Enteral nutrition in the ICU: How we should be feeding our critically ill patients.

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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

These are the ASPEN guidelines that were published in 2016. They were created to assist us in providing patients with appropriate nutrition while they recover from critical illness. This paper is free and although the 53 pages seem intimidating, the last 11 pages are the references. Also, the font is large and the format is easy to digest as it is laid out in a question/answer type format. I honestly look forward to the updated guidelines but these have a bunch of goodies that I do not feel the vast majority of my colleagues are aware of. I must admit, the majority of the recommendations are based on consensus rather than solid data. If that's what we have, though, we must make do while asking healthy questions.

Fun facts I've picked up on re-reading these guidelines that I had missed out on previous reads and that I may or may not have known:
- clear liquid diet is not necessary after post-op. Patients can be provided with solid food.
- patients should be getting 1.2-2.0g/kg of body weight of protein/ day. Some standard tube feeds may not reach this target in certain patients.
- I knew this but it begs reminding: DO NOT CHECK RESIDUALS!
- fancy formulas may be more confusing that practical for a standard patient in the MICU at the time of this publication.
- they made no recommendations for probiotics but I have found data stating otherwise.
- don't bother with high-fat low carb formulations for reps failure
- check phosphorus levels regularly in respiratory failure patients. That was you can replace the K with K/Phos instead of compartmentalizing the electrolytes.
A 🎩 tip to the many contributors to this guideline.

That's enough for today
-EJ


 

The gut microbiome alters immunophenotype and survival from sepsis

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I've had very similar patients with very similar infections where one was out of the ICU in a short amount of time and the other died in flames. Many variables in play, of course, but you get my point. Could the gut microbiome hold a key regarding which patients do well and which patients don't? My ignorance on the matter is through the roof and my research made me stumble on this gem of a study. I am usually not a fan of mice studies but they have their place in medicine. Here, they showed how mice with almost genetically identical backgrounds who underwent cecal ligation and puncture to make them septic, and had completely different rates of death. One group obtained from a certain location had a mortality rate of 90% whereas the other group had a mortality rate of 53%. Then they had another group subset where they mixed females of the two groups (bc the males rip each other to shreds) for 3 weeks and then performed the same process. The group with the 90% mortality, after being cohoused, had the same mortality rate as that which had the 53% mortality. That’s absolutely fascinating! Now, the authors admit that there are other factors at play, but they did a ton of fancy genetic and bacterial testing to help explain the differences. I leave it up to them to better explain it. A definite 🎩 tip to them.

-EJ

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Enteral Nutrition Can Be Given to Patients on Vasopressors

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I have always been interested in the nutritional status of our patients in the ICU and I don't quite have my mind made up regarding a lot of things. Actually, within the next few months I am going to be asking my registered dietician colleagues here for help with a number of clinical questions.
Truth is that there is a void of solid data regarding nutrition, when to start, how much, how much protein, etc. I understand the ASPEN guidelines have provided some consensus, but much of it is expert opinion rather than actual data. I digress. A topic for another day.
Regarding this article that was published yesterday, the author detailed the vasopressors doses at which one should start feeds (or not start, norepinephrine > 0.3-0.5mcg/kg/min is a no-no), resuscitation markers that should make us feel more comfortable with starting feeds such as decreasing downtrending vasopressor doses.  He also describes the feeding strategy of starting with tropic feeds at 10-20cc/hr.  Lastly, he describes signs of intolerance including residuals > 500cc, note, not 250, not 300... 500.
I have some honest questions for which I personally do not know the answer, though. I need help with this if someone knows the answer. From an evolutionary standpoint, we do not eat when we are ill. Just remember your appetite for a big delicious meal when you last had a significant viral illness. Should we really start to immediately feed these patients? Also, I do not feel that our bodies are accustomed to this whole continuous feeds phenomenon. We normally bolus feed ourselves. Are we shocking the system by doing continuous feeds? See? This is why I need help from some badass registered dietitians.
A 🎩 tip to the author!

-EJ

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Fluid responsiveness: how to predict

If your way of determining whether a patient is fluid responsive or not is to see if the blood pressure went up after giving a bolus, you are doing it WRONG! You need to stop, take a deep breath, and reassess your way of thinking about fluid responsiveness. This (FREE!) article dives into why fluids should not be provided arbitrarily go make us feel good inside and make us feel like we at least "did something" in response to that low mean arterial pressure. No, I do not use SBP and DBP off of the BP cuff in my practice. More on that at another time. This article also goes briefly into why we should not be checking CVP (duh). Bottom line is that we can't accurately predict fluid responsiveness without an arterial line and some sort of device to predict stroke volume, stroke volume variation, cardiac index/output. You could have some really good echo nunchuck skills as well. This study also emphasizes why looking at IVC variations is not the best test. Ultimately, we all need to get better at this, myself included. I feel that this article is particularly important for nurses as you all are the ones who relay the BP concerns to the clinicians essentially ordering the fluids. These three authors are legends of critical care. A real treat that Annals of Intensive Care published this for free.

