Transcript ICU Nutrition RXH Jan 2010

Feeding the critically ill
infant and child
By : Shihaam Cader
Principal Dietitian [HOD]
Red Cross Children's
Hospital
By : Prof A Argent
Head PICU
Red Cross Children's
Hospital
By : Dr L Goddard
GIT Consultant
Red Cross Children's
Hospital
Red Cross Childrens Hospital : Refresher Course Feb 2010
Introduction
• Nutrition is an essential part of the treatment and
management of critically ill infants and children
• Its benefits include maintaining vital body
functions, reducing the effects of catabolism
• And reducing morbidity, mortality and length of
hospital stay
Red Cross Childrens Hospital : Refresher Course Feb 2010
Introduction
•Optimal nutrition is challenging task since, age, type
of diagnosis, injury & individual metabolic response
may vary between patients
•Basic concepts of managing these patients needs to
be highlighted for optimal nutrition therapy
• Main areas are:
•Early enteral feeding
• Calories needed for critically ill
• Ways to overcome barriers related to nutrition
therapy
Red Cross Childrens Hospital : Refresher Course Feb 2010
An approach
to feeding the
critically ill infant & child
Red Cross Childrens Hospital : Refresher Course Feb 2010
Feed protocol
• Studies have shown that feeding protocols may
assist in achieving optimal nutritional care
• Using standardized feeding protocol, will alleviate
some of the barriers
• Feeding protocol development should be multidisciplinary including dietitians, nursing, medical
team
Red Cross Childrens Hospital : Refresher Course Feb 2010
Enteral Feeding protocol
STEP 1
STEP 2
Nutritional assessment
Early Enteral Nutrition
ABCD approach
Initiate within 24 hours
STEP 3
Type & rate of feeding
STEP 4
Route of feeding
•Depends on age, nutritional
needs, fluid restrictions, disease
condition
•Naso/oro-gastric feeding
•Nasojejenal feeding
STEP 5
STEP 6
Monitoring tolerance of
feeding
Managing the barriers to feeding
•Input
•GI disturbances: vomiting, stools, NGA
•Output: vomiting, stools, NGA
•Fluid restrictions
•Interruptions to feeding & calorie deficits
•Other: abdominal distention
Total Parenteral Nutrition
Only considered if all the above steps have failed and not able to achieve
enteral nutrition by day 3-5 of NPM
Red Cross Childrens Hospital : Refresher Course Feb 2010
Enteral Feeding protocol
STEP 1
Nutritional assessment
ABCD approach
Red Cross Childrens Hospital : Refresher Course Feb 2010
Nutrition Assessment
ABCD approach
Anthropometry
Weight, length, classifications, growth charts, NRS
•
Biochemistry/Special Investigations
Electrolytes, CMP, hemoglobin, etc
•FOG,Fecal elastase, alpha1 antitrypsin, etc
•
Clinical Considerations
Disease specific nutritional management
•
Dietary Assessment
Diet history
•Energy and protein requirements
•Choosing appropriate feeds
•
Determining the route of feeding
•
Red Cross Childrens Hospital : Refresher Course Feb 2010
Anthropometry
• Difficult to assess accurate growth
parameters or trends in ICU setting
• However basics still needs to be
evaluated:
• Weight
•Height or length
• Growth charts
•Other measurements done when
weight is not a true reflection eg.
MUAC -not affected by edema
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Growth charts used to
classify patients, eg,
wasting and stunting,
acute or chronic
malnutrition
Growth trends
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Biochemistry
• Abnormal growth factors needs monitoring and
restored
• If they are abnormal, growth and development is not
possible no matter how much calories are provided
• Growth factors are:
PHOSPHATE
SODIUM
CALCIUM
MAGNESIUM
POTASSIUM
Red Cross Childrens Hospital : Refresher Course Feb 2010
HEMOGLOBIN
Biochemistry
•Albumin: Poor marker of nutrition & rather prognostic indicator
• Most abundant plasma protein with MW of 65 kDa, synthesized
by liver
•Half - life of 20 days
• Many other causes for hypoalbuminemia:
• Decreased synthesis or increase losses
• Dilutional - fluid retention, edema
• Increased catabolism of albumin - sepsis, acute phase
response
•Lactate: indicator of tissue perfusion
•Prealbumin and CRP:
•Prealbumin has a half-life of 24-48 hours
• Prealbumin + CRP are inversely related
[ASPEN 2009]
• Increase CRP + decrease Prealbumin = acute phase
Nutrition 2009 (25)1004-1005
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Clinical assessment/diagnosis
• Assessing the patients body for any signs of
nutritional deficiencies, such as sparse hair, wasting,
etc
•Diagnosis plays a large part on the type of nutritional
regime required, such as :
Liver disease
Renal disease
Chronic lung disease
Critically ill
Metabolic disorders
Cardiac disease
Burns
Severe malnutrition
Red Cross Childrens Hospital : Refresher Course Feb 2010
Dietary assessment and management
•Once the nutritional status and clinical diagnosis is
determined, a dietary plan is prescribed for the
medical team
•Dietary plan includes:
•Calories and protein required
•Type of feed
•Rate / volume of feed
• Route of feed
Enterally OR Parenterally
Orally OR Nasogastric OR
Nasojejenally OR Gastrostomy
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Energy
• Gold standard of determining energy expenditure is
with the use of indirect calorimeter
• Predictive equations are used for practical reasons –
but needs to be noted to either under or over estimate
• Energy needs are lower during acute phase and
increases when in the recovery phase
• Overfeeding is found to be as detrimental as
underfeeding
•Excess CHO – lipogenesis, hyperglycemia, prolongs
duration of mechanical ventilation & hospital stay
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Protein
• Adequate protein needed for lean body mass, wound
healing
• Those fed high protein [~2,8g/kg] had positive protein
balance and lower protein oxidation compared to those fed
1.7g/kg
• Infants need:
•7.5 -12% of energy for protein
• Childrens need:
• 5 – 15% energy for protein
Catch – up growth
• 9% protein and adequate micronutrients required
J Hum Nutr Diet 2007;20:329
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Additional nutrients...
• Thamine – deficient in malnourished patient
• Folate – anemia and antioxidant properties
•Zinc
• required for protein metabolism, wound healing,
immune function, antioxidant properties
• involved in many enzyme functions
•Particularly given to malnourished patients, burns,
diarrhea
Red Cross Childrens Hospital : Refresher Course Feb 2010
Enteral Feeding protocol
STEP 1
STEP 2
Nutritional assessment
Early Enteral Nutrition
ABCD approach
Initiate within 24 hours
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Early enteral nutrition
• Initiate enteral nutrition within 24 hours once hemodynamically
stable
• Feeding started after 72 hours has shown increase risk of gut
permeability, bacterial translocation and increased inflammatory
response
•
•
•
•
•
• The initiation of Early enteral nutrition- unless:
Patient is unstable requiring frequent resusc. or vasopressor
manipulation
Patient will be orally fed within next 24 hours
Anticipated extubation or intubation in next 6 hours
Patient is NPO for a procedure
There is a contra indication for feeds
Red Cross Childrens Hospital : Refresher Course Feb 2010
Enteral Feeding protocol
STEP 1
Nutritional assessment
ABCD approach
STEP 2
Early Enteral Nutrition
Initiate within 24 hours
STEP 3
Type & rate of feeding
•Depends on age, nutritional
needs, fluid restrictions, disease
condition
Red Cross Childrens Hospital : Refresher Course Feb 2010
Types and rate of feeding
Rate of feeding
• Enteral feeding is recommended to maintain gut
integrity
•Depending on age/size of infant and child, initiate
starting rate
• 50 -60% of maintenance volume for age
• Goal of feeding to be achieved within 2-3 days
If the gut is working enteral feeding rate need NOT be
cautiously introduced UNLESS there has been a surgical
procedure or the patient is shocked
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Types of feeds: Infants
Breastfeeding
• Complete with all the nutrients needed to ensure
good growth.
• Has growth factors suitable for bowel adaptation
• Easily digested.
• Protective factors against common infections.
• Improves cognitive development
• Safe and clean
• and FREE.
• Bonding
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Types of feeds: Infants
Expressed breastmilk
• Should be included in the protocol
• Moms should shown how to express and provided
with cups or bottles needed to express into
• Encouragement is needed and reassured that
frequent times of expressing will increase their
supply
• Small amounts of EBM to placed into mouth for
comfort
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Alternative to breastfeeding
Types of enteral nutrition [infants & children]:
1. Standard infant formula
2. Energy dense formula,
3. Soya based formula,
4. Hydrolysed formula [peptide based]
5. Amino acid based
6. Specialized products, eg, for management of
chylothorax
All these products needs to administered in safest
way due to the risk of bacterial contamination...
