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Why Is It Called Nutrition Therapy? Beyond the Cal ...
Why Is It Called Nutrition Therapy? Beyond the Calorie Reasons to Feed the Gut!
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Good afternoon, and thank you everyone for attending this session. So I was charged with why I call it nutrition therapy, and to go beyond the caloric reasons. So all of you have heard multiple times, I'm sure, about the why you should feed and such, and I hopefully will give you a little bit more background as to why it really is important to all of our patient populations. My disclosures, some objectives for today, I really want you to walk away from this thinking of this as more of therapy versus support, which are the words that you've heard for years and years and years. So I'm a nurse, I'm a nurse researcher, and I'm a Peds Critical Care Nurse Practitioner in the ICU at the Children's Hospital of Philadelphia, and I do a lot in terms of looking at data around nutrition. So when I start something like this, and being charged as I was, I had to go and give you some definitions. What is therapy versus what is support? So if you look here, therapy is the intended, right, to relieve or heal a disorder, whereas support is to give assistance to. So I just want you to keep that in mind as I go through this and as all the rest of my panel goes through this. You put that together and you look at the leading organization that deals in clinical nutrition, and that's the American Society for Parenteral and Enteral Nutrition, and they have put together Nutrition Support Therapy, putting it all together and calling it the provision of enteral or parenteral nutrition to treat or prevent malnutrition. And that's the basis that we start from, and at the same time we're looking to use that to also maintain or restore optimal nutrition status and health. Now keep in mind that optimal is going to be very individualized. There is no one size fits all for what is optimal. So just to give a little bit of background, this is a schematic that I'm sure many of you know and have seen before, but just to understand that when we talk about changes in critical illness, particularly the metabolic changes, we are looking at when you are hit with critical illness. For whatever reasons, there is automatically and instantaneously a cessation of intake. So when that happens, we begin to break down our muscles. We go through lipolysis, the glycolysis process and such. The bottom line is we are not providing nutrients to our patients when this happens, and that causes havoc in the metabolic scheme of things in terms of nutrition and in terms of how we expect our patients to progress forward. Because we all know we don't really have protein stores, and so we're going to break down muscle to get amino acids, and only some of them are used for protein synthesis. The others go into gluconeogenesis, and I don't need to go through this whole cascade for you all. We're critical care providers, so we understand this. My point here is for everyone to understand that there is a definite change that occurs, and we need to be cognizant of that change as we treat our patients. So what do we know? The current evidence tells us that deprivation of enteral nutrition, in particular, okay, in critically ill patients is associated with a loss of the epithelial barrier and its functions, particularly in the GI tract. Increased inflammatory conditions can occur. There's a shift in that intestinal mucosa-associated microbiome. We've heard so much talk over the last few years, particularly about the microbiome and how it supports us, right? And when you have the disruption of that intima, you are at increased risk for translocation of gut microbes and bacteria-derived toxins, and then that cascade that follows from that. What we know about these intestinal microbes are that they are diverse, and they have a key role in maintaining homeostasis in all of us, in health, and then, again, in illness. So if we are not maintaining them in illness, we run the risk of exacerbating what that illness looks like, right? And so those microbiomes utilize complex carbohydrates, right, for the production of short-chain fatty acids, and that helps maintain that mucosa. So then, again, if we are not giving anything to support that microbiome, we are missing out on maintenance of a good, healthy intestinal mucosa. It also supports the immune system. So while most of the time I'm going to talk about enteral nutrition, parenteral nutrition in isolation, right, can also shift that microbiota in the mucosa, and that can happen in as little as five to seven days. So as we talk about when is the time to feed, keep that in mind, that you can be causing a shift very early in the patient's course of illness. The other things that we know is the absence of gut stimulation. You cause a decrease in the luminal nutrients necessary for metabolism. And that we know that data tells us that there is a high causal relationship that is suggested between the absence of that gut stimulation and initiation of an inflammatory response and translocation. So why is any of this important, and how does that come to play in terms of what we do in the ICU? So one of the things you have to think about that we