Enteral Nutrition in Critically Ill Children

7/30/2019 Enteral Nutrition in Critically Ill Children

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ENTERAL NUTRITION INENTERAL NUTRITION INCRITICALLY ILLCRITICALLY ILL

CHRIS A JOHANNES

R.S.P.A.D GATOT SUBROTO

JAKARTA


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LEARNING GOALSLEARNING GOALS

Impact of Critical Illness

Importance of Nutrition

Goals of nutritional support

Enteral vs Parenteral

When and how to initiate and advance Nutrition

Monitoring


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IMPACT OF CRITICAL ILLNESSIMPACT OF CRITICAL ILLNESS--11

Physiologic stress response :Catabolic phase

increased caloric needs, urinary nitrogen losses

protein stores, gluconeog

enesis

mass reduction of muscle-protein breakdown


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IMPACT OF CRITICAL ILLNESSIMPACT OF CRITICAL ILLNESS--22

Increased energy expenditure

Pain

nx e y

Fever

Muscular effort-WOB,

shivering


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RESPONSE TO INJURYRESPONSE TO INJURY


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WHY IS NUTRITION IMPORTANTWHY IS NUTRITION IMPORTANT

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

Prolonged ventilator dependency

Heightened susceptibility

to nosocomial

infections MSOF

Increased mortality with mild/moderate or

severe malnutrition


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NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALS

ACCP Consensus statement, 1997ACCP Consensus statement, 1997

Provide nutritional support appropriate

for the individual patients

Medical condition

Nutritional status

Available routes for admin

istration


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NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALS

Prevent/treat macro/micronutrient

deficiencies

metabolism

Avoid complications

Improve patient outcomes


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IMPACT OF STARVATIONIMPACT OF STARVATION--11

Negative nitrogen balance, further wt loss

Morphological changes in the gut

Mucosal thickness

Ce pro erat on

Villus height

Functional changes

Increased permeability Decreased absorption of amino acids


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IMPACT OF STARVATIONIMPACT OF STARVATION--22

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


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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


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ENTERAL WITH PARENTERALENTERAL WITH PARENTERAL

IS THE COMBINATION BETTERIS THE COMBINATION BETTER 120 adult patients, (medical and surgical)

Combination vs enteral feeds alone

Prospective, randomized, double blind, controlled

, - 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


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A PRACTICAL APPROACHA PRACTICAL APPROACH--11

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 18-21 d),

transferrin (t 8 d), prealbumin (t 2 d),

RBP (t 0.5 d)


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A PRACTICAL APPROACHA PRACTICAL APPROACH--22

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, RespiratoryQuotient


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WHEN TO INITIATEWHEN TO INITIATE

ENTERAL NUTRITION:ENTERAL NUTRITION: ASAP-usually within 24 hours in severe

trauma, burns and catabolic states

Nonfunctional gut, anatomic disruption, gut

ischemia

Severe peritonitis

Severe shock states


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ROUTE OF FEEDINGROUTE OF FEEDING

Nasogastric Requires gastric motility/emptying

Transpyloric

Effective in gastric atony/ colonic ileus

Positioning, Prokinetic agents/ fluoroscopic/ pH/

endoscopic guidance

Percutaneous/surgical placement

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


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POTENTIAL DRAWBACKSPOTENTIAL DRAWBACKS

OF ENTERAL FEEDSOF ENTERAL FEEDS

Gastric emptying impairments

As iration of astric contents Diarrhea

Sinusitis

Esophagitis /erosions

Displacement of feeding tube


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NUTRITIONAL REQUIREMENTSNUTRITIONAL 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)

+ ct v ty + growt

Factors increasing EE

Fever 12%

Burns upto 100%

Sepsis 40-50 %

Major surgery 20-30%


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Resting Energy ExpenditureResting 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



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Factors adding to REEFactors adding to REE

Multiplication factor

Maintenance 0.2

Activity 0.1-0.25

Fever 0.13/per degree > 38C

Simple Trauma 0.2

Multiple Injuries 0.4

Burns 0.5-1Sepsis 0.4

Growth 0.5


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NUTRITIONAL REQUIREMENTSNUTRITIONAL 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


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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


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FORMULA COMPOSITIONFORMULA COMPOSITION

Proteins

-polymeric (pancreatic enzymes required) orpeptides

Small peptides from whey protein hydrolysis

a sor e e er an ree

Fibers

Insoluble-reduce diarrhea, slower transit-better

glycemic control Degraded to SCFA-trophic to colon


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COMPOSITIONCOMPOSITION--SPECIALSPECIAL

FORMULASFORMULAS Pulmonary: High fat( 50%), Low CHO

Hepatic: High BCAA, low aromatic AA,

. Renal: Low protein, calorically dense, low

PO4 , K, Mg

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

GFR


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IMMUNE MODULATIONIMMUNE 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)


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Glutamine+arginine+Branched chain AA

(Immunaid)

- 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)


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MECHANISMS ARE UNCLEARMECHANISMS ARE UNCLEAR Reduction of duration and magnitude of

inflammatory response

Will this disrupt the balance between proand anti-inflammatory processes??

