A different form of
malnutrition?
Health Care Associated
Malnutrition
Nutrition deficiencies associated with
physiological derangement and organ
dysfunction that occurs in a health care facility
Patients who will benefit the most from nutrition
therapy and who will be harmed the most from
by iatrogenic malnutrition (underfeeding)
Adequacy
of EN
kcal
Increasing Calorie Debt Associated with worse Outcomes
Prescribed Engergy
2000
1800
1600
1400
1200
1000
800
600
400
200
0
Energy Received From Enteral Feed
Caloric Debt
1
3
5
7
9
11
13
15
17
19
21
Days
 Caloric debt associated with:
 Longer ICU stay
 Days on mechanical ventilation
 Complications
  Mortality
Rubinson CCM 2004; Villet Clin Nutr 2005; Dvir Clin Nutr 2006; Petros Clin Nutr 2006
• Point prevalence survey of nutrition
practices in ICU’s around the world
conducted Jan. 27, 2007
• Enrolled 2772 patients from 158 ICU’s over
5 continents
• Included ventilated adult patients who
remained in ICU >72 hours
Relationship of Caloric Intake, 60 day Mortality and BMI
60
BMI
All Patients
< 20
20-25
25-30
30-35
35-40
>40
Mortality (%)
50
40
30
20
10
0
0
500
1000
1500
Calories Delivered
2000
Mechancially Vent’d patients >7days
(average ICU LOS 28 days)
Faisy BJN 2009;101:1079
Effect of Increasing Amounts of Calories
from EN on Infectious Complications
Multicenter observational study of 207 patients >72 hrs in ICU
followed prospectively for development of infection
for increase of 1000 cal/day, OR of infection at 28 days
Heyland Clinical Nutrition 2010
Relationship between increased nutrition intake and
physical function (as defined by SF-36 scores)
following critical illness
Multicenter RCT of glutamine and antioxidants (REDOXS Study)
First 364 patients with SF 36 at 3 months and/or 6 months
Model *
Estimate (CI)
P values
PHYSICAL FUNCTIONING (PF) at 3 months
3.2 (-1.0, 7.3)
P=0.14
ROLE PHYSICAL (RP) at 3 months
4.2 (-0.0, 8.5)
P=0.05
(A) Increased energy intake
for
STANDARDIZED PHYSICAL COMPONENT
1.8 (0.3, 3.4)
SCALE (PCS) at 3 months
P=0.02
PHYSICAL FUNCTIONING (PF) at 6 months
0.8 (-3.6, 5.1)
P=0.73
ROLE PHYSICAL (RP) at 6 months
2.0 (-2.5, 6.5)
P=0.38
STANDARDIZED PHYSICAL COMPONENT
0.70 (-1.0, 2.4)
P=0.41
SCALE (PCS)
at 6gram/day,
months
increase
of 30
OR of infection at 28 days
Heyland Unpublished Data
More (and Earlier) is Better!
If you feed them (better!)
They will leave (sooner!)
Permissive Underfeeding
(Starvation)?
 187 critically ill patients
 Tertiles according to ACCP recommended levels of
caloric intake
 Highest tertile (>66% recommended calories) vs.
Lowest tertile (<33% recommended calories)
  in hospital mortality
  Discharge from ICU breathing spontaneously
 Middle tertile (33-65% recommended calories) vs.
lowest tertile
 Discharge from ICU breathing spontaneously
Krishnan et al Chest 2003
Optimal Amount of Calories for
Critically Ill Patients:
Depends on how you slice the cake!
• Objective: To examine the relationship between the
amount of calories recieved and mortality using various
sample restriction and statistical adjustment techniques and
demonstrate the influence of the analytic approach on the
results.
• Design: Prospective, multi-institutional audit
• Setting: 352 Intensive Care Units (ICUs) from 33
countries.
• Patients: 7,872 mechanically ventilated, critically ill
patients who remained in ICU for at least 96 hours.
Heyland Crit Care Med 2011
Association between 12 day average caloric adequacy and
60 day hospital mortality
(Comparing patients rec’d >2/3 to those who rec’d <1/3)
A. In ICU for at least 96 hours. Days
after permanent progression to
exclusive oral feeding are included as
zero calories*
B. In ICU for at least 96 hours. Days
after permanent progression to
exclusive oral feeding are excluded from
average adequacy calculation.*
C. In ICU for at least 4 days before
permanent progression to exclusive oral
feeding. Days after permanent progression
to exclusive oral feeding are excluded from
average adequacy calculation.*
Unadjusted
Adjusted
D. In ICU at least 12 days prior to
permanent progression to exclusive oral
feeding*
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Odds ratios with 95% confidence intervals
*Adjusted for evaluable days and covariates,covariates include region (Canada, Australia and New Zealand,
USA, Europe and South Africa, Latin America, Asia), admission category (medical, surgical), APACHE II score,
age, gender and BMI.
Association Between 12-day Caloric
Adequacy and 60-Day Hospital Mortality
Optimal
amount=
80-85%
Heyland CCM 2011
More (and Earlier) is Better!
