1.13/ Nutrition Post-ICU

INTRO: Hello, and welcome to Clinical Nutrition Notes, a podcast where we speak with guest experts and opinion leaders about the art and science of clinical nutrition. Brought to you by Nestlé Health Science Canada. This podcast is intended for healthcare professionals for educational purposes. I’m your host Cindy Steele, medical affairs manager with Nestlé Health Science.

Steel: Today we’ll be speaking with Dr. Lesley Moisey, to get a better understanding of the unique nutrition needs of those individuals who have survived critical illness and to shed some light on how these patients recover. Ultimately, we’re hoping to gain a few nutrition management strategies to help enhance the recovery of critically ill patients. So let’s start with an introduction, Dr. Lesley Moisey is a registered dietitian, and an assistant professor at the University of Saskatchewan in the College of Pharmacy and Nutrition. She completed her PhD at the University of Waterloo where she examined nutrition in survivors of critical illness and developed expertise in assessing body composition using advanced imaging modalities. Her primary research interests focus on critical care nutrition, with a specific interest in optimizing nutrition in ICU survivors. She is particularly interested in developing evidence-informed, integrated nutrition and rehabilitative interventions to enhance nutritional and functional outcomes and quality of live in these patients.

Welcome and thank you for joining us Lesley. So today, we’re talking about nutrition and ICU survivorship. I think it makes sense to start by taking a look at how things have changed in the past decade or so. In this time, we have seen hospital mortality from sepsis and critical illness significantly reduced, which means we have more and more patients surviving and having to recover from critical illness. Lesley, your PhD focused primarily on understanding nutritional needs of these ICU survivors. To start our conversation off, can you tell us what makes survivors of critical illness a unique patient group?

Dr. Moisey: So that’s a great question Cindy. You are correct that despite the high severity of illness of critically ill patients in Canada, ICU mortality rates are actually less than 10%. However, we really need to be mindful that survival and quality of life are two very different concepts and surviving an ICU stay is often the beginning of a very long and arduous journey to recovery for many patients. So something that we’ve come to learn over the last several years is that many ICU survivors may become affected by a condition termed Post Intensive Care Syndrome or PICS. This is defined as a constellation of morbidities or impairments across three broad health domains: physical functioning, cognition and psychological health. For example, survivors may experience reduced muscle strength and function, which can translate into the inability to perform basic activities of daily living and this can persist for several years following ICU discharge. Some survivors may also experience memory loss, or deficits in executive functioning, and others may develop depression, anxiety, or signs/symptoms of PTSD that is related to their ICU stay. But coming back to your question, I think the key point to get across here is that the phenomenon of PICS, as described in its name, is specific to the critically ill and not something seen in other non-critically ill patient populations such as your general medical or surgical patients.

Steel: So when you studied survivors of critical illness, what did you uncover about their nutritional needs and the challenges that they faced?

Dr. Moisey: So the group of patients I was interested in studying were those that were a bit sicker and had required ventilator support for at least 3 days. In Canada, we really had no idea what was happening to patients from a nutritional perspective once they were extubated or taken off the ventilator. So the first step was really to try and characterize what exactly was going on. And one of the first things I looked at was how patients were being fed. For example, did they continue to be fed via feeding tube, which is very common in the ICU, or were these tubes removed and the patients were progressed to an oral diet right away. And then I also characterized how much they were able to consume in comparison to their prescribed nutrition goals which were determined by the dietitian. What we found was that about 15% of the patients had their tubes removed the same day they were taken off the ventilator and, on average, most patients had their enteral nutrition or tube feeding stopped 4 days following extubation. Not unexpectedly, those who continued to receive tube feeding almost always received all of what was prescribed in terms of their calories and protein. In contrast, patients who were prescribed oral diets didn’t come close to consuming to what was prescribed. I think a lot of people will say “this really wasn’t unexpected”, what really shocked me was how little these patients were actually consuming. On average, a patient who was prescribed an oral diet was taking in the equivalent of about 0.4g of protein per kg of body weight, which is well below the (protein) recommendation for even a healthy adult, and this translated to consuming about a quarter of what was prescribed. Patients who were on oral diets faired a little bit better with their calorie or energy intake, but still only consumed about half of what was prescribed. When we asked patients if they had any barriers to eating, it became really clear that the poor intake was largely driven due to physiological barriers and this includes poor appetite, nausea, vomiting, feeling full very quickly and experiencing some taste changes. And I think what makes feeding the patients quite challenging is that barriers such as these are not easily modified and the solution in the setting of let’s say, having no appetite, can’t be to simply give a patient more food. In fact, when I measured how much patients were eating I was also able to calculate quite accurately how much food was wasted and I found that almost 60% of all of the food and fluids that were provided to patients, ended up in the garbage. So there’s definitely a lot of challenges, and we need to be really creative in finding solutions and a lot of that is going to centre around personalizing care, especially because what works for patient A might not work for patient B.

