Michael Smith, MD, and Sarah Vest Cogle, PharmD, BCCCP, review current methodologies for managing nutrition concerns for critically ill morbidly obese patients.
Dr. Cogle discusses the role of nutrition risk assessment outlined in the joint American Society for Parenteral and Enteral Nutrition and SCCM nutrition guidelines published in Critical Care Medicine in 2016.
Dr. Cogle is assistant clinical professor at Auburn University’s Harrison School of Pharmacy and a critical care and nutrition support clinical pharmacist at East Alabama Medical Center in Auburn, Alabama, USA.
This podcast is sponsored by Nestlé Health Science.
Estimated Time: 18:40 min
Announcer: This podcast is sponsored by Nestle Health Science, the makers of Peptamen formulas, the only peptide-based formulas with enzymatically hydrolyzed 100% whey protein to help with tube feeding intolerance. Used by healthcare professionals for over 30 years with more than 60 clinical studies. To learn more visit www.petamen.com.
Dr. Michael Smith (Host): Hello and welcome to the Society of Critical Care Medicine’s iCriticalCare Podcast. I’m your host, Dr. Mike Smith. Today, I will be speaking with Dr. Sarah Vest Cogle. She’s a PharmD and we’re going to talk about managing nutrition concerns for critically ill, morbidly obese patients. Dr. Vest Cogle is Assistant Clinical Professor at Auburn University’s Harrison’s School of Pharmacy and a Critical and Nutrition Support Clinical Pharmacist at East Alabama Medical Center in Auburn, Alabama. Dr. Vest Cogle, welcome to the show.
Sarah Vest Cogle, PharmD, BCCCP (Guest): Yes. Thank you so much for having me on.
Dr. Smith: I think this is a fascinating topic and I know you had mentioned before that you do a lot in the surgical ICU, right and that you see a lot of these types of patients. So, you have a lot of experience with this and I wanted to start off with what are some of the nutritional challenges that you guys face when you’re managing a critically ill morbidly obese patient?
Dr. Vest Cogle: Well I think you know one of the initial challenges we have is just determining which of our patients, obese or not are actually at the highest nutrition risk. I think that it’s a very common thought that maybe obese patients have more nutritional reserves per se, just do to their obesity and so maybe there’s a thought that they are not going to benefit from nutrition support therapy. And maybe we can wait a little bit longer before we implement these therapies in these patients.
That’s actually not the case. Quite a large percentage of patients with obesity are considered to be malnourished. It’s just a bit harder to detect in patients who have obesity. And ASPEN which is the American Society of Parenteral and Enteral Nutrition and FCCM have some joint guidelines on how to manage nutrition support in critically ill patients. And one of the things that are really emphasized in these newer guidelines is the use of nutrition risk assessment. And in these nutrition risk assessments, we use markers like body mass index or BMI to determine which patients are obese and that kind of drives out nutrition assessment. But those really aren’t great markers for determining nutrition assessment in general. Because they don’t account for muscle mass.
And so we don’t really know which patients with obesity maybe are at higher risk and so maybe they are at a higher weight, but they are actually malnourished. So, it can just be difficult in general, to determine how much we should be feeding people and which patients are going to benefit the most from receiving nutrition support therapy.
Dr. Smith: So, when you look at the nutrition risk index, so some of the limitations and some of those standard markers that you look at simply just don’t give you the whole story. So, how do you get the whole story then? What else are we doing when we look at a morbidly obese ICU patient? What else are you looking at to help you define whether that person is malnourished?
Dr. Vest Cogle: Well, there’s new scores that we look. There’s two that you can use. They are called the Nutric Score or the NRS 2002 Score. So we do look at things like height and weight because you have to start somewhere. But we also look to see how severely injured or ill the patient is at the moment because that can also drive their need for nutrition therapy. So how acutely ill they are. Have they had recent weightloss or weight gain? Kind of what is their baseline. And that can be difficult to determine as well, but we do our best to try to look at that.
