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Curley MAQ, Dawkins-Henry OS, Kalvas LB, Perry-Eaddy MA, Georgostathi G, Yuan I, Wypij D, Asaro LA, Zuppa AF, Kudchadkar SR. The Nurse-Implemented Chronotherapeutic Bundle in Critically Ill Children, RESTORE Resilience (R2): Pilot Testing in a Two-Phase Cohort Study, 2017-2021. Pediatr Crit Care Med 2024:00130478-990000000-00373. [PMID: 39133067 DOI: 10.1097/pcc.0000000000003595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
OBJECTIVES Pilot test the nurse-led chronotherapeutic bundle in critically ill children, RESTORE Resilience (R2). DESIGN A two-phase cohort study was carried out from 2017 to 2021. SETTING Two similarly sized and organized PICUs in the United States. PATIENTS Children 6 months to 17 years old who were mechanically ventilated for acute respiratory failure. INTERVENTIONS R2 seven-item chronotherapeutic bundle, including: 1) replication of child's pre-hospital daily routine (i.e., sleep/wake, feeding, activity patterns); 2) cycled day-night light/sound modulation; 3) minimal effective sedation; 4) night fasting with bolus enteral daytime feedings; 5) early progressive mobility; 6) nursing care continuity; and 7) parent diaries. MEASUREMENTS AND MAIN RESULTS Children underwent environmental (light, sound) and patient (actigraphy, activity log, salivary melatonin, electroencephalogram) monitoring. Parents completed the Child's Daily Routine and Sleep Survey (CDRSS) and Family-Centered Care Scale. The primary outcome was post-extubation daytime activity consolidation (Daytime Activity Ratio Estimate [DARE]). Twenty baseline-phase (2017-2019) and 36 intervention-phase (2019-2021) participants were enrolled. During the intervention phase, nurses used the CDRSS to construct children's PICU schedules. Overall compliance with nurse-implemented R2 elements 1-5 increased from 18% (interquartile range, 13-30%) at baseline to 63% (53-68%) during the intervention phase (p < 0.001). Intervention participants were exposed to their pre-hospitalization daily routine (p = 0.002), cycled day-night light/sound modulation (p < 0.001), and early progressive mobility on more PICU days (p = 0.02). Sedation target identification, enteral feeding schedules, and nursing care continuity did not differ between phases. Parent diaries were seldom used. DARE improved during the intervention phase and was higher pre-extubation (median 62% vs. 53%; p = 0.04) but not post-extubation (62% vs. 57%; p = 0.56). CONCLUSIONS In the PICU, implementation of an individualized nurse-implemented chronotherapeutic bundle is feasible. Children who received the R2 bundle had increased pre-extubation daytime activity consolidation compared to children receiving usual care. Given variation in protocol adherence, further R2 testing should include interprofessional collaboration, pragmatic trial design, and implementation science strategies.
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Affiliation(s)
- Martha A Q Curley
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Laura Beth Kalvas
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Mallory A Perry-Eaddy
- University of Connecticut School of Nursing, Storrs, CT
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT
- Pediatric Intensive Care Unit, Connecticut Children's Medical Center, Hartford, CT
| | - Georgia Georgostathi
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ian Yuan
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Athena F Zuppa
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sapna R Kudchadkar
- Pediatric Intensive Care Unit, Children's Center, Johns Hopkins Medicine, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD
- Department of Pediatrics, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Philpott JD, Hovnanian KMR, Stefater-Richards M, Mehta NM, Martinez EE. The enteroendocrine axis and its effect on gastrointestinal function, nutrition, and inflammation. Curr Opin Crit Care 2024; 30:290-297. [PMID: 38872371 PMCID: PMC11295110 DOI: 10.1097/mcc.0000000000001175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
PURPOSE OF REVIEW Gastrointestinal (GI) dysfunction limits enteral nutrition (EN) delivery in critical illness and contributes to systemic inflammation. The enteroendocrine (EE) axis plays an integral role in this interface between nutrition, inflammation, and GI function in critical illness. In this review, we present an overview of the EE system with a focus on its role in GI inflammation and function. RECENT FINDINGS Enteroendocrine cells have been primarily described in their role in macronutrient digestion and absorption. Recent research has expanded on the diverse functions of EE cells including their ability to sense microbial peptides and metabolites and regulate immune function and inflammation. Therefore, EE cells may be both affected by and contribute to many pathophysiologic states and interventions of critical illness such as dysbiosis , inflammation, and alternative EN strategies. In this review, we present an overview of EE cells including their growing role in nonnutrient functions and integrate this understanding into relevant aspects of critical illness with a focus on EN. SUMMARY The EE system is key in maintaining GI homeostasis in critical illness, and how it is impacted and contributes to outcomes in the setting of dysbiosis , inflammation and different feeding strategies in critical illness should be considered.
