Oongress Rev|ew www.sccm.

org June/Ju|y 2011

c
9
Farticipants must respono to all evaluation
ano post-test questions to receive a statement
ol creoit. Once the evaluationpost-test
is completeo, the Society ol Critical Care
Meoicine ,SCCM, will review your application
ano e-mail your certilicate within 1! oays ol
receipt.
Learn|ng Object|ves
At the conclusion ol this activity participants
shoulo be able to:
Discuss approaches to screen lor oelirium
ano consioer both pharmacologic ano non-
pharmacologic approaches to prevention
ano management
Minimize the oevelopment ol malnutrition
through goal-oirecteo therapy combining
the use ol enteral ano parenteral nutrition
Recognize new therapies lor sepsis in the
intensive care unit ano the limitations ol
current research lor better translation ol
evioence to the beosioe
Type of Act|v|ty
This activity was oesigneo as an evioenceo-
baseo lorum to review expert opinions ol
various topics in critical care. This activity
will locus on increasing knowleoge ano its
application to practice.
Facu|ty D|sc|osures Iaculty have reporteo the lollowing oisclosures. A copy ol SCCM`s policy on resolving conllicts ol interest
can be louno at www.sccm.orgprolessional_oevelopment.
Dorok C. Angus, MD, MPH, FCCM
University ol Fittsburgh
CRISMA Laboratory
Fittsburgh, Fennsylvania, USA
Cooltoot, M.oo.r: DSMB
R..orc/ Croot: Ioo/ T.c/ol, Ioc.,
Eli Lill, ooo Cooo, ooo Eioi Ioc.
]osoph F. Dnstn, Msc, FCCM
University ol Texas
The Ohio State University
Austin, Texas, USA
Cooltoot : Hiro, Ioc.,
Coo.oc. P/orooc.oticol, ooo
)o..lio P/orooc.oticol Ioc.
S.o/.r: T/. Frooc. Fooootio
(or.o o, Hiro, Ioc.,
CECME Enouring Material
Release Date: June 2011
Expiration oate: June 2012
Competenc|es
SCCM supports recommenoations that will
promote lilelong learning through continuing
eoucation. SCCM promotes activities that
encourage the highest quality in eoucation
that will enhance knowleoge, competence or
perlormance in critical care practice. This
activity will meet the lollowing:
Fatient- ano Iamily-Centereo Care
Fractice Applications
Quality Improvement
Multiprolessionalism
Target Aud|ence
This continuing meoical eoucation ollering is
intenoeo to meet the neeos ol all physicians,
nurses, pharmacists, respiratory therapists
ano other provioers who care lor critically ill
patients.
Physicinns
Jccr.oitotio Stot.o.ot
This activity has been planneo ano
implementeo in accoroance with the Essential
Areas ano policies ol the Accreoitation Council
lor Continuing Meoical Eoucation by SCCM.
SCCM is accreoiteo by ACCME to provioe
continuing meoical eoucation lor physicians.
Earn Continuing Education Credit at www.sccm.org/2011ConRev
Cr|t|ca| Care Congress Rev|ew
D.iootio Stot.o.ot
The Society oesignates this home stuoy
eoucational activity lor a maximum ol 1 JMJ
PRJ Cot.r, 1 Cr.oit. Fhysicians shoulo claim
creoit commensurate with the extent ol their
participation in the activity.
Nursos
SCCM is approveo by the Calilornia Boaro
ol Registereo Nursing, Frovioer No. 8181 ano
approves this panel lor 1 contact hour.
Phnrnncists
The Society is accreoiteo by the
Accreoitation Council lor Fharmacy
Eoucation ,ACFE, as a provioer ol
continuing pharmaceutical eoucation. This
monograph will provioe 1 continuing eoucation
hour. ,023o-0000-11-190-H01-F, Once you
have completeo the online evaluation, posttest
ano CE application as stateo above, you will
receive your certilicate via email within 1! oays.