As you said, some of the markers that we normally use say in the outpatient setting to determine if patients are malnourished like albumin are not accurate in critically ill patients. So, we really can’t use those and instead we use these scoring systems to try to identify the patients who are at highest risk. And from there, you can use either weight-based calculations. You can use predictive formulas, or you can use indirect calorimetry which is really the gold standard for determining energy requirements in all patients. But unfortunately, this is not a widely used tool anymore just because it’s expensive. A lot of institutions may not even have the capability to perform it. And we have to have really pristine conditions to get accurate readings. So, a lot of times, we are not able to use indirect calorimetry, so we do have to use either predictive equations or we just do simplistic weight-based equations.
Dr. Smith: You had mentioned before, and I thought this was interesting that maybe in the recent past, that when there was a morbidly obese patient admitted to the ICU; because of this idea that they have these energy reserves, that maybe a nutrition risk index wasn’t done right off the bat for that patient. Has that changed? Are we recognizing that there may be some faulty thinking there in that these patients need that nutrition risk assessment right away?
Dr. Vest Cogle: Yes. This is actually quite a shift with newer data that is coming out. So, previously, we preferred doing tube feeding or enteral nutrition in patients who came in and where determined to need nutrition support therapy. But if they needed IV nutrition or parenteral nutrition; we would wait a full week before we started that. And based on newer data we have for patients who are at high nutrition risk; it’s really important to start those therapies sooner. So, we don’t want to wait a week anymore. And that goes with obese patients as well. And so as I said, we preciously thought well heh, they have a lot of nutritional reserves so we can wait on this, but what we’ve actually seen in some studies is that obese patients may have a little bit of issue utilizing fuel and instead of breaking down fat stores which is what you would sort of assume would happen; they actually are more likely to breakdown lean muscle mass. And that can be really difficult in the recovery phase of their critical illness.
Dr. Smith: Yeah, that’s a good point. It doesn’t take long for a patient who is laying in a hospital bed, not really being that active to start to have signs of sarcopenia, right, like they are losing muscle mass which can be really tough for recovery and I think that’s an excellent point. How common is it though? I know where you are practicing, and your approach is to get that nutrition risk assessment done immediately. Is that something that is common throughout the United States now in intensive care units? Or are there – or are a lot of places still waiting that week?
Dr. Vest Cogle: I think it’s becoming more common to go ahead and do the risk assessment when patients are admitted and then as soon as it’s safe to begin enteral nutrition once patients are adequately resuscitated to go ahead and get those therapies on board. I would say that that is a shift that’s occurring. So, I don’t know that it’s being done consistently everywhere but there is a lot of data to support this. There are new studies that come out fairly regularly about how we should be managing patients who are at the highest risk of malnutrition. Because those are the people who are really going to benefit from nutrition therapy.
If you are at low nutrition risk, we can do nutrition support therapy and it may not be harmful but it’s less likely to be helpful in these patients. So, we are really trying to target our high nutrition risk patients, whether they are obese or not.
Dr. Smith: What I find interesting in all of this, because I remember as a young physician, and being taught that if somebody is overweight or obese, they have these energy reserves and there’s some small studies showing that that might actually impact recovery and all this kind of stuff. But I think most of us now appreciate with the standard American diet, that most Americans are overfed and undernourished. So, most people coming in to a critical care situation are probably malnourished. What do you think?
Dr. Vest Cogle: Oh, I would absolutely agree with that. With some of the data I have seen is that it is up to even maybe 60% of critically ill patients who are obese are malnourished. So, it’s definitely something we’re seeing a lot more.
Dr. Smith: Are there specific cases or some large research trials that have demonstrated the effectiveness of following this nutrition risk index and following through with nutritional therapy when necessary?
Dr. Vest Cogle: There are actually some studies to support how we feed our patients. So, we don’t feed our obese patients the same way we feed typical patients. What we do, is we provide what they call hypocaloric, high protein nutrition support regimens. So, we provide less overall energy or calories but the same amount of protein essentially that you would be providing to a normal weight patient. And the rationale for this is so we can preserve lean muscle mass, we can mobilize the patient fat stores more effectively and decrease any metabolic complications that we might see from overfeeding.
