Nutrition definiton

8/13/2019 Nutrition definiton

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ENTERAL AND

PARENTERAL NUTRITIONIN CRITICALLY ILL

CHILDREN

Mudit Mathur, M.D.

SUNY Downstate Medical Center



LEARNING GOALS

Impact of Critical Illness Importance of Nutrition

Goals of nutritional support

Nutritional requirements

Enteral vs Parenteral

When and how to initiate and advance Nutrition

Monitoring



IMPACT OF CRITICAL ILLNESS-1

Physiologic stress response :Catabolic phase

increased caloric needs, urinary nitrogen losses

inadequate intake wasting of endogenous

protein stores, gluconeogenesis

mass reduction of muscle-protein breakdown



IMPACT OF CRITICAL ILLNESS-2

Increased energy expenditure

– Pain

– Anxiety

– Fever

– Muscular effort-WOB, shivering



RESPONSE TO INJURY



WHY IS NUTRITION IMPORTANT

CRITICAL ILLNESS + POOR NUTRITION =

Prolonged ventilator dependency

Prolonged ICU stay

Heightened susceptibility to nosocomial

infections MSOF

Increased mortality with mild/moderate or

severe malnutrition



NUTRITION: OVERALL GOALS

ACCP Consensus statement, 1997Provide nutritional support appropriate

for the individual patient’s – Medical condition

– Nutritional status

– Available routes for administration



NUTRITION: OVERALL GOALS

Prevent/treat macro/micronutrient

deficiencies

Dose nutrients compatible with existing

metabolism

Avoid complications

Improve patient outcomes



ENTERALOR

PARENTERAL



IMPACT OF STARVATION-1

Negative nitrogen balance, further wt loss

Morphological changes in the gut

– Mucosal thickness

– Cell proliferation

– Villus height

Functional changes – Increased permeability

– Decreased absorption of amino acids





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



ENTERAL WITH PARENTERAL

IS THE COMBINATION BETTER 120 adult patients, (medical and surgical)

Combination vs enteral feeds alone

Prospective, randomized, double blind, controlled

RBP, pre albumin increased significantly D 0-7

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



A PRACTICAL APPROACH-1

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 ½ 18-21 d),transferrin (t ½ 8 d), prealbumin (t ½ 2 d),

RBP (t ½ 0.5 d)



A PRACTICAL APPROACH-2

Assessment of the present illness

Hypermetabolism-burns, sepsis, MSOF,

trauma

GI surgical procedures-prolonged NPO End-organ failure (Hepatic/renal etc)

Metabolic Cart-facilitates assessmentof energy expenditure, Respiratory

Quotient



WHEN TO INITIATE

ENTERAL NUTRITION: ASAP-usually within 24 hours in severe

trauma, burns and catabolic states

Contraindications to enteral nutrition:

– Nonfunctional gut, anatomic disruption, gut

ischemia

– Severe peritonitis – Severe shock states



ROUTE OF FEEDING

Nasogastric

– Requires gastric motility/emptying

Transpyloric

– Effective in gastric atony/ colonic ileus

– Silicone/polyurethane tubing

– Positioning, Prokinetic agents/ fluoroscopic/ pH/endoscopic guidance

Percutaneous/surgical placement – PEG if > 4 weeks nutritional support anticipated

– Jejunostomy if GE reflux, gastroparesis, pancreatitis



POTENTIAL DRAWBACKS

OF ENTERAL FEEDS

Gastric emptying impairments

Aspiration of gastric contents Diarrhea

Sinusitis

Esophagitis /erosions

Displacement of feeding tube



NUTRITIONAL 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)

+ Activity + growth

Factors increasing EE

– Fever 12%

– Burns upto 100%

– Sepsis 40-50 %

– Major surgery 20-30%



Resting Energy Expenditure

Age (years) REE (kcal/kg/day)

