Risk factors for gastrointestinal complications in critically ill children with transpyloric enteral nutrition

Procedures for a Transpyloric Feeding Tube Inserted Into Newborns and Infants: A Systematic Review

BACKGROUND

Enteral feeding by a transpyloric tube in critically ill infants is indicated when there is a failure in gastric feeding. However, there is a wide variability regarding the insertion technique.

PURPOSE

To perform a systematic review of the methods for inserting a transpyloric feeding tube in newborns and infants.

DATA SOURCES

Nine databases, without date or language restrictions, accessed in September 2021.

STUDY SELECTION

A systematic review of experimental and nonexperimental studies, according to the "Patient/problem; Intervention; Comparison; Outcome" strategy and the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. The clinical question was about the measurement and insertion techniques, as well as the success rates of properly placing a transpyloric tube in newborns and infants.

DATA EXTRACTION

Two authors (N.M.Q. and J.F.S.) analyzed 6 observational descriptive prospective studies, all of them published in peer-reviewed indexed medical journals and one in the official journal of the National Association of Neonatal Nurses.

RESULTS

The success rate varied between 70% and 100%. There was an important variability in the type of tube, measurement method, and insertion techniques. It was found that the most common strategies to achieve proper positioning were glabella-calcaneal measurements, gastric air insufflation, and right lateral decubitus.

IMPLICATIONS FOR PRACTICE

A transpyloric catheter insertion protocol needs to be established in each neonatal unit, according to the literature findings.

IMPLICATIONS FOR RESEARCH

Randomized controlled studies that evaluate the gastric air insufflation technique and other adjuvant measures could elucidate the knowledge gap concerning the correct positioning of transpyloric tubing in newborns and infants.

Nutrition in critically ill children with acute kidney injury on continuous kidney replacement therapy: a 2023 executive summary

OBJECTIVES

Nutrition plays a vital role in the outcome of critical illness in children, particularly those with acute kidney injury. Currently, there are no established guidelines for children with acute kidney injury treated with continuous kidney replacement therapy. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with acute kidney injury receiving continuous kidney replacement therapy.

METHODS

An electronic search using PubMed and an inclusive academic library search (including MEDLINE, Cochrane, and Embase databases) was conducted to find relevant English-language articles on nutrition therapy for children (<18 y of age) receiving continuous kidney replacement therapy.

RESULTS

The existing literature was reviewed by our work group, comprising pediatric nephrologists and experts in nutrition. The modified Delphi method was then used to develop a total of 45 clinical practice points. The best methods for nutritional assessment are discussed. Indirect calorimetry is the most reliable method of predicting resting energy expenditure in children on continuous kidney replacement therapy. Schofield equations can be used when indirect calorimetry is not available. The non-intentional calories contributed by continuous kidney replacement therapy should also be accounted for during caloric dosing. Protein supplementation should be increased to account for the proteins, peptides, and amino acids lost with continuous kidney replacement therapy.

CONCLUSIONS

Clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with acute kidney injury and on continuous kidney replacement therapy based on the existing literature and expert opinions of a multidisciplinary panel.

Advances in pediatric acute kidney injury pharmacology and nutrition: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

BACKGROUND

In the past decade, there have been substantial advances in our understanding of pediatric AKI. Despite this progress, large gaps remain in our understanding of pharmacology and nutritional therapy in pediatric AKI.

METHODS

During the 26th Acute Disease Quality Initiative (ADQI) Consensus Conference, a multidisciplinary group of experts reviewed the evidence and used a modified Delphi process to achieve consensus on recommendations for gaps and advances in care for pharmacologic and nutritional management of pediatric AKI. The current evidence as well as gaps and opportunities were discussed, and recommendations were summarized.

RESULTS

Two consensus statements were developed. (1) High-value, kidney-eliminated medications should be selected for a detailed characterization of their pharmacokinetics, pharmacodynamics, and pharmaco-"omics" in sick children across the developmental continuum. This will allow for the optimization of real-time modeling with the goal of improving patient care. Nephrotoxin stewardship will be identified as an organizational priority and supported with necessary resources and infrastructure. (2) Patient-centered outcomes (functional status, quality of life, and optimal growth and development) must drive targeted nutritional interventions to optimize short- and long-term nutrition. Measures of acute and chronic changes of anthropometrics, body composition, physical function, and metabolic control should be incorporated into nutritional assessments.

CONCLUSIONS

Neonates and children have unique metabolic and growth parameters compared to adult patients. Strategic investments in multidisciplinary translational research efforts are required to fill the knowledge gaps in nutritional requirements and pharmacological best practices for children with or at risk for AKI.

Nutrition in Critically Ill Children with AKI on Continuous RRT: Consensus Recommendations

BACKGROUND

Nutrition plays a vital role in the outcome of critically ill children, particularly those with AKI. Currently, there are no established guidelines for children with AKI treated with continuous RRT (CRRT). A thorough understanding of the metabolic changes and nutritional challenges in AKI and CRRT is required. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with AKI receiving CRRT.