Steel: That’s really interesting and I’m sure those findings translate across the country and not just in the setting that you did your research in because I have heard that from other clinicians. So the traditional approaches of providing a nutritional supplement or as you said, more food, won’t necessarily work.

Dr. Moisey: Well, quite frankly Cindy, there really hasn’t been a traditional approach to date. So it’s really only been in recent years that post ICU nutrition has even made a blip on the radar. Across the globe, there are only around 20 studies, give or take, that have been published that really focus on any aspect of post ICU nutrition. And this is in stark contrast to, as your listeners are probably aware, to the hundreds of studies that have looked at nutrition in patients who are admitted to the ICU who are mechanically ventilated. However, I think the good news is that we’re starting to see a shift in focus and researchers and clinicians are starting to realize that we do need to pay more attention to post ICU and not just what’s happening while patients are in the ICU.

Steel: Yeah, I think you hit the nail on the head there. I found an article the other day and it was about nutrition in ICU survivorship and I was excited, and it turned out they were talking about certain people that survived their ICU stay, but the study ended on discharge of ICU. So they were survivors but, yet, it wasn’t looking at that period that your research looked at which was just after the ICU, which is really important.

Dr. Moisey: Yeah, and that’s actually really common in the literature. I get excited about these post ICU papers, only to see that the nutrition component talks about nutrition in the ICU.

Steel: I had the same response. So then if you could wave a magic wand, what are one or two things that you would change about current clinical practice as you know it, to help improve the nutrition care of clinical care survivors?

Dr. Moisey: Oh wow, don’t we all wish we had a magic wand. I have to say as I delve more into the research in post ICU nutrition, but also engaged with clinicians and ICU survivors, I think there are a couple of themes that have really come up for me. The first is just simply increasing awareness about the unique health challenges of ICU survivors. One of my students actually just completed a really nice survey this summer. We asked dietitians across Canada about post ICU nutrition and we found that only 55% of our respondents, and we actually had over 200 respondents, had even heard of the term Post Intensive Care Syndrome. So I think it’s really important to educate clinicians. However, it’s also important to educate patients and families about what to expect following an ICU stay. Knowledge is certainly very powerful, and what again I’ve learned from talking to some patients is that knowing what you might be experiencing or what you could experience and normalizing - can really help. That actually leads to the second thing I’d love to see, and this relates to ensuring we facilitate better transitions of care for our patients. What I mean by that, is from a nutrition perspective, patient nutrition care plans should be transferred from the ICU to the ward dietitians, but this wouldn’t only include nutrition prescriptions, which were traditionally transferred over, but also talking about barriers to achieving good nutrition that a patient in the ICU may have faced. Another big care transition is when a patient is discharged from a hospital, and I think it’s really important that patients and their families leave the hospital with the tools they need, or referrals to community resources that will ensure their nutritional problems are addressed. Unfortunately, in Canada, we do have very limited resources and services in many parts of our country, so I think I’d really use that magic wand to increase dietitian numbers so that these services could be provided.

