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
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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

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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

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IMPACT OF CRITICAL ILLNESS-2

• Increased energy expenditure
• Pain
• Anxiety
• Fever
• Muscular effort-WOB, shivering

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RESPONSE TO INJURY
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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

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NUTRITION OVERALL GOALSACCP Consensus
statement, 1997

• Provide nutritional support appropriate for the
  individual patients
• Medical condition
• Nutritional status
• Available routes for administration

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NUTRITION OVERALL GOALS

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

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ENTERAL OR PARENTERAL
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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

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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

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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

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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

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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)

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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

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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

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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

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POTENTIAL DRAWBACKS OF ENTERAL FEEDS

• Gastric emptying impairments
• Aspiration of gastric contents
• Diarrhea
• Sinusitis
• Esophagitis /erosions
• Displacement of feeding tube

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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

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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
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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
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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

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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

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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

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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

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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)

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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)

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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

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IMMUNE MODULATION
Conclusive studies, clear indications
Cost-benefit analysis are still needed
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ENTERAL NUTRITION IN CRITICAL ILLNESS

• Maintains nutritional status
• Prevents catabolism
• Provides resistance to infection
• Potential effect on immune modulation

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PARENTERAL NUTRITION (PN)

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

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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.

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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

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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
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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
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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
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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
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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

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Calculations

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

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Calculations

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

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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)

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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

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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

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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

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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.

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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