Annette Prinsloo RD(SA)) Chief Dietitian ... - Critical Care · •Postpyloric feeding •Nutrition algorithms Optimal EN delivery = 66.6% of daily energy goal in 1st week in ICU

Annette Prinsloo RD(SA))Chief DietitianChris Hani Baragwanath Academic Hospital

Goals of nutritional support

• Minimize effect of starvation due to suboptimal feeding

• Prevent overfeeding and underfeeding

• Prevent micronutrient deficiencies

• Sustain organ function

• Prevent dysfunction of the cardiovascular, respiratory and immune systems until the acute phase inflammatory response resolves

• Maintain lean body mass

• Improve muscle function

Nutritional status

Nutritional status

Double burden: PEM vs Obesity

Nutritional status is determined using z-scores:

W//L < - 2 z scoreBMI//age < -2 z score

BMI//age > + 2 z score

MALNOURISHED

OBESE

Trends in the prevalence of under nutrition in children, SA 2005 – 2012

(SANHANES)

1 -3 years 4 – 6 years

Prevalence of overweight and obesity in children aged 2 – 14 years, SA 2012

Scenarios

• Malnourished child on admission – risk of refeeding

syndrome

• Child becoming malnourished during admission

• Overweight/obese child – greater risks for complications increased length of stay, and loss of muscle tissue

Obese children

“There is not adequate evidence to assess the

clinical outcomes of hypocaloric or hypercaloric

feeding during hospitalization of obese children.

Therefore, the goals for the provision of energy to

pediatric obese inpatients should be similar to the

goals for their nonobese counterparts until more

evidence is available. (Grade: E)”

ASPEN, 2010

Obese children

Obese children are at increased risk for:

• Anemia

• Low fat-soluble vitamins levels (vitamin D)

• Low vitamin B status

• Hyperlipidemia

• Insulin resistance

• Hyperglycemia

Weight

Weight measurement can be unreliable in critically ill children with:

• Fluid imbalance from resuscitation fluids

• Volume overload

• Capillary leak with subsequent anasarca

• Diuresis.

Route and timing

of

nutrition support

Route of feeding

• EN preferred above PN

• EN infection morbidity

LOS

cost of nutrition

• Supplementary PN (functional GIT) might be required as a result of problems with airway management,

clinical instability, diagnostic procedures etc.

TPN costs (Pediatric) = R 288 – R 1007/ bag

EN costs (Pediatric) = R24 – R60/bag

EN delivery

Impeding factors

• Feeding intolerance

• Aspiration of gastric

contents

• ICU procedures

Practices to

maximize EN delivery

• Prokinetics

• Postpyloric feeding

• Nutrition algorithms

Optimal EN delivery = 66.6% of daily energy goal in 1st week in ICUMartinez et al. NCP 2014

Contra indications to EN

Absolute contraindications:

• Paralytic or mechanical ileus

• Intestinal obstruction

• Perforation

• Necrotising enterocolitis.

Relative contraindications include:

• Intestinal dysmotility

• Toxic megacolon

• Peritonitis

• Gastrointestinal bleeding

• High-output enteric fistula

• Severe vomiting

• Intractable diarrhea.

Trophic feeding

“Even minimal quantities of nutrients in the gastrointestinal tract (trophic feeding) may promote intestinal perfusion, initiate release of enteral hormones and improve gut barrier function”

ESPHGAN 2010

Hemodynamic stability

• Clinical guidelines recommend EN to be withheld in patients on high dose inotropic support -

risk for subclinical ischemia/ reperfusion injury

• No consensus on the definition of hemodynamic instability

• Pediatric patients requiring cardiovascular medi-cation in the ICU tolerated EN well

– King et al JPEN 2004

Calculating

nutritional

requirements

Calculating energy requirements

ENERGY BALANCE

ORGAN SUPPORT (Decrease demand)• Mechanical ventilation• Muscle relaxants• Sedation• Non nutritive calories

STRESS (Increased demand)• Surgery• Illness• Procedures

∆ according to disease severity and interventions

Distribution of methods used for estimation of energy expenditure in 524 pediatric intensive care unit patients.RDA, Recommended Dietary Allowance; WHO, World Health Organization.

Martinez et al. NCP 2014

46%

26%

1%

27%

Schofield

WHO

Indirect calorimetry

Other- White, Talbot,

Harris Benedict, RDA

other

Predictive equations

Limitations:

• Based on healthy populations

• Not intended for critically ill patients or patients with develop-mental disorders

• Overestimate energy expenditure overfeeding

• In absence of indirect calorimetry predictive equations

(WHO, Schofield) should be used but without stress factors

• The application of stress and activity factors to BMR leads to

further inaccuracies, and risks overfeeding in most critically ill

children

Skillman & Mehta, Curr Opin in Crit Care, 2012

Indirect calorimetry

The Gold Standard

Not reliable in children if:

• On an FiO2 > 60%

• Leaks of > 10% from ET tube

• During ECMO

• On CVVHD

Protein requirements

Estimated protein requirements for injured children per age group:

0–2 years: 2–3 g/kg/day

2–13 years: 1.5–2 g/kg/day

13–18 years: 1.5 g/kg/day.

ASPEN Clinical Guidelines: Metha et al JPEN, 2009

In a review of protein supplementation trials in

critically ill infants and children, positive protein balance was only achieved in patients receiving a minimum of 57 kcal/kg/day and 1.5 g/kg/day

protein

L. J. Bechard, J Pediatr 2012

“Enteral diets for infants and children contain aninsufficient protein concentration when a restricted

caloric intake is given as it usually occurs in thecritically ill patient (50–60 % of calories in relation

to their age).”

Urbano J et al, Diet and Nutrition in Critical Care, 2014

Some studies have found that protein-enriched

diets:

protein synthesis and related biochemical para-

meters,

availability of essential and branched amino acids in plasma

improve nitrogen balance.

Broader studies are needed to assess the impact of diets supplemented with proteins in anthropometric biochemical, and clinical parameters in critically ill

children.

Urbano J et al, Diet and Nutrition in Critical Care, 2014

Practically……………?

Monitoring

tolerance

Gastric residual volumes

• Current recommendations in adults tolerate larger thresholds for GRV’s

• In adults the absence of GRV monitoring was not associated with an in VAP

• GRV monitoring can result in EN interruptions and impede achieving EN goals

• No reference values for GRV’s in children• GRV monitoring not recommended in children

Martinez et al, NCP 2014

Key messages

• Evidence based guidelines for nutrition support i.t.omacronutrient delivery in the pediatric ICU are lacking.

• Available pediatric products (in SA?) are not in line with current practice.

• Continuous monitoring of nutritional status is essential

to ensure optimal nutrient delivery

• Adult practice guidelines could not summarily

be applied to the pediatric critically ill population.

Thank you! Travel safe! Goodbye!