Download Nutrition in Pediatric Cardiac Intensive Care

QUALITY IMPROVEMENT
INITIATIVE
Nutrition in Pediatric
Cardiac Intensive Care
María Balestrini, MD
Pediatric Cardiac Intensive Care Unit
Pediatric Hospital J. P. Garrahan
Buenos Aires
Argentina
PCICU – PEDIATRIC HOSPITAL J. P. GARRAHAN
21 BEDS, 2 EXCLUSIVE OPERATING ROOMS, 5 SENIOR SURGEONS,
CARDIOLOGISTS AND PEDIATRIC CARDIAC INTENSIVISTS
PCICU - HOSPITAL GARRAHAN
New patients admitted for
surgery 2014
563
Total assignable RACHS-1
patients
514
Neonatal surgeries
67
By pass
Mortality rate
Other programs
85%
5%
ECMO, Chronic
ventricular support and
heart transplant
PILLARS OF NUTRITIONAL
SUPPORT IN THIS PERIOD
• Preserve the function of vital organs,
minimizing the loss of lean body mass,
although it can not completely prevent
catabolism.
• Achieve positive nitrogen balance, which is
crucial to growth
• Avoid over feeding, leading to CO2
retention, difficulty in weaning ventilator
and impaired immune function.
METABOLIC CHANGES IN THE
IMMEDIATE POST SURGICAL
• Limited glycogen storage
• Cytokine mobilization
• Mobilization of amino
acids for gluconeogenesis
METABOLIC
RESPONSE TO
STRESS
INCREASED
METABOLIC RATE
• More important in
neonates
• Returns to baseline
values between 12 and
24 hours
• Generalized edema
• Capillaritis (capillary
leak syndrome)
• Multiorgan failure.
INCREASED
INFLAMMATORY
RESPONSE
NUTRITIONAL SUPPORT
PROGRAM DEVELOPEMENT
• Discuss common feeding issues in
patients with complex congenital
heart disease
• We reviewed previous practices and
made a new feeding protocol
• We examined preliminary data
after the initiation of the new
protocol at Garrahan Hospital.
FAILURE OF GROWTH
Common among infants with complex CHD:
• Inefficient circulation
• High metabolic demand during post-operative
healing
• Alterations in growth factors and growth
hormone
• Genetic syndromes
• Poor oral skills
• Gastrointestinal pathology
• Associated with worse outcomes in CHD
patients
PERIOPERATIVE FEEDING
CONSIDERATIONS
Preoperatively
• Cyanosis and
compromised
systemic output
• Cardiac disease
Prostaglandin (PGE)
dependent
• Need of Umbilical
Catheters
Postoperatively
• Clinical weakness
• High respiratory
support
• Inotropic support
• Poor oral skills
• Gastric dysmotility
• Vocal cord paralysis
PREOPERATIVE FEEDING IN PGE
DEPENDENT PATIENTS
• No increased risk of necrotizing
enterocolitis (NEC) with early feeding
in hemodynamically stable, cyanotic
infants
• No increase in adverse events with
enteral feeding
• No increased risk of NEC with umbilical
artery catheters
BENEFITS OF EARLY
ENTERAL FEEDING
• Improved nutritional status and growth
prior to surgery
• Improved surgical outcome
• Enhanced intestinal maturation
• Improved feeding tolerance postoperatively
• Decreased length of parental nutrition
• Increased immunity
CONSENSUS FEEDING GUIDELINE
National Pediatric Cardiology Quality
Improvement Collaborative
• Created in 2009 to improve outcomes
among single ventricle patients
• Multidisciplinary Feeding Work Group
• Devised first consensus feeding guidelines
for single ventricle infants
• Released guidelines in 2011
OUR FEEDING GUIDELINES
Previous guidelines
• No recommendations on timing of pre or postoperative feed initiation
• Post-operative feeds started continuously at
2 ml/hr
• Increased by 1 ml/hr every 6 hours
• Once at goal volume, caloric density slowly
increased
• Once at goal calories, progression to bolus
schedule
OUR FEEDING GUIDELINES
Previous guidelines
• Parenteral nutrition was not initiated
within 24 hours of surgery
• Parenteral nutrition had significant deficit
of nutrients
• We invited a multidisciplinary committee
to revise feeding guidelines
• New protocol implemented in January 2013
NEW FEEDING GUIDELINES
Focus of new guidelines
• Early initiation of enteral feeds pre and postoperatively
• Oral feeding and breast feeding when possible
• Vocal cord paralysis assessment after aortic arch
interventions
• Nasogastric tube bolus as preferred
postoperative enteral feeding choice
• Rapid full protein-caloric requirements
achievement
• A standard parenteral nutrition formula for
infants with congenital heart disease was
developed.
