The Last Frontier: Nutrition Support in the Pediatric ...

The Last Frontier: Nutrition Support in the Pediatric Intensive

Care Unit

Bodil Larsen BSC, RD, PhD Candidate

Clinical Dietitian, PICUStollery Pediatric Intensive CareApril 27, 2007

April 27, 2007

Edmonton and Area.

www.capitalhealth.ca

Objectives

• Patient Population• Barriers and Challenges of nutrition support• Energy expenditure and determination• Parenteral Nutrition• Enteral Nutrition• Biochemistry• Physiology of metabolic stress• What can we do?

April 27, 2007

Edmonton and Area.


Stollery PICU Patient Population

• 36 wks gestation to 16 yrs old• Heart, gastrointestinal, liver, neuro, airway,

renal, traumas, transplants, sepsis• ECMO, peritoneal dialysis, CVVHD, pre and

post-op, chylothorax• Sedation, paralysis, ventilation, drugs• Sepsis, multi-organ failure

April 27, 2007

Edmonton and Area.


Stollery PICU Patient Population

All require modification or consideration when providing metabolic or nutrition

support

*Not a feeding and growing unit

April 27, 2007

Edmonton and Area.


Barriers and Challenges of Nutrition Support

• Metabolic vs nutrition support• Wasting specific lesions (pre-operative

nutritional status)• Hemodynamic instability• Severe hypotensive gut• Fluid restriction• Enteral vs parenteral• Philosophy nutrition support will do more harm

than good in immediate post-operative period• Urgency to remove central line

April 27, 2007

Edmonton and Area.


Too Little vs Too Much

Diamond 1995

April 27, 2007

Edmonton and Area.


Too Little vs Too Much

• Sedation• Paralysis• Intubation/ventilation• + inotropes• + wasting

April 27, 2007

Edmonton and Area.


Determining Caloric Requirements

April 27, 2007

Edmonton and Area.


Tools Used for Determination

• Indirect calorimetry• Underlying disease process• Biochemistrys and nitrogen balance• Published papers (reference charts)• Nutritional status

April 27, 2007

Edmonton and Area.


Under or Overfeeding the Critically Ill Child

• Caloric overfeeding cannot reverse obligatory catabolism during hypermetabolic states and is associated with increased mortality and clinical detriment.

• Caloric under feeding can effect ventilator days, length of stay and number of infections

• Pre-operative nutritional status is important• The lower the weight, the higher the risk• How long are we comfortable leaving without support.

April 27, 2007

Edmonton and Area.


Expectations of Nutrition Support

pre-op nutrition support

rehabing

feeding - growing (anabolic)

____________________________________

post-op metabolic support

critically ill

ventilated

sedated (catabolic)

April 27, 2007

Edmonton and Area.


CHEST; The Cardiopulmonary and Critical Care Journal;

Chest 2003; 124; 297-305

April 27, 2007

Edmonton and Area.


Pilot Study

Larsen, Joffe et al 2004 unpublished data

PICU/NICU Stollery

April 27, 2007

Edmonton and Area.


Cachexia

Ref: Am J. Clin Nutr 2006;83:735-43

April 27, 2007

Edmonton and Area.


Ref: Cuur Opin Clin Nutr Metab Care 9:297-303, 2006

April 27, 2007

Edmonton and Area.


“Measured EE was stable and not significantly different from predicted values over the course of hospitalization. Underfeeding was frequently present and mainly due to prescription and administration of energy amounts inferior to measured EE values in enterally fed patients”

Pediatric Crit Care Med 2006; 7:147-153

April 27, 2007

Edmonton and Area.


Route of Administration: Enteral vs Parenteral

Indications for TPN:• SBS• Ileus• Severe dysmotility• NEC• Unable to provide adequate support with

enteral nutrition

The gut can be used in critical illness

April 27, 2007

Edmonton and Area.


Journal of Pediatric Gastroenterology and Nutrition. 41: S1-S4

April 27, 2007

Edmonton and Area.


• TPN initiation dependent on age, size, nutritional status, disease, surgery or medical intervention

• In small preterm infants starvation for 1 day may be detrimental

• Older children can wait up to 7 days dependent on circumstance

Journal of Pediatric Gastroenterology and Nutrition. 41: S1-S4

Espghan Guidelines

April 27, 2007

Edmonton and Area.


Enteral:

Enteral Nutrition Advantages:• Decreased cost• Decreased metabolic abnormalities• Decreased infectious risk• Promotes GI integrity• Stimulates enteric secretions, hormones and

blood flow• Decreased bacterial translocation

April 27, 2007

Edmonton and Area.


Enteral:

Critically ill pediatric patients have multiple

factors that decrease gastric emptying:• Formula osmolarity• Fat content• Lipid carbon chain length• Medications (narcotics, benzodiazepines,

sedatives)

Continuous feeds are best

Small bowel feeds very successful

April 27, 2007

Edmonton and Area.


Enteral Nutrition and Cardiovascular Medication in the Pediatric Intensive Care Unit

King et al, JPEN 28(5), 2004

April 27, 2007

Edmonton and Area.


April 27, 2007

Edmonton and Area.


April 27, 2007

Edmonton and Area.


Causes of Diarrhea in Enterally Fed Children

Patient specific Extrinsic Feeding delivery related

Mucosal atrophy Antibiotics I mproper tube placement

Short bowel syndrome Sorbitol-containing medications

Hyperosmolar f ormula

Bacterial overgrowth Bacterial contamination of f ormula

I nfusion rate too rapid

Lactase deficiency I nfection Substrate intolerance Fecal impaction with overflow diarrhea

April 27, 2007

Edmonton and Area.


