Docstoc

Inpatient nutrition_Creamer

Document Sample
Inpatient nutrition_Creamer Powered By Docstoc
					The Science of Effective
  Pediatric Inpatient
    Nutrition 2005

    Kevin M. Creamer M.D., FAAP
  Medical Director, PICU WRAMC
Chief, Pediatric Nutrition Support Team
      A hypothetical case
 StarvinMarvin is a 2 y.o. who presents with
  a 2-3 week Hx of fevers, weight loss, pallor,
  decreased energy, appetite and activity
 PE reveals Wt 13kg , down 1.5 kg, pallor,
  petechia,+ HSM
 Labs reveal WBC 26 K with 50% blasts,
  anemia and thrombocytopenia
         Hospital Course
 Day 1 - NPO, IVFs, labs, Xrays
 Day 2 – NPO for BM and LP, as well as
  Hickman
 Day 3- Chemo, picky PO
 Day 4-6 - continued poor PO, with emesis
  occasionally
 Day 7-10 – emesis resolves, PO inadequate
 Day 12 – pancytopenia, sepsis with GNR
        Teaching points
Nutritionally-at-risk   from the word GO
  • Debilitated Ortho spine patient
  • Recurrent bowel obstruction patient
No  nutrition plan, No monitoring, No
 intervention
Hope is not a method
Could sepsis event been avoided??
        Inpatient Nutrition Goals
       Think about nutritional status on every patient
       Outline the dynamic between illness,
        nutritional state and secondary morbidity
       Recognize need to estimate/calculate goals
        calories in order to reach the goal
    •     Individualized goals for time course, and disease
          process
       Institute effective nutrition support with the
        help of Pediatric nutritionist
Acute Stress
The 5 W’s of Inpatient Nutrition




Why, Who, When, Where, What ?
               Acute Stress
 Major    Surgery, Sepsis, Burns, Trauma
  • Result in massive outpouring of catechols,
    ACTH, GH, ADH, glucagon, somatomedins
     – Insulin inhibition, elevation of glucose and free fatty
       acids
  • ↑ Inflammatory Cytokines: TNF, IL 1, IL-6
     – PMN release and degranulation  Mucosal permeability
       hormones and mediators ↑ release of
 Stress
  cAMP which down-regulate lymphoid
  immune activity
              Acute Stress
 NPO   state starves gut mucosa
  • Gut mass  50% in 7 days of fasting
  • Gut contains 80% of body’s immune tissue
     – “GALT and MALT”
  • Intestinal sIgA ↓ in 5 days
  • ↑ Th1 pro-inflammatory lymphocytes
 Major   stress doubles protein turnover
  • Skeletal muscle cannibalized for fuel for
    enterocytes (glutamine)
                     Stechmiller JK, Am J Crit Care, 1997
Bacterial Translocation
   Disruption of mucosal
    barrier
    • Ischemia-reperfusion during
      shock  risk of ulceration
      and  permeability
   Bacterial translocation
    • Culture(-), found bacterial
      DNA in blood stream
   Cytokine amplification
    in lymphatics and liver
        Bacterial Translocation
 Enteral nutrition can              prevent translocation
   • Trophic feeds stimulate gut hormones and nourish
     mucosa, increase blood flow, re-energize tight
     junctions, improve brush border
   • Enteral vs. Parenteral feeds -  postop septic related
     complications
             stimulate Th2 lymphocytes which
 Enteral feeds
   PMN adhesion in lung
Deitch EA, Ann Surg, 1987, 1990;Border JR, AnnSurg, 1987; Carrico CJ, Arch Surg,
1986; Alverdy JC, Surgery, 1988; Moore J, JPEN, 1991,Kudsk,Am J Surg, 2002
           WHY ?
Is nutrition such a big deal?