METHODS

PubMed, MEDLINE, Cochrane, and Embase databases were searched for articles related to the topic. Expertise of the authors and a consensus of the workgroup were additional sources of data in the article. Available articles on nutrition therapy in pediatric patients receiving CRRT through January 2023.

RESULTS

On the basis of the literature review, the current evidence base was examined by a panel of experts in pediatric nephrology and nutrition. The panel used the literature review as well as their expertise to formulate clinical practice points. The modified Delphi method was used to identify and refine clinical practice points.

CONCLUSIONS

Forty-four clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with AKI and on CRRT on the basis of the existing literature and expert opinions of a multidisciplinary panel.

Nutritional management of children with acute kidney injury-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

The nutritional management of children with acute kidney injury (AKI) is complex. The dynamic nature of AKI necessitates frequent nutritional assessments and adjustments in management. Dietitians providing medical nutrition therapies to this patient population must consider the interaction of medical treatments and AKI status to effectively support both the nutrition status of patients with AKI as well as limit adverse metabolic derangements associated with inappropriately prescribed nutrition support. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPR) for the nutritional management of children with AKI. We address the need for intensive collaboration between dietitians and physicians so that nutritional management is optimized in line with AKI medical treatments. We focus on key challenges faced by dietitians regarding nutrition assessment. Furthermore, we address how nutrition support should be provided to children with AKI while taking into account the effect of various medical treatment modalities of AKI on nutritional needs. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. CPRs will be regularly audited and updated by the PRNT.

Nutrition for critically ill children and neonates requiring dialysis: Application of clinical practice recommendations

Approximately 30% of all children and neonates admitted to the intensive care unit (ICU) experience acute kidney injury (AKI). Children with AKI are largely poorly fed and experience high rates of malnutrition. Nutrition prescription and provision are exceptionally challenging for critically ill neonates, infants, and children with AKI given the dynamic nature of AKI and its respective treatment modalities. Managing the nutrition prescription of critically ill neonates, infants, and children with AKI requires nutrition support clinicians to have a high-level understanding of the various treatment modalities for AKI, which can affect the patient's protein, fluid, electrolyte, and mineral needs. Accurate and timely nutrition assessment in critically ill neonates and children with AKI can be flawed owing to difficulty obtaining accurate anthropometric parameters. Recently, the Pediatric Renal Nutrition Taskforce introduced clinical practice recommendations for the nutrition management of children with AKI. In this review, we will discuss the practical implications of these recent guidelines and work to bridge the knowledge and practice gaps for pediatric and neonatal nutrition support clinicians providing nutrition therapy for patients with AKI in the ICU. We also appraise special nutrition-related considerations for neonates with AKI given newer available renal replacement treatment modalities.

Risk factors for hypokalemia and its association with postoperative recovery in patients scheduled for radical gastrectomy: a retrospective study

BACKGROUND

Hypokalemia is common in patients of various operations, especially gastrointestinal surgery, which seriously affects the safety and enhanced recovery after surgery. Our study aims to explore the risk factors of preoperative hypokalemia of radical gastrectomy for gastric cancer and analyze its impact on postoperative recovery.

METHODS

A total of 122 patients scheduled for radical gastrectomy from September, 2022 to December, 2022 were retrospectively analyzed. According to the serum potassium level before skin incision, patients were divided into hypokalemia group (n = 64) and normokalemia group (n = 58). Factors including age, gender, BMI, ASA classification, glutamic pyruvic transaminase (ALT), glutamic oxaloacetic transaminase (AST), creatinine, blood urea nitrogen (BUN), albumin, hypertension history, whether taking calcium channel blockers, β-receptor blockers, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor antagonist (ARB), thiazide diuretics and other drugs, anemia history, diabetes mellitus history, inability to eat or intestinal obstruction, vomiting, diarrhea, hypokalemia on admission and whether under cooperation with clinical nurse specialist were compared between groups. Univariate logistic regression analysis was used to determine risk factors for hypokalemia with p < 0.2 included as a cutoff. Multivariate logistic regression was used to analyze the influencing factors of preoperative hypokalemia for the indicators with differences. A receiver operating characteristic (ROC) curve was used to evaluate the efficacy of the regression model. Primary exhaust time and defecation time after surgery were compared between the two groups.

