The Use of Transpyloric Enteral Nutrition in the Critically Ill Child

REVIEW OF A LARGE CLINICAL SERIES

The Use of Transpyloric Enteral Nutrition in theCritically Ill Child

Cesar Sanchez, MD,Jesus Lopez-Herce, MD,Marıa Moreno de Guerra, MD,Angel Carrillo, MD,Ramon Moral, MD,and Luis Sancho, MD

Sanchez C, Lopez-Herce J, Moreno de Guerra M, Carrillo A, The nutritional status of the critically ill patient hasMoral R, Sancho L. The use of transpyloric enteral nutrition in

a significant influence on prognosis, with a higherthe critically ill child. J Intensive Care Med 2000;15:247–254.morbidity and mortality in malnourished patients

To assess the use and complications of transpyloric enteral [1,2]. The basic aims of nutritional treatment in thenutrition (TEN) in the critically ill child we evaluated pro- critically ill child are, on the one hand, to speed upspectively all children who received TEN in a pediatric inten-

resolution of the illness and, on the other, to returnsive care unit (PICU) of a tertiary university hospital. Thethe patient to a nutritional status as near normal astype of nutrition used, its duration, medication administered,

tolerance, gastrointestinal complications (vomiting, abdomi- possible.nal distension or excessive gastric residue, diarrhea, and Feeding via the enteral route is the best method,pulmonary aspiration), nongastrointestinal complications, as it allows the maintenance of adequate intestinaland mortality were assessed. A comparative analysis was

tropism; stimulates the immune system; maintainsmade between the first 2 years of the study and the remainingthe integrity of the intestinal tract, reducing bacterialperiod. Over a period of 4.5 years, 152 patients between

the ages of 3 days and 17 years received TEN for a duration translocation, sepsis and multisystem failure; andof 19 5 32.3 days (range 1–240 days). Forty-one patients has fewer side effects [3,4]. For these reasons, itsreceived TEN during the first 2 years; 100 patients received indications and use have increased in intensive careTEN in the postoperative period after cardiac surgery (66%).

units (ICUs) over the past years [5]. Although oralOne hundred seventeen patients (77%) received sedationand nasogastric tube feeding are the most physio-and 65 (43%) received muscle relaxants, presenting no extra

complications. Twenty-four patients (15.8%) presented with logical, these are frequently not possible in the criti-gastrointestinal complications: abdominal distension and/or cally ill child due to the reduction in gastric motilityexcessive gastric residue in 17 and diarrhea in 11. Gastroin- secondary to the use of sedatives or muscle relax-testinal intolerance was associated with pulmonary infection

ants or due to the underlying disease itself, increas-(p < 0.05), altered hepatic function (p < 0.001), and hypoka-ing the possibility of abdominal distension andlemia or hypocalcemia (p < 0.05). Diarrhea was more fre-

quent in patients with shock (p < 0.05), altered hepatic intolerance to the feeding [6]. Also, there may be afunction (p < 0.05), excessive gastric residue (p < 0.001), greater risk of pulmonary aspiration, especially inand hypokalemia or hypocalcemia (p < 0.05). In the second those patients on mechanical ventilation. To over-study period, the number of patients on TEN and the doses

come these difficulties, attempts have been madeof sedatives, muscle relaxants, and vasoactives were higherprovide enteral nutrition using a catheter that pas-(p < 0.05), with no increase in the incidence of complica-

tions. TEN is a useful method of nutrition with few complica- ses through the pylorus to reach the duodenum ortions in the critically ill child. jejunum. Several studies in adults have shown that

transpyloric enteral nutrition (TEN) is a good tech-nique for maintaining the nutritional status of thecritically ill patient [7,8], but there is still little experi-ence with its use in children [9,10]. The aim ofthe present study was to analyze the use and theassociated complications of transpyloric enteral nu-

From the Pediatric Intensive Care Unit, Gregorio Maranon Uni- trition in critically ill children.versity General Hospital, Madrid, Spain.

Received Sep 30, 1999, and in revised form Mar 9, 2000. Accepted Patients and Methodsfor publication Mar 16, 2000.

Address correspondence to Dr Jesus Lopez-Herce, Unidad deIn March 1994, a TEN protocol to provide enteralCuidados Intensivos Pediatricos, H.G.U. Gregorio Maranon, Dr.

Castelo 49, 28009 Madrid, Spain. E-mail: [email protected] feeding for critically ill children was started in the

Copyright q 2000 Blackwell Science, Inc. 247

248 Journal of Intensive Care Medicine Vol 15 No 5 September/October 2000

pediatric intensive care unit (PICU) at Gregorio triglycerides or cereals. In children more than 3years old, normocaloric (1 ml 4 1 kcal) or hyperca-Maranon University General Hospital. All children

who could not start oral or nasogastric feeding loric (1 ml 4 1.5 kcal) commercial liquid prepara-tions were used according to needs. The infusionwithin the first 48–72 hours after admission to the

PICU were included in the protocol. Parenteral nu- rate was controlled using a volumetric pump, be-ginning at 0.5 ml/kg/hr and increasing progres-trition was started in those cases in which there

were contraindications to the use of the enteral sively (in steps of 0.5–1 ml/kg/4 hr), according totolerance, until the required calorie delivery wasroute or when it was impossible to insert the trans-

pyloric catheter. The following were considered reached in 24–48 hours.The following data were collected prospectivelycontraindications to enteral nutrition: the first hours

of severe shock, recent gastrointestinal surgery, me- in all patients receiving TEN: age, sex, weight, diag-nosis, surgery, prior parenteral nutrition and its du-chanical gastrointestinal obstruction, intestinal

ileus, severe gastrointestinal hemorrhage, general- ration, indication for TEN, time from admission tostarting TEN, type of feeding catheter used andized peritonitis, severe pancreatitis, actinic enteritis,

and short bowel syndrome without enteral toler- method of insertion, type of feed, maximum vol-ume and calorie delivery achieved, duration of TEN,ance. Perforated 6, 8, and 10 French catheters (Flex-

iflo, Abbott, Madrid, Spain) were used, inserted via reason for withdrawal of TEN, and the type of feed-ing thereafter. A record was also kept of all vaso-the nasogastric route, except in one patient with a

gastrostomy in whom the catheter was inserted via active drugs, sedatives, and muscle relaxantsadministered while on TEN, and their maximumthe gastrostomy orifice. Correct positioning of the

catheter was checked using pH measurement of doses, and the use of assisted ventilation and itsduration. Episodes of shock occurring during TENthe aspirate with a reagent strip (pH > 6 was consid-

ered a probable sign of transpyloric positioning), were recorded and also if the patient developedinfection and at what site. Periodic controls, at leastwith radiologic confirmation in all cases. In one

patient in whom it was not possible to advance the twice weekly, were made of the renal function (cre-atinine and urea), with altered function defined astranspyloric catheter spontaneously after several at-

tempts, intravenous metoclopramide was given a creatinine value of more than 1.5 mg/dl and/orthe need for dialysis. Hepatic function (AST, ALT,(0.15 mg/kg) followed by oral erythromycin (10

mg/kg), achieving transpyloric positioning in this GGT, alkaline phosphatase, and total bilirubin) wassimilarly controlled, with altered function definedway [11,12]. In three patients, endoscopy was used

to position the transpyloric catheters due to a failure as ALT > 100 IU/L, gamma glutamyltransferase >100 IU/L, and/or total bilirubin > 2 mg/dl. Regularof indirect insertion. All the catheters were situated

between the first and fourth portions of the duode- controls were also made of serum electrolytes (so-dium, potassium, chloride, calcium, and magne-num. A nasogastric tube was also placed in all pa-

tients in order to empty and measure the residue; sium) at least once a day. TEN tolerance wasassessed by the presence or absence of vomiting,aspiration was performed every 4 hours. A patient

was considered not to tolerate TEN if there was abdominal distension, gastric residue (registeringthe maximum daily volume), and diarrhea (notingsignificant abdominal distension or if more than

50% of the volume administered in 4 hours was the maximum number of stools per day), andwhether these complications caused the temporaryrecovered as residue in the gastric aspirate. If the

gastric aspirate contained residue from the nutri- or definitive withdrawal of TEN. Pulmonary aspira-tion was also recorded if it occurred.tion, radiologic control was performed to confirm

that the catheter had not moved; if the position was Statistical analysis of the results was performedusing the SPSS statistical package, version 8. Quan-correct, feeding was stopped temporarily or the

infusion rate reduced. The indications for with- titative variables are expressed as the mean andstandard deviation and the qualitative variables asdrawal of the transpyloric nutrition were the

appearance of complications associated with trans- percentages. Simple or bivariant analyses wereused to reveal associations. The chi-squared testpyloric nutrition, the need for surgery, the appear-

ance of medical complications contraindicating the was used for qualitative variables and Fisher’s exacttest for quantitative variables when N was less thanuse of enteral nutrition, or resolution of the indica-

tion for transpyloric enteral nutrition, for example, 20 or when any of the theoretical values were lessthan 5. These are presented as 2 2 2 tables. The t-extubation of the patient, if this permitted the initia-

tion of nasogastric or oral feeding. test was used to compare the means of quantitativevariables between independent groups. The studyChildren less than 3 years old were fed using

infant formulas or casein hydrolysate according to was divided into two separate periods. The first 2years, during which the technique and protocolthe state of the patient, adding calorie supplements

in the form of dextrinomaltose and medium chain were developed and set up, and the latter 2.5 years

