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

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

  1. 1. The Last Frontier: Nutrition Support in the Pediatric Intensive Care Unit Bodil Larsen BSC, RD, PhD Candidate Clinical Dietitian, PICU Stollery Pediatric Intensive CareApril 27, 2007
  2. 2. April 27, 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?
  3. 3. April 27, Edmonton and Area. www.capitalhealth.ca 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
  4. 4. April 27, Edmonton and Area. www.capitalhealth.ca Stollery PICU Patient Population All require modification or consideration when providing metabolic or nutrition support *Not a feeding and growing unit
  5. 5. April 27, Edmonton and Area. www.capitalhealth.ca 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
  6. 6. April 27, Edmonton and Area. www.capitalhealth.ca Too Little vs Too Much Diamond 1995
  7. 7. April 27, Edmonton and Area. www.capitalhealth.ca Too Little vs Too Much • Sedation • Paralysis • Intubation/ventilation • + inotropes • + wasting
  8. 8. April 27, Edmonton and Area. www.capitalhealth.ca Determining Caloric Requirements
  9. 9. April 27, Edmonton and Area. www.capitalhealth.ca Tools Used for Determination • Indirect calorimetry • Underlying disease process • Biochemistrys and nitrogen balance • Published papers (reference charts) • Nutritional status
  10. 10. April 27, Edmonton and Area. www.capitalhealth.ca 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.
  11. 11. April 27, Edmonton and Area. www.capitalhealth.ca Expectations of Nutrition Support pre-op nutrition support rehabing feeding - growing(anabolic) ____________________________________ post-op metabolic support critically ill ventilated sedated (catabolic)
  12. 12. April 27, Edmonton and Area. www.capitalhealth.ca CHEST; The Cardiopulmonary and Critical Care Journal; Chest 2003; 124; 297-305
  13. 13. April 27, Edmonton and Area. www.capitalhealth.ca Pilot Study Larsen, Joffe et al 2004 unpublished data PICU/NICU Stollery
  14. 14. April 27, Edmonton and Area. www.capitalhealth.ca Cachexia Ref: Am J. Clin Nutr 2006;83:735-43
  15. 15. April 27, Edmonton and Area. www.capitalhealth.ca Ref: Cuur Opin Clin Nutr Metab Care 9:297-303, 2006
  16. 16. April 27, Edmonton and Area. www.capitalhealth.ca “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
  17. 17. April 27, Edmonton and Area. www.capitalhealth.ca 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
  18. 18. April 27, Edmonton and Area. www.capitalhealth.ca Journal of Pediatric Gastroenterology and Nutrition. 41: S1-S4
  19. 19. April 27, Edmonton and Area. www.capitalhealth.ca • 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
  20. 20. April 27, Edmonton and Area. www.capitalhealth.ca 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
  21. 21. April 27, Edmonton and Area. www.capitalhealth.ca 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
  22. 22. April 27, Edmonton and Area. www.capitalhealth.ca Enteral Nutrition and Cardiovascular Medication in the Pediatric Intensive Care Unit King et al, JPEN 28(5), 2004
  23. 23. April 27, Edmonton and Area. www.capitalhealth.ca
  24. 24. April 27, Edmonton and Area. www.capitalhealth.ca
  25. 25. April 27, Edmonton and Area. www.capitalhealth.ca Causes of Diarrhea in Enterally Fed Children Patient specific Extrinsic Feeding delivery related Mucosal atrophy Antibiotics Improper tube placement Short bowel syndrome Sorbitol-containing medications Hyperosmolar formula Bacterial overgrowth Bacterial contamination of formula Infusion rate too rapid Lactase deficiency Infection Substrate intolerance Fecal impaction with overflow diarrhea
  26. 26. April 27, Edmonton and Area. www.capitalhealth.ca Feeding the Hypotensive Patient shocked bypass resuscitated pressors ± ileus hypoperfusion ± sepsis hypotension Enteral is good but can we feed without exacerbating intestinal hypoxia?
  27. 27. April 27, Edmonton and Area. www.capitalhealth.ca Feeding the Hypotensive Patient 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%
  28. 28. April 27, Edmonton and Area. www.capitalhealth.ca Feeding the Hypotensive Patient 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.
  29. 29. April 27, Edmonton and Area. www.capitalhealth.ca Feeding the Hypotensive Patient 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.
  30. 30. April 27, Edmonton and Area. www.capitalhealth.ca Feeding the Hypotensive Patient 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.
  31. 31. April 27, Edmonton and Area. www.capitalhealth.ca 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
  32. 32. April 27, Edmonton and Area. www.capitalhealth.ca Parenteral Metabolic Complications: • Amino acids – toxic • Carbohydrate – Hepatic stenosis – Cholestasis -↑ alk phos - ↑ GGT - ↑ bili • Fat – depressed immune function – Reduced bacterial clearance – Increased triglycerides
  33. 33. April 27, Edmonton and Area. www.capitalhealth.ca 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
  34. 34. April 27, Edmonton and Area. www.capitalhealth.ca
  35. 35. April 27, Edmonton and Area. www.capitalhealth.ca 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
  36. 36. April 27, Edmonton and Area. www.capitalhealth.ca 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
  37. 37. April 27, Edmonton and Area. www.capitalhealth.ca 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
  38. 38. April 27, Edmonton and Area. www.capitalhealth.ca 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.
  39. 39. April 27, Edmonton and Area. www.capitalhealth.ca Expected Results J. Of Pediatric Surgery, Vol. 39, #12 (Dec. 2004; pp 1832-1834; Alaedeen et al
  40. 40. April 27, Edmonton and Area. www.capitalhealth.ca Critical Care 2004, 8:R234 – R242 Critical Care 2006, 10:R125 – R134
  41. 41. April 27, Edmonton and Area. www.capitalhealth.ca Sepsis vs TNF vs LPL Langenbeck’s Arch Surg (2001) 386: 369-376
  42. 42. April 27, Edmonton and Area. www.capitalhealth.ca Impact of n-6 vs n-3 Current Opinion in Clinical Nutrition and Metabolic Care 2006, 9:140-148
  43. 43. April 27, Edmonton and Area. www.capitalhealth.ca Signs and Symptoms of Refeeding Syndrome
  44. 44. April 27, Edmonton and Area. www.capitalhealth.ca A Metabolic Model of Critical Illness Nutrition in Clinical Practice 21:587-604, December 2006
  45. 45. April 27, Edmonton and Area. www.capitalhealth.ca 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

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