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Bracken JM, Pappas L, Wilkins J, Tracy K, Al-Rajabi TR, Abdelhadi RA. Measuring growth in critically ill neonates and children. Nutr Clin Pract 2023; 38 Suppl 2:S28-S38. [PMID: 37721462 DOI: 10.1002/ncp.11057] [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: 05/30/2023] [Revised: 07/14/2023] [Accepted: 07/21/2023] [Indexed: 09/19/2023] Open
Abstract
Critical illness increases the risk of malnutrition in both infants and children. Malnutrition risk is multifactorial and includes premorbid factors as well as changes in nutrient metabolism and energy demands during critical illness. Inadequate nutrition has been linked to poor health outcomes and prolonged length of stay in the intensive care unit, demonstrating the importance of both recognizing and addressing malnutrition in this population. Assessing growth and identifying malnutrition requires methodical measurement of growth and a collaborative, multimodal approach to nutrition assessment. Among the nutrition assessment and growth evaluation tools, neonatal, preterm, pediatric, and disease-specific growth charts remain an important component of growth assessment and should be used along with a nutrition-focused physical examination. Routine measurement promotes the identification of potential growth delays that may require interventions. Indirect calorimetry adds an additional layer of detail for a complete picture of each infant or child's unique nutrition status and progress. Quality improvement research on a national level is urgently needed to assess the adequacy and availability of resources in neonatal and pediatric critical care units and to further the development of standard clinical outcome measures for nutrition assessment and intervention in the critically ill neonate and child.
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Affiliation(s)
- Julia M Bracken
- Department of Pediatrics, Division of Gastroenterology, Children's Mercy Hospital, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Lucy Pappas
- Department of Nutrition, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Jamie Wilkins
- Department of Nutrition, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Kelly Tracy
- Department of Nutrition, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Taiseer R Al-Rajabi
- College of Liberal Arts and Sciences, University of Kansas, Lawrence, Kansas, USA
| | - Ruba A Abdelhadi
- Department of Pediatrics, Division of Gastroenterology, Children's Mercy Hospital, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
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2
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Barrocas A, Schwartz DB, Bistrian BR, Guenter P, Mueller C, Chernoff R, Hasse JM. Nutrition support teams: Institution, evolution, and innovation. Nutr Clin Pract 2023; 38:10-26. [PMID: 36440741 DOI: 10.1002/ncp.10931] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022] Open
Abstract
The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.
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Affiliation(s)
- Albert Barrocas
- Department of Surgery, Tulane University School of Medicine, Atlanta, Georgia, USA
| | - Denise Baird Schwartz
- Bioethics Committee, Providence Saint Joseph Medical Center, Burbank, California, USA
| | - Bruce R Bistrian
- Division of Clinical Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition (ASPEN), Moses Lake, Washington, USA
| | - Charles Mueller
- Department of Nutrition and Food Studies, New York University/Steinhardt, New York, New York, USA
| | - Ronni Chernoff
- Donald Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jeanette M Hasse
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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3
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Lyons GCE, Summers MJ, Marshall AP, Chapple LAS. Systematic review of clinicians' knowledge, attitudes, and beliefs about nutrition in intensive care. Nutr Clin Pract 2021; 37:825-842. [PMID: 34617630 DOI: 10.1002/ncp.10785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Nutrition is a key component of care for critically ill patients; yet nutrition delivery is below international recommendations. In order to improve nutrition delivery to critically ill patients, an understanding of the barriers that prevent guideline adherence is required. It is known that clinicians' knowledge, attitudes, and beliefs of the role of nutrition may act as a potential barrier to nutrition delivery, but whether this remains true in critical care is unknown. The aim of this systematic scoping review was to summarize the literature exploring the knowledge, attitudes, and beliefs of clinicians around nutrition support in critically ill patients. A search of four online databases (MEDLINE via Ovid, Emcare via Ovid, PsycINFO, and CINAHL via EBSCOhost) was conducted on August 14, 2020, to identify literature that reported on clinicians' knowledge, attitudes, and beliefs of nutrition in adult intensive care patients. Data were extracted on study and participant characteristics, methodology, and key study outcomes related to nutrition. Eighteen articles met eligibility criteria and were included in the review. Key findings included the following: nutrition was seen as a priority that ranked below life-saving interventions; differences in perceived clinician responsibilities exist; common barriers to nutrition delivery included inadequate resourcing, lack of nutrition protocols, and gastrointestinal intolerance; and identified facilitators included nutrition education and the presence of a supportive multidisciplinary team. The implementation of nutrition protocols, enhanced clinical nutrition education, and further clarification of roles and responsibilities pertaining to nutrition may assist in improving nutrition delivery in critical care.
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Affiliation(s)
- Gemma C E Lyons
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Matthew J Summers
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Andrea P Marshall
- Gold Coast University Hospital, Southport, Queensland, Australia
- Griffith University, Gold Coast Campus, Southport, Queensland, Australia
| | - Lee-Anne S Chapple
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
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4
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Nursing-Sensitive Outcomes among Patients Cared for in Paediatric Intensive Care Units: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189507. [PMID: 34574430 PMCID: PMC8468044 DOI: 10.3390/ijerph18189507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 12/04/2022]
Abstract
Measuring the effectiveness of nursing interventions in intensive care units has been established as a priority. However, little is reported about the paediatric population. The aims of this study were (a) to map the state of the art of the science in the field of nursing-sensitive outcomes (NSOs) in paediatric intensive care units (PICUs) and (b) to identify all reported NSOs documented to date in PICUs by also describing their metrics. A scoping review was conducted by following the framework proposed by Arksey and O’Malley. Fifty-eight articles were included. Publications were mainly authored in the United States and Canada (n = 28, 48.3%), and the majority (n = 30, 51.7%) had an observational design. A total of 46 NSOs were documented. The most reported were related to the clinical (n = 83), followed by safety (n = 41) and functional (n = 18) domains. Regarding their metrics, the majority of NSOs were measured in their occurrence using quantitative single measures, and a few validated tools were used to a lesser extent. No NSOs were reported in the perceptual domain. Nursing care of critically ill children encompasses three levels: improvement in clinical performance, as measured by clinical outcomes; assurance of patient care safety, as measured by safety outcomes; and promotion of fundamental care needs, as measured by functional outcomes. Perceptual outcomes deserve to be explored.
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Pettit RJ, Pruitt LCC, Iantorno S, Bucher BT. Variability in Parenteral Nutrition Use in US Children's Hospitals. JPEN J Parenter Enteral Nutr 2020; 45:1213-1220. [PMID: 32895946 DOI: 10.1002/jpen.2014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND The variability of parenteral nutrition (PN) use for pediatric inpatients is currently unknown. In this study, we aim to determine the variability in PN use in US children's hospitals and the association of PN initiation with inpatient PN use. METHODS We performed a retrospective cohort study of children who received PN during an inpatient encounter in US children's hospitals. Hospitals were divided into tertiles based on their rates of PN use: low (<36.9 of 1000 encounters), medium (36.9-51.8 of 1000 encounters), and high (>51.8 of 1000 encounters). Multivariable regression models were developed to assess the associations between hospital PN use and time to PN initiation, PN duration, and encounter length of stay after adjustment for salient patient characteristics. RESULTS The cohort included 82,142 patients receiving PN, and rates of hospital PN use ranged from 5.9 to 76.7 patients receiving PN per 1000 inpatient encounters. After multivariable adjustment, patients treated at high-use hospitals had a significantly shorter time to initiation of PN compared with low-use hospitals (incident rate ratio [95% CI]: 0.78 [0.69-0.89]; P < .001). There was no significant association between low- and medium- or high-use hospitals regarding PN duration or hospital length of stay. CONCLUSION Large variation in PN use exists among US children's hospitals. High-use hospitals are more likely to start PN earlier but do not have longer PN duration or encounter length of stay. This variability makes PN use an ideal target for hospital quality improvement efforts to improve adherence to PN evidence-based guidelines.
