventions started at different time points in the first week of critical illness (Fig 6.1) These three trials, altogether involving more than 6000 patients, unequivocally showed that early administration of supplemental PN did not have a clinical benefit Moreover, one RCT, the EPaNIC study, even showed net harm by early administration of supplemental PN The most recent RCT, the Australian Early PN trial (see Fig 6.1), studied the initiation of supplemental parenteral nutrition very early in the disease course, within a few hours after ICU admission, in patients with a relative and rather short—48 h—contraindication for enteral nutrition [18] The nutrition 84 J Gunst and M.P Casaer Total energy (Kcal) 2500 Early PN (n = 2312) Late PN (n = 2328) Early PN (n = 686) Standard (n = 686) Full (n = 492) Trophic (n = 508) SPN (n = 153) EN only (n = 152) REE (n = 65) Calculated (n = 65) 2000 1500 1000 500 ICU day EDEN trial Medical (ALI) Patients 7 7 Early PN trial EPaNIC trial SPN trial Mixed medical/surgical Mixed medical/surgical (unselected) With nutritional risk (NRS≥3) Mixed medical/surgical (on day 4) Eligible for EN but