Of the multiple ingredients in these specialformulas: which is the one

Beneficial effects seen in patients achievingearly EN


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Conclusive studies, clear


&

Cost-benefit analysis arestill needed


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Maintains nutritional status

ENTERAL NUTRITION IN

CRITICAL ILLNESS:

Provides resistance to infection

Potential effect on immune

modulation


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PARENTERAL NUTRITIONPARENTERAL NUTRITION

(PN)(PN)The PN formulation is based on:

Energy Requirements

Vitamins

Trace elements Other additives-Heparin, H2 blocker etc


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Fluid RequirementsFluid RequirementsFluid requirements = maintenance + repair of dehydration +

replacement of ongoing losses.

Maintenance Fluid Requirements

1 - 10 kg = 100 ml/kg/day

10 - 20kg = 1000 ml + 50 ml for each kg > 10 kg

=

PN generally should be used forthe maintenance needs.

Deficit and replacement of losses should be providedseparately.

Remember to consider medications, flushes, drips,pressures lines and other IV fluids in your calculations.


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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


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PNPN--suggested guidelines forsuggested guidelines for

Initiation and MaintenanceInitiation and Maintenance

Substrate Initiation Advance

ment

Goals Comments

Dextrose 10% 2-5%/day 25% Increase as tolerated.

hyperglycemic

Amino

acids

1 g/kg/day 0.5-1

g/kg/day

2-3

g/kg/day

Maintain

calorie:nitrogen ratio

at approximately

200:120%

Lipids

1 g/kg/day 0.5-1

g/kg/day

2-3

g/kg/day

Only use 20%


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Resting Energy ExpenditureResting Energy Expenditure

Age (years) REE (kcal/kg/day)

0 1 55

1 3 57

4 6 48

7 10 40




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Factors adding to REEFactors adding to REE

Multiplication factor

Maintenance 0.2

Activity 0.1-0.25

Fever 0.13/per degree > 38C

Simple Trauma 0.2

Multiple Injuries 0.4

Burns 0.5-1Sepsis 0.4

Growth 0.5


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Suggested monitoring ProtocolSuggested monitoring Protocol

Weight Urine dipfor

glucose

Bedsideglucose

Labs

First week Daily Q shift Q shift Daily SMA-7, Ca,

, ,triglycerides

Q OD LFTs

Subsequently Daily Q shift Q shift SMA-7, Ca, Mg,

Phos 2x/wk

CBC, LFTsweekly

Triglycerides

2x/wk


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CalculationsCalculations

Dextrose

____g/100ml Dextrose ____ml/day =

____ _____g/day (weight 1.44) = _____mg/kg/min

_____g/kg/day 3.4 kcal/g = _____ kcal/kg/day


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Fat

20 grams/100ml Fat _____ml/day =

_____ _____g/kg/day 9 kcal/g = _____

kcal/kg/day


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grams Protein 6.25 = _____ Nitrogen

Non-protein calories Nitrogen =


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DANGERS OF OVERFEEDINGDANGERS OF OVERFEEDING

Secretory diarrhea (with EN)

Hyperglycemia, glycosuria, dehydration,lipogenesis, fatty liver, liver dysfunction

4 , , Volume overload, CHF

CO2production- ventilatory demand

O2 consumption

Increased mortality (in adult studies)


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MONITORINGMONITORING

Prevent OverfeedingPrevent 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


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CONCLUSIONSCONCLUSIONS

Start nutrition early

Enteral route is preferred when available

Dose nutrients compatible with existing

metabolism

Appropriate monitoring is essential

Avoid overfeeding


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QUESTION 1QUESTION 1

When should nutritional support be initiated

in critically ill patients?

Onl after extubation

After 3 days of NPO status



ASAP, preferrably within 24 hours ofadmission


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What would be the preferred mode for nutritionalsupport 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.


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What would be the initial TPN composition

for a 10 kg 18 month year old child

Glucose 10% Protein 20 /da li ids 5 /d

Glucose 10%, Protein 10 g/day, lipids 15g/d


Glucose 12.5%, Protein 20 g/day, lipids 10g/d


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Enteral Nutrition in Critically Ill Children