In
Knowledge Translation:
The Critical Care
Experience
1
Outline of Session
Guidelines for Nutrition Therapy in the ICU : How do they differ?
Rupinder Dhaliwal, RD
WHAT SHOULD BE DONE?
Improving the practices of Nutrition Therapy in the Critically ill
Naomi Cahill, RD
WHAT IS BEING DONE?
Bridging the Gap: Effective Dissemination Strategies for Improving
Nutrition Practices in the ICU
Daren Heyland, MD
HOW TO NARROW THE GAP?
Questions to be held at the end of the session
1
Guidelines for Nutrition Therapy in
the ICU: How do they differ?
Rupinder Dhaliwal, RD
Team Leader/Project Leader
Clinical Evaluation Research Unit
Critical Care Nutrition
Kingston ON, Canada
1
Conflict of interest
Co-author of Canadian Clinical Practice
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
1
Proliferation of guidelines
1
The more guidelines they publish,
the more confused I get!
Objectives
Compare the content of recently published nutrition
guidelines
Differences between the recommendations
Similarities in the recommendations
Highlight the need for harmonization
1
North American guidelines
www.criticalcarenutrition.com
Available
Online
1
What differences?





1
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
needing 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
unclear
Outcomes
clinical outcomes
clinical and non
clinical outcomes
clinical and non
clinical outcomes
Grading
Strongest
Weakest
Canadian
ADA
ASPEN/SCCM
“Strongly recommend”
no reservations re:
endorsement
(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%)
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
1

External review

Procedure for updating the CPG
AGREE Qual Saf Health Care 2003;12:18
Integration of values
evidence
integration
of
values
+
practice
guidelines
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
1
Differences: recommendations
Dose of enteral nutrition and 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
1
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
1
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
11 RCTs
2 RCTS harm
earlier meta-analyses showing
no benefit
RCT showing benefit
Grade A: based on elective
surgery patients
1
Differences: recommendations
Enteral Glutamine
Canadian
Burns:
Recommended
Trauma: Should be
considered
ADA
ASPEN/SCCM
--------
Grade B
Burns, Trauma
and mixed ICU
patients
Other ICU:
Insufficient data
9 RCTS
1
1 RCT
Differences: recommendations
Peptides
Canadian
Recommend
polymeric (since no
benefit for peptides)
4 RCTs
1
ADA
ASPEN/SCCM
---------
Grade E
Use small peptides in
diarrhea
1 non RCT
zzzz…….
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
1
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
1
Differences: recommendations
Intensive Insulin Therapy
Canadian
ADA
Recommend
Target 8.0 mmol/L
Range 7-9 mmol/L
Strong
Grade B
Medical: 4.4-6.1 mmol/L Moderate strict
control
Most recent metaanalyses
1
ASPEN/SCCM
Grade E
6.1-8.3 mmol/L
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
Continuous vs. other
ADOPT
NOW!



insufficient
----
High risk (D)
Not be used
----
Not for 7 days
No soy based
----
No soy based
PN Glutamine

----

Low dose of PN

----

AOX/vits/minerals

----

PN vs std care
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
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
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Summary
Differences exist between the guidelines:


Populations, levels of evidence, time frames, etc
Recommendations: due to interpretation of the evidence, lack of
transparency
Similarities in many of the recommendations
Highlight the need for harmonization across North
American Societies
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Implications
Similarities should be adopted without hesitation
Differences
Harmonize between societies
Define critically ill patient
Transparency needed (websites)
Practitioner: right recommendation for the right person
1
Upcoming in JPEN
Available online
Knowledge
Translation issue Fall
2010
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Ahhh…..Harmonized Guidelines!