General Nutrition Guidelines
1. Calculation of maintenance fluids based on wt in kg. a) Over 24 hours: i) 100 ml/kg for first 10 kg ii) 50 ml/kg for next 10 kg
iii) 20 ml/kg for every kg above 20 kg. iv) Divide by 24 for ml/hr or use 4 ml/kg for first 10 kg, 2 ml/kg for next 10 kg, and then 1 ml/kg for every kg above 20 kg.
* If mechanically ventilated, the patient has minimal respiratory insensible losses due to the heated/humidified circuit. Thus, maintenance fluid requirements are generally ~80% of that calculated above.
2. Fluids should be adjusted to take into account extra losses, fever, dehydration,additional volume from drips and other medications, fluid restriction, etc. Also paralyzed, sedated, intubated patients have decreased insensible losses and thus decreased maintenance fluid requirements.
3. Basic Nutrition Goals: for the critically ill intensive care patients:
a) Energy Needs (Maintenance + Growth) Term Infant 90‐120 kcal/kg/day
1‐3 yrs 75‐90 kcal/kg/day
4‐6 yrs 65‐75 kcal/kg/day
7‐10 yrs 55‐75 kcal/kg/day
11‐18 yrs 40‐45 kcal/kg/day
>18 yrs 20‐35 kcal/kg/day
b) Protein Needs (Maintenance + Growth) <1 yr 2‐4 gm/kg/day
Adolescent 0.8‐0.9 gm/kg/day
> 1 yr Critically ill 1.5 times normal
Parenteral:
Timing: Fivez et al, NEJM 2016, found in a RCT of 1440 PICU patients, improved clinical outcomes (shorter ICU stay (6.5 vs 9.2 days), less new infections (10.7 vs 18.5%), shorter hospital stay, less renal replacement therapy, and shorter duration of mechanical ventilation in patients started "late" (day 8 of ICU stay) vs early (within 24 hours of PICU admission). Basically, in general, starting TPN later is preferable based on the available evidence.
Reserved to patients in which enteral nutrition is contraindicated.
1. Total needs and blood chemistry levels largely determine tolerance to parenteral nutrition solutions. (Refer to TPN sheets for monitoring)
a) Renal panel, Magnesium and Triglyceride should be checked daily until the patient is on stable TPN.
b) Blood sugars should be followed closely when on high GIR’s especially when weaning off TPN in infants.
2. Carbohydrates: GIR (glucose infusion rate) is the milligrams of dextrose delivered per kilogram weight per minute: i) GIR = dextrose (gm/ml) x 1000 (mg/gm) x infusion rate (ml/hour) 60 min/hour x wt (kg)
ii) Initial GIR needs Neonates 6‐8 mg/kg/min Infants 5‐7 Mg/kg/min
iii) Maximum GIR Infant/Pediatric Range 12‐14 mg/kg/min Adult range 7 mg/kg/min
a) Increase by 20‐50%/day until at goal of total kcal b) Should be up to 60‐70% of total calories c) Excessive dextrose associated with fatty liver and increased VCO2 d) Calculate calories: (1) grams of dextrose = total volume of TPN * Dextrose % (2) Kcals from dextrose = grams of dextrose * 3.4 kcal/gm
3. Amino Acids: Start at 1 gram protein/kg/day and advance by 0.5‐1 gm /kg/day until you reach the goal unless contraindicated by alterations in protein metabolism, (ie. renal or liver disease, inborn error of metabolism,...etc.). a) Calculate calories i) gm/day AA = gm /kg/day * kg ii) kcal AA/day = gm/day AA * 4.3 kcal/gm
4. Lipids: use the 20% solution at 0.5‐1gm/kg/day ...may increase to maximum of 3gm/kg/day a) Calculate Calories: (25‐30% of total calories) There are 20 gms of lipid per 100 ml of 20% lipid with 2 kcals/ml. i) ml of fat/day = total grams of fat/day * 5 ml/gm
ii) kcal fat/day = ml/day x 2 kcal/ml
b) Lipids can be run over 12‐18 hours (in this institution). In neonates not to exceed 0.15 gm/ml/hr. c) Rapid infusion of lipids may be associated with a decreased lipid clearance &/or respiratory &/or platelet aggregation complications.
Peripheral Parenteral Nutrition (PPN): may be use to support blood glucose levels &/or supply short term nutrition support and may be use in transition to TPN (while waiting for central access).
1. Dextrose is usually not greater than 10% (final concentration) but can be maximized at 12.5 %. 2. The total osmotic limits of peripheral parenteral nutrition is near 800‐900 mOsm: a) 250 mOsm per 5% dextrose b) 100 mOsm per 1% amino acids c) Pharmacy will determine if the components of the PPN affect the osmolality
Enteral Nutrition: First choice whenever possible as it is associated with better patient tolerance and outcomes. Significantly reduced risks.
1. Feeding tubes may be placed in the stomach when the risk of aspiration or reflux is a) Transpyloric feeding tubes can be if there is altered G.I. function with delayed gastric emptying, (duodenal trophic feeding can be initiated even in the absence of bowel sounds). b) Continuous delivery tube feedings are usually tolerated better that bolus feeding in the intensive care patients as this allows for slower delivery and minimal gastric distention. c) When initiating tube feeds in the PICU please use the Gastric feeding protocol unless special circumstances (i.e. only giving trophic feeds, patients with known feeding issues) a) Most standard formulas are isotonic and appropriate for the majority of patients. Specialized formulas are indicated for problems of intolerance or special patient needs. b) Hyperosmotic solutions can be used to reduce volume loads, yet some patients may occasionally develop diarrhea or delayed gastric emptying with these formulas, so individualized feeding rates may be necessary in these circumstances 3. Infant formulas: are usually 20 kcal/oz (0.67 kcal/cc) in isotonic, starting solutions. a) Breast milk is by far the best tolerated formula and should be utilized when ever possible. Powdered formula or fortifiers may be combined with pumped breast milk to increase the nutrient delivery in smaller volumes. b) Cow milk based formulas such as: Enfamil & Similac are similar in composition to breast milk and are usually well tolerated. c) Soy based formulas such as: Isomil & Prosobee are used for lactose intolerance or milk protein allergies (both are rare in infants). d) Hypoallergenic formulas such as: Pregestimil, Nutramagen & Alimentum contain protein hydrolysates. Formulas such as Neocate and EleCare contain free amino acids and are indicated for infants sensitive to intact proteins, malabsorption and/or allergies. e) Fat malabsorption due to damage to the lymphatic system or thoracic duct may require use of medium chain triglyceride containing formulas, such as: Portagen. 4. Pediatric Formulas for 1‐10 years of age: are usually 1 kcal/ml (30 kcal/oz) in isotonic, starting solutions a) Pediasure & Nutren Jr. with fiber are lactose free and nutritionally complete in 1000 ml for kids 1‐10 years of age. b) Specialized Pediatric Formulas: Peptamen Jr., EleCare may be indicated for malabsorption, short bowel syndrome, and allergies. 5. Adult Formulas (>10 yrs): are usually 1 kcal/ml & isotonic in the starting solutions. a) Standard: Osmolite, Jevity contain fiber b) Specialized formulas: i.e. high protein, low protein, high calorie may be used in
Source: Akron Children's PICU Resident Curriculum: https://www.akronchildrens.org/cms/resource_library/files/picu_curriculum/picucurriculum.pdf, accessed 3/8/2016.
Benefits of EN
- Prevention of mucosal atrophy
- Preservation of balanced gut flora
- Reduced risk of infection
- Ameliorate
oxidative stress --> reduced gut permeability --> reduced bacterial
translocation
- Increases GI blood flow (postprandial hyperemic response)
- Reduced mortality, hospital LOS, and cost associated
w/ nutrition therapy
So we now know why it's important to start EN as
soon as possible. But...
Gastric vs. Postpyloric FeedsTheoretical benefit of reduced risk of aspiration with postpyloric feeds
- HOWEVER: No clear evidence showing this is the case. In a randomized trial, Kamat et al (PCCM 2008) added methylene blue to feeds and then examined tracheal aspirates with spectrophotometry for evidence of aspiration. There was no difference in the rates of aspiration between postpyloric and NG groups. Furthermore, the PP group had a longer time to initiation of feeds and required more x-rays for confirmation of tube placement.
- Meert et al (Chest 2004 did a randomized trial comparing postpyloric to gastric feeds in 74 critically ill children who were mechanically ventilated. They used the presence of gastric pepsin via immunoassay in trachea aspirates to detect evidence of aspiration. They found no difference in rates of aspiration. However, the postpyloric feeding group did have less interruptions in delivery of nutrition and thus more of their daily caloric goal delivered than did patients fed gastrically. No differences were found in rates of feeding tube displacement, abdominal distension, vomiting, or diarrhea between groups
Vasoactives and Enteral Nutrition
Complications with EN While on Vasopressor/Inotropic Agents
- Increase
in splanchnic blood flow from feeding without increase in overall cardiac
output --> less blood to vital organs (clinical impact unclear)
- Gut
ischemia (without progression to necrosis)
- Due
to increased gut O2 demand vs. reperfusion injury
- Evidence
behind ischemia from animal studies only (unclear of clinical relevance in
humans)
- Most
reported cases occurred with tube feeds (TF) through surgically placed
jejunostomy tubes in surgery/trauma/burn pts
- No
reported cases in medical ICU pts without history of GI surgery
- Very
little documentation regarding an association with concomitant vasopressor
use
- Defined
as increased gastric aspirate volume vs. vomiting
- Usually
occurred within the first 48hrs of starting EN
- Associated
w/ aspiration PNA, longer LOS in the ICU, greater risk of mortality in 1
study
Overall, literature evaluating complications
with EN + hemodynamic instability lacking and basically non-existent in the
pediatric population. What are our current recommendations from the experts?
2009 Adult Guideline for Nutrition in the ICU
- EN
should be started within 24-48hrs following admission
- EN
should be withheld if:
- Initiating
use of vasopressors (DA, NE, epi, phenyl)
- Escalating
dose of such agents
- EN may be provided with caution if on stable or
"low dose" of pressors (no
explanation of "low dose")
- Any
sign of intolerance should be viewed as early signs of gut ischemia
2009 Pediatric Guideline for Nutrition in the
PICU
- No statement on whether EN can be initiated with
vasopressor/inotropic agents
They're not very clear on whether EN should be
started while on vasopressor/inotropic agents. What are the evidence behind
starting vs. withholding EN in hemodynamically unstable pts?
2000 - EN in Adult Post-Cardiac Surgery Pts
- Hemodynamically
stable vs. unstable pts (requiring vasopressors) receiving EN
- Unstable
pts tolerated EN as well as the stable pts
2001 - Splanchnic Response to EN in Adult
Post-Cardiac Surgery Pts on Pressors
- EN
not associated with decrease in gastric mucosal pH, suggesting lack of
splanchnic ischemia
- Actually
showed increase in splanchnic blood flow
2004 - Enteral Nutrition and CV Meds in the
PICU (JPEN), attached
- 52
pts from single center receiving both EN (via NG, NJ, or oral) and
cardiac meds (DA, dobut, epi, NE, phenyl) within the same 24hr period
- Most
common pressors used = high dose DA; DA + NE (>70% of pts)
- Only
29% of pts had feedings held for some time for perceived intolerance
- 2
pts had clinically insignificant heme-positive stools
- 2 pts had more extensive GIB but were also
coagulopathic from liver failure/DIC
- PICU pts tolerated EN well while on pressors without
much adverse events
2010 - Early EN in Adult Pts with Pressors and
Mechanical Ventilation (AJCC), attached
- 1174
medical ICU pts on DA, epi, NE, and/or phenyl during the first 2 days
of ventilatory support divided into:
- Early
EN group (EN started within the first 2 days while on pressors)
- Late
EN group (after 2 days; may or may not be on pressors)
- Early
EN group associated w/ lower risk of hospital mortality (35%
decreased risk of death)
- Survival
difference evident within the first week of ventilation
- Benefit
of early EN more evident in the sickest pts who:
- Received
multiple pressors
- Required
pressors for >2 days
- Results
remained true at 28 days
- EN within the first 2 days of mechanical ventilation
was associated with reduction in hospital mortality in hemodynamically
unstable pts
Bottom Line
- Many
benefits of early EN in kids and adults
- Inotropes (Dobut, mil; increases CO --> increases
splanchnic blood flow) should not dissuade us from initiating EN
- Vasopressors (DA,
Epi, NE, vaso, phenyl) should not entirely preclude clinicians from using
EN, but risks may exist especially with NJ feeds
- If pressor doses stable or low (very subjective),
consider early EN feed
- Worsening hemodynamic instability should warrant
discontinuation of EN
- Randomized
controlled trials needed as evidence above are from retrospective analyses
Respiratory Quotient- "R" a dimensionless number that describes the ratio of CO2 eliminated to the amount of O2 consumed. It is used in the alveolar gas equation :PAO2= FiO2 (Patm - PH2O) - PaCO2/R
- R varies based on diet/what is being broken down
- Normally, we assign a value of 0.8 to R to represent a normal diet
- R can go above 1 in the setting of lipogenesis (ie due to overfeeding)
- The respiratory quotient can become clinically relevant in a patient with difficulty ventilating as their nutritional intake and composition can significantly affect their CO2 production. In addition, medications such as propofol, delivered in lipids, can increase CO2 produced (even though the RQ of lipids/fat is 0.7).
Resting Energy Expenditure (REE)
- REE
= calories needed by the body at rest during a 24 hr period (~70% of
calories used by the body)
- Overfeeding -->
increased CO2 production (can lead to resp failure), hyperglycemia,
steatohepatitis
- Underfeeding
--> malnutrition, muscle weakness, impaired immunity
- Good
control of energy balance guided by indirect calorimetry (measures
REE) --> decreased hospital mortality
- Many
equations exist to predict REE but were found to be inaccurate
- REE
determined by: analyzing expired gas by looking at the volume and concentration of expired gas --> amount of O2 extracted
(body burns fuel/energy using O2) and amount of CO2 expelled
(byproduct of metabolism)
- Limitation
of measuring REE: air leaks (from ventilator or chest tube), CO2
removal by CRRT/ECMO, or high vent settings that trigger a lot of air flow
- Who
benefits from measuring REE? Here's the ASPEN pt criteria:
- underweight/overweight
- fluctuating weights
- failure to wean from vent
- hypermetabolic state (dysautonomia, oncologic dx,
seizure, hyperthermia, SIRS)
- hypometabolic state (hypothermia, hypothyroidism,
coma)
- burn injury
- in the ICU for >4 wks
- 1
study found that ~70% of PICU pts meet the above criteria!
2) Meert KL, Daphtary KM, Metheny NA: Gastric vs small bowel feeding in critically ill children receiving mechanical ventilation: A randomized control trial.Chest 2004; 126:872–878
3) Fivez T, Kerklaan D, Mesotten D, Verbruggen S, Wouters PJ, Vanhorebeek I,Debaveye Y, Vlasselaers D, Desmet L, Casaer MP, Garcia Guerra G, Hanot J, JoffeA, Tibboel D, Joosten K, Van den Berghe G. Early versus Late Parenteral Nutritionin Critically Ill Children. N Engl J Med. 2016 Mar 15.
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