Enteral Nutrition in the Critically Ill Child: Challenges and Current Guidelines

Transcription

1 Enteral Nutrition in the Critically Ill Child: Challenges and Current Guidelines 1 Presented on January 24, 2017 Jorge A. Coss-Bu, MD Associate Professor of Pediatrics Section of Critical Care Baylor College of Medicine Texas Children s Hospital Houston, Texas, USA 1 Sponsor Disclosure: Financial support for this presentation was provided by Nestlé Health Science. The views expressed herein are those of the presenter and do not necessarily represent Nestlé s views. The material herein is accurate as of the date it was presented, and is for educational purposes only and is not intended as a substitute for medical advice. Reproduction or distribution of these materials is prohibited Nestlé. All rights reserved. 2 Learning Objectives Describe the changes of the intestinal barrier in critical illness List the challenges to delivering enteral nutrition in the critically ill child Identify current guidelines regarding provision of enteral nutrition Explain the association of adequate nutrition intake and clinical outcomes 3 1

2 Gut Barrier Physical Barrier Gut Microbiota Intestinal Mucus Epithelial Cells Functional Barrier Gut Associated lymphoid tissue or GALT Turner J. Nature Reviews Immunology 2009; 9, Benefits of Enteral Nutrition Preservation of gut integrity Favorable mucosal immunity Improved nutritional indices Lower infection rates Decreased costs Gramlich L et al. Nutrition Intestinal Ischemia Tight Junction loss n= 20 Age: 17 mos Functional Enterocyte mass Intestinal Permeability 6 2

3 Single-center, prospective, randomized study of 27 neonates ( 37 weeks) requiring cardiac surgery; patients randomized preoperatively to: 1) NPO; n =13 2) Trophic (10ml/kg/day) breast milk feeds; n = 14 3) Urine L/M ratios done at 0, 7, and 14 days JPediatr 2015;167: The results indicate a disruption of the intestinal barrier before and after surgery There was an association with worsening intestinal permeability and severity of illness The intestinal barrier dysfunction in this population of critically ill children is present in the 2 nd week after surgery 8 Do we have a defintion of early enteral nutrition? 9 3

4 Pediatric Studies Author Design Population, n Time to start feeds Gottschlich, M; 2002 RCT Burns, n=77 24 hrs Venter, M; 2007 RCT Burns, n=18 24 hrs Khorasani, E; 2010 RCT Burns, n= hrs Briassoulis, G; 2005 RCT PICU, n=50 12 hrs van Waardenburg, D;2009 RCT PICU, n=20 24 hrs Sánchez, C; 2007 a Prospective PICU, n= hrs López-Herce, J; 2008 a Prospective PICU, n=65 24 hrs Petrillo-Albarano, T; 2006 Retrospective PICU, n=93 6 hrs Mikhailov, T; 2014 Retrospective PICU, n= hrs Canarie, M; 2015 Retrospective PICU, n= hrs RCT: Randomized Control Trial; a same group of patients 10 Pediatric Studies: Burns PICU LOS days Length of MV days Mortality Early Late Early Late Early Late n=36 n=36 n=36 n=36 n=36 n=36 Gottschlich, M; ±6 55±5 25±5 22±4 11% 8% n=9 n=9 n=9 n=9 Venter, M; NA NA 22% 11% n=366 n=322 n=366 n=322 Khorasani, E; ±1 16±4* NA NA 8.5% 12%* LOS: Length of stay; MV: Mechanical ventilation; Values are mean± SE or total days; * p < Pediatric Studies: PICU PICU LOS days Length of MV days Mortality Control Exp. Control Exp. Control Exp. n=25 n=25 n=25 n=25 n=25 n=25 Briassoulis, G; % 12% n=10 n=8 n=10 n=8 van Waardenburg; 7±1 9±3 6±1 7±2 NA NA 2009 LOS: Length of stay; MV: Mechanical ventilation; Values are mean± SE or total days; * p <

5 Challenges to Enteral Nutrition Pediatric Intensive Care Unit Mehta NM et al. JPEN J Parenter Enteral Nutr ; 34(1): Nutritional Practices: An International Cohort Study Initiation of Enteral Nutrition (EN); n = 440 children Patients (%) Prior to ICU admission 39 (8.8%) On the first ICU day 83 (18.8%) On the second ICU day 146 (33.1%) On the third ICU day 86 (19.5%) On the fourth ICU day 87 (19.7%) Frequency of EN interruptions (days) 1.9 ± 1.9* Duration of EN interruptions (hrs/day) 1.8 ± 2.1* Values are mean ± SD Mehta N. et al Crit Care Med 2012;40:

6 Early 16 Challenges to Enteral Nutrition Risk factors associated with delayed enteral nutrition the first 48 hrs of PICU admission 1) Noninvasive positive-pressure ventilation (odds ratio, 3.37; 95% CI, ) 2) Invasive positive-pressure ventilation (odds ratio, 2.06; 95% CI, ) 3) Severity of illness (odds ratio,1.39; 95% CI, ) 4) Procedures (odds ratio, 3.33; 95% CI, ) 5) Gastrointestinal disturbances (odds ratio, 2.05; 95% CI, ) 17 Nutrition Support in PICU Underprescription & Underdelivery Percentage of intake of < 90% of estimated needs PICU Admission A total of 240 pts reviewed (6 months) admitted > 48 hrs to the PICU 60% had chronic conditions, 60% were on MV on day 1 with PRISM score of 6±5 (SD), and 40% had chronic malnutrition. 66% of patients had a consult by a dietitian by day 3. Kyle U et al. J Acad Nutr Diet Dec;112(12):

7 Post Surgical Children for Congenital Heart Disease Nutritional Intake by Day of Admission % Estimated needs Caloric Intake % Estimated needs Protein Intake 0 Error Bars ±95% CI Days Error Bars ±95% CI Days Patients with Acute or Chronic Malnutrition 50% and 40 % n = 121 pts., avg age: 5 mos, avg wt: 5.3 kg Toole BJ. et al. Congenit Heart Dis Jan-Feb;9(1): Post Surgical Children for Congenital Heart Disease Enteral vs. Parenteral intake by day of admission % of caloric intake PN EN 6.5 kcal/kg/d 33 kcal/kg/d 60 kcal/kg/d 70 kcal/kg/d n = 121 n = 120 n = 95 n = 70 Toole BJ. et al. Congenit Heart Dis Jan-Feb;9(1):

8 PICU Nutrition Support Guidelines How well are we doing? Change Caloric intake: % of ideal intake 76±49 88±40 a 12% Protein intake: % of ideal intake 37±30 55±23 b 18% Patients with new weight (%) 38±14 56±15 a 18% Patients with new labs (%) 47±7 86±12 b 39% Dietitian consult (%) c 24% Values are mean ± SD. a p < 0.05, b p < by t-test; c p < by chi-square. Thank you! All your hard work is paying off We have improved, however there is still room for more improvement For copies of the PICU nutrition guideline please ask Laura PICU dietician. Nutrition risk referrals for all intubated patients or if weight for length is < 10 th percentile Twice weekly weights (Monday and Thursday) FOC weekly if < 2 years of age Labs (see your badge guide) 22 Feeding Protocols in PICU Audit Cycles on Nutritional Practices 50% 70% Meyer R et al. J Hum Nutr Diet Oct;22(5): Does initiation of early enteral nutrition and the use of Nutrition Support Guidelines & Nutrition algorithms have an effect on outcomes? 24 8

9 25 Postoperative Group Before n=23 After n=25 Before n=35 Medical Group After n=36 Time to start of enteral nutrition (hrs) Enteral nutrition initiated <24 hrs n (%) 12 (52) 17 (68) 31 (89) 33 (92) EN (%) total fluid, median (IQR) 39 (35) 46 (26) 68 (31)* 77 (22)* Energy (% BMR); median (IQR) 50 (47) 55 (46) 77 (43)* 100 (38)* * P < 0.05 between period A and B 26 1) Available Enteral Nutrition algorithm details from 31 international PICUs were obtained 2) A minority of PICUs ( 30%) use enteral nutrition algorithms; recommendations were variable and not in agreement with national guidelines 27 9

10 Enteral Nutrition & Mortality VPS Virtual PICU Database 28 A higher percentage of goal energy intake via enteral nutrition route was significantly associated with lower 60-day mortality. 29 Protein Needs of the Critically Ill Child N=1245, age 1.7 years ( ) Mehta, NM et al Am J Clin Nutr 2015;102:

11 Protein Needs of the Critically Ill Child Mehta, NM et al Am J Clin Nutr 2015;102: Nutrition Adequacy and Outcomes Wong J. et al. Journal of Parenteral and Enteral Nutrition

12 Texas Children s Hospital Nutrition Support Guidelines Energy Goals The goals of nutrition care are to meet 50% of energy requirements by 48 hours and 100% by days 3-5, based on Schofield. Protein Goals The goals of nutrition care should be to meet 50% of protein requirements based on ASPEN guidelines by 48 hours and 100% by days Texas Children s Hospital Enteral Nutrition Support Guidelines 35 Texas Children s Hospital Enteral Nutrition Support Guidelines 36 12

13 Conclusions There is evidence that intestinal permeability is disrupted in the post-surgical critically ill child There is wide variability in the definition of early enteral nutrition in the critically ill child among the studies published in the literature One RCT in children with burns, showed mortality benefit of early initiation of enteral nutrition 37 Early Conclusions Nutrition Support Practices worldwide indicate that half of the PICUs utilize Nutrition Protocols and around 50% initiate enteral feeding on the first day of admission to the PICU The implementation of Nutrition Support Guidelines and Nutrition algorithms improve nutrition intake Recent evidence indicates a survival benefit of higher nutrition intake in critically ill children 38 Nutrition-related resources and tools are available from Nestlé Nutrition Institute: Visit the New and improved MyCE site at MyCEeducation.com Offering CE to dietitians and nurses 39 13