Ior more inlormation on the Congress Review,
please contact SCCM at congresssccm.org or
call -1 8! 82-o888.
Ior aooitional inlormation on these topics ano
other areas, please visit www.learnicu.org
Tinothy D. Girnrd, MD, MSCI
Vanoerbilt University School ol Meoicine
Nashville, Tennessee, USA
Hororio: Hiro, Ioc
Ainsloy Mnlono, RD, MS, LD, CNSD
Mount Carmel West Hospital
Columbus, Ohio, USA
^ fiooociol r.lotio/i
]ohn C. Mnrshnll, MD, FRCSC
University ol Toronto
Toronto, Ontario, Canaoa
Poio o.oo.r f t/. Clioicol E.olootio Cooitt..
fr o triol or.o o, Eioi Ioc.
]ny M. Mirtnllo, MS, RPh, BCNSP
The Ohio State University, College ol
Fharmacy
Columbus, Ohio, USA
S.o/.r Bor.oo M.oo.r: Boxt.r
Stovon M. Opnl, MD, MS
Memorial Hospital ol Rhooe Islano
Alpert Meoical School ol Brown University
Frovioence, Rhooe Islano, USA
Croot R.cii.ot: J.ooix, Jtro.o.co,
Jtx Bi, Eioi Ioc.
Knron Snnds, APRN-BC, ANP,
CCRN, MSN
Iorsyth Meoical Center
Winston-Salem, North Carolina, USA
S.o/.r Bor.oo M.oo.r: JCHL, EPICC,
Hiro, Ioc., ooo Hill-Ro
Chnrlos W. Vnn Wny III, MD, FCCM
University ol Missouri School ol Meoicine
Truman Meoical Center-Hospital Hill
Kansas City, Missouri, USA
Cooltoot: Boxt.r ooo ^.tl/ ^otritio
Supported by education grants from Baxter Healthcare, Hospira, lnc., and Eisai lnc.
14
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June/Ju|y 2011 +1 847 827-6869 Oongress Rev|ew
40th Or|t|ca| Oare Oongress Rev|ew view these articles at www.sccm.org/criticalconnections
Goal-oirecteo nutrition therapy seeks to lino a balance between the
two major mooes ol nutrition support, explaineo Charles W. Van Way
III, MD, ICCM. Accoroing to proponents ol goal-oirecteo nutrition
therapy, combining enteral ano parenteral nutrition to meet oaily
energy requirements can avoio energy oebt ano improve outcomes.
The rationale supporting the hypothesis ol goal-oirecteo therapy
begins with the observation that energy oebt is a marker lor nutritional
risk ano is olten built up ouring the lirst week ol an ICU stay. Improveo
energy balance has been associateo with shorter hospital length ol stay,
reouceo complications, ano lower rates ol hospital mortality. Given
these benelits, the strategy ol increasing the caloric intake ol a patient on
enteral nutrition has great merit ano can be achieveo in oillerent ways,
noteo Van Way. We can be more aggressive with enteral leeoing, or we
can supplement with parenteral nutrition. The important point is that we
oo something to avoio energy oebt.
Nutritional stress can be oelineo best as nutritional requirements
in excess ol some percentage ol normal, such as 150. Acute
malnutrition is intake ol nutrients sulliciently below current neeos so as
to allect systemic lunctions. A patient ooes not have to be chronically
malnourisheo to be acutely malnourisheo, stateo Van Way.
Malnutrition is a clinical oiagnosis, characterizeo by unintenoeo
weight loss ,e.g.,10 pounos in 3 months, 20 pounos in o months,, muscle
wasting, lailure to heal, subjective global assessment, oiminisheo visceral
proteins, ano vitamin oeliciencies. Laboratory tests, most commonly
albumin or thyroxin-binoing pre-albumin, support but oo not oeline
the oiagnosis ol malnutrition.
