Bridging the Guideline-Practice Gap:
The Critical Care Experience
Rupinder Dhaliwal, RD
Daren Heyland, MD
Guidelines for Nutrition
Therapy in the ICU
Rupinder Dhaliwal, RD
Operations Manager
Clinical Evaluation Research Unit
Kingston, Ontario
Disclosure
Rupinder Dhaliwal
Canadian Clinical Practice Guidelines for Nutrition
Support for the Mechanically Ventilated Critically ill
• Co-Author
Critical Care Nutrition
The right nutrient/nutritional strategy
The right timing
The right patient
The right intensity (dose/duration)
With the right outcome!
www.criticalcarenutrition.com
www.criticalcarenutrition.com
A Continuous Quality Improvement Effort
What ought to be done?
RCTs, Systematic Reviews, and
Evidence-based practice guidelines
How to change?
What
done?
What isis
done?
www.criticalcarenutrition.com
“KT strategies”
Survey results
What do we need to do differently?
“Gaps” - site reports
Objectives
To identify the similarities and the differences between
the recommendations of three North American Clinical
Practice Guidelines
Understand why these differences occur
Need for harmonization across guidelines
Why bother with guidelines?
Clinical practice guidelines are
“systematically developed statements to assist practitioner and
patient decisions about appropriate health care for specific clinical
circumstances.”
Best available evidence with integration of potential benefits,
harm, feasibility, cost
Reduce variability in care, improve quality, reduce costs and can
improve outcomes
Proliferation of guidelines
The more guidelines they
publish, the more confused I get!
Review of guidelines needed
Assesses the process
of development
A review of the content and the
evidence used to formulate the
recommendations
Which Guidelines to compare?
 Critically ill populations
 Developed by North American professional/national organization
 Published/online 1999-2009
 Addressed more than one single topic
 Were not consensus statements (i.e. immunonutrition )
 Were original work vs. part of cluster RCTs
North American Guidelines
www.criticalcarenutrition.com
What differences?
• Population
• Levels of Evidence
• Grading used
• Time frames, outcomes
• Level of transparency between evidence and
recommendation
Differences
Area
Canadian
ADA
ASPEN/SCCM
Population
Mechanically ventilated
critically ill patients
Critically ill patients
eligible for EN
Medical and surgical
critically ill patients
no elective surgery
no burns
expected to stay in the
ICU > 2-3 days
RCTs, meta analyses
All levels of evidence
All levels of evidence
Level 1 or 2 based on
validity of evidence
Grade 1-5 based on
validity of evidence
Minimum n>20
Level 1-5 based on
validity of evidence
Level of
evidence
Time Frame
1980-2009
1993-2003
1993-2009
1996-2006 (2009)
unclear
Outcomes
clinical outcomes
clinical and non
clinical outcomes
clinical and non
clinical outcomes
Grading
Canadian
ADA
ASPEN/SCCM
(5%)
“Strong”
benefits exceed harm
high quality evidence
anticipated benefits
(41%)
“A”
supported by at least
2 Level 1
(RCT n > 100)
(3%)
“Recommend”
supportive evidence but
minor uncertainties re:
safety/feasibility or costs
“Fair”
Same as above but
quality of evidence is
not as strong
“B”
supported by 1 level 1
“Should be considered”
Evidence was weak or
major uncertainties re:
safety/cost/feasibility
“Weak”
Suspect quality of
evidence
little clear benefit
“C”
Level 2 (RCTs <100)
“Insufficient data”
Inadequate data or
conflicting evidence
(51%)
“Consensus”
Expert opinion
“D”
At least 2 Level 3
(non RCT,
contemporaneous
controls)
“Insufficient evidence”
No pertinent evidence
and harm/risk is ?
(37%)
“E”
Level 4 (non RCT,
historical controls)
Level 5 (case series),
expert opinion (39%)
Strongest “Strongly recommend”
no reservations re:
endorsement
Weakest
Criteria High Quality CPGs
Rigor of development:
– Provide detailed information on the search strategy, the
inclusion/exclusion criteria, and methods used to formulate the
recommendation (reproducible).
Transparent link between evidence, values, and resulting
recommendation
– External review
– Procedure for updating the CPG
AGREE Qual Saf Health Care 2003;12:18
Integration of values
evidence
+
practice
guidelines
integration of values
Validity
Homogeneity
Safety
Feasibility
Cost
Differences: recommendations
Indirect calorimetry vs. predictive equations
Canadian
ADA
ASPEN/SCCM
Insufficient data
Strong
Grade E
Use indirect
calorimetry
Use either, caution
with equations
Non RCTs, no clinical
outcomes
Narrative review
article
1 small RCT burn patients
Differences: recommendations
Dose of EN/Achieving target range
Canadian
ADA
ASPEN/SCCM
Should be considered
Fair
Grade C
Use strategies to optimize
EN i.e. goal rate start,
250 mls GRVs, m. agents,
small bowel feeding
Give at least 60-70%
energy within first
week
Provide >50-65% goal
calories in first week
Specifics for Obese
(Grade E and D)
No threshold
1 RCT and 2 Cluster RCTs
2 RCTs and 2 non
RCTs
1 RCT and 1 non RCT
Differences: recommendations
Gastric Residual Volumes & Motility agents
GRVs
Canadian
ADA
ASPEN/SCCM
Should be
considered
250 mls
Consensus
Grade B
250 mls
500 mls
1 RCT and 2 Cluster
RCTs
Motility agents
Recommend
metoclopromide
4 RCTs
Strong
metoclopromide
Grade C
Metoclopromide
Erythromycin
Opiod
antagonists
Differences: recommendations
Arginine
Canadian
ADA
ASPEN/SCCM
Recommend
NOT be used
Fair
Not be used
Grade A Surgical
Grade B Medical
Cautious in severe sepsis
Volume use 50-65% goal
Meta-analyses of 22 RCTs
3 RCTs harm
(Bower. Bertolini, Dent)
11 RCTs
2 RCTS harm
(Bower, Bertolini)
earlier meta-analyses showing
no benefit
RCT showing benefit (Galban)
Grade A: based on elective
surgery patients
Differences: recommendations
Enteral Glutamine
Canadian
Burns & Trauma:
ADA
ASPEN/SCCM
--------
Grade B
Should be considered
Other ICU:
Insufficient data
9 RCTS
Burns, Trauma
and mixed ICU
patients
1 RCT (Jones
mixed ICU pts)
Differences: recommendations
Peptides
Canadian
Recommend
polymeric (since no
benefit for peptides)
4 RCTs
ADA
ASPEN/SCCM
---------
Grade E
Use small peptides in
diarrhea
1 non RCT
Differences: recommendations
Fibre
Canadian
ADA
ASPEN/SCCM
Insufficient data
---------
Grade E
Use soluble fibre
3 RCTs
6 RCTs
Grade C
Avoid soluble and insoluble fibre
for bowel ischemia/severe
dysmotility
2 non RCTs (review, case study)
Differences: recommendations
Probiotics
Canadian
ADA
ASPEN/SCCM
Insufficient data
--------No benefit in outcomes,
potential for harm
Grade C
Use in transplant,
major abd surgery,
severe trauma
Not in necrotizing
pancreatitis
12 RCTs
5 RCTs (elective sx)
Differences: recommendations
Intensive Insulin Therapy
Canadian
ADA
ASPEN/SCCM
Recommend
Target around 144 mg/dl
(8.0 mmol/L)
Strong
Medical: 80-110 mg/dL
(4.4-6.1 mmol/L)
Grade B
Moderate strict
control
Range 120-160 mg/dL
(7-9 mmol/L)
Grade E
BEING UPDATED 2009 110-150 mg/dL
(6.1-8.3 mmol/L)
Keep < 180 mg/dL
(10 mmol/L) in all
Most recent metaanalyses includes NICE
SUGAR
Similarities?
Topic
Canadian
ADA
ASPEN/SCCM
Use of EN over PN