RESULTS

The use of ACEI or ARB [OR 0.08, 95% CI (0.01 to 0.58), p = 0.012] and thiazide diuretics [OR 8.31, 95% CI (1.31 to 52.68), p = 0.025], inability to eat for more than 3 days or intestinal obstruction [OR 17.96, 95% CI (2.16 to 149.43), p = 0.008], diarrhea for more than 48 h [OR 6.21, 95% CI (1.18 to 32.61), p = 0.031] and hypokalemia on admission [OR 8.97, 95% CI (1.05 to 77.04), p = 0.046] were independent influencing factors of hypokalemia before skin incision. Primary postoperative exhaust time and defecation time was significantly longer in the hypokalemia group than in the normokalemia group, no matter after laparoscopic radical gastrectomy (p = 0.044, p = 0.045, respectively) or open radical gastrectomy (p = 0.033, p = 0.019, respectively).

CONCLUSION

Early attention and management of serum potassium in patients undergoing radical gastrectomy can better reduce perioperative adverse reactions and promote recovery of gastrointestinal function.

The effect of transpyloric enteral nutrition on inflammatory response and prognosis for patients with Corona Virus Disease-19 in intensive care unit: A STROBE compliant study

To investigate the effect of transpyloric enteral nutrition (TEN) on NLRP1, inflammatory response and prognosis for patients with Corona Virus Disease-19 (COVID-19) in intensive care unit (ICU). The present prospective observational study included 29 cases of COVID-19 patients in ICU who admitted to our hospital during February 2020 to March 2020. All the patients were divided into gastrogavage groups (n = 16) and TEN group (n = 13) according to route of enteral nutrition. Serum levels of C-reactive protein (CRP), interleukin-1 β (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) and NLRP1 (NLR family pyrin domain containing 1) was detected by enzyme linked immunosorbent assay (ELISA). Serum levels of lymphocyte, albumin and hemoglobin was detected using an automatic biochemical analyzer. Patients' demographic and clinical characteristics were collected and analyzed. Kaplan-Meier (K-M) curve was conducted for survival analysis and receiver operating characteristic curve was used for the analysis of diagnostic value of biomarkers. All the patients were followed-up for 3 months. This study found that the survival group had higher rate of TEN therapies than the deceased. COVID-19 patients in ICU on TEN had lower APACHE II scores, frequency of feeding suspension and mortality, however, with higher content of albumin was found at 5th day. The incidence of nutritional intolerance including abdominal distension and gastric retention in patients on TEN was notably lower than those on gastrogavage. The serum levels of NLRP1, CRP, IL-1β, IL-6 and TNF-α decreased in a time-dependent manner, but patients on TEN had lower levels of NLRP1, CRP and IL-1β than patients on gastrogavage. A positive correlation was found among NLRP1 and inflammatory factors, and COVID-19 patients with lower NLRP1 had longer survival time. Serum NLRP1 also exhibited diagnostic value for the death of COVID-19 patients. TEN decreased inflammatory response and improved the prognosis for COVID-19 patients in ICU.

Accuracy of clinical indicators of the nursing diagnosis of dysfunctional gastrointestinal motility in infants

This study aimed to analyze the accuracy of the clinical indicators of the nursing diagnosis of dysfunctional gastrointestinal motility in infants from neonatal units and identify their association with clinical variables. This is a study of the diagnostic accuracy of clinical indicators of the diagnosis of dysfunctional gastrointestinal motility, with a cross-sectional design, performed on 228 hospitalized infants in neonatal units. A high prevalence of dysfunctional gastrointestinal motility was identified in the studied population. Regarding accuracy measures, clinical indicators such as increased gastric residual, changes in bowel sounds, bile-colored gastric residual, regurgitation, absence of flatus, and hard and formed stool were useful to discriminate between infants with and without dysfunctional gastrointestinal motility. The findings can help nurses during the diagnostic process, as they identify which defining characteristics can be used to confirm or rule out the probability of occurrence of the diagnosis.

Acute gastrointestinal injury in critically ill children: Impact on clinical outcome

AIM

To estimate acute gastrointestinal injury (AGI) in critically ill children and association of its severity with mortality.

METHODS

In a prospective cohort study, critically ill children (1 month-18 years) were enrolled. Gastrointestinal symptoms over the first week of admission were classified into AGI grades 1 through 4, using a paediatric adaptation of European Society of Intensive Care Medicine AGI definitions. Performance of AGI grades in predicting 28-day mortality was evaluated.

RESULTS

Of 151 children enrolled, 71 (47%, 95% confidence interval (CI): 38.9-55.3%) developed AGI, with AGI grades 1, 2, 3 and 4 in 22.5%, 15.9%, 6.6% and 2%, respectively. The 28-day mortality progressively increased with AGI grade 0 (15%), 1 (35%), 2 (50%), 3 (70%), through 4 (100%), P < 0.001. Association of AGI grades with 28-day mortality was significant even after adjustment for disease severity, age and nutritional status (odds ratio (OR) = 2.152, 95% CI: 1.455, 3.184). Among AGI grades, and paediatric logistic organ dysfunction-2 score components, cardiovascular (OR = 1.525, 95% CI: 1.142, 2.037) and haematological (OR = 1.719, 95% CI: 1.067, 2.772) components of paediatric logistic organ dysfunction-2 score and AGI grades (OR = 1.565, 95% CI: 1.001, 2.449) showed significant association with 28-day mortality.

CONCLUSIONS

Nearly half of the critically ill children developed AGI. AGI grades were independently associated with increased mortality, and mortality progressively increased with AGI grade.

Fluid overload in children with pediatric acute respiratory distress syndrome: A retrospective cohort study

OBJECTIVES

To assess the association of cumulative fluid overload (FO) up to 14 days from the diagnosis of pediatric acute respiratory syndrome (PARDS) with pediatric intensive care unit (PICU) mortality, 28-day mechanical ventilation free days (VFD), and 28-day intensive care unit free days (IFD). We hypothesized that fluid overload, even beyond the acute period, would be associated with increased morbidity and mortality.

METHODS

We conducted a retrospective cohort study of PARDS patients admitted to PICU from 2009 to 2015. For repeated admissions, we considered the admission with the highest oxygenation index (OI). Daily FO (%) was calculated as (intake - output)/weight at PICU admission × 100. Peak cumulative FO (CFO) was the highest CFO from the diagnosis of PARDS to Day 14 or to PICU discharge or mortality, whichever was earliest. Rate to peak CFO was the peak CFO divided by the number of days to reach that highest CFO. The association of FO with mortality, VFD and IFD were analyzed with logistic and linear regression models, with the following covariates: Pediatric Index of Mortality 2 score, PARDS severity, and the presence of acute kidney injury (AKI).

RESULTS

There were 165 patients included in this study, with a mortality rate of 45.5% (75/165), median age 3.2 years (interquartile range [IQR] 0.7-9.9) and OI 15.8 (IQR 9.5-27.9). Seventy-three (44.2%) patients had severe PARDS and 64 (38.8%) had AKI. AKI (aOR [adjusted odds ratio] 3.19, 95% CI [confidence interval] 1.43-7.09, p = 0.004) and rate to peak cumulative FO (aOR 1.23, 95% CI 1.07-1.42, p = 0.004) were associated with mortality. AKI and peak cumulative FO were associated with decreased VFD and IFD.

CONCLUSION

The rate to peak CFO over the first 14 days of PARDS was associated with mortality and peak CFO was associated with decreased VFD and IFD.

Early Enteral Nutrition and Gastrointestinal Complications in Pediatric Patients on Extracorporeal Membrane Oxygenation

OBJECTIVES

To assess the safety of enteral nutrition (EN) in children on extracorporeal membrane oxygenation (ECMO). To describe nutritional status and the characteristics of the nutritional support in this population.

METHODS

A retrospective single-center analysis (2006-2016) including children <18 years on ECMO. Demographic data, nutritional status, characteristics of nutritional support, and development of gastrointestinal (GI) complications were recorded.

RESULTS

One hundred children, with a median age of 9.7 months (interquartile range [IQR] 3.9-63.1) were enrolled. Undernutrition was prevalent among children on ECMO (33.3%) mainly in patients <2 years (P = 0.042). Most patients (64%) received EN at some point during ECMO therapy. EN was administered in the first 48 hours after ECMO initiation (48HEN) to 60.3% of the children.Mortality rate in the Pediatric Intensive Care Unit was lower in patients who received EN as the initial artificial nutrition support (ANS) (37.7 vs 51%, P = 0.005) and in children on 48HEN (34% vs 50%, P = 0.04). In the logistic regression analysis, duration of ECMO support and low cardiac output indication were the only factors associated with mortality.Although most patients on ECMO (45%) developed digestive complications, they were mostly mild, being constipation the most prevalent. In the logistic regression analysis, EN was not associated with an increase in GI complications (P = 0.09). Only three patients developed intestinal ischemia (one without EN and two on EN).

CONCLUSIONS

Undernutrition is prevalent among children on ECMO, mainly in infants <2 years. EN is not associated with severe gastrointestinal complications or higher mortality in these children.

Gastrointestinal Complications in Critically Ill Children: Experience from A Resource-Limited Country

Objectives:

To determine the frequency and predictors of outcome of gastrointestinal complications (GIC) in critically ill children.

Methods:

This descriptive study was prospectively conducted in The Pediatric Intensive Care Unit (PICU), The Aga Khan University Hospital (AKUH), Karachi, from September 2015 to January 2017. After obtaining approval from the Ethical Review Committee of AKUH and informed consent from the parents, all children (aged one month to 18 years), of either gender, admitted to the Pediatric Intensive Care Unit (PICU) during the study period were included. The frequency of the defined GIC: vomiting, high gastric residue volume (GRV), diarrhea, constipation, and gastrointestinal bleed were recorded daily for the first week of the PICU stay. The data was collected by the primary investigator on a predesigned data collection form with inclusion of variables and predictors in light of existing literature and local expertise. The questionnaire was shared with the Pediatric Critical Care Medicine faculty and a consensus was sought on the elements to be incorporated.