IMPLEMENTATION OF NUTRITIONAL SUPPORT
IN THE IMMEDIATE POSTOPERATIVE PERIOD
Day 1
Standard Total
Parenteral
Nutrition
Day 2-3
Standard Total
Parenteral
Nutrition+Start
enteral feeding
Onwards
Decrease in Total
Parenteral Nutrition
and progression of
enteral feeding
PARENTERAL NUTRITIONAL
SUPPORT
• Volume: 60
ml/kg/day
• Glucose flow:
7mg/kg /min
• Amino acids: 3
g/kg/day
• Lipids: 3 g/kg/day
• Preparation 2 in 1
• Central Line
• Provides: 1 kcal/ml
• Calories: 55-60
Kcal / kg / day
• Goal Calories: 90 –
100 Kcal/kg/day
• Increase volumen
• Glucose Peak flow
10 mg/kg/min
• Check glycosuria
• Suspend the TPN
only if managed to
obtain 75% of the
total calories by
enteral feeding
ENTERAL NUTRITION SUPPORT
Trophic
mode
feeding
Nasogastric
tube (NG)
20-30
ml/Kg/day
Feeding
mode
- NG
- Oral
- Bolus
- Continuous
enteral
feeding
Feeding
options
Volume and
Calories
Goal
- Human milk
preferred
- Volume
- Standard
formula
100-140
ml/Kg/d
- Hydrolyzed
formula
- Calories
120- 150
Kcal/kg/d
NUTRITIONAL SUPPORT PROGRAM
IMPACT EVALUATION
• We conducted a prospective clinical study
from 1 January 2013 to 31 December 2014
• Less than 3 months perioperative patients,
were included.
CLINICAL STUDY
Hospital
Discharge
7th day
72hs
Initial evaluation
Clinical,
Anthropometric
Laboratory,
Feeding
Clinical,
Laboratory,
Feeding.
Clínical,
Laboratory,
Feeding
Clinical,
Anthropometric
Laboratory,
Feeding
REE
Anthropometric: Weight, height, head circumference. (mean and SD)
Laboratory: Glucose, albumin, total and ionized calcium, total magnesium,
phosphorus, electrolytes, triglycerides
Resting energy expenditure (REE) assessment: using Schoffield and WHO
equations.
Feeding characteristics: volume, formula, calories, proteins, lipids; enteral and
parenteral
CLINICAL STUDY
• N 70 patients
• Female 55%
• Median age 17 days
•
•
•
•
•
(r1-120).
95% neonates
All term infants
Median weight 3,2 Kg
(r1,9-5)
LOS 13 day (r1-160)
Survival 93%
• Diagnoses assignable
RACHS-1 patients
RACHS- 1
%
2
14,3
3
34,2
4
43
6
8,5
CLINICAL STUDY
Initial
evaluation
72 hs
70 Patients
68 patients
2 deaths
64 PATIENTS
COMPLETED THE STUDY
7th
Day
5 deaths - 9
early Discharge
Hospital
Discharge
PREOPERATIVE
Schoffield
WHO
TPN
MEDIAN
STANDARD
DEVIATION
VOLUME
ML/KG
78,2
± 21
CALORIES
KCAL/KG
59
± 10
ENTERAL
MEDIAN
STANDARD
DESVIATION
VOLUME
ML/KG
77
± 43
CALORIES
KCAL/KG
62
± 38
% REE
MEDIAN
162
163
SD
±86
±78
POST
OPERATIVE
72 HS
•The sum of enteral and
parenteral gives 66 kcal/
kg/day (r 27 -117)
•70% arrived at suggested
target
TPN 55%
MEDIAN
RANGE
VOLUME
ML/KG
55
30-80
CALORIES
KCAL/KG
60
30-76
ENTERAL
49%
MEDIAN
RANGE
VOLUME
ML/KG
60
20-140
CALORIES
KCAL/KG
50
10- 117
% REE
MEDIAN
Schoffield
WHO
127.7
137
RANGE/SD
41-328
±51
DISCHARGE
• 78% discharge with oral
feeding,
• 22% by nasogastric tube.
• 13 patients with exclusive
breast feeding
• 9 patients combined breast
feeding and formula
• 42 patients formula
ENTERAL
VOLUME
ML/KG
CALORIES
KCAL/KG
MEDIAN RANGE
140
60-160
120
40-148.5
WEIGHT (kg)
MEDIAN
SD
ADMISSION
3,32
± 0,68
DISCHARGE
3,5
± 0,78
CONCLUSION
• Cardiovascular TPN standard was safely
implemented.
• Parenteral and enteral nutrition, alone or in
combination exceeded REE requeriments,
during perioperative course in all patients.
• There were no patients with NEC
• There was an increase in weight. Head
circumference and height remained stable.
SUMMARY
• Nutrition is a major focus in improving the
outcome of children with complex CHD
• Early pre-operative enteral feeding in this
patient population is safe.
• Standardized approach in nutritional support is
likely to improve outcomes in patients with
congenital heart surgery, specially neonates and
small infants.
THANK YOU VERY MUCH