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Affiliation(s)
- Jordan D. Philpott
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children’s Hospital, Boston, Massachusetts, USA
- Mucosal Immunology and Biology Research Center, Mass General for Children, Boston, Massachusetts, USA
| | - K. Marco Rodriguez Hovnanian
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children’s Hospital, Boston, Massachusetts, USA
- Mucosal Immunology and Biology Research Center, Mass General for Children, Boston, Massachusetts, USA
| | - Margaret Stefater-Richards
- Department of Medicine, Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M. Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Enid E. Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children’s Hospital, Boston, Massachusetts, USA
- Mucosal Immunology and Biology Research Center, Mass General for Children, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Fell DM, Bitetto EA, Skillman HE. Timing of enteral nutrition and parenteral nutrition in the PICU. Nutr Clin Pract 2023; 38 Suppl 2:S174-S212. [PMID: 37721466 DOI: 10.1002/ncp.11050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/04/2023] [Accepted: 07/08/2023] [Indexed: 09/19/2023] Open
Abstract
The timing of nutrition support initiation has the potential to positively impact nutrition and clinical outcomes in infants and children with critical illness. Early enteral nutrition within 24-48 h and attainment of both a 60% energy and protein goal by the end of the first week of pediatric intensive care unit admission are reported to be significantly associated with improved survival in large observational studies. The results of one randomized controlled trial demonstrated increased morbidity in infants and children with critical illness assigned to early vs delayed supplemental parenteral nutrition. Observational studies in this population also suggest increased mortality with exclusive parenteral nutrition and worse nutrition outcomes when parenteral nutrition is delayed. Subsequently, current nutrition support guidelines recommend early enteral nutrition and avoidance of early parenteral nutrition, although the available evidence used to create the guidelines was inadequate to inform bedside nutrition support practice to improve outcomes. These guidelines are limited by the included studies with small numbers and heterogeneity of patients and research design that confound study outcomes and interpretation. This article provides a narrative review of the timing of nutrition support on outcomes in infants and children with critical illness, strategies to optimize timing and adequacy of nutrition support, and literature gaps, including the timing of parenteral nutrition initiation for children with malnutrition and those with contraindications to enteral nutrition and accurate measurement of energy requirements.
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Affiliation(s)
- Donna M Fell
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Emily A Bitetto
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Heather E Skillman
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
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Veldscholte K, Cramer ABG, de Jonge RCJ, Rizopoulos D, Joosten KFM, Verbruggen SCAT. Intermittent feeding with an overnight fast versus 24-h feeding in critically ill neonates, infants, and children: An open-label, single-centre, randomised controlled trial. Clin Nutr 2023; 42:1569-1580. [PMID: 37478810 DOI: 10.1016/j.clnu.2023.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND & AIMS Critically ill children are fed day and night, assuming this improves enteral tolerance and the probability of achieving nutritional goals. It was previously shown that a fasting response, reflected by increased ketosis, at least partly explained the beneficial outcome of delayed initiation of supplemental parenteral nutrition. This study aims to investigate whether an overnight fast increases ketosis and is feasible and safe in critically ill children. METHODS The Continuousversus Intermittent Nutrition in Paediatric Intensive Care (ContInNuPIC) study is a randomised controlled trial in a tertiary referral Paediatric Intensive Care Unit (PICU) in the Netherlands. Critically ill children (term newborn-18 years) with an expected PICU stay ≥48 h, dependent on artificial nutrition, were eligible. Participants were randomly assigned (1:1, stratified for age group) to intermittent feeding, with interruption of feedings during an age-dependent overnight period of eight to 12 h, or to continuous feeding, with the administration of feedings day and night. In both groups, similar daily caloric targets were pursued. For children younger than one year, mandatory minor glucose infusions were provided during fasting. The primary outcome was the feasibility, defined as two conditions (1): a significant difference in the patients' highest daily ketone (3-β-hydroxybutyrate, BHB) levels during each overnight period, and (2): non-inferiority regarding daily caloric intake, examined using a two-part mixed-effects model with a predefined non-inferiority margin of 33%, in an intention-to-treat analysis. The study is registered in the Netherlands Trial Register (NL7877). RESULTS Between May 19, 2020, and July 13, 2022, 140 critically ill children, median (first quartile; third quartile) age 0.3 (0.1; 2.7) years, were randomised to intermittent (n = 67) or continuous feeding (n = 73). In the intermittent feeding group, BHB levels were significantly higher (median 0.4 (0.2; 1.0) vs. 0.3 (0.1; 0.7) mmol/L, p < 0.001). The ratio of total caloric intake in the intermittent feeding group to the intake in the continuous feeding group was not consistently significantly more than 0.67, thus not proving non-inferiority. No severe, resistant hypoglycaemic events, nor severe gastrointestinal complications related to the intervention occurred, and feeding intolerance did not occur more often in the intermittent than in the continuous feeding group. CONCLUSION Compared with day and night feeding, intermittent feeding with an overnight fast and mandatory glucose infusion for children younger than one year marginally increased ketosis and did not lead to more hypoglycaemic incidents in critically ill children. Because non-inferiority regarding daily caloric intake was not proven, the feasibility of an overnight fast could not be shown in the current study. However, as feeding intolerance did not increase during the condensed feeding periods, the nutritional intake was probably limited by the prescription of nutrition and interruptions. More research is needed to determine the optimal level and duration of clinically relevant ketosis and the best method to achieve this.
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Affiliation(s)
- Karlien Veldscholte
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Arnout B G Cramer
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rogier C J de Jonge
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Koen F M Joosten
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sascha C A T Verbruggen
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.
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Continuous versus Intermittent Enteral Feeding in Critically Ill Children: A Systematic Review. Nutrients 2023; 15:nu15020288. [PMID: 36678158 PMCID: PMC9867148 DOI: 10.3390/nu15020288] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/08/2023] Open
Abstract
Administration of enteral nutrition (EN) in critically ill pediatric patients admitted to the pediatric intensive care unit (PICU) constitutes a major challenge due to the increased risk of complications, as well as the lack of well-trained healthcare professionals. EN is usually delivered via cyclic, continuous, or intermittent feeding; however, a number of potential barriers have been reported in the literature regarding different feeding regimens. The purpose of this review was to assess the effectiveness of continuous and intermittent bolus feeding on critically ill children. A systematic search was conducted in PubMed, Scopus Cochrane Central Register of Controlled Trials (CENTRAL) and a clinical trial registry up to September 2022, including randomized controlled trials (RCTs) published in the English language. Four studies met the inclusion criteria with a total population of 288 patients admitted to the PICU. Three studies were rated with a high risk of bias and one with some concerns. There was high heterogeneity between the studies in regard to the reporting of outcomes. Three studies measured the total time needed to reach prescribed caloric intake with conflicting results, while two studies evaluated the length of stay (LOS) in PICU with no difference between the two arms. One study assessed the time weaning from mechanical ventilation, favoring the bolus group. No data were provided for gastric residual volume (GRV), anthropometric measurements, and biochemical markers. Additional randomized trials with better methodology are needed to assess the efficacy of the two enteral feeding regimens in critically ill PICU patients.
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Martinez EE, Bechard LJ, Brown AM, Coss-Bu JA, Kudchadkar SR, Mikhailov TA, Srinivasan V, Staffa SJ, Verbruggen SSCAT, Zurakowski D, Mehta NM. Intermittent versus continuous enteral nutrition in critically ill children: A pre-planned secondary analysis of an international prospective cohort study. Clin Nutr 2022; 41:2621-2627. [PMID: 36306567 PMCID: PMC9722589 DOI: 10.1016/j.clnu.2022.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/14/2022] [Accepted: 09/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Intermittent enteral nutrition (EN) may have physiologic benefits over continuous feeding in critical illness. We aimed to compare nutrition and infection outcomes in critically ill children receiving intermittent or continuous EN. METHODS International, multi-center prospective observational study of mechanically ventilated children, 1 month to 18 years of age, receiving EN. Percent energy or protein adequacy (energy or protein delivered/prescribed × 100) and acquired infection rates were compared between intermittent and continuous EN groups using adjusted-multivariable and 4:1 propensity-score matched (PSM) analyses. Sensitivity analyses were performed after excluding patients who crossed over between intermittent and continuous EN. RESULTS 1375 eligible patients from 66 PICUs were included. Patients receiving continuous EN (N = 1093) had a higher prevalence of respiratory illness and obesity, and lower prevalence of neurologic illness and underweight status on admission, compared to those on intermittent EN (N = 282). Percent energy or protein adequacy, proportion of patients who achieved 60% of energy or protein adequacy in the first 7 days of admission, and rates of acquired infection were not different between the 2 groups in adjusted-multivariable and propensity score matching analyses (P > 0.05). CONCLUSION Intermittent versus continuous EN strategy is not associated with differences in energy or protein adequacy, or acquired infections, in mechanically ventilated, critically ill children. Until further evidence is available, an individualized feeding strategy rather than a universal approach may be appropriate.
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Affiliation(s)
- Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, MA, USA; Perioperative and Critical Care - Center for Outcomes Research (PC-CORE), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Lori J Bechard
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, MA, USA; Perioperative and Critical Care - Center for Outcomes Research (PC-CORE), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Jorge A Coss-Bu
- Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Austin, TX, USA
| | - Sapna R Kudchadkar
- Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Theresa A Mikhailov
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Vijay Srinivasan
- Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Steven J Staffa
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA
| | - S Sascha C A T Verbruggen
- Pediatric Intensive Care Unit, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, NL, USA
| | - David Zurakowski
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, MA, USA; Perioperative and Critical Care - Center for Outcomes Research (PC-CORE), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.
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