Feeding the critically ill child

Transcription

1 Feeding the critically ill child Khaw Sia ( ) Lee Jan Hau, MBBS, MRCPCH, MCI Children s Intensive Care Unit September

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3 3 No disclosures

4 Outline Is there a need to optimize enteral nutrition? Challenges in PICU nutritional practices Current evidence for best practices in PICU nutrition Concluding remarks 4

5 Malnutrition in the PICU Malnutrition is common in critically ill children Associated with increased morbidity and mortality Adequate nutritional support is a fundamental component in management of critically ill children Mehta et al. JPEN J Parenter Enteral Nutrition 2009 Mueller et al. JPEN J Parenter Enteral Nutrition 2011 Metha et al. Crit Care Med

6 6 Metha et al. Crit Care Med 2012

7 Impact of Protein Inadequacy Metha et al. Am J Clin Nutr

8 8 Wong et al. JPEN 2016

9 After adjusting for severity illness scores, oxygenation index, presence of comorbidities, inadequate protein intake was associated with mortality Wong et al. JPEN

10 The New Power Couple Protein + Energy 10 A minimum intake of 57 kcal/kg/day and 1.5 g protein/kg/day associated with positive protein balance Bechard et al. J Peds 2012

11 74 children [median: 21 (4-35) months] 54 patients had surgical diagnoses 402 measurements of total urinary nitrogen and resting energy expenditure Chaparro et al. Nutr Clin

12 Nitrogen balance was achieved with 1.5 (95% CI: ) g/kg/day Energy balance was achieved with 58 (95% CI: 53 63) kcal/kg/day Chaparro et al. Nutr Clin

13 Outline Is there a need to optimize enteral nutrition? Challenges in PICU nutritional practices Current evidence for best practices in PICU nutrition Future directions 13

14 Patients Heterogeneity in the PICU o Background nutrition status Case mix o Type of cases Manpower o Number of doctors, nurses and dieticians Resources o Equipment, assess to specialized formulas 14

15 Leong et al. Ped Crit Care Med

16 29/31 (93%) sites had dedicated intensive care unit dietician 10/31 (32%) units had guidelines/protocols for initiating and advancing enteral nutrition intake No consistent practice with regard to: Timing of initiation of enteral nutrition Use of motility agents Metha et al. Crit Care Med

17 35 centers from 18 countries Dedicated dietitian in 13 (37%) center 11 (31%) centers utilized feeding protocols Lack of consensus on when to start feeding and when to use feeding adjuncts 17

18 156 PICUs from 52 countries 52% have nutrition protocols 57% have nutrition support teams < 15% have indirect calorimetry 60% aim to start enteral nutrition within 24 hours of PICU admission Kerklaan et al. Ped Crit Care Med

19 Challenges in Assessment of Caloric Needs in the PICU Indirect Calorimetry Gold standard Not applicable in certain clinical situations: Leak High oxygen requirement High respiratory rate Equations Which ones do we use? Stress factors Risk of overfeeding 19

20 Protein Homeostasis During Critical Illness Protein Synthesis Protein Catabolism Coss-Bu et al. Nutr Clin Pract

21 Challenges in Assessment of Protein Homeostasis in the PICU Traditional markers are not robust BMI, skin-fold thickness Body composition measurements Dual-energy x-ray absorptiometry, CT, MRI Serum biomarkers Albumin, pre-albumin, plasma amino acid Nitrogen balance Ong C et al. Clin Nutr 2014 Coss-Bu et al. Nutr Clin Pract

22 Outline Is there a need to optimize enteral nutrition? Challenges in PICU nutritional practices Current evidence for best practices in PICU nutrition Concluding remarks 22

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25 Potential Solutions Manpower Resources Protocols Identify Unique Challenges Patients Case Mix Stratified Approach 25

26 PubMed 159 citations Cochrane 101 citations EMBASE 427 citations CINAHL 189 citations Improvement in time of initiation and achievement of goal feeds Reduction in infective and gastrointestinal complications 854 non duplicate citations screened 112 citations retrieved 9 studies included 742 citations excluded after screening the title and abstract 46 questionnaires/survey, reviews, clinical guidelines, letters, commentaries or teaching modules 36 studies involved exclusively adults or premature neonates 21 did not utilise feeding protocols or did not report outcomes of interest 26 Wong et al. J Parenter Enteral Nutrition 2014

27 Stratified Approach Congenital heart disease Extra-corporeal membrane oxygenation 27

28 Congenital Heart Disease: Factors Influencing Energy Expenditure 28 Wong et al. World Journal for Pediatric and Congenital Heart Surgery 2015

29 Be careful of overfeeding in the postoperative period Post-operative Fontan s surgery Metha et al. Journal of Parenteral and Enteral Nutrition

30 Congenital Heart Disease: Energy Expenditure after CPB Metha et al. Journal of Parenteral and Enteral Nutrition

31 Barriers and Strategies to Optimize Nutrition 31 Wong et al. World Journal for Pediatric and Congenital Heart Surgery 2015

32 Nutrition in Pediatric ECMO Delivery of optimal nutrition in children with ECMO remains a challenge Concerns Gut hemorrhage Gut ischemia (e.g., NEC) Very limited data in this aspect of ECMO management 32

33 33 Describe EN practice in neonatal and pediatric ECMO Web-based survey 122/521 respondents from 96/187 institutions ~ 85% utilized EN during ECMO Top 4 factors considered in EN provision Vasopressor requirement Underlying diagnosis Pharmacologic paralysis Mode of ECMO Desmarais et al. Journal of Pediatric Surgery 2015

34 Our Experience A review of all children (1 month 18 years) requiring ECMO between 2010 and 2016 Data on enteral and parenteral energy and protein intake in the first 7 days of ECMO were collected Describe the association between nutritional adequacy and mortality in children supported on ECMO 34

35 Patients Characteristics Variables Non-survivors (n=28) Survivors (n=23) p-value Age at start of ECMO, years 1.33 ( ) 5.82 ( ) Male gender, n (%) 15 (53.6) 9 (39.1) Weight at start of ECMO, kg 8.0 ( ) 20.0 ( ) Primary indication for ECMO, n (%) Myocarditis 4 (14.3) 8 (34.8) Complex heart disease post-op 15 (53.6) 9 (39.1) Sepsis/ARDS 7 (25.0) 6 (26.1) Pulmonary hypertension 2 (7.1) 0 (0.0) Veno-arterial ECMO, n (%) 25 (89.3) 18 (78.3) Maximum number of inotropes/ vasopressor drugs required on ECMO 3 (2 5) 2 (1 3) Vasopressor-inotropic score before start of ECMO 20.0 ( ) 14.0 (0 20.0) ECMO duration, days 13.4 ( ) 7.1 ( ) ICU LOS, days 19.3 ( ) 15.2 ( ) Hospital LOS, days 22.5 ( ) 29.0 ( ) Ong et al. Clinical Nutrition ESPEN 2018

36 Nutritional Adequacy Variables Non-survivors (n=28) Survivors (n=23) p value Initiated EN in first 7d, n (%) 17 (60.7) 16 (69.6) Time EN initiated after ECMO started, hours 49.6 ( ) 36.8 ( ) Energy intake on ECMO, kcal/kg/d 23.2 ( ) 23.9 ( ) Protein intake on ECMO, kcal/kg/d 0.80 ( ) 0.80 ( ) After adjusting for days on ECMO, maximum number of drugs on ECMO and need for CRRT, we found a significant association between EN energy adequacy and mortality [adjusted OR: 0.93 ( )] Adequacy of total energy intake, % a 45.3 ( ) 50.2 ( ) Adequacy of total protein intake, % a 43.0 ( ) 50.6 ( ) Adequacy of EN energy intake, % a 0.5 (0 4.4) 11.8 (0 24.5) Adequacy of PN energy intake, % a 44.2 ( ) 37.6 ( ) Adequacy of EN protein intake, % a 0.1 (0 3.5) 6.3 (0 18.9) Adequacy of PN protein intake, % a 40.7 ( ) 40.6 ( ) Achieved 80% energy requirements by day 3, n (%) 5 (17.9) 8 (34.8) Achieved 80% protein requirements by day 3, n (%) 6 (21.4) 4 (17.4) a adequacy = total intake versus requirements over 7 days, expressed as a percentage Ong et al. Clinical Nutrition ESPEN

37 Conclusion We need to be mindful of caloric and protein provision in critically ill children Too much and too little can be bad Future studies are still needed to address the issue of the clinical impact of caloric intake and protein supplementation Chuah Thean Teng ( ) 37

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39 Thank you