Category Archives: Abdomen

Nestlé industry session: COVID-19 & Nutrition

COVID-19: The good, the bad and the ugly

Zudin Puthucheary  (London, UK)

 

THE UGLY:  CRIT-CON Pandemic Levels and their ethical risks

0 – Normal

1 – Preparatory

  • Drawbridge ethics: withholding certain services in hospital / community to protect ourselves
  • Moral panic: change in behaviour due to belief that we are at later stages of CRIT-CON than in reality

2 – Sustained surge (current state in the UK and many parts of Europe)

  • Magic number ethics : using untested / unvalidated scoring systems, thereby relinquishing responsibility of decision making
  • Moral blindness: taking on new concepts without rigour of evidence base
  • Paternalism: making decisions believing they are the right ones, without discussing with colleagues / patients

3 – Super surge

  • Moral confusion: making random decisions

4 – Code Red

  • Moral paralysis: nobody makes decisions
  • Hobbesian ethics: those who have loudest voices have most confidence in their views and therefore become dominant

 

Ethical risks in Nutritional care during COVID-19
  • First, do no harm – Remember best practice, consider actions with regards to CRIT-CON levels
  • Be aware of deviation from best practice

Example 1. Are HMB / probiotics / Vit C / Vit D justified just because of the pandemic?  – no evidence for these in normal critical care, let alone COVID-19

Example 2. Running out of feeding pumps – what to do, especially in pts proned for long duration

Systematic review: Administration of enteral nutrition in prone position  

  • sparse, limited quality data on Enteral feeding in prone pts
  • contradictory results re gastric residual volumes

Largest study of Enteral Nutrition in prone pts for ARDS

  • only 47 pts
  • apparently safe, BUT pts were not in prone position for long duration as seen in COVID-19 pts

==>> BDA provided guidance in response to these issues

  • Avoid bolus feeding in prone position (no evid of safety)
  • Consider gravity feeding if no pumps available

 

Effect of intermittent / continuous feeding on muscle wasting (Phase 2 clinical trial)

  • intermittent feeding safe, tolerable and feasible in supine pts (no prone pts)
  • but did not ameliorate acute skeletal muscle wasting

==>> BDA provided guidance on the basis of this trial

  • bolus feed ONLY if no pump available, NOT FOR prone / GI tract abnormalities / via jejunal tube
  • while safe, it is NOT standard of care

 

LESSONS:
  1. Do not get caught up in moral confusion – maintain best practice
  2. Refer to guidelines and updates, especially in evolving situation
  3. Leave unproven interventions to RCTs

 

THE BAD: Persistent critical illness

UK Length of stay (LOS) in ICU survivors – mean 4.7 days  (stable for past 5 years)

Internationally, LOS in COVID-19 survivors  – median 12 days (5-28d) = more than twice usual LOS

Day 9/10 –> transition to Persistent critical illness

  • antecedent characteristics e.g. age / pre-existing conditions more likely to kill than the illness itself (probably related to duration mech ventilation / muscle wasting)
  • only 16% pts stay longer than 9/10 days
  • COVID-19 pts (median LOS 12 days) are therefore all at risk of Persistent critical illness

  • Rapid recovery –> Basic ADLs at 1-year
  • Persistent critical illness –> no ADLs, not mobilising at 1-year

Muscle protein synthesis essential for rehabilitation from muscle wasting

Metabolic abnormalities likely limit energy and protein utilisation during persistent critical illness

Increased LOS / severity of illness = more severe muscle wasting

Muscle protein synthesis on Day 1 of critical illness is the same as Fasted controls (despite feeding) and has a variable recovery period

Muscle protein synthesis takes up to 30days to normalise 

Muscle protein synthesis is highly energy dependent

Critical illness (hypoxia + inflammation) reduces ATP generation from glucose and fatty acids

 

THE GOOD: Teamwork for rehabilitation

Mortality from COVID-19 is falling – more pts will survive

They WILL need nutrition, protein and energy for late phase of rehab

UK initiative to assess pts for post-ICU syndrome, initiate early rehabilitation, establish a framework to be used for both COVID and non-COVID pts

 

* Each coloured dot represents a specialist therapy

  • size of dots reflects extent of requirement for that therapy
  • lines indicate correlation; thickness of lines indicates strength of correlation

==>> In critical illness, there is an almost equal need for all classes of specialist therapy, with interlinkage between them and no single therapy more crucial than the others

 

Exercise ALONE is catabolic

Exercise must be combined with adequate protein intake

Older pts need more exercise, and have a narrower window for muscle synthesis post-exercise  –>> Quantity and Timing of feeding are both important

Before COVID-19: prevalence of  laryngeal pain (76%) and dysphagia (49%) in crit illness

COVID-19 likely to result in a ‘pandemic’ of SALT issues including dysphagia, preventing pts from successful oral feeding

* A ‘cheat sheet’ for ICU doctors, nurses and dieticians

Occupational Therapist: not available in all centres; roles expanding in COVID-19 – assessment / guidance on meal preparation, positioning, adaptive cutlery etc… Ask an Occupational Therapist to see how they can help!

