Interviewer: Also contribute to the guidelines.
Interviewee: What I am is a professor in intensive care in charge of the nutrition program of the ICU and member of the guidelines. [unintelligible 00:00:14]
Interviewer: [unintelligible 00:00:15] I have covered pretty much everything [unintelligible 00:00:17]
Interviewee: You have [unintelligible 00:00:19] weight loss [unintelligible 00:00:20] amazingly.
[laughter]
Interviewer: Good to go?
Interviewee: Yes.
Interviewer: It's funny anyway. I'm here with Professor Mette Berger, who is professor of intensive care at the [unintelligible 00:00:32] in Lausanne in Switzerland, and also software for the nutrition program and Professor Mette Berger has also been a key contributor to the western's EPEN guidelines. [unintelligible 00:00:43] to present-- We're here, by the way, at the ESICM in Berlin the 32nd meeting this year. With me to present a [unintelligible 00:00:53] on the ESICM and the new ESPEN guidelines, what do you see as the biggest impact they've made so far?
Interviewee: Actually these new guidelines are something which resolves the multiple puzzle issues we've had until now. We have had many controversies. Why so? Because we have not understood to express that the patient's journey through the ICU is a very changing one. There is an early phase where the patients are unstable, catabolic their [unintelligible 00:01:28] are not working normally. Then, if they respond to your therapy, they will actually stay behind. Their metabolic functions will be [unintelligible 00:01:39] will improve, the needs will change and eventually they go into recovery, the anabolic phase or they get more complicated and worsen again.
What we now have understood is that there are an early phase, an intermediate phase, a delayed phase, where the needs do differ, and where the metabolic responses differ.
By taking this into account, we now know that due to the patient's response to disease with an endogenous recourse production which helps overcome the first fears of starving. If you're [unintelligible 00:02:17] you're wrong.
On the top of that, it's a conflict you may promote [unintelligible 00:02:22] syndrome because many of our patients come in being sick and not having anything [unintelligible 00:02:28] Moreover, finally, by doing [unintelligible 00:02:32] feeding the compromised gut will not be able to accommodate that, so you've made that into complication. What has changed is most of you don't have indirect calorimetry to assess the energy needs. Goal, of course, first week 20 calories per kilo bodyweight and you achieve it by day three, four, five that's progressive increase. If the patient has a non-functional gut you can see the personal nutritionist. Think that is the summary of the guidelines.
Interviewer: It's the first time guidelines have really reflected the patient's metabolic condition?
Interviewee: Yes.
Interviewer: What are the biggest challenges in implementing things?
Interviewee: There are many beliefs. Many trials have actually just made the appreciation of the results very complex. All the big trials have been carried out very professionally, but they have not considered the true needs of patients, nor the stage of disease. This is why many trials either have no result or have had bad results in term of increased complications.
Now that we now address this issue of the need and try to go in individually, we have seen that the latest trials which have been productive with goals determined individually by calorimetry have better outcomes. [inaudible 00:04:01] measures the infection, the length of stay and so on. Clearly, this individualized nutrition is now coming in strong [unintelligible 00:04:10].
Interviewer: Therefore there's not one product for all intensive care sessions?
Interviewee: Exactly. You've got it. It's very important because the energy needs are lower during the early phase to have products which contain high amounts of protein if possible well digestible. Later on, we go in with products. You'll have had proteins but also energy and fibers. We should go in also with fibers early on to maintain back the intestinal function.
Interviewer: We've just come a lunch symposium for the nursing staff. What do you see the role as to intensive care nurse in relation to nutrition, professor?
Interviewee: I love my nurses because when they are with me on board, the patient gets fed and they are the best to do that. Nutrition without nurses is bound to fail. We have those who are sitting at the bedside. Sitting, standing, being around the patient, who are able to see how the patient responds metabolically. If the gap is working, if the [unintelligible 00:05:16] are in charge, if the catheter is doing well. Nurse-driven policies are those who have the highest success because they are really there and they watch the patient. Food nutrition is exactly the same. If you have a nurse team which is well trained in nutrition, then we'll be able to progress and adapt to the patient. If you define exactly their roles and the borders where they should warn the doctor because this is not anymore, let's say, a routine patient. They will feel [inaudible 00:05:53] and empowered to go within those limits, and this role improves the patient's outcome.
Interviewer: Would you expect every intensive care to have protocols or safety nets contribution, or is there another way?
Interviewee: This is absolutely necessary. Unless our theories don't tally, they should implement it. Only if the roles are defined and you have standard operating procedures everybody knows where their comfort zone is, and they can warn, "I need the dietician to help me with nurse," say, if she doesn't get it right with the protein, or if the patient definitely if he doesn't accept in intro feeding. We'll tap on the doctor's file and say, "Hey, maybe we should consider [unintelligible 00:06:35] nutrition if this is not working in this patient on non-invasive ventilation." If you define exactly the role then the patient is taken well care of.
Interviewer: It's been 18 months, nearly two years since the guidelines have come out. Have they been successive?
Interviewee: They seem to have been well accepted. You know that the list of authors, we've had people who have been representing different [unintelligible 00:07:04] and we were able to unite over this paper. I think these guidelines finally are bringing new expertise into the world of nutrition.
Interviewer: [laughs] Thank you very much, it's been a pleasure.
Interviewee: Thank you, that was great.
Interviewer: The next steps will be if we refine it and I'll send the link to you before we put it on the website and it's put a disclaimer that says you agree that we put that publicly. You can then present and support so that we can share by social media, so we can share [inaudible 00:07:36]
[00:08:00] [END OF AUDIO]