Nutrition Without Harm: Feeding the Critically Ill Patient

NUTRITION WITHOUT HARM: FEEDING THE
CRITICALLY ILL PATIENT
NUTRITION SANS PREJUDICE: NOURRIR LE
PATIENT EN ETAT CRITIQUE
Wednesday, March 11 2015
Mercredi 11 Mars 2015

Your Hosts & Presenters
Vos hôtes et présentateurs
Leanne Couves, Improvement Advisor
L. John Hoffer, MD, PhD, FRCPC; Professor of
Medicine, McGill University; Attending Physician
Jewish General Hospital.
Paule Bernier, P.DT., MSc.; Présidente, Ordre professionnel des
diététistes du Québec; Sir MB David Jewish General Hospital
(McGill University), Montreal
Ardis Eliason, Technical Host
Hélène Riverin, French Language Support, CPSI
211/03/2015

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11/03/2015

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511/03/2015

11/03/2015 6
Objectives of the Call
 To understand the current evidence on ICU
nutrition.
 To translate this evidence into practice for
energy.
 To translate this evidence into practice for
macronutrients.

Dr. John Hoffer
NUTRITION WITHOUT HARM: FEEDING
THE CRITICALLY ILL PATIENT
NUTRITION SANS PREJUDICE: NOURRIR
LE PATIENT EN ETAT CRITIQUE

Canadian Patient Safety Institute
Nutrition Without Harm:
Feeding the Critically Ill Patient ~
Protein and Energy Requirements
L. John Hoffer, MD PhD FRCPC
McGill University
March 11, 2015

Objectives
• Describe shortcomings and misunderstanding of the
evidence regarding optimal protein and energy provision
in critical illness with attention to the relationships
between protein and energy provision
• Highlight contradictory recommendations for protein
provision in critical illness
• Suggest a rational and testable approach to protein
provision in the ICU

Financial Interest Disclosure
No relevant financial relationships with any
commercial interests

Why Such Contradictory
Recommendations?
• ASPEN: Critical illness dramatically increases
protein requirement; therefore provide
– 1.5 g protein/kg per day + full energy provision for
non-obese patients: e.g. Ziegler NEJM 2009;361:1088
– 2.0-2.5 g protein/kg IBW + 50-75% energy for obese
patients: Choban et al JPEN 2013;37:714
• Recent high profile clinical review:
– Recommends hypocaloric “permissive underfeeding”
– Protein is unimportant
• Casaer and van den Berghe NEJM 2014;370:1227

Early Generous Nutritional Support Doesn’t
Improve ICU Outcomes
Casaer and van den Berghe NEJM 2014;370:1227

The Nutritional Physiology of Critical
Illness
• The body cell mass (BCM) contains two
compartments
– peripheral (80%); muscle, slow turnover
– central (20%); viscera etc, rapid turnover

Fat
20%
Body cell mass
50%
Extracellular fluid
20%
Structural tissues 10%

Nutritional Pathology of Critical
Illness
• Severe systemic inflammation dramatically increases net
muscle proteolysis, increases central protein synthesis
(rate-limited by free amino acid availability), and
increases amino acid catabolism-urea synthesis
• Consequent rapid dramatic muscle atrophy leading to
weakness, debilitation and inadequate central protein
synthesis to support healing and immunity

Obesity Does Not Preclude Protein
Malnutrition
• Muscle atrophy vastly outstrips fat loss in critical illness
• Most ICU patients are overweight or obese
• Severe muscle atrophy is likely very common in the ICU,
but goes unnoticed, and rarely thought about
• Obesity misleads physicians into assuming their patient
is “well nourished”

Recommendations for Protein
Provision in Critical Illness
• ASPEN: Critical illness dramatically increases
protein requirement
– 1.5 g protein/kg per day + full energy provision for
non-obese patients: e.g. Ziegler NEJM 361:1088 (2009)
– 2.0-2.5 g protein/kg IBW + 50-75% energy for obese
patients: Choban et al JPEN 37:714, 2013
– Normal people require ~ 0.8 g protein/kg/day

Scanty and Abysmal Clinical Evidence
• Unclear definitions of critical illness
• Very low enrolments, enormous inter-group
heterogeneity, hopelessly low statistical power
• Impossible to identify any average protein level as
maximally beneficial
• Deliberate energy over-feeding in order to maximize
muscle protein accretion
• Failure to appreciate that average intake is not “safe”
protein intake

Abysmal, ctd.
• Failure to stipulate how body weight determined, and
how corrected for over-hydration and obesity
• Aqueous solutions of mixed amino acids provide 17%
less protein substrate than widely assumed
– Thus,1.8 g mixed free amino acids must be infused to provide
1.5 g protein substrate

But…
• Every study indicated improving N balance, protein
turnover, or better clinical outcomes as protein or amino
acid provision increased to the maximum provided dose
of 2.5 g/kg per day

Conclusions
• Widespread view that 1.2-1.5 g protein/kg/day is
“sufficient” – hence not to be exceeded – is based upon
an unrepresentative biased subset of low-quality studies
• Patients were deliberately energy over-fed; appropriately
limited energy provision calls for much more protein
• On balance, the existing evidence compatible with
average requirement > 2.0 g/kg/day
• 2.5 - 3.0 appears safe (specific exceptions)

Contradictory Recommendations
• ASPEN: Critical illness dramatically increases protein
requirement
– 1.5 g protein/kg per day + full energy provision for non-obese
patients: e.g. Ziegler NEJM 361:1088 (2009)
– 2.0-2.5 g protein/kg IBW + 50-75% energy for obese patients:
Choban et al JPEN 37:714, 2013
• Casaer and van den Berghe: Allow hypocaloric feeding
(“permissive underfeeding”) for up to 7 days: NEJM
370:1227, 2014
– Protein unproven and not important

