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ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY ILL CHILDREN

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ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY ILL CHILDREN Mudit Mathur, M.D. SUNY Downstate Medical Center LEARNING GOALS Impact of Critical Illness Importance of ... – PowerPoint PPT presentation

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Title: ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY ILL CHILDREN


1
ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY
ILL CHILDREN
Mudit Mathur, M.D. SUNY Downstate Medical Center
2
LEARNING GOALS
  • Impact of Critical Illness
  • Importance of Nutrition
  • Goals of nutritional support
  • Nutritional requirements
  • Enteral vs Parenteral
  • When and how to initiate and advance Nutrition
  • Monitoring

3
IMPACT OF CRITICAL ILLNESS-1
  • Physiologic stress response Catabolic phase
  • increased caloric needs, urinary nitrogen losses
  • inadequate intake wasting of endogenous
    protein stores, gluconeogenesis
  • mass reduction of muscle-protein breakdown

4
IMPACT OF CRITICAL ILLNESS-2
  • Increased energy expenditure
  • Pain
  • Anxiety
  • Fever
  • Muscular effort-WOB, shivering

5
RESPONSE TO INJURY
6
WHY IS NUTRITION IMPORTANTCRITICAL ILLNESS
POOR NUTRITION
  • Prolonged ventilator dependency
  • Prolonged ICU stay
  • Heightened susceptibility to nosocomial
    infections MSOF
  • Increased mortality with mild/moderate or severe
    malnutrition

7
NUTRITION OVERALL GOALSACCP Consensus
statement, 1997
  • Provide nutritional support appropriate for the
    individual patients
  • Medical condition
  • Nutritional status
  • Available routes for administration

8
NUTRITION OVERALL GOALS
  • Prevent/treat macro/micronutrient deficiencies
  • Dose nutrients compatible with existing
    metabolism
  • Avoid complications
  • Improve patient outcomes

9
ENTERAL OR PARENTERAL
10
IMPACT OF STARVATION-1
  • Negative nitrogen balance, further wt loss
  • Morphological changes in the gut
  • Mucosal thickness
  • Cell proliferation
  • Villus height
  • Functional changes
  • Increased permeability
  • Decreased absorption of amino acids

11
IMPACT OF STARVATION-2
  • Enzymatic/Hormonal changes
  • Decreased sucrase and lactase
  • Impact on immunity
  • Cellular Decreased T cells, atrophied germinal
    centers, mitogenic proliferation,
    differentiation,
  • Th cell function, altered homing
  • Humoral Complement, opsonins, Ig, secretory IgA
  • (70-80 of all Ig produced is secretory IgA)
  • Increased bacterial translocation

12
ENTERAL or PARENTERAL?
  • Enteral Nutrition Superior to Parenteral
  • Trophic effects on intestinal villus
  • Reduces bacterial translocation
  • Supports Gut-associated Lymphoid Tissue
  • Promotes secretory IgA secretion and function
  • Lower cost
  • Parenteral Nutrition
  • IV access
  • Infectious risk

13
ENTERAL WITH PARENTERALIS THE COMBINATION BETTER
  • 120 adult patients, (medical and surgical)
  • Combination vs enteral feeds alone
  • Prospective, randomized, double blind, controlled
  • RBP, pre albumin increased significantly D 0-7
  • No reduction in ICU morbidity
  • No reduction in ICU LOS/ vent, MSOF, dialysis
  • Reduced hospital stay (by 2 days)
  • Mortality at 90 days and 2 years was identical
  • Bauer et al, Intensive care med. 2000 26,
    893-900

14
A PRACTICAL APPROACH-1
  • Nutritional assessment
  • History-preexisting malnutrition, underlying
    disease, recent wt loss (gt 5 in 3 wks or gt10 in
    3 months)
  • Physical-anthropometrics, BMI, evidence of
    wasting
  • Labs-albumin (t ½ 18-21 d),
  • transferrin (t ½ 8 d), prealbumin (t ½ 2 d),
    RBP (t ½ 0.5 d)

15
A PRACTICAL APPROACH-2
  • Assessment of the present illness
  • Hypermetabolism-burns, sepsis, MSOF, trauma
  • GI surgical procedures-prolonged NPO
  • End-organ failure (Hepatic/renal etc)
  • Metabolic Cart-facilitates assessment of energy
    expenditure, Respiratory Quotient

16
WHEN TO INITIATE ENTERAL NUTRITION
  • ASAP-usually within 24 hours in severe trauma,
    burns and catabolic states
  • Contraindications to enteral nutrition
  • Nonfunctional gut, anatomic disruption, gut
    ischemia
  • Severe peritonitis
  • Severe shock states