This article is going to be part of the bibliography for the talk I will be giving in Portland, OR in August of 2020.

-EJ

Monnet, X., Marik, P.E. & Teboul, J. Prediction of fluid responsiveness: an update. Ann. Intensive Care 6, 111 (2016). https://doi.org/10.1186/s13613-016-0216-7

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Mechanism of Hypokalemia in Magnesium Deficiency

In the ICU, we are at times obsessed with making our patients “euboxic” or better said, all labs values within normal ranges. That being said, electrolytes are something we replete every day and our nurses often have protocols which instruct them on how to manage and correct these derangement to hopefully optimize the outcomes of our patients. When I was a resident, one of my mentors and a good friend to this day taught me to correct the Magnesium before correcting the potassium. This left me scratching my head. It made no sense. And the he went on to explain the mechanisms listed in this article and my mind was blown. How much other stuff do I not know? How come I wasn’t taught this in med school? Well friends, there A LOT that we weren’t taught in med school or even residency and fellowship training for that matter. That pretty much why I’m on this lifelong learning journey and hopefully bringing you all along for the ride. This article is free and it’s a good review for you all to check out. To the cool nurses on Instagram, mid sharing this with your colleagues? This is also must know medicine for any internal medicine intern and resident working the wards and ICU. Tony Breu totally killed this subject in a much more thorough and intelligent manner than I did several months ago on twitter. Follow him @tony_breu.
-EJ

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Huang, C.-L., & Kuo, E. (2007). Mechanism of Hypokalemia in Magnesium Deficiency. Journal of the American Society of Nephrology, 18(10), 2649–2652.

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One-Year Outcomes Following Tracheostomy for Acute Respiratory Failure

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Generally speaking, one has a gut feeling of how long a patient is going to be on mechanical ventilation. Usually around day 7 or 8 I start warning families that a tracheostomy may be in the near future for their loved one and ask if that is something that if the patient knew full and well everything that a tracheostomy would entail, would they want to move forward with the surgical procedure?

This article is a retrospective cohort study where the authors looked at a number of outcomes but primarily mortality. This article is extremely important as it provides data that we can guide those who we take care of with what to expect. In patients 65 years of age or greater, mortality at 30 days is 25%, 90 days is 42% and 1 year is 55%. Those are abysmal numbers and numbers that people should know before putting their loved ones through that. It's definitely something to think about. Just because we can do some things doesn't mean we should.

-EJ

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Iatrogenic anemia: Let's Save Some Blood

Our curiosity is what drove is to our respective fields in medicine. As an intensivist, I LOOOOVE trending numbers and analyzing the minutia of the details to predict in what direction my patient is going. There is a difference, though, between utilizing labs to better serve your patient and using labs to satisfy your academic curiosity. I admit that I have been guilty of this and still am at times, but it's something we should definitely work on. We should not be blindly ordering labs and having the vampires come in the middle of the night sucking blood out just because we like to look at numbers in the morning, but rather because it's providing value to our patients. Are we going to make a specific decision based on that or are we just going to be looking at a mostly pointless white count (while ignoring the bands)? This study was published last night. It's worth a read and it's free! But it should put front and center in the minds of all my colleagues in training as well as nurses to think "why am I ordering this lab and what am I going to do with the result differently that what I'm doing right now?". We can save a ton of money for our broke healthcare system, save the patients from the morbidity of a ton of needle sticks, and save our patients from the undeniable anemia that they will eventually fall into. It's not just something else that they need to recover from at the end of the day.
As always, a hat tip to the authors.

-EJ

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Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Heparin Shortage: 2019

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Imminent risk of a global shortage of heparin caused by the African Swine Fever afflicting the Chinese pig herd

By no means am I a fear mongering here, but I am legitimately concerned about the inaction of our health care systems to worry about this issue until it was too late. We were warned last year. It's now August. Heparin is on backorder, folks. I know you and I are going to be just fine but our patients may suffer. This is a good time to check out which of your patients could be switched from heparin to lovenox/enoxaparin, fondaparinux/arixtra, and other alternatives. Remember that there are certain vascular surgery and cardiothoracic procedures where there are no alternatives for heparin and we need to make sure that these patients have the medication they need as we try to weather the storm. Have you all had meetings yet to address this issue at your shop? Nurses, have you been kept in the loop of these impending issues? Pharmacists, am I overreacting?