In creating a oelinition ol malnutrition that can be useo by meoical
ano public health prolessions worlowioe, the International Consensus
Guioeline Committee, an international workgroup lormeo by the
European Society lor Clinical Nutrition ano Metabolism ,ESFEN, ano
the American Society lor Farenteral ano Enteral Nutrition ,A.S.F.E.N.,
has been aooressing the concept ol etiology-baseo malnutrition, in
which nutritional status interacts with patient oisease to allect outcome
,see Iigure 1,. Fatients who exhibit nutritional risk ,compromiseo intake
or loss ol booy mass on the basis ol low nutrition, shoulo be assesseo lor
inllammation. The absence ol inllammation suggests chronic starvation-
relateo malnutrition, whereas its presence suggests chronic oisease-
relateo malnutrition. Severe inllammation, as seen in ICU patients, is
associateo with acute oisease or injury-relateo malnutrition ,Jensen GL,
et al. )PE^. 2009,33:10, )PE^. 2010,3!:15o,.
The lact that malnutrition is olten either unrecognizeo or untreateo
is a major problem in the care ol the acutely ill tooay, Van Way saio. All
ol us can lino at least two or three patients in our ICU whose nutritional
neeos are not being met, ano whose acute malnutrition appears to be
allecting their outcome. The question is: What can we oo about it?
The selection ol the nutrition intervention oepenos largely on
treatment ol the unoerlying conoition. At the same time, the ouration,
cost ano ellectiveness ol treatment are oetermineo by the nutritional
intervention. Malnutrition interacts with the illness to oetermine outcome
ano works with the intervention to oetermine the ellectiveness ol
therapy. There are expenoitures associateo with enteral ano parenteral
leeoing that aren`t incurreo il we simply let the patient become more
malnourisheo, but to ellectively treat the malnutrition ol acute illness
ano improve outcomes incluoing the total cost ol care we neeo to
speno the resources up lront, Van Way urgeo.
Malnutrition is present in 30 to 50 ol hospitalizeo patients at
aomission in the Uniteo States ,Thomas D. ^otritio. 2003,19:90,.
I oon`t think we can say on the basis ol this or other oata that the
incioence ol malnutrition is higher in the ICU, but I think we can say
that the incioence ol nutritional stress is higher, remarkeo Van Way.
The incioence ol malnutrition concurrent with treatment is also high,
shown to be 2 ol patients on one general meoical waro ,Thomas D.
^otritio. 2003,19:90,. Contributing lactors were oetermineo to be poor
recognition ol malnutrition, poor monitoring, inaoequate intake ol
nutrients lor oays at a time, ano severe illness. Malnutrition is associateo
with a higher incioence ol complications ,Naber TH, et al. Jo ) Clio
^otr. 199,oo:1232, ano higher risk ol oeath ,Weinsier RL. Jo ) Clio
^otr. 199,32:!18,.
Metabolism oillers greatly in the lasting versus the stresseo state. In
lasting metabolism, the energy requireo ,1500 kcaloay, is relatively
mooest ano the amount ol muscle breakoown that occurs ,5 goay,
is relatively small. The glucose requirement ol 180 goay is generateo
largely lrom muscle breakoown ano is utilizeo by the central nervous
ano hematopoietic systems. Iatty acios in the amount ol 120 goay
are releaseo to the rest ol the booy. Unoer the stress ol inllammation,
metabolic neeos magnily. Energy requirements may oouble ,to as much
as 3000 kcaloay, ano glucose requirements may triple ,to !50 goay,
Minimizing the oevelopment ol malnutrition is ol crucial importance lor patients in the intensive care unit ,ICU,. Over the past 30 years, signilicant swings in
the penoulum have taken place regaroing how to best provioe nutrition to these patients, lrom olten over-enthusiastic use ol nutritional support in the 1980s, to
lrequent unoer-nutrition tooay. Now emerging oata are pointing to a mioole grouno, suggesting that outcomes may be improveo through goal-oirecteo therapy
an approach that combines the use ol enteral ano parenteral nutrition to achieve oesireo energy requirements lor ICU patients.
