It only seems fitting that the dietitian is right after lunch. But I promise I'm not going to talk about things like GI function and everything. But I'm going to add two comments to the talks we heard today. So be thankful I didn't hear all the talks. I would have had more. And one, that is, if you're in the ICU and you're doing a palliative extubation and they have a feeding tube in their nose, just get that little finger there and go, oops, and pull that out at the same time. Because it's very difficult. I will often do some of the consultation. Families will not want their loved one to starve. They'll say, I don't want him to starve to death. And if they get off the vent and they're breathing, you don't want to be the next Terry Schiavo or anything. And I'm from Barnes-Jewish where we did have the Quinlan case. I was there at the time. And the other comment I'm going to make is glycemic control. Yes, we're not doing tight control. But don't throw away your protocols. Just readjust your target range. Because I'm sure all of you, if you talk to your patient safety officers at your hospital, are getting dinged for every hyperglycemia and hypoglycemia. In the hospital right now with CMS, it's a reportable thing. So I would just try to adjust that so you kind of keep that. And it's always the ICUs that are guilty for hyperglycemia, pretty much. And also, the other thing we've done is we've engaged endocrine to help us for when we start steroids. So we're right on top of that. And that doesn't shoot up our hyperglycemia. OK, now I'm going to go over some other things. These are objectives today. And we're going to start with a case like everyone. So we have a 55-year-old African-American male who's got a history of asthma, admitted with flu shortness of breath, gets into the hospital about day three, decompensates, ends up in respiratory failure, and goes to the ICU. The only thing we know about this patient as far as nutrition goes is that he's lost 9% of his body weight over the past month, and he has a BMI of 22. So when you're thinking about the different phases of acute care, and the days, we have days up here, but you all know those are arbitrary. For some patients, that acute phase can last longer than one to two days. But what we do know is there are a lot of times where we have metabolic instabilities. In fact, they're very prone to metabolic instabilities during this acute early phase. And our patients are in a state of hypercatabolism, so they're kind of building up a caloric debt. They're also undergoing proteolysis. So if they're in these phases for a long period of time, they're also going to be prone to develop sarcopenia. So something to keep in mind. But the one thing I find that we don't think about all the time is the gut dysfunction that these patients have during this early acute phase. And this gut dysfunction can drive multiple organ dysfunction in several ways, as you see here on the slide. And we'll talk about a few of those. So in a healthy individual, generally, we have a healthy microbiota. And we have tight junctions in our gut epithelium that keeps all those bad humors from our GI tract going systemic, right? And keep in mind that the gut is your largest immune organ in your body. A lot of us kind of forget that. But what happens when our patients are sick or we're treating them, right? So what happens now is they may have low flow to their gut. They're septic. They're not going to be able to handle the nutrients that we give them. Some of our treatments also can impact. If we have to do a resuscitation, that gut gets really edematous. And it really shortens that microvilli. And the medications are totally going to wipe out their microbiota that's trying to survive in a hostile environment. And in this study, it was done some time ago. But it looked at 115 critically ill patients. And it compared it to a healthy individual from the American Gut Project. So down here is the healthy individual. And you can see, by the time a patient's even admitted to the ICU, they're already in a state of dysbiosis. By the time they're discharged, that has even worsened. And do you know how soon this can happen? If they're already this way at admission, what do you think? Within 48 hours. So within 48 hours, that healthy flora probably is getting wiped out in their GI tract. And so what happens then? Then what we do is we have a breach of that epithelial barrier. So we lose those tight junctions. And then what we have is this emergence of this pathobiome that then can go systemic. Usually, it goes to the lungs first. So sometimes that respiratory insufficiency you see may be partially due to this, if you look at some of those organisms. And you have this gut-derived inflammation going into multi-organ failure. So the question becomes, what can we do about it? Does giving a patient enteral nutrition make a difference? An older study looking at two groups of patients, one group that was fed perennial, one enteral, saw that in the perennial group, they did have dysbiosis. When they were able to advance to enteral feed, they were able to reverse some of that. And we've got more data, a lot of animals, some human, that supports that even a small amount of enteral nutrition helps to preserve that barrier to some extent. So since it's helping to preserve that barrier, we want to think about, when should we get that started? So if we look at our case, our patient has now got his resuscitation. He's on a little bit of pressures and an acute kidney injury. And I'm in rounds with the team. And they're asking me, how should we proceed with nutrition therapy? Before I answer that question, I'm thinking about these questions in my mind. So if I asked you right now, is this patient at what we call nutrition risk, how many of you would say yes? If I ask you, does this patient have a medical diagnosis of malnutrition, how many of you would say yes? If I said, is this patient at risk of receiving syndrome, how many of you have no idea and you hope I tell you? A few. And we'll talk about the hemodynamic stability here in a minute. So what do the guidelines say about nutrition risk? And I have some guidelines slides. Those are the ones you'll want to look at to know what you're answering against the guidelines. Say that we should check for nutrition risk in our patients within 48 