And there have been studies done in this, particularly in trauma patients where they were able to see that patients who were fed with these regimens had shorter lengths of stay, fewer days on antibiotic therapy and there was even a trend towards less time on mechanical ventilation.
Dr. Smith: When you look at some studies looking at the lean muscle loss or fat-free muscle loss in patients that ae in hospitals, laying in the bed, not getting the activity that they should be getting; there are some studies, nutritional studies that show additional amino acids like creatine or HMB when added to these nutritional therapies can help. Do you guys utilize some of those amino acids that have been shown to protect muscle mass?
Dr. Vest Cogle: We don’t do that routinely at my institution. I think a lot of this is more just kind of hypothesis generating and not really widely practiced or recommended at this time. But I think there’s definitely potential for that in the future. Maybe to try to tailor more individualized regimens for a specific patient. But there’s just not enough data to support that widely right now.
Dr. Smith: Okay. So, when you look at everything that you’re doing, you look at the approach, the guidelines, the nutrition risk index; what do you believe as the expert here, what do you believe are some of the most important areas that we can improve on?
Dr. Vest Cogle: Well I definitely think performing the nutrition assessments in general just on all patients but making sure that we are doing them in obese patients and not just again, assuming that they have nutritional reserves. Also making sure that we are providing adequate protein provision for these patients because we know protein is really important for maintaining that lean muscle mass and for wound healing especially in the surgical ICU and trauma ICU and some of those settings. And doing frequent reassessment of the patient to make sure that what your initial plan or what you came up with initially is still working as you go through the patient’s ICU stay. So, I think those are the things that we really need to emphasize and there’s a lot of research going on now to try to determine the optimal amount of protein. We have ranges that we work within, but everybody is always wondering is there a specific amount that if patients can get this along with their physical therapy and occupational therapy and other interventions that are ongoing; can we improve outcomes in these patients.
Dr. Smith: So, speaking about improving outcomes, and I know – so this maybe is a tough question to answer because there’s so many factors involved with a critically ill patient. So, I get that; but when you look at the approach to the obese critically ill patient versus the normal weight critically ill patient; what are the outcome differences right there? I mean what does obesity really do just in general to the outcome of these critically ill patients?
Dr. Vest Cogle: Well as you said, that is a difficult question to answer in terms of direct causes from obesity. But I think the same things that you see in the outpatient setting how obesity can affect quality of life, morbidity and mortality. We are going to see those same things in the inpatient setting. If patients have uncontrolled hyperglycemia, we can see infectious complications. They may be on the vent longer. They may have oxygenation issues. They may be difficult to intubate or maintain good oxygenation. And so, just a lot of things that again, may be difficult to quantify being specifically related to their obesity but it’s definitely contributing to all of those things. And ultimately, that can increase length of stay and perhaps mortality.
Dr. Smith: Yeah and as hard as that might be, if we could imagine if you could – we’re going to stretch our imaginations a little bit here Dr. Vest Cogle. But if we could hold a lot of those issues, those factors constant right, how critically ill they are, how long they have already been in the hospital, if we could how a lot of that constant and we just simply look at focused nutritional therapy that’s currently being used for an obese critically ill patient; are the outcomes better right now than they were in the past for that same patient?
Dr. Vest Cogle: I think so. I think that with all of the literature that’s come out and updated guidelines relating to nutrition support therapy in the last say 10-15 years; I definitely think that we are doing a much better job than we ever have been treating these patients. We know a lot more about how to manage complications and what we should be doing on the frontend in order to mitigate complications from arising. There’s also some exciting technological advances going on where we are looking at using CT scans or MRIs or ultrasounds in order to determine how much lean muscle mass patients have so that maybe we can try to use maybe more objective information rather than these just predictive formulas which are really just educated guesses on how much we should be providing to these patients.
So, I think there’s a lot of exciting stuff coming down the pipeline that we are still just really trying to flush out at this point.