17
ROUTE OF FEEDING
  • Nasogastric
  • Requires gastric motility/emptying
  • Transpyloric
  • Effective in gastric atony/ colonic ileus
  • Silicone/polyurethane tubing
  • Positioning, Prokinetic agents/ fluoroscopic/ pH/
    endoscopic guidance
  • Percutaneous/surgical placement
  • PEG if gt 4 weeks nutritional support anticipated
  • Jejunostomy if GE reflux, gastroparesis,
    pancreatitis

18
POTENTIAL DRAWBACKS OF ENTERAL FEEDS
  • Gastric emptying impairments
  • Aspiration of gastric contents
  • Diarrhea
  • Sinusitis
  • Esophagitis /erosions
  • Displacement of feeding tube

19
NUTRITIONAL REQUIREMENTS
  • 25-30 non protein Kcal/kg/d adult males
  • 20-25 non protein Kcal/kg/d adult females
  • Children BMR 37-55 Kcal/kg/d (50 of EE)
  • Activity growth
  • Factors increasing EE
  • Fever 12
  • Burns upto 100
  • Sepsis 40-50
  • Major surgery 20-30

20
Resting Energy Expenditure
Age (years) REE (kcal/kg/day)
0 1 55
1 3 57
4 6 48
7 10 40
11-14 (Male/Female) 32/28
15-18 (Male/Female) 27/25
21
Factors adding to REE

Multiplication factor
Maintenance 0.2
Activity 0.1-0.25
Fever 0.13/per degree gt 38ºC
Simple Trauma 0.2
Multiple Injuries 0.4
Burns 0.5-1
Sepsis 0.4
Growth 0.5
22
NUTRITIONAL REQUIREMENTS
  • Initial protein intake 1.2-1.5 gram/kg/d
  • Micronutrients-added if feeds are small in volume
    or patient has excessive losses
  • Tailor individually, 24-30 cal/oz formula
  • Usually continuous feeds are tolerated better
  • Add for catch up growth upon recovery
  • Adequate calories adequate growth

23
FORMULA COMPOSITION
  • Carbohydrates 60-70 of non protein calories
  • Polysaccharides/disaccharides/monosaccharides
  • Glucose polymers better absorbed
  • Lipids 30-40 of non protein calories
  • Source of EFA
  • Concentrated calories-but poorer absorption
  • MCT direct portal absorption-better

24
FORMULA COMPOSITION
  • Proteins
  • -polymeric (pancreatic enzymes required) or
    peptides
  • Small peptides from whey protein hydrolysis
    absorbed better than free AA
  • Fibers
  • Insoluble-reduce diarrhea, slower transit-better
    glycemic control
  • Degraded to SCFA-trophic to colon

25
COMPOSITION-SPECIAL FORMULAS
  • Pulmonary High fat( 50), Low CHO
  • Hepatic High BCAA, low aromatic AA, lt0.5 gm/kg/d
    protein in encephalopathy
  • Renal Low protein, calorically dense, low PO4 ,
    K, Mg
  • GFR gt25 0.6-0.7 g/kg/d
  • GFR lt25 0.3 g/kg/d
  • Immune-enhancing

26
IMMUNE MODULATION
  • Glutamine
  • Arginine
  • Fatty acids (w-3)
  • Nucleotides
  • Vitamins and minerals
  • Pediatric burn patients Arginine w-3 fatty
    acid supplements reduce infections, LOS
  • ( Gottslisch J Parenter. Ent. Nutr. 14 225,
    1990)

27
IMMUNE MODULATION
  • GlutaminearginineBranched chain AA (Immunaid)
  • Arginineomega-3 Fatty acidsRNA (Impact)
  • EN started within 36 hrs
  • Mortality, bacteremic episodes reduced
  • More pronounced effect in APACHE II 10-15 Galban
    et al, CCM, 2000 28 3, (643-48)

28
IMMUNE MODULATION MECHANISMS ARE UNCLEAR
  • Reduction of duration and magnitude of
    inflammatory response
  • Will this disrupt the balance between pro and
    anti-inflammatory processes??
  • Of the multiple ingredients in these special
    formulas which is the one
  • Beneficial effects seen in patients achieving
    early EN

29
IMMUNE MODULATION
Conclusive studies, clear indications
Cost-benefit analysis are still needed
30
ENTERAL NUTRITION IN CRITICAL ILLNESS
  • Maintains nutritional status
  • Prevents catabolism
  • Provides resistance to infection
  • Potential effect on immune modulation

31
PARENTERAL NUTRITION (PN)
  • The PN formulation is based on
  • Fluid Requirements
  • Energy Requirements
  • Vitamins
  • Trace elements
  • Other additives-Heparin, H2 blocker etc

32
Fluid Requirements
  • Fluid requirements maintenance repair of
    dehydration replacement of ongoing losses.
  • Maintenance Fluid Requirements
  • 1 - 10 kg 100 ml/kg/day
  • 10 - 20kg 1000 ml 50 ml for each kg gt 10 kg
  • 20 kg 1500 ml 20ml for each kg gt 20 kg
  • PN generally should be used for the maintenance
    needs.
  • Deficit and replacement of losses should be
    provided separately.
  • Remember to consider medications, flushes, drips,
    pressures lines and other IV fluids in your
    calculations.

