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Gillis HC, Lin A, Jackson K, Stewart C. Postpyloric feeding tube placement at the bedside: Complication rate and impact on length of stay. Nutr Clin Pract 2021; 36:1290-1295. [PMID: 34245472 DOI: 10.1002/ncp.10732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Postpyloric feeding tube (PPFT) placement is essential for the ongoing nutrition care of critically ill children requiring noninvasive and invasive ventilation. PPFTs are placed by a variety of providers, including advanced practice nurses (APNs), surgeons, gastroenterologists, and radiologists. Complication rates, time to enteral nutrition (EN) following placement, and association with length of stay (LOS) have not been well documented. METHODS A query of the electronic medical record identified patients in the pediatric intensive care unit (PICU) in whom PPFTs were placed. A retrospective chart review was performed to identify patient demographics; PPFT placement provider, indication, and duration; PICU LOS; hospital LOS; and patient pediatric risk of mortality (PRISM) scores. RESULTS A total of 452 PPFTs were placed in 346 patients , with 318 placed by APNs. There was only one complication in 452 placed PPFTs. PRISM scores between patient groups for APN-placed PPFTs and non-APN-placed PPFTs were not significantly different. Mean time from hospital admission to PPFT placement was 1.5 days (APN) to 2.0 days (non-APN) (P < .02). Spearman correlation coefficients demonstrated shorter hospital and PICU LOS were associated with shorter duration to insertion. CONCLUSION Overall complication rates of PPFT insertion is very low and do not significantly differ between provider type , even in patients with higher PRISM scores. Additionally, early time to insertion of PPFT is associated with decreased hospital and PICU LOS. Further research is needed to determine if the earlier time to insertion of PPFTs is associated with the achievement of goal feeds.
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Affiliation(s)
- Holly Catherine Gillis
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Present address: Holly Catherine Gillis, MD, Department of Anesthesiology, College of Medicine, The Ohio State University, Doan Hall 4th Floor, 410 W 10th Street, Columbus, OH, 43210, USA
| | - Ada Lin
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kenneth Jackson
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Claire Stewart
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
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2
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The Use of Jejunal Tube Feeding in Children: A Position Paper by the Gastroenterology and Nutrition Committees of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition 2019. J Pediatr Gastroenterol Nutr 2019; 69:239-258. [PMID: 31169666 DOI: 10.1097/mpg.0000000000002379] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Jejunal tube feeding (JTF) is increasingly becoming the standard of care for children in whom gastric tube feeding is insufficient to achieve caloric needs. Given a lack of a systematic approach to the care of JTF in paediatric patients, the aim of this position paper is to provide expert guidance regarding the indications for its use and practical considerations to optimize its utility and safety. METHODS A group of members of the Gastroenterology and Nutrition Committees of the European Society of Paediatric Gastroenterology Hepatology and Nutrition and of invited experts in the field was formed in September 2016 to produce this clinical guide. Seventeen clinical questions treating indications and contraindications, investigations before placement, techniques of placement, suitable feeds and feeding regimen, weaning from JTF, complications, long-term care, and ethical considerations were addressed.A systematic literature search was performed from 1982 to November 2018 using PubMed, the MEDLINE, and Cochrane Database of Systematic Reviews. Grading of Recommendations, Assessment, Development, and Evaluation was applied to evaluate the outcomes.During a consensus meeting, all recommendations were discussed and finalized. In the absence of evidence from randomized controlled trials, recommendations reflect the expert opinion of the authors. RESULTS A total of 33 recommendations were voted on using the nominal voting technique. CONCLUSIONS JTF is a safe and effective means of enteral feeding when gastric feeding is insufficient to meet caloric needs or is not possible. The decision to place a jejunal tube has to be made by close cooperation of a multidisciplinary team providing active follow-up and care.
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Baǧci S, Keleş E, Girgin F, Yıldızdaş DR, Horoz ÖÖ, Yalındağ N, Tanyıldız M, Bayrakçi B, Kalkan G, Akyıldız BN, Köker A, Köroğlu T, Anıl AB, Zengin N, Dinleyici EÇ, Kıral E, Dursun O, Yavuz ST, Bartmann P, Müller A. Early initiated feeding versus early reached target enteral nutrition in critically ill children: An observational study in paediatric intensive care units in Turkey. J Paediatr Child Health 2018; 54:480-486. [PMID: 29278447 DOI: 10.1111/jpc.13810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 09/25/2017] [Accepted: 10/03/2017] [Indexed: 01/12/2023]
Abstract
AIM Although early enteral nutrition (EN) is strongly associated with lower mortality in critically ill children, there is no consensus on the definition of early EN. The aim of this study was to evaluate our current practice supplying EN and to identify factors that affect both the initiation of feeding within 24 h after paediatric intensive care unit (PICU) admission and the adequate supply of EN in the first 48 h after PICU admission in critically ill children. METHODS We conducted a prospective, multicentre, observational study in nine PICUs in Turkey. Any kind of tube feeding commenced within 24 h of PICU admission was considered early initiated feeding (EIF). Patients who received more than 25% of the estimated energy requirement via enteral feeding within 48 h of PICU admission were considered to have early reached target EN (ERTEN). RESULTS Feeding was initiated in 47.4% of patients within 24 h after PICU admission. In many patients, initiation of feeding seems to have been delayed without an evidence-based reason. ERTEN was achieved in 43 (45.3%) of 95 patients. Patients with EIF were significantly more likely to reach ERTEN. ERTEN was an independent significant predictor of mortality (P < 0.001), along with reached target enteral caloric intake on day 2 