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Affiliation(s)
- Robert John Pettit
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Liese C C Pruitt
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Stephanie Iantorno
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Brian T Bucher
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Li J, Li B, Qian J, Zhang J, Ren H, Ning B, Wang Y. Nutritional survey in critically ill children: a single center study in China. Transl Pediatr 2020; 9:221-230. [PMID: 32775240 PMCID: PMC7347761 DOI: 10.21037/tp-19-173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The incidence of malnutrition in children, who were admitted to the pediatric intensive care unit (PICU), has kept high level over the past 30 years. In addition, nutrition status of critically ill children deteriorates further during the changing of their conditions and may have a negative effect on patients' outcomes. This study aimed to determine the nutritional status of critically ill children and to survey current nutrition practices and support in PICU. METHODS In this prospective observational study, 360 critically ill children stayed in the PICU not less than 3 days from Feb. to Nov. in 2017 were enrolled. Each patient underwent nutrition assessment. Nutritional status was determined using Z-scores of length/height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ), body mass index-for-age (BAZ), based on the World Health Organization child growth standards. We also observed the patients' intake of calories and protein during the first 10 days after admission. RESULTS Three hundred and sixty were enrolled in the study. One hundred and eighty-six patients (51.67%) were malnourished at PICU admission, above 50% and 56.45% (105/186) of malnourished patients had severe malnutrition. Except fasting in case of clinical instability in 5.3% (19/360), nutrition was provided in the form of oral feeding in 26.6% (96/360), enteral nutrition (EN) in 56.1% (202/360), parenteral nutrition (PN) in 6.4% (23/360) and mixed support (EN + PN) in 5.6% (20/360). Totally 384 times interruption of feeding happened in the process of EN, and 1.9 times feeding interruption happened to each patient. Twenty-seven point two percent of these patients had more than three times feeding interruption. The severe malnutrition group had significantly greater length of ICU stay and higher mechanical ventilation support rate (P=0.007, P=0.029). Total 44 (44/360, 12.22%) patients died in the study, and the malnutrition was not statistically different between survivor group and death group (P=0.379). More than 85% of the patients had lower daily nutritional intake compared with prescribed goals. Sixty-eight point three percent of the patients received the required calories during EN with median time of 2 [2-4] days. Only 32.7% of patients underwent EN received estimated protein requirements. CONCLUSIONS These results showed that malnutrition was common among children admitted to PICU. Furthermore, nutrition delivery was generally inadequate in critically ill children, and nutritional status was getting worsening during PICU.
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Affiliation(s)
- Jingjing Li
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Biru Li
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Juan Qian
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Zhang
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Ren
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Botao Ning
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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7
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Barrocas A. Demonstrating the Value of the Nutrition Support Team to the C-Suite in a Value-Based Environment: Rise or Demise of Nutrition Support Teams? Nutr Clin Pract 2020; 34:806-821. [PMID: 31697446 DOI: 10.1002/ncp.10432] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Nutrition support teams (NSTs) in the United States have had to justify their existence since their inception in the 1970s. Concomitant with those efforts, changes in healthcare financing have challenged hospital administrators to adapt their reimbursement strategies and methods. NSTs, if they are to survive and/or thrive, must be aware of the convulsive currents of change faced by those who determine which programs move downstream and which find their demise on the banks of the stream. This review provides a historical perspective of both the US healthcare financing system and the NST experiences of nutrition clinicians over the past 4 decades. Focused discussions of 5 teams are provided from individual members of those varied NSTs. Additional recommendations from the administrative side of the equation are presented by 3 administrators. Whether NSTs will "rise or demise" depends on many factors. Understanding what those who control the purse strings are seeking in terms of salutary cost and quality outcomes in the current value-based system will facilitate the NST's communication with them. The demonstration of the NST's value is more likely to succeed when bolstered by current evidence-based data as applied to the specific institution. These efforts can be carried out by a formal NST in larger or academic institutions or a "virtual" team with a single individual coordinating the services in a transdisciplinary fashion, employing the acronym ACT (accountability, communication, [transdisciplinary] teamwork).
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Affiliation(s)
- Albert Barrocas
- WellStar Atlanta Medical Center, Atlanta, Georgia, USA.,Tulane School of Medicine, New Orleans, Louisiana, USA.,ALMA, LLC, Atlanta, Georgia, USA
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8
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Tume LN, Valla FV, Joosten K, Jotterand Chaparro C, Latten L, Marino LV, Macleod I, Moullet C, Pathan N, Rooze S, van Rosmalen J, Verbruggen SCAT. Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations. Intensive Care Med 2020; 46:411-425. [PMID: 32077997 PMCID: PMC7067708 DOI: 10.1007/s00134-019-05922-5] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/28/2019] [Indexed: 01/09/2023]
Abstract
Background Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines. Objective To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children. Design The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds. Results The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions. Conclusions We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions. Electronic supplementary material The online version of this article (10.1007/s00134-019-05922-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lyvonne N Tume
- Faculty of Health and Society, University of Salford, Manchester, M6 6PU, UK. .,Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L12 2AP, UK.
| | - Frederic V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, CarMEN INSERM UMR, 1060 Hospices Civils de Lyon, Lyon-Bron, France
| | - Koen Joosten
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Delémont, Switzerland.,Pediatric Intensive Care Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Lynne Latten
- Nutrition and Dietetics, Alder Hey Children's Hospital Liverpool, Liverpool, UK
| | - Luise V Marino
- Department of Dietetics/Speech and Language Therapy, NIHR Biomedical Research Centre Southampton, University Hospital Southampton, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Isobel Macleod
- Pediatric Intensive Care Unit, Royal Hospital for Children, Glasgow, UK
| | - Clémence Moullet
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Delémont, Switzerland.,Pediatric Intensive Care Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nazima Pathan
- Department of Pediatrics, University of Cambridge, Hills Road, Cambridge, UK
| | - Shancy Rooze
- Pediatric Intensive Care Unit, Queen Fabiola Children's University Hospital, Brussels, Belgium
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sascha C A T Verbruggen
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
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10
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Gomes MMA, Silva JM, Silva Ferreira ÁR, Vasconcelos Generoso S, Correia MITD. Implementing Quality Assessment Is Fundamental to Guarantee Optimal Nutrition Therapy. JPEN J Parenter Enteral Nutr 2019; 44:274-281. [DOI: 10.1002/jpen.1600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/22/2019] [Indexed: 11/08/2022]
Affiliation(s)
| | - Jessica Moreira Silva
- Nutrition Post Graduation Program Nursing School Universidade Federal de Minas Gerais
| | | | | | - Maria Isabel Toulson Davisson Correia
- Surgical Department, and Applied Sciences in Surgery and Ophtalmology Post Graduation Program Medical School, and Nutrition Post Graduation Program Nursing School Universidade Federal de Minas Gerais Belo Horizonte Minas Gerais Brazil
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ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Organisational aspects. Clin Nutr 2018; 37:2392-2400. [DOI: 10.1016/j.clnu.2018.06.953] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/18/2022]
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12
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Ukleja A, Gilbert K, Mogensen KM, Walker R, Ward CT, Ybarra J, Holcombe B. Standards for Nutrition Support: Adult Hospitalized Patients. Nutr Clin Pract 2018; 33:906-920. [DOI: 10.1002/ncp.10204] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Andrew Ukleja
- Beth Israel Deaconess Medical Center; Division of Gastroenterology; Boston Massachusetts USA
| | - Karen Gilbert
- Thomas Jefferson University Hospital; Philadelphia Pennsylvania USA
| | - Kris M. Mogensen
- Department of Nutrition; Brigham and Women's Hospital; Boston Massachusetts USA
| | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center; Houston Texas USA
| | | | - Joe Ybarra
- Medical City McKinney; McKinney Texas USA
| | - Beverly Holcombe
- American Society for Parenteral and Enteral Nutrition; Silver Spring Maryland USA
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13
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Zaher S, White D, Ridout J, Valla F, Branco R, Meyer R, Pathan N. Association between enteral macronutrient delivery and inflammatory response in critically ill children. Clin Nutr 2018; 38:2287-2296. [PMID: 30352749 DOI: 10.1016/j.clnu.2018.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/17/2018] [Accepted: 10/02/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS An important goal of nutrition support in paediatric critical illness is minimising catabolism. While focussing on providing full energy requirements, macronutrient balance is often neglected. Studies suggest that there is interplay between nutrition and inflammation. We aimed to assess the amount of enteral macronutrients delivered compared to estimated requirements, and the association between delivered macronutrients and systemic inflammation in critically ill children. METHOD We prospectively evaluated energy and macronutrient intake in critically ill children who required at least 72 h of mechanical ventilation. Data on enteral energy and macronutrient intake was collected and expressed as a percentage of the estimated requirements. Circulating levels of inflammatory cytokines were measured by ELISA and association assessed with delivery of macronutrients from the previous 24 h. RESULTS A total of 87 children (0-16 years) were included in this study. By day 3 the median (IQR) intake of energy, fat, carbohydrate (CHO) and protein were 75% (50-103), 85% (43-120), 63% (42-102) and 45% (23-65) respectively. We have also shown that delivery of enteral fat and protein was associated with elevation in the levels of tumour necrosis factor alpha (TNF-α) and interleukin-6 (IL-6). CONCLUSION The inflammatory response in critically ill children is influenced by the amount of enteral fat and protein delivered. Our data suggests that within the feed delivered, fat is often higher than protein and CHO. It is crucial to take into account the proportion of macronutrients required and not only aim to achieve the energy goal.
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Affiliation(s)
- Sara Zaher
- Department of Paediatrics, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK; Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Saudi Arabia.
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Jenna Ridout
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Frederic Valla
- Hospices Civils de Lyon, Paediatric Intensive Care, Hôpital Femme Mère Enfant, 59 bd Pinel, Lyon-Bron, FR 69500, France
| | - Ricardo Branco
- Department of Paediatrics, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK; Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Rosan Meyer
- Imperial College London, Kensington, London, SW7 2AZ, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK; Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
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Abstract
BACKGROUND Growth failure is prevalent among infants with CHD. A Standardized Clinical Assessment and Management Plan was introduced at Boston Children's Hospital's cardiac medical ward to identify patients with growth failure, evaluate relevant contributing conditions, and recommend a management plan including collaboration with nutrition physicians. OBJECTIVE The objective of this study was to determine whether enrolled patients had improved growth compared with historical controls. METHODS A total of 29 patients were enrolled in the period July, 2013-June, 2014. In all, 42 historical controls who met eligibility criteria for enrolment were selected for comparison from patients admitted to the same ward in the period June, 2010-June, 2011. Patients with CHD aged <1 year , with growth failure defined as weight-for-age z-score <-2, or failure to sustain adequate weight gain were eligible for participation. Primary outcome was change in weight-for-age z-score from enrolment to most recent weight measurement among patients with at least 6 months of follow-up. RESULTS Control patients were older at baseline admission weight (118 versus 95 days, p=0.33), and had a higher weight-for-age z-score, -2.9 (-3.1, -2.6) versus -3.7 (-4.3, -3.0) (p=0.02), compared with enrolled patients. Enrolled patients had greater gain in weight-for-age z-score, 2.7 (2.0, 3.4) versus 1.8 (1.5, 2.2) (p=0.03), from baseline to most recent follow-up. CONCLUSION Patients enrolled in a nutrition-focused protocol had greater weight improvement than historical controls. Identification of growth failure and collaboration with a nutrition support team was associated with improved weight gain among CHD patients experiencing growth failure. CHD programmes should consider a structural approach, including nutrition expertise to address growth failure.
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15
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Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children. World J Pediatr 2018; 14:419-428. [PMID: 30155618 DOI: 10.1007/s12519-018-0175-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND This document represents the first evidence-based guidelines to describe best practices in nutrition therapy in critically ill children (> 1 month and < 18 years), who are expected to require a length of stay more than 2 or 3 days in a Pediatric Intensive Care Unit admitting medical patients domain. METHODS A total of 25,673 articles were scanned for relevance. After careful review, 88 studies appeared to answer the pre-identified questions for the guidelines. We used the grading of recommendations, assessment, development and evaluation criteria to adjust the evidence grade based on the quality of design and execution of each study. RESULTS The guidelines emphasise the importance of nutritional assessment, particularly the detection of malnourished patients. Indirect calorimetry (IC) is recommended to estimate energy expenditure and there is a creative value in energy expenditure, 50 kcal/kg/day for children aged 1-8 years during acute phase if IC is unfeasible. Enteral nutrition (EN) and early enteral nutrition remain the preferred routes for nutrient delivery. A minimum protein intake of 1.5 g/kg/day is suggested for this patient population. The role of supplemental parenteral nutrition (PN) has been highlighted in patients with low nutritional risk, and a delayed approach appears to be beneficial in this group of patients. Immune-enhancing cannot be currently recommended neither in EN nor PN. CONCLUSION Overall, the pediatric critically ill population is heterogeneous, and an individualized nutrition support with the aim of improving clinical outcomes is necessary and important.
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Abstract
PURPOSE OF REVIEW Nutritional status and nutrient delivery during critical illness impact clinical outcomes. We have reviewed recent studies that may guide best practices regarding nutrition therapy in critically ill children. RECENT FINDINGS Malnutrition is prevalent in the pediatric ICU population, and is associated with worse outcomes. Nutrition support teams, dedicated dietitians, and educational programs facilitate surveillance for existing malnutrition and nutrition risk, but specific tools for the pediatric ICU population are lacking. Estimation of macronutrient requirements is often inaccurate; novel strategies to accurately determine energy expenditure are being explored. Indirect calorimetry remains the reference method for measuring energy expenditure. Enteral nutrition is the preferred route for nutrition in patients with a functioning gut. Early enteral nutrition and delivery of adequate macronutrients, particularly protein, have been associated with improved clinical outcomes. Delivery of enteral nutrition is often interrupted because of fasting around procedures and perceived intolerance. Objective measures for detection and management of intolerance to nutrient intake are required. In low-risk patients who are able to tolerate enteral nutrition, supplemental parenteral nutrition may be delayed during the first week of critical illness. SUMMARY Systematic research and consensus-based practices are expected to promote optimal nutritional practices in critically ill children with the potential to improve clinical outcomes.
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Ladd AK, Skillman HE, Haemer MA, Mourani PM. Preventing Underfeeding and Overfeeding: A Clinician's Guide to the Acquisition and Implementation of Indirect Calorimetry. Nutr Clin Pract 2017; 33:198-205. [PMID: 28549221 DOI: 10.1177/0884533617710214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In critically ill patients, indirect calorimetry (IC) is the gold standard to determine energy needs, as the use of predictive equations can result in underfeeding or overfeeding. The aim of this quality improvement (QI) initiative was to describe the rationale for and implementation of a process to target energy provision according to IC measurements in a tertiary academic medical center pediatric intensive care unit (PICU). MATERIALS AND METHODS To justify the purchase of an indirect calorimeter for clinical use, a needs assessment was conducted, followed by a training and implementation period. PICU patients were selected for IC according to published guidelines. Measured energy expenditure was compared with predicted energy expenditure and the provided energy prescription. The dietitians assessed IC results and adjusted energy prescriptions, if indicated. RESULTS Thirty-five total tests were completed with 24 patients. Sixty-nine percent of measurements resulted in energy delivery adjustments. Fifteen (47%) energy prescriptions decreased by a mean of 27% ± 11%, and 7 (22%) increased by a mean of 17% ± 15%. Staff and patient/guardians accommodated the use of IC, and PICU dietitian recommendations for IC tests and to adjust nutrition regimens were universally implemented. CONCLUSIONS Data to support the procurement of IC are vital to promote best practice to measure energy expenditure. Critically ill pediatric patients exhibit metabolic alterations that cannot be predicted by standard equations. Our QI initiative demonstrated the implementation and application of IC in the critically ill population and the ability to target energy provision to prevent energy imbalances.
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Affiliation(s)
- Amy K Ladd
- 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
| | - Matthew A Haemer
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Peter M Mourani
- Department of Pediatrics, Section of Critical Care, University of Colorado School of Medicine, Aurora, Colorado, USA
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Chapple LA, Chapman M, Shalit N, Udy A, Deane A, Williams L. Barriers to Nutrition Intervention for Patients With a Traumatic Brain Injury: Views and Attitudes of Medical and Nursing Practitioners in the Acute Care Setting. JPEN J Parenter Enteral Nutr 2017; 42:318-326. [PMID: 29443400 DOI: 10.1177/0148607116687498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/10/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Nutrition delivered to patients with a traumatic brain injury (TBI) is typically below prescribed amounts. While the dietitian plays an important role in the assessment and provision of nutrition needs, they are part of a multidisciplinary team. The views and attitudes of medical and nursing practitioners are likely to be crucial to implementation of nutrition to patients with TBI, but there is limited information describing these. METHODS A qualitative exploratory approach was used to explore the views and attitudes of medical and nursing practitioners on nutrition for patients with TBI. Participants at 2 major neurotrauma hospitals in Australia completed individual semi-structured interviews with a set of questions and a case study. Interviews were transcribed and coded for themes. RESULTS Thirty-four health practitioners participated: 18 nurses and 16 physicians. Three major themes emerged: (1) nutrition practices over the hospital admission reflect the recovery course, (2) there are competing priorities when caring for patients with TBI, and (3) the implementation of nutrition therapy is influenced by practitioner roles and expectations. CONCLUSION Use of qualitative inquiry in the study of attitudes toward nutrition provision to patients with TBI provided detailed insights into the challenges of operationalizing nutrition therapy. These insights can be used to clarify communication between health practitioners working with patients with TBI across the continuum of care.