Sanchez et al.: Transpyloric Enteral Nutrition 249

in which the technique was considered to be a part During the first 2 years of the study 41 patients(5.2% of all children admitted to the PICU) receivedof the routine clinical practice of the PICU. The aim

of this division was to enable a comparative analysis TEN [10] and during the latter 2.5 years, 111 patients(10.4% of all admissions) (p < 0.05): 87 (57%) wereto be made between the development phase and

the routine practice phase. The variables compared boys and 65 (43%) were girls with a mean age of18.8 5 37.2 months (range 3 days–17 years); 99include the number of patients receiving TEN, the

clinical indications for its use, and the incidence of (65%) were less than 6 months old and 28 (18%)less than 1 month old. The mean weight was 8 5complications.9.3 kg (range 2.5–66 kg). The patients’ diagnoses,grouped by categories, are shown in Table 1 andthe indications for TEN in Table 2. Table 3 showsResultsa summary of the types of nutrition administeredin each period of the study. In 81 (53%) patients,Between March 1994 and October 1998, 152 pa-TEN was the first method of feeding after admissiontients received TEN, corresponding to 8.2% of allto the PICU. During the first period of the studychildren admitted to the PICU during this period.

Table 1. Diagnoses of the Patients

Diagnosis Global First Period Second Period

Postoperative cardiac surgery 100 (65.8%) 28 (68.2%) 72 (51%)Respiratory insufficiency 31 (20.4%) 6 (14.6%) 25 (17.7%)Acute neurological alteration 13 (8.6%) 3 (7.3%) 10 (7%)Gastrointestinal pathologya 3 (2%) 1 (2.4%) 2 (1.4%)Othersb 5 (3.2%) 3 (7.3%) 2 (1.4%)

aGastrointestinal pathology: pancreatitis, Crohn’s disease, liver tumor.bOthers: oncologic (3), pseudohypoaldosteronism, cardiopulmonary arrest.

Table 2. Indications for Transpyloric Enteral Nutrition

Indication Global First Period Second Period

Mechanical ventilation 133 (88%) 37 (90%) 96 (86%)Respiratory insufficiency without mechanical ventilation 11 (7%) 1 (2.4%) 10 (7%)Intolerance to nasogastric feeding 5 (3%) 1 (2.4%) 4 (2.8%)Neurological alteration 2 (1.5%) 1 (2.4%) 1 (0.7%)Abdominal surgery 1 (0.6%) 1 (2.4%) 0

Table 3. Comparison of Nutrition Between the Two Periods of Study

DifferencesGlobal First Period Second Period Period 1 vs Period 2

Time to start TEN (days)a 8.1 5 8.7 11.1 5 10.1 4.7 5 4.9 p < 0.05Maximum infusion volume (ml/kg/

day) 134.3 5 45.7 131 5 46 137.9 5 43.4 NSMaximum caloric delivery (kcal/

kg/day) 91.3 5 29.6 87.5 5 34.2 93.4 5 27 NSDuration of TEN (days) 19 5 32.3 20 5 26.8 18.7 5 34.3 NS

Number of Patients (%)

TPN before TEN 65 (43%) 33 (80.4%) 32 (28.8%) p < 0.05Infant formula 90 (59%) 24 (58.5%) 66 (59.5%) NSCasein hydrolysate 26 (17%) 5 (12.2%) 21 (18.9%) NSInfant formula and casein

hydrolysate 13 (9%) 6 (14.6%) 7 (6.3%) NSCommercial liquid preparations 19 (12.5%) 5 (12.2%) 14 (12.6%) NSMilk 3 (2%) 1 (2.4%) 2 (1.8%) NSMaternal milk 1 (0.7%) 1 (0.9%) NS

aTime to start TEN after admission to the PICU.NS 4 nonsignificant difference.


more patients received total parenteral nutrition which was more frequent in the second period,10.8% compared to no patients in the first period(TPN) prior to TEN and the mean time to the starting

of TEN was longer than in the second period (p < (p < 0.05). In 11 (15%) of the patients who hadpreviously received TPN, altered hepatic function0.05). The maximum infusion rate was between 7

and 260 ml/kg/day, and the duration of TEN was was discovered prior to the starting of TEN. A fur-ther three (2%) patients presented with altered he-between 9 hours and 240 days. There were no

significant differences between the two study peri- patic function after starting TEN. Only one patientsuffered a complication secondary to the introduc-ods.