If you feed them (better!)
They will leave (sooner!)
Trophic vs. Full enteral feeding in critically ill
patients with acute respiratory failure
• Single center study of 200 mechanically ventilated patients
• Trophic feeds: 10 ml/hr x 5 days
Rice CCM 2011;39:967
Trophic vs. Full enteral feeding in critically ill
patients with acute respiratory failure
Did not measure infection nor physical function!
Rice CCM 2011;39:967
Trophic vs. Full enteral feeding in critically ill
patients with acute respiratory failure
“survivors who received
initial full-energy enteral
nutrition were more likely to
be discharged home with or
without help as compared to a
rehabilitation facility (68.3%
for the full-energy group vs.
51.3% for the trophic group;
p = .04).”
Rice CCM 2011;39:967
Trophic vs. Full enteral feeding in critically ill
patients with acute respiratory failure
•
•
•
•
•
Average age 51
Few comorbidities
Average BMI 29
All fed within 24 hrs (benefits of early EN)
Average duration of study intervention 5 days
No effect in young, healthy,
overweight patients who
have short stays!
Large multicenter trial of this concept
(EDEN study) by ARDSNET just finished
ICU patients are not all created equal…should
we expect the impact of nutrition therapy to be
the same across all patients?
How do we figure out who will benefit
the most from Nutrition Therapy?
Health Care Associated
Malnutrition
Do Nutrition Screening tools help us
discriminate those ICU patients that will benefit
the most from artificial nutrition?
Patients who will benefit the most from nutrition
therapy and who will be harmed the most from
by iatrogenic malnutrition (underfeeding)
All ICU patients
treated the same
Albumin: a marker of malnutrition?
• Low levels very prevalent in critically ill patients
• Negative acute-phase reactant such that synthesis,
breakdown, and leakage out of the vascular
compartment with edema are influenced by
cytokine-mediated inflammatory responses
• Proxy for severity of underlying disease
(inflammation) not malnutrition
• Pre-albumin shorter half life but same limitation
Subjective Global Assessment?
• When training
provided in
advance, can
produce reliable
estimates of
malnutrition
• Note rates of
missing data
• mostly medical patients; not all ICU
• rate of missing data?
• no difference between well-nourished and malnourished
patients with regard to the serum protein values on
admission, LOS, and mortality rate.
“We must develop and validate
diagnostic criteria for appropriate
assignment of the
described malnutrition syndromes
to individual patients.”
A Conceptual Model for Nutrition Risk
Assessment in the Critically Ill
Acute
Chronic
-Reduced po intake
-pre ICU hospital stay
-Recent weight loss
-BMI?
Starvation
Nutrition Status
micronutrient levels - immune markers - muscle mass
Inflammation
Acute
-IL-6
-CRP
-PCT
Chronic
-Comorbid illness
The Development of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
• When adjusting for age, APACHE II, and
SOFA, what effect of nutritional risk factors
on clinical outcomes?
• Multi institutional data base of 598 patients
• Historical po intake and weight loss only
available in 171 patients
• Outcome: 28 day vent-free days and mortality
Heyland Critical Care 2011, 15:R28
What are the nutritional risk factors
associated with clinical outcomes?
(validation of our candidate variables)
Age
Baseline APACHE II score
Baseline SOFA
# of days in hospital prior to ICU admission
Baseline Body Mass Index
Body Mass Index
Non-survivors by day 28
(n=138)
Survivors by day 28
(n=460)
p values
71.7 [60.8 to 77.2]
61.7 [49.7 to 71.5]
<.001
26.0 [21.0 to 31.0]
20.0 [15.0 to 25.0]
<.001
9.0 [6.0 to 11.0]
6.0 [4.0 to 8.5]
<.001
0.9 [0.1 to 4.5]
0.3 [0.0 to 2.2]
<.001
26.0 [22.6 to 29.9]
26.8 [23.4 to 31.5]
0.13
0.66
<20
≥20
6 ( 4.3%)
122 ( 88.4%)
3.0 [2.0 to 4.0]
# of co-morbidities at baseline
Co-morbidity
Patients with 0-1 co-morbidity
20 (14.5%)
Patients with 2 or more co-morbidities
118 (85.5%)
¶
135.0 [73.0 to 214.0]
C-reactive protein
4.1 [1.2 to 21.3]
Procalcitionin¶
158.4 [39.2 to 1034.4]
Interleukin-6¶
171 patients had data of recent oral intake and weight loss
% Oral intake (food) in the week prior to enrolment
% of weight loss in the last 3 month
25 ( 5.4%)
414 ( 90.0%)
3.0 [1.0 to 4.0]
<0.001
<0.001
140 (30.5%)
319 (69.5%)
108.0 [59.0 to 192.0]
0.07
1.0 [0.3 to 5.1]
<.001
72.0 [30.2 to 189.9]
<.001
Non-survivors by day 28
(n=32)
Survivors by day 28
(n=139)
p values
4.0[ 1.0 to 70.0]
50.0[ 1.0 to 100.0]
0.10
0.0[ 0.0 to
2.5]
0.0[ 0.0 to
0.0]
0.06
What are the nutritional risk factors
associated with clinical outcomes?