33
Energy Requirements
  • Total Daily Energy Requirements (kcal/day)
    Resting Energy Expenditure (REE) REE ? (Total
    Factors)
  • Factors Maintenance Activity Fever Simple
    Trauma Multiple Injuries Burns Growth

34
PN-suggested guidelines for Initiation and
Maintenance
Substrate Initiation Advancement Goals Comments
Dextrose 10 2-5/day 25 Increase as tolerated. Consider insulin if hyperglycemic
Amino acids 1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day Maintain calorienitrogen ratio at approximately 2001
20 Lipids 1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day Only use 20
35
Resting Energy Expenditure
Age (years) REE (kcal/kg/day)
0 1 55
1 3 57
4 6 48
7 10 40
11-14 (Male/Female) 32/28
15-18 (Male/Female) 27/25
36
Factors adding to REE
Multiplication factor
Maintenance 0.2
Activity 0.1-0.25
Fever 0.13/per degree gt 38ºC
Simple Trauma 0.2
Multiple Injuries 0.4
Burns 0.5-1
Sepsis 0.4
Growth 0.5
37
Suggested monitoring Protocol
Weight Urine dip for glucose Bedside glucose Labs
First week Daily Q shift Q shift Daily SMA-7, Ca, Mg, Phos, triglycerides Q OD LFTs
Subsequently Daily Q shift Q shift SMA-7, Ca, Mg, Phos 2x/wk CBC, LFTs weekly Triglycerides 2x/wk
38
Calculations
  • Dextrose
  • ____g/100ml Dextrose ? ____ml/day ____grams/day
  • _____g/day ? (weight ? 1.44) _____mg/kg/min
  • _____g/kg/day ? 3.4 kcal/g _____ kcal/kg/day

39
Calculations
  • Fat
  • 20 grams/100ml Fat ? _____ml/day
    _____grams/day
  • _____g/kg/day ? 9 kcal/g _____ kcal/kg/day

40
Calculations
  • grams Protein ? 6.25 _____ Nitrogen
  • Non-protein calories ? Nitrogen
    CalorieNitrogen ratio

41
DANGERS OF OVERFEEDING
  • Secretory diarrhea (with EN)
  • Hyperglycemia, glycosuria, dehydration,
    lipogenesis, fatty liver, liver dysfunction
  • Electrolyte abnormalities PO4 , K, Mg
  • Volume overload, CHF
  • CO2 production- ventilatory demand
  • O2 consumption
  • Increased mortality (in adult studies)

42
MONITORINGPrevent Overfeeding
  • Carbohydrate High RQ indicates CHO excess, stool
    reducing substances
  • Protein Nitrogen balance
  • Fat triglyceride
  • Visceral protein monitoring
  • Electrolytes, vitamin levels
  • Caloric requirement assessment by metabolic cart

43
CONCLUSIONS
  • Start nutrition early
  • Enteral route is preferred when available
  • Set goals for the individual patient
  • Dose nutrients compatible with existing
    metabolism
  • Appropriate monitoring is essential
  • Avoid overfeeding

44
QUESTION 1
  • When should nutritional support be initiated in
    critically ill patients?
  • Only after extubation
  • After 3 days of NPO status
  • After 5 days of NPO status
  • After 7 days of NPO status
  • ASAP, preferrably within 24 hours of admission

45
QUESTION 2
  • What would be the preferred mode for nutritional
    support in a 10 year old boy with head injury,
    raised ICP and aspiration pneumonia that
    developed after he vomited during intubation in
    the field.
  • Parenteral nutrition
  • Enteral nutrition
  • A combination of enteral and parenteral nutrition
  • IV fluids alone until ICP is better controlled.

46
QUESTION 3
  • What would be the initial TPN composition for a
    10 kg 18 month year old child
  • Glucose 10, Protein 20 g/day, lipids 5g/d
  • Glucose 10, Protein 10 g/day, lipids 15g/d
  • Glucose 15, Protein 5 g/day, lipids 20g/d
  • Glucose 12.5, Protein 20 g/day, lipids 10g/d
  • Glucose 10, Protein 10 g/day, lipids 10g/d
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