Registered Dietitian Consultation STAT!
https://anchor.fm/restoringlife/episodes/Episode-90-Registered-Dietitian-Consultation-STAT-e1a7a7r
What role do registered dietitians play in patient outcomes in the ICU?
Why is malnutrition such an emergency?
How can we better utilize the expertise of registered dietitians?
What does the latest research show about our performance with nutrition in the ICU?
Megan Dockweiler, MS, RD, CNSC, and Amand Bakko, MS, RD CNSC share with us their expertise as ICU Registered Dietitians.
Have more questions for them? Email them!
Amanda: abakko545@gmail.com
Malnutrition
1. Guenter P, et al. Malnutrition diagnoses and associated outcomes in hospitalized patients: United States, 2018. Nutrition in Clinical Practice. 2021;1–13. DOI: 10.1002/ncp.10771.
● Malnutrition is associated with unfavorable outcomes, including higher infection rates, poor wound healing, longer lengths of stay, higher mortality and readmission rates, and ultimately increased costs, as compared with those without malnutrition.
● Malnutrition continues to be underdiagnosed in many hospitals, and approximately one-third of patients who are not malnourished on admission may become malnourished while hospitalized.
● Statistics: (poorer outcomes and higher economic burden)
o Total cost associated with malnutrition stays is >$58 billion.
o Malnutrition is common in older adults; 55% of malnourished patients who were readmitted within 30 days were 65 years of age or older.
o LOS and costs were nearly 2x higher than those without malnutrition.
o Malnourished patients added ~$10,000 more to hospital cost of stay.
o 2x higher discharge rate to LTC or rehab facility.
o 1.4x higher need for home healthcare.
2. Hoyois A, et al. Nutrition evaluation and management of critically ill patients with COVID-19 during post-intensive care rehabilitation. Journal of Parenteral and Enteral Nutrition. 2021;45:1153–1163. DOI: 10.1002/jpen.2101.
● At ICU discharge, 60% of patients presented with >10% of weight loss compared with their weight before hospital admission.
● Low muscle mass can profoundly influence post-ICU rehabilitation and ensuing functional limitations may persist even after hospital discharge in 65% of patients.
● Maintaining EN after ICU d/c through the use of NGT or PEG is mandatory to provide optimal nutrition support.
● Nutrition support with adequate protein intake (>1.5g/kg/d) remains crucial even after hospital discharge.
3. Whittle J, et al. Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19. Critical Care. 2020;24:581.
● Longitudinal IC data presented here demonstrate a progressive hypermetabolic phenotype beginning 1-week post-intubation in COVID-19 ICU patients, with significantly greater mREE versus predictive equations or ASPEN-recommended 11–14kcal/kg ABW for obese subjects used currently to determine energy requirements.
● Our data support use of standard predictive equations or ~ 20 kcal/kg as a reasonable approximation of mREE in 1st ICU week in COVID- 19 patients.
4. Vasileiou G, et al. Continuous Indirect Calorimetry in Critically Injured Patients Reveals Significant Daily Variability and Delayed, Sustained Hypermetabolism. Journal of Parenteral and Enteral Nutrition. 2020;44:5:889–894. DOI: 10.1002/jpen.1713.
● REE fluctuates widely during the first few days following injury and 1 single measurement of REE during steady state might not represent a patient’s average daily metabolic status or energy needs during the first 14 days.
5. Preiser J, et al. Metabolic and nutritional support of critically ill patients: consensus and controversies. Critical Care. 2015;19:35.
● The metabolic response to stress is part of the adaptive response to survive acute illness.
● As a result of this complex metabolic response, the control of energy substrate utilization is only partially regulated by substrate availability. Instead, pathways of energy production are altered and alternative substrates can be used. Clinically, one can identify a variety of changes, including increased energy expenditure (EE), stress hyperglycemia, loss of muscle mass, and eventually psychological and behavioral problems.
● In critically ill patients, the rate of protein degradation increases more than the rate of protein synthesis, resulting in a negative muscle protein balance.
o The loss of LBM, together with physical inactive, is associated with increased proteolysis via the proteasome/ubiquitin pathway.
● Using predictive equations can lead to over- or underfeeding especially if EE may be elevated and can vary over time.
● Consequences of refeeding:
o Complications include electrolyte abnormalities along with sodium and fluid retention potentially leading to heart failure, respiratory failure, and death. Severe hypophosphatemia is an early warning sign.
● Consequences of overfeeding:
o May be associated with hypercapnia and refeeding syndrome and may occur in up to 19% of mechanical ventilation days.
o High doses of protein may lead to azotemia, hypertonic dehydration, and metabolic acidosis.
o High doses of glucose infusion may result in hyperglycemia, hypertriglyceridemia, and hepatic steatosis.
● The concept of EEN, defined as enteral nutrition initiated within 24 hours after admission, has been adopted by many ICUs on the basis of its positive influence on gut barrier function, increasing secretion of mucus, bile, and immunoglobulin and favorable effects on gut-associated/mucosa-associated lymphoid tissue, release of incretins and other entero-hormones that have a major effect on intermediary metabolism, gut function, and hepatic functions, and its significant effects on morbidity and mortality.
● In stable patients on vasopressors, EEN commenced after initial resuscitation appears to be safe and confers a survival benefit. Several independent meta-analyses have confirmed a better outcome in patients receiving EEN compared with patients not receiving EEN.
6. Allen K, Hoffman L. Enteral Nutrition in the Mechanically Ventilated Patient. Nutrition in Clinical Practice. 2019;34:4:540–557. DOI: 10.1002/ncp.10242
● Many critically ill patients often have preexisting conditions, including malnutrition (undernutrition and/or overnutrition).
● Patients who were identified as having malnutrition were noted to have an increased 90-day mortality post discharge.
● Overfeeding, even for short periods of time, can lead to hyperglycemia and increases time on the ventilator. Conversely, an increasing calorie deficit (persistent underfeeding) also increases time on the ventilator.
o CO2 production only becomes clinically significant to prolong mechanical ventilation when patients are overfed.
● IC is the gold standard, but a 2015 estimate showed that only 2% of ICUs were regularly using IC.
● Many patients receive non-nutrition sources of calories in sedation (propofol), hydration (IV glucose solutions), and/or dialysate solutions.
● Protein is independently important for supporting clinical outcomes. Patients who received adequate protein were more likely to be weaned from the ventilator and had a lower ICU and overall in-hospital mortality and greater 60-day survival than those who did not meet protein needs, even when their overall energy intake was adequate.
● Nutrition support protocols: Early Enteral Nutrition (EEN) and Volume-Based Feeding Protocols.
● Disease-Specific EN
o Renal:
▪ AKI is associated with changes in the normal metabolism of protein, carbohydrate, and fats. Impaired lipolysis from altered fat metabolism is often associated with AKI, resulting in an increase in triglycerides and low-density lipoproteins and a decrease in total cholesterol and high-density lipoprotein. Carbohydrate metabolism is altered with AKI, and patients experience exacerbated insulin resistance. Patients with AKI who also experience significant insulin resistance have an increased risk of mortality compared with patients with AKI alone.
▪ AKI is a catabolic state and severely alters normal protein metabolism. Protein intake should be increased in patients receiving renal replacement therapy, up to a maximum of 2.5 g/kg/d per the SCCM/ASPEN 2016 guidelines. Patients with AKI without renal replacement therapy should have between 1.2 and 2 g/kg/d of protein.
o Obese Patients:
▪ Often experience more complications compared with patients with a normal BMI.
▪ Obese patients derived only 39% of their energy expenditure from fat compared with 61% in patients with a normal BMI. They also metabolize lean mass at higher rates, creating an increased risk for loss of LBM.
7. Sharma K, et al. Pathophysiology of Critical Illness and Role of Nutrition. Nutrition in Clinical Practice. 2019;34:1:12–22. DOI: 10.1002/ncp.10232
● Prevalence of malnutrition in the ICU ranges from 38% to 78% and is independently associated with poor outcomes.
8. Moisey L, et al. Adequacy of Protein and Energy Intake in Critically Ill Adults Following Liberation From Mechanical Ventilation Is Dependent on Route of Nutrition Delivery. Nutrition in Clinical Practice. 2020. DOI: 10.1002/ncp.10558.
● Patients exclusively prescribe oral diets post-LMV (liberation from mechanical ventilation), found that 7-days post-extubation adequacy of protein and energy intake was quite poor, with intake never exceeding 37% and 55% of estimated requirements, respectively.
● Noted that patients who continued to receive enteral nutrition in combination with oral diets met their estimated requirements.
● Early feeding tube removal occurs when staff lack the necessary knowledge to attend to the specialized nutrition care needs of post-ICU patients.
● The most common barriers to eating were the physiological effects of illness, including poor appetite, early satiety, taste changes, nausea/vomiting, and disliking food served.
9. Wischmeyer P, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Anesthesia Analgesia. 2018; 126:1883–95.
● It is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Malnourished surgical patients have significantly higher postoperative mortality, morbidity, length of stay (LOS), readmission rates, and increased hospital costs. It is estimated that 24%–65% of patients undergoing surgery are at nutrition risk.