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Affiliation(s)
- Lee-Anne Chapple
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,National Health and Medical Research Council Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Adelaide, Australia
| | - Marianne Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,National Health and Medical Research Council Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Adelaide, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Natalie Shalit
- Australian Centre for Health Innovation, Melbourne, Australia
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Adam Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,National Health and Medical Research Council Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Adelaide, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Lauren Williams
- Menzies Health Institute of Queensland, Griffith University, Australia
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Park YE, Park SJ, Park Y, Cheon JH, Kim TI, Kim WH. Impact and outcomes of nutritional support team intervention in patients with gastrointestinal disease in the intensive care unit. Medicine (Baltimore) 2017; 96:e8776. [PMID: 29245235 PMCID: PMC5728850 DOI: 10.1097/md.0000000000008776] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Nutritional support has become an important intervention for critically ill patients. Many studies have reported on the effects of nutritional support for the patients within the intensive care unit (ICU); however, no studies have specifically assessed patients with gastrointestinal diseases who may have difficulty absorbing enteral nutrition (EN) in the ICU.Sixty-two patients with gastrointestinal disease were admitted to the ICU between August 2014 and August 2016 at a single tertiary university hospital. We analyzed 2 different patient groups in a retrospective cohort study: those who received nutritional support team (NST) intervention and those who did not.Forty-four (71.0%) patients received nutritional support in ICU and 18 (29.0%) did not. Variables including male sex, high albumin or prealbumin level at the time of ICU admission, and short transition period into EN showed statistically significant association with lower mortality on the univariate analysis (all P < .05). Multivariate analysis revealed that longer length of hospital stay (P = .013; hazard ratio [HR], 0.972; 95% confidence interval [CI], 0.951-0.994), shorter transition into EN (P = .014; HR, 1.040; 95% CI, 1.008-1.072), higher prealbumin level (P = .049; HR, 0.988; 95% CI, 0.976-1.000), and NST intervention (P = .022; HR, 0.356; 95% CI, 0.147-0.862) were independent prognostic factors for lower mortality.In conclusion, NST intervention related to early initiated EN, and high prealbumin levels are beneficial to decrease mortality in the acutely ill patients with GI disease.
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Affiliation(s)
| | - Soo Jung Park
- Department of Internal Medicine
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yehyun Park
- Department of Internal Medicine
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Hee Cheon
- Department of Internal Medicine
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Il Kim
- Department of Internal Medicine
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Internal Medicine
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kyle UG, Lucas LA, Mackey G, Silva JC, Lusk J, Orellana R, Shekerdemian LS, Coss-Bu JA. Implementation of Nutrition Support Guidelines May Affect Energy and Protein Intake in the Pediatric Intensive Care Unit. J Acad Nutr Diet 2017; 116:844-851.e4. [PMID: 27126156 DOI: 10.1016/j.jand.2016.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 01/12/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Critically ill children are at risk of developing malnutrition, and undernutrition is a risk factor for morbidity and mortality. OBJECTIVE The study evaluated changes in the energy and protein intake before and after implementation of nutrition support (NS) guidelines for a pediatric critical care unit (PICU). DESIGN This retrospective study documented energy and protein intake for the first 8 days of PICU stay. Basal metabolic rate and protein needs were estimated by Schofield and American Society for Parenteral and Enteral Nutrition Guidelines, respectively. PARTICIPANTS/SETTING Three hundred thirty-five children from August to December 2012 (pre-implementation) and 185 from October to December 2013 (post-implementation). INTERVENTION Implementation of NS Guidelines. MAIN OUTCOME MEASURES Changes in actual energy and protein intake in the post- compared with the pre-Implementation period. STATISTICAL ANALYSIS PERFORMED Unpaired t tests, Pearson's χ(2) (unadjusted analysis) were used. Logistic regressions were used to estimate odds ratios and 95% confidence intervals for protein and energy intake, adjusted for age, sex, and Pediatric Risk of Mortality score. RESULTS After the implementation of guidelines, significant improvements were seen during days 5 through 8 in energy intake among children 2 years of age and older, and in protein intake in both age groups (P<0.05). For the 8-day period, statistically or clinically significant improvements occurred in the cumulative protein deficit/kg/day, as follows: younger than 2-year-olds, -1.5±0.7 g/kg/day vs -1.3±0.8 g/kg/day, P=0.02; 2-year-olds or older, -1.0±0.6 g/kg/day vs -0.7±0.8 g/kg/day, P=0.01; and for the energy deficit/kg/d in 2-year-olds and older, -17.2±13.6 kcal/kg/day vs -13.3±18.1 kcal/kg/day, unpaired t test, P=0.07, in the pre- vs post-implementation period, respectively. CONCLUSIONS The implementation of NS guidelines was associated with improvements in total energy in 2-year-olds and older and protein in younger than 2 and 2 years and older children by days 5 through 8, and protein deficits were significantly lower in the post- vs the pre-implementation period. The implementation of NS guidelines may have had a positive effect on improving NS in critically ill children.
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Kochevar M, Guenter P, Holcombe B, Malone A, Mirtallo J. A.S.P.E.N. Statement on Parenteral Nutrition Standardization. JPEN J Parenter Enteral Nutr 2017; 31:441-8. [PMID: 17712154 DOI: 10.1177/0148607107031005441] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In response to questions regarding use of standardized parenteral nutrition (PN) formulations, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) developed a Task Force to address some of these issues. A.S.P.E.N. envisions standardized PN as a broader issue rather than simply using a standardized, commercially available PN product. A standardized process for PN must be explored in order to improve patient safety and clinical appropriateness, and to maximize resource efficiency. A standardized process may include use of standardized PN formulations (including standardized, commercial PN products) but also includes aspects of ordering, labeling, screening, compounding, and administration of PN. A safe PN system must exist which minimizes procedural incidents and maximizes the ability to meet individual patient requirements. Using clinicians with nutrition support therapy expertise will contribute to that safe PN system. The purpose of this statement is to present the published literature associated with standardized PN formulations, to provide recommendations, and to identify areas in need of future research.
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Abstract
With the development of specialized nutrition support, an interdisciplinary approach was essential to translating this medical breakthrough from the laboratory to the bedside. As this new innovation was adopted, interdisciplinary nutrition support teams were created to optimize the effectiveness and safety of this therapy. The impact of standardization and the use of an interdisciplinary team to provide specialized nutrition support have been shown to improve outcomes and safety and to have a positive financial impact on healthcare institutions. Yet many hospitals do not have nutrition support teams, and the numbers that do may have decreased. To be effective, nutrition support teams need to practice at an evidence-based level and measure their performance. Nutrition support teams include many of the components of the healthcare delivery system that are advocated for the future, and nutrition support teams should be encouraged as the preferred system of providing specialized nutrition support.
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Affiliation(s)
- Philip J Schneider
- Latiolais Leadership Program, The Ohio State University, 500 West 12 Avenue, College of Pharmacy, Columbus, OH 43210, USA.
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Martinez EE, Ariagno KA, Stenquist N, Anderson D, Muñoz E, Mehta NM. Energy and Protein Delivery in Overweight and Obese Children in the Pediatric Intensive Care Unit. Nutr Clin Pract 2016; 32:414-419. [PMID: 28490231 DOI: 10.1177/0884533616670623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Early and optimal energy and protein delivery have been associated with improved clinical outcomes in the pediatric intensive care unit (PICU). Overweight and obese children in the PICU may be at risk for suboptimal macronutrient delivery; we aimed to describe macronutrient delivery in this cohort. METHODS We performed a retrospective study of PICU patients ages 2-21 years, with body mass index (BMI) ≥85th percentile and >48 hours stay. Nutrition variables were extracted regarding nutrition screening and assessment, energy and protein prescription, and delivery. RESULTS Data from 83 patient encounters for 52 eligible patients (52% male; median age 9.6 [5-15] years) were included. The study cohort had a longer median PICU length of stay (8 vs 5 days, P < .0001) and increased mortality rate (6/83 vs 182/5572, P = .045) than concurrent PICU patient encounters. Detailed nutrition assessment was documented for 60% (50/83) of patient encounters. Energy expenditure was estimated primarily by predictive equations. Stress factor >1.0 was applied in 44% (22/50). Median energy delivered as a percentage of estimated requirements by the Schofield equation was 34.6% on day 3. Median protein delivered as a percentage of recommended intake was 22.1% on day 3. CONCLUSIONS The study cohort had suboptimal nutrition assessments and macronutrient delivery during their PICU course. Mortality and duration of PICU stay were greater when compared with the general PICU population. Nutrition assessment, indirect calorimetry-guided energy prescriptions, and optimizing the delivery of energy and protein must be emphasized in this cohort. The impact of these practices on clinical outcomes must be investigated.