-EJ

Other links:
https://www.ashp.org/drug-shortages/current-shortages/Drug-Shortage-Detail.aspx?id=353
https://www.upi.com/Top_News/US/2019/05/01/Chinas-African-swine-fever-epidemic-could-cause-global-heparin-shortage/5881556646708/
https://www.raps.org/news-and-articles/news-articles/2018/2/concern-over-heparin-supply-prompts-call-for-fda-i
https://www.reuters.com/article/us-congress-heparin-china/congress-seeks-briefing-on-potential-threat-to-u-s-heparin-supply-idUSKCN1UP1TX
https://www.fiercepharma.com/manufacturing/congress-hits-panic-button-over-potential-shortage-chinese-heparin-as-chinese-swine

Estimated Resupply Dates per "https://www.ashp.org/drug-shortages/current-shortages/Drug-Shortage-Detail.aspx?id=353"

•Fresenius Kabi has heparin 5,000 unit/mL 10 mL vials on back order and the company estimates a release date of mid- to late-August 2019. The 5,000 unit/mL 1 mL syringes are on back order and the company estimates a release date of mid-August 2019. The 10,000 unit/mL 4 mL vials are on back order and the company cannot estimate a release date. There are short-dated 20,000 unit/mL 1 mL vials available with an expiration date of < 7 months. All other presentations are on allocation.

•Hikma has 1,000 unit/mL 2 mL vials, 5,000 unit/mL 2 mL vials, and 10,000 unit/mL 2 mL vials on allocation.

•Pfizer has 5,000 unit/mL 1 mL Carpuject syringes on back order and the company estimates a release date of August 2019. The 5,000 unit/mL 1 mL glass vials are on back order and the company estimates a release date of August 2019. The 5,000 unit/mL 10 mL vials are on back order and the company estimates a release date of December 2019. The 1,000 unit/mL 10 mL glass vials are on back order and the company estimates a release date of December 2019. The 1,000 unit/mL 30 mL vials are on back order and the company estimates a release date of August 2019. The 10,000 unit/mL 0.5 mL Carpuject syringes are available in limited supply. The 1,000 unit/mL 10 mL vials (NDC 00069-0058-01) are available in limited supply.

•Sagent has 1,000 unit/mL 2 mL and 10 mL vials on back order and the company estimates a release date of August 2019. The 1,000 unit/mL 1 mL and 30 mL vials are on back order and the company estimates a release date of September 2019. The 5,000 unit/mL 1 mL and 10 mL vials are on back order and the company estimates a release date of August 2019. The 10,000 unit/mL 1 mL and 4 mL vials are on back order and the company estimates a release date of August 2019.

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Balanced Crystalloids Versus Saline in Critically Ill Adults: A Systematic Review and Meta-analysis

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I honestly wonder how much data is enough data to change some minds. This is why I am counting on you all, people who are trying to keep up with this flurry of data to the best of your ability, to go through medical school, residency, possibly fellowship with a healthy respect for 0.9% saline solution. It may seem like it's hopeless from time to time to change decades worth of practice. Heck, my first IVF resuscitation video is almost 2.5 years old and has almost 39000 views! Hopefully the studies which will be published within the upcoming 2 years will hit the nail on the head. You can see the data from the slides, using saline versus balanced salt solutions increased mortality in the critically ill, increased acute kidney injury, and kept the patients on the ventilator for a longer period of time. To those harping about the increased costs of one fluid versus the next, consider the cost of one ventilator day. Consider the risks involved with each day on the vent. Consider the financial strain from working up every-single-case of AKI. This stuff adds up, colleagues. Anyway. A hat tip to the authors! 

- EJ

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Optimal norepinephrine-equivalent dose to initiate epinephrine in patients with septic shock

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I am quite confused by this article. I was hoping for some answers on how to manage norepinephrine and epinephrine in septic shock but instead I am left scratching my head wondering what in the world happened here. If you're on my page and following along in on this journey, then you know a thing or two about septic shock patients. This article was supposed to provide us with some data regarding when to start epinephrine on these patients once levophed was already running. Instead, you find a retrospective observational study with a statistically significant difference between the optimal dose group and the non-optimal dose group. Within the subgroup analysis, though, you can find that 83.3% of the optimal dose group was also on vasopressin while 62.3% of the non-optimal group was on vasopressin (p=0.001). Does this mean that there's a dose to start epinephrine when a patient is on norepinephrine, or does this mean that before starting epi, you should have vasopressin on board? 

-EJ

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.