Anxiety, depression and PTSD extremely common – 50% critically ill pts will have combination of these

  • ICD-10 criteria for anxiety: difficulty swallowing, nausea, abdo distress
  • ICD-10 criteria for depression: loss of interest / pleasure, alteration in appetite
  • Will impact on eating and nutrition

Deprivation = major reason for poor quality nutrition + protein intake – pts from deprived background unlikely to have good nutrition / good recovery

 

LESSONS:

  1. COVID-19 pts likely to have metabolic derangements of persistent critical illness
  2. Rehabilitation is a team game
  3. Be aware of deprivation as a significant barrier to rehab + recovery –> it will undo all the good work by healthcare team

Critical Care Refresher Course: Trauma and Surgery

GI Bleed (Kumar)

What is a massive GI bleed?

  • Bleeding resulting in CVS collapse
  • mortality up to 40%
  • over 75% due to upper GI bleed (lower GI bleed mortality 2%)

Etiology

  • Ulcers (Duodenal > Gastric)
  • Gastritis
  • Varices
  • Oesophagitis

Team: Gastroenteritis, Surgeon, Interventional Radiologists

Pharmacotherapy

Acute pancreatitis (Marshall)

Pancreatitis is a chemical burn of the retroperitoneum

Incidence 10-80/100,000

Mortality 10-25%

Pathophysiology

  • Fluid collection, ascites
  • Pseudocyst
  • Fat necrosis

Severity scores –

Resist antibiotics

No other intervention except PATIENCE!

Early surgery for pancreatitis do badly.

How to feed the critically ill – Dr James Day

Why is hypocaloric feeding better- Casear

Doesn’t kill nor saves lives

May avoid infections and enhance recovery

Doesn’t compromise recovery

Reduction of ICU acquired weakness

Early nutrient restriction and hypocalorific feeding are harmless and may enhance recovery

Early nutrient restriction avoids early suppression of autophagy in skeletal muscle

The optimal duration of nutrient restriction and role of different macro nutrients needs to be further eleucidated

Should autophagy be respected or activated?

 

References

EPaNIC Study

Review: Timing of PN

CALORIES trial

 

Feeding and Chronically Critically ill-Guttormsem

What does chronically critically ill mean:

  • Presence of tracheostomy
  • On ICU>7 days

Unresolved issues:

  • How much energy to give?
  • Hypocaloric or isocalorific- different targets in different phases of the ICU/hospital stay

How much protein to give- need to see energy, protein and muscle as unity.

Is it possible to identify the critically ill patient at nutritional deficiency?

Energy demands may double in the rehabilitation phase of critical illness. They are back on the ward then.

When pt out of bed (i.e. rehabilitation phase) feed to put on weight (muscle mass)

 

References:

The evolution of nutrition in critical care: how much, how soon?

 

What to do when there is no EBM?

Septic patients (Perel)

EBM de-emphasises intuition, unsystematic clinical experience & pathophysiological rationale as sufficient grounds for clinical decision making & stresses the examination of evidence from clinical research

No benefit to ARISE, PROCESS, PROMISE

Have multimodal approach to monitoring the CV system of septic patients

Solve therapeutic conflicts by choosing the least harmful option

Aim to de-escalate treatment as soon as possible and do not aim to normalise values

 

References:

Positive fluid balance in septic patients

A protocol-less approach to septic patient

 

The High Risk Surgical Patient (Zsolt)

References

EuSOS study

Pro-AQT study

OPTIMISE Study

Choice of monitoring device amongst anaesthetists

No benefits of SV optimisation in elective abdo surgery

 

Liver Failure (Wendon)

EASL Practical guidelines for the management of alcoholic liver disease

EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis

Hepatorenal syndrome: the 8th international consensus conference of the Acute Dialysis Quality Initiative (ADQI) Group

 

Subarachnoid Haemorrhage (Polderman)

Unsecured aneurysms rebleed 9-17% on day 0

Fever associated with poor outcomes

High incidence of CV dysfunction. Therefore would advocate CO monitoring

References

Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference.