Nutrition Management of the Critically Ill Pediatric Patient: Facilitating the Transition to Enteral Nutrition

Transcription

1 Nutrition Management of the Critically Ill Pediatric Patient: Facilitating the Transition to Enteral Nutrition Ana Abad-Jorge, EdD, MS, RDN, CNSC Program Director, Bachelor of Professional Studies in Health Sciences Management School of Continuing and Professional Studies, University of Virginia Food & Nutrition Conference & Expo October 20 th 2014 Presentation Objectives Describe current practice guidelines for timing and provision of enteral nutrition in critically ill children Identify common barriers to the delivery of optimal EN in the PICU setting. Discuss specific strategies to optimize EN delivery in the challenging PICU setting. Select appropriate formula for EN in critically ill children based on age, clinical status and GI function. Discuss the literature with regards to the use of immune enhancing formulas in pediatric patients. I. Introduction a. Optimal nutrition plays a key role in sustaining organ function b. Also helps to prevent dysfunction of the cardiovascular, respiratory and immune system until the acute phase inflammatory response resolves. c. Requires energy balance to prevent both: Overfeeding can lead to...increased CO 2 production leading to difficulties in weaning from the ventilator and hepatic complications Underfeeding (more prevalent in PICU) leads to: reduced wound healing & increased sepsis d. Despite numerous advances in both technology and formulations, malnutrition in the PICU has remained relatively unchanged for the past 20 years. e. Studies indicate that 24% - 55% of patients present with acute or chronic malnutrition on admission. II. Goals of Nutrition Support in Critically Ill Children a. Provision of nutrition screening in a timely manner to identify those with existing malnutrition or those nutritionally at risk. b. Comprehensive nutritional assessment with the development of a nutrition care plan. Use of the Nutrition Care Process c. Assessment of energy & protein needs throughout the course of illness to prevent overfeeding and underfeeding while providing adequate calories & protein to minimize catabolic response. d. Provision of nutrition support in a timely manner: within hours in children < 2 years old and at nutrition risk, within hours in children > 2 or those previously well-nourished and not at risk. e. Using indirect calorimetry (IC) to assess energy expenditure is preferred; however, if IC is not feasible or available, initial guidelines may be based on published formulas with adjustments as needed, based on clinical status. f. Use of EN as the preferred modality of nutrition support for critically ill children.

2 g. Optimization of EN to meet needs while identifying potential barriers and avoidable interruptions. III. Nutrition Support Guidelines in Peds Critical Care: Enteral (Mehta & Compher, JPEN 2009) IV. Pediatric Patients Most at Nutrition Risk in the PICU Clinical Conditions a. Hypermetabolic states: trauma, head injury, spinal cord injury, thermal injury b. Cardiorespiratory illness: congenital heart disease, chronic lung disease c. Post-surgical patients (particularly non-elective) d. GI disease and dysfunction: short gut syndrome, inflammatory bowel disease with h/o PEM, biliary atresia, pancreatitis e. Neurologic, muscular disease: genetic syndromes, muscular dystrophy, history of CP/MR requiring G-tubes Other Factors a. Underweight: BMI < 5th%-ile for age b. Overweight: BMI > 95th%-ile for age c. Children with either significant weight loss (>10%) or weight gain (>10%) during PICU admission d. Failure to consistently meet prescribed energy and protein requirements e. Failure to wean off the ventilator f. Need for muscle relaxants for > 7days V. Enteral Nutrition: Benefits, Timing, Common Barriers, Optimal Routes & Methods a. Benefits More physiological Maintains physiologic and functional integrity of gut mucosa by nourishing the gut first May prevent or decrease risk of bacterial translocation Decreased infectious complications Often easier to manage fluid and electrolyte balance

3 May have anti-inflammatory effects by decreasing cytokine production, i.e. TNF-α, interleukin-6 More cost effective than parenteral nutrition (PN): $20-$30/day vs. > $200/day b. Optimal early EN guidelines, particularly for infants < 2 and children at nutritional risk : within hours of PICU admission. Study: Mikhailov et al. Early Enteral Nutrition is Associated with Lower Mortality in Critically Ill Children. Journal of Parenteral and Enteral Nutrition, May Design: Multicenter retrospective cohort study in 12 PICUs, Results: 5105 patient within 12 centers; 5.3% mortality with EEN; Children on EEN were less likely to die than those who did not (OR, 0.51). c. Intestinal Dysfunction in the PICU Dysmotility due to hypoperfusion, sedation & paralysis, minimal EN stim. Malabsorption poor nutritional status, minimal EN stimulation Loss of GI Barrier Function Hypoperfusion, toxins & cytokines d. Common Barriers to Initiation & Advancement of EN in the PICU Severe fluid restrictive policies Hemodynamic instability with use of high doses of vasoactive medication, i.e. epinephrine, vasopressin Severe deterioration in respiratory status, requiring endotracheal intubation Surgical post-operative orders Patient is perceived as being too ill to feed Frequent procedures requiring NPO status e. Optimal Site of EN: Gastric vs. Post-Pyloric? Insufficient data to make recommendations regarding the optimal site for EN Study: Meert el al. Chest, 2004.Studied 74 critically ill Randomized to receive either gastric or post-pyloric; EN interrupted frequently Unblinded RCT no differences in microaspiration, EN device displacement and feeding intolerance. f. Optimal Method for EN in the PICU: Continuous or Intermittent? Study: Horn et al. American Journal of Critical Care, children admitted to PICU randomized to receive either continuous or intermittent gastric feeds (every 2 hrs); measured tolerance to enteral feedings Results: number of daily stools and diarrheal or vomiting episodes was similar between the two groups g. Common Challenges and Barriers to Optimal EN in the PICU Study: Mehta et al. JPEN, 2010 Prospective observational study in a 29 bed PICU over a 4 week period Measurements: daily nutrient intake & factors causing avoidable interruptions Clinical characteristics, time to reach calorie goals, and PN use were compared in patients with and without avoidable EN interruptions Objectives: identify risk factors associated with avoidable interruptions to EN in PICU Results: EN was interrupted in 24 patients (30%) at times per patient (88 episodes = 1483 hours); of the 88 episodes, 51 (58%) were deemed avoidable. VI. Enteral Nutrition for PICU Patient: a. Strategies for Minimizing Interruptions:

4 1. Careful attention to procedure times to prevent prolonged fasting and undue delays in resuming EN 2. Clear communications between PICU team members to ensure timely re-initiation of EN following procedures, i.e. following extubation. 3. Active role of the RD in the education of PICU physicians, residents and nursing staff on optimizing EN, troubleshooting GI intolerance to determine alternate causes other than formula intolerance. b. Use of Algorithms and Protocols 1. Use clinical practice guidelines or algorithms for initiation and advancement of EN based on acuity level, age, GI function, intolerance. 2. Four prospective cohort studies from have shown that enteral feeding guidelines or protocols can improve caloric delivery and decrease time to full feeds. 3. Question EN practices which lack evidence 4. Study: Martinez et al. Nutrition Algorithms in PICUs, Nutr Clin Pract, June 2014 A minority of PICUs use EN algorithms only 29% of sample Recommendations varied greatly and did not follow national guidelines Optimal EN was achieved in < 1/3 of the study s cohort 5. Consider starting with trophic feedings: on POD #1or #2 - providing at least 10-15% of calorie needs via EN has been demonstrated to prevent or minimize gut atrophy and potential translocation (Okada et al., 1988). VII. Enteral Formula Choices for the Critically Ill Pediatric Patient: Formulas a. Selection is based on: Patient Factors age, diagnosis, nutritional problems, specialized needs Formula Factors osmolality, renal solute load, caloric density, viscosity, nutrient composition, immunonutrients? b. Immune-Enhancing Formulas Use in Pediatrics? Key Nutrients arginine, glutamine, omega-3 fatty acids, nucleotides, antioxidants Adult Studies - > 30 studies 1. ASPEN Guidelines - use of immunonutrition in critically ill adults, McClave et al. JPEN, 2009:

5 2. Immune-modulating enteral formulations should be used for the appropriate patient populations (major elective surgery, trauma, burns, heads and neck cancer, and critically ill patients on mech. ventilation), with caution in patients with severe sepsis. 3. While meta-analyses found reduced infection rates, Sub-group analysis conducted by the Heyland et al. meta-analysis showed no differences in mortality between treatment and control groups. 4. Study limitations: only 25% of the studies used intention to treat analysis. As such, there could have been an overestimation of the treatment effect. Pediatric Studies 1. Briassoulis et al. Nutrition, a. Blinded RCT in PICU patients (n=50, 25 in each group) b. Patients randomized to an adult Immune (I) formula which included glutamine, arginine, omega-3 FA and antioxidants or conventional (C) pediatric formulas for children < or > 6 years. c. Results: Nitrogen balance in 64% of patients in I group vs. 40% in C group, no changes in mortality, trend towards decrease in nosocomial infections rates and positive gastric culture rates, transient diarrhea in the I group. d. Limitations: adult formulation used, formulas NOT isonitrogenous, two separate formulas for the control group. 2. Briassoulis et al. Pediatr Crit Care Med, a. Blinded RCT in PICU pts with severe head injury (n=40). Age: months b. Patients received adult immune enhancing formula (IE) vs. regular formula. IE formula much higher in protein. c. Results: Improved nitrogen balance and decreased interleukin-8 levels in the IE group, less gastric cultures were positive in the IE group. d. No differences in rates of nosocomial infections, length of stay, length of mechanical ventilation or survival. 3. Summary - May be beneficial in older pediatric patients (>15 years or >50 kg) with the following criteria: trauma, malnourished adolescent undergoing surgery or consider use of the product upon which most studies were based, i.e. Impact (higher arginine levels, nucleotides, omega-3 FA) VIII. Enteral Case Study: Adolescent Trauma a. 15 year old male who sustained closed head injury, skull fracture, splenic laceration, and femur fracture following a skiing accident is admitted to the PICU. b. Anthropometrics: Previously well-nourished Weight: 64 kg (75th%-ile) Height: 177 cm (75th 90th%-ile): BMI: 19.4 c. Clinical Considerations: Clinical Status: Increased ICP, on mechanical ventilator Current medications: epinephrine, fentanyl, versed, IV phenytoin Surgery on Hospital Day #1 for craniotomy Clinical status stabilizing with decreased ICPs and weaning on ventilator d. Estimating Nutrition Requirements: Calories & Protein If available, order indirect calorimetry Alternative: BEE (for weight & sex) X stress factor (limited data)

6 1793 kcal (initial goal) for first 1-2 days, then Move towards factor of ; endpoint goal of kcal. Protein: gm protein/kg or gm protein e. Enteral Nutrition Management Possible Approach Use standard formula with fiber, i.e. Jevity OR Use calorically dense/ high protein formula if fluid restricted Formula Options: Promote, Jevity 1.5 Alternative: May consider immunonutrition formula, i.e Impact with Glutamine Begin at 20 ml/hr, advance by 20 ml/hr every 6-8 hours, to goal ml/hr. Jevity 1.0 will provide = 2798 kcal, 116 gm protein. Monitor GI tolerance, obtain prealbumin initially and weekly (measure of disease acuity to gauge transition from catabolism to anabolism). Some PICUs are also measuring CRP. Reference List 1. Abad-Jorge, A. Chapter 12 Critical Care. In Kane-Alves, V. and Tarrant, S. (eds): The Nutrition Care Process in Pediatric Practice. Academy of Nutrition and Dietetics, Pediatric Nutrition Dietetic Practice Group, September Abad-Jorge, A. Nutrition Management of the Critically Ill Pediatric Patient: Minimizing Barriers to Optimal Nutrition Support, J Infant, Child & Adolescent Nutrition, 2013; 5(4): Abad-Jorge, A., Roman, B., Perks, P., Hubbard, A. and Buck, M. Pediatric Nutrition Support Handbook, University of Virginia Health System, Briassoulis, G., Filippou, O., Kanarious, M., Hatzi, E., Hatzis, T. and Papassotiriou, I. Temporal nutritional and inflammatory changes in children with severe head injury fed a regular or an immune-enhancing diet: A randomized, controlled trial. Pediatr Crit Care Med 2006; 7(1): Cook, R.C. and Blinman, T.A. Nutritional support of the pediatric trauma patient. Seminars in Pediatric Surgery, 2010; 19: Horn, D., Chalboyer, W. Gastric feeding in critically ill children: a randomized controlled trial. Am Journal of Crit Care 2003; 12: Meert,, K.L., Daphtary, K.M., Metheny, N.A. Gastric vs. small-bowel feeding in critically ill children receiving mechanical ventilation: a randomized controlled trial. Chest 2004; 126: Mehta, N.M. and Compher, C. ASPEN Clinical Guidelines: Nutrition support of the Critically Ill Child. Journal of Parenteral and Enteral Nutrition, 2009; 33(3): Mehta, N.M. Approach to enteral feeding in the PICU. Nutrition in Clinical Practice 2009; 24(3): Mehta, N., McAleer, D., Hamilton, S., Naples, E., Leavitt, K. Mitchell, P. and Duggan, C. Challenges to optimal enteral nutrition in a multidisciplinary pediatric intensive care unit. J Parenteral and Enteral Nutrition 2010; 34: Mikhailov, T.A., Kuhn, E.M., Manzi, J. et al. Early enteral nutrition is associated with lower mortality in critically ill children. J Parenteral & Enteral Nutrition, 2014; 38(4): Tume, I., Latten, I., Darbyshire, A. An evaluation of enteral feeding practices in critically ill children. Nurs Crit Care. 2010; 15: Zamberlain, P., Delgado, AF, Leone C. et al. Nutrition therapy in a pediatric intensive care unit: indications, monitoring and complications. J Parenter & Enter Nutr, 2011; 35: