SSC 2012 Guidelines

Nutrition
F. Machado, D. Angus
Nutrition
General
Other

Copyright 2014 SCCM/ESICM

SSC Nutrition
Extensive literature
Often not recent
Often small studies with methodological
issues
Often not directly assessing sepsis
Only four statements included in guidelines
When to start
Amounts to be given
The use of parenteral nutrition
Immunonutrition
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Nutrition
We suggest administering oral or enteral
feedings, as tolerated, rather than complete
fasting or provision of only intravenous
glucose within the first 48 hours after a
diagnosis of severe sepsis/septic shock
(Grade 2C).

Marik and Zaloga. Crit Care Med. 2001;29:22642270

Heyland et al. JPEN J Parenter Enteral Nutr. 2003;27:355-373
Doig et al. Intensive Care Med. 2009;35:20182027
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Reviews of Early Feeding

Marik and Zaloga. Crit Care Med. 2001;29:2264-2270

(15 studies, n=753; mortality data only on 6)

Heyland et al. JPEN J Parenter Enteral Nutr. 2003;27:355-373

(8 studies , n=317)

Enteral feeding in up to 36 hours of hospital admission or after surgery

No difference in mortality
Lower risk of infection relative risk 0.45 (0.300.66)
Shorter hospital length of stay: 2.2 days (0.813.63)
Enteral feeding started in 24 to 48 hours
Trends towards reduction in mortality and infectious disease
complications

Doig et al. Intensive Care Med. 2009;35:2018-2027

(6 studies, n=234; 3 trauma, 1 surgical, 1 burn, 1 critically ill)

Enteral feeding in the first 24 hours of ICU admission or injury

Significant reduction in mortality [odds ratio = 0.34 (0.140.85)]
Significant reduction in pneumonia [odds
ratio = 0.31
Indirectness:
not (0.120.78)]
in septic patients
Weak evidence but no sign of harm
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Nutrition
We suggest avoiding mandatory full caloric
feeding in the first week, but rather suggest
low-dose feeding (e.g., up to 500 kcal per
day), advancing only as tolerated (Grade
2B).

Taylor et al. Crit Care Med. 1999;27:25252531

Ibrahim et al. JPEN J Parenter Enteral Nutr. 2002;26:174181
Arabi et al. Am J Clin Nutr. 2011;93:569577
Rice et al. Crit Care Med. 2011;39:967974
Rice et al. JAMA. 2012;137:795803
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n= 200
Target
Control: 25-30 kcal/kg/day
Trophic feeding : 240-480 kcal/day
Up to day 6

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Possible increase in gastrointestinal complications with enhanced feeding

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JAMA. 2012;137:795803
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JAMA. 2012;137:795803
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N= 233
Target: permissive 60%-70%; enhanced: 90%-100%

Percentage of energy intake requirements

Permissive 60% vs enhanced 71%
Target not achieved in the enhanced group

Hospital mortality
Underfeeding 30.0% vs. target group 42.5%
Relative risk, 0.71 (0.50, 0.99); P= 0.04
Not powered for mortality assessment
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Nutrition
We suggest using intravenous glucose and
enteral nutrition rather than total parenteral
nutrition alone or in conjunction with enteral
feeding (Grade 2B).

Braunschweig et al. Am J Clin Nutr. 2001;74:534542

Heyland et al. JPEN J Parenter Enteral Nutr. 2003;27:355373
Gramlich et al. Nutrition. 2004;20:843848
Dhaliwal et al. Intensive Care Med. 2004;30:16661671
Peter et al. Crit Care Med. 2005; 33:213220
Simpson and Doig. Intensive Care Med. 2005;31:1223
Casaer et al. N Engl J Med. 2011;365:506517
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N = 4640
Early parenteral nutrition: within 48 hours of ICU admission
Late parenteral nutrition: on day 8

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Nutrition
We suggest using nutrition with no specific
immunomodulating supplementation in
patients with severe sepsis (Grade 2C).

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Arginine
Arginine should not be used
Can lead to unwanted vasodilation,
hypotension, and enhanced inflammation
Only small and underpowered studies
reported

Bower et al. Crit Care Med. 1995;23:436449.

Galbn et al. Crit Care Med. 2000;28:643648.
Caparrs et al. JPEN J Parenter Enteral Nutr. 2001;25:299308
Preiser et al. JPEN J Parenter Enteral Nutr. 2001;25:18218

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Glutamine
Glutamine should not be used
No impact on mortality
Some positive secondary outcomes
(reduction in infections and organ
dysfunction)

Single Studies
Meta-analyses

Heyland et al. JPEN. 2003;27:355

Jian et al. Zhonghua Shao Shang Za
Zhi. 2009;25:325
Avenell A et al. Proc Nutr Soc.
2006;65:236
Avenell A et al. Proc Nutr Soc.
2009;68:261
Novak et al. Crit Care Med.
2002;30:2022

Fuentes-Orozco et al. Clin Nutr.

2004;23:13
Beale et al. Crit Care Med.
2008;36:131
Grau et al. Crit Care Med.
2011;39:1263
Wernerman et al. Acta Anaesthesiol
Scand. 2011;55:812
Andrews et al. BMJ. 2011;342:d1542
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Glutamine-supplemented parenteral or enteral nutrition in critically ill patients

No effect on mortality

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After guidelines were published

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Omega-3 Fatty Acids

Omega-3 fatty acids should not be used

Previous studies showing benefit used omega-6
enriched diets in the control arms

Pontes-Arruda et al. Crit Care Med. 2006;34:2325

Gadek et al. Crit Care Med. 1999;27:1409
Singer et al. Crit Care Med. 2006;34:1033

More recent studies showed no benefit and possible

harm

Friesecke et al. Intensive

Care Med. 2008;34:1411
Barbosa et al. Crit Care.
2010;14:R5
Gupta et al. Indian J Crit
Care Med. 2011;15:108

Rice et al. JAMA. 2011;

306:1574
Stapleton et al. Crit Care
Med. 2011;39:1655
Grau-Carmona et al. Clin
Nutr. 2011;30:578

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60-day hospital mortality: 26.6% vs. 16.3%, P=.054

75% with sepsis or pneumonia

JAMA. 2011;306:15741581
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Summary
SSC guidelines
Generally supportive of minimal
nutritional intervention during initial ICU
stay
Statements largely suggestions, rather
than recommendations
Lack of large, robust, targeted
randomized controlled trials

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