D|agnos|ng Ma|nutr|t|on and Nutr|t|on R|sk |n the Cr|t|ca| Care Sett|ng
Nutr|t|on |n the ICU: Ear|y Goa|-D|rected Therapy Is Key
Figure 1.
Nutr|t|ona| R|sk:
Compromised intake or
loss of body mass
Is |namat|on present?
Chron|c D|sease-Re|ated
Ma|nutr|t|on
(pancreatic cancer, rheumatoid
arthritis, sarcopenic obesityj
Yes
(Mild to Moderatej
No
Yes
(Severej
Starvat|on-Re|ated
Ma|nutr|t|on
(chronic starvation,
anorexia nervosaj
Acute D|sease or Injury-
Re|ated Ma|nutr|t|on
(sepsis, burn, trauma,
closed head injuryj
Et|o|ogy-Based Ma|nutr|t|on
Pr..ot.o o, C/orl. J. 1oo Jo, III, MD, FCCM, o oricol iot.oi.it,
.o.rol ooo t/rocic or.o, rf.r f or.r,, ooo t/. Slooo.Miori
Eooo.o C/oir f Troooo S.r.ic. ot t/. Uoi..rit, f Miori Sc/l f
M.oicio. io Iooo Cit,. H. roctic. ot Troooo M.oicol C.ot.r - Hitol
Hill io Iooo Cit,, Miori, USJ.
Adapted from 17,5 2009;33:710
Oongress Rev|ew www.sccm.org June/Ju|y 2011
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15
40th Or|t|ca| Oare Oongress Rev|ew
to luel the immune system, regenerate tissue ano nourish the central
nervous system. The amount ol lat liberateo also increases ,up to 200 g
oay,, but to a lesser oegree than energy ano glucose neeos. The net result
lrom the aooitional neeo lor glucose is increaseo muscle breakoown to
provioe the builoing blocks lor gluconeogenesis. Muscle catabolism may
quaoruple to 300 goay.
With acute oisease-relateo malnutrition, the best we may be able to
oo is stabilize the patient while treating the unoerlying problem, saio
Van Way. But, il we oon`t stabilize the patient nutritionally, he or she
may never survive the treatment ol the unoerlying problem. The oual
roles ol the inllammatory response ano nutritional stress are illustrateo
in Iigure 2. The inllammatory response activates cytokines ano white
cells, oxioative oamage ano seconoary inlections occur, ano oamage to
the organ system ensues. At the same time, nutritional stress results in
the mobilization ol nutrients lrom tissue ano accentuates oamage to
organ systems, leaoing to multiple organ lailure ano oeath.
In closing, Van Way askeo, Does it really work to give enteral ano
parenteral nutrition together, in oroer to meet the nutritional target?
Certainly, we can come closer to meeting a patient`s nutritional neeo.
But will that actually allect patient outcomes? We still oon`t know,
he saio. However, we oo know that conventional enteral nutrition is
inaoequate, especially in ICU patients ano especially ouring the lirst
week. We know that goal-oirecteo nutrition can signilicantly increase
When provioing nutrition to ICU patients, our goal is to provioe
100 ol their requirements. However, as many ol us in practice have
louno, this is not always easily oone ano olten ooes not occur, stateo
Ainsley Malone, MS, RD, LD, CNSC. Frevention ol an energy oelicit
is important in critically ill patients to avoio the poor outcomes that
have been reporteo in the literature. In aooition to being associateo
with a higher risk ol mortality ,Bartlett RH, et al. Sor.r,.1982,92:1,,
a negative energy balance has also been linkeo to a higher incioence ol
complications such as acute respiratory oistress synorome, sepsis ano
renal lailure among ICU patients ,Dvir D, et al. Clio ^otr. 200o,25:3,,
as well as greater lengths ol time on mechanical ventilation ano in the
ICU ,Mault J, et al. ) Por.ot.r Eot.rol ^otr. 2000,2!:S!,.
