Hello, everyone. My name is Keaton Smitana. I am a neurocritical care pharmacist at The Ohio State University in Columbus, Ohio. And today during this portion of the year in review, we will be discussing updates and nutrition for the critically ill. I have no financial conflicts of interest to disclose. And these are the two studies that we'll be highlighting during this discussion and kind of leading to some of the questions that we'll be posing on how we approach general nutrition in our critical care patients. So when it comes to nutrition, it's not or shouldn't be a surprise to most of you that we often fall short of the goals that we are setting out to achieve. And this has been shown time and time again, and studies that have been published. In this specific study, this was our own experience in a neurocritical care unit. And we looked at the first seven days of general nutrition that a patient received. And we compared that to indirect calorimetry data. We would receive indirect calorimetry within 48 hours. And then we extrapolated the daily resting energy expenditure for the first seven days of their stay to look at the differences. And this is in 91 neuro ICU patients. And to orient you to the graph zero or where the blue box is pointing would mean that the K-cals received within the first seven days of their stay was equivalent to what we extrapolated out as their seven day energy expenditure needs. As you can see, it's pretty evident that for majority of the patients, we fell short, not often being anywhere from five to 10,000 caloric deficit within seven days. So our first study that we'll look at is an improvement in protein delivery for critically ill patients requiring high-dose propofol therapy and internal nutrition. And this study was conducted between February and October of 2018. This was a retrospective single center study, and they evaluated first the amount of calories provided by propofol and internal nutrition therapy. And then secondarily, they compared protein intake using a modified approach of protein supplementation to just conventional internal nutrition formulas when given without protein boluses. So on the bottom left, if you look at their modified internal nutrition approach with protein supplements in terms of what they were using for baseline formula was dependent upon the injury severity score with a cutoff of 20. So those with less than 20 received what they labeled as a very high protein formula, and those greater than equal to 20 had a high protein formula there. Their inclusion criteria were patients greater than or equal to 18 years old that had sustained a TBI, admitted to their trauma ICU, who also had a nutrition support service consult. Additionally, they had to have received propofol for greater than or equal to two days. They excluded patients that had died within seven days, received parental nutrition, or had inadequate documentation. Again, this is just to highlight on the left, the differences of that nutrition therapy that was given in the, between a very high protein formula and a standard protein formula. And it's important to note that in their intervention groups, both use protein supplementation. On the right yellow box there, you can see their nutrition targets was based off of BMI. So those with a BMI less than 30, their goal caloric energy that they gave was 30 to 32 kcal per kilo per day with a goal protein of two to 2.5 grams per kilo per day. And they labeled patients as being overfed if they were over 32 kcals per kilo per day. And the BMI greater than equal to 30, you see there that they based it off of ideal body weight with a kcal goal of 22 to 25, and then a protein goal of two to 2.5 grams per kilo per day. And that group was, had overfeeding labeled as greater than 25 kcals per kilo of ideal body weight per day. From a results standpoint, they screened 118 patients and excluded 67 with most either having died within seven days, having inadequate documentation, or most of the 20, about 20 patients not receiving propofol with a total inclusion of 51 patients. To orient you to the graph that you see here on the y-axis is their caloric intake and on the x-axis is their trauma ICU day. They did not include day one as it could have just represented a partial feeding day as they titrated up. The black bar is total calories received. The lighter gray is their internal nutrition calories. And the darker gray bar is their propofol calories throughout days two to seven. When you look at the characteristics of propofol, they found that patients received a median of 356 kcals per day, and that would equate to a rate of propofol of around 27 mics per kilo per minute in an 83 kilo patient, just to put it in some other terminology. And then on the internal nutrition characteristics, they looked at day two and day seven. As you can see there, day two had a median of 7 kcals per kilo per day versus day seven having 16 kcals per kilo per day. With this graph, they looked at the protein that was delivered. So y-axis is the grams per kilo per day of protein intake, x-axis again, same time period. As you can see there, they have the different bars labeled as A, B, and I think day two on the far left, the dark gray bar should have been C. But they equate to the actual intake being the dark, or the black bars that were labeled with A, and then the various projected intakes based on if you used a high protein formula, which would be B, and then a standard protein formula, which would be C here. And they found that when they compared protein intake using their modified regimen of supplementation to the very high protein formula, that it increased protein delivery of about 24 to 38%. And then when you compared their modified regimen of protein supplementation to a standard protein, internal nutrition formula was about twofold higher. It is important to note, if you kind of look across the graph here, that it takes a couple of days to even get up to a gram per kilo per day, and they weren't necessarily attaining their target of 2 kcals per kilo per day throughout the time period. So in conclusion, the study, supplemental protein as liquid protein boluses improved protein delivery without the risk of overfeeding when modifying internal nutrition rates to maintain their caloric needs. A limitation, as I said just a moment ago, was that their protein delivery was still fell short of their goals. This is likely due to withholding internal nutrition for various regions. This is surgical and diagnostic procedures. And then lastly, just in general consideration, we're thinking about protein delivery as a whole. We don't necessarily have a reliable biomarker that can tell us what someone's protein needs are, such as indirect calorimetry giving us resting energy expenditures. So this is something to keep in mind moving forward, that instead of just having a range of 2 to 2.5, maybe we could individualize this to the patient's protein needs and then see how this impacts long-term outcomes. So a polling question, and I believe this should be on your pop-up, kind of in the chat area for you to answer. And then this might also be on Twitter for those that are on Twitter, if they want to answer and follow along there. But what would you change with your current practice for patients who are receiving propofol to attain macronutrient goals? And answers being, you know, no change. So I don't modify internal nutrition based on propofol rates. No change, I don't modify in addition to attain protein goals that we've set out. Number three being, I'll start using supplemental protein to attain these protein goals that we're setting out in the beginning of their therapy. And four being, I'll start using high-protein formulas. Let's give everyone a few seconds to kind of answer these in the chat. Okay, so our next study, the FEED-MORE study, is a volume-based feeding enhances internal delivery by maximizing the optimal rate of internal feeding. This was published in J-PEN in 2020. Their methods for this study was they looked at patients between September of 2015 to March of 2017. This was a retrospective, single-center, quasi-experimental study with their primary aim being to evaluate the mean percentage of total energy delivered by internal nutrition until seven days, ICU transfer or removal of the feeding tube, or they received an oral diet. Secondarily, they looked at the mean percentage of total protein, the percentage of patients meeting 80% of their energy and protein goals, which is a goal recommendation in the Aspen critical care guidelines for nutritional delivery. They also looked at time to goal rate, days of ventilation, and then ICU and hospital length of stay. On the safety standpoint, they looked at the rates of patients who had elevated glucoses, which they leveled as greater than 250 during their catch-up periods for those that were on the rate-based versus volume-based, and then they looked at gastric residual volumes over 400, and then just a general discontinuation due to intolerance of the volume-based feeding protocol. On the bottom left, if you look at their rate-based feeding, they based their nutritional goals, so their caloric needs and protein off of the Aspen guidelines. They would start at 10 to 20 mLs per hour, advanced every six to 24 hours, and this was per provider. The volume-based feeding group, they started slightly higher, 30 mLs per hour, and they advanced to goal at four hours with a daily catch-up phase on day two, and when they were doing the volume-based feeding, their maximum rate that they would go up to was 150 mLs per hour. They included adults in the medical and neurosurgical ICU, and between the years of 2015 to 16, they did rate-based feeding, and then 16 and 17, after a washout period, volume-based feeding, and excluded those that received perennial nutrition or had an ICU length of stay of less than 24 hours. They screened 331 patients during this time period, and a majority of the excluded patients were just in ICU length of stay less than 24 hours, including 189 patients, 100 being in the rate-based group, 89 in the volume-based group. When you look at their results, so the total energy delivered, 100% was attained with the volume-based feeding that they were wanting to give, and you see a 25% less attainment of total energy delivered in the rate-based feeding group. The total protein delivered was 19% lower in the rate-based feeding group at 68% versus 87%, and those who attained 80% of their goal energy, which again was that Aspen guideline recommendation, you see a difference of nearly 30% with only 42% in the rate-based feeding group versus 71% in the volume-based feeding group, and then from a goal protein standpoint, you see a 23% less attainment in the rate-based feeding group, as you see there with 34% versus 57% attaining those goals. From an efficacy standpoint, the time-to-goal rate, which isn't too surprising given that the difference was based off of a increase over 6 to 24 hours in the rate-based group versus advancing to goal at 4 hours with volume-based feeding, was 13 hours versus 7.7 hours. If you look at the chart on your right, they looked at the mean cumulative caloric deficit by day, and the yellow line is the volume-based feeding group, which had that catch-up period versus the blue line, which is the rate-based feeding group, and the yellow line, as you can see, hovered around 1,000 kcal's deficit over the time period, but you see a precipitous drop with the rate-based group out to 7 days. From a safety standpoint, so one thing that's come up that's discussed is the risk of hyperglycemia in patients that you're bolusing essentially to try to get them to their target daily calories for the day, but they only saw a 10% increase in hyperglycemic episodes during the catch-up periods of those on the volume-based feed group. When they looked at gastric residual volume incidents, which, again, greater than 400 mLs, they saw a 1.4% increase in those in the volume-based feeding group. ICU length of stay was a day shorter in those with volume-based feeding, so 5 versus 6, and then in terms of hospital length of stay, they actually saw a shorter length of stay in those in the rate-based feeding group of 16 versus 20. So, in conclusion, volume-based feeding significantly increased the energy and protein delivery in a safe manner. We saw there was, you know, overall in the volume-based feeding, about 16% of patients during that catch-up period had hyperglycemic episodes over 250, and a relatively small rate of gastric residual volume being over 400. The rate-based feeding group's rate of titration was not standardized, but the goals were consistent with the Aspen Guidelines, so, again, going back to providers saying how to titrate over time in the rate-based volume versus, or rate-based feeding versus volume-based feeding group. A limitation and consideration, just in general, about the collection was there was no data collected on the use of opiates or prokinetic agents, nor severity of illness, and so on. Nor severity of illness, which may impact GRV, length of stay, et cetera. And just in general, overall, you know, further studies are necessary evaluating patient-specific needs, and if outcomes differ, if we attain these goals, this 80% goal set out by the Aspen Guidelines versus those that might be slightly under in the early part of their critical, their ICU stay. So, our polling question for this is, does your institution use volume-based feeding in patients receiving internal nutrition? Again, this should pop up in the chat with, yes, all patients receive volume-based feeding in our institution. Yes, but only in select patients do we use volume-based feeding. Number three, we do not use volume-based feeding. Number four, we do not use volume-based feeding, but based off of this study and some other considerations, you may start using this moving forward in select patients. Okay, I will say at our institution, we do this in select patients, specifically in our burn population, but given the initial study I shared with you all looking at our caloric deficits and how it builds over the first week, this is something that we're considering trialing in our neuro ICU and seeing if that helps attain our goals for caloric needs and then hopefully protein needs as well. I'd like to thank my year in review mentors and also the CPP program committee members. And finally, just some general thoughts to help maybe guide some discussions if you're able to answer on Twitter or in the in the poll here and we could try to respond. When we think about supplemental liquid protein, it can help us get closer to attaining our protein goals, but as we saw in the study didn't actually meet the goals they set out. So some general thoughts, maybe should supplements be used as a bridge until goal and all nutrition is reached. So depending on how long it takes for you to titrate to goal, should you be using protein supplementation? And then the second question is how much protein is too much. So in general, the thought is the body can absorb around 10 grams per hour of protein or 20 to 25 grams per sitting. So how many packets will you use per day and how do you separate that out? Mostly I don't see us going beyond two packets of 15 grams of protein, so a total of 30 grams, three times daily. And then on the volume based side, if we're going to consider this in the ICU, what barriers would you need to overcome to implement this practice? So obviously there would be a lot of education on how to attain these goals. What part of the shift would you try to attain or try to implement this change and reach your goals? And is there anything from the medical record side of thing that you need to do? So how can we maybe leverage technology to improve nutrition delivery? So what we did in the last few years, which has been a major help, was that we were able to actually track internal nutrition into our continuous, basically where our drips would show up on our Mars. So we're able to go back and look when it was held and then also look at total volume received. So that's been a better way to at least kind of have a general sense of how close we're getting to our goals. So thank you for listening and I look forward to interacting with you on the chat box.

Keaton Smitana

neurocritical care pharmacist

updates

nutrition

critically ill patients