feeding the critically ill child -...
TRANSCRIPT
Lee Jan Hau, MBBS, MRCPCH, MCI
Children’s Intensive Care Unit
September 2018
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Feeding the
critically ill child
Khaw Sia (1913 – 1984)
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No disclosures
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Outline
• Is there a need to optimize enteral nutrition?
• Challenges in PICU nutritional practices
• Current evidence for best practices in PICU nutrition
• Concluding remarks
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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
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Mehta et al. JPEN J Parenter Enteral Nutrition 2009
Mueller et al. JPEN J Parenter Enteral Nutrition 2011
Metha et al. Crit Care Med 2012
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Metha et al. Crit Care Med 2012
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Metha et al. Am J Clin Nutr 2015
Impact of Protein Inadequacy
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Wong et al. JPEN 2016
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Wong et al. JPEN 2016
After adjusting for severity illness scores, oxygenation
index, presence of comorbidities, inadequate protein
intake was associated with mortality
The New Power Couple
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Protein + Energy
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
• 74 children [median: 21 (4-35) months]
– 54 patients had surgical diagnoses
• 402 measurements of total urinary nitrogen and
resting energy expenditure
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Chaparro et al. Nutr Clin 2016
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Chaparro et al. Nutr Clin 2016
Nitrogen balance was achieved
with 1.5 (95% CI: 1.4 – 1.6)
g/kg/day
Energy balance was achieved
with 58 (95% CI: 53 – 63)
kcal/kg/day
Outline
• Is there a need to optimize enteral nutrition?
• Challenges in PICU nutritional practices
• Current evidence for best practices in PICU nutrition
• Future directions
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Heterogeneity in the PICU
• Patients
o Background nutrition status
• Case mix
o Type of cases
• Manpower
oNumber of doctors, nurses and dieticians
• Resources
o Equipment, assess to specialized formulas
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Leong et al. Ped Crit Care Med 2014
• 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
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Metha et al. Crit Care Med 2012
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• 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
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Kerklaan et al. Ped Crit Care Med 2016
• 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
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
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Protein Homeostasis During Critical
Illness
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Coss-Bu et al. Nutr Clin Pract 2017
Protein Synthesis
Protein Catabolism
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
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Ong C et al. Clin Nutr 2014
Coss-Bu et al. Nutr Clin Pract 2017
Outline
• Is there a need to optimize enteral nutrition?
• Challenges in PICU nutritional practices
• Current evidence for best practices in PICU nutrition
• Concluding remarks
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Potential Solutions
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Patients
Manpower
Resources
Case Mix
Stratified
Approach
Protocols
Identify
Unique
Challenges
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Wong et al. J Parenter Enteral Nutrition 2014
PubMed 159
citations
Cochrane101
citations
CINAHL 189
citations
EMBASE 427
citations
854 non duplicate citations screened 742 citations excluded after
screening the title and abstract
112 citations retrieved 46 questionnaires/survey,
reviews, clinical guidelines, letters, commentaries or
teaching modules
9 studies included
21 did not utilise feeding protocols or did not report
outcomes of interest
36 studies involved exclusively adults or premature neonates
Improvement in
time of initiation
and achievement
of goal feeds
Reduction in
infective and
gastrointestinal
complications
Stratified Approach
• Congenital heart disease
• Extra-corporeal membrane oxygenation
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Congenital Heart Disease: Factors
Influencing Energy Expenditure
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Wong et al. World Journal for Pediatric and Congenital Heart Surgery 2015
Be careful of overfeeding in the
postoperative period
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Metha et al. Journal of Parenteral and Enteral Nutrition 2012
Post-operative
Fontan’s surgery
Congenital Heart Disease: Energy
Expenditure after CPB
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Metha et al. Journal of Parenteral and Enteral Nutrition 2012
Barriers and Strategies to Optimize Nutrition
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Wong et al. World Journal for Pediatric and Congenital Heart Surgery 2015
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
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• 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
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Desmarais et al. Journal of Pediatric Surgery 2015
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
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Patients’ Characteristics
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Variables Non-survivors (n=28) Survivors (n=23) p-value
Age at start of ECMO, years 1.33 (0.45 – 6.19) 5.82 (1.51 – 10.47) 0.051
Male gender, n (%) 15 (53.6) 9 (39.1) 0.304
Weight at start of ECMO, kg 8.0 (5.0 – 16.8) 20.0 (10.0 – 25.0) 0.062
Primary indication for ECMO, n (%)
0.216
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) 0.281
Maximum number of inotropes/
vasopressor drugs required on ECMO 3 (2 – 5) 2 (1 – 3) 0.007
Vasopressor-inotropic score before start
of ECMO 20.0 (0.75 – 55.2) 14.0 (0 – 20.0) 0.155
ECMO duration, days 13.4 (7.0 – 19.5) 7.1 (4.7 – 8.7) 0.010
ICU LOS, days 19.3 (10.1 – 40.1) 15.2 (10.1 – 24.3) 0.642
Hospital LOS, days 22.5 (14.5 – 45.8) 29.0 (25.0 – 49.0) 0.125
Ong et al. Clinical Nutrition ESPEN 2018
Nutritional Adequacy
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Variables Non-survivors (n=28) Survivors (n=23) p value
Initiated EN in first 7d, n (%) 17 (60.7) 16 (69.6) 0.510
Time EN initiated after ECMO started, hours 49.6 (39.4 – 82.7) 36.8 (26.2 – 46.4) 0.028
Energy intake on ECMO, kcal/kg/d 23.2 (16.0 – 35.9) 23.9 (15.6 – 38.4) 0.719
Protein intake on ECMO, kcal/kg/d 0.80 (0.43 – 1.38) 0.80 (0.50 – 1.20) 0.798
Adequacy of total energy intake, % a 45.3 (23.1 – 59.3) 50.2 (35.8 – 70.5) 0.233
Adequacy of total protein intake, % a 43.0 (26.2 – 69.3) 50.6 (29.8 – 67.0) 0.705
Adequacy of EN energy intake, % a 0.5 (0 – 4.4) 11.8 (0 – 24.5) 0.034
Adequacy of PN energy intake, % a 44.2 (22.8 – 50.1) 37.6 (19.1 – 53.4) 0.596
Adequacy of EN protein intake, % a 0.1 (0 – 3.5) 6.3 (0 – 18.9) 0.065
Adequacy of PN protein intake, % a 40.7 (25.7 – 66.3) 40.6 (9.7 – 52.8) 0.495
Achieved 80% energy requirements by day 3, n (%) 5 (17.9) 8 (34.8) 0.168
Achieved 80% protein requirements by day 3, n (%) 6 (21.4) 4 (17.4) 1.000
a adequacy = total intake versus requirements over 7 days, expressed as a percentage
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 (0.86 – 0.99)]
Ong et al. Clinical Nutrition ESPEN 2018
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
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Chuah Thean Teng (1914 – 2008)
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Thank you [email protected]