immune modulating formula on ITU

[gatkinson39]

I work in a mixed ITU (surgical and medical). Currently we use jevity
feed (jevity plus, jevity plus HP) as our standard feeds. Our lead
consultant has been visited by the Nestle rep who is trying to
persuade that Peptamen AF is a must use feed on ITU. I'm not convinced
as the evidence seems poor/lacking. However i have been thinking about
Impact (Nestle) as a feed for critically ill patients both surgical
and medical (i'm aware of the ASPEN SCCM guidelines in this respect).
I am also going to start using Oxepa for patients diagnosed with ARDS
and severe ALI. I wondered if anyone could offer their advice/
experiences

- is it easy for ITU staff to understand that Impact can be used in
sepsis but not severe sepsis. i.e. is there a risk that if Impact is
available on the unit patients may receive it inappropriately?

- rather than having 2 feeds can Oxepa be used in ARDS, severe ALI and
SIRS? I wasn't sure how robust the evidence was to use Oxepa in SIRS
despite Abbott's claims.

ALSO is anyone using partially hydrolysed guar gum (OptiFibre) to
help with diarrhoea? If so how are you administering this and in what
dose.

Many thanks

[Daren Heyland]

Hi
I would discourage people from using arginine diets in the ICU EXCEPT with
elective surgical patients who might spend a few days in your ICU being
monitored. We just reviewed the literature in the elective surgery patient
and conclude the data are overwhelming in favor of using this in elective
surgery (See attached). But we can not apply this to the critically ill
patient. The most current evidence for these diets in the ICU is summarized
on our website and does not support its use. I do not agree with the
SCCM/ASPEN CPGs and I have publically debated with bob Martindale and steve-
we agree to disagree.
On the other hand, lots of positive data on oxepa and products like it are
recommended so would rather see you use that as your diet for 'inflammed'
patients. Hope that helps
Cheer
Daren

Many thanks

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[KM]

I realize this wasn't the intent of your post, but, would you consider
changing your standard basic formula to a high protein fibre free
formula like Promote or Isosource VHP? Also included in the SCCM
guide for our ICU patients. We use Oxepa for our ARDS/ALI/'inflamed'
patients. No experience with a guar gum supplement.

Kristen

[gatkinson39]

Thanks for your response. Can I ask you what your thoughts with
regards to the borage oil in the Oxepa. Does the fact that Oxepa
contains EPA and GLA give it an edge over formulas that contain fish
oil without the GLA?

many thanks

Gill Atkinson

>  Drover, (2011) Perioperative Use of Arginine-supplemented Diets - A Systematic Review of Evidence.pdf
> 3291KViewDownload- Hide quoted text -
>
> - Show quoted text -

[Daren Heyland]

There is physiological rationale that this is the case but I can not find
any clinical studies in ICU patients to demonstrate that borage oils is
responsible for the clnical benefit. Having said that, the diets that have
been studied do contain fish oils, borage oils, and antioxidants so hard to
attribute the benefit to anything but the combination of ingredients,

[Rho]

Hi there,

Lots of questions all of which I have an opinion!

1) The hospital that I am working in has been using Jevity 1.2 and
1.5 for years and I have never had a problim in ICU with gut ischemia
(10years). The ASPEN guidelines did make one statement based on one
study with very small n if I recall, nothing to warrent my change in
practice regarding fibre in feeds.

2) Interestingly we have recently been told that our formulary is
changing from Abbott to Nestle. This means that the source of fibre in
the equivalent hose feeds will be guar gum (soluble fibre) and
significantly less than it's predesessor. As well there is no pre-
biotic source in these feeds. I am not sure that I am happy about this
so if anyone has experience with this source and less of it in the ICU
please share. I have to do some research.

3) I have been using Oxepa consistantly for ARDS/ALI in this ICU
atleast since SARS and have been involved in round-table discussions
on it and am a believer, but I have no controlled study of my own to
prove any positive outcomes in my patients. As long as I do no harm,
it's composition suits the bill for all ICU patients who are not in
renal failure and not on dialysis. As far as I can tell it is not
harmful to use Oxepa in SIRS and Sepsis and may actually improve
mortality. I am still waiting for results of Intersept Study from
Pontes-Arruda(Brazil). I agree with Dr. Heyland about the combination
of nutrients when using Oxepa, to date no other product mimics the
amount and combination of nutrients for which positive outcomed have
been shown.

4) I used Impact in Trauma over 10 years ago, but since it fell out of
favour in the ICU I never re-examined it it my current population,
which is mainly elderly, respiratory failure.

5) As for Nestle promoting the use of Peptamen producta as ICU house
feeds I can not endorse the use of chemically defined product across
the board as it is just not indicated or cost effective. Polymeric
feeds do the trick for me and have for over 35 years. I am OK with
providing in-soluble fibre and FOS (pre-biotic) to my patients.

