Transcript Document

Nutrition in the critically-ill
Child. Past and Future.
Dr. Rainer Paulino Basulto. Msc
Dra.Mileidis Pupo Vera.
Dr. Willians Rios. I
Katima Mulilo. Caprivi Health Directorate.
Abstract
Enteral feeding is a commonly used form of nutritional supplementation for
patients with intestinal failure, both in hospitals and in the community. This article
concentrates on the basic principles of enteral feeding, including the physiological
effects of feeding into the intestinal tract. It covers the indications for enteral
feeding, the different methods of supplying enteral feeds to the gastrointestinal
tract, and the potential complications.
INTRODUCTION
Enteral nutrition consists of providing nutrients via the gastrointestinal tract. Although
the term technically refers to nutrition given either by mouth or through a feeding tube,
in common usage the term usually refers to tube feeding. In comparison to parenteral
nutrition (the provision of nutrients via a venous catheter directly into the bloodstream),
enteral nutrition offers several advantages, including lower costs, beneficial effects
from utilization of the gastrointestinal tract, and avoidance of the many potential
complications of parenteral nutrition.
Parental Nutrition
Enteral nutrition
The mucosal associated lymphoid tissues (MALT) are the
specific arm of the immune system which protects the
intestinal and extraintestinal external mucosal surfaces
through production and secretion of IgA. MALT contains 50%
of the body's total immune cell mass and produces more IgA
than all other antibodies combined.
•Short enteral fasting (3 days), causes gut
mucosal atrophy, expressed as a decrease in
villus height and crypt depth
Normal
Atrophy.
Mixed
infection.
Intestinal Failure (stress).
Bacterial Translocation.
Provide humoral protection as a frontline defense against pathogen borne in
aerosols, environment, and the diet.
CD4
Hypothesis
Critically ill children need enteral feeding for survival, so nutrition plays
an important role on the health and development of a critically ill child.
Scientific problem
COST.
Although enteral nutrition therapy is more costly than standard feeds, compared to
parenteral nutrition therapy, enteral nutrition is approximately two- to fourfold
cheaper on an inpatient or out-patient basis. Based on US Medicare charges, the
annual cost of providing enteral nutrition per patient is approximately US$9,605
US$9,327 compared with US$55,193. US$30,596 for parenteral solu-tions.4 In
addition, the frequency and cost of hospitalization is higher for patients supported on
parenteral nutrition therapy compared with enteral nutrition therapy
Cheap
Objective.
1.To evaluate those factors that impact on the
delivery of enteral tube feeding.
Method
Prospective studies With
transversal curt.
In 33 patient with
Severe dehydration,
Severe malnutrition,
Severe Sepsis.
Severe Malaria.
prematurity
Bolus feeding(without
pump)
Bolus feeding involves the delivery
of 10mls to 30mls over a period of
10-30minutes and can be given 46 times a day depending on
patients individual feeding regime.
Administration can be with a
syringe using only the barrel as a
funnel to allow the feed to infuse
using gravity.
Result. Table 1
Age distribution
Age
Number
Percent.
1m - 1y.
9
27.2
1y - 2y
11
33.3
2 -
8
24.2
5
15.1
>5Y
5y
Result. Table 2.Distribution according to diagnosis
Diagnosis.
Number
Percent.
Severe
malnutrition
11
47.8
Severe Sepsis
8
34.7
Acute
7
gastroenteritis with
severe
dehydration.
17.3
Cerebral malaria
3
9
Prematurity New
born
4
12.1
Table.3 Feeding Used.
Feeding used
number
percent
Milk
16
69.5
Pediasure and
Milk
11
47.8
Resomal
12
52.1
ORS
2
8.6
Juice
18
78.2
Hyper caloric food
24
72.7
Table. 4 Physiological effects of feeding into the intestinal tract
Physiological
effects
Became down 72h After 72 h
Fever behavior
28 / 84.8.%
90
80
70
60
50
40
30
20
10
0
Category 1
Category 2
5 / 15.1%
Table. 5 Physiological effects of feeding into the intestinal tract. Hemodynamic
Parameter.
Physiological
effects
Getting normal
72h
After 72 h
HR
29 / 87.8%
4 / 12.1%
BP
31 / 93.9%
2 / 6%
Neurological
condition
28/ 84.8%
5/ 15.1 %
Table 6.Physiological effects of feeding into the intestinal tract. General condition.
General condition
Improving 72h
After 72 h
Good external
connection
29 / 87.8%
4 / 12.1%
100
90
80
70
60
50
40
30
20
10
0
Category 1
Category 2
Table 7. Physiological effects of feeding into the intestinal tract. Metabolic control.
Metabolic control
First 72h
After 72 h
Hypo glycaemia
1 / 4.3%
0
hyper glycaemia
5 / 21.7%
2 / 8.6%
25
20
15
10
5
0
Category 1 Category 2
Table 8. Physiological effects of feeding into the intestinal tract
Physiological
effects
< 36 c
> 36 c
Temperature
management
2/6%
31 / 93.9%
Table 9.Physiological effects of feeding into the intestinal tract. Weigh behavior
.
Physiological
effects
Weigh gain first
72h
Weigh loss first
72h
Weigh behavior
19/57.5%
14/42.4%
20
15
10
5
0
Category 1
Category 2
Table.10.Gastrointestinal complications in critically ill
children with enteral tube nutrition
Complication.
Number
percent
Abdominal
distension
5
15.1%
Gastro intestinal
bleeding.
0
0
Duodenal
perforation
0
0
Tube occlusion.
2
3%
Pulmonary
aspiration
0
0
Accidental tube
removal
3
9%
Table 11. Mortality rate.
Diagnosis.
Number
Percent
Severe
Malnutrition.
1
3.03%
Severe Sepsis.
2
6.06%
1
3.03%
Acute
gastroenteritis with
severe
dehydration.
Cerebral malaria
Prematurity
Conclusions.
Early enteral feedings are feasible, well tolerated, and cost effective in critically
ill pediatric patients.
WHEN THE ENTERAL
ROUTE IS AVAILABLE
USE IT !
REFERENCES
1. Harkness L. The history of enteral nutrition therapy: From raw eggs and nasal tubes
to purifi ed amino acids and early post-operative jejunal delivery. J Am Diet Assoc
2002;102:399–404.
2. Braga M, Gianotti L, Gentilini O, et al. Early postopera-tive enteral nutrition improves
gut oxygenation and reduces costs compared with total parenteral nutrition. Crit
Care Med 2001;29:242–8.
3. de Lucas C, Moreno M, Lopez-Herce J, et al. Transpyloric enteral nutrition reduces
the complication rate and cost in the critically ill child. J Pediatr Gastroenterol Nutr
2000;30:175–80.
4. Reddy P, Malone M. Cost and outcome analysis of home par-enteral and enteral
nutrition. JPEN J Parenter Enteral Nutr 1998;22:302–10.
5. North American Home Parenteral and Enteral Nutrition Patient Registry. Annual report
with outcome profi les 1985–1992. Albany, NY: Oley Foundation; 1994.
6. Howard L, Ament M, Fleming CR, et al. Current use and clinical outcome of home
parenteral and enteral nutri-tion therapies in the United States. Gastroenterology
1995;109:355–65.
7. Board of Directors and Clinical Guidelines Task Force, American Society for Parenteral
and Enteral Nutrition. Guidelines for the use of parenteral and enteral nutrition in adults
and pediatric patients. JPEN J Parenter Enteral Nutr 2002;26:18SA–9SA.
8. Braunschweig CL, Levy P, Sheean PM, et al. Enteral com-pared with parenteral
nutrition: A meta-analysis. Am J Clin Nutr 2001;74:534–42