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Dr. Muhammed Saiful IslamPhase A, Resident, Paediatric Surgery

BSMMU

NUTRITION AND FLUID MANAGEMENT IN ICU ADMITTED PAEDIATRIC PATIENTS.

Nutritional requirements in Paediatric Patients: To maintain weight, 50-60 kcal/kg/day. To induce weight gain, 100-120 kcal/kg/day.

Carbohydrates: 10-30 g/kg/day to provide 40-50% of total calories.

Proteins: 2.25-4.0 g/kg/day (7-16% of total calories).

Fats: 5-7 g/kg/day (limit: 40-55% of total calories, or ketosis may result).

Consequences of malnutrition:

Underfeeding Overfeeding

Loss of muscle mass Increased VO2

Reduced respiratory function Increased VCO2

Reduced immune function Hyperglycaemia

Poor wound healing Fatty infi ltration of liver

Gut mucosal atrophy

Reduced protein synthesis

Nutrition may be provided: • Enteral: Oral or Gavage feedings. • Parenteral :

A)Total parenteral nutrition (TPN): is intravenous administration of all nutrients (fats, carbohydrates, proteins, vitamins, and minerals).

B) Supplemental Parenteral nutrition (SPN).

Enteral Nutrition: Routes include nasogastric,

nasoduodenal/jejunal, gastrostomy, and jejunostomy.

Benefits over Parenteral nutrition are:Provides a more complete diet.Maintains structural integrity of the gut.Improves bowel adaptation after resection. Reduces infection risk.

Management of enteral nutrition: Iso-osmolar, non-lactose feed. 0.5 to 1 ml/h is the starting feed. After four hour feed should be stopped

for 30 minutes and aspiration of gastric contents.

If aspirate is <3ml/kg body wt infusion rate increased at 1ml/kg body wt then process is repeated until target feed achieved.

Indications of Parenteral nutrition (PN):

Surgical conditions: Neonates:necrotizing enterocolitis (NEC), Gastroschisis, Omphalocele, Tracheo-esophageal fistula (TEF), Intestinal atresia,Mal-rotation of gut, Short bowel syndrome. Meconium ileus.Intussusception.

Indications of Parenteral nutrition (PN): Continued.

Medical Conditions: Infants <28 wk or <1000 gm.Infants 28 -32wk or 1000-1500 gm and

anticipated to be not on significant feeds for 3 or more days.

Infants >32 wk or >1500 gm and anticipated to be not on significant feeds for 5 or more days.

Babies those are term but hemodynamically unstable.

Sources of parenteral solutions:

Constituent PreparationDextrose Dextrose 5%, 10%, 25%

Amino acid Amino acid 5%

Lipid Intralipid 10%, 20%

Sodium NaCl 0.9%, 3%, 0.45%, 0.225%

Potassium KCl

Calcium Ca gluconate 10%, 10mg/ml

Magnesium Mg sulphate 50%

Vitamin Multivitamin infusion

Dextrose: Caloric value of dextrose is 3.4 kcal /g. Starting at 6 mg/kg/min. Increase by daily increments of 2

mg/kg/min if tolerated to a maximum of 12 mg/kg/min.

Using a peripheral cannula maximum dextrose concentration is 12.5% and up to 25% in central line.

Amino acids (AA): Caloric value of amino acids is 4 kcal/g. AA can be initiated on day 1 in a dose of

1-1.5 g/kg/day and increase by 0.5 g/kg/day upto 3.5 g/kg/day

Energy intake should be at least 40-50 kcal/kg/day for optimal amino acids utilization.

Caution is taken in children with renal impairment.

Lipids: Caloric value is 10 kcal/g Lipids can be started at 1 g/kg/day and

increase by 1 g/kg/day up to 3.5 g/kg/day Use of 20% emulsion is preferred. Use with caution in babies with sepsis,

respiratory failure or severe jaundice. Lipids are potentially vulnerable to photo-

oxidation and should be covered with sterile opaque paper.

Electrolytes: • Sodium and potassium are added to

PN usually from day 2. • Maintenance dose of sodium is 2-4

mmol/kg/day. • Maintenance dose of potassium is 1-2

mmol/kg/ day.

Minerals: • Calcium should be added from day 1. • Dose of calcium 200-800 mg/kg/day in

4 divided doses. • Dose of phosphate is 0.5-1.5

mmol/kg/day (Not available in Bangladesh).

• Dose of magnesium is 0.25-0.5 mmol/kg/day ( Not available in Bangladesh).

Trace elements: • Zinc is recommended from day 1 of

PN ( Parenteral formulation not available).

• Other trace minerals are generally provided after two weeks’ of PN.

Routes of parenteral nutrition (PN) administration:

A) Central-PICC (Percutaneous peripherally inserted central catheter).

B) Peripheral line. C) Umbilical catheters (in case of neonate).

• Use of peripheral line is safer when PN is needed for less than 14 days.• Central PN allows the use of more hypertonic solutions but incurs catheter related sepsis.

PICC line is inserted when:

• Concentrations of >12.5% glucose are needed.

• Osmolarity of solution is >900 mOsm/L. • Prolonged period of PN is anticipated.

When on full PN (must keep in mind): Strict fluid balance. Blood glucose 12-24 hourly. Twice-weekly:

○ Serum sodium, potassium, calcium level.○ Serum Creatinine. ○ Acid-base balance. ○ Plasma magnesium, phosphorus, alkaline

phosphatase, albumin, transaminases, triglycerides.

○ Serum bilirubin.

Complications: Sepsis Metabolic: azotemia, hyperammonemia,

metabolic acidosis. Cholestasis. Metabilic bone disease. Related to lipid emulsions:

hyperlipidemia, indirect hyperbilirubinemia.

Daily water requirements by body weight in children:

Weight (kg) Water requirements

0 to 10 4 ml/kg/h

10 to 20 40 m/kg/h + 2 ml/kg/h for each kg > 10kg

> 20 60 ml/kg/h + 1 ml/kg/h for each kg > 20kg

Monitoring of hydration status of a newborn:

Appearance (Irritable/ lethargic) Anterior fontanel CRT (Capillary refill time) Pulse Respiratory rate BP Skin pinch Oedema Body weight Urine output S. Electrolytes particularly sodium.

During fluid challenge:

If CVP rises,>7 mmHg, patient is Hypervolaemic.Within 3 mmHg of the original value, the

patient is euvolaemic.< 3 mmHg, the patient is hypovolaemic.

Thank you