Other linoings have revealeo that surgical patients who oevelopeo
a large energy oelicit ouring the lirst week in the ICU hao a greater
incioence ol total inlectious complications than patients with no energy
oelicit ouring that lirst week ,Villet S, et al. Clio ^otr. 2005,2!:502,. The
authors ol this observational stuoy concluoeo that energy oebt occurs
early in the ICU ano is oillicult to overcome. The stuoy also louno that
patients who receiveo enteral ano parenteral nutrition in combination
were able to achieve 98 ol their goal energy requirements compareo
with o2 achieveo by patients receiving enteral nutrition alone.
Aooitional positive outcomes were observeo in a ranoomizeo trial
evaluating the combineo use ol enteral ano parenteral therapy ,Anbar
R, et al. Clio ^otr. 2008,3:11,. In this stuoy, the control group receiveo a
stanoaro amount ol calories ,25 kcalkgoay,, a common methoo lor
estimating energy requirements in ICU patients. Ior the stuoy group,
energy expenoiture was measureo using a metabolic cart ano energy
was provioeo to achieve those requirements. Fatients who achieveo their
energy targets receiveo supplemental parenteral nutrition. Although
the results showeo no oillerence in ICU outcomes, hospital length ol
stay ano mortality rates were lower in the stuoy group, saio Malone.
The oetermination ol a patient`s energy requirement is what guioes
the practice ol provioing energy intakes, Malone stateo. Methoos
lor estimating resting metabolic rate, ano hence energy requirements,
lall into three categories: inoirect calorimetry, preoictive equations,
ano nomograms. Inoirect calorimetry is the golo stanoaro, but many
institutions oon`t have this technology. In the absence ol this methoo,
we can use either preoictive equations baseo on selecteo variables or a
nomogram with a specilic level ol calories per kilogram.
Inoirect calorimetry has receiveo the highest evioence graoe by the
American Dietetic Association ,ADA, Evioence Analysis Library, a large
booy ol systematic reviews ol various nutrition topics. Although inoirect
calorimetry is the stanoaro lor oetermination resting metabolic rate in
critically ill patients, it has limitations. The methoo cannot be useo in
patients receiving more than o0 ol their lraction ol inspireo oxygen
,IiO
2
, level or high amounts ol positive eno-expiratory pressure ,FEEF,. As
another orawback, inoirect calorimetry requires the ability to completely
collect expireo gases, making accurate measurement oillicult with patients
who are not on a ventilator but receiving supplemental oxygen. Lack ol
aoequately traineo stall can also curtail use ol this methoo. In aooition,
the timing ol the measurement is important, especially when making
ventilator changes or when patients are unoergoing proceoures.
Target|ng Goa|s for Energy and Prote|n |n Cr|t|ca||y I|| Pat|ents
Figure 2.
Relative Risk, Malnourished Patients
vs Well-Nourished Patients
3.3
1.7
Combi lndex*
(Crude ORj
Combi lndex
|
(Multivariate
|
ORj
Data derived from (T1*SPU5\[Y 1997;66:1232
Concurrent Ro|es of the Inf|ammatory Response
and Nutr|t|ona| Stress
Pr..ot.o o, Jiol., Molo., RD, MS, LD, C^SD, o ootritio ort oi.titioo
io t/. /orooc, o.orto.ot f Moot Coro.l J.t Hitol io Cloooo,
O/i, USJ. S/. /o oit.o io t/. oooo.o.ot f ootritio ort t/.ro,
fr criticoll, ill oti.ot fr or. t/oo 25 ,.or.
caloric ano nitrogen oelivery ano can meet the patient`s nutritional
neeos. What we oo not know is whether this impacts outcomes. Large
prospective stuoies on goal-oirecteo nutrition therapy are now unoer
way in Europe ano Israel ano will be soon in the Uniteo States. We
look lorwaro to reviewing the oata.
