第二代腸內(nèi)營養(yǎng)給藥方法與策略

DarenK.HeylandProfessorofMedicineQueen’sUniversity,KingstonGeneralHospitalKingston,ONCanadaSecondGenerationEnteralNutritionFeedingProtocols:TakingusthethenextlevelofperformanceMrCD47renaltransplantSevereCAPSepticshock,ARDS,MODsRequiresvasopressorsfordaysDay3-tricklefeeds(20cc/hr)FeedsonandoffagainforwholefirstweekNursesnotesgastricresidualvolumeof60ccAskresidentwhattodoResidentsayswaittillroundsCaseScenarioCahillNCritCareMed2010(inpress)Inpatientswithhighgastricresidualvolumes:useofmotilityagents58.7%(siteaveragerange:0-100%)useofsmallbowelfeeding14.7%(range:0-100%)CahillNECCM2010(inpress)AveragetimetostartofENwas46.5hours(siteaveragerange:8.2-149.1hours)ConsequencesofIatrogenicMalnutritionCaloricdebtassociatedwith:LongerICUstayDaysonmechanicalventilationComplications

MortalityAdequacyofENRubinsonCCM2004;VilletClinNutr2005;DvirClinNutr2006;AlberdaICM2009AdequacyofENCaloricDebtRCTLevelofEvidencethat

MoreEN=ImprovedOutcomesRCTsofaggressivefeedingprotocolsResultsinbetterprotein-energyintakeAssociatedwithreducedcomplicationsandimprovedsurvivalTayloretalCritCareMed1999;MartinCMAJ2004Meta-analysisofEarlyvsDelayedENReducedinfections:RR0.76(.59,0.98),p=0.04ReducedMortality:RR0.68(0.46,1.01)p=0.06MoreisBetter!OurFieldofDreamIfyoufeedthem(better!)Theywillleave(sooner!)UpdatedJanuary2009Summarizes191trialsstudying>15000patients34topics18recommendations“Useofafeedingprotocolthatincorporatesmotilityagentsandsmallbowelfeedingtubesshouldbeconsidered”TheImpactofEnteralFeedingProtocols

onEnteralNutritionDelivery:

Resultsofamulticenterobservationalstudy

International,prospective,observational,cohortstudiesconductedin2007and2008from269IntensiveCareUnits(ICUs)in28countriesIncluded5497mechanicallyventilatedadultpatients>3daysinICUSitesrecordedthepresenceorabsenceofafeedingprotocolSitesprovidednutritionaldataonenrolledpatientsfromICUadmissiontoICUdischargeforamaxof12days.HeylandJPEN2010(inpress)CharacteristicsTotaln=269FeedingProtocolYes208(78%)GastricResidualVolumeToleratedinProtocolMean(range)217ml(50,500)ElementsincludedinProtocolMotilityagents68.5%Smallbowelfeeding55.2%HOBElevation71.2%TheImpactofEnteralFeedingProtocols

onEnteralNutritionDelivery:

Resultsofamulticenterobservationalstudy

HeylandJPEN2010(inpress)15.2%usingtherecommendedthresholdvolumeof250mlTheImpactofEnteralFeedingProtocols

onEnteralNutritionDelivery:

Resultsofamulticenterobservationalstudy

TimetostartENfromICUadmission41.2inprotocolizedsitesvs57.1hoursinthosewithoutaprotocolPatientsrec’ingmotilityagents61.3%inprotocolizedsitesvs49.0%inthosewithoutHeylandJPEN2010(inpress)P<0.05P<0.05DoesOneSizeFitAll?ResuscitationisthepriorityNosenseinfeedingsomeonedyingofprogressivecirculatoryfailureHowever,ifonstableordecliningdosesofvasopressors:WhatAboutFeedingtheHypotensivePatient?SafetyandEfficacyofEnteralFeeding??PurcellAmJSurg1993;165:188DogModelwithIVoleicacidlunginjury9patientsday1Post-opfollowingCPBrequiringinotropesandvasopressorsFeedenterally;metabolicresponseconsistentwithsubstratesbeingutilizedProspectivelycollectedmulti-institutionalmedicalintensivecareunit(ICU)database.1,174patientswereidentifiedwhorequiredmechanicalventilationformorethantwodaysandwereplacedonvasopressoragentstosupportbloodpressure.Patientsdividedaccordingtowhetherornottheyreceivedenteralnutritionwithin48hoursofmechanicalventilationonset.707patients(60%)whodidwerelabeledasthe“earlyenteralnutritiongroup”andtheremaining467patients(40%)werelabeledas“l(fā)ateenteralnutritiongroup”.TheprimaryendpointswereoverallICUandhospitalmortality.DataalsoanalyzedaftercontrollingforconfoundingbymatchingforpropensityscoreFeedingtheHypotensivePatient?DiGiovineetal.AJCC2009(inpress)FeedingtheHypotensivePatient?DiGiovineetal.AJCC2009(inpress)Thebeneficialeffectofearlyfeedingismoreevidentinthesickestpatients,i.e,thoseonmultiplevasopressoragents.“TrophicFeeds”ProgressiveatrophyofvillousheightandCryptdepthinabsenceofENLeadstoincreasedpermeabilityanddecreasedIgAsecretionCanbepreservedbyaminimumof10-15%ofgoalcalories.ObservationalstudyofxxcriticallyillpatientssuggestsTPN+trophicfeedsassociatedwithreducedinfectionandmortalitycomparedtoTPNalone^A=NoEN;B=100%ENOhtaAmJSurgery2003;185:79-85^MarikCritCare&Shock2002;5:1-10InitialEfficacyandTolerabilityofEarlyEnteralNutritionwithImmediateorGradualIntroductioninIntubatedPatientsDesachyICM2008;34:1054Thisstudyrandomized100mechanicallyventilatedpatients(notinshock)toImmediategoalratevsgradualrampup(ourusualstandard).Theimmediategoalgrouprec’dmorecalorieswithnoincreaseincomplicationsDarenK.HeylandProfessorofMedicineQueen’sUniversity,KingstonGeneralHospitalKingston,ONCanadaEfficacyofEnhancedProtein-EnergyProvisionviatheEnteralRouteinCriticallyIllPatients:ThePEPuPProtocolASinglecenterfeasibilitytrialNotallcriticallyillpatientsarethesame;wehavedifferentfeedingoptionsbasedonhemodynamicstabilityandsuitabilityforhighvolumeintragastricfeeds.Inselectpatients,westarttheENimmediatelyatgoalrate,notat25ml/hr.Wetargeta24hourvolumeofENratherthananhourlyrateandprovidethenursewiththelatitudetoincreasethehourlyratetomakeupthe24hourvolume.ToleratehigherGRVthreshold(250mlormore)Motilityagentsandproteinsupplementsarestartedimmediately,ratherthanstartedwhenthereisaproblem.TheEfficacyofEnhancedProtein-EnergyProvisionviatheEnteralRouteinCriticallyIllPatients:

ThePEPuPProtocol!AMajorParadigmShiftinHowweFeedEnterallyBegin24hourvolume-basedfeeds.Afterinititaltubeplacementconfirmed,startPepatmen1.5.Totlalvolumetoreceivein24hoursis17mlxweight(kg)=<writein24targetvolume>.DetermineinitialrateasperVolumeBasedFeedingSchedule.MonitorgastricresidualvolumesasperAdultGastricFlowChartandVolumeBasedFeedingSchedule.

ORBeginPeptamen1.5

at10mL/hafterinitialtubeplacementconfirmed.Holdifgastricresidualvolume>500mlandaskDoctortoreassess.Reassessabilitytotransitionto24hourvolume-basedfeedsnextday.{Intendedforpatientwhoishemodynamicallyunstable(onhighdoseorescalatingdosesofvasopressors,orinadequatelyresuscitated)ornotsuitableforhighvolumeenteralfeeding(rupturedAAA,upperintestinalanastomosis,orimpendingintubation)}ORNPO.Pleasewriteinreason:________________________.(onlyifcontraindicationtoENpresent:bowelperforation,bowelobstruction,proximalhighoutputfistula.RecentoperationandhighNGoutputnotacontraindicationtoEN.)Reassessabilitytotransitionto24hourvolume-basedfeedsnextday.StablepatientsshouldbeabletotolerategoalrateWeuseaconcentratedsolutiontomaximizecaloriespermlDrsneedtojustifywhytherearekeepingpatientsNPOIfunstableorunsuitable,justusetrophicfeedsWewanttominimizetheuseofNPObutifselected,needtoreassessnextdayThePEPuPProtocolNote,thereareonlyafewabsolutecontraindicationstoENNoteindicationsfortrophicfeedsRatherthanhourlygoalrate,wechangedtoa24hourvolume-basedgoal