don't talk about very much is flint neck circulation, because it supplies all of our GI tract. It is a heterogeneic kind of distribution of blood flow that is tempered, and we don't have a good way to measure exactly what that looks like. So we have to go by what other things we're doing to our patients. So we don't know if in splint neck circulation after rounds and rounds of resuscitation, if there is edema there and that blood flow is going to be different. We also don't know that when we pull fluid off, is it causing decreased flow in that splint neck circulation, because we don't have a way to measure that. What we do know, however, is when you don't feed the gut, then you are causing a disruption of splint neck circulation, because it doesn't really have a place to go, and the blood flow and the tempering of the blood flow in the splint neck circulation is heterogeneic. So why does any of that make a difference? So when you take it down to the level of the intima, the GI intima, and you think about what do we need to look at and utilize? These are the tight junctions that we are used to and the junctions that are necessary for us to have the homostasis that we need in terms of nutrition and such, right? These are the claudins, the oculin, the junctional adhesion molecules, and tricellin. Those are intact when we are healthy and when we're feeding the gut. When we don't feed the gut for a period of time, you can cause what you see on this end of this schematic opening of those junctions. That's when translocation begins to occur. And in critical illness, you will lose that mucosal barrier, because at the same time that that's happening, these villi that stand up because we're feeding it, when we stop feeding it, those villi begin to lay down, and you increase the risk of translocation of the bacteria that we know lives within the depths of that villi. So successful enteral nutrition is dependent upon, as I just described, normal splantnik circulation, the status of the gut permeability, and that's what I'm trying to depict here, and what, when, and how we deliver nutrition therapy to our patients. So what about the microbiome? I talked a little bit about it, but in health, the microbiome has a large amount of microbial diversity. In critical illness, particularly when we're not feeding, you decrease that diversity. And then we put our patients at risk to become more opportunistic, the opportunistic pathogens attack them, okay? And some of what we do in our therapy is also attacking, if you will, the healthy microbiome, right? Because medications can make a difference, inotropic and vasoactive drugs can make a huge difference on that. So years ago, we used to talk about there was no blood flow to the gut, and that's why they were getting worse, but it might be that we are just wiping out this microbiome because we are not feeding it to help it try to fight off some of these toxins and such. And so we know that enteral nutrition is a determinant of the gut microbial composition for all the reasons that I have been saying. So you'll hear this recurring theme of maintaining immunologic integrity and function, decreasing bacterial translocation, and it helps to blunt the inflammatory response. What's the contribution directly on the gut microbiota? It positively influences some of the organisms that we know live in that area that are necessary for us to maintain homeostasis. Carbohydrate through the fermentation process produces short-chain fatty acids, which supports the oxidation of butyrate that we all need, both in our lungs and in our gut. And there was a talk Friday about the transference of gut microbiome into the lung in ARDS in some patients. And what are we doing? How are we helping our patients get past that in addition to some of the medications that we give? Through protein, it contributes to the regulation of nitrogen balance and amino acid synthesis and lipids. It's not completely clear that when you're giving enteral nutrition that has a fat composition, it's not completely clear, but we do know that there is some involvement in the regulation of fat metabolism. So you can't give a talk like this and not bring up malnutrition, right? And so when you have a patient who is malnourished from trauma, from sepsis, from any kind of insult to them that causes them to be critically ill, you have to look at, there are minimal substrate reserves that we have. We have altered their metabolisms for a number of reasons. There's inadequate nutrient delivery early on. And what was their presenting nutrition status? You have to take that into consideration because how they present is part and parcel as to how they will do during the course of illness. It influences our patient outcomes, how they present and whether or not malnutrition is a key factor. And in children, there are about 30, somewhere around 30% may present with an existing malnutrition status and then 66%, so in our care, 66% may be discharged in a malnourished status. All of these things need to come into account when we talk about, is this therapy or is this support? So evidence in the literature, in pediatric critical illness, the current pediatric nutrition guidelines, and my colleague Dr. Mehta is going to go through this a little bit more, but we know that nutrition