Mahmoud Tarek PICU Nutrition Fainal 29-3-09

8/14/2019 Mahmoud Tarek PICU Nutrition Fainal 29-3-09

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NUTRITIONALNUTRITIONAL

STRATEGIES IN PICUSTRATEGIES IN PICU

Mahmoud Tarek Abdelmonim, MDMahmoud Tarek Abdelmonim, MD

Professor of Pediatrics, Faculty Of Medicine,Professor of Pediatrics, Faculty Of Medicine,

Ain Shams University, Cairo, Egypt.Ain Shams University, Cairo, Egypt.


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LEARNING GOALSLEARNING GOALS

Impact of Critical IllnessImpact of Critical Illness

Enteral vs Parenteral nutrition in the PICUEnteral vs Parenteral nutrition in the PICUPatientPatient Importance of Nutrition & Goals ofImportance of Nutrition & Goals of

nutritional supportnutritional support Monitoring of the nutritional statusMonitoring of the nutritional status Nutritional requirements in the PICUNutritional requirements in the PICU

PatientPatient


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Why Is Nutrition Important ?Why Is Nutrition Important ?

Prolonged ventilator dependencyProlonged ventilator dependency

Prolonged ICU stayProlonged ICU stay

Heightened susceptibility to nosocomialHeightened susceptibility to nosocomialinfections MSOFinfections MSOF

Increased mortalityIncreased mortality

CRITICAL ILLNESS + POOR NUTRITIONCRITICAL ILLNESS + POOR NUTRITION

==


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Impact of critical illnessImpact of critical illness

Inadequate intake wasting of endogenousInadequate intake wasting of endogenousprotein stores and increased muscle-protein breakdown &protein stores and increased muscle-protein breakdown &gluconeogenesisgluconeogenesis

Increased energy expenditure : ( Pain,Increased energy expenditure : ( Pain,

Anxiety, Fever, Muscular effort-WOB &Anxiety, Fever, Muscular effort-WOB &

shivering)shivering)

Catabolic phaseCatabolic ph

ase


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Negative nitrogen balanceNegative nitrogen balance

Morphological changes in the gut (MucosalMorphological changes in the gut (Mucosal

thickness, Cell proliferation and Villus height)thickness, Cell proliferation and Villus height)

Functional changes (Increased permeability &Functional changes (Increased permeability &

Decreased absorption of amino acids)Decreased absorption of amino acids)

Enzymatic/Hormonal changes (DecreasedEnzymatic/Hormonal changes (Decreasedsucrase and lactaseetc)sucrase and lactaseetc)

Impact of starvationImpact of starvation


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Impact on immunityImpact on immunity

Cellular: Decreased T cells, atrophiedCellular: Decreased T cells, atrophied

germinal centers, mitogenic proliferation,germinal centers, mitogenic proliferation,

differentiation, Th cell function, altereddifferentiation, Th cell function, altered

hominghoming

Humoral: Complement, opsonins, Ig, secretoryHumoral: Complement, opsonins, Ig, secretory

IgA (70-80% of all Ig produced is secretoryIgA (70-80% of all Ig produced is secretory

IgA)IgA)

Impact of starvationImpact of starvation


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Bed side questionsWhen What How

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ENTERALENTERALOR PARENTERALOR PARENTERAL

????????????????????


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ENTERAL or PARENTERAL?ENTERAL or PARENTERAL?

Enteral Nutrition: Superior to ParenteralEnteral Nutrition: Superior to Parenteral

Trophic effects on intestinal villusTrophic effects on intestinal villusSupports Gut-associated Lymphoid TissueSupports Gut-associated Lymphoid Tissue

Promotes secretory IgA secretion andPromotes secretory IgA secretion and

functionfunction

Lower costLower cost

No needs for IV accessNo needs for IV accessLower Infectious riskLower Infectious risk

EEPP


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ENTERAL FEEDINGENTERAL FEEDING
http://funyumfriends.com/


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WHEN TO INITIATE ENTERAL NUTRITION ?WHEN TO INITIATE ENTERAL NUTRITION ?

ASAP-usually within 24 hours even in severe statesASAP-usually within 24 hours even in severe states

CONTRAINDICATIONS TO ENTERAL NUTRITIONCONTRAINDICATIONS TO ENTERAL NUTRITION

Nonfunctional gut, anatomic disruption, gutNonfunctional gut, anatomic disruption, gut

ischemiaischemia Severe peritonitisSevere peritonitis Severe shock statesSevere shock states


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ROUTE OF FEEDINGROUTE OF FEEDING

NasogastricNasogastric

Requires gastric motility/emptyingRequires gastric motility/emptying

TranspyloricTranspyloric

Effective in gastric atony/ ileusEffective in gastric atony/ ileus

Percutaneous/surgical placementPercutaneous/surgical placement-Gastrostomy if > 4 weeks nutritional-Gastrostomy if > 4 weeks nutritional

support anticipatedsupport anticipated

-Jejunostomy if GE reflux,-Jejunostomy if GE reflux,

gastroparesis, pancreatitisgastroparesis, pancreatitis


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POTENTIAL DRAWBACKS OFPOTENTIAL DRAWBACKS OF

ENTERAL FEEDSENTERAL FEEDS

Gastric emptying impairmentsGastric emptying impairments

Aspiration of gastric contentsAspiration of gastric contents DiarrheaDiarrhea SinusitisSinusitis Esophagitis /erosionsEsophagitis /erosions Displacement of feeding tubeDisplacement of feeding tube
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PARENTERALPARENTERAL

FEEDINGFEEDING


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IndicationsIndications ::

Intractable vomiting, ileus, short bowel syndromeIntractable vomiting, ileus, short bowel syndrome

Severe diarrheaSevere diarrhea

Severe malnourishmentSevere malnourishment

After gastrointestinal surgeryAfter gastrointestinal surgery

Severe mucositis, exacerbation of inflammatorySevere mucositis, exacerbation of inflammatorybowel disease, Necrotizing enterocolitis etcbowel disease, Necrotizing enterocolitis etc

Respiratory illness until enteral feeding isRespiratory illness until enteral feeding isestablishedestablished


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ENTERAL OR PARENTRALENTERAL OR PARENTRAL????????

It is best to feed the patientIt is best to feed the patientthrough the enteral routethrough the enteral route

whenever possible.whenever possible.If the GI tract works, use it


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Nutrition formulationNutrition formulation

Fluid RequirementsFluid Requirements

Energy RequirementsEnergy Requirements

Protein, Fat and CHO RequirementsProtein, Fat and CHO Requirements

VitaminsVitamins

Trace elementsTrace elements
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Fluid Requirements:Fluid Requirements:

Fluid requirements = maintenance + repair of dehydration +Fluid requirements = maintenance + repair of dehydration +replacement of ongoing losses.replacement of ongoing losses.

Maintenance Fluid RequirementsMaintenance Fluid Requirements

1 - 10 kg =1 - 10 kg = 100 ml/kg/day100 ml/kg/day

10 - 20kg = 1000 ml + 50 ml for each kg > 10 kg10 - 20kg = 1000 ml + 50 ml for each kg > 10 kg20 kg20 kg == 1500 ml + 20ml for each kg > 20 kg1500 ml + 20ml for each kg > 20 kg

Remember to consider medications, flushes, drips, transfusionRemember to consider medications, flushes, drips, transfusion

therapy and other IV fluids in your calculations.therapy and other IV fluids in your calculations.
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Energy RequirementsEnergy Requirements

Total Daily Energy Requirements (kcal/day)Total Daily Energy Requirements (kcal/day)

==Resting Energy Expenditure (REE)Resting Energy Expenditure (REE)

++

REEREE (Total stress Factors)(Total stress Factors)


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Resting Energy Expenditure (REE)Resting Energy Expenditure (REE)Age (years) REE (kcal/kg/day)

0 1 55

1 3 57

4 6 48

7 10 4011-14 (Male/Female) 32/28

15-18 (Male/Female) 27/25

Energy Requirements


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Factors adding to REE :Factors addingto REE :

Factor 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 0.5-1

Sepsis 0.4


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ExampleExample

A critically ill child aged 2.5 years, bodyA critically ill child aged 2.5 years, bodyweight is 14 kg. The patient is active but hasweight is 14 kg. The patient is active but hasfever 39C and evidence of sepsis.fever 39C and evidence of sepsis.

REE = 14 X 57 = 798 Kcal/day

Stress factors = 0.2 + 0.2 + 0.26 +0.4 = 0.86(0.86 X 798 = 686 Kcal/day )

Total Daily Energy Requirement = 798 +686 = 1484 Kcal/day


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- Caloric values : 3.4 Kcal/g for dextrose & amino acids - 9- Caloric values : 3.4 Kcal/g for dextrose & amino acids - 9Kcal/g for fatKcal/g for fat

-At least 80% of necessary calories should be provided.-At least 80% of necessary calories should be provided.

-A positive nitrogen balance can be achieved by 60 Kcal/kg-A positive nitrogen balance can be achieved by 60 Kcal/kg/day of IV glucose + 2.5 g/kg/day of a.a./day of IV glucose + 2.5 g/kg/day of a.a.

-Higher energy intakes improve nitrogen retention and spare-Higher energy intakes improve nitrogen retention and sparefat reservesfat reserves

Energy Requirements


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PN-suggested guidelines for InitiationPN-suggested guidelines for Initiationand Maintenanceand Maintenance

Substrate Initiation Advancement GoalsDextrose 10% 2-5%/day 25%

Amino acids 1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day

20% Lipids 1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day

Dextrose Concentrations of 10-12.5 % can be used in peripheralDextrose Concentrations of 10-12.5 % can be used in peripheralveins. Higher concentration (up to 25%) can be used in centralveins. Higher concentration (up to 25%) can be used in central

veins.veins.


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Minerals:Minerals: Sodium : 3 3.8 mEq/kg/daySodium : 3 3.8 mEq/kg/day Potassium : 1-1.2 mEq/kg/dayPotassium : 1-1.2 mEq/kg/day Chloride : 2 mEq/kg/dayChloride : 2 mEq/kg/day Calcium : 80 mg/kg/day (20 mg/dl=0.5Calcium : 80 mg/kg/day (20 mg/dl=0.5

mmol/dl=1 mEq/dl)mmol/dl=1 mEq/dl) Magnesium : 6 mg/kg/day (12 mg/dl=0.5Magnesium : 6 mg/kg/day (12 mg/dl=0.5

mmol/dl=1mEq/dl)mmol/dl=1mEq/dl)

Phosphhrus : 60 mg/kg/dayPhosphhrus : 60 mg/kg/day


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Trace elementsTrace elements

Zinc : 300-450 ug / dlZinc : 300-450 ug / dl

Copper : 20-30 ug/dlCopper : 20-30 ug/dlChromium:0.2-0.3 ug/dlChromium:0.2-0.3 ug/dl

Manganese: 5-7 ug/dlManganese: 5-7 ug/dl

Selenium: 1.5-2 ug/dlSelenium: 1.5-2 ug/dl

Trace elements should be stopped or given less frequentlyTrace elements should be stopped or given less frequently

ininsevere cholestasissevere cholestasis (copper & Mg are eleminated in bile)(copper & Mg are eleminated in bile)

or inor in renal failurerenal failure (Se & chromium accumulations).(Se & chromium accumulations).

However in both situations Zn should be given the sameHowever in both situations Zn should be given the same


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Monitoring:Monitoring: Daily weightDaily weight Routine nursing observationsRoutine nursing observations Laboratory investigations :Laboratory investigations :

-CBC-CBC

-Urine (sugar, acetone)-Urine (sugar, acetone)-Electrolytes-Electrolytes-Transaminases, alkaline phosphatase and bilirubin levels-Transaminases, alkaline phosphatase and bilirubin levels-Urea & creatinine-Urea & creatinine

-Lipid levels-Lipid levelsFat infusion should be stopped 2-4 hours before taking bloodFat infusion should be stopped 2-4 hours before taking bloodsamples (8 hours for lipid tests)samples (8 hours for lipid tests)


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Complications :Complications :

InfectionInfection Hepatic dysfunctionHepatic dysfunction Metabolic complications: hyperglycemia,Metabolic complications: hyperglycemia,

hypoglycemia, acidosis, hypomagnesemia,hypoglycemia, acidosis, hypomagnesemia,hyperlipidemia, hypocalcemiahyperlipidemia, hypocalcemia

Trace metal deficienciesTrace metal deficiencies

Mechanical complications: dysrrhythmias, venousMechanical complications: dysrrhythmias, venousthrombosis, air embolism & skin sloughsthrombosis, air embolism & skin sloughs Bilirubin displacement by intralipidBilirubin displacement by intralipid


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OVERFEEDINGOVERFEEDING


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Dangers of overfeeding:Dangers of overfeeding:

Secretory diarrhea (with EN)Secretory diarrhea (with EN)

Hyperglycemia, glycosuria, dehydration, lipogenesis,Hyperglycemia, glycosuria, dehydration, lipogenesis,

fatty liver, liver dysfunctionfatty liver, liver dysfunction

Electrolyte abnormalities: POElectrolyte abnormalities: PO44, K, Mg, K, Mg

Volume overload, CHFVolume overload, CHF

COCO22 production- ventilatory demand production- ventilatory demand

OO22consumptionconsumption


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Nutrition support of theNutrition support of the

critically ill patientcritically ill patientwithwith

Organ FailureOrgan Failure


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Respiratory FailureRespiratory Failure


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General treatment goals for respiratory failureGeneral treatment goals for respiratory failure

Treat underlying conditionTreat underlying condition

Support physiologic functionSupport physiologic function

Maintain tissue oxygen deliveryMaintain tissue oxygen delivery

Minimize pulmonary edemaMinimize pulmonary edema

Give nutrition supportGive nutrition supportPrevent/manage infectionPrevent/manage infection


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Nutrient Requirements in Pulmonary FailureNutrient Requirements in Pulmonary Failure

Calories: dont overfeed when weaning to preventCalories: dont overfeed when weaning to preventincreased CO2 productionincreased CO2 production

(Provide 25-30 kcal/kg or resting energy expenditure)(Provide 25-30 kcal/kg or resting energy expenditure)


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Respiratory Quotient (RQ)Respiratory Quotient (RQ)

RQ is the ratio of carbon dioxide produced toRQ is the ratio of carbon dioxide produced to

oxygen consumed.oxygen consumed.

RQ is an indicator of fuel utilizationRQ is an indicator of fuel utilization

Normal (physiologic) range is 0.5 to 1.5Normal (physiologic) range is 0.5 to 1.5

High RQ in a ventilator patient may make itHigh RQ in a ventilator patient may make it

difficult to wean the patient from the respiratordifficult to wean the patient from the respirator


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Respiratory Quotient Values forRespiratory Quotient Values for

Various Fuel SubstratesVarious Fuel Substrates

Fat 0.7

Protein 0.8

Carbohydrate 1.0

Mixed Diet ~0.85

Underfed 1.0


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Protein: 1.5-2 g/kgProtein: 1.5-2 g/kg

Amino acids may increase ventilation, increase O2Amino acids may increase ventilation, increase O2

consumption.consumption.

Fat: OMEGA 3 FA may be anti-inflammatoryFat: OMEGA 3 FA may be anti-inflammatory

and alter immune status in sepsis/ARDSand alter immune status in sepsis/ARDS

Nutrient Requirements in Pulmonary FailureNutrient Requirements in Pulmonary Failure


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Liver FailureLiver Failure


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CaloriesCalories: caloric requirements affected by: caloric requirements affected byacuteness of disease, seriousness of injury,acuteness of disease, seriousness of injury,

absorption, other organ failure, sepsis; accurateabsorption, other organ failure, sepsis; accurate

calculation of REE & total energy nereds.calculation of REE & total energy nereds. CHO:CHO: ~70% non-protein calories; in acute~70% non-protein calories; in acute

failure, may need continuous glucose infusionfailure, may need continuous glucose infusion

Chronic: may have diabetes/altered glucoseChronic: may have diabetes/altered glucose

levels requiring controlled CHO and insulin.levels requiring controlled CHO and insulin.

Nutrient Requirements in liver Failure


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Protein:Protein: well nourished/low stress: 0.8 g/kg;well nourished/low stress: 0.8 g/kg;malnourished/with metabolic stress: up to 1.5malnourished/with metabolic stress: up to 1.5

g/kgg/kg

FAT:FAT: 30% non-protein calories.30% non-protein calories.

Evaluate and compensate for vitamins andEvaluate and compensate for vitamins and

mineral deficiencies especially fat solublemineral deficiencies especially fat soluble

vitaminsvitamins

Nutrient Requirements in liver Failure


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Nutrition in PediatricNutrition in PediatricAcute Renal FailureAcute Renal Failure


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Nutrition Implications of ARFNutrition Implications of ARF

ARF causes anorexia, nausea, vomiting, bleedingARF causes anorexia, nausea, vomiting, bleeding

ARF causes rapid nitrogen loss and lean body mass loss (hypercatabolism)ARF causes rapid nitrogen loss and lean body mass loss (hypercatabolism)

ARF causes gluconeogenesis with insulin resistanceARF causes gluconeogenesis with insulin resistance

Dialysis causes loss of amino acids and proteinDialysis causes loss of amino acids and protein

Uremia toxins cause impaired glucose utilization and protein synthesisUremia toxins cause impaired glucose utilization and protein synthesis


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- Impaired Lipolysis- Impaired Lipolysis

Lipase Activity ~50%Lipase Activity ~50%impaired Lipoprotein Lipaseimpaired Lipoprotein Lipase

impaired Hepatic Triglyceride Lipaseimpaired Hepatic Triglyceride Lipase

Nutrition Implications of ARFNutrition Implications of ARF

-Impaired a.a metabolism : impaired conversion and resultant deficienciesof Gly, Ala (Tubular protectant) & Arg (Preserves renal perfusion)

..AA Supplementation helps renal perfusion and GFR and diuresis.


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VitaminsVitamins

Vitamin A: elevated vitamin A levels areVitamin A: elevated vitamin A levels are

known to occur with RFknown to occur with RF Vitamin B prevent B6 deficiency by givingVitamin B prevent B6 deficiency by giving

10 mg pyridoxine hydrochloride/day10 mg pyridoxine hydrochloride/day

Vitamin C:


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SIRSSIRS

&&Multiple Organ FailureMultiple Organ Failure


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Nutrition/Metabolism ConsiderationsNutrition/Metabolism Considerations

3-5 times higher catabolism3-5 times higher catabolism

Increased skeletal muscle proteolysisIncreased skeletal muscle proteolysis

Higher shift of amino acids forHigher shift of amino acids forgluconeogenesisgluconeogenesis


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Nutrient Needs in MODSNutrient Needs in MODS

Calories: Adequate intakeCalories: Adequate intake

Protein: up to 1.5-2.0 g/kgProtein: up to 1.5-2.0 g/kg

Fat: 30% nonprotein caloriesFat: 30% nonprotein calories Micronutrients: evaluate individuallyMicronutrients: evaluate individually

Fluid: based on fluid statusFluid: based on fluid status


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CONCLUSIONSCONCLUSIONS

Start nutrition earlyStart nutrition early Enteral route is preferred when availableEnteral route is preferred when available Set goals for the individual patientSet goals for the individual patient Appropriate monitoring is essentialAppropriate monitoring is essential Avoid overfeedingAvoid overfeeding

Critically ill patients with organ failureCritically ill patients with organ failurepresent special challenges to the nutritionpresent special challenges to the nutritioncare professional and medical teamcare professional and medical team


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Thank youThank you


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DextroseDextrose - Begin PN at 10 - 15% dextrose depending on whether the line is- Begin PN at 10 - 15% dextrose depending on whether the line isperipheral or central and the clinical status and age of the child. Advance by 2.5 -peripheral or central and the clinical status and age of the child. Advance by 2.5 -5% in older infants and children and by 5 - 10% per day in adolescents until an5% in older infants and children and by 5 - 10% per day in adolescents until anendpoint of D12.5% dextrose for PPN or generally between 20 - 25% dextrose forendpoint of D12.5% dextrose for PPN or generally between 20 - 25% dextrose forCPN, as needed to meet nutritional needs.CPN, as needed to meet nutritional needs.

Provision of excess carbohydrate calories may lead to the following adverseProvision of excess carbohydrate calories may lead to the following adverseeffects: hyperglycemia, hepatotoxicity, cholestasis, glycosuria, osmotic diuresiseffects: hyperglycemia, hepatotoxicity, cholestasis, glycosuria, osmotic diuresis

Insulin UseInsulin Use - Critically ill pediatric patients experiencing hyperglycemia from- Critically ill pediatric patients experiencing hyperglycemia fromstress or medical management may need to have insulin added to the TPN.stress or medical management may need to have insulin added to the TPN.

Initiation and advancement of Macronutrients:


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ProteinProtein - Infants under 2 years of age should be started on a- Infants under 2 years of age should be started on apediatric parenteral amino acid solution such aspediatric parenteral amino acid solution such as TrophAmineTrophAmine(B. Braun, Irvine, CA). This amino acid formulation for(B. Braun, Irvine, CA). This amino acid formulation forpediatric patients provides numerous advantages including:pediatric patients provides numerous advantages including:provides essential amino acids for infants, promotes plasmaprovides essential amino acids for infants, promotes plasma

amino acid profiles within normal neonatal target range,amino acid profiles within normal neonatal target range,decreases the tendency for development of cholestasis, anddecreases the tendency for development of cholestasis, anddecreases the pH of the solution thus improving calcium anddecreases the pH of the solution thus improving calcium andphosphorus solubility (7.2 mEq of Ca + Phos per 100 ml of PNphosphorus solubility (7.2 mEq of Ca + Phos per 100 ml of PNsolution).solution).

Protein Advancement in Infants and ChildrenProtein Advancement in Infants and Children - Begin at 1.5 -- Begin at 1.5 -2 gm/kg per day and advance to endpoint goal by Day 2. In2 gm/kg per day and advance to endpoint goal by Day 2. Ininfants with renal insufficiency or failure may need to limitinfants with renal insufficiency or failure may need to limitprotein to 1.0 gm/kg/day on first day of PN.protein to 1.0 gm/kg/day on first day of PN.



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LipidsLipids - Lipids may be safely used on a daily basis in most- Lipids may be safely used on a daily basis in mostpatients. Begin lipids at 1.0 gm/kg and advance by 1.0 gm/kg perpatients. Begin lipids at 1.0 gm/kg and advance by 1.0 gm/kg perday depending on a child's age and lipid clearance to theday depending on a child's age and lipid clearance to theappropriate endpoint goal of 3 gm/kg in infants and 1 - 2.0 gm/kgappropriate endpoint goal of 3 gm/kg in infants and 1 - 2.0 gm/kgin older children and adolescents, depending on clinical status.in older children and adolescents, depending on clinical status.

Essential Fatty Acid (EFA) RequirementsEssential Fatty Acid (EFA) Requirements - 20% Intralipid (2- 20% Intralipid (2kcal/cc) should be provided at a minimum dose of 0.5 - 1.0 gm/kgkcal/cc) should be provided at a minimum dose of 0.5 - 1.0 gm/kgper day for provision of essential fatty acid (EFA) requirements.per day for provision of essential fatty acid (EFA) requirements.Signs of EFA deficiency include: reduced growth rate, impairedSigns of EFA deficiency include: reduced growth rate, impairedwound healing, increased susceptibility to infections,wound healing, increased susceptibility to infections,

thromobocytopenia, and flaky dry skin .thromobocytopenia, and flaky dry skin .



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Mahmoud Tarek PICU Nutrition Fainal 29-3-09

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