ENTERAL AND ENTERAL AND PARENTERAL NUTRITION PARENTERAL NUTRITION

IN CRITICALLY ILL IN CRITICALLY ILL CHILDRENCHILDREN

Mudit Mathur, M.D.

SUNY Downstate Medical Center

LEARNING GOALSLEARNING GOALSImpact of Critical IllnessImportance of NutritionGoals of nutritional supportNutritional requirementsEnteral vs Parenteral When and how to initiate and advance NutritionMonitoring

IMPACT OF CRITICAL ILLNESS-1IMPACT OF CRITICAL ILLNESS-1Physiologic stress response :

Catabolic phaseincreased caloric needs, urinary nitrogen lossesinadequate intake wasting of endogenous

protein stores, gluconeogenesismass reduction of muscle-protein breakdown

IMPACT OF CRITICAL ILLNESS-2IMPACT OF CRITICAL ILLNESS-2

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

RESPONSE TO INJURYRESPONSE TO INJURY

WHY IS NUTRITION IMPORTANTWHY IS NUTRITION IMPORTANT

CRITICAL ILLNESS + POOR NUTRITION =CRITICAL ILLNESS + POOR NUTRITION =

Prolonged ventilator dependencyProlonged ICU stayHeightened susceptibility to nosocomial

infections MSOFIncreased mortality with mild/moderate or

severe malnutrition

NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALSACCP Consensus statement, 1997ACCP Consensus statement, 1997

Provide nutritional support appropriate for the individual patient’s– Medical condition– Nutritional status– Available routes for administration

NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALS

Prevent/treat macro/micronutrient deficiencies

Dose nutrients compatible with existing metabolism

Avoid complicationsImprove patient outcomes

ENTERAL ENTERAL OR OR

PARENTERALPARENTERAL

IMPACT OF STARVATION-1IMPACT OF STARVATION-1

Negative nitrogen balance, further wt lossMorphological changes in the gut

– Mucosal thickness– Cell proliferation– Villus height

Functional changes– Increased permeability– Decreased absorption of amino acids

IMPACT OF STARVATION-2IMPACT OF STARVATION-2Enzymatic/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 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 PARENTERALENTERAL WITH PARENTERALIS THE COMBINATION BETTERIS THE COMBINATION BETTER

120 adult patients, (medical and surgical)Combination vs enteral feeds aloneProspective, randomized, double blind, controlledRBP, pre albumin increased significantly D 0-7No reduction in ICU morbidityNo reduction in ICU LOS/ vent, MSOF, dialysisReduced hospital stay (by 2 days)Mortality at 90 days and 2 years was identicalBauer et al, Intensive care med. 2000: 26, 893-900

A PRACTICAL APPROACH-1A 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-2A PRACTICAL APPROACH-2Assessment of the present illness

Hypermetabolism-burns, sepsis, MSOF, trauma

GI surgical procedures-prolonged NPOEnd-organ failure (Hepatic/renal etc)

Metabolic Cart-facilitates assessment of energy expenditure, Respiratory Quotient

WHEN TO INITIATE WHEN TO INITIATE ENTERAL NUTRITION: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 FEEDINGROUTE OF FEEDINGNasogastric

– Requires gastric motility/emptyingTranspyloric

– Effective in gastric atony/ colonic ileus– Silicone/polyurethane tubing – Positioning, Prokinetic agents/ fluoroscopic/ pH/

endoscopic guidancePercutaneous/surgical placement

– PEG if > 4 weeks nutritional support anticipated– Jejunostomy if GE reflux, gastroparesis, pancreatitis

POTENTIAL DRAWBACKS POTENTIAL DRAWBACKS OF ENTERAL FEEDSOF ENTERAL FEEDS

Gastric emptying impairmentsAspiration of gastric contentsDiarrheaSinusitisEsophagitis /erosionsDisplacement of feeding tube

NUTRITIONAL REQUIREMENTSNUTRITIONAL REQUIREMENTS25-30 non protein Kcal/kg/d adult males20-25 non protein Kcal/kg/d adult femalesChildren: BMR 37-55 Kcal/kg/d (50% of EE)

+ Activity + growthFactors increasing EE

– Fever 12%– Burns upto 100%– Sepsis 40-50 %– Major surgery 20-30%

Resting Energy Expenditure 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 REEFactors adding to REE

Multiplication factor

Maintenance 0.2

Activity 0.1-0.25

Fever 0.13/per degree > 38ºC

Simple Trauma 0.2

Multiple Injuries 0.4

Burns 0.5-1

Sepsis 0.4

Growth 0.5

NUTRITIONAL REQUIREMENTSNUTRITIONAL REQUIREMENTSInitial protein intake 1.2-1.5 gram/kg/dMicronutrients-added if feeds are small in

volume or patient has excessive losses

Tailor individually, 24-30 cal/oz formulaUsually continuous feeds are tolerated betterAdd for catch up growth upon recoveryAdequate calories = adequate growth

FORMULA COMPOSITIONFORMULA 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 COMPOSITIONFORMULA COMPOSITIONProteins

– -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 COMPOSITION-SPECIAL FORMULASFORMULAS

Pulmonary: High fat( 50%), Low CHOHepatic: High BCAA, low aromatic AA,

<0.5 gm/kg/d protein in encephalopathyRenal: Low protein, calorically dense, low

PO4 , K, Mg

GFR >25: 0.6-0.7 g/kg/d

GFR <25: 0.3 g/kg/dImmune-enhancing

IMMUNE MODULATIONIMMUNE MODULATIONGlutamineArginine Fatty acids (w-3)NucleotidesVitamins and minerals

Pediatric burn patients: Arginine & w-3 fatty acid supplements reduce infections, LOS

( Gottslisch: J Parenter. Ent. Nutr. 14: 225, 1990)

IMMUNE MODULATIONIMMUNE 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 MODULATIONIMMUNE MODULATION MECHANISMS ARE UNCLEARMECHANISMS ARE UNCLEARReduction of duration and magnitude of

inflammatory responseWill this disrupt the balance between pro

and anti-inflammatory processes??Of the multiple ingredients in these special

formulas: which is “the” oneBeneficial effects seen in patients achieving

early EN

Conclusive studies, clear indications

&

Cost-benefit analysis are still needed

IMMUNE MODULATIONIMMUNE MODULATION

Maintains nutritional statusPrevents catabolismProvides resistance to infectionPotential effect on immune

modulation

ENTERAL NUTRITION IN CRITICAL ILLNESS:

PARENTERAL NUTRITION PARENTERAL NUTRITION (PN)(PN)

The PN formulation is based on:

Fluid RequirementsEnergy Requirements VitaminsTrace elementsOther additives-Heparin, H2 blocker etc

Fluid RequirementsFluid RequirementsFluid requirements = maintenance + repair of dehydration +

replacement of ongoing losses. Maintenance Fluid Requirements

1 - 10 kg = 100 ml/kg/day10 - 20kg= 1000 ml + 50 ml for each kg > 10 kg20 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 RequirementsEnergy 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 PN-suggested guidelines for Initiation and Maintenance 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 calorie:nitrogen ratio at approximately 200:1

20% Lipids

1 g/kg/day 0.5-1 g/kg/day

2-3 g/kg/day

Only use 20%

Resting Energy Expenditure 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 REEFactors adding to REE

Multiplication factor

Maintenance 0.2

Activity 0.1-0.25

Fever 0.13/per degree > 38ºC

Simple Trauma 0.2

Multiple Injuries 0.4

Burns 0.5-1

Sepsis 0.4

Growth 0.5

Suggested monitoring ProtocolSuggested 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

CalculationsCalculations

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

CalculationsCalculations

Fat 20 grams/100ml Fat _____ml/day =

_____grams/day_____g/kg/day 9 kcal/g = _____

kcal/kg/day

CalculationsCalculations

grams Protein 6.25 = _____ NitrogenNon-protein calories Nitrogen =

Calorie:Nitrogen ratio

DANGERS OF OVERFEEDINGDANGERS OF OVERFEEDINGSecretory diarrhea (with EN)Hyperglycemia, glycosuria, dehydration,

lipogenesis, fatty liver, liver dysfunctionElectrolyte abnormalities: PO4 , K, MgVolume overload, CHF CO2 production- ventilatory demand O2 consumptionIncreased mortality (in adult studies)

MONITORINGMONITORINGPrevent OverfeedingPrevent Overfeeding

Carbohydrate: High RQ indicates CHO excess, stool reducing substances

Protein: Nitrogen balanceFat: triglycerideVisceral protein monitoringElectrolytes, vitamin levelsCaloric requirement assessment by metabolic cart

CONCLUSIONSCONCLUSIONS

Start nutrition earlyEnteral route is preferred when availableSet goals for the individual patientDose nutrients compatible with existing

metabolismAppropriate monitoring is essentialAvoid overfeeding

QUESTION 1QUESTION 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 2QUESTION 2What 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 3QUESTION 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