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7/30/2019 Enteral Nutrition in Critically Ill Children
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ENTERAL NUTRITION INENTERAL NUTRITION INCRITICALLY ILLCRITICALLY ILL
CHRIS A JOHANNES
R.S.P.A.D GATOT SUBROTO
JAKARTA
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LEARNING GOALSLEARNING GOALS
Impact of Critical Illness
Importance of Nutrition
Goals of nutritional support
Enteral vs Parenteral
When and how to initiate and advance Nutrition
Monitoring
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IMPACT OF CRITICAL ILLNESSIMPACT OF CRITICAL ILLNESS--11
Physiologic stress response :Catabolic phase
increased caloric needs, urinary nitrogen losses
protein stores, gluconeog
enesis
mass reduction of muscle-protein breakdown
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IMPACT OF CRITICAL ILLNESSIMPACT OF CRITICAL ILLNESS--22
Increased energy expenditure
Pain
nx e y
Fever
Muscular effort-WOB,
shivering
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RESPONSE TO INJURYRESPONSE TO INJURY
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WHY IS NUTRITION IMPORTANTWHY IS NUTRITION IMPORTANT
CRITICAL ILLNESS + POOR NUTRITION =CRITICAL ILLNESS + POOR NUTRITION =
Prolonged ventilator dependency
Heightened susceptibility
to nosocomial
infections MSOF
Increased mortality with mild/moderate or
severe malnutrition
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NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALS
ACCP Consensus statement, 1997ACCP Consensus statement, 1997
Provide nutritional support appropriate
for the individual patients
Medical condition
Nutritional status
Available routes for admin
istration
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NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALS
Prevent/treat macro/micronutrient
deficiencies
metabolism
Avoid complications
Improve patient outcomes
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IMPACT OF STARVATIONIMPACT OF STARVATION--11
Negative nitrogen balance, further wt loss
Morphological changes in the gut
Mucosal thickness
Ce pro erat on
Villus height
Functional changes
Increased permeability Decreased absorption of amino acids
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IMPACT OF STARVATIONIMPACT OF STARVATION--22
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
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ENTERAL or PARENTERAL?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
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ENTERAL WITH PARENTERALENTERAL WITH PARENTERAL
IS THE COMBINATION BETTERIS THE COMBINATION BETTER 120 adult patients, (medical and surgical)
Combination vs enteral feeds alone
Prospective, randomized, double blind, controlled
, - 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
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A PRACTICAL APPROACHA PRACTICAL APPROACH--11
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 18-21 d),
transferrin (t 8 d), prealbumin (t 2 d),
RBP (t 0.5 d)
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A PRACTICAL APPROACHA PRACTICAL APPROACH--22
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, RespiratoryQuotient
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WHEN TO INITIATEWHEN TO INITIATE
ENTERAL NUTRITION:ENTERAL NUTRITION: ASAP-usually within 24 hours in severe
trauma, burns and catabolic states
Nonfunctional gut, anatomic disruption, gut
ischemia
Severe peritonitis
Severe shock states
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ROUTE OF FEEDINGROUTE OF FEEDING
Nasogastric Requires gastric motility/emptying
Transpyloric
Effective in gastric atony/ colonic ileus
Positioning, Prokinetic agents/ fluoroscopic/ pH/
endoscopic guidance
Percutaneous/surgical placement
PEG if > 4 weeks nutritional support anticipated Jejunostomy if GE reflux, gastroparesis, pancreatitis
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POTENTIAL DRAWBACKSPOTENTIAL DRAWBACKS
OF ENTERAL FEEDSOF ENTERAL FEEDS
Gastric emptying impairments
As iration of astric contents Diarrhea
Sinusitis
Esophagitis /erosions
Displacement of feeding tube
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NUTRITIONAL REQUIREMENTSNUTRITIONAL 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)
+ ct v ty + growt
Factors increasing EE
Fever 12%
Burns upto 100%
Sepsis 40-50 %
Major surgery 20-30%
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Resting Energy ExpenditureResting Energy Expenditure
Age (years) REE (kcal/kg/day)
0 1 55
1 3 57
4 6 48
7 10 40
11-14 (Male/Female) 32/28
15-18 (Male/Female) 27/25
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Factors adding to REEFactors adding to REE
Multiplication factor
Maintenance 0.2
Activity 0.1-0.25
Fever 0.13/per degree > 38C
Simple Trauma 0.2
Multiple Injuries 0.4
Burns 0.5-1Sepsis 0.4
Growth 0.5
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NUTRITIONAL REQUIREMENTSNUTRITIONAL 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
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FORMULA COMPOSITIONFORMULA 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
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FORMULA COMPOSITIONFORMULA COMPOSITION
Proteins
-polymeric (pancreatic enzymes required) orpeptides
Small peptides from whey protein hydrolysis
a sor e e er an ree
Fibers
Insoluble-reduce diarrhea, slower transit-better
glycemic control Degraded to SCFA-trophic to colon
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COMPOSITIONCOMPOSITION--SPECIALSPECIAL
FORMULASFORMULAS Pulmonary: High fat( 50%), Low CHO
Hepatic: High BCAA, low aromatic AA,
. Renal: Low protein, calorically dense, low
PO4 , K, Mg
GFR >25: 0.6-0.7 g/kg/d
GFR
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IMMUNE MODULATIONIMMUNE 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)
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IMMUNE MODULATIONIMMUNE MODULATION
Glutamine+arginine+Branched chain AA
(Immunaid)
- 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)
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IMMUNE MODULATIONIMMUNE MODULATION
MECHANISMS ARE UNCLEARMECHANISMS ARE UNCLEAR Reduction of duration and magnitude of
inflammatory response
Will this disrupt the balance between proand anti-inflammatory processes??