Results:

GIC developed within the first 48 hours of admission in 78 (41%) patients. Of the patients who developed GIC, 37 (47.4%) patients developed high GRV: 31 (39.7%) patients developed constipation, 18 (23.1%) patients developed vomiting, 14 (17.9%) patients developed abdominal distension. With regards to prevalence by occurrence, 32/78 (41%) of patients presented with two GI complications, followed by 21 patients (27%) who presented with a single GIC. Only 11 patients (14%) presented with more than three complications. Median length of stay was higher in patients with GIC (8 days) than with those who did not develop GIC (4 days). The frequency of gastrointestinal complications was significantly higher in children receiving mechanical ventilation, on sedatives and relaxants and those with multiorgan dysfunction syndrome (MODS) and inotropes

Conclusion:

GI complications are a frequent occurrence in the PICU and are associated with worse clinical outcomes. The use of sedative drugs and the presence of shock with MODS were amongst the important contributing factors.

Hypophosphatemia in critically ill adults and children - A systematic review

BACKGROUND & AIMS

Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphatemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphatemia, associated morbidity and treatments.

METHODS

A systematic review was conducted (PROSPERO CRD42020163191). Nine clinically relevant questions were generated, seven for adult and two for pediatric critically ill patients, and prevalence of hypophosphatemia was assessed in both groups. We identified trials through systematic searches of Medline, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Quality assessment was performed using the Cochrane risk of bias tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies.

RESULTS

For all research questions, we identified 2727 titles in total, assessed 399 full texts, and retained 82 full texts for evidence synthesis, with 20 of them identified for several research questions. Only 3 randomized controlled trials were identified with two of them published only in abstract form, as well as 28 prospective and 31 retrospective studies, and 20 case reports. Relevant risk of bias regarding selection and comparability was identified for most of the studies. No meta-analysis could be performed. The prevalence of hypophosphatemia varied substantially in critically ill adults and children, but no study assessed consecutive admissions to intensive care. In both critically ill adults and children, several studies report that hypophosphatemia is associated with worse outcome (prolonged length of stay and the need for respiratory support, and higher mortality). However, there was insufficient evidence regarding the optimal threshold upon which hypophosphatemia becomes critical and requires treatment. We found no studies regarding the optimal frequency of phosphate measurements, and regarding the time window to correct hypophosphatemia. In adults, nutrient restriction on top of phosphate repletion in patients with refeeding syndrome may improve survival, although evidence is weak.

CONCLUSIONS

Evidence on the definition, outcome and treatment of clinically relevant hypophosphatemia in critically ill adults and children is scarce and does not allow answering clinically relevant questions. High quality clinical research is crucial for the development of respective guidelines.

Barriers to Delivery of Enteral Nutrition in Pediatric Intensive Care: A World Survey

OBJECTIVES

To explore the perceived barriers by pediatric intensive care healthcare professionals (nurses, dieticians, and physicians) in delivering enteral nutrition to critically ill children across the world.

DESIGN

Cross-sectional international online survey adapted for use in pediatric settings.

SETTING

PICUs across the world.

SUBJECTS

PICU nurses, physicians, and dietitians.

INTERVENTIONS

The 20-item adult intensive care "Barriers to delivery of enteral nutrition" survey was modified for pediatric settings, tested, and translated into 10 languages. The survey was distributed online to pediatric intensive care nurses, physicians, and dieticians via professional networks in March 2019 to June 2019. Professionals were asked to rate each item indicating the degree to which they perceived it hinders the provision of enteral nutrition in their PICUs with a 7-point Likert scale from 0 "not at all a barrier" to 6 "an extreme amount."

MEASUREMENT AND MAIN RESULTS

Nine-hundred twenty pediatric intensive care professionals responded from 57 countries; 477 of 920 nurses (52%), 407 of 920 physicians (44%), and 36 of 920 dieticians (4%). Sixty-two percent had more than 5 years PICU experience and 49% worked in general PICUs, with 35% working in combined cardiac and general PICUs. The top three perceived barriers across all professional groups were as follows: 1) enteral feeds being withheld in advance of procedures or operating department visits, 2) none or not enough dietitian coverage on weekends or evenings, and 3) not enough time dedicated to education and training on how to optimally feed patients.

CONCLUSIONS

This is the largest survey that has explored perceived barriers to the delivery of enteral nutrition across the world by physicians, nurses, and dietitians. There were some similarities with adult intensive care barriers. In all professional groups, the perception of barriers reduced with years PICU experience. This survey highlights implications for PICU practice around more focused nutrition education for all PICU professional groups.

