ENTERAL FEEDING IN CRITICALLY ILL CHILDREN

ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY ILL CHILDREN Mudit Mathur, M.D. SUNY Downstate Medical Center LEARNING GOALS  Impact of Critical Illness  Importance of Nutrition  Goals of nutritional support  Nutritional requirements  Enteral vs Parenteral  When and how to initiate and advance Nutrition  Monitoring IMPACT OF CRITICAL ILLNESS-1 Physiologic stress response : Catabolic phase increased caloric needs, urinary nitrogen losses  inadequate intake wasting of endogenous protein stores, gluconeogenesis  mass reduction of muscle-protein breakdown  IMPACT OF CRITICAL ILLNESS-2  Increased – Pain – Anxiety energy expenditure – Fever – Muscular effort-WOB, shivering RESPONSE TO INJURY WHY IS NUTRITION IMPORTANT CRITICAL ILLNESS + POOR NUTRITION =  Prolonged ventilator dependency  Prolonged ICU stay  Heightened susceptibility to nosocomial infections MSOF  Increased mortality with mild/moderate or severe malnutrition NUTRITION: OVERALL GOALS ACCP Consensus statement, 1997  Provide nutritional support appropriate for the individual patient’s – Medical condition – Nutritional status – Available routes for administration NUTRITION: OVERALL GOALS  Prevent/treat macro/micronutrient deficiencies  Dose nutrients compatible with existing metabolism  Avoid complications  Improve patient outcomes ENTERAL OR PARENTERAL IMPACT OF STARVATION-1  Negative nitrogen balance, further wt loss  Morphological changes in the gut – Mucosal thickness – Cell proliferation – Villus height  Functional changes – Increased permeability – Decreased absorption of amino acids IMPACT OF STARVATION-2   Enzymatic/Hormonal changes – Decreased sucrase and lactase Impact on immunity – Cellular: Decreased T cells, atrophied germinal centers, mitogenic proliferation, differentiation, Th cell function, altered homing – Humoral: Complement, opsonins, Ig, secretory IgA – (70-80% of all Ig produced is secretory IgA) – Increased bacterial translocation ENTERAL or PARENTERAL?  Enteral Nutrition: Superior to Parenteral – Trophic effects on intestinal villus – Reduces bacterial translocation – Supports Gut-associated Lymphoid Tissue – Promotes secretory IgA secretion and function – Lower cost  Parenteral Nutrition – IV access – Infectious risk ENTERAL WITH PARENTERAL IS THE COMBINATION BETTER  120 adult patients, (medical and surgical)  Combination vs enteral feeds alone  Prospective, randomized, double blind, controlled  RBP, pre albumin increased significantly D 0-7  No reduction in ICU morbidity  No reduction in ICU LOS/ vent, MSOF, dialysis  Reduced hospital stay (by 2 days)  Mortality at 90 days and 2 years was identical Bauer et al, Intensive care med. 2000: 26, 893-900 A PRACTICAL APPROACH-1  Nutritional assessment – History-preexisting malnutrition, underlying disease, recent wt loss (> 5% in 3 wks or >10% in 3 months) – Physical-anthropometrics, BMI, evidence of wasting – Labs-albumin (t ½ 18-21 d), transferrin (t ½ 8 d), prealbumin (t ½ 2 d), RBP (t ½ 0.5 d) A PRACTICAL APPROACH-2 Assessment of the present illness Hypermetabolism-burns, sepsis, MSOF, trauma  GI surgical procedures-prolonged NPO  End-organ failure (Hepatic/renal etc)  Metabolic Cart-facilitates assessment of energy expenditure, Respiratory Quotient WHEN TO INITIATE ENTERAL NUTRITION:  ASAP-usually within 24 hours in severe trauma, burns and catabolic states  Contraindications to enteral nutrition: – Nonfunctional gut, anatomic disruption, gut ischemia – Severe peritonitis – Severe shock states ROUTE OF FEEDING  Nasogastric – Requires gastric motility/emptying  