Of the multiple ingredients in these specialformulas: which is the one
Beneficial effects seen in patients achievingearly EN
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Conclusive studies, clear
IMMUNE MODULATIONIMMUNE MODULATION
&
Cost-benefit analysis arestill needed
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Maintains nutritional status
ENTERAL NUTRITION IN
CRITICAL ILLNESS:
Provides resistance to infection
Potential effect on immune
modulation
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PARENTERAL NUTRITIONPARENTERAL NUTRITION
(PN)(PN)The PN formulation is based on:
Energy Requirements
Vitamins
Trace elements Other additives-Heparin, H2 blocker etc
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Fluid RequirementsFluid RequirementsFluid requirements = maintenance + repair of dehydration +
replacement of ongoing losses.
Maintenance Fluid Requirements
1 - 10 kg = 100 ml/kg/day
10 - 20kg = 1000 ml + 50 ml for each kg > 10 kg
=
PN generally should be used forthe maintenance needs.
Deficit and replacement of losses should be providedseparately.
Remember to consider medications, flushes, drips,pressures lines and other IV fluids in your calculations.
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Energy RequirementsEnergy Requirements
Total Daily Energy Requirements (kcal/day) =
Resting Energy Expenditure (REE) + REE
Total Factors
Factors = Maintenance + Activity + Fever + Simple
Trauma + Multiple Injuries + Burns + Growth
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PNPN--suggested guidelines forsuggested guidelines for
Initiation and MaintenanceInitiation and Maintenance
Substrate Initiation Advance
ment
Goals Comments
Dextrose 10% 2-5%/day 25% Increase as tolerated.
hyperglycemic
Amino
acids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
Maintain
calorie:nitrogen ratio
at approximately
200:120%
Lipids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
Only use 20%
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Resting Energy ExpenditureResting Energy Expenditure
Age (years) REE (kcal/kg/day)
0 1 55
1 3 57
4 6 48
7 10 40
11-14 (Male/Female) 32/28
15-18 (Male/Female) 27/25
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Factors adding to REEFactors adding to REE
Multiplication factor
Maintenance 0.2
Activity 0.1-0.25
Fever 0.13/per degree > 38C
Simple Trauma 0.2
Multiple Injuries 0.4
Burns 0.5-1Sepsis 0.4
Growth 0.5
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Suggested monitoring ProtocolSuggested monitoring Protocol
Weight Urine dipfor
glucose
Bedsideglucose
Labs
First week Daily Q shift Q shift Daily SMA-7, Ca,
, ,triglycerides
Q OD LFTs
Subsequently Daily Q shift Q shift SMA-7, Ca, Mg,
Phos 2x/wk
CBC, LFTsweekly
Triglycerides
2x/wk
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CalculationsCalculations
Dextrose
____g/100ml Dextrose ____ml/day =
____ _____g/day (weight 1.44) = _____mg/kg/min
_____g/kg/day 3.4 kcal/g = _____ kcal/kg/day
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CalculationsCalculations
Fat
20 grams/100ml Fat _____ml/day =
_____ _____g/kg/day 9 kcal/g = _____
kcal/kg/day
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CalculationsCalculations
grams Protein 6.25 = _____ Nitrogen
Non-protein calories Nitrogen =
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DANGERS OF OVERFEEDINGDANGERS OF OVERFEEDING
Secretory diarrhea (with EN)
Hyperglycemia, glycosuria, dehydration,lipogenesis, fatty liver, liver dysfunction
4 , , Volume overload, CHF
CO2production- ventilatory demand
O2 consumption
Increased mortality (in adult studies)
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MONITORINGMONITORING
Prevent OverfeedingPrevent 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
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CONCLUSIONSCONCLUSIONS
Start nutrition early
Enteral route is preferred when available
Dose nutrients compatible with existing
metabolism
Appropriate monitoring is essential
Avoid overfeeding
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QUESTION 1QUESTION 1
When should nutritional support be initiated
in critically ill patients?
Onl 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 ofadmission
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QUESTION 2QUESTION 2
What would be the preferred mode for nutritionalsupport 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.
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QUESTION 3QUESTION 3
What would be the initial TPN composition
for a 10 kg 18 month year old child
Glucose 10% Protein 20 /da li ids 5 /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