Steel: That’s a great answer and we do see a big difference across the country, from province to province, in the resources in the home for people after discharge. And for this population it’s so important. So then when you say that, for clinicians, what would be a first step they can take to help the care of these survivors, or improve their knowledge, or increase the awareness - what are some things/first steps that clinicians can take to help improve the care of this group?

Dr. Moisey: Yeah, and I think you hit it right on the nose there, and it does play to your last question. I think it’s really important that we enhance the knowledge about the nutrition issues that ICU survivors face. Certainly, I think it’s really important that dietitians working on a ward understand the unique health issues that some ICU survivors face. For example, in an ideal world, a ward dietitian would see or screen every patient who is transferred from an ICU. But of course, that really comes back to needing that magic wand to be able to increase nutrition services. But as a medical/surgical dietitian myself, I know my caseload is really heavy, and I wouldn’t have been able to see every patient coming from the ICU. But, back then, I also didn’t know about Post Intensive Care Syndrome, and I think if I were to go back to my practice today, I would definitely make sure that patients transferred from the ICU, were on my radar, regardless of whether they’re on nutrition support therapy or not. Sometimes I think as dietitians, we prioritize patients who are on enteral or parenteral nutrition, but really it’s those ones transferred out that have been on oral diets that might need a little bit more help and attention, than the ones on nutrition support.

Steel: Isn’t that interesting. It’s a different approach. You’re right, when I was a clinical dietitian, we prioritized people on enteral and parenteral, but when you think about it, those are the people that are getting their needs met, not the others that are left to their own devices to eat orally, and we’re just sort of hoping, and assumed they were lower risk, though what we know now, and thanks to your research we’re learning that that’s definitely not the case. So then when we think about these people, you mentioned post discharge from acute care into the community, do we know anything about the longer term nutritional needs of these survivors, and how long it takes for them to “return to normal”, and what recovery looks like for them when they get out of the hospital?

Dr. Moisey: This is actually really an untapped area in the literature, and we really don’t know a lot. Dr. Judith Merriweather, she is a dietitian in Edinburgh, and she’s actually done some nice qualitative work that examined nutrition rehabilitation in patients in the months following their hospital discharge. What she found is that it was actually during this phase, so a few months after discharge, that nutrition becomes a more relevant issue to patients. So usually in the hospital patients are more focused on their medical needs and just recovering from a medical perspective. However, nutrition becomes more important to them in the months following their discharge. For example, for a lot of patients, their appetite wasn’t back to normal, and something else that really stood out is that what she found is that patients experienced significant changes to their body image and their identity. This is related to those dramatic changes in physical appearance that these survivors undergo. They have quite a bit of weight loss. They lose a lot of their muscle and function. They also have increased fatigue that occurs because of their illness. I think that’s a really neat area that she’s uncovered. In contrast though, I just had the opportunity to visit some of my colleagues in the United Kingdom who’ve been involved with post ICU clinics, and another nutrition issue that’s quite common that they were telling me about, is that patients also tend to gain weight in recovery. But often it’s fat mass, and not muscle or lean tissue mass, and this is also supported in some of the newer studies that are coming out. Thus, patients are often coming to these clinics hoping to lose weight and that’s really where I think we need to start looking at how nutrition combined with physical activity intervention can help to enhance physical function and ICU recovery.

Steel: So having listened to that, it makes me wonder, whose responsibility is it for ensuring that these patients recover well? Is it the ICU dietitian? Is it the physio, the ward dietitian, the patient, the doctor? Who do you think is responsible in ensuring that the recovery is appropriate?