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Affiliation(s)
- Enid E Martinez
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Harvard Medical School, Boston, Massachusetts, USA
| | - Katelyn A Ariagno
- 3 Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicole Stenquist
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Daniela Anderson
- 4 University of São Paulo-Ribeirao Preto School of Medicine, São Paulo, Brazil
| | - Eliana Muñoz
- 5 Universidad de Chile, Hospital Dr. Luis Calvo Mackenna, Providencia, Chile
| | - Nilesh M Mehta
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Harvard Medical School, Boston, Massachusetts, USA.,3 Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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Park YH, Park SJ. [Organization and the Role of Nutirition Support Team]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 65:342-5. [PMID: 26087688 DOI: 10.4166/kjg.2015.65.6.342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
With the development of specialized nutrition therapy and the need for interdisciplinary approach, nutrition support teams (NSTs) were created to optimize effectiveness and safety of nutritional therapy. NSTs are interdisciplinary support teams with specialty training in nutrition that are typically comprised of physicians, dietitians, nurses, pharmacists, and others. Their role includes nutrition screening, assessment, determination of nutrition needs, recommendations for appropriate nutrition therapy, management of nutrition support therapy, and monitoring. Studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes as well as reductions in costs when patients were appropriately managed by NSTs. Organization and the role of NSTs are discussed in this review.
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Affiliation(s)
- Ye Hyun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Abstract
OBJECTIVES Serum albumin is a strong biomarker of disease severity and prognosis in adult patients. In contrast, its value as predictor of outcome in critically ill children has not been established. We aimed to determine whether admission hypoalbuminemia is associated with outcome in a general pediatric population of critically ill patients, taking into account the inflammatory response, disease severity, and nutritional status of the patient. DESIGN Analysis of prospectively collected database. SETTING PICU of a teaching hospital. PATIENTS Two hundred seventy-one patients consecutively admitted. Neonates, patients with chronic liver or kidney disease, inborn errors of metabolism, those who received prior administration of albumin solution, and readmissions were excluded. MEASUREMENTS AND MAIN RESULTS Outcome variables were 60-day mortality, probability of ICU discharge at 60 days, and ventilator-free days. Potential exposure variables for the outcome were sex, age, nutritional status, albumin, C-reactive protein and serum lactate at admission, and Pediatric Index of Mortality 2 score. Admission hypoalbuminemia was present in 64.2% of patients. After adjustment for confounding factors, only serum lactate, Pediatric Index of Mortality 2 score, and serum albumin were associated with higher mortality: the increase of 1.0 g/dL in serum albumin at admission resulted in a 73% reduction in the hazard of death (hazard ratio, 0.27; 95% CI, 0.14-0.51; p < 0.001). The increase of 1 g/dL in serum albumin was also independently associated with a 33% rise in the probability of ICU discharge (subhazard ratio, 1.33; 95% CI, 1.07-1.64; p = 0.008) and increased ventilator-free-days (odds ratio, 1.86; 95% CI, 0.56-3.16; p = 0.005). CONCLUSIONS Hypoalbuminemia at admission to a PICU is associated with higher 60-day mortality, longer duration of mechanical ventilation, and lower probability of ICU discharge. These associations are independent of the magnitude of inflammatory response, clinical severity, and nutritional status.
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Abstract
OBJECTIVE To assess current nutritional practices in critically ill children worldwide. DESIGN A two-part online, international survey. The first part, "the survey", was composed of 59 questions regarding nutritional strategies and protocols (July-November 2013). The second part surveyed the "point prevalence" of nutritional data of patients present in a subgroup of the responding PICUs (May-September 2014). SETTING Members of the World Federation of Pediatric Intensive and Critical Care Societies were asked to complete the survey. SUBJECTS Pediatric critical care providers. INTERVENTIONS Survey. MEASUREMENTS AND MAIN RESULTS We analyzed 189 responses from 156 PICUs in 52 countries (survey). We received nutritional data on 295 patients from 41 of these 156 responding PICUs in 27 countries (point prevalence). According to the "survey", nutritional protocols and support teams were available in 52% and 57% of the PICUs, respectively. Various equations were in use to estimate energy requirements; only in 14% of PICUs, indirect calorimetry was used. Nutritional targets for macronutrients, corrected for age/weight, varied widely. Enteral nutrition would be started early (within 24 hr of admission) in 60% of PICUs, preferably by the gastric route (88%). In patients intolerant to enteral nutrition, parenteral nutrition would be started within 48 hours in 55% of PICUs. Overall, in 72% of PICUs supplemental parenteral nutrition would be used if enteral nutrition failed to meet at least 50% of energy delivery goal. Several differences between the intended (survey) and the actual (point prevalence) nutritional practices were found in the responding PICUs, predominantly overestimating the ability to adequately feed patients. CONCLUSION Nutritional practices vary widely between PICUs worldwide. There are significant differences in macronutrient goals, estimating energy requirements, timing of nutrient delivery, and threshold for supplemental parenteral nutrition. Uniform consensus-based nutrition practices, preferably guided by evidence, are desirable in the PICU.
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.3918/jsicm.23.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
OBJECTIVE Delayed enteral nutrition, defined as enteral nutrition started 48 hours or more after admission to the PICU, is associated with an inability to achieve full enteral nutrition and worse outcomes in critically ill children. We reviewed nutritional practices in six medical-surgical PICUs and determined risk factors associated with delayed enteral nutrition in critically ill children. DESIGN Retrospective cross-sectional study using medical records as source of data. SETTING Six medical-surgical PICUs in northeastern United States. PATIENTS Children less than 21 years old admitted to the PICU for 72 hours or more excluding those awaiting or recovering from abdominal surgery. MEASUREMENTS AND MAIN RESULTS A total of 444 children with a median age of 4.0 years were included in the study. Enteral nutrition was started at a median time of 20 hours after admission to the PICU. There was no significant difference in time to start enteral nutrition among the PICUs. Of those included, 88 children (19.8%) had delayed enteral nutrition. Risk factors associated with delayed enteral nutrition were noninvasive (odds ratio, 3.37; 95% CI, 1.69-6.72) and invasive positive-pressure ventilation (odds ratio, 2.06; 95% CI, 1.15-3.69), severity of illness (odds ratio for every 0.1 increase in pediatric index of mortality 2 score, 1.39; 95% CI, 1.14-1.71), procedures (odds ratio, 3.33; 95% CI, 1.67-6.64), and gastrointestinal disturbances (odds ratio, 2.05; 95% CI, 1.14-3.68) within 48 hours after admission to the PICU. Delayed enteral nutrition was associated with failure to reach full enteral nutrition while in the PICU (odds ratio, 4.09; 95% CI, 1.97-8.53). Nutrition consults were obtained in less than half of the cases, and none of the PICUs used tools to assure the adequacy of energy and protein nutrition. CONCLUSIONS Institutions in this study initiated enteral nutrition for a high percentage of patients by 48 hours of admission. Noninvasive positive-pressure ventilation was most strongly associated with delay enteral nutrition. A better understanding of these risk factors and assessments of nutritional requirements should be explored in future prospective studies.
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Abstract
Nutrition is an essential component of patient management in the pediatric intensive care unit (PICU). Poor nutrition status accompanies many childhood chronic illnesses. A thorough assessment of the critically ill child is required to inform the plan for nutrition support. Accurate and clinically relevant nutritional assessment, including growth measurements, provides important guidance. Indirect calorimetry provides the most accurate measurement of resting energy expenditure, but is too often unavailable in the PICU. To prevent inappropriate caloric intake, reassessment of the child's nutrition status is imperative. Enteral nutrition is the recommended route of intake. Human milk is preferred for infants.
