nutrition support during extracorporeal membrane oxygenation...
TRANSCRIPT
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NUTRITION SUPPORT DURING EXTRACORPOREAL MEMBRANE
OXYGENATION (ECMO) IN CRITICALLY ILL ADULT PATIENTS
Haley Murrell, March 19, 2015
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Objectives
• Provide an overview of Extracorporeal Membrane Oxygenation (ECMO)• Definition
• VA vs. VV- ECMO
• History of use
• ECMO and nutrition support
• Discuss research related to enteral nutrition tolerance during ECMO
• Discuss case study and nutrition recommendations• Review energy and protein requirements in the critically ill
• Provide conclusions about EN in ECMO patients
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Extracorporeal Membrane Oxygenation
Definition:
• Mechanical device designed to temporarily support the failing heart or lungs 1
How it works:
• A centrifugal pump drives the blood from the patient through an external membrane oxygenator system (allowing CO2 and O2 exchange) and then re-infused blood to the patient
2 cannulation sites:
• Venoarterial ECMO (VA)
• Venovenous ECMO (VV)
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VA vs. VV ECMO2,3
Venoarterial Venovenous
Femoral artery and vein cannulation sites Internal jugular vein/right atrium and common femoral vein cannulation sites
Bypasses pulmonary circulation Maintains pulmonary blood flow
Haemodynamic support No haemodynamic support
Cardiac indications: Refractory cardiogenic shock with an underlying potentially reversible heart condition, bridge to VAD or cardiac transplantation VV-ECMO
Respiratory indications: ARDS, graft dysfunction after lung transplantation
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VA-ECMO vs. VV-ECMO4
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History of ECMO3,5
• 1972: First successful VA ECMO case in adults
• 1979: NIH multicenter randomized trial of VA ECMO vs. conventional ventilation
• 1979: Developed concept of VV ECMO
• 1980s-1990s: Only case reports and small series in adults showed success –little use of ECMO in adults at this time
• 2009: CESAR trial: 180 patient multicenter randomized trial showed improvements in 6 month survival in ECMO group
• 2009-2010: ECMO use in H1N1 influenza
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ECMO and Nutrition6, 7
• Limited research regarding nutrition support and ECMO in adult patients
• Most large ECMO studies do not mention nutrition interventions
• Previously thought that haemodynamic alterations in VA ECMO decrease blood flow to the gut and can cause intolerance
• Supposed that paralysis and/or heavy sedation may have effected gut function in neonatal ECMO patients
• ECMO itself activates systemic inflammation
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Nutrition Support During Extracorporeal Membrane Oxygenation (ECMO) in adults: a Retrospective Audit of 86 Patients
• Authors: Suzie Ferrie, Robert Herkes, Paul Forrest
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Research: Intro
• Purpose: • Determine if enteral feeding is appropriate while on ECMO
• Assess the frequency of EN intolerance
• Identify barriers to nutrition delivery
• Determine if a difference in tolerance exists between VA and VV ECMO
• Importance/Issue addressed: • Increased use of ECMO in adults with very few research regarding nutrition
• Previously believed that ECMO may cause EN intolerance
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Research: Methods
• Study design: Retrospective Audit
• Subjects: n= 86• 50 men: 36 women
• VA ECMO for cardiac indications (n=31)• Surgical cardiac failure
• Medical cardiac failure
• Chest trauma
• VV ECMO for respiratory indications (n= 55)
• Influenza A (H1N1)
• Infectious respiratory failure
• Other respiratory failure
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Research: Data Collection• Inclusion criteria:
• Patients on nutrition support receiving VA or VV ECMO in critical care unit at a large Australian referral hospital; those not on ECMO were excluded
• Data collection methods: retrospective data collection of total nutritional intake for each day of the first 2 weeks of ICU admission from all ECMO patients between 01/2007 and 07/2012
• Analysis processes: • SPSS• Student’s t test used to compare groups• Chi square to compare proportions• Significance set at p-Value <0.05
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Research: Nutrition Considerations