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

OBJECTIVES

To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

DESIGN

A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

METHODS

The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

RESULTS

The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified.

CONCLUSIONS

A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children

OBJECTIVES

To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

DESIGN

A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

METHODS

The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

RESULTS

The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified.

CONCLUSIONS

A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

[Nutrition in children with continuous renal replacement therapy]

INTRODUCTION

The aim of this study was to analyse the nutritional state, diet and gastrointestinal complications of children that require continuous renal replacement therapy (CRRT).

MATERIAL AND METHODS

A retrospective analysis of a database, which included the information about patients who required CRRT between the years 2013 and 2017. Data were collected on the replacement technique, type of nutrition, calorie and protein intake, gastrointestinal complications, and clinical course.

RESULTS

A total of 65 children (61.5% male) were treated with CRRT, and 24 patients (37%) also needed ECMO support. Just over one-quarter (27.7%) of patients had a weight less than P3, and 48.4% of them a height less than P3. At the beginning of the technique, 31 children (47.7%) received enteral nutrition, at the end, there were 52 patients receiving enteral nutrition (80%). The transpyloric tube was used to provide nutrition in 76% of the cases. The median caloric intake was 63kcal/kg/day, and the protein intake was 1.6g/kg/day. There were gastrointestinal difficulties during the process in 48 patients (73.8%), with 29 (44.6%) patients being diagnosed with gastric distension or excessive gastric remains, 22 (33.8%) with constipation, 8 (12.3%) with vomiting, and 4 (6.1%) diarrhoea. One patient treated with ECMO presented with intestinal ischaemia. Enteral nutrition was cancelled in 3 patients (4.6%) due to the complications. There was no relationship between complications and type of diet or ECMO assistance.

CONCLUSIONS

A high percentage of children treated with CRRT showed undernutrition but they had adequate tolerance to the enteral nutrition. Although the gastrointestinal complications percentage was high in few subjects, these complications are the reason why enteral nutrition was stopped.

The Use of Jejunal Tube Feeding in Children: A Position Paper by the Gastroenterology and Nutrition Committees of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition 2019

OBJECTIVES

Jejunal tube feeding (JTF) is increasingly becoming the standard of care for children in whom gastric tube feeding is insufficient to achieve caloric needs. Given a lack of a systematic approach to the care of JTF in paediatric patients, the aim of this position paper is to provide expert guidance regarding the indications for its use and practical considerations to optimize its utility and safety.

METHODS

A group of members of the Gastroenterology and Nutrition Committees of the European Society of Paediatric Gastroenterology Hepatology and Nutrition and of invited experts in the field was formed in September 2016 to produce this clinical guide. Seventeen clinical questions treating indications and contraindications, investigations before placement, techniques of placement, suitable feeds and feeding regimen, weaning from JTF, complications, long-term care, and ethical considerations were addressed.A systematic literature search was performed from 1982 to November 2018 using PubMed, the MEDLINE, and Cochrane Database of Systematic Reviews. Grading of Recommendations, Assessment, Development, and Evaluation was applied to evaluate the outcomes.During a consensus meeting, all recommendations were discussed and finalized. In the absence of evidence from randomized controlled trials, recommendations reflect the expert opinion of the authors.

RESULTS

A total of 33 recommendations were voted on using the nominal voting technique.

CONCLUSIONS

JTF is a safe and effective means of enteral feeding when gastric feeding is insufficient to meet caloric needs or is not possible. The decision to place a jejunal tube has to be made by close cooperation of a multidisciplinary team providing active follow-up and care.

Prevalence and risk factors for hypokalemia in patients scheduled for laparoscopic colorectal resection and its association with post-operative recovery

Background

Perioperative serum potassium levels are closely associated with postoperative clinical outcomes after gastrointestinal surgery. The aim of our retrospective study was to identify the prevalence and risk factors for preoperative hypokalemia (before pneumoperitoneum) and to evaluate the influence of preoperative hypokalemia on the recovery of postoperative gastrointestinal function.

Methods

In this retrospective study, patients scheduled for laparoscopic colorectal resection from November 11 2014 to October 20 2016, were considered for inclusion. A blood potassium level between 3.5 and 5.5 mmol/L was defined as normal, with levels between 3.0 to 3.5 mmol/L, 2.5 to 3.0 mmol/L and < 2.5 mmol/L considered as slight, moderate, and severe level of hypokalemia. The factors including age, gender, ASA grade, BMI, hypertension, diabetes, anti-hypertension drugs, lactose oral soluble, oral cathartics, oral cathartics, cathartic enemas, and blood potassium level before gastrointestinal preparation which might be associated with blood potassium level before pneumoperitoneum were analysed. The time to postoperative first flatus (FFL) and first feces (FFE) was compared between patients with and without hypokalemia.