Feeding the Hypotensive Patient

shocked bypass

resuscitated pressors

ileus hypoperfusion

sepsis hypotension

Enteral is good but can we feed without

exacerbating intestinal hypoxia?

April 27, 2007

Edmonton and Area.



Splancnic bed gets:

25% cardiac output at rest

30% of oxygen consumption is in the splancnic

bed small

intestine 44%

* Arterial blood flow stomach 12%

colon 17%

April 27, 2007

Edmonton and Area.



Villus tips suffer most damage during hypoxia

they have the greatest digestive function.

When we feed the gut, the selection of

nutrients will alter the metabolic function and

oxygen demand of the enterocyte.

April 27, 2007

Edmonton and Area.



There is the potential to do harm as the presence of food in the intestine may increase oxygen demand beyond available delivery of blood flow, leading to necrotic bowel.

April 27, 2007

Edmonton and Area.



Polymeric formulas require more oxygen and

blood to be metabolized, therefore, you need:– increased blood flow– increased energy expenditure– increased oxygen

Complex formulas crave more than elemental

food stuffs.

April 27, 2007

Edmonton and Area.


Elemental Feeds

• mother’s milk vs formula• if no EBM we use elemental

– art vs science– higher protein– feeding on inotropes/hypotensive gut– MCT fatty acids are not inflammatory and

cannot be used for eicosanoid production– decreases bacterial translocation– digested and absorbed faster

April 27, 2007

Edmonton and Area.


Parenteral

Metabolic Complications:• Amino acids – toxic• Carbohydrate

– Hepatic stenosis– Cholestasis

- alk phos - GGT - bili• Fat – depressed immune

function– Reduced bacterial clearance– Increased triglycerides

April 27, 2007

Edmonton and Area.


Total Parenteral Nutrition

• central vs peripheral line

• 1000 vs 2000 mosmols/L

• ++ electrolyte increases osmolarity

• severe fluid restrictions

• 15+ % protein, 45% carbohydrate, 40% fat (8-10 mg/kg/min

• carnitine

• 1:1 heparin

• control over lytes, extra glucose, D5W - D5W - D12

April 27, 2007

Edmonton and Area.


April 27, 2007

Edmonton and Area.


Biochemistries in PICU• Serum albumin, urea, triglycerides, magnesium

– ↓ Mg – 20%– ↑ trig – 25%– ↑ urea – 30%– ↓ albumin – 52%

• ↑ uremia → ↓ SD scores for weight and arm circumference between admission and discharge

• ↑ triglycerides → > ventilator dependence days and length of stay than children with triglyceride levels

Journal of Nutritional Biochemistry 17 (2006) 57-62

April 27, 2007

Edmonton and Area.


Association of timing, duration, and intensity of hyperglycemia with intensive care unit mortality in Critically Ill Children

• Retrospective, 152 children, ventilated, inotropes• 1 – 21 years• Measured peak glucose, time to peak, duration of

hyperglycemia were analyzed for association with PICU mortality

• Non-survivors had higher peaks (17 vs 11 mmol/L)• Non-survivors had longer duration (71% vs 37%

days)• Positive independent association with mortality• More research needed Pediatric Critical Care Medicine 2004, Vol. 5, No. 4

April 27, 2007

Edmonton and Area.


Persistent hyperglycemia in Critically Ill Children

• Retrospective 95 infants (6508 glucose samples) with confirmed NEC

• Incidence of hyperglycemia in infants with NEC and relationship between glucose levels and outcome

• 69% were hyperglycemic (> 8mmol/L(0.5-35)• Mortality higher in >11.9 mmol/L group than <

11.9 mmol/L group (32/95 – died)• G-max group mortality 29% vs 2%• G-max group significantly related to LOS

Journal of Pediatric Surgery, Vol. 39, No 6 (June), 2004: pp. 898-901

April 27, 2007

Edmonton and Area.


Glucose level and risk of mortality in Pediatric Septic Shock

• Prospective, observational cohort x 32 months

• 57/1053 enrolled• In non survivors peak glucose was 14.5

mmol/L vs 9.2 in survivors• Conclusion in patients with septic shock a

peak glucose level of 9.9 is associated with increased risk of death.

April 27, 2007

Edmonton and Area.


Expected Results

J. Of Pediatric Surgery, Vol. 39, #12 (Dec. 2004; pp 1832-1834; Alaedeen et al

April 27, 2007

Edmonton and Area.


Critical Care 2004, 8:R234 – R242

Critical Care 2006, 10:R125 – R134

April 27, 2007

Edmonton and Area.


Sepsis vs TNF vs LPL

Langenbeck’s Arch Surg (2001)386: 369-376

April 27, 2007

Edmonton and Area.


Impact of n-6 vs n-3

Current Opinion in Clinical Nutrition and Metabolic Care 2006, 9:140-148

April 27, 2007

Edmonton and Area.


Signs and Symptoms of Refeeding Syndrome

April 27, 2007

Edmonton and Area.


A Metabolic Model of Critical Illness

Nutrition in Clinical Practice 21:587-604, December 2006

April 27, 2007

Edmonton and Area.


Nutrition Support in the ICU is not generic but:

1. Patient specific

2. Disease specific

3. Macro and Micronutrient specific

4. Biochemically specific

5. Stage specific

The Last Frontier: Nutrition Support in the Pediatric ...

Health & Medicine

enteral nutrition advantages

op nutrition support

op metabolic support

adequate support

ill pediatric patients

little vs

metabolic abnormalities

critical care journal