The Role of Parenteral Nutrition in PEDIATRIC INTENSIVE CARE UNIT Dzulfikar DLH Pediatric Emergency and Intensive Care Unit Department of Child Health, Faculty of Medicine Universitas Padjajaran, Hasan Sadikin Hospital Bandung
Goals of nutrition support To preserve a good nutritional status To prevent malnutrition To provide therapy to help patients with various disorders To provide adequate nutritient to meet metabolic needs To improve the nutritional and metabolic condition (Kolaric et al 2006, Spagnuolo et al 2010)
GOALS The goal of nutrition supportive therapy in PICU setting is to augment the short-term benefits of the pediatric stress response while minimizing the long-term harmful consequences The delivery of these nutrients requires careful selection of the appropriate mode of feeding and monitoring the success of the feeding strategy
INTRODUCTION Critical illness has a major impact on the nutritional status in children Critically ill infants and children may be at a risk of morbidity and mortality from cumulative nutritional deficiencies during their course in the pediatric intensive care unit (PICU) Malnutrition is one of many factors which play a major role in raised morbidity and mortality rate of critically ill children in PICU
INTRODUCTION Optimizing nutrition therapy is a potential avenue for improving clinical outcomes in critically ill children Provision of optimal nutrition therapy is a fundamental goal of critical care
When to start parenteral nutrition?
In preparing and planning for a patient to receive PN, the goals should be clearly stated by determining the patient s: 1.nutritional requirements 2.baseline metabolic parameters 3.anticipated PN duration 4.accessibility of central veins 5.the most appropriate device for placement 6.the complications of therapy ASPEN 2002
Nutrition assessment Nutrition assessment of children during the course of critical illness is desirable and can be quantitatively assessed by routine anthropometric measurements Weight changes and other anthropometric measurements during the PICU admission should be interpreted in the context of fluid therapy Hulst JM, van Goudoever JB, Zimmermann LJ, et al. The effect of cumulative energy and protein deficiency on anthropometric parameters in a pediatric ICU population. Clin Nutr 2004
Others.. 1. 2. 3. 4. Nitrogen balance and resting energy expenditure Albumin, which has a large pool and much longer half-life (14 20 days), is not indicative of the immediate nutrition status Prealbumin Serum acute-phase protein levels (burn injury) Measurement of visceral protein status in assessing protein and energy malnutrition: standard of care. Prealbumin in Nutritional Care Consensus Group. Nutrition 1995. Dickson PW, Bannister D, Schreiber G. Minor burns lead to major changes in synthesis rates of plasma proteins in the liver. The Journal of trauma 1987. Letton RW, Chwals WJ, Jamie A, Charles B. Early postoperative alterations in infant energy use increase the risk of overfeeding. Journal of pediatric surgery 1995.
Indication for Parenteral Nutrition Patient is unable to meet their nutrient requirements orally or enterally. Example : intestinal failure. to prevent or correct malnutrition or to sustain appropriate growth The maximum period of tolerable undernutrition depends on the patient s age, baseline nutrition status, and underlying medical conditions PN should be initiated: within 1 day of birth in neonates within 5 to 7 days in pediatric patients ASPEN 2002, Horn 2003, Koletzko et al 2005 A short PN course of < 5 days is unlikely to give significant nutrition benefits Spagnuolo et al 2010
Indications for Parenteral Nutrition Examples Clinical Condition Intractable diarrhea, impaired absorption Short bowel syndrome withweight loss; fluid and electrolyte disturbance High-output enterocutaneous fistula Severe infectious colitis, such asclostridium difficile Small bowel obstruction Severe inflammatory bowel disease Ischemic bowel Worthington, 2012
Indications for Parenteral Nutrition Clinical Condition Motility disorders Examples Prolonged ileus Pseudo-obstruction Scleroderma Worthington, 2012
Indications for Parenteral Nutrition Clinical Condition Inability to achieve or maintain enteral access Examples Hemodynamic instability Massive gastrointestinal bleeding High risk for procedure-related complications Worthington, 2012
SELECTION IN PEDIATRIC NUTRITION Yes Oral Feeding Possible PN Try to advance EN/Oral Add PN Try to advance EN/Oral No Oral Diet No EN Possible Yes EN EN amount satisfactory?
