1. Optimizing the Benefits and Minimizing the Risk of Nutrition Support in the Critically Ill Evidence Based on Canadian Clinical Practice Guidelines Dalhousie Critical Care Lecture Series

4. If you’ve ever questioned the risks of nutrition…..

6. EN vs. PN in the Critically Ill Patient

7. EN vs. PN in the Critically Ill Patient

9. TPN

11. Early vs Delayed Nutrient Intake Criticalcarenutrition.com

12. Early vs Delayed Nutrient Intake Criticalcarenutrition.com

13. Does it Matter What you Feed? JAMA 2001;286:944

15. Underlying Rationale Wheeler NEJM 1999;340:207 Surgical Critically ill

16. Population Nutrients Immunonutrition: What Nutrient for What Population? Possible Benefit … … … … … Omega 3 FFA … … … … Possible Benefit … Antioxidants … EN Possibly Beneficial EN Possibly Beneficial … PN Beneficial (? receiving EN) Possible Benefit Glutamine No benefit No benefit No benefit Harm No benefit Benefit Arginine Acute Lung Injury Burns Trauma Septic General Elective Surgery Critically Ill

19. Is more better? Taylor CCM 1999;27:2525 p=0.08 p=0.046 p=0.02 Good Outcome

22. Strategies to Maximize the Benefits and Minimize the Risks of Enteral Nutrition

26. Amount of Gastroesophageal Regurgitation Mean Net CPM/GM P=0.04 Day 1 * Day 2 NS Day 3 NS

27. Amount of Aspiration Mean Net CPM/GM * P=0.09 Day 1 NS Day 2 NS Day 3 NS

28. Does Postpyloric Feeding Reduce Risk of GER and Aspiration? P=0.004 P=0.09 11.7 75 33 Total 0 5 1 D4 1.8 11 3 D2 4.1 27 8 D1 5.8 32 21 Stomach % positive for Aspiration % positive for GER # of patients Tube Position

30. Small Bowel vs. Gastric Feeding: A meta-analysis Effect on VAP Criticalcarenutrition.com

32. Pro-motility agents?

33. EN >>>PN Feeding Protocols Small bowel > gastric Semi-recumbent position Pro-motility drugs

34. TPN

37. Supplemental PN: Benefit? Mortality 35.7% 25.0% 0.001 0.39 Deegan Clin Inten Care 1999;10:131 A Retrospective Study Study Outcomes 0.01 6305.5 ±1464.9 4388.7 ±2159.2 Total Energy Rec’d/day (kJ) 36.4 19.6 Hospital stay (days) 0.001 18.3 8.7 ICU stay (days) 0.04 75.0 ±19.9 51.2 ±25.2 Total Protein Rec’d/day (g) P value Combo group (n =28) Enteral group (n=28) Description

38. TPN

39. Prospective Studies Criticalcarenutrition.com

40. Prospective Studies Criticalcarenutrition.com

41. TPN

43. Strategies to Maximize the Benefits and Minimize the Risks of Parenteral Nutrition

45. Lipids in Critically Ill Patients? 2.4 1.4 0.04 Battistella J Trauma 1997;43:52 * Depressed T-cell function in Lipids Group 0.0001 21 ±2 28 ±2 Nonprotein calories 0.78 -9 ± 5 -9 ±7 Nitrogen balance 5 (19%) 13 (43%) Line Sepsis 0.05 13 (48%) 22 (73%) Pneumonia Infections/patient 39 72 Total Infections P value No Lipids (n =27) Lipids (n=30) Outcomes

46. Lipids in Critically Ill Patients? Battistella J Trauma 1997;43:52 Days

47. TPN

51. Timing of TPN Sandstrom Ann Surg 1993;217:185 % (days) Minimal nutrition support for more than 2 weeks associated with worse outcomes

54. TPN

55. Effect of Parenteral Glutamine in the Critically Ill

57. Aggressive EN Feeding Protocols Small bowel > gastric Semi-recumbent position Pro-motility drugs Limited Role for TPN

61. RCT’s in Pancreatitis PN vs Standard EN vs PN Am J Surg Sax 1987 Am J Clin Nutr Louie 2002 Gut Windsor 1998 Nitrition Olah 2002 JPEN McClave 1997 BJS Kalfrentzos 1997 Am J Gastr Abou-Assi 2002 EN with glutamine EN with probiotics (lactobacillus) Clin Nutr Ockenga 2002 PN with parenteral glutamine Hepatogastr Halllay 2001 BJS Olah 2002 Nutr Hosp Hernandez-Ara 1996 Eur J Surg Pupelis 2000 EN vs Standard (post-op) BJS Powell 2000 EN vs Standard

62. EN vs PN in Acute Pancreatitis EN feed n Population Study polymeric 25 abstract severe (>4days) Louie 2002 polymeric 34 pseudorand acute Windsor 1998 polymeric 89 pseudorand acute Olah 2002 semi-elemental 38 mild, acute on chronic McClave 1997 semi-elemental 38 severe Kalfarentzos 1997 elemental 53 acute Abou-Assi 2002

66. Patient Characteristics Kalfarentzos BJS 1997 39(22-73) 40(25-83) Hosp LOS 23+/a-6 22+/-6 Antibiotics days 15(11-19) 14(12-16) hemodialysis 11(7-31) 15(6-16) vent days 12(5-24) 11(5-21) ICU LOS 16 14 gallstones PN n=20 EN n=18

67. Patient Outcomes: Kalfarentzos *values in parentheses are total numbers of complications 2 1 mortality 15(27)* 8(10)* patients with any comp 10(15)* 5(6)* patients with septic comp 4 2 pneumonia/ARDS 2 1 UTI 3 1 bacteremia 2 0 pancreatic fistula 1 0 pseudocyst 0 1 abscess 4 1 infected pancreas 9 4 hyperglycemia 2 0 CRBI