Download ENTERAL FEEDING IN CRITICALLY ILL CHILDREN

ENTERAL AND
PARENTERAL NUTRITION
IN CRITICALLY ILL
CHILDREN
Mudit Mathur, M.D.
SUNY Downstate Medical Center
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
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

IMPACT OF CRITICAL ILLNESS-2
 Increased
energy expenditure
– Pain
– Anxiety
– Fever
– Muscular effort-WOB, shivering
RESPONSE TO INJURY
WHY IS NUTRITION IMPORTANT
CRITICAL ILLNESS + POOR NUTRITION =

Prolonged ventilator dependency
 Prolonged ICU stay
 Heightened susceptibility to nosocomial
infections
MSOF
 Increased mortality with mild/moderate or
severe malnutrition
NUTRITION: OVERALL GOALS
ACCP Consensus statement, 1997
 Provide
nutritional support appropriate
for the individual patient’s
– Medical condition
– Nutritional status
– Available routes for administration
NUTRITION: OVERALL GOALS

Prevent/treat macro/micronutrient
deficiencies
 Dose nutrients compatible with existing
metabolism
 Avoid complications
 Improve patient outcomes
ENTERAL
OR
PARENTERAL
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
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
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
ENTERAL WITH PARENTERAL
IS 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
A PRACTICAL APPROACH-1
 Nutritional assessment
– History-preexisting malnutrition, underlying
disease, recent wt loss (> 5% in 3 wks or >10%
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)
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
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
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 > 4 weeks nutritional support anticipated
– Jejunostomy if GE reflux, gastroparesis, pancreatitis
POTENTIAL DRAWBACKS
OF ENTERAL FEEDS

Gastric emptying impairments
 Aspiration of gastric contents
 Diarrhea
 Sinusitis
 Esophagitis /erosions
 Displacement of feeding tube
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%
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
Factors adding to REE
Maintenance
Activity
Fever
Simple Trauma
Multiple Injuries
Burns
Sepsis
Growth
Multiplication factor
0.2
0.1-0.25
0.13/per degree > 38ºC
0.2
0.4
0.5-1
0.4
0.5
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
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
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
COMPOSITION-SPECIAL
FORMULAS

Pulmonary: High fat( 50%), Low CHO
 Hepatic: High BCAA, low aromatic AA,
<0.5 gm/kg/d protein in encephalopathy
 Renal: Low protein, calorically dense, low
PO4 , K, Mg
GFR >25: 0.6-0.7 g/kg/d
GFR <25: 0.3 g/kg/d
 Immune-enhancing
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)
IMMUNE MODULATION

Glutamine+arginine+Branched chain AA
(Immunaid)
 Arginine+omega-3 Fatty acids+RNA (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)
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
IMMUNE MODULATION
Conclusive studies, clear
indications
&
Cost-benefit analysis are
still needed
ENTERAL NUTRITION IN
CRITICAL ILLNESS:
 Maintains
nutritional status
 Prevents catabolism
 Provides resistance to infection
 Potential effect on immune
modulation
PARENTERAL NUTRITION
(PN)
The PN formulation is based on:

Fluid Requirements
 Energy Requirements
 Vitamins
 Trace elements
 Other additives-Heparin, H2 blocker etc
Fluid Requirements
Fluid requirements = maintenance + repair of dehydration +
replacement of ongoing losses.
 Maintenance Fluid Requirements
1 - 10 kg =
10 - 20kg =
20 kg
=

100 ml/kg/day
1000 ml + 50 ml for each kg > 10 kg
1500 ml + 20ml for each kg > 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.
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
PN-suggested guidelines for
Initiation and Maintenance
Substrate Initiation
Advance Goals
ment
Comments
Dextrose
10%
2-5%/day
Amino
acids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
20%
Lipids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
Increase as tolerated.
Consider insulin if
hyperglycemic
Maintain
calorie:nitrogen ratio
at approximately
200:1
Only use 20%
25%
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
Factors adding to REE
Maintenance
Activity
Fever
Simple Trauma
Multiple Injuries
Burns
Sepsis
Growth
Multiplication factor
0.2
0.1-0.25
0.13/per degree > 38ºC
0.2
0.4
0.5-1
0.4
0.5
Suggested monitoring Protocol
Weight
Urine dip Bedside
for
glucose
glucose
Labs
First week
Daily
Q shift
Q shift
Subsequently
Daily
Q shift
Q shift
Daily SMA-7, Ca,
Mg, Phos,
triglycerides
Q OD LFTs
SMA-7, Ca, Mg,
Phos 2x/wk
CBC, LFTs
weekly
Triglycerides
2x/wk
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
Calculations
Fat
 20 grams/100ml Fat  _____ml/day =
_____grams/day
 _____g/kg/day  9 kcal/g = _____
kcal/kg/day
Calculations
grams Protein  6.25 = _____ Nitrogen
 Non-protein calories  Nitrogen =
Calorie:Nitrogen ratio

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)
MONITORING
Prevent 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
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
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
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.
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