Dr. Moisey: Well, one of the things I try to hammer into my undergraduate dietetic students is that nutrition care, or the nutrition care of patients can be impacted by almost every member of the multi-disciplinary team. So as dietitians, our responsibility is to identify patients who will benefit from or require nutrition intervention and then recommend the appropriate nutrition prescription. However, we’re seldom the ones to operationalize it. For example, we can prescribe a tube feeding regimen, but we might require a physician to sign off on our order, a nurse or physician would need to insert a feeding tube, if it isn’t already in place. The nurses are typically members of the team who will ensure the nutrition is actually delivered. And then you might have a speech language pathologist who’s following a patient to see if they can swallow and maybe eat orally in the near future. Nutrition is definitely a team affair. One of the other things that I preach to my students and this comes directly from my experience as a clinician, is that dietitians are key in both advocating for proper nutrition in our patients as well as helping to educate our fellow team members. When this is done well, there’s actually many times, it’s our team members who might be the ones to identify a patient who has fallen through the cracks from a nutritional perspective, and send a referral our way. Honestly, I think this really holds for all of our hospital patients not just the critically ill.

Steel: Yes, that definitely makes sense, for sure. We’ve been saying that for a number of years, haven’t we. Nutrition is a team sport. So we know that the research is in its infancy is this area, what are the key gaps, or what would you like to see happen next in the research?

Dr. Moisey: That’s the million dollar question. There are several directions that I think we can take. First of all, I think it’s important we continue to identify barriers and facilitators to nutrition care. Or optimizing nutrition in ICU survivors, particularly over the longer term period, so months that follow hospital discharge. To do this I think it’s really important to get the perspective of dietitians as well as other members of the multi-disciplinary team, and then also, I think, it’s really important that we talk to patients and their families to get a sense of how they feel, what nutrition issues are or are not important to them. Then also identify what strategies they’ve been employing to improve their nutritional health. Certainly, I think patients and families can be quite creative, and I think we, as healthcare professionals, also have a lot to learn from them. I also talked about this earlier, but I’m quite interested in getting a better sense of where Canadian dietitians are at in terms of their knowledge of Post Intensive Care Syndrome and post ICU nutrition, and also what barriers they’re facing to enhancing the care of ICU survivors. I think once we nail down some of these barrier in the Canadian context, we can start to come up with interventions or strategies to improve their nutrition care. Another direction really relates to this concept of post ICU recovery clinics or rehab programs. In Canada, there are a few of these programs. As far as I’m aware, I don’t believe dietitians or nutrition interventions are a part of these programs, and I would really like to see this change. Let’s be honest, nutrition isn’t going to be a make or break factor in improving ICU recovery. However, I think it needs to be considered or put on the table. For example, if a malnourished post ICU patient is undergoing a physical rehabilitation program, perhaps it’s possible that if we apply an intervention that enhances this patient’s nutritional status then their response to the physical rehabilitation would actually be augmented.

Steel: And we look forward to you tackling all of those issues next year. Thanks so much Lesley, and finally, so our listeners can get to know you a little more, we have been asking all of our speakers to tell us how they first became interested in the field of nutrition?

Dr. Moisey: That’s a loaded question. I was always very involved in athletics growing up and thus naturally, and I see this with a lot of my students, I had a huge interest in sport nutrition. So that’s what really drove me to do my undergraduate education in nutrition. However, I also had the wonderful opportunity to do a dietetic internship at St. Michael’s hospital in downtown Toronto. This is a huge inner city hospital. It was then when I was introduced to inpatient clinical nutrition, and it was really that experience where I fell in love with clinical nutrition. I loved working with patients and their families and learning about some of the tough medical issues that they experienced. So that’s what’s really driven my passion for nutrition and certainly it’s also really helped me to develop my research questions. It was definitely an evolving process, and again, I like to refer back to a lot of my students, but I think the biggest piece of advice I would give anyone is to never keep blinders on. You never know what experiences or opportunities will find you, or how you’ll feel when you’re immersed in a new situation.

Steel: I think that’s some great advice to end the podcast with. And on that note, I’d like to thank Dr. Lesley Moisey for joining us and for shedding some light on this really interesting area and helping us to improve the care of nutrition in ICU survivors. Thank you to all of our listeners.