hours. In the ICU, predominantly, we use a modified NUTRIX score to determine nutrition risk. It's been the most studied in intensive care patients. And nutrition risk is really to say if that patient were to develop malnutrition, could it impact their outcome? And can we treat it nutritionally, right? So in our patient, we run them through. And he has a score of six. That puts him in a high-risk category. So whoever said yep, bingo, you got it right. And a lot of times, people ask me, do you really calculate that on everyone? Nope, because how many of us got it right just thinking that from the end of the bed sometimes and from their history, you know where they're going to fall after a while? And then protein, calorie, malnutrition. There are, as a nutrition and medical diagnosis, which are basically the same, you want to get the medical diagnosis added, especially if your dietician brings it up. Our patient has some of those factors and, in fact, meets the criteria for severe acute malnutrition. Now, the one that you'll probably see most often and will become probably in the next guidelines as recommended will be the global leadership or the GLIM criteria, because those are international guidelines to determine malnutrition. And we know that malnutrition makes a difference. These patients are going to have more complications, maybe not just in the ICU, but also beyond the ICU as well. And a lot of these patients will end up being some of our PICS patients that we'll take care of. Refeeding syndrome. These are the risk factors. Our patient did fall in there at risk for refeeding syndrome. You're correct. So if you have a patient, this often goes unnoticed, I think. Because how many of you, if you get labs on your patient, get a BMP or CMP? How many of you add the MAG and FOS every time? Pun omission. OK, that's good. Not everybody does, so they don't see the low MAG and FOS. So if someone's at risk, you should check that baseline and get it repleted before you start feeding. And it should be a slow feed. And you should also get them started on some thiamine. What kind of acidosis would you see in someone who has a severe thiamine deficiency or someone who went into refeeding? All right. So that's the other type of acidosis we can see with refeeding. So what do we say about timing? So the guidelines still are saying that we should think about feeding within 20 to 48 hours. And enteral is still preferred over perennial. If you can't get to enteral, you will start perennial. But this is different. In the guidelines that just came out, we used to say try to start around 20 to 25 cows within that first three days. That has changed on the guidelines to 12 to 25 calories in the first seven days. And the protein requirement was prior to the effort trial coming out, and it hasn't been changed. So let me show you a little bit about why these have changed. It's been a big year for nutrition studies, a big, actually, decade. But over the past year, we've had some big studies come out. This is one of them, the FRON study. It had 1,200 patients, and they were looking at early enteral, early perennial, versus no early nutrition. And it was multiple ICUs, an observational study. But they did a great job of recording what was actually delivered as opposed to what was prescribed. So just because I always tell my critical care fellows just because you write it on that board doesn't mean it actually happens all the time. You've got to see what actually happened. And let me see if I still got that. Yeah, so in the beginning, they have ICU days on the bottom, patients on the top. Most patients that weren't getting fed were in those first few days. But you see by day five, a lot of patients were getting fed. Most patients, the orange is enteral nutrition. Never was there a lot of perennial nutrition used. But I think the key is here. For patients that were fed early, this is their line, by day three, they were getting about 20 cows per kilo, and it leveled off. The ones that they didn't automatically start early, but as they felt they looked like they could be fed, there was this nice, slow progression in calories. And what they found in terms of mortality was that those who did not get early feeding did better as far as ICU and 28-day mortality in these patients. In this group, they kind of looked at not just the FRON study, but every big study that has been out there that looked at this full versus less feed, so it kind of pulls it all together. And what you can see that whether it's full energy delivery versus permissive underfeeding or trophic feeding, which is about 10 mils, 20 mils an hour, or the slow progression like we saw in the FRON study, in every case, the full feed people where they fed a lot in the very beginning of their ICU stay did worse. Now, if we go back to our case, we talk about is the patient hemodynamically stable? You know there's really no definition for that. But one of the things about these patients is when they're in this kind of flux stage, they cannot handle metabolism of these macronutrients we're giving them. So your body's working hard on other things. It's not able to handle the nutrients. What you see here is just expert opinion. When I worked with my attendings during COVID, when I got kicked out of the ICU and couldn't around. As far as Beth, we got to know when to turn off the two feeds and discuss what we should do. So I kind of gave them an outline. You can take it or leave it. The other thing that looked at feeding in shock as far as early feeding to try and answer that question of enteral and parenteral was the Neutrea 2 trial. And it was a huge trial. This is back in 2018. You can see 1,200 patients in each one. But they started at high calorie, normal calories, early in both of them. And it made no difference in 28-day mortality where they were looking at 35% to 37% mortality in both sets of patients. So still high mortality in both sets. And a little bit more ballaschemia. Not a lot of mortality. Not cases in the early fed. But then Neutrea 3, they came up to look at this question. This is just out this past year. And they wanted to kind of answer more so that question of low versus standard feeds. And again, very large, 3,000 patients. And they did a great job here really getting a distinction between the groups. In nutrition studies, often we don't