Nutrient requirements during the acute phase: The baby stomach concept

Transcription

1 Colours of Sepsis, Ostrava, Jan 30, 2018 Nutrient requirements during the acute phase: The baby stomach concept Jan Wernerman MD, PhD Professor of Intensive Care Medicine Karolinska Huddinge Stockholm, Sweden

2 Jan Wernerman Disclosure of potential conflicts of interest during the last 2 years: Member of the Medical Advisory Boards and also invited speaker for Baxter, Danone, Fresenius-Kabi, GE Health Care, Grifols, and Nestlé jw18

3 Nutrient requirements during the acute phase: The baby stomach concept Preiser & Wernerman, AJRCCM 2017;196: jw 17

4 jw 18

5 Rule of thetumb 1. Set nutrition target (kcal+prot) 2. Start EN when possible 3. Calculate caloric and protein balances 4. Complementary PN on day jw 18

6 Rule of thetumb jw 177

7 What do we know about energy needs? jw 18

8 jw11

9 Cumulated energy deficit v. infections Villet et al, Clin Nutr 24:502 (2005) jw11

10 Weijs et al, cc 2014 jw15

11 Krishnan et al. Chest124:297 (2003) jw10

12 27 kcal/kg Krishnan et al. Chest124:297 (2003) jw10

13 27 kcal/kg 9-18 kcal/kg Krishnan et al. Chest124:297 (2003) jw10

14 Zusman et al, Crit Care 2016;20:367 jw 17

15 Mortalitet 100 % efter 3 månader Mortalitet 0 % efter 3 månader jw15

16 Nutrition status Acute disease Acute phase Stable multiple organ failure phase Relevant co-morbidities Rehabilitation phase jw15

17 Energy Expenditure Over-fed ICU patient Activity induced Diet induced Basal Total energy intake Stored energy Endogenous energy stores jw16

18 Wolfe, ejcn 1999;53(suppl 1):S136-S142 jw 17

19 Rusavy et al, Crit Care 2004,8;R213-R220 jw 18

20 Olthof et al, Clin Nutr 2017 (Epubl) jw 18

21 What do we know about energy needs? In the early phase of critical illness there is a mobilisation of endogenous stores that cannot be inhibited by exogenous nutrition supply. Adjust energy target accordingly in particular when there are symptoms (or suspicion) of refeeding jw 18

22 What about the Leuven experience? jw 18

23 Casaer et al, nejm 2011;365: jw 11

24 Casaer et al, nejm 2011;365: jw 11

25 Casaer et al, nejm 2011;365: jw 11

26 Casaer et al, nejm 2011;365: jw 11

27 Early PN All patients Late PN Casaer et al, ajrccm 2013;187: jw 13

28 Fivez et al, nejm 2016;374: jw 16

29 Fivez et al, nejm 2016;374: jw 16

30 Fivez et al, nejm 2016;374: jw 16

31 Vanhorebeek et al, lancet resp med 2017;5: jw 18

32 Vanhorebeek et al, lancet resp med 2017;5: jw 18

33 What about the Leuven experience? Post hoc analysis of Leuven data suggest a lessfavorable outcome related to protein (amio acid) intake during the acute phase of critical illness. jw 18

34 So is hypocaloric feeding better? jw 16

35 Randomized studies with hypocaloric feeding Kortez, JPEN 40: (2016) jw16

36 So is hypocaloric feeding better? So far there is poor evidence for a systematic hypocaloric feeding jw 16

37 What do we know about protein needs? jw 18

38 Cumulated nitrogen balance over 1 w (g N) daily nitrogen supply ( g/kg bw) Larsson et al, Br J Surg 1990;77:413 jw09

39 Change in Total Body Protein Ishibashi et al, CCM 1998;26: jw10

40 Zusman et al, Crit Care 2016;20:367 jw 17

41 Weijs et al, Crit Care 2014;18:701 jw15 ISICEM Mar 22, 2017

42 Davis et al, CCR 2017;19: jw 17

43 Allingstrup et al, ICM 2017;43: jw 18

44 Doig et al, ICM 2015;41: jw 18

45 What do we know about protein needs? There is very limited evidence for a beneficial effect from a high protein intake in the early phase of critical illness, and it rests solely on observational data. Also safety data are limited, and the Leuven experience is contradictory. jw 18

46 Rule of thetumb 1. Set nutrition target (kcal+prot) 2. Start EN when possible 3. Calculate caloric and protein balances 4. Complementary PN on day Nutrition target by indirect calorimetry (or 20 kcal/kg), (50-)80-100%, g protein/kg jw 18

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48 Thank you for listening! jw12