Red Cross Childrens Hospital : Refresher Course Feb 2010
Closed enteral feeding system
• Recommended for institutions with patients who
are critically ill , immuno-compromised
• Increased risk of bacterial contamination of
powdered milk products if not prepared and
handled correctly
• Benefits other than safety include:
• Quality of product
• No labour required – ready available
Red Cross Childrens Hospital : Refresher Course Feb 2010
Types of enteral nutrition available
Infant products [0-1 year]
1. Standard infant formula
• complete polymeric
•67kcal/ml and 1.5g protein/100ml
2. Energy dense formula,
• complete feed
•1.0kcal/ml and 2.6g protein / 100ml
3. Soya based formula,
• complete lactose free, 67kcal/ml and 1.6g protein /
100ml
4. Hydrolysed formula [peptide based + LCT + MCT]
5. Amino acid based [+LCT]
6. Specialized products, eg, for management of chylothorax
Red Cross Childrens Hospital : Refresher Course Feb 2010
Types of enteral nutrition available
Pediatric products [1-10 year]
1. Standard infant formula
• complete polymeric, usually with soluble fibre
•1.0kcal/ml and 2.8 - 3g protein/100ml
2. Energy dense formula,
• complete feed
•1.5kcal/ml and 3.8g protein / 100ml
3. Hydrolysed formula [peptide based + LCT + MCT]
5. Amino acid based [+LCT]
6. Specialized products, eg, for management of chylothorax
Note: ALL pediatric products are lactose free
Red Cross Childrens Hospital : Refresher Course Feb 2010
Concentration of feeds...
1. Feed Supplementation can be requested when the calories
cannot be achieved because of fluid restrictions
• However maximum concentrations should not be exceeded, i.e:
• Carbohydrate concentrations [g/100ml]
• < 6 mths: 10 -12%
• 6-12 mths: 12- 15%
• 1-2 yrs: 15 – 20%
• children: 20 – 30%
•Fat concentrations [g/100ml]
• Infants: 5 – 6 %
• Children: 7%
Note: No supplementation is recommended if there is diarrhea
or any malabsorption
Red Cross Childrens Hospital : Refresher Course Feb 2010
Concentration of feeds...
Type of feed supplementation
• CHO
•glucose polymer – lesser osmotic effect than mono –
or disaccharides
•Added in increments of 1%
• Fat
• LCT – lower osmotic effect and source of EFAs
• MCT – only for fat malabsorption
• higher osmotic effect and can cause
abdominal cramps
Red Cross Childrens Hospital : Refresher Course Feb 2010
Enteral Feeding protocol
STEP 1
STEP 2
Nutritional assessment
Early Enteral Nutrition
ABCD approach
Initiate within 24 hours
STEP 3
Type & rate of feeding
•Depends on age, nutritional
needs, fluid restrictions, disease
condition
STEP 4
Route of feeding
•Naso/oro-gastric
feeding
•Nasojejenal feeding
Red Cross Childrens Hospital : Refresher Course Feb 2010
Route of feeding
Gastric feeding
• More physiological - Well tolerated , safe and easily placed
• However, due to GIT complications, small bowel feeding can
be considered
Small bowel feeding [jejenum]
• Tolerated in most patients in the ICU
•But not easy to site & requires AXR to ensure accurate
placement
• Also likely to be dislodged and blocked
• However, maintains adequate feeds by allowing less NPM
periods prior to any procedure, such as, surgery or extubation
Recommendations are to initiate gastric feeding first with transition
to jejenal feeding if the gastric route is not tolerated
Red Cross Childrens Hospital : Refresher Course Feb 2010
Route of feeding
Remember when using nasojejenal feeding:
• CAUTION: Use in preterms/neonates
• And cyanotic heart disease patients should not be
given NJT feeds due to risk of NEC [JPGN 2007]
• No bolus feeding can be administered
• No water solutions is advised via NJT [JPEN 2004;28;27]
Nutrition; 2007:23;16-22
Red Cross Childrens Hospital : Refresher Course Feb 2010
Route of feeding
Pro’s & Cons to both
– Often remains
preference of unit
Bolus
– More physiological
– However, ICU is not a
normal environment!