ROUTE ADMINISTRATION OF PN Central iv line Osm may exceed 900 mosm/l Full PN support in children Prolonged PN associated with infectious and mechanical complications Peripheral iv line Not to exceed 900 mosm/l limited to dextrose concentrations of less than 12.5% partial PN supplementation bridge therapy for patients awaiting central access Short term (< 2 weeks)
FLUID REQUIREMENTS Fluid needs vary with the age & weight of the child and should be adjusted accordingly. Total water requirements consist of: the maintenance needs replacement of ongoing losses (insensible water loss, urinary losses, and stool losses) replacement of deficits Renal failure, congestive heart failure, etc Fever, hyperventilation, hypermetabolism, GI losses, etc ASPEN 2002, Horn 2003, Koletzko et al 2005
FLUID REQUIREMENTS Body weight Fluid requirements < 10 kg 100 ml/kg per day 11 20 kg 1,000 ml per day + 50 ml/kg for each kg above 10 kg > 20 kg 1,500 ml per day + 20 ml/kg for each kg above 20 kg ASPEN 2002, Horn 2003, Koletzko et al 2005
CALORIC REQUIREMENTS Energy in a child is required for both maintenance of body metabolism as well as for growth ASPEN 2002, Horn 2003, Koletzko et al 2005 Estimation Of Caloric Requirements 0-1 0-1 yo: yo: 90 90 120 120 kcal/kg/day kcal/kg/day 1-7 1-7 yo: yo: 75 75 90 90 kcal/kg/day kcal/kg/day 7-12 7-12 yo: yo: 60 60 75 75 kcal/kg/day kcal/kg/day 12-18 12-18 yo: yo: 30 30 60 60 kcal/kg/day kcal/kg/day 0-1 0-1 yo: yo: 90 90 120 120 kcal/kg/day kcal/kg/day
COMPONENTS OF PN Macronutrients Carbohydrate (Dextrose) Protein (Amino Acids) Lipid Micronutrient Electrolytes Vitamins Trace Elements
CARBOHYDRATE REQUIREMENTS Carbohydrates are the main sources of energy should comprise 40% to 50% of the caloric intake in infants and children. The most commonly used carbohydrate is glucose readily used by all body tissues Initial glucose concentration usually 5-10% Gradually increase up to 17.5% - 20% Concentration > 12.5% central venous access Total amount should not exceed daily amount the body can utilize. If exceeded: fatty liver insulin resistance hyperglycemia Carbohydrate administration should be closely monitored and adjusted in the postoperative period in neonates and children to avoid hyperglycemia. ASPEN 2002, Koletzko et al 2005, Kolaric et al 2006
PROTEN REQUIREMENTS Protein (amino acids) requirements should be adjusted according to the age of the child Amino acid preparation crystalline, branched amino acids Amino acids are generally not metabolized to supply energy but to provide structural and visceral proteins and enzymes Age Protein requirements (g/kg/day) 1 to 10 years 1.0 1.2 Adolescence Boys Girls 0.9 0.8 Critically ill child/adolescent 1.5 ASPEN 2002, Kolaric et al 2006
LIPID REQUIREMENTS Providing high energy needs without carbohydrate overload Carbohydrate overload can cause: increase in CO2 levels in blood (hypercapnia) hyperglycaemia due to insulin resistance Low osmolality good use in peripheral applications 20% lipid emulsion preferred over 10% 10% has higher phospholipid to triglyceride ratio decreased lipid clearance & elevated TG levels Doses: Initiate: 1 g/kg/day Max: 2 3 g/kg/day Koletzko et al 2005, Kolaric et al 2006 Example: Lipofundin MCT/LCT 20% (100 ml)
ELECTROLYTES REQUIREMENTS Electrolytes are added to PN according to patient s individual requirements based on blood chemistry The basic daily requirements influenced by multiple factors: increased body temperature abnormal losses through the gastroenterological tract (vomiting, diarrhoea) increased anabolism (starvation) increased loss of water through damaged skin in heart and kidney malfunctions medical drug therapy External factors (humidity, outside temperature) burn patients Horn 2003,, Kolaric et al 2006
ELECTROLYTES REQUIREMENTS electrolytes Requirements (mmol/kg/day) Infants Children sodium 2-5 1-2 Potassium 2-3 1-2 Calcium 1-2 0.5-1.0 Magnesium 0.6-1.0 0.5-1.0 Phosphate 1-2 0.5-1.0 Chloride 2-5 1-2 Horn 2003,, Kolaric et al 2006
VITAMINS & TRACE ELEMENTS Essential in the metabolism of carbohydrates, protein and fats Water soluble vitamins Soluvit N (Paeds) 1ml/kg BW (max 10 ml) Lipid soluble vitamins Vitalipid N Infant 4 ml/kg BW (max 10 ml) for chidren < 11 years Vitalipid N Adult 10 ml for patients over 11 years Trace elements Proven essential : Zinc, copper, iodine, iron, manganese, chromium, cobalt, selenium, molybdenum Peditrace 1 ml/kg/day (max 15 ml)
COMPLICATIONS OF PN Mechanical Catheter related sepsis Pneumothorax Dislocation of catheter Air embolism Venous thrombosis Infiltration & phlebitis Blockage of TPN infusion Infectious Catheter-related sepsis Other Infections Metabolic Hypo/hyperglycemia Allergic reaction to AA / fats Electrolytes disturbances Thrombocyte & neutrophil dysfunction Hepatic dysfunction Metabolic acidosis Nutritional Inadequate feeding Over feeding Refeeding syndrome
Clinical conditions warranting caution when initiating PN Worthington. Risk, complications, and management of PN, 2012.
Metabolic problems link to overfeeding Worthington. Risk, complications, and management of PN, 2012.
MONITORING Clinical monitoring Vital signs, temperature Fluid balance (input/output), edema Weight Infusion site Infusion rate / pump Change administration tubing 24 H Biochemical monitoring Blood glucose CBC LFT Serum creatinine Lipid profile