0 – 1 551 – 3 57

4 – 6 48

7 – 10 40

11-14 (Male/Female) 32/28

15-18 (Male/Female) 27/25



Factors adding to REE

Multiplication factor

Maintenance 0.2

Activity 0.1-0.25Fever 0.13/per degree > 38ºC

Simple Trauma 0.2

Multiple Injuries 0.4Burns 0.5-1

Sepsis 0.4

Growth 0.5



NUTRITIONAL 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



FORMULA 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



FORMULA COMPOSITION

Proteins – -polymeric (pancreatic enzymes required) or

peptides

– Small peptides from whey protein hydrolysisabsorbed better than free AA

Fibers

– Insoluble-reduce diarrhea, slower transit-betterglycemic control

– Degraded to SCFA-trophic to colon



COMPOSITION-SPECIAL

FORMULAS

Pulmonary: High fat( 50%), Low CHO

Hepatic: High BCAA, low aromatic AA,

<0.5 gm/kg/d protein in encephalopathy

Renal: Low protein, calorically dense, low

PO4 , K, Mg

GFR >25: 0.6-0.7 g/kg/d

GFR <25: 0.3 g/kg/d

Immune-enhancing



IMMUNE 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)





IMMUNE MODULATION

MECHANISMS 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



Conclusive studies, clear

indications

&

Cost-benefit analysis arestill needed

IMMUNE MODULATION



Maintains nutritional status

Prevents catabolism

Provides resistance to infection

Potential effect on immunemodulation

ENTERAL NUTRITION IN

CRITICAL ILLNESS:



PARENTERAL NUTRITION

(PN)The PN formulation is based on:

Fluid Requirements

Energy Requirements

Vitamins

Trace elements

Other additives-Heparin, H2 blocker etc



Fluid 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

20 kg = 1500 ml + 20ml for each kg > 20 kg

PN generally should be used for the 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.



Energy Requirements

Total Daily Energy Requirements (kcal/day) =

Resting Energy Expenditure (REE) + REE

(Total Factors)

Factors = Maintenance + Activity + Fever + Simple

Trauma + Multiple Injuries + Burns + Growth

f



PN-suggested guidelines for

Initiation and Maintenance

Substrate Initiation Advance

ment

Goals Comments

Dextrose 10% 2-5%/day 25% Increase as tolerated.

Consider insulin if

hyperglycemic

Amino

acids

1 g/kg/day 0.5-1

g/kg/day

2-3

g/kg/day

Maintain

calorie:nitrogen ratio

at approximately200:1

20%

Lipids

1 g/kg/day 0.5-1

g/kg/day

2-3

g/kg/day

Only use 20%





Factors adding to REE

Multiplication factor

Maintenance 0.2

Activity 0.1-0.25Fever 0.13/per degree > 38ºC

Simple Trauma 0.2

Multiple Injuries 0.4Burns 0.5-1

Sepsis 0.4

Growth 0.5





Calculations

Dextrose

____g/100ml Dextrose ____ml/day =

____grams/day

_____g/day (weight 1.44) = _____mg/kg/min

_____g/kg/day 3.4 kcal/g = _____ kcal/kg/day



Calculations

Fat

20 grams/100ml Fat _____ml/day =

_____grams/day

_____g/kg/day 9 kcal/g = _____

kcal/kg/day



Calculations

grams Protein 6.25 = _____ Nitrogen

Non-protein calories Nitrogen =

Calorie:Nitrogen ratio



DANGERS OF OVERFEEDING

Secretory diarrhea (with EN)

Hyperglycemia, glycosuria, dehydration,lipogenesis, fatty liver, liver dysfunction

Electrolyte abnormalities: PO4 , K, Mg

Volume overload, CHF

CO2 production- ventilatory demand

O2 consumption

Increased mortality (in adult studies)

MONITORING



MONITORING

Prevent 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



CONCLUSIONS

Start nutrition early

Enteral route is preferred when available

Set goals for the individual patient

Dose nutrients compatible with existing

metabolism

Appropriate monitoring is essential

Avoid overfeeding



QUESTION 1

When should nutritional support be initiated

in critically ill patients?

– Only 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 of

admission



QUESTION 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 inthe field.

– Parenteral nutrition

– Enteral nutrition – A combination of enteral and parenteral nutrition

– IV fluids alone until ICP is better controlled.



QUESTION 3

What would be the initial TPN composition

for a 10 kg 18 month year old child

– Glucose 10%, Protein 20 g/day, lipids 5g/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

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Nutrition definiton