– Difficulties with
monitoring tolerance
– Requires additional
nursing time
Continuous
– Less time consuming
– Easier to monitor
– May delay gastric
emptying [adult ICU]
– May reduce gall bladder
contraction
Absence of consensus
– Adequate delivery of
nutrients should be
main goal
– This should not be
hampered by route
Shaw & Lawson 2007 3rd Ed
Red Cross Childrens Hospital : Refresher Course Feb 2010
Enteral Feeding protocol
STEP 1
STEP 2
Nutritional assessment
Early Enteral Nutrition
ABCD approach
Initiate within 24 hours
STEP 3
Type & rate of feeding
•Depends on age, nutritional
needs, fluid restrictions, disease
condition
STEP 4
Route of feeding
•Naso/oro-gastric
feeding
•Nasojejenal feeding
STEP 5
Monitoring tolerance of
feeding
•Input
•Output: vomiting, stools, NGA
•Other: abdominal distention
Red Cross Childrens Hospital : Refresher Course Feb 2010
Monitoring the tolerance of feeding
Common complications are:
1. Vomiting
• Prokinetic – erythromycin low dose 2 – 10mg/kg 6 hourly
• NJT
• Reflux - consider omeprazole
2. High gastric aspirates
• No actual reference values – except for any amount of greater than 50%
of volume administered in the previous 4 hours [Curr Opin Clin Nutr Met ab Care
2009]
3. Diarrhea
• Sepsis – related, antibiotic use
• If persists – investigate stool MC+S, reducing sub, Fecal omolar
gap
4. Constipation
5. Refeeding syndrome
Red Cross Childrens Hospital : Refresher Course Feb 2010
Enteral Feeding protocol
STEP 1
STEP 2
Nutritional assessment
Early Enteral Nutrition
ABCD approach
Initiate within 24 hours
STEP 3
Type & rate of feeding
•Depends on age, nutritional
needs, fluid restrictions, disease
condition
STEP 5
Monitoring tolerance of
feeding
•Input
•Output: vomiting, stools, NGA
•Other: abdominal distention
STEP 4
Route of feeding
•Naso/oro-gastric feeding
•Nasojejenal feeding
STEP 6
Managing the barriers to feeding
•Interruptions to feeding & calorie
deficits
•GI disturbances: vomiting, stools,
NGA
•Fluid restrictions
Red Cross Childrens Hospital : Refresher Course Feb 2010
Managing the barriers to feeding
Main barriers to optimum feeding:
1. Fluid restrictions
• Common for infants/ children restricted to 40 –
60ml/kg/day
• Most common in cardiac infant and those with
severe pneumonia
• Prioritizing the use of fluid for nutrition
• Using energy dense formula
2. Feed interruptions
• Interruption of feeds – procedures/ trial extubation
• Feeds - often re-started at a graded rate – takes days
to get back to full volume
• Using NJT feeds may assist in reducing time periods
of NPM if patient is expected to have many
procedures done in ICU, eg burns
Red Cross Childrens Hospital : Refresher Course Feb 2010
Optimise calories and reduce calorie deficits
• Assessment of nutrition needs
– Daily assessment of actual nutrition intake vs.
required
– Calculation of cumulative energy deficit
• Enteral formula with high energy density
– < 1 yr 1kcal/ml
– > 1 yr 1.5kcal/ml
– Bolus flushes with MCT/LCT & CHO powder
– Do not exceed recommendations and
concentration of feeds
• Note: not to exceed protein levels i.e
– Infants 4g/kg
– Children 3g/kg
Curr Op Clin Nutr Met Care. 2006; 9: 297-303
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Immunonutrition
Adult studies:
• Glutamine
– fuel for enterocytes
• Arginine
– cautioned in use of septic-critically ill
• Omega-3s
– anti-inflammatory / antioxidant properties
– Acute respiratory distress syndrome [ARDS]
Pediatrics:
• Limited evidence does NOT support the use of these
products in PICU yet
• May have detrimental effects
ASPEN 2009
Nutrition 2005; 21: 799 - 807
Red Cross Childrens Hospital : Refresher Course Feb 2010
When enteral nutrition fails…
Total parenteral is only considered for the following
reasons:
1. Unable to feed enterally due to abdominal surgery
and/or loss of gut function
2. If enteral nutrition is not tolerated, i.e.
• Ongoing losses through, NGAs, chylothorax,
malabsorption
• Not able to meet all calorie needs orally or
NPM for 3 days
TPN needs close monitoring for all complications,
namely: sepsis, liver dysfunction
Red Cross Childrens Hospital : Refresher Course Feb 2010
Conclusion
• Nutrition is integral part of management
• Early enteral nutrition needs to be initiated 24hrs
• Energy needs are reduced in acute phase & then
increases in the recovery phase
• Enteral nutrition is well tolerated and choice of types
and routes of delivery can improve the tolerance of
feeding
• Main barriers of feeding are challenging
•But with the help of standardized feeding protocol
and a multidisciplinary team, these challenges can be
effectively managed
Red Cross Childrens Hospital : Refresher Course Feb 2010
Thank you!
Acknowledgements:
L Marino [certain slides]
Prof Argent and Dr Goddard
Red Cross Childrens Hospital : Refresher Course Feb 2010
References
1. Nutrition support to pediatrics within the pediatric intensive setting. Pediatr
Anesthesia 2009; 19:300-312
2. Strategies to manage GI symptoms: Complications of EN JPEN 2009;33:21
3. ASPEN Clinical guidelines: Nutrition support of critically ill child.JPEN
2009;33:260
4. The impact of enteral feeding protocols on nutritional support in critically ill
children. JHum NutrDiet 2009;22:428-436
5. Nutrition therapy in critically ill infants and children.JPEN 2008;32:52
6. GI compliations in critically ill: whar differs between adults and children. Curr
OpinClin Nutr Metab Care.2009;12:180-185
7. Critically ill infants benefit from early administration of and energy-enriched
formula. Clinical Nutrition 2009;28:249-255
Red Cross Childrens Hospital : Refresher Course Feb 2010