     Malnutrition Prevalence
   Nutrition Status and Outcomes
    Gut Bacterial Translocation
        Malnutrition Prevalence
 15    to 50 % of hospitalized pediatric
     inpatients are malnourished on
     presentation (down from 35-65%)
      • 15 to 20 % of critically ill patients
      • 33% patients with congenital heart disease
      • 39% awaiting elective surgery

Parsons, AJCN,1980; Mize, Nutr Supt Ser, 1984; Merritt, Am J Clin Nutr, 1979, Huddleston
KC, CC Clin of NA, 1993, Cameron, Arch Ped 1995, Cooper, J Ped Surg 1981
       Malnutrition Snapshot
 Inpatient populationof Boston Children’s
  Hospital was surveyed Sept 24,1992
  • 268 children ages 0-18 years
 Using   Waterlow criteria:
  • 25% were acutely malnourished, 27% were
    chronically malnourished
 Of 17 ICU patients, 4 (24%) were classified
  with severe PEM
                            Hendricks, Arch Ped Adol Med, 1995
     Nutrition and Outcome
                 State of nutrition vs. LOS and Cost

18
                                       $16,691
16
14
12                  $14,118
10   $7,692
 8
 6
 4
 2
 0
        Normal         Borderline       Malnourished
                                            Robinson G, JPEN, 1987
        Nutrition and Outcome
Low Prealbumin 95%                         20
  specific, in 147                         18
                                           16
  consecutive admissions                   14
                                           12                                     PCM
8 measures of malnutrition                 10                                     No PCM
  in 134 patients                           8                                     PCM*
                                            6                                     No PCM*
50 cardiac surgery patients                 4
  assessed                                  2
                                            0
    • Low Prealbumin                                LOS          Mortality (%)
      predictive post-op
      infectious complication
Potter, Clin Invest Med, 1999; Weinsier,Am J Clin Nut, 2005 Leite, Rev Paul Med, 1995
Parameter Low Risk High Risk
Hosp. Days   7        13.5
Mech. Vent.  0         8.5
NPO days     3         8.5
Days on O2   4         20
                    P< 0.02

Nutrition Screen predictive of outcome
in 25 RSV PICU admits
                       Mezoff, Pediatrics, 1996
       Nutrition and Outcome
 60 PICU patients had nutrition status
  evaluated, with PSI, and TISS applied
 Acute PEM associated (P<0.01) with 
  physiologic instability,  mortality and 
  quantity of care
 Malnutrition can result in delayed wound
  healing, respiratory failure, increased
  potential for infection, death
                            Pollack MM, JPEN, 1985
Nutrition and Outcome
  Ventilator      Weaned Died
  Patients:
 No Specific
Nutrition Plan      18         15
   Focused
Nutrtional Care     13          1

                  Bassili HR, JPEN,1980
  Nutrition and Outcome
PICU  Outcomes in 323 patients after
 Nutrition support team instituted
  • Use of Enteral nutrition (EN) in medical
    patients increased 25% to 67%
Mortality risk decreased 83% for those
 receiving EN >50% of LOS
  • EN independent predictor of survival in
    multiple regression analysis.
                               Gurgueira, JPEN, 2005
  WHO ?
Needs to know?
Gets assessed?

ALL Physicians!
 ALL Patients!
        Nutrition Dichotomy
79    FP residents
    • Nutrition Interest (72.2%) vs. Perceived
      Knowledge
       – Parenteral and enteral nutrition 34.2%, Infant
         nutrition 27.5 %, Nutrition assessment 17.7%
   3416 Primary Care physicians
    • < 40% practiced what they preached
Lasswell AB, J of Med Ed, 1984, Levine BS, Am J Clin Nut, 1993
Nutrition Practice: Uphill battle
Adult ICU group found their patients only
 received 52% of goal calories
 • Reasons included physician under ordering,
   frequent cessations, and slow advancement
Designed   a protocol but only 58% went
 on it
                               Spain, JPEN, 1999
I wonder if I’m
missing out on
  some critical
    piece of
  information
           Nutrition Screen
Should  be completed within 24 hours of
 admission
High risk surgical patients should be
 screened weeks to months ahead of
 planned surgery         In your continuity clinic
  • Multidisciplinary team
  • Supplement , reassess, or reschedule
        Nutritionally-at-risk
 Weight for age < 10th % tile
 Weight for Height < 10th % tile
 Acute weight loss > 5% over 1 month or >10% total
 Birth weight < 2 SD below mean for gestational age
 Increased metabolic requirements 2 chronic disease
 Impaired ability to ingest or tolerate oral feeds
 Weight % tile crossing 2 contour lines over time
  (FTT)
             Prealbumin
Transthyretin   has nothing to do with
 albumin
  • Small body pool and half life of 2 days
    makes prealbumin an reasonable monitor of
    visceral protein homeostasis
Drops  during the first 3-5 days of stress
 it should rise thereafter
 Daily rise of 1mg/dl indicates anabolism
Plasma Protein Stress Response
                    CRP