16
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June/Ju|y 2011 +1 847 827-6869 Oongress Rev|ew
40th Or|t|ca| Oare Oongress Rev|ew view these articles at www.sccm.org/criticalconnections
Use ol preoictive equations to estimate resting metabolic rate is an
option when inoirect calorimetry cannot be perlormeo. Most ol these
equations are oeriveo lrom inoirect calorimetry, using a variety ol
variables rellective ol clinical status ,e.g., height, weight, age, trauma,
burns, temperature, minute ventilation,. The ADA Evioence Analysis
Library examineo all ol the available preoictive equations ano louno that
the Fenn State equation, ioentilieo in 2003, provioes the greatest oegree
ol accuracy lor non-obese aoult critically ill patients, with accuracy rates
ol o9 lor patients unoer o0 years ol age ano lor those o0 years
ano oloer. Among obese aoult critically ill patients, the greatest accuracy
,0, again occurreo with the Fenn State equation. A mooilieo Fenn
State equation, publisheo in 2010 lor a subset ol obese patients ageo
o0 years or oloer, was louno to achieve a ! rate ol accuracy. In my
opinion, equations that incluoe more variables associateo with clinical
status have a higher oegree ol accuracy, aooeo Malone.
Other methoos lor oetermining energy requirements incluoe the
calories per kilogram techniques, which Malone consioereo a quick
starting point. The 2009 guioelines lor nutritional support in critically
ill aoults lrom A.S.F.E.N. ano the Society ol Critical Care Meoicine
,SCCM, recommeno 25 kcalkgoay as one ol the three suggesteo
methoos ,Martinoale RD, et al. Crit Cor. M.o. 2009,3:15,
Turning to the topic ol obesity ano the hypocaloric approach to
nutrition, Malone noteo that a booy ol work has locuseo on ioentilying
obese patients ano provioing lewer calories. By provioing reouceo energy
to the obese patient, perhaps we can minimize some ol the metabolic
exacerbation that occurs because ol the combination ol the obesity
ano the critical illness, she saio. Il weight loss occurs, preservation ol
lean booy mass is key. The A.S.F.E.N.SCCM guioelines recommeno
provioing the hypocaloric approach lor the obese patient, as lollows:
11 kcalkg to 1! kcalkg actual booy weight per oay or 22 kcalkg to
25 kcalkg ioeal booy weight per oay.
High protein intake is essential in the obese critically ill patient.
Increaseo amounts ol protein are neeoeo to support lean booy mass.
Frotein requirements are 2 gkg booy weight lor patients with a booy
mass inoex ,BMI, between 30 ano !0, ano 2.5 gkg booy weight lor
those with a BMI over !0 ,Choban FS, Dickerson RN. ^otr Clio Proct.
2005,20:!80,.
Frotein is essential in critical illness to minimize loss ol lean booy
mass, avoio the accompanying lunctional impairment ano increase
lunction recovery, saio Malone. In the critically ill patient, muscle
protein catabolism is positively correlateo with resting metabolic rate ,see
Iigure 3,. Although we cannot stem the loss ol protein, we can certainly
try to balance it. Generally, protein requirements in critical illness are
1.5 to 2 gkgoay. Selecteo populations, such as those with burns or on
continuous renal replacement therapy, have higher requirements.
Malone summarizeo her remarks by emphasizing that energy
expenoiture among ICU patients is highly variable, ano an energy
oelicit is associateo with negative outcomes. Inoirect calorimetry is
the ioeal methoo lor assessing energy requirements, but in its absence
clinicians will lino the Fenn State equation to be the most accurate
preoictive equation.
Ensuring salety in the prescription ano oelivery ol parenteral nutrition
begins with carelul attention to inoications ano caloric oose. These
lactors are essential to meoication salety, saio Jay M. Mirtallo, MS,
RFh, BCNSF,.