• Needs calculated by ICU dietitian• Energy via the Schofield equation with stress factor (1.1-1.2)
• Protein of at least 1.2 g/kg body weight
• Intolerance definition: 2 or more consecutive gastric aspirates of >200 mL with abdominal distension or discomfort• Prokinetic agents added per protocol
• Supplemental PN considered on day 3 of intolerance
• Propofol: goal TF rates adjusted if propofol was providing >250 kcal/day or 15% of total requirements
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Research: Results
Intolerance:
• 33 patients (38%) experienced feeding intolerance – 20 managed on prokinetic medications• VA ECMO: 45%
• VV ECMO: 35%
• No significant difference in intolerance between VA and VV ECMO (p = 0.04)
• Patients tolerated an average of 79.7% of energy and 73.0% of protein goals
• Use of paralysis and sedation did not significantly affect feeding tolerance
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Research: Results
Barriers to Nutrition Delivery
• Propofol use:• 72 patients (81.6%) needed TF adjustment to prevent overfeeding while on
propofol
• Fluid Restrictions: • 68 patients (77.6%) required fluid restrictions which in turn restricted nutrition
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Research: Results
VA vs. VV ECMO
• Intolerance did not differ between ECMO modes (p = 0.04)
• VV ECMO patients reached goal earlier than VA ECMO
• VV ECMO received less protein than VA ECMO
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Research: Conclusions
• Early EN can be initiated and EN tolerance can be achieved in ECMO patients
• Nutrition delivery can be limited by the use of propofol for sedation and fluid restrictions
• No differences in tolerance between VA and VV ECMO patients
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Research: Evaluation
Strengths
• Adequate total sample size
• Assessed both VA and VV ECMO
• Included propofol in nutrition delivery
Limitations
• Audit of only one hospital
• Retrospective
• Did not include patient weights
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Clinical Practice:
• Suggestions for future research:• Guidelines for estimation of energy and protein needs in ECMO
• Nutrition in obese ECMO patient
• Take Home Message: • TF is appropriate in ECMO patients
• No specific recommendations for this population – follow current ICU protocols with professional judgement
• Monitor for intolerance
• ECMO patients should not be excluded from the benefits of early EN in the setting of critical illness
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References1. Combes A, Brodie D, Bartlett R, et al. Position paper for the organization of extracorporeal membrane oxygenation programs for acute
respiratory failure in adult patients. Critical Care Perspective. 2014;190(5):488-496.
2. Martinez G, Vuylsteke A. Extracorporeal membrane oxygenation in adults. Cont Edu Anaesth Crit Care and Pain. 2012;12(2):57-61.
3. 1. Lafçı G, Budak AB, Yener AÃ, Cicek OF. Use of extracorporeal membrane oxygenation in adults. Heart, Lung and Circulation. ;23(1):10-23. http://www.heartlungcirc.org/article/S1443-9506(13)01144-X/abstract. doi: 10.1016/j.hlc.2013.08.009.
4. Gilotra NA, Stevens GR. Temporary mechanical circulatory support: A review of the options, indications, and outcomes. Clin Med Insights Cardiol. 2015;8(Suppl 1):75-85. doi: 10.4137/CMC.S15718 [doi].
5. Turner D, Cheifetz I. Extracorporeal mambrane oxygenation for adult respiratory failure. Respiratory Care. 2013;58(6):1038-1052.
6. Scott K, Boudreaux K, Thaljeh F, Grier L, Conrad S. Early enteral feedings in adults receiving venovenous extracorporeal membrane oxygenation. Journal of Parenteral and Enteral Nutrition. 2004;28(5):295-300.
7. Ferrie S, Herkes R, Forrest P. Nutrition support during extracorporeal membrane oxygenation (ECMO) in adults: A retrospective audit of 86 patients. Intensive Care Medicine. 2013;39(11):1989-1994.
8. Choban P, Dickerson R, Malone A, Worthington P, Compher C, American Society for Parenteral and Enteral Nutrition. A.S.P.E.N. clinical guidelines: Nutrition support of hospitalized adult patients with obesity. JPEN J Parenter Enteral Nutr. 2013;37(6):714-744. doi: 10.1177/0148607113499374 [doi].
9. Umezawa Makikado LD, Flordelis Lasierra JL, Perez-Vela JL, et al. Early enteral nutrition in adults receiving venoarterial extracorporeal membrane oxygenation: An observational case series. JPEN J Parenter Enteral Nutr. 2013;37(2):281-284. doi: 10.1177/0148607112451464 [doi].
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Questions?