                           Prealbumin
              Fleck, A. Br J Clin Pract, 1988
      Prealbumin as a predictor
   Surgically stressed           Infants
      • Prolonged ↑ CRP with ↓ Prealbumin had ↑
        mortality
          – Strongest predictor POD#5 prealbumin depression
   Prealbumin ideal           nutrition screen for:
      • 50 children with solid tumors
          – before and during chemo
      • 86 Adult post-op patients requiring TPN

Chwals WJ, Surg Clin NA, 1992, Elhasid, Cancer, 1999, Erstad, Pharmaco, 1994
            Prealbumin
Measure   twice weekly
Once 65% of needs met expect levels
 to rise 1mg/dl a day
 If weekly rise is less than 4mg/dl
  • check N2 balance and CRP to determine
    if cause is nutritional inadequacy or
    ongoing SIRS
                      Expert roundtable, 10th World
                      Congress of Gastroenterolgy
        WHEN?
     Should I start?


Early Enteral vs Standard timing
    Enteral Contraindications
 Intubation/extubation planned within 4°
 Hemodynamic instability requiring
 escalation in therapy
 Intestinal obstruction
 Massive UGI bleed
 Gut ischemia
 I’m nervous about this kid
       Early feeds vs. Standard
Adults  with gut malignancies and
 neurotrauma has shorter LOS and fewer
 infections when fed early
19 controlled studies (24° vs 3-5 days)
   • 16/19 studies showed improved outcome
   • Improved healing,  complications and LOS
   • Recommended for critically ill surgical pts
Braga, CCM, 2001 Grahm T, Neurosurgery, 1989 Taylor, CCM 1999 Heyland
DK, CC Clin of NA, 1998 Zaloga. CCM 1999
    Early feeds: Pediatrics
 Tolerated pediatric burn   patients
 42 ventilated children (76% on vasoactive
  meds)
   • Transpyloric feeding tubes placed at bedside
   • 74% of patients reached full feeds within 24
     hrs, rest within 48 hrs
     – No complications
              Chellis MJ, JPEN, 1996, Trocki, Burns, 1995
         All is Not Rosy
 AllMechanical Ventilated patients
 Lots of exclusions
 Group Early (75) Late (75)           p
   VAP        49.3%     30.7%        .02
  C diff      13.3%     4.0%        .042
ICU stay 13.6± 14.2 9.8 ± 7.4       .043
Mortality      20%      26.7%       .334
                             Ibraham, JPEN, 2002
        WHERE?
In the gut do I put the food?