Dr. Smith: Speaking of that, so what do you see as the future opportunities then when managing the critically ill obese patient? When you look at some of the research proposals, what might be going on; what do you think are those future opportunities where we can make improvements and truly improve outcome?
Dr. Vest Cogle: I definitely think the increased use of technology could be a real game changer for nutrition support therapy. I think as I said, the use of radiological scans or bedside ultrasounds in order to determine how much lean muscle patients have so we can get a better picture of what type of obesity do these patients have and hopefully tailor their nutrition regimens to better suit the individual patient off the front end. But also, doing more investigational studies to determine how we use these things to assess our adequacy of nutrition support therapy as the regimen is continued because that’s something that we really haven’t seen a lot of yet. But I think this could really change the way we manage these patients. I think we may be looking more at this and getting away from simplistic calculations and kind of just guessing.
Dr. Smith: Right, and then of course, when you think about all the different technologies that are coming out and that are being improved upon; everything in science, especially medical science is moving so fast. And it could be difficult to kind of predict where we might be. But I know that technology and having some of those more detailed measurements that are constant and right there at the bedside; is going to be pretty powerful. Obviously, you work with a lot of different people in the critical care setting, but when it comes specifically to the nutrition risk index and when to start nutrition therapy; who are some of the other professionals you are working with?
Dr. Vest Cogle: So, I work very closely with – I’m a pharmacist by trade, but I work very closely with our Registered Dieticians, our bedside nurses, and our intensivist physicians and so, usually it is a collaborative effort to determine that the patient needs nutrition support therapy and then they are evaluated closely to determine whether we want to do PN or do we want to EN. At our institution, our dieticians write all of the enteral nutrition orders and the pharmacists write the parenteral nutrition orders but there is a lot of overlap between the entire team trying to figure out the best management for this patient.
Dr. Smith: So, Dr. Vest Cogle, in summary, what would you like people to know about the nutritional challenges faced for a morbidly critically ill obese patient?
Dr. Vest Cogle: I think the big takeaway here is just to remember that you can’t assume that just because patients are obese that they are not malnourished and that they are not at nutrition risk. And these patients need to be closely evaluated the same way that you would evaluate a patient who you could look at and assume that they were malnourished. In studies where they have looked at patients, it’s called the Obesity Paradox; there has been some data to show that patients that had a smaller degree of obesity actually had lower mortality rates, but it was kind of a U-shaped curve in a lot of those studies. So, actually, the patients who were at the highest risk of mortality are going to be the patients who are very, very obese and the patients who are underweight.
So, we really need to be looking at those patients kind of in the same category although they are just at different extremes of weight. So, I guess the take home point there is just to make sure that we are not assuming that these patients don’t need nutritional management because they are morbidly obese.
Dr. Smith: Excellent summary. Dr. Sarah Vest Cogle, I want to thank you for coming on the show today. and this concludes another addition of the iCriticalCare Podcast. For the iCriticalCare Podcast, I’m Dr. Mike Smith. Thanks for listening.
Announcer: Michael A. Smith, MD, received his medical doctorate from the University of Texas, Southwestern Medical Center. He practiced internal medicine and radiology in Dallas, Texas in the early 2000s before transitioning to the pharmaceutical and nutraceutical industries as an educator and consultant.
This podcast is sponsored by Nestle Health Science, the makers of Peptamen formulas. The only peptide-based formulas with enzymatically hydrolyzed 100% whey protein to help with tube feeding intolerance. Used by healthcare professionals for over 30 years with more than 60 clinical studies. To learn more visit www.peptamen.com. Join or renew your membership with SCCM, the only multiprofessional society dedicated exclusively to the advancement of critical care. Contact a customer service representative at 847-827-6888 or visit www.sccm.org/membership for more information.
Second Announcer: The iCriticalCare Podcast is copyrighted material and all rights are reserved. Statements of fact and opinion expressed in this podcast, are those of authors and participants and do not imply an opinion on the part of the Society of Critical Care Medicine or its officers or members.