1. ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY ILL CHILDREN Mudit Mathur, M.D. SUNY Downstate Medical Center

2. 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

3. 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

4. IMPACT OF CRITICAL ILLNESS-2 Increased energy expenditure – Pain – Anxiety – Fever – Muscular effort-WOB, shivering

5. RESPONSE TO INJURY

6. 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

7. NUTRITION: OVERALL GOALS ACCP Consensus statement, 1997 Provide nutritional support appropriate for the individual patient’s – Medical condition – Nutritional status – Available routes for administration

8. NUTRITION: OVERALL GOALS Prevent/treat macro/micronutrient deficiencies Dose nutrients compatible with existing metabolism Avoid complications Improve patient outcomes

9. ENTERAL OR PARENTERAL

10. 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

11. IMPACT OF STARVATION-2 Enzymatic/Hormonal changes – Decreased sucrase and lactase Impact on immunity – Cellular: Decreased T cells, atrophied germinal centers, mitogenic proliferation, differentiation, Th cell function, altered homing – Humoral: Complement, opsonins, Ig, secretory IgA – (70-80% of all Ig produced is secretory IgA) – Increased bacterial translocation

12. 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

13. 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

14. 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)

15. 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 assessment of energy expenditure, Respiratory Quotient

16. 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

17. 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

18. POTENTIAL DRAWBACKS OF ENTERAL FEEDS Gastric emptying impairments Aspiration of gastric contents Diarrhea Sinusitis Esophagitis /erosions Displacement of feeding tube

19. 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%

20. Resting Energy Expenditure Age (years)REE (kcal/kg/day) 0 – 155 1 – 357 4 –648 7 –1040 11-14 (Male/Female)32/28 15-18 (Male/Female)27/25

21. Factors adding to REE Multiplication factor Maintenance0.2 Activity0.1-0.25 Fever0.13/per degree > 38ºC Simple Trauma0.2 Multiple Injuries0.4 Burns0.5-1 Sepsis0.4 Growth0.5

22. 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

23. 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

24. FORMULA COMPOSITION Proteins – -polymeric (pancreatic enzymes required) or peptides – Small peptides from whey protein hydrolysis absorbed better than free AA Fibers – Insoluble-reduce diarrhea, slower transit-better glycemic control – Degraded to SCFA-trophic to colon

25. 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 PO 4, K, Mg GFR >25: 0.6-0.7 g/kg/d GFR <25: 0.3 g/kg/d Immune-enhancing

26. 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)

27. IMMUNE MODULATION Glutamine+arginine+Branched chain AA (Immunaid) Arginine+omega-3 Fatty acids+RNA (Impact) – EN started within 36 hrs – Mortality, bacteremic episodes reduced – More pronounced effect in APACHE II 10-15 Galban et al, CCM, 2000; 28: 3, (643-48)

28. IMMUNE MODULATION MECHANISMS ARE UNCLEAR Reduction of duration and magnitude of inflammatory response Will this disrupt the balance between pro and anti-inflammatory processes?? Of the multiple ingredients in these special formulas: which is “the” one Beneficial effects seen in patients achieving early EN

29. Conclusive studies, clear indications & Cost-benefit analysis are still needed IMMUNE MODULATION

30. Maintains nutritional status Prevents catabolism Provides resistance to infection Potential effect on immune modulation ENTERAL NUTRITION IN CRITICAL ILLNESS:

31. PARENTERAL NUTRITION (PN) The PN formulation is based on: Fluid Requirements Energy Requirements Vitamins Trace elements Other additives-Heparin, H2 blocker etc

32. Fluid Requirements Fluid 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 provided separately. Remember to consider medications, flushes, drips, pressures lines and other IV fluids in your calculations.

33. 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

34. PN-suggested guidelines for Initiation and Maintenance SubstrateInitiation Advance ment GoalsComments Dextrose10%2-5%/day25%Increase as tolerated. Consider insulin if hyperglycemic Amino acids 1 g/kg/day0.5-1 g/kg/day 2-3 g/kg/day Maintain calorie:nitrogen ratio at approximately 200:1 20% Lipids 1 g/kg/day0.5-1 g/kg/day 2-3 g/kg/day Only use 20%

35. Resting Energy Expenditure Age (years)REE (kcal/kg/day) 0 – 155 1 – 357 4 –648 7 –1040 11-14 (Male/Female)32/28 15-18 (Male/Female)27/25

36. Factors adding to REE Multiplication factor Maintenance0.2 Activity0.1-0.25 Fever0.13/per degree > 38ºC Simple Trauma0.2 Multiple Injuries0.4 Burns0.5-1 Sepsis0.4 Growth0.5

37. Suggested monitoring Protocol WeightUrine dip for glucose Bedside glucose Labs First weekDailyQ shift Daily SMA-7, Ca, Mg, Phos, triglycerides Q OD LFTs SubsequentlyDailyQ shift SMA-7, Ca, Mg, Phos 2x/wk CBC, LFTs weekly Triglycerides 2x/wk

38. 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

39. Calculations Fat 20 grams/100ml Fat  _____ml/day = _____grams/day _____g/kg/day  9 kcal/g = _____ kcal/kg/day

40. Calculations grams Protein  6.25 = _____ Nitrogen Non-protein calories  Nitrogen = Calorie:Nitrogen ratio

41. DANGERS OF OVERFEEDING Secretory diarrhea (with EN) Hyperglycemia, glycosuria, dehydration, lipogenesis, fatty liver, liver dysfunction Electrolyte abnormalities: PO 4, K, Mg Volume overload, CHF CO 2 production- ventilatory demand O 2 consumption Increased mortality (in adult studies)

42. 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

43. 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

44. 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

45. QUESTION 2 What would be the preferred mode for nutritional support in a 10 year old boy with head injury, raised ICP and aspiration pneumonia that developed after he vomited during intubation in the field. – Parenteral nutrition – Enteral nutrition – A combination of enteral and parenteral nutrition – IV fluids alone until ICP is better controlled.

46. 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