Results

The final analysis was based on the data of 108 patients. Hypokalemia was identified in 70.37% patients, with the following distribution of blood potassium levels before pneumoperitoneum: slight, 49 (45.37%) patients; moderate, 23 (21.30%); and severe, 4 (3.70%) patients. Hypokalemia was significantly associated with hypertension and the use of ≥2 types of oral cathartics for preoperative gastrointestinal preparation. With treatment, potassium levels recovered to normal levels in all patients within 48 h postoperatively. Hypokalemia was associated with a longer postoperative time to first feces, compared to patients with a normal potassium level before pneumoperitoneum.

Conclusions

Our findings underlie the importance of early monitoring and management of serum potassium levels in these patients.

Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome

Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.

Nonpulmonary treatments for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE

To describe the recommendations from the Pediatric Acute Lung Injury Consensus Conference on nonpulmonary treatments in pediatric acute respiratory distress syndrome.

DESIGN

Consensus conference of experts in pediatric acute lung injury.

METHODS

A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The nonpulmonary subgroup comprised three experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was utilized.

RESULTS

The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 30 of which related to nonpulmonary treatment. All 30 recommendations had strong agreement. Patients with pediatric acute respiratory distress syndrome should receive 1) minimal yet effective targeted sedation to facilitate mechanical ventilation; 2) neuromuscular blockade, if sedation alone is inadequate to achieve effective mechanical ventilation; 3) a nutrition plan to facilitate their recovery, maintain their growth, and meet their metabolic needs; 4) goal-directed fluid management to maintain adequate intravascular volume, end-organ perfusion, and optimal delivery of oxygen; and 5) goal-directed RBC transfusion to maintain adequate oxygen delivery. Future clinical trials in pediatric acute respiratory distress syndrome should report sedation, neuromuscular blockade, nutrition, fluid management, and transfusion exposures to allow comparison across studies.

CONCLUSIONS

The Consensus Conference developed pediatric-specific definitions for pediatric acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These recommendations for nonpulmonary treatment in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for patients with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

Malnutrition in the critically ill child: the importance of enteral nutrition

Malnutrition affects 50% of hospitalized children and 25-70% of the critically ill children. It increases the incidence of complications and mortality. Malnutrition is associated with an altered metabolism of certain substrates, increased metabolism and catabolism depending on the severity of the lesion, and reduced nutrient delivery. The objective should be to administer individualized nutrition to the critically ill child and to be able to adjust the nutrition continuously according to the metabolic changes and evolving nutritional status. It would appear reasonable to start enteral nutrition within the first 24 to 48 hours after admission, when oral feeding is not possible. Parenteral nutrition should only be used when enteral nutrition is contraindicated or is not tolerated. Energy delivery must be individually adjusted to energy expenditure (40-65 kcal/100 calories metabolized/day) with a protein delivery of 2.5-3 g/kg/day. Frequent monitoring of nutritional and metabolic parameters should be performed.

Effect of multifibre mixture with prebiotic components on bifidobacteria and stool pH in tube-fed children

The objective of the present study was to evaluate the effect of a paediatric tube feed supplemented with a multifibre mixture on the gut microbiota and nutritional and micronutrient status of children on long-term enteral nutrition (EN). A randomised, controlled, double-blind, cross-over trial (2 × 3 months) with a washout period of 1 month was carried out. Twenty-seven children (80 % neurologically impaired) aged 11·9 (sd3·9) years, on long-term EN (4·8 (sd3·9) years) were recruited. The analyses of the children's faecal pH, microbiota along with anthropometric measures, bowel movements and markers of blood micronutrient status were made. Twenty children completed the study. A significant increase in the proportion of stool bifidobacteria (+16·6 %,P < 0·05) was observed during the multifibre period than during the fibre-free period, together with a significant reduction in stool pH (P < 0·001). Stool frequency and consistency as well as growth did not differ between the two periods. There was a significant increase (P < 0·05) in plasma ferritin at the end of the fibre-free period, but plasma ferritin levels remained within normal ranges during both periods. No diet effects on other blood parameters were observed. In conclusion, addition of a multifibre mixture with prebiotic components to paediatric EN is well tolerated, promotes bifidobacteria and reduces stool pH, indicating an improved gut health.

Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition

Enteral nutrition support (ENS) involves both the delivery of nutrients via feeding tubes and the provision of specialised oral nutritional supplements. ENS is indicated in a patient with at least a partially functioning digestive tract when oral intake is inadequate or intake of normal food is inappropriate to meet the patients' needs. The aim of this comment by the Committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition is to provide a clinical practice guide to ENS, based on the available evidence and the clinical expertise of the authors. Statements and recommendations are presented, and future research needs highlighted, with a particular emphasis placed on a practical approach to ENS.Among the wide array of enteral formulations, standard polymeric feeds based on cow's-milk protein with fibre and age adapted for energy and nutrient content are suitable for most paediatric patients. Whenever possible, intragastric is preferred to postpyloric delivery of nutrients, and intermittent feeding is preferred to continuous feeding because it is more physiological. An anticipated duration of enteral nutrition (EN) exceeding 4 to 6 weeks is an indication for gastrostomy or enterostomy. Among the various gastrostomy techniques available, percutaneous endoscopic gastrostomy is currently the first option. In general, both patients and caregivers express satisfaction with this procedure, although it is associated with a number of well-recognised complications. We strongly recommend the development and application of procedural protocols that include scrupulous attention to hygiene, as well as regular monitoring by a multidisciplinary nutrition support team to minimise the risk of EN-associated complications.

Clinical severity scores do not predict tolerance to enteral nutrition in critically ill children

The objective of the present study was to analyse whether there is a relationship between the clinical severity at the time of starting transpyloric enteral nutrition (TEN) and the onset of digestive tract complications in critically ill children. Between May 2005 and December 2007, we performed a prospective, observational study with the participation of 209 critically ill children aged between 3 d and 17 years and who received TEN. The characteristics of the nutrition and its tolerance were compared with the paediatric risk of mortality (PRISM), the paediatric index of mortality (PIM) and the paediatric logistic organ dysfunction index (PELOD) at the time of starting the nutrition. Higher PRISM and PELOD scores correlated with a later time of starting enteral nutrition, a longer time to reach the maximum daily energy delivery and a longer duration of the TEN. However, the severity scores did not correlate with the maximum energy delivery achieved. Abdominal distension or excessive gastric residues were observed in 4.7 % of the patients and diarrhoea in 4.3 %. The ability of the severity scores to predict diarrhoea was of 0.67 for PRISM, 0.63 for PELOD and 0.60 for PIM-2.The severity scores were not able to predict other digestive tract complications. Higher scores of clinical severity at the time of starting enteral nutrition correlate with a later initiation of the nutrition, a longer time to reach the maximum energy delivery and a longer duration of TEN. However, their ability to predict digestive tract complications is low.

Gastrointestinal complications in critically ill patients: what differs between adults and children?

PURPOSE OF REVIEW

The objective of this review has been to analyse and compare the causes, incidence, severity and treatment of gastrointestinal complications in critically ill children and adults.

RECENT FINDINGS

The incidence of gastrointestinal complications in critically ill patients published in the literature is very variable owing to the absence of unified diagnostic criteria both in children and adults. The incidence of gastrointestinal complications related to nutrition appears to be lower in children than in adults, and there are no differences in the incidence of gastrointestinal complications between gastric and transpyloric nutrition except with respect to the volume of gastric residues. The most important risk factors for digestive tract complications are shock and the administration of drugs (catecholamines, sedatives and muscle relaxants). Altered gastrointestinal motility is the principal mechanism underlying an excessive gastric residue, abdominal distension and constipation.

SUMMARY

Gastrointestinal complications limit the efficacy of enteral nutrition in the critically ill patient and can affect morbidity and mortality. Consensus must be reached on the definition of the criteria of excessive gastric residues, constipation and diarrhoea, and studies must be performed that evaluate the efficacy of prokinetic agents on altered gastrointestinal motility and the effects of diet and laxatives on constipation in the critically ill adult and child.

Postpyloric enteral nutrition in the critically ill child with shock: a prospective observational study

Background

Tolerance to enteral nutrition in the critically ill child with shock has not been studied. The purpose of the study was to analyze the characteristics of enteral nutrition and its tolerance in the critically ill child with shock and to compare this with non-shocked patients.

Methods

A prospective, observational study was performed including critically ill children with shock who received postpyloric enteral nutrition (PEN). The type of nutrition used, its duration, tolerance, and gastrointestinal complications were assessed. The 65 children with shock who received PEN were compared with 461 non-shocked critically ill children who received PEN.

Results

Sixty-five critically ill children with shock, aged between 21 days and 22 years, received PEN. 75.4% of patients with shock received PEN exclusively. The mean duration of the PEN was 25.2 days and the maximum calorie intake was 79.4 kcal/kg/day. Twenty patients with shock (30.7%) presented gastrointestinal complications, 10 (15.4%) abdominal distension and/or excessive gastric residue, 13 (20%) diarrhoea, 1 necrotising enterocolitis, and 1 duodenal perforation due to the postpyloric tube. The frequency of gastrointestinal complications was significantly higher than in the other 461 critically ill children (9.1%). PEN was suspended due to gastrointestinal complications in 6 patients with shock (9.2%). There were 18 deaths among the patients with shock and PEN (27.7%). In only one patient was the death related to complications of the nutrition.

Conclusion

Although most critically ill children with shock can tolerate postpyloric enteral nutrition, the incidence of gastrointestinal complications is higher in this group of patients than in other critically ill children.