Start EN within 24-48 hr



EN Fish Oils

-----

Insufficient
-----
Insufficient
 (45)
 (45)



CHO/Fat
Body position
Small bowel vs. gastric
ADOPT
NOW!

Continuous vs. other
insufficient
----
High risk (D)
PN vs std care
Not be used
----
Not for 7 days
No soy based
----
No soy based
PN Glutamine

----

Low dose of PN

----

AOX/vits/minerals

----

Type of IV lipids
Slight difference in strength
Enteral Nutrition over Parenteral Nutrition
Canadians and ADA: Strongest
ASPEN/SCCM: second strongest
Feeding Protocols
Canadians and ASPEN/SCCM: weaker recommendation
ADA: none for feeding protocol per se, but for GRV : expert opinion
EN plus PN
Canadian: recommend NOT be used until strategies to maximize EN adopted
ASPEN/SCCM: not be started for 7 -10 days (grade C)
Blue Dye
ASPEN/SCCM : not recommend
ADA : do not recommend but highest level of evidence
Conclusions
Differences exist between the guidelines:
– Populations
– Levels of evidence: not enough RCTs so tendency to make
a recommendation
– Time frames of literature searches and updates
– Recommendations: due to interpretation of the evidence,
lack of transparency
Similarities in many of the recommendations
Implications
Similarities should be adopted without hesitation
Differences
Define critically ill patient
Transparency needed (websites)
Harmonize between societies
Practitioner: right recommendation for the right person
JPEN Nov 2010:625-643
Ahhh…..Harmonized Guidelines!
Thank You!