Feasibility of initiating early enteral feeding

1. dr. Zakky Hazami
DEPARTMENT OF PEDIATRICS
HARAPAN KITA WOMEN AND CHILDREN HOSPITAL
AUGUST 2018

2. • Neonatus undergoing cardiac surgery
cardiopulmonary bypass more profound metabloic
stress
• Children have extreamly vulnerable to negative metabolic
impact induced by stress
• The impact and feasibility of enteral nutrition immediately in
CHD repair is not well documented
INTRODUCTION

3. • To assess feasibility and impact of initiaitng enteral nutrition
support with first 24 h of congenital heart repair in neonatus
and infants
AIMS AND
OBJECTIVE

4. STUDY DESIGN
• Prospective randomize single blind trial In PICU in unit
tertiary hospital in New Delhi oct 2015- feb 2017

5. PATIENTS
Inclusion criteria:
Cyanotic CHD with increased PBF
Weight less than 5 kg
Undergoing cardiac repair
Exclusion Criteria:
Those with palliative procedure e.g PA banding
Requiring ECMO before leaving operating room
Having contraindication of enteral feeding
Refuse joining

6. DESIGN
Randomized using variable block size 1;1
Randomized within 4-6 h after compliting surgery

7. INTERVENTION
Subjec
t
Randomize
1:1
Treating group
Trophic Feed (@10-20
ml/kg/day)
Control Group
Within 4-6 h after
surgery. The feed
gradually
increased 5-6 days
Received enteral
feeds after
extubations

8. MEASUREMENT
Length of
Mechanical
ventilation
Length of ICU stay
Primary Outcome

9. Secondary Outcomes
Blood
sugar
levels
Acute
Phase
protein:
CRP, TNP
alpha
Total
leucocyte
Sepsis
amd
intoropes
used

10. SAMPLE SIZE AND
STASTICAL ANALYSIS
 Using SPSS 17.0 version
 T test and levine test for counting
variance
 Fisher exact test or Chi Square for
catagorical variables

11. SAMPLE
508 admission in PICU
356
excluded
122
excluded
30 subject
Control
(n=15)
Treatment
(n=15)

12. RESULT
Mean duration used of mechanical
ventilation in treatment group
shorter than control group (p<0,05)
Both CRP and TNF alpha both group
has no different
Total Leucocyte count has no
significant different in both group

13. RESULT
Blood mean sugar higher in NPO
than treatment group during first 72
h after surgery
3 patients in NPO group developed
organ failure

14. DISSCUSSION
• There was a study telling early enteral study (48-72 h) post surgery is
not suitable
• Splachnic vasocontriction due to vasopressor and gut edema due to
cardiopulmonary bypass makes tolerability is unlikely
• Infants in trophic feeding had significantly lower glucose level in 72 h
after surgery
• Enteral nutrition has been shown to attenuate :
• the hypermetabolism of critical illness
• decrease infectious complications
• length of mechanical ventilation
• shorten ICU and hospital length of hospital

15. DISCUSSION
Trophic feeds Restoring circulation in gut Helps maintaining
gut barriers
Reduces Bacterial
translocation
Preventing SepsisPrevent Organ
Failure

16. TAKE HOME MESSAGE
• This study shows a new paradigm about
early enteral nutrition after surgical CHD
• More RCT with larger sample is needed to
prove the concept
• The RCT with sub group analysis should had
be done after RCT with large sample size
exist

17. CRITICAL APPRAISAL

18. VALIDITAS INTERNAL
• Cause and effect causality?
• Design: RCT single blind
• Similiar characteristic
• No similiar concomitant intervention (different surgical
procedure)
• Biological Plausibility and consistency?
• Another study in adult
• Asociation ? P<0,05
• Trophied nutrition lowering long of stay (LOS) and mechanical
ventilation needed

19. IMPORTANCE
Early enteral nutrition reduces LOS, mechanical ventilation
needed, and preventing sepsis

20. APLICABILTY
• More reasearch with large sample should be done before
trying it