Accoroing to the 2009 A.S.F.E.N.SCCM guioelines, parenteral
nutrition is inoicateo in patients who cannot receive enteral therapy ,i.e.,
those with bowel obstruction, listula, ano mesenteric ischemia,. The
guioelines also recommeno that in the absence ol malnutrition, stanoaro
nutrition ,i.e., oral oiet, be given, ano parenteral therapy is inoicateo alter
seven oays il enteral nutrition is not leasible. The problem is that lor the
critically ill patient, stanoaro nutrition` usually means no nutrition at all,
ano caloric oelicits oevelop, explaineo Mirtallo. He went on to explain
that the evioence on which this recommenoation was baseo may be
outoateo. The recommenoation rellects oata lrom two meta-analyses
that noteo increaseo inlections ano complications in patients receiving
parenteral nutrition versus no nutrition whatsoever. However, the stuoies
incluoeo in the meta-analyses were olo, with publication oates ranging
lrom 19 to 199!. Iurthermore, there was great variability in oosing
ano glucose control among the stuoies.
In oiscussing the current valioity ol this recommenoation, Mirtallo
mentioneo the swinging penoulum regaroing nutritional support.
The early use ol parenteral nutrition, which was associateo with many
Pract|ca| Aspects of Goa|-D|rected Parentera| Nutr|t|on Therapy:
Safe Prescr|pt|on and De||very
Pr..ot.o o, )o, M. Mirtoll, MS, RP/, BC^SP, oo ociot. rf.r
f clioicol /orooc, ot T/. O/i Stot. Uoi..rit,, Cll.. f P/orooc,
io Cloooo, O/i, USJ.
Figure 3.
N
i
t
r
o
g
e
n

P
r
o
d
u
c
t
i
o
n

R
a
t
e

(
g
/
k
g

b
o
d
y

w
t
j
0.6
0.5
0.4
0.3
0.2
0.1
0.0
10 15 20 25 30 35 40
R
2
=0.25
M
u
s
c
l
e

C
a
t
a
b
o
l
i
c

R
a
t
e

g
/
k
g

b
o
d
y

w
t
j

w
t
j
3.0
2.5
2.0
1.5
1.0
0.5
0.0
10 15 20 25 30 35 40
R
2
=0.37
Resting Metabolic Rate (kcal/kgj
Oongress Rev|ew www.sccm.org June/Ju|y 2011
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17
40th Or|t|ca| Oare Oongress Rev|ew
complications, lell out ol lavor ano gave way to the use ol enteral
nutrition. Now we may be moving somewhere in the mioole, where
we`ll lino the true benelits ol both therapies, Mirtallo saio. He noteo
that lor glucose control in the ICU patient, the 2009 A.S.F.E.N.SCCM
guioelines recommeno a range 110 mgoL to 150 mgoL lor best
outcomes lrom parenteral nutrition.
When malnutrition is present in a critically ill patient, the 2009
guioelines recommeno initiation ol parenteral nutrition upon aomission
to the ICU. The guioelines oeline malnutrition as a recent weight loss
greater than 10 to 15 or booy weight less than 90 ol ioeal booy
weight. Ior patients unoergoing major upper gastrointestinal surgery,
parenteral nutrition is recommenoeo il enteral therapy is not leasible.
In such cases, it is optimal to provioe preoperative parenteral nutrition
ano continue it postoperatively. The guioelines caution against starting
parenteral therapy postoperatively because the ability to impact the
patient`s outcome is lost, ano in some patients the outcomes are worse,
aooeo Mirtallo. Iurthermore, they recommeno that parenteral
nutrition be useo only il the ouration is anticipateo to be more than
seven oays, because less than that is likely to have no ellect.
Three major concepts aooresseo in the 2009 A.S.F.E.N.SCCM
guioelines permissive parenteral nutrition unoerleeoing, supplemental
parenteral nutrition, ano hypocaloric leeoing lor obese patients have
captureo the attention ol experts as approaches to minimize aoverse
ellects ano improve ellicacy. The aim ol permissive unoerleeoing in
critically ill patients is to minimize the aoverse ellects ol caloric oelivery
by provioing 80 ol their requirements. Supplemental parenteral
nutrition is useo in patients at risk ol a caloric oelicit that woulo impact
their outcomes at some point. Hypocaloric leeoing lor obese patient is
useo to inouce weight loss.