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Affiliation(s)
- Judy Verger
- Pediatric Acute Care Nurse Practitioner Program, Critical Care Department, School of Nursing, Children's Hospital of Philadelphia, University of Pennsylvania, 17 Ridings Way, Chadds Ford, PA 19317, USA; Pediatric Clinical Nurse Specialist Program, Critical Care Department, School of Nursing, Children's Hospital of Philadelphia, University of Pennsylvania, 17 Ridings Way, Chadds Ford, PA 19317, USA; Neonatal Clinical Nurse Specialist Program, Critical Care Department, School of Nursing, Children's Hospital of Philadelphia, University of Pennsylvania, 17 Ridings Way, Chadds Ford, PA 19317, USA.
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Brown AM, Carpenter D, Keller G, Morgan S, Irving SY. Enteral Nutrition in the PICU: Current Status and Ongoing Challenges. J Pediatr Intensive Care 2015; 4:111-120. [PMID: 31110860 DOI: 10.1055/s-0035-1559806] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Malnutrition in the critically ill or injured child is associated with increased morbidities and mortality in the pediatric intensive care unit (PICU), whether present upon admission or acquired during the PICU stay. Particular subpopulations such as those with congenital heart disease or severe thermal injury are at highest risk for malnutrition which can worsen with illness progression. A growing body of evidence suggests the presence of a positive association between nutrition support during critical illness and patient outcomes. Enteral nutrition (EN), the preferred route of nutrient delivery, may be a crucial component of care provided in the PICU which modifies the response to critical illness or injury, resulting in improved outcomes. Numerous challenges exist in the delivery of the EN goal in critically ill children. These include accurate assessment of nutrient requirements, hemodynamic instability, feeding intolerance, feeding interruptions, and the lack of a standardized approach to nutrition support. This article describes the current state of the science and challenges related to EN prescription and delivery in the critically ill child. Suggestions for improving EN practice are then presented, in addition to a platform for further research inquiry.
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Affiliation(s)
- Ann-Marie Brown
- School of Nursing, The University of Akron, Akron, Ohio, United States.,Division of Critical Care, Akron Children's Hospital, Akron, Ohio, United States
| | - Debbie Carpenter
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Gerri Keller
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Sherry Morgan
- Biomedical Library, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Sharon Y Irving
- Department of Nursing, Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,School of Nursing, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Can Teaching Programs Optimize Nutritional Evaluation and Improve Outcome in the PICU? Pediatr Crit Care Med 2015; 16:601. [PMID: 26154909 DOI: 10.1097/pcc.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mehta NM, Bechard LJ, Zurakowski D, Duggan CP, Heyland DK. Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study. Am J Clin Nutr 2015; 102:199-206. [PMID: 25971721 PMCID: PMC4480666 DOI: 10.3945/ajcn.114.104893] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 04/15/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The impact of protein intake on outcomes in pediatric critical illness is unclear. OBJECTIVE We examined the association between protein intake and 60-d mortality in mechanically ventilated children. DESIGN In a prospective, multicenter, cohort study that included 59 pediatric intensive care units (PICUs) from 15 countries, we enrolled consecutive children (age: 1 mo to 18 y) who were mechanically ventilated for ≥48 h. We recorded the daily and cumulative mean adequacies of energy and protein delivery as a percentage of the prescribed daily goal during the PICU stay ≤10 d. We examined the association of the adequacy of protein delivery with 60-d mortality and determined variables that predicted protein intake adequacy. RESULTS We enrolled 1245 subjects (44% female) with a median age of 1.7 y (IQR: 0.4, 7.0 y). A total of 985 subjects received enteral nutrition, 354 (36%) of whom received enteral nutrition via the postpyloric route. Mean ± SD prescribed energy and protein goals were 69 ± 28 kcal/kg per day and 1.9 ± 0.7 g/kg per day, respectively. The mean delivery of enteral energy and protein was 36 ± 35% and 37 ± 38%, respectively, of the prescribed goal. The adequacy of enteral protein intake was significantly associated with 60-d mortality (P < 0.001) after adjustment for disease severity, site, PICU days, and energy intake. In relation to mean enteral protein intake <20%, intake ≥60% of the prescribed goal was associated with an OR of 0.14 (95% CI: 0.04, 0.52; P = 0.003) for 60-d mortality. Early initiation, postpyloric route, shorter interruptions, larger PICU size, and a dedicated dietitian in the PICU were associated with higher enteral protein delivery. CONCLUSIONS Delivery of >60% of the prescribed protein intake is associated with lower odds of mortality in mechanically ventilated children. Optimal prescription and modifiable practices at the bedside might enhance enteral protein delivery in the PICU with a potential for improved outcomes. This trial was registered at clinicaltrials.gov as NCT02354521.
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Affiliation(s)
- Nilesh M Mehta
- Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, and Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and
| | - Lori J Bechard
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and
| | - David Zurakowski
- Department of Anesthesiology, Perioperative and Pain Medicine, and Harvard Medical School, Boston, MA; and Kingston General Hospital, Kingston, Canada
| | - Christopher P Duggan
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and
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A training program for anthropometric measurements by a dedicated nutrition support team improves nutritional status assessment of the critically ill child. Pediatr Crit Care Med 2015; 16:e82-8. [PMID: 25607742 DOI: 10.1097/pcc.0000000000000363] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The cornerstone of an optimal nutrition approach in PICUs is to evaluate the nutritional status of any patient. Anthropometric measurements and nutritional indices calculation allow for nutritional status assessment, which is not often part of routine management, as it is considered difficult to perform in this setting. We designed a study to evaluate the impact of a training program by the PICU nutritional support team on the implementation of routine anthropometric measurements on our PICU. DESIGN A prospective study was performed over a 2-year period, which included: a baseline evaluation of nutritional assessment, knowledge, anthropometric measurements (weight, height, and head and mid upper arm circumferences), and nutritional indices calculation in patient files. This was followed by a training program to implement the newly developed nutrition assessment guidelines, which included anthropometrical measurements and also the interpretation of these. The impact of this nutritional assessment program was reviewed annually for 2 years after the implementation. SETTING PICU--Lyon, France. PATIENTS AND SUBJECTS PICU nursing and medical staff, and patients admitted in February 2011, 2012, and 2013. INTERVENTIONS Training program. MEASUREMENTS AND MAIN RESULTS Ninety-nine percent of staff (n = 145) attended the individual teaching. We found significant progress in nutritional awareness and confidence about nutritional assessment following the teaching program. In addition, an improvement in staff knowledge about undernutrition and its consequences were found. We enrolled 41, 55, and 91 patients in 2011, 2012, and 2013, respectively. There was a significant increase in anthropometric measurements during this time: 32%, 65% (p = 0.002), and 96% in 2013 (p < 0.001). Nutritional indices were calculated in 20%, 74% (p < 0.001), and 96% (p < 0.001) of cases. CONCLUSIONS This is the first study, showing that a targeted nutritional assessment teaching program that highlights both the importance and techniques of anthropometrical measurements has successfully been implemented in a PICU. It managed to improve staff knowledge and nutritional practice.
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Gentles E, Mara J, Diamantidi K, Alfheeaid HA, Spenceley N, Davidson M, Gerasimidis K. Delivery of enteral nutrition after the introduction of practice guidelines and participation of dietitians in pediatric critical care clinical teams. J Acad Nutr Diet 2014; 114:1974-80.e3. [PMID: 24961555 DOI: 10.1016/j.jand.2014.04.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 04/25/2014] [Indexed: 12/13/2022]
Abstract
Provision of optimal nutrition is often difficult to achieve in the critically ill child, but can improve with better nutritional support practices. This study evaluated the joint impact of the introduction of enteral feeding practice guidelines and participation of dietitians in daily ward rounds on enteral nutrition (EN) intake and practices in children in intensive care. Nutritional intake and EN practices were audited before (period A) and after (period B) the introduction of enteral feeding practice guidelines and participation of dietitians in daily ward rounds in a pediatric intensive care unit. Information was collected on a daily basis and nutritional intake was compared with predefined targets and the United Kingdom dietary reference values. There were 65 patients and 477 nutritional support days in period A and 65 patients and 410 nutritional support days in period B. Basal metabolic rate (BMR) energy requirements were achieved in a larger proportion of nutritional support days in period B (BMR achieved [% nutritional support days]; period A: 27% vs period B: 48.9%; P<0.001). In patients admitted for nonsurgical reasons, median energy, protein, and micronutrient intake improved significantly. In the same group, the percentage of daily fluid intake delivered as EN increased post implementation (period A: median=66.8%; interquartile range=40.9 vs period B: median=79.6%; interquartile range=35.2; P<0.001). No significant changes were seen in patients admitted for corrective heart surgery. Implementation of better EN support practice can improve nutritional intake in some patients in critical care, but can have limited benefit for children admitted for corrective heart surgery.