High level calorie provision does not
improve short-term clinical outcomes in
the ICU
---Casaer and van den Berghe NEJM 2014;370:1227
Calorie Support RCTs in the ICU

Daily Protein Provision* (% of formal recommendation**)
in RCTs of Early Nutritional Interventions in Critical Illness
Study Dose on protocol day 6 or 7 Average dose days 1 thru 6 or 7
NHLB Institute
(2012) EDEN
Intervention: 0.68 (45%)
Control: 0.22 (15%)
Control: 0.22 (15%)
Doig et al
(2013) Early PN
Intervention: ~ 0.67 (45%)
Control: ~ 0.43 (29%)
Control: ~ 0.43 (29%)
Caesar et al
(2011) EpaNIC
Control: ~ 0.10 (07%)
Control: ~ 0.10 (07%)
Heidigger et al
(2013) SPN
Control: 0.80 (53%
Control: 0.80 (53%
Singer et al
(2011) TICACOS
Control: 0.63 (43%)
Control: 0.63 (43%)
Harvey et al
(2014) CALORIES
Control: 0.75 (53%)
Control: 0.60 (40%)
* g/kg
** 1.5 g/kg

High CALORIE provision does not
improve short-term clinical outcomes
in the ICU
But PROTEIN provision was grossly
“inadequate” in almost every RCT

Why the Obsession with Calories?

What is the Scientific Basis for the
Assertion that ICU Patients Need Lots of
Calories?
• Energy expenditure increases in critical illness
• Hypocaloric conditions promote muscle wasting
• Deficient calorie provision is associated with
worse clinical outcomes
– Casaer and van den Berghe NEJM 2014;370:1227

All These Premises are Wrong
• Energy is indeed important for efficient dietary protein
retention, but providing more than ~ 50% of energy
expenditure improves N balance very little further,
especially in critical illness

Dickerson Curr Opin Clin Nutr Metab Care 8:189,2005

False Premises Explained
• Hypocaloric states do indeed reduce the efficiency of dietary protein
retention, but energy provision greater than ~ 50% of energy
expenditure improves N balance very little further, especially in
critical illness
• The quintessential protein-sparing nutrient is protein, not
calories
• The observed association between low calorie intakes and poor
outcomes is far more rationally explained by extremely low protein
intakes
• Most ICU patients have at least ample body fat. Why would they
need more calories?

This is what we may conclude from
the current data: High CALORIE
provision doesn’t improve short-term
clinical outcomes in the ICU

But protein provision was inadequate
in every clinical trial, even though the
physiological data overwhelmingly
indicate it is the crucial macronutrient
to provide in this setting

Why the Obsession with Calories?
• Ignorance of nutritional principles; over-simplified
and physiologically naïve therapeutic hypotheses
• Nutritional bigotry and the streetlight effect

Bigotry
• Unreflective & often unconscious
oversimplification, stereotyping and labelling

2.0-2.5 g protein/kg IBW + 50-75% energy expenditure

A Plea for Evidence-based Medicine in
the ICU – Pending Adequate RCTs
• For patients who have an adequate store of body fat,
hypocaloric high-protein nutrition is safest and most
physiologically logical
• Therefore, follow the ASPEN guidelines for obese
patients for all patients with BMI > 20
• Highest priority patients: existing low muscle mass
and/or major protein catabolism

Physiologically-based Nutritional
Therapy in the ICU
• Avoid toxic energy overfeeding by limiting calories to 2/3
estimated energy expenditure
• Use PN to provide 1.8 g mixed amino acids* and 3 g
dextrose/kg normalized dry BW per day within 48 h of
admission
• Adjust PN appropriately every 48 h as EN increases
* Equivalent to 1.5 g protein

Priority Patients
• Borderline or subnormal muscle mass
– Protein energy malnutrition, cachexia, disuse atrophy,
old age, neuromuscular disease
– Examine muscle mass; discount BMI
• Patients experiencing intense protein catabolism

Cautions
• Significant fat depletion (BMI < 18-20)
• Severe liver dysfunction
– Advanced liver disease, hypoperfusion, ornithine
transcarbamoylase deficiency, valproic acid therapy
• Renal insufficiency if renal replacement therapy is
unavailable.

Why parenteral and enteral
solutions of free amino acids
provide 17% less protein and
energy than intact protein
Hoffer LJ Am J Clin Nutr 2011; 94:1396

http://schoolworkhelper.net/protein-structures-primary-
secondary-tertiary-quaternary/

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“Taking the Pulse” Poll
11/03/2015 49

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11/03/2015 50

Canadian ICU Collaborative
Faculty
Paule Bernier, P.Dt., Msc, Présidente, Ordre professionnel des diététistes du Québec; Sir MB David Jewish General Hospital
(McGill University), Montreal
Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary
Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre
Leanne Couves, Improvement Advisor, Improvement Associates Ltd.
Carla Williams, Patient Safety Improvement Lead, CPSI
Bruce Harries, Collaborative Director, Improvement Associates Ltd.
Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University
Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology,
University of Western Ontario; Chair/Chief of Critical Care Western
Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist – Critical Care, London Health Sciences Centre;
John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital
Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium
Guidelines, Society of Critical Care Medline (SCCM)
5111/03/2015

Reminders
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 Call is recorded
 Slides and links to
recordings will be
available on Safer
Healthcare Now!
Communities of Practice
 Additional resources are
available on the SHN
Website and
Communities of Practice
 L'appel est enregistré
 Les diapositives et liens
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soins de santé plus
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Communautés de pratique
 Des ressources
supplémentaires sont
disponibles sur le site Web
SSPSM et Communautés
de Pratique
5211/03/2015

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11/03/2015

Nutrition Without Harm: Feeding the Critically Ill Patient

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