(validation of our candidate variables)
Spearman
correlation with
VFD within 28
days
p values
Number of
observations
Age
Baseline APACHE II score
Baseline SOFA
-0.1891
-0.3914
-0.3857
<.0001
<.0001
<.0001
598
598
594
% Oral intake (food) in the week prior to enrollment
0.1676
0.0234
183
number of days in hospital prior to ICU admission
-0.1387
0.0007
598
% of weight loss in the last 3 month
Baseline BMI
# of co-morbidities at baseline
Baseline CRP
Baseline Procalcitionin
Baseline IL-6
-0.1828
0.0581
-0.0832
-0.1539
-0.3189
-0.2908
0.0130
0.1671
0.0420
0.0002
<.0001
<.0001
184
567
598
589
582
581
Variable
The Development of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
For example, exact quintiles and logistic parameters for age
Exact Quintile
Parameter
Points
19.3-48.8
referent
0
48.9-59.7
0.780
1
59.7-67.4
0.949
1
67.5-75.3
1.272
1
75.4-89.4
1.907
2
The Development of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
Variable
Age
APACHE II
SOFA
# Comorbidities
Range
<50
50-<75
>=75
<15
15-<20
20-28
>=28
<6
6-<10
>=10
0-1
2+
Points
0
1
2
0
1
2
3
0
1
2
0
1
Days from hospital to ICU admit
0-<1
1+
0
1
IL6
0-<400
400+
0
1
AUC
Gen R-Squared
Gen Max-rescaled R-Squared
0.783
0.169
0.256
BMI, CRP, PCT, weight loss, and oral intake were excluded because they were not significantly
associated with mortality or their inclusion did not improve the fit of the final model.
Observed
Model-based
40
20
n=12
n=33
0
1
n=55
n=75
n=90
n=114
n=82
n=72
n=46
n=17
2
3
4
5
6
7
8
9
n=2
0
Mortality Rate (%)
60
80
The Validation of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
Nutrition Risk Score
10
Observed
Model-based
10
8
6
4
2
n=12
n=33
n=55
n=75
n=90
n=114
n=82
n=72
n=46
n=17
n=2
0
1
2
3
4
5
6
7
8
9
10
0
Days on Mechanical Ventilator
12
14
The Validation of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
Nutrition Risk Score
The Validation of the NUTrition Risk in the
Critically ill Score (NUTRIC Score).
1.0
Interaction between NUTRIC Score and nutritional adequacy (n=211)*
9
0.8
9
9
0.6
8 88
0.2
0.4
77 7
2
0
9
9
7
4
0.0
28 Day Mortality
P value for the
interaction=0.01
9
8888
7 7
7
8888
8
9
10
10
888
77
88
77 7
77 7
88
7
77
6
7
7777
6 66666 6
9
66666 6 6 66
6 666666666
666 6 6 66
7
5
555
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
4 4 3
5 55 555 55 555 55
5
5 5
44 4 43
4
4
4
2
4
4
4
3
44444444
33
444 4444
3
4
3
4
1
4
22
3
4 4
3 3 33 2 22 2 1
3
11
33 3
2
1 11 1 1
50
100
3
3
5
9
8
150
Nutrition Adequacy Levles (%)
Heyland Critical Care 2011, 15:R28
Who might benefit the most from
nutrition therapy?
• High NUTRIC Score?
• Clinical
– BMI
– Projected long length of stay
• Others?
Do we have a problem?
Preliminary Results of INS 2011
Overall Performance: Kcals
120
% received/prescribed
100
84%
56%
80
60
40
15%
20
0
1
2
3
4
5
6
7
8
9
10
11
12
ICU Day
Mean of All Sites
Best Performing Site
Worst Performing Site
N=211
Failure Rate
% patients who failed to meet minimal quality targets (80% overall energy adequacy)
Can we do better?
The same thinking that got you into
this mess won’t get you out of it!
The Efficacy of Enhanced Protein-Energy Provision via the
Enteral Route in Critically Ill Patients:
The PEP uP Protocol!
•
•
•
•
•
In select patients, we start the EN immediately at goal
rate, not at 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.
Start with a semi elemental solution, progress to
polymeric
Tolerate higher GRV threshold (300 ml or more)
Motility agents and protein supplements are started
immediately, rather than started when there is a
problem.
A Major Paradigm Shift in How we Feed Enterally
Heyland Crit Care 2010
In Conclusion
• Health Care Associate Malnutrition is rampant
• Not all ICU patients are the same in terms of ‘risk’
• Iatrogenic underfeeding is harmful in some ICU
patients or some will benefit more from aggressive
feeding (avoiding protein/calorie debt)
• BMI and/or NUTRIC Score is one way to quantify
that risk
• Need to do something to reduce iatrogenic
malnutrition in your ICU!
– Audit your practice first!
www.criticalcarenutrition.com
Questions?
www.criticalcarenutrition.com