Nursehasresponsibilitytoadministerthanvolumeoverthe24periodwiththefollowingguidelines:Orderforvolumebasedenteralfeedingwillbetotalvolumegoalfor24hours.24hourperiodgoesfrom7amto7ameachday.Ifthetotalvolumeorderedis1800mLthehourlyamounttofeedis75mL/hour.Ifpatientwasfed450mLoffeeding(6hours)andthetubefeedingison“hold”for5hours,thensubtractfromgoalvolumetheamountoffeedingpatienthasalreadyreceived.VolumeOrderedper24hours1800mL–Tubefeedingin(currentday)450=Volumeoffeedingremainingindaytofeed.1800-450=1350mLremainingtofeedPatientnowhas13hoursleftinthedaytoreceive1350mLoftubefeeding.Divideremainingvolumeoverremaininghours(1350ml/13hrs)todeterminenewhourlygoalrateRoundupsonewratewouldbe105ml/hrfor13hours.Thefollowingday,atshiftchange,theratedropsbackto75ml/hour.AchartisprovidedtohelpwiththecalculationsPleasecontactdietitianifyouhaveanyquestionsAsaconsequence,ourbedsidefeedingalgorithmhaschanged...AdultICUGastricFeedingFlowChartPlacefeedingtubeoruseexistinggastricdrainagetube.X-raytoconfirmplacement(asrequired)Attempttoelevateheadofbedto45°unlesscontraindicated.Startfeedatinitialrateordered.Measuregastricresidualvolumesq4h.Istheresidualvolumegreaterthan250mL?NOTE:Donotaspiratesmallboweltubes.Replace250mLofaspirate.Reducerateby25mL/htonolessthan10mL/h.Step1:Consideraddingerythromycin200mgIVq12h(mayprolongQtc.).If4doseserythromycinineffective,gotoStep2.Step2:Considersmallbowelfeedingtubeplacementanddiscontinuemotilityagentsthereafter.Wastheresidualvolumegreaterthan250mLthelasttimeitwasmeasured?Replaceaspirate.SetrateofENbasedonremainingvolumesandremainingtimestillendofshift.SeeflowchartAHastheprescribedvolume/daybeendelivered?Replaceaspirate.Reassessmotilityagentsafterfeedstoleratedattargetratefor24hours.YesYesNo

YesNoNoIt’snotjustaboutcalories...

ProteinsupplementBeneprotein?14gramsmixedin120mlssterilewateradministeredbidviaNG

Soinordertominimizethis,weorder:LossofleanmusclemassInadequateproteinintakeImmunedysfunctionWeakProlongedmechanicalventilationAggressivefeedinginpatientswhohaven’tbeeneatingmuchorinskinnypatients,maycauseproblemswithelectrolyteandPhosbalance.That’swhywecheckthelytes,Phos,MgandCaatleasttwiceadayforthefirst3days,andthenifnoproblem,backtousualICUbloodwork.Ifthereareproblemsthenatrateoffeedingneedstobedecreasedornotaccelerateduntilthelytesetc.arecorrected.PotentialforrefeedingsyndromeOtherStrategiestoMaximizetheBenefitsandMinimizetheRisksofENHeadofBedelevationto45(oratleast30ifthepatientdoesn’ttolerate45)Thiswillreduceregurgitation,aspirationandsubsequentPneumoniaListofContraindicationstoHOBElevation

unstablec-spinehemodynamicallyunstablePelvicfractureswithinstabilityPronepositionIntra-aorticballonpumpProceduresUnablebecauseofobesityOtherStrategiestoMaximizetheBenefitsandMinimizetheRisksofENMotilityagentsstartedatinitiationofENratherthatwaitingtillproblemswithHighGRVdevelop.Maxeran10mgIVq6h(halvedinrenalfailure)Ifstilldevelopshighgastricresiduals,addErythromycin200mgq12h.Canbeusedtogetherforupto7daysbutshouldbediscontinuedwhennotneededanymoreReassessneedformotilityagentsdailyOtherStrategiestoMaximizetheBenefitsandMinimizetheRisksofENIfintragastricfeedsnottolerated,problemswithhighGRVsrefractorytomotilityagents,werecommendsmallbowelfeedingtubeHeyDr.canwegetthatsmallboweltubeinplacesoIcangettheirvolumeofENinasap!TheymayneedagentleremindertogetthesmallbowelfeedingtubeinplaceAChangetoNursingReportAdequacyofNutritionSupport=24hourvolumeofENreceived Volumeprescribedtomeetcaloricrequirementsin24hoursPleasereportthis%onroundsaspartoftheGIsystemsreportEvaluationPlanPurpose:toevaluatethesafetyandacceptibilityofthisnewprotocolBefore(n=20)andafter(n=30)studyConsecutiveeligiblemechanicallyventilatedpatients>3daysComparednutritionaloutcomesAttheendofeachnursingshift,willaskthenursethefollowing4questions:EvaluationQuestionsWereyouexposedtotheeducationalinterventionsandifso,howusefuldidyoufindthem?Didyouencounteranysituationoreventthatinyouropinion,compromisedthepatient’ssafety?Overall,howacceptablewasthisnewprotocol(1-totallyunacceptable;10-totallyacceptable)Any