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Dokken M, Rustøen T, Stubhaug A. Indirect calorimetry reveals that better monitoring of nutrition therapy in pediatric intensive care is needed. JPEN J Parenter Enteral Nutr 2013; 39:344-52. [PMID: 24255088 DOI: 10.1177/0148607113511990] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Monitoring nutrition therapy is essential in the care of critically ill children, but the risk of nutrition failure seems to remain. The aims of the present study were to examine the prevalence of underfeeding, adequate feeding, and overfeeding in mechanically ventilated children and to identify barriers to the delivery of nutrition support. MATERIALS AND METHODS Children aged 0-14 years who fulfilled the criteria for indirect calorimetry were enrolled in this prospective, observational study and were studied for up to 5 consecutive days. Actual energy intake was recorded and compared with the required energy intake (measured energy expenditure plus 10%); energy intake was classified as underfeeding (<90% of required energy intake), adequate feeding (90%-110%), or overfeeding (>110%). The reasons for interruptions to enteral and parenteral nutrition were recorded. RESULTS In total, 104 calorimetric measurements for 140 total days were recorded for 30 mechanically ventilated children. Underfeeding, adequate feeding, and overfeeding occurred on 21.2%, 18.3%, and 60.5% of the 104 measurement days, respectively. There was considerable variability in the measured energy expenditure between children (median, 37.2 kcal/kg/d; range, 16.81-66.38 kcal/kg/d), but the variation within each child was small. Respiratory quotient had low sensitivity of 21% and 27% for detecting underfeeding and overfeeding, respectively. Fasting for procedures was the most frequent barrier that led to interrupted nutrition support. CONCLUSION The high percentage of children (~61%) who were overfed emphasizes the need to measure energy needs by using indirect calorimetry.
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Affiliation(s)
- Mette Dokken
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Tone Rustøen
- Division of Emergencies and Critical Care, Department of Research and Development, Ullevål, Oslo University Hospital, Oslo, Norway Unit of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Audun Stubhaug
- Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway Faculty of Medicine, University of Oslo, Oslo, Norway
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Abstract
Provision of optimal nutritional support to children in the pediatric intensive care unit (PICU) is important for optimizing nutritional management, yet challenging because of a variety of factors. Previous nutritional status, degree of malnutrition, and variability in disease states differ significantly among PICU patients. Although there are numerous benefits for enteral nutrition (EN) in critically ill children, obstacles exist within the PICU that prevent the initiation and delivery of appropriate EN and parenteral nutritional (PN) support. Evidence-based nutrition care guidelines have been established to promote optimal nutrition support practice in PICU patients, including identification of those at greatest nutritional risk, initiating EN or PN in a timely manner, and providing EN as the preferred nutrition support modality for children with a functioning gastrointestinal tract. Strategies can be implemented to minimize avoidable delays or interruptions to the optimal delivery of PN and EN, including establishing nutrition support guidelines to promote consistency in practice, promoting clear and consistent communication among the PICU team via direct communication, unit rounds, and the medical record. The education of frontline PICU staff by trained professionals such as pediatric registered dietitians board certified in pediatric nutrition or nutrition support practice can also help promote improved nutritional support practice and outcomes. Specific strategies to optimize nutritional support and EN initiation and delivery at the author’s institution are also presented.
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Affiliation(s)
- Ana Abad-Jorge
- Department of Nutrition Services, University of Virginia Health System, Charlottesville, Virginia
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Abdul Manaf Z, Kassim N, Hamzaid NH, Razali NH. Delivery of enteral nutrition for critically ill children. Nutr Diet 2013. [DOI: 10.1111/1747-0080.12007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Zahara Abdul Manaf
- Dietetic Programme; School of Healthcare Sciences; Faculty of Health Sciences; National University of Malaysia; Malaysia
| | - Norasimah Kassim
- Dietetics and Food Services Department; Hospital Kuala Lumpur; Kuala Lumpur; Malaysia
| | - Nur Hana Hamzaid
- Dietetic Programme; School of Healthcare Sciences; Faculty of Health Sciences; National University of Malaysia; Malaysia
| | - Nurul Huda Razali
- Dietetic Programme; School of Healthcare Sciences; Faculty of Health Sciences; National University of Malaysia; Malaysia
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Nutritional practices and their relationship to clinical outcomes in critically ill children--an international multicenter cohort study*. Crit Care Med 2012; 40:2204-11. [PMID: 22564954 DOI: 10.1097/ccm.0b013e31824e18a8] [Citation(s) in RCA: 285] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To examine factors influencing the adequacy of energy and protein intake in the pediatric intensive care unit and to describe their relationship to clinical outcomes in mechanically ventilated children. DESIGN, SETTING, PATIENTS We conducted an international prospective cohort study of consecutive children (ages 1 month to 18 yrs) requiring mechanical ventilation longer than 48 hrs in the pediatric intensive care unit. Nutritional practices were recorded during the pediatric intensive care unit stay for a maximum of 10 days, and patients were followed up for 60 days or until hospital discharge. Multivariate analysis, accounting for pediatric intensive care unit clustering and important confounding variables, was used to examine the impact of nutritional variables and pediatric intensive care unit characteristics on 60-day mortality and the prevalence of acquired infections. MAIN RESULTS 31 pediatric intensive care units in academic hospitals in eight countries participated in this study. Five hundred patients with mean (SD) age 4.5 (5.1) yrs were enrolled and included in the analysis. Mortality at 60 days was 8.4%, and 107 of 500 (22%) patients acquired at least one infection during their pediatric intensive care unit stay. Over 30% of patients had severe malnutrition on admission, with body mass index z-score >2 (13.2%) or <-2 (17.1%) on admission. Mean prescribed goals for daily energy and protein intake were 64 kcals/kg and 1.7 g/kg respectively. Enteral nutrition was used in 67% of the patients and was initiated within 48 hrs of admission in the majority of patients. Enteral nutrition was subsequently interrupted on average for at least 2 days in 357 of 500 (71%) patients. Mean (SD) percentage daily nutritional intake (enteral nutrition) compared to prescribed goals was 38% for energy and 43% (44) for protein. A higher percentage of goal energy intake via enteral nutrition route was significantly associated with lower 60-day mortality (Odds ratio for increasing energy intake from 33.3% to 66.6% is 0.27 [0.11, 0.67], p = .002). Mortality was higher in patients who received parenteral nutrition (odds ratio 2.61 [1.3, 5.3], p = .008). Patients admitted to units that utilized a feeding protocol had a lower prevalence of acquired infections (odds ratio 0.18 [0.05, 0.64], p = .008), and this association was independent of the amount of energy or protein intake. CONCLUSIONS Nutrition delivery is generally inadequate in mechanically ventilated children across the world. Intake of a higher percentage of prescribed dietary energy goal via enteral route was associated with improved 60-day survival; conversely, parenteral nutrition use was associated with higher mortality. Pediatric intensive care units that utilized protocols for the initiation and advancement of enteral nutrient intake had a lower prevalence of acquired infections. Optimizing nutrition therapy is a potential avenue for improving clinical outcomes in critically ill children.
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Massanet P, Morquin D, Richard C, Jonquet O, Corne P. Stratégie d’optimisation multimodale et pluridisciplinaire de la nutrition en réanimation. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0492-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Factors associated with peptide-based formula prescription in a pediatric intensive care unit. J Pediatr Gastroenterol Nutr 2012; 54:620-3. [PMID: 22249807 DOI: 10.1097/mpg.0b013e31824a0149] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES There is no evidence-based consensus on the use of peptide-based formulas for critically ill children. The present study aimed to identify the factors associated with the choice of peptide-based formulas in the first enteral nutrition prescription for critically ill children and to compare the direct costs of the enteral formulas used in a pediatric intensive care unit. METHODS In a prospective study, children admitted to the intensive care unit and receiving tube feeding for ≥48 hours were evaluated. The potential exposure variables for the use of peptide-based formulas as the first nutrition prescription were age, sex, malnutrition, sepsis/septic shock, fasting period >2 days, use of α-adrenergic drugs before initiating first diet, and the revised Pediatric Index of Mortality score. A direct cost comparison of prescribed formulas was performed. RESULTS Of 291 patients included, 85 (29.2%) were given peptide-based formulas in the first nutrition prescription. This choice was independently associated with malnutrition (odds ratio [OR] 2.94; 95% confidence interval [CI] 1.60%-5.39%; P < 0.01), fasting period >2 days (OR 3.46; 95% CI 1.93%-6.20%; P < 0.01), and use of α-adrenergic drugs (OR 2.32; 95% CI 1.24%-4.31%; P < 0.01). Peptide-based formula costs were up to 10 times higher than standard polymeric formula costs. CONCLUSIONS The choice of peptide-based formula as the first enteral nutrition prescription is associated with the greater severity of patients' clinical status-patients receiving α-adrenergic drugs, those who are malnourished, and those with longer fasting periods. These prescriptions engender costs higher than those associated with standard polymeric formula.
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Ukleja A, Freeman KL, Gilbert K, Kochevar M, Kraft MD, Russell MK, Shuster MH. Standards for nutrition support: adult hospitalized patients. Nutr Clin Pract 2011; 25:403-14. [PMID: 20702847 DOI: 10.1177/0884533610374200] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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DeLegge M, Wooley JA, Guenter P, Wright S, Brill J, Andris D, Wagner P, Filibeck D. The State of Nutrition Support Teams and Update on Current Models for Providing Nutrition Support Therapy to Patients. Nutr Clin Pract 2010; 25:76-84. [DOI: 10.1177/0884533609354901] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Mark DeLegge
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Jennifer A. Wooley
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Sheila Wright
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Joel Brill
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Deb Andris
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Pam Wagner
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Don Filibeck
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
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Effect of nutritional support team restructuring on the use of parenteral nutrition. Nutrition 2009; 26:735-9. [PMID: 20018482 DOI: 10.1016/j.nut.2009.08.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Revised: 06/23/2009] [Accepted: 08/08/2009] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The inappropriate use of parenteral nutrition (PN) continues to be a problem, despite several decades of efforts to improve the situation. We restructured our existing nutritional support team employing methods involving the institution's systems and individual physician interaction and education. Our aim was to study the effects of these changes on the use of PN in our institution. METHODS Records of all non-critically ill patients seen by our nutritional support team for PN during 2003-2004 (phase I, before restructuring) and 2005-2006 (phase II) were reviewed. Patients were classified under "appropriate," "inappropriate," and "marginal" categories based on published guidelines. During phase II, a new committee was formed, policies and procedures were updated, educational activities were increased, emphasis was placed on evidence-based guidelines, and periodic bedside rounds with the team physicians were initiated. Communication with referring physicians was improved. RESULTS Three hundred three of 335 patients in phase I and 271 of 333 patients in phase II were eligible for inclusion in analysis. Appropriate PN increased from 71.3% to 83.4%; inappropriate PN decreased from 16.5% to 8.9% (P = 0.002). CONCLUSION Restructuring of the nutritional support team improved the proper utilization of PN and decreased inappropriate use of PN in a public teaching hospital.
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Abstract
A significant proportion of critically ill children admitted to the pediatric intensive care unit (PICU) present with nutritional deficiencies. Malnourished hospitalized patients have a higher rate of complications, increased mortality, longer length of hospital stay, and increased hospital costs. Critical illness may further contribute to nutritional deteriorate with poor outcomes. Younger age, longer duration of PICU stay, congenital heart disease, burn injury, and need for mechanical ventilation support are some of the factors that are associated with worse nutritional deficiencies. Failure to estimate energy requirements accurately, barriers to bedside delivery of nutrients, and reluctance to perform regular nutritional assessments are responsible for the persistence and delayed detection of malnutrition in this cohort.
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Affiliation(s)
- Nilesh M. Mehta
- Instructor, Harvard Medical School, Faculty in Division of Critical Care, Anesthesia, Children's Hospital, Boston MA 02115
| | - Christopher P. Duggan
- Associate Professor of Pediatrics – Harvard Medical School, Director, Clinical Nutrition Service - Children's Hospital, Boston, Division of Gastroenterology/Nutrition, Children's Hospital, Boston MA 02115
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Affiliation(s)
- Nilesh M. Mehta
- From the Division of Critical Care Medicine, Children's Hospital, Boston, Massachusetts
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Mehta NM, Compher C. A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child. JPEN J Parenter Enteral Nutr 2009; 33:260-76. [DOI: 10.1177/0148607109333114] [Citation(s) in RCA: 301] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Nilesh M. Mehta
- From Critical Care Medicine, Dept. of Anesthesia, Children's Hospital, Boston, and University of Pennsylvania School of Nursing, Philadelphia
| | - Charlene Compher
- From Critical Care Medicine, Dept. of Anesthesia, Children's Hospital, Boston, and University of Pennsylvania School of Nursing, Philadelphia
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Abstract
BACKGROUND Hypophosphatemia is a disorder with potential complications and is often unrecognized in critically ill patients. AIMS To identify the prevalence of hypophosphatemia and risk factors associated to this disorder in critically ill children. METHODS In a prospective cohort study, 82 children admitted consecutively to a pediatric intensive care unit (ICU) were monitored regarding phosphorus serum levels during the first 10 days of admission. The following variables were analyzed as independent for hypophosphatemia: age, gender, diagnosis at admission, malnutrition, phosphorus intake, clinical severity score at admission (pediatric index of mortality 2) and daily scores (Pediatric Logistic Organ Dysfunction), sepsis, use of dopamine, furosemide and steroids, starvation period, and refeeding. Children with a z score of less than -2 of expected weight for age or body mass index (National Center for Health Statistics, 2000) were considered malnourished. Variables significantly associated with hypophosphatemia by bivariate analysis (p < 0.1) were included in a multiple logistic regression model. RESULTS The rate of hypophosphatemia was 61% during the first 10 days of pediatric ICU stay, and 12 patients developed hypophosphatemia during the study period. Malnutrition was present in 39.1% of patients, and the sera phosphorus concentration was significantly lower in malnourished than in well-nourished children (2.6 +/- 0.7 mg/dL vs. 3.5 +/- 0.8 mg/dL, p = 0.01). The multiple logistic regression model indicated the diagnosis of acute respiratory disease (odds ratio: 3.22; confidence interval: 1.03-10.1; p = 0.04), use of dopamine (odds ratio: 8.65; confidence interval: 1.58-47.3; p = 0.01), and malnutrition (odds ratio: 3.96; confidence interval: 1.19-13.3; p = 0.02) as independent risk factors for hypophosphatemia. None of the other potential risk factors discriminated for hypophosphatemia. CONCLUSIONS Hypophosphatemia was common in the first 10 days of ICU hospitalization and was associated with the diagnosis of respiratory disease, use of dopamine, and malnutrition. These factors should be taken into account during clinical follow up of critically ill children, especially when these conditions are found together.
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Mehta NM, Bechard LJ, Leavitt K, Duggan C. Cumulative energy imbalance in the pediatric intensive care unit: role of targeted indirect calorimetry. JPEN J Parenter Enteral Nutr 2009; 33:336-44. [PMID: 19126761 DOI: 10.1177/0148607108325249] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Failure to accurately estimate energy requirements may result in underfeeding or overfeeding. In this study, a dedicated multidisciplinary nutrition team measured energy expenditure in critically ill children. METHODS Steady-state indirect calorimetry was used to obtain measured resting energy expenditure, which was compared with equation-estimated energy expenditure and the total energy intake for each subject. The children's metabolic status was examined in relation to standard clinical characteristics. RESULTS Sixteen measurements were performed in 14 patients admitted to the multidisciplinary pediatric intensive care unit over a period of 12 months. Mean age of subjects in this cohort was 11.2 years (range 1.6 months to 32 years) and included 7 males and 7 postoperative patients. Altered metabolism was detected in 13 of 14 subjects and in 15 of 16 (94%) measurements. There was no correlation between the metabolic status of subjects and their clinical characteristics. Average daily energy balance was 200 kcal/d (range -518 to +859 kcal/d). Agreement between measured resting energy expenditure and equation-estimated energy expenditure was poor, with mean bias of 72.3 +/- 446 kcal/d (limits of agreement -801.9 to + 946.5 kcal/d). CONCLUSIONS A disparity was observed between equation-estimated energy expenditure, measured resting energy expenditure, and total energy intake, with a high incidence of underfeeding or overfeeding. A wide range of metabolic alterations were recorded, which could not be accurately predicted using standard clinical characteristics. Targeted indirect calorimetry on high-risk patients selected by a dedicated nutrition team may prevent cumulative excesses and deficits in energy balance.
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Affiliation(s)
- Nilesh M Mehta
- Divisions of Critical Care Medicine and Gastroenterology and Nutrition, Children's Hospital, Boston, MA, USA.
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