Transpyloric – Effective in gastric atony/ colonic ileus – Silicone/polyurethane tubing – Positioning, Prokinetic agents/ fluoroscopic/ pH/ endoscopic guidance  Percutaneous/surgical placement – PEG if > 4 weeks nutritional support anticipated – Jejunostomy if GE reflux, gastroparesis, pancreatitis POTENTIAL DRAWBACKS OF ENTERAL FEEDS  Gastric emptying impairments  Aspiration of gastric contents  Diarrhea  Sinusitis  Esophagitis /erosions  Displacement of feeding tube NUTRITIONAL REQUIREMENTS  25-30 non protein Kcal/kg/d adult males  20-25 non protein Kcal/kg/d adult females  Children: BMR 37-55 Kcal/kg/d (50% of EE) + Activity + growth  Factors increasing EE – – – – Fever 12% Burns upto 100% Sepsis 40-50 % Major surgery 20-30% Resting Energy Expenditure Age (years) 0–1 1–3 4 –6 7 –10 REE (kcal/kg/day) 55 57 48 40 11-14 (Male/Female) 15-18 (Male/Female) 32/28 27/25 Factors adding to REE Maintenance Activity Fever Simple Trauma Multiple Injuries Burns Sepsis Growth Multiplication factor 0.2 0.1-0.25 0.13/per degree > 38ºC 0.2 0.4 0.5-1 0.4 0.5 NUTRITIONAL REQUIREMENTS  Initial protein intake 1.2-1.5 gram/kg/d  Micronutrients-added if feeds are small in volume or patient has excessive losses  Tailor individually, 24-30 cal/oz formula  Usually continuous feeds are tolerated better  Add for catch up growth upon recovery  Adequate calories = adequate growth FORMULA COMPOSITION  Carbohydrates: 60-70% of non protein calories – Polysaccharides/disaccharides/monosaccharides – Glucose polymers better absorbed  Lipids: 30-40% of non protein calories – Source of EFA – Concentrated calories-but poorer absorption – MCT direct portal absorption-better FORMULA COMPOSITION  Proteins – -polymeric (pancreatic enzymes required) or peptides – Small peptides from whey protein hydrolysis absorbed better than free AA  Fibers – Insoluble-reduce diarrhea, slower transit-better glycemic control – Degraded to SCFA-trophic to colon COMPOSITION-SPECIAL FORMULAS  Pulmonary: High fat( 50%), Low CHO  Hepatic: High BCAA, low aromatic AA, <0.5 gm/kg/d protein in encephalopathy  Renal: Low protein, calorically dense, low PO4 , K, Mg GFR >25: 0.6-0.7 g/kg/d GFR <25: 0.3 g/kg/d  Immune-enhancing IMMUNE MODULATION  Glutamine  Arginine  Fatty acids (w-3)  Nucleotides  Vitamins and minerals Pediatric burn patients: Arginine & w-3 fatty acid supplements reduce infections, LOS ( Gottslisch: J Parenter. Ent. Nutr. 14: 225, 1990) IMMUNE MODULATION  Glutamine+arginine+Branched chain AA (Immunaid)  Arginine+omega-3 Fatty acids+RNA (Impact) – EN started within 36 hrs – Mortality, bacteremic episodes reduced – More pronounced effect in APACHE II 10-15 Galban et al, CCM, 2000; 28: 3, (643-48) IMMUNE MODULATION MECHANISMS ARE UNCLEAR  Reduction of duration and magnitude of inflammatory response  Will this disrupt the balance between pro and anti-inflammatory processes??  Of the multiple ingredients in these special formulas: which is “the” one  Beneficial effects seen in patients achieving early EN IMMUNE MODULATION Conclusive studies, clear indications & Cost-benefit analysis are still needed ENTERAL NUTRITION IN CRITICAL ILLNESS:  Maintains nutritional status  Prevents catabolism  Provides resistance to infection  Potential effect on immune modulation PARENTERAL NUTRITION (PN) The PN formulation is based on:  Fluid Requirements  Energy Requirements  Vitamins  Trace elements  Other additives-Heparin, H2 blocker etc Fluid Requirements Fluid requirements = maintenance + repair of dehydration + replacement of ongoing losses.  Maintenance Fluid Requirements 1 - 10 kg = 10 - 20kg = 20 kg =  100 ml/kg/day 1000 ml + 50 ml for each kg > 10 kg 1500 ml + 20ml for each kg > 20 kg PN generally should be used for the maintenance needs.  Deficit and replacement of losses should be provided separately.  Remember to consider medications, flushes, drips, pressures lines and other IV fluids in your calculations. Energy Requirements Total Daily Energy Requirements (kcal/day) = Resting Energy Expenditure (REE) + REE  (Total Factors) Factors = Maintenance + Activity + Fever + Simple Trauma + Multiple Injuries + Burns + Growth PN-suggested guidelines for Initiation and Maintenance Substrate Initiation Dextrose 10% Advance Goals ment 2-5%/day 25% Comments Increase as tolerated. Consider insulin if hyperglycemic Maintain calorie:nitrogen ratio at approximately 200:1 Only use 20% Amino acids 1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day 20% Lipids 1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day Resting Energy Expenditure Age (years) 0–1 1–3 4 –6 7 –10 REE (kcal/kg/day) 55 57 48 40 11-14 (Male/Female) 15-18 (Male/Female) 32/28 27/25 Factors adding to REE Maintenance Activity Fever Simple Trauma Multiple Injuries Burns Sepsis Growth Multiplication factor 0.2 0.1-0.25 0.13/per degree > 38ºC 0.2 0.4 0.5-1 0.4 0.5 Suggested monitoring Protocol Weight Urine dip Bedside for glucose glucose Q shift Q shift Labs First week Daily Subsequently Daily Q shift Q shift Daily SMA-7, Ca, Mg, Phos, triglycerides Q OD LFTs SMA-7, Ca, Mg, Phos 2x/wk CBC, LFTs weekly Triglycerides 2x/wk Calculations Dextrose  ____g/100ml Dextrose  ____ml/day = ____grams/day  _____g/day  (weight  1.44) = _____mg/kg/min  _____g/kg/day  3.4 kcal/g = _____ kcal/kg/day Calculations Fat  20 grams/100ml Fat  _____ml/day = _____grams/day  _____g/kg/day  9 kcal/g = _____ kcal/kg/day Calculations grams Protein  6.25 = _____ Nitrogen  Non-protein calories  Nitrogen = Calorie:Nitrogen ratio  DANGERS OF OVERFEEDING  Secretory diarrhea (with EN)  Hyperglycemia, glycosuria, dehydration, lipogenesis, fatty liver, liver dysfunction  Electrolyte abnormalities: PO4 , K, Mg  Volume overload, CHF  CO2 production- ventilatory demand  O2 consumption  Increased mortality (in adult studies) MONITORING Prevent Overfeeding  Carbohydrate: High RQ indicates CHO excess, stool reducing substances  Protein: Nitrogen balance  Fat: triglyceride  Visceral protein monitoring  Electrolytes, vitamin levels  Caloric requirement assessment by metabolic cart CONCLUSIONS  Start nutrition early  Enteral route is preferred when available  Set goals for the individual patient  Dose nutrients compatible with existing metabolism  Appropriate monitoring is essential  Avoid overfeeding QUESTION 1  When should nutritional support be initiated in critically ill patients? – Only after extubation – After 3 days of NPO status – After 5 days of NPO status – After 7 days of NPO status – ASAP, preferrably within 24 hours of admission QUESTION 2  What would be the preferred mode for nutritional support in a 10 year old boy with head injury, raised ICP and aspiration pneumonia that developed after he vomited during intubation in the field. – Parenteral nutrition – Enteral nutrition – A combination of enteral and parenteral nutrition – IV fluids alone until ICP is better controlled. QUESTION 3  What would be the initial TPN composition for a 10 kg 18 month year old child – Glucose 10%, Protein 20 g/day, lipids 5g/d – Glucose 10%, Protein 10 g/day, lipids 15g/d – Glucose 15%, Protein 5 g/day, lipids 20g/d – Glucose 12.5%, Protein 20 g/day, lipids 10g/d – Glucose 10%, Protein 10 g/day, lipids 10g/d