10/3/2012. Pediatric Parenteral Nutrition A Comprehensive Review

Transcription

1 Critical Care Nutrition Foundation for Moving Forward Justine Turner MD PhD Department of Pediatric Gastroenterology and Nutrition University of Alberta I have the following financial relationships to disclose: Fresenius Kabi* Research Funding * No products or services produced by this this company are relevant to my presentation. Pediatric Parenteral Nutrition A Comprehensive Review OBJECTIVES: Review the current state of nutrition in Pediatric Intensive Care Review the pathophysiology of nutritional problems in critically ill children Consider what is needed to move forward in providing optimal nutrition for critically ill children Ex 29 weeks Admitted PICU at 5mo severe CLD and pulmonary hypertension Discharged PICU at 8mo ventilator dependent unstable to transfer recurrent vomiting, abdominal distention t and constipation o unable to be fully fed enterally partial PN added after 2 months 1

2 Ex 29 weeks weighed 1.5kg Admitted PICU at 5mo weighing g 5.0kg weighed 7 times Discharged PICU weighing 5.12kg BUT, DOES IT REALLY MATTER? WHERE IS THE EVIDENCE? Cochrane says... Joffe et al,2009 "There is little evidence to support or refute the need to provide nutrition to critically ill children... during the first week of their critical illness... we suggest that randomized trials of nutritional support in critically ill children during the first week of critical illness should include a control arm in which no nutritional support is administered..." Based on one RCT Gottschlich et al, 2002 Early ( 48h) n=36 Control ( 48h) n=36 %Third degree burn %Ventilated Tube feed start time (h) Energy deficit 1 wk* (kcal) Length of stay (d) Death 4 3 Discharge weight (% prior) Observation nutrition and survival in ventilated pediatric critically ill medical patients (n=71) repletion of energy deficits predicts survival (R ) Briassoulis et al, Nutrition,

3 Observation nutrition and prolonged ventilation and LOS in pediatric critical care patients (n=385) Ventilation Requires Muscle Mass 136 Adults Ventilated in ICU 80 Adults with GI Diseases 20% loss protein stores critically impairs muscle function De Souza Menezes et al, Nutrition, 2012 Ali et al, Am J Resp & Crit Care Med, 2008 Windsor & Hill, Br J Surg 1988 SIRS Critical Cycles: SIRS to CARS and Back Critical Illness: A New Complex Chronic Illness Modified from Moore & Moore, Nutr Clin Pract, 2009 Second Hits Malnutrition TPN?? role of gut immune dysfuntion and translocation Poor healing Modified from Moore & Moore, Nutr Clin Pract, 2009 EN can reduce CARS KEY POINTS Why early after injury hypermetabolism may predominate, later on - particularly with sepsis - either hypo or hyper metabolism may occur and cannot be predicted on clinical criteria Nutritional assessment will have to occur as often as these ups and downs! 3

4 ... and Metabolism? Acute metabolic response generates glucose, fatty acids and amino acids for energy substrates acute phase proteins, immune response, wound healing and cellular repair induces insulin resistance (hyperglycemia and hypertrigylceridemia) Metabolically vulnerable to over feeding especially with organ failure mitochondrial dysfunction Metabolic Problems Hyperglycemia sepsis and poor wound healing retained CO2 and difficulty weaning from ventilation lipogenesis i and hepatic steatosis t Hypertriglyceridemia hepatic steatosis impair immune function Protein Both protein breakdown & synthesis are increased in critical illness Protein losses not reflected by weight Protein oe supply ppy is sc critical c tools to evaluate nitrogen balance limited Energy Predictive equations are unreliable Metabolic status difficult to predict based on clinical factors Measurement using calorimetry gold standard see high risk criteria Mehta et al, JPEN, 2009 Activity is important e.g. assisted vs controlled ventilation with sedation Organ failure and muscle mass are important Shaw et al, Ann Surg, 1987 Current State of Nutrition in PICU and why 24% children admitted to PICU are malnourished Nutritional status deteriorates over PICU stay especially in preterm and term infants 30% of all children decline in weight for age by 1SD recovery of nutritional status by 6 months Hulst et al, Clinical Nutrition, % children receive EER during PICU admission especially cardiac PICU Rogers et al, Nutrition, because Figure we 1. Reasons don't for EN interruption. feed children EARLY & CONTINUOSLY Mehta N M et al. JPEN J Parenter Enteral Nutr 2010;34:38-45 Copyright by The American Society for Parenteral and Enteral Nutrition 4

5 Feeding Truths Special Nutrients Early enteral nutrition improves anastomotic healing in major GI surgery Cochrane, Anderson et al, 2004 Early enteral nutrition improves gastroparesis and ileus Franklin et al, JPEN, 2004 Early enteral nutrition is feasible in the sickest neonates on ECMO! Jaksic et al, JPEN, 2004 Early enteral nutrition is feasible in cardiac patients on inotropes Revelly et al, Int Care Med, 2001 Wischmeyer, Current Opinion in Anaesthesiology, 24(4):381, 2011 RCT parenteral soy vs fish oil in infants pre and post open heart surgery Larsen et al, Clinical Nutrition, 2012 Intralipid Lipoplus (Soy LCT) (soy & fish LCT & n = 16 MCT) n = 16 TNF- pre (pg/ml)* TNF- post (pg/ml)* Increasing 15.4 Decreasing 6.0 PICU days TNF- correlated 7.8 with TNF- correlated 15.2 with Ventilator days Increased LOS p=0.01, R Decreased LOS p=0.004, 9.5 R Total LOS Sepsis number 6 6 The costs of not feeding critically ill children EARLY & CONTINUOSLY? Secondary analysis: Cumulative calorie intake days 0-10, < 689kcal (approx 63Kcal/kg/d) associated with: Longer PICU days (5d, p=0.04) 04) Longer Ventilator days (5d, p=0.01) Longer total LOS (25d, p=0.001) Larsen, PhD Thesis, 2011 Accurate prediction of his protein and energy needs accurate assessment of where he is in the critical illness cycle - SIRS, CARS, homeostasis-recovery Actual delivery of his needs using the enteral route combined with PN when needed using the best macronutrient and specific nutrient combinations State of the Art Measure weight and body composition Measure energy expenditure Provide early and continuous nutrition Use feeding protocols based on truth Provide multidisciplinary care (appropriate to any chronic illness) physicians, nursing, dietitetics, pharmacy, and nutrition support teams include physiotherapists and occupational therapists 5

6 Moving Forward Better tools to measure LBM and protein status Tools to predict ebb, flow and recovery SIRS biomarkers for immune and gut function Nutrient manipulation to manage SIRS & CARS pharmaconutrition Do the pediatric trials!!!! Pediatric Guidelines Grade D-E Mehta et al, JPEN, 2009 Adult Guidelines Grade A-B Heyland et al, JPEN, 2009 McClave et al, JPEN, 2009 Coming Soon Pediatric Enteral Nutrition Slide Set 6