status, nutrition prescription, and nutrition therapy are key components and we also know that delivering those has an impact on outcomes in terms of mortality, hospital acquired infections, days of mechanical ventilation, and length of stay, both in the ICU and hospital length of stay. Again, a benefit of it, gastrointestinal delivery supports that mucosal integrity and motility. There's an attenuation of the inflammatory process when we feed them and optimal energy uptake, up to 60% within the first four days, studies have shown, is associated with decreased mortality and improved clinical outcomes in the pediatric population. It lowers the inflammatory burden, it decreases catabolism with the use of EN, and using feeding guidelines and protocols helps to attain target feeds within a reasonable period of time. So it's been thought of as supportive, however, there are studies in children that show we're a little beyond supportive, okay? And so this study by Nikolaev and colleagues, over 5,000 patients that received early enteral nutrition, mechanical ventilation was decreased and they had decreased mortality. Srinivasan and colleagues looked at 600 patients who received early enteral nutrition, they had a lower 90-day hospital mortality and more ICU, hospital, and mechanical ventilation free days. And then lastly, in a targeted group of children with traumatic brain injury, Bakla Krishnan showed in 416 patients that received, 83% of whom received enteral nutrition, they had less disability and they had a decreased PICU length of stay. So there is data that shows feeding early does help our patients. Pediatric cardiac intensive care, right, this is an area that is still the jury's out, right? There are so many variables in this population, however, they are even more unpredictable as to their response to therapy because there are so many different cardiovascular and hemodynamic defects that we're dealing with in this population. However, the multifactorial etiologies, there are some anecdotal studies out there that show us feeding these children even early after surgery, they have better outcomes. But there's no consensus yet from a review that was done by Dr. Justice and colleagues on what's the optimal feeding strategy in that group. Pediatric acute respiratory distress syndrome, something that we deal with a lot in our ICUs, this hits 3% of the PICU population globally and they have about a 17% mortality. So a large number of children with a high rate of death. Early enteral nutrition with them has been associated with decreased mortality, increased ventilator-free days, and decreased PICU days. And that was in a study that was done by Powell and colleagues who looked at over 400 patients, a retrospective look, but they looked at when did we feed, how did we feed, where did we feed, gastric versus small intestine, and these were some of their summations from that. So in summary, therapy is intended to relieve or heal a disorder, remember I said that early on, and hopefully I've been able to show that nutrition is associated with the treatment or prevention of untoward effects of critical illness. The information that I've given you has shown that with decreased risk of malnutrition early in the course of illness, enteral nutrition can help you with that. Nutrition in general can maintain and or repair the gastrointestinal mucosa, decreasing the potential for bacterial translocation, decreases catabolism, and minimizes protein deprivation. So with all of that, hopefully I've laid the landscape for you to really begin to think about nutrition as a therapy and not just supportive because we are treating and or trying to prevent further untowards effects in our patients in the ICU. Thank you so much.
Video Summary
In this video, the speaker discusses the importance of nutrition therapy in critical care patients. They explain that nutrition support therapy, such as enteral or parenteral nutrition, can relieve or heal disorders and prevent malnutrition. They highlight the changes that occur in critical illness, including a cessation of intake and breakdown of muscles. Lack of nutrition can lead to inflammatory conditions and a disruption of the intestinal microbiome. The speaker emphasizes the importance of maintaining the intestinal mucosa and supporting the immune system through proper nutrition. They also discuss the role of nutrition in maintaining homoeostasis and fighting off toxins. The speaker presents evidence that early enteral nutrition has been associated with improved outcomes in patients, including decreased mortality, infections, and length of stay. They conclude by encouraging the audience to view nutrition as therapy rather than just support.
Asset Subtitle
GI and Nutrition, 2023
Asset Caption
Type: two-hour concurrent | What's Cooking in the ICU? Nutritional Considerations in the Critically Ill (SessionID 1201836)
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Presentation
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GI and Nutrition
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Professional
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Nutrition
Year
2023
Keywords
nutrition therapy
critical care patients
enteral nutrition
parenteral nutrition
malnutrition
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