The percentage of patients treated with vaso- tion of the transpyloric catheter when this was acci-dentally passed into the respiratory tract, despiteactive drugs, sedatives, and muscle relaxants and

the mean doses are shown in Table 4. The doses the presence of a cuffed tracheal tube, causing asmall right pneumothorax that was drained by aspi-administered of all these drugs were significantly

higher during the second period (Table 5). ration with no respiratory repercussion. Twenty-six(17%) patients died, but in only 1 patient could theThe incidence of shock, renal insufficiency,

altered hepatic function, pulmonary infection, gas- TEN have contributed to death (1 patient died asa result of multisystem failure secondary to necrotiz-trointestinal hemorrhage, pneumothorax, and mor-

tality are shown in Table 6. The only significant ing enterocolitis). No statistically significant differ-ences in mortality were found between the twodifference found on comparing the two periods of

the study was in the incidence of renal insufficiency, study periods.

Table 4. Vasoactive Drugs, Sedatives, and Muscle Relaxants Administered During TEN

Drug Number (%) Dose (mean 5 SD) Range

Midazolam 117 (77) 6.6 5 4.7 mg/kg/min 1–27 mg/kg/minFentanyl 116 (76) 5.8 5 4.2 mg/kg/h 1–25 mg/kg/hVecuronium 65 (43) 0.12 5 0.11 mg/kg/h 0.1–0.6 mg/kg/hDopamine 121 (80) 7.6 5 6.3 mg/kg/min 3–50 mg/kg/minAdrenaline 45 (30) 0.4 5 0.94 mg/kg/min 0.1–5 mg/kg/minMilrinone 72 (47) 0.8 5 2.9 mg/kg/min 0.07–25 mg/kg/minPGE1 25 (16) 0.043 5 0.07 mg/kg/min 0.01–0.28 mg/kg/min

Table 5. Comparison Between the Drug Doses Administered in the First and Second Study Periods

Drug Period I Dose (mean 5 SD) Period II Dose (mean 5 SD) Statistical Significance

Midazolam 4.7 5 4.4 7.4 5 4.6 0.005Fentanyl 4.2 5 4.2 6.6 5 4.2 0.006Vecuronium 0.06 5 0.08 0.17 5 0.1 0.0001Dopamine 6.5 5 8.6 8 5 5 0.0001Adrenaline 0.2 5 1.1 0.4 5 0.8 0.009Milrinone 0.3 5 0.2 0.5 5 0.1 0.01Prostaglandin E1 0.002 5 0.005 0.1 5 0.17 0.001

Table 6. Comparison of Shock, Renal Insufficiency, Alteration of Hepatic Function, Pulmonary Infection, GastrointestinalHemorrhage, Pneumothorax, and Mortality Between the Two Periods of Study

DifferencesFirst vs Second

Global First Period Second Period Period

Shock 10 (6.6%) 2 (4.8%) (0.5–16.5%) 8 (5.6%) (3.1–13.7%) NSRenal insufficiency 12 (8%) 0 (8.8–34.8%) 12 (10.8%) (5.7–18.1%) p < 0.05Pulmonary infection 21 (13.8%) 8 (19.5%) (8.8–34.8%) 13 (9.2%) (6.4–19.1%) NSHepatic alteration 4 (2%) 0 (0–8.6%) 3 (2%) (0.5–7.6%) NSCholestasis 1 (0.7%) 1 (2.4%) (0.06–12.8%) 0 (0–3.2%)Gastrointestinal hemorrhage 1 (0.7%) 1 (2.4%) (0.06–12.8%) 0 (0–3.2%) NSPneumothorax 1 (0.7%) 0 (0–8.6%) 1 (0.7%) (0.02–49%) NSMortality 26 (17%) 5 (12%) (4–26.2%) 21 (14.8%) (12.1–27.4%) NS


Table 7. Gastrointestinal and Electrolyte Complications Associated with Transpyloric Enteral Nutrition

DifferenceFirst vs Second

Global First Period Second Period Period

Abdominal distention 17 (11.2%) 6 (14.6%) (5.5–29.1%) 11 (7.8%) (5–17%) NSDiarrhea 11 (7%) 4 (9.7%) (2.7–23.1%) 7 (4.9%) (2.5–12.5%) NSNecrotizing enterocolitis 2 (1.3%) 0 (0–8.6%) 2 (1.4%) (0.2–6.3%) NSHypokalemia 63 (41%) 17 (41.5%) (26.3–57.8%) 46 (32.6%) (32.1–51.1%) NSHypocalcemia 26 (17%) 4 (9.7%) (2.7–23.1%) 22 (15.6%) (12.8–28.4%) NSHypophosphatemia 8 (5%) 3 (7.3%) (1.5–19.9%) 5 (3.5%) (1.4–10.1%) NSHyponatremia 6 (4%) 3 (7.3%) (1.5–19.9%) 3 (2.1%) (0.5–7.6%) NS

The incidence of gastrointestinal and electrolyte calcemia (Table 9). There were no significant differ-ences in the incidence of diarrhea between thedisturbances is shown in Table 7. Gastrointestinal

complications occurred in 24 (15.8%) patients dur- types of nutrient [infant formula (5.6%), protein hy-drolysate (7.7%), commercial preparations (5.3%)].ing TEN. Two neonates who had undergone cardiac

surgery presented with necrotizing enterocolitis With respect to feeding after TEN, 68 patients(44.7%) were able to pass directly to oral feeding,during an epidemic period secondary to coloniza-

tion by betalactamase-positive gram-negative 20 (13%) received enteral nutrition via a nasogastrictube, and 5 (3.3%) via a gastrostomy. Thirty-onebacilli. Seventeen (11.2%) children presented ab-

dominal distension or excessive gastric residue, but (20%) were transferred from this unit with the trans-pyloric catheter in situ. TEN was suspended be-only 3 (2%) required definitive withdrawal of the

TEN; in the rest, a temporary reduction in the infu- cause of complications or contraindications to itsuse in 11 (7.8%) patients: chylothorax in 3 cases,sion rate improved the symptoms. Eleven (7%) pa-

tients developed diarrhea during TEN, leading to surgery in 2, gastrointestinal complications in 6(necrotizing enterocolitis in 2, diarrhea in 2, andthe definitive withdrawal of TEN in 2 patients

(1.3%). Five patients presented with excessive resi- abdominal distension/residue in 2); these patientswere changed to parenteral nutrition. Seventeendue and/or abdominal distension together with the

diarrhea. Abdominal distension and/or excessive (11.1%) patients died while receiving TEN.residue were more frequent in patients with pulmo-nary infection, altered hepatic function, hypoka-

Discussionlemia, and hypocalcemia (Table 8). No differenceswere found in the incidence of abdominal disten-

Enteral nutrition is the best method for maintainingsion and/or excessive residue with respect to ageadequate nutritional support in the critically ill pa-(older or younger than 6 months), sex, type oftient so long as there are no contraindications tonutrient received, presence of shock, renal insuffi-its use. Studies in critically ill adults [13,14] andciency, the use of mechanical ventilation, sedativeschildren [15,16] have shown not only that enteralor muscle relaxants, or mortality. The incidence ofnutrition is safe, with very few complications anddiarrhea was higher in patients with shock, altered

hepatic function, abdominal distension and/orexcessive gastric residue, hypokalemia, and hypo- Table 9. Incidence of Diarrhea in Relation to Other

Alterations

StatisticalYes No SignificanceTable 8. Incidence of Abdominal Distention or Excessive

Gastric Residue in Relation with Other AlterationsShock 30% 5.6% 0.05Altered hepaticStatistical

function 66.6%a 6% 0.05Yes No SignificanceAbdominal distention

or excessive gastricPulmonary infection 25% 8.6% 0.05Altered hepatic function 100%a 9.5% 0.001 residue 29.4% 4.3% 0.001

Hypokalemia 9.5% 5.6% 0.05Hypokalemia 19% 5.5% 0.05Hypocalcemia 19% 9.5% 0.05 Hypocalcemia 11.5% 6.3% 0.05

aThe three patients with altered hepatic function after starting aTwo of the three patients with altered hepatic function afterstarting TEN.TEN.


low cost, but also that it reduces the risk of bacterial The gastrointestinal complications seen duringthis study were infrequent and, in general, did nottranslocation, with its secondary complications, by

maintaining the integrity of the gastrointestinal mu- require withdrawal of nutrition. The incidence ofdiarrhea was clearly lower than that described forcosa and stimulating its immunologic function [5].

In our experience, TEN is a simple method, with studies in adults [31–33], perhaps due to the goodtolerance seen with the infant formulas and proteina low failure rate in its set-up and easy control of

positioning. It allows the early initiation of feeding hydrolysates in small children [34]. Only two pa-tients showed severe complications, necrotizing en-with sufficient calorie delivery, even in the immedi-

ate postoperative period after major surgery, as has terocolitis, which was related to hypoperfusion andsepsis by betalactamase-positive gram-negativebeen shown in adult studies [17]. Placing the trans-

pyloric catheter could be one of the limitations for bacteria in the postoperative period of cardiac sur-gery [35], causing the death of one of these patients.its use in critically ill children due to the small size

of the pyloric canal. However, in our experience, With respect to the nongastrointestinal compli-cations, the most frequent alterations were elec-it is possible even in neonates without the serious

complications, such as intestinal perforation or en- trolytic, especially hypokalemia (41%) andhypocalcemia (17%). These complications are fre-terocutaneous fistulae, described in other series

[18–20]. There are several techniques for insertion quent in critically ill patients and are usually sec-ondary to the use of diuretics, not to the feeding;of the catheter [21–23] and, though some studies

have described the use of air injection and metoclo- it is also possible that diarrhea could have causedthese alterations in some patients by increasingpramide [11], insertion was achieved easily by nasal

insertion in most of our patients. The position of electrolyte loss in the feces. In patients on TENshowing electrolyte disturbances, we have used thethe catheter was checked by the pH of the aspirate

and confirmed by radiologic control [24]. Drugs or intestinal route for correction, supplementing thefood with the deficient electrolytes. Sixteen percentthe use of endoscopy [25–27] were required in only

a few cases. There was only one complication sec- of the patients in the study presented respiratorytract infection during TEN; in three of these, theondary to the introduction of the transpyloric cathe-

ter, being that it entered the airway, a complication infection occurred before starting feeding. Thesefigures are similar to those of previous studies inpreviously described with the insertion of nasogas-

tric tubes [28,29]. This was rapidly resolved with adults and children [36]. However, the frequencyof altered hepatic function and of cholestasis (2%)no further complications. This study has provided

objective evidence that TEN is adequately tolerated was low, well below that associated with parenteralnutrition in the critically ill patient, confirming thatin pediatric patients of all ages and is an appropriate

therapeutic alternative, even in neonates [22]. this is one of the advantages of enteral nutritionover parenteral [37,38].The advantages of transpyloric nutrition over gas-

tric nutrition include a reduction in the risk of aspi- No differences have been found in the incidenceof complications between the different diagnosticration and secondary pulmonary infection, and the

possibility of rapidly reaching the necessary calorie groups, indicating that TEN can be used early andeffectively in all patients being admitted to PICUsdelivery. This study shows that transpyloric feeding

can be used very safely in patients on mechanical [39,40]. We think that the higher incidence of renalinsufficiency in the second period was not a compli-ventilation, even in those requiring the administra-

tion of sedatives and muscle relaxants, without in- cation of the nutrition, but was due to the severityof illness, because renal insufficiency was presentcreasing the risk of pulmonary aspiration or

gastrointestinal intolerance [30]. A large number of before TEN was started. The association betweenshock and diarrhea is probably due to the fact thatour patients received high doses of midazolam and

fentanyl without this affecting tolerance to TEN. shock can cause intestinal ischemia, leading to in-testinal malabsorption and thus to diarrhea. In thisAlso, in only 3 of the 65 patients administered mus-

cle relaxants was it necessary to suspend TEN. We study, intestinal intolerance was associated with thepresence of pulmonary infection. Although pulmo-would suggest that, in these three cases, the intoler-

ance was probably due more to hypoperfusion sec- nary infection could be secondary to microaspir-ations due to altered gastric emptying, it wouldondary to the clinical situation (postoperative

cardiac surgery in all three cases) than to reduced seem more likely to be related to the duration ofmechanical ventilation.intestinal motility. This is supported by the fact that

there was no statistically significant association be- Previous studies in adults and children havefound that intolerance to enteral feeding is a poortween poor tolerance or diarrhea and the adminis-

tration of muscle relaxants, but there was an prognostic sign [6,30]. In this study, although themortality in patients with gastrointestinal complica-association with the presence of shock (p < 0.05).


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The Use of Transpyloric Enteral Nutrition in the Critically Ill Child