6) Dr. Heyland, I was not in agreement with the choice of feed for the
Pep - Up study as I feel it sends the wrong message and hopefully
company reps will not try to encourage their use in the general ICU
population.

I hope that helps to some degree.

Rhona Nayman, RD.

On Mar 25, 10:55 am, gatkinson39 <gatkinso...@googlemail.com> wrote:

[Daren Heyland]

Rhona
I agree we have a messaging problem with our choice of Peptamen in the PEP
up study. I try to explain to people that the PEP up protocol is meant to be
a 'safe start' protocol, that everything can be changed including the use of
Peptamen can be revised the next day when the dietitian or other trained
professional provides the precise nutritional prescription. But if you were
going to desing a safe start strategy to maximize intake and minimize risk,
there is some level of evidence in trauma and other non ICU patients that
the semi digested solutions are better absorbed and assimilated. That is the
rationale. We have not changed our guideline that a polymeric solution is
the recommended solution for MAINTENANCE feeding and all patients who are
tolerating their safe start on pep up trial will be switched to a polymeric
eventuatlly.

For the purposes of the PEP up study evaluation protocol, we had to
standardize our starting solution and picked Peptamen. If you do not have
access to a semi digested solution or want to use antoher polymeric
solution, in the real world setting, others will do this and let's see how
well it is tolerated. May be won't make much of a difference. But when
designing a study, we want to employ all strategies that maximize the
likelihood of a 'safe start.'

Hope that helps
Daren

-----Original Message-----
From: criticalca...@googlegroups.com
[mailto:criticalca...@googlegroups.com] On Behalf Of Rho
Sent: Monday, March 28, 2011 12:28
To: Critical Care Nutrition
Subject: [Critical Care Nutrition] Re: immune modulating formula on ITU

Hi there,

Rhona Nayman, RD.

--

[Bela]

Hi
Just some comments with regards to your questions:
Our Nestle rep has been very "active" promoting Peptamen in our ICU
with very little success. We also use Jevity as our standard feed,
which is well tolerated and up to date i have not seen any adverse
effects of using fibre in critially ill patients.
We do not use Impact at the moment, of course one of the reasons is
the arginine but mainly due to cost and the fact that we only have it
available in a powder form.
I have been using Oxepa for years (am a believer) and have seen the
"magic" it can do but almost all of my patients develop quite bad
diarrhea by day 3-5. Was wondering if anyone else has experienced that
with Oxepa.
I don't have experience with OptiFibre but we had some free samples of
Benefibre once, which we enthusiastically used up with variable
results.

Cheers
Bela

[Andrea Maudsley]

Hi Bela
Yes I have also found patient's on oxepa get diarrhea quite frequently. I
thought it was due to the fact that its 50 % of calories from fat.

Andrea

-----Original Message-----
From: criticalca...@googlegroups.com
[mailto:criticalca...@googlegroups.com] On Behalf Of Bela
Sent: Tuesday, March 29, 2011 2:03 AM
To: Critical Care Nutrition
Subject: [Critical Care Nutrition] Re: immune modulating formula on ITU

Cheers
Bela

--

[Kathleen Blizzard]

Hello, 

What are your thoughts on Impact AR in the surgical onc population? I am unsure of the specific nucleotide profile in the supplement but was wondering if there could be a potential contraindication especially for patients who are on antimetabolite chemodrugs. Could dietary nucleotides potentially be tumor promoters in this setting? I can't find anything in the literature or guidelines. Please advise. Thanks.

Kathleen Blizzard, MS, RDN, LD, CNSC

Sent from 

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[Drover, Dr. John W.]

I see at least two separate issues in this. The first is about the effect in cancer patients undergoing surgery. This is bulk of the population that was studied that has shown a positive effect and this was mostly in patients with GI cancer and H&N cancer. Are there some cancers in which they may be tumor promoters? This is also unknown but it is possible.

 

The second issue is what is the interaction of the supplements with chemotherapeutic agents. That is unknown and untested. Of course the positive effects on surgical patients has been shown with relatively brief exposure in the perioperative period and almost without exception the surgical patient will not be receiving chemo during the time around their surgery.

 

The bottom line is there is strong evidence that arginine supplemented enteral feeds are associated with reduced infections in surgical patients. As noted by Dr. Heyland in the earlier note surgical patients having a scheduled procedure coming to the ICU for a few days or less of monitoring are different than surgical patients coming for an emergency such as a septic complication. Patients having a major scheduled surgery should be considered for administration of Impact AR before and/or after their procedure.

Cheers

 

John W. Drover, MD, FRCSC, FACS, CCPE
Professor and Head
Department of Critical Care Medicine
Queen’s University
Program Medical Director, Critical Care Program
Davies 2
Kingston General Hospital
76 Stuart Street
Kingston, Ontario
Canada
K7L 2V7
Phone 613-549-6666 ext 6335
Fax 613-548-1325

 

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