Nutrition in Pediatric Cardiac Intensive Care QUALITY IMPROVEMENT INITIATIVE Nutrition in Pediatric Cardiac Intensive Care María Balestrini, MD Pediatric Cardiac Intensive Care Unit Pediatric Hospital J. P. Garrahan Buenos Aires Argentina

PCICU – PEDIATRIC HOSPITAL J. P. GARRAHAN 21 BEDS, 2 EXCLUSIVE OPERATING ROOMS, 5 SENIOR SURGEONS, CARDIOLOGISTS AND PEDIATRIC CARDIAC INTENSIVISTS

PCICU - HOSPITAL GARRAHAN New patients admitted for surgery 2014 563 Total assignable RACHS-1 patients 514 Neonatal surgeries 67 By pass 85% Mortality rate 5% Other programs ECMO, Chronic ventricular support and heart transplant

PILLARS OF NUTRITIONAL SUPPORT IN THIS PERIOD Preserve the function of vital organs, minimizing the loss of lean body mass, although it can not completely prevent catabolism. Achieve positive nitrogen balance, which is crucial to growth Avoid over feeding, leading to CO2 retention, difficulty in weaning ventilator and impaired immune function.

METABOLIC CHANGES IN THE IMMEDIATE POST SURGICAL Limited glycogen storage Cytokine mobilization Mobilization of amino acids for gluconeogenesis METABOLIC RESPONSE TO STRESS More important in neonates Returns to baseline values between 12 and 24 hours INCREASED METABOLIC RATE Generalized edema Capillaritis (capillary leak syndrome) Multiorgan failure. INCREASED INFLAMMATORY RESPONSE

NUTRITIONAL SUPPORT PROGRAM DEVELOPEMENT Discuss common feeding issues in patients with complex congenital heart disease We reviewed previous practices and made a new feeding protocol We examined preliminary data after the initiation of the new protocol at Garrahan Hospital.

FAILURE OF GROWTH Common among infants with complex CHD: • Inefficient circulation • High metabolic demand during post-operative healing • Alterations in growth factors and growth hormone • Genetic syndromes • Poor oral skills • Gastrointestinal pathology • Associated with worse outcomes in CHD patients

PERIOPERATIVE FEEDING CONSIDERATIONS Preoperatively • Cyanosis and compromised systemic output • Cardiac disease Prostaglandin (PGE) dependent • Need of Umbilical Catheters  Postoperatively • Clinical weakness  • High respiratory support  • Inotropic support  • Poor oral skills  • Gastric dysmotility  • Vocal cord paralysis

PREOPERATIVE FEEDING IN PGE DEPENDENT PATIENTS • No increased risk of necrotizing enterocolitis (NEC) with early feeding in hemodynamically stable, cyanotic infants  • No increase in adverse events with enteral feeding  • No increased risk of NEC with umbilical artery catheters

BENEFITS OF EARLY ENTERAL FEEDING • Improved nutritional status and growth prior to surgery • Improved surgical outcome • Enhanced intestinal maturation • Improved feeding tolerance post-operatively • Decreased length of parental nutrition • Increased immunity

CONSENSUS FEEDING GUIDELINE National Pediatric Cardiology Quality Improvement Collaborative • Created in 2009 to improve outcomes among single ventricle patients • Multidisciplinary Feeding Work Group • Devised first consensus feeding guidelines for single ventricle infants • Released guidelines in 2011

OUR FEEDING GUIDELINES Previous guidelines  • No recommendations on timing of pre or post-operative feed initiation  • Post-operative feeds started continuously at 2 ml/hr  • Increased by 1 ml/hr every 6 hours  • Once at goal volume, caloric density slowly increased  • Once at goal calories, progression to bolus schedule 

OUR FEEDING GUIDELINES Previous guidelines Parenteral nutrition was not initiated within 24 hours of surgery Parenteral nutrition had significant deficit of nutrients We invited a multidisciplinary committee to revise feeding guidelines  New protocol implemented in January 2013

NEW FEEDING GUIDELINES Focus of new guidelines Early initiation of enteral feeds pre and post-operatively  Oral feeding and breast feeding when possible  Vocal cord paralysis assessment after aortic arch interventions  Nasogastric tube bolus as preferred postoperative enteral feeding choice Rapid full protein-caloric requirements achievement A standard parenteral nutrition formula for infants with congenital heart disease was developed.

IMPLEMENTATION OF NUTRITIONAL SUPPORT IN THE IMMEDIATE POSTOPERATIVE PERIOD Day 1 Standard Total Parenteral Nutrition Day 2-3 Standard Total Parenteral Nutrition+Start enteral feeding Onwards Decrease in Total Parenteral Nutrition and progression of enteral feeding

PARENTERAL NUTRITIONAL SUPPORT Volume: 60 ml/kg/day Glucose flow: 7mg/kg /min Amino acids: 3 g/kg/day Lipids: 3 g/kg/day Preparation 2 in 1 Central Line Provides: 1 kcal/ml Calories: 55-60 Kcal / kg / day Goal Calories: 90 – 100 Kcal/kg/day Increase volumen Glucose Peak flow 10 mg/kg/min Check glycosuria Suspend the TPN only if managed to obtain 75% of the total calories by enteral feeding

ENTERAL NUTRITION SUPPORT Trophic mode feeding Nasogastric tube (NG) 20-30 ml/Kg/day Feeding mode - NG - Oral - Bolus - Continuous enteral feeding Feeding options - Human milk preferred - Standard formula - Hydrolyzed formula Volume and Calories Goal - Volume 100-140 ml/Kg/d - Calories 120- 150 Kcal/kg/d

NUTRITIONAL SUPPORT PROGRAM IMPACT EVALUATION We conducted a prospective clinical study from 1 January 2013 to 31 December 2014 Less than 3 months perioperative patients, were included.

Initial evaluation Clinical, Anthropometric Laboratory, Feeding REE 72hs Clinical, Laboratory, Feeding. 7th day Clínical, Laboratory, Feeding Hospital Discharge Clinical, Anthropometric Laboratory, Feeding CLINICAL STUDY Anthropometric: Weight, height, head circumference. (mean and SD) Laboratory: Glucose, albumin, total and ionized calcium, total magnesium, phosphorus, electrolytes, triglycerides Resting energy expenditure (REE) assessment: using Schoffield and WHO equations. Feeding characteristics: volume, formula, calories, proteins, lipids; enteral and parenteral

Diagnoses assignable RACHS-1 patients CLINICAL STUDY N 70 patients Female 55% Median age 17 days (r1-120). 95% neonates All term infants Median weight 3,2 Kg (r1,9-5) LOS 13 day (r1-160) Survival 93% Diagnoses assignable RACHS-1 patients RACHS- 1 % 2 14,3 3 34,2 4 43 6 8,5

5 deaths - 9 early Discharge CLINICAL STUDY Initial evaluation 70 Patients 72 hs 68 patients 2 deaths 7th Day 5 deaths - 9 early Discharge Hospital Discharge 64 PATIENTS COMPLETED THE STUDY

PREOPERATIVE VOLUME ML/KG 78,2 ± 21 CALORIES KCAL/KG 59 ± 10 TPN MEDIAN STANDARD DEVIATION VOLUME ML/KG 78,2 ± 21 CALORIES KCAL/KG 59 ± 10 PREOPERATIVE ENTERAL MEDIAN STANDARD DESVIATION VOLUME ML/KG 77 ± 43 CALORIES KCAL/KG 62 ± 38   % REE MEDIAN SD Schoffield 162 ±86 WHO 163 ±78

TPN 55% MEDIAN RANGE VOLUME ML/KG 55 30-80 CALORIES KCAL/KG 60 30-76 POST OPERATIVE 72 HS The sum of enteral and parenteral gives 66 kcal/ kg/day (r 27 -117) 70% arrived at suggested target ENTERAL 49% MEDIAN RANGE VOLUME ML/KG 60 20-140 CALORIES KCAL/KG 50 10- 117 % REE MEDIAN RANGE/SD Schoffield  127.7 41-328 WHO 137 ±51

DISCHARGE ENTERAL MEDIAN RANGE 78% discharge with oral feeding, VOLUME ML/KG 140 60-160 CALORIES KCAL/KG 120 40-148.5 DISCHARGE 78% discharge with oral feeding, 22% by nasogastric tube. 13 patients with exclusive breast feeding 9 patients combined breast feeding and formula 42 patients formula WEIGHT (kg) MEDIAN SD ADMISSION 3,32 ± 0,68 DISCHARGE 3,5 ± 0,78

CONCLUSION Cardiovascular TPN standard was safely implemented. Parenteral and enteral nutrition, alone or in combination exceeded REE requeriments, during perioperative course in all patients. There were no patients with NEC There was an increase in weight. Head circumference and height remained stable.

SUMMARY Nutrition is a major focus in improving the outcome of children with complex CHD Early pre-operative enteral feeding in this patient population is safe. Standardized approach in nutritional support is likely to improve outcomes in patients with congenital heart surgery, specially neonates and small infants.

THANK YOU VERY MUCH