     Oral vs.Tube feeding
   Gastric vs. Transpyloric feeds
Tube Feeding Considerations
 Nutritionally-at-risk with inadequate
 oral intake for the past 3-5 days.
 Meeting <50% estimated needs orally
 for previous 7-10 days.
    • Shorten to 3-5 days if traumatized or
      severely catabolic
Disease     state preventing adequate P.O.
    intake for >5 days
        Gastric vs. Transpyloric
 No  aspiration difference in 54 patients receiving
  gastric vs transpyloric radiolabeled feeds
 33 mechanicaly ventilated  Micro-aspiration
  7.5 >> 3.9% in NJ fed patients
 80 adult trauma victims
   • Duodenally fed patients reached goal calories 34 vs.
     44 hours with had less pneumonia 27% vs 42%*
 80   ventilated adults randomized
   • gastric feeds + E-mycin 200 mg q8 (55% / 74%)
   • Transpyloric feeds (44% / 67%)
Esparza, Intens C Med, 2001,Kortbeek, J Trauma, 1999, Heyland, CCM, 2001, Boivin, CCM, 2001
          Transpyloric
59 ventilated children randomized to
 receive continuous or interrupted
 transpyloric feeds during the day
 before and of extubation
 • Continuous group got >90% goal calories
   both day vs 73% and 46%
 • No aspiration events or difference in
   adverse events
                             Lyons, JPEN, 2002
Neuromuscular blockade and ECMO?
 May  decreased REE by 10-15 %
 Primary Neurotransmitter in Gut is VIP not
  acetylcholine
  • Neuromuscular blockade work via AcH receptors
 By what mechanism do neuromuscularly
  blocked patients become intolerant of enteral
  feeds?
  • Gastric atony 2° Benzodiazepines and narcotics
 Enteral feeds for Pediatric ECMO patients is
  safe with trends toward improved survival
                                    Pettignano, CCM, 1998
                 Enteral Pitfalls
2adult studies with 95 ICU pts, had 66%-78% of
 goal feeds prescribed, 52%- 71% delivered
 • Gastric Intolerance (Residuals #1)
     – BZD and Narcs effect stomach > intestine
 • Airway management
     – 22/26 PICU pts had feeds held for extubation that only 5 got
 • Diagnostic procedures
     – Some ventilated patients fed right up to OR
                             McClave SA, CCM, 1999,DeJonghe, CCM,
                             2001, Fry-Brower +McCunn, CCM(a), 2002,
        WHAT?
Amount of calories do I Feed
          Them?


       How much to feed
         Trophic feeds
      Enteral vs. Parenteral
          Lipid phobia
             Caloric Goals?
BrazilianPICU reviewed 37 charts
Only 3 had an assessment done in 425
 days
No Patient had caloric goals set
  • Only 29.7% met goals
  • 80.5 % fed Parenterally

                       Leite, Rev Assoc Med Bras, 1996
Steady State Energy Requirements

                          120


                          100                                                Activity
  Calories per Kilogram




                                                                             Growth
                           80                                                BMR