get a true difference. But as you can see here on the calories, in the low group, they were getting like six calories per kilogram. In the high group, 22. So you got a big distinction. Also in protein, about 0.3 to 0.4 grams versus about 1.2. So they really had two distinct groups. And what they found was, while there wasn't really a significant difference if you look up here in mortality, what they found was that still, those that got fed the lower amount in those early days of the acute phase had less ventilator days, better readiness for discharge, and then the less GI dysfunction that we know is a problem in those patients. The effort protein trial, trying to look at the difference, just keeping the calories the same in the group, lower calories, and then trying to adjust the protein. Now they didn't get as good of a separation on what was actually delivered. So they didn't hit significance, but you can see there was a trend for more complication at 60-day mortality in the higher-fed group. You're all sitting there going, is this dietician really telling us not to feed anybody in the first few days? It's blowing your mind. I know it is. So we gotta find the sweet spot, right? So if we look at the percent of calorie protein requirements delivered versus risk of harm on here, you'll see that this is like the neutral zone, and we can get up, we don't wanna stay too long there because we don't want to get too much of a deficit. We wanna be able to recover. But we see it at about 70%. We don't wanna go over 70% of their caloric goals in that first week of ICU because it might cause more harm than good, right? And then also if you look at what spectrum of disease, do they get the most benefit from nutrition support? The mild disease are probably gonna get better no matter kind of what we do to them, but that moderate to moderate severe are gonna benefit the most from nutrition, and then those very severe, severe patients are not gonna get that benefit as much, especially in the early phase. So let's wrap it up and say, how do we feed them, Beth? So this is what is recommended at this time is that we do start early, but we're starting internal nutrition early at a very low level, at 10 mil, 15 mils per hour to keep that GI tract healthy. So we're doing it almost for non-nutritional. We're giving them calories, that's true, but a low amount, but we wanna bathe that GI mucosa and maintain that barrier and that immune function as much as we can. We are not gonna exceed 70% of their needs in that early phase of acute illness, however that may be. I mean, we can assume it's seven days, but we know that's arbitrary. And then after they're beyond that, we want to push them to 80 to 100%, which often gets missed, that we forget to then bump them up as they go into the recovery stage. I'll see a lot of patients that will leave the ICU and I'll check on them. I think, why are they still getting just this small amount of feeding? Now's the time when they're doing rehab, they need more calories. So what's the answer? Shut it out? There you go. So back to our case, what did we do with him? He got started on low dose internal feeds, so 29% of his needs, still on some pressers with the goal to advance when he started to get off pressers. This is just for you to look at. I took the guidelines and I made a little cheat sheet on how much protein I would give per condition. So that's just expert opinion, but based on guidelines. So our case, but what happened after day three of internal nutrition? It wasn't an aspiration, but there was a decline in respiratory status, ended up going on ECMO. So internal nutrition stopped. So now what do you do? It's been six days, you rarely got any internal nutrition. We know he's at high nutrition risk, he's malnourished. So then you have to start to think about perinatal nutrition. Now some of these cases up here are kind of no brainers. You'd be able to answer, that's when they get perinatal nutrition. But often we forget about the failed internal trials. So if you get to the point where someone's having failed internal trials, you wanna think about perinatal nutrition, especially in those patients that have a degree of malnutrition or at high nutrition risk. But it doesn't mean you have to start them off the bank at goal calories. Everyone's like, oh, if you do perinatal nutrition, I can start them at goal. You still wouldn't do that in someone who's still in an acutely phased kind of, and this is probably like a second hit right here. So you still wouldn't go to full calories right away. So what happened with our patient, they did get the supplemental perinatal nutrition with the goal to restart them on internal, keep trying it, just lower the amount. And they got it to the point where once they got off ECMO, they were able to advance internal nutrition. The best way to do it is bring one down while you bring the other up, not just stop, stop. But try to keep the carbohydrate amount that you're giving stable to keep help with your blood glucose control at the same time. I bring up this intermodular protein because if you calculate protein on some of our products that doesn't meet their needs, but it's tough to make sure those actually get in patients. Then our patient went on to get better. And you'll see on day 13, the yogurt with probiotics. I like to try and get it reestablished, that microbiota, as soon as we can. Get some healthy bacteria in there. So we do have that available at our hospital that they can order if they're willing to eat it. And so in summary, you're gonna still answer that early internal is preferred over perinatal, mostly for the beneficial effect on our GI barrier. Gonna avoid overfeeding, so you're not gonna go above 70% in that first week. If you can't get them to go in that first week, you're gonna add supplemental perinatal nutrition, especially if they're at high nutrition risk or severely malnourished. And then you're gonna reevaluate and once they get to the recovery phase and push those back up. And so which of these is correct? One, two, nobody knows? Two, all right, that's right. Both provide low calories and low protein in the first few days. And with that, I am done and I'm passing it off. Thank you.

ICU nutrition

palliative extubation

glycemic control

enteral nutrition

metabolic instability

parenteral nutrition