Other approaches to minimizing the aoverse ellects ol parenteral
nutrition involve using a protocol to mooerately control glucose ano
using intravenous ,IV, oelivery ol lat emulsions. Baseo on strong
evioence lrom a prospective ranoomizeo trial, the 2009 guioelines
recommeno that IV soy-baseo lat emulsions be withhelo lor seven oays
in parenteral therapy to reouce the risk ol inlection. Expanoing on this
recommenoation, Mirtallo noteo, When we revieweo the salety ol lat
emulsions, it became clear that the problem was not so much with the
type ol lat emulsion, but rather how it was oelivereo ano aoministereo.
A review ol the literature inoicateo that rate ol inlusion has a signilicant
impact on salety regaroing both immunologic ano pulmonary lunction
,Mirtallo JM, et al. Joo P/orooct/.r. 2010,!!:o88,. Therelore, we now
make sure our inlusion ol lat emulsions is given continuously over a
2!-hour perioo, which seems to be the salest, most ellective way ol
oelivering the proouct, rather than given through intermittent inlusion,
which was the methoo useo in the stuoy that showeo great benelits to
withholoing IV lat emulsions.
Other aspects ol oelivery also have a major impact on salety.
Delivery ol parenteral nutrition occurs either through central venous
access, which carries the potential lor blooostream inlections, or through
peripheral oelivery, which poses the risk ol thrombosis or extravasation.
In central parenteral nutrition, stall training in proper catheter care is
vital to reouce the incioence ol blooostream inlection, Mirtallo saio
Another lactor allecting salety is the system useo lor oroering
ano compounoing. In a survey ol A.S.F.E.N. members, 88 ol
responoents inoicateo that they use stanoaroizeo parenteral nutrition
lorms ,Seres D, et al. ) Por.ot.r Eot.rol ^otr. 200o,30:259,. Nearly two
thiros ol responoents saio they observeo one to live errors a month.
Survey responses also revealeo signilicant variation regaroing the
manner in which parenteral nutrition is oroereo or labeleo. With
this in mino, A.S.F.E.N. recommenos that a stanoaroizeo approach
to parenteral nutrition is useo to improve patient salety ano clinical
appropriateness, remarkeo Mirtallo.
Among the parenteral nutrition errors noteo on the survey, 1 involveo
electrolytes. One issue relates to whether the pharmacy uses a stanoaroizeo
mix ol electrolytes, which has lew electrolyte abnormalities, ano then applies
that to the patient population, Mirtallo explaineo. The lewer aooitives
that you use, the lewer the errors you`ll have in compounoing.
Concluoing that parenteral nutrition is an important aspect ol
managing the critically ill patient, Mirtallo emphasizeo that the 2009
A.S.F.E.N.SCCM guioelines serve as a gooo lounoation but are not a
complete answer to many ol the challenges ol inoivioualizing therapy.
The sale prescription ano oelivery ol parenteral nutrition is oepenoent
on its inoication, oose ano inlusion as well as the system by which it is
oelivereo, he saio.
Sponsored by an educat|ona| grant from Baxter Hea|thcare.
Cont|nu|ng Educat|on Se|f-Assessment
Nutr|t|on |n the ICU: Ear|y Goa|-D|rected Therapy Is Key
3. How can nutr|t|ona| requ|rements be affected when metabo||sm changes from
fast|ng to stressed status?
a. The energy and g|ucose requ|rements may near|y doub|e.
b. The energy and g|ucose requ|rements may near|y tr|p|e.
c. The energy requ|rement may doub|e, and the g|ucose requ|rement
may near|y tr|p|e.
d. The energy requ|rement may tr|p|e, and the g|ucose requ|rement may
near|y quadrup|e.
4. A.S.P.E.N./SOOM gu|de||nes recommended that, when |t |s used, parentera|
nutr|t|on have a m|n|mum durat|on of:
a. 2 days
b. 3 days
c. 5 days
d. 7 days