                           60


                           40


                           20


                            0
                                0   1   2   3   4   5   6    7 8 9 10 11 12 13 14 15 16
                                                            Age in Years
     Energy Requirements
 Calorie needs change during the course of the
  hospitalization.
  • Hemodynamically unstable?
  • Ventilated vs Extubated
 Ebb  phase (Hypometabolic): obligate (–)
  nitrogen balance during acute critical illness
  • No need for growth calories (BMR may suffice?)
  • Watch out for overfeeding
     – Steatosis, Hyperglycemia, Hypertriglyceridemia
        Therapeutic window
 187   critically ill adults >96º in ICU
  • Tertiles of % ACCP recommended caloric intake
 Patients receiving 33-65% goal     Vs. <33%
  (18kcal/kg)
  • OR survival 1.22, discharge without sepsis 1.2,
    without vent 1.8
  • Patients > 65% goal OR 0.82, 0.75, 0.69
 Sickest   patients (SAPS>50)
  • Did worse when they received >33% goal
                                       Krishnan, Chest, 2003
      Energy Requirements
   Flow phase (Hypermetabolic)
    • As the child improves and becomes
      anabolic, calorie needs for growth and
      activity must be included
Underestimating       needs can increase
    risk for infection, poor wound healing,
    poor growth, and overall poor outcome
      Energy Requirements
12   Septic and 12 Traumatized patients
  • Total energy expenditure and REE
    measured for 2 separate 5-day periods
  • TEE Sepsis 25kcal/kg >>> 47kcal/kg
  • TEE Trauma 31kcal/kg >>> 59kcal/kg
Second   week TEE: indirect calorimetry
 X1.8
TEE remained elevated for weeks
                                Uehara, CCM,1999
1º Fever
 ↑12%
            Trophic Feeds
 Rats fed 15% calories enterally had 
  permeability and bacterial translocation
 10 post-op infants fed trophically (21cal/kg/d)
  had improved Staph killing vs TPN alone
  • 37% vs. 52% vs. 65% (Controls)
     – Related to production of TNFα
>  6kcal/kg (>25% ACCP cal goals) in 138
  adult MICU patients reduced BSI (relative
  hazard 0.24)
            Omura, Ann Surg, 2000, Okada, J Ped Surg, Robinson,CCM, 2004
              Trophic feeds
Feed type # Patients Mortality                   SMR
 Enteral           167            25%             .71
Parenteral          26            54%             1.4
Parenteral          24            38%              .9
+ Trickle
Trophic feeds are stress ulcer and antibiotic prophylaxis
rolled into one
                                          Marik, CCM(a), 2002
      Trophic Feeds Vs. TPN
100
                                                             92.4
 90
 80
 70                                                   70.3
 60
 50
 40                                           36.1
                              32.6
 30                                    24.8
                20.2   20.6
 20      14.1
 10
  0
      Assisted Vent     PN           Full Enteral      Hosp.
                                                     Discharge
                                McClure RJ, Arch Dis child , 2000
          Enteral Feeds vs. TPN
 Enteral          feeds in Critically ill population
      • improve wound healing,  mucosal
        permeability
 > 10 studies show enteral feeds are safe,
  feasible and cheaper than TPN
 Meta analysis adult ICU patients Enteral
  feeds vs. TPN RR infection 0.66
Schroeder D, JPEN, 1991, Hadfield R, Am J Resp Crit Care Med, 1995 Robert Dimand, UC
Davis, Peds CC Update 2002, Gramlich, Nutrition, 2004
                  TPN vs. Hope
 Meta     Analysis 26 studies (210 reviewed)
    • 2211 patients
    • Trend toward reduced complications in TPN
      patients (risk ratio 0.84)
4    studies used TPN > 3 weeks
    • Mortality in TPN pts was 6.8% vs. 12.4%
 Meta     Analysis 11 studies
    • Parenteral nutrition vs. delayed enteral improved
      mortality
    • Increased infectious risk (OR 1.65 CI1.1-2,5) in
      PN vs. all enteral
Heyland DK, JAMA, 1999, Simpson, Int Care Med, 2005, Doig, CCM(A) 2005
 Parenteral Considerations
Nutritionally-at-risk        patient with non-
 functional gut.
Adequate nutritional status on
 admission but non-functioning gut 3-5
 days after admission

       “The major advance in TPN since the
        1980’s is that it is not used as much”
              Lipid Phobia?
 When    infants given TPN without lipids
  • CHO only TPN resulted in  amino acid oxidation,
    proteolysis, CO2 production and  lipogenesis
 Lipid   requirements
  • Essential fatty acid (0.5gm/kg/d), Promote
    Nitrogen sparing, Increased lipid clearance during
    stress
 Balanced approach      to fulfilling energy
 requirements
                            Bresson, Am J Clin Nut 1991,Tilden,
                          AJDC, 1989, Schears, Crit Care Clin, 1997
                        Lipids
 Original 10%    lipid compounds
     – Intravenous fat emulsions contain 50-60% linoleic acid
       a precursor to arachidonic acid
     – May disturb balance between thromboxane and
       prostacyclin production
 Modern   20% emulsion cause less Trig 
  • Neonates clear better, less phospholipids
  • No problems with oxygenation when given as 18-
    24° infusion
  • No immune problems when Triglycerides <700
        Monitor Outcomes
 Residuals              Proper  wound
 Age appropriate         healing
  weight gain            Fluid and
 Diarrhea /              electrolyte balance
  Constipation           Euglycemia
 Medication             Improved N2
  Compatibility?          balance and
 Emesis / Aspiration     Prealbumin
HOPE IS NOT A METHOD!
Who?   Is you, screening all your patients
Why? They’ll do worse if you don’t
When? The sooner the better
What? Enteral better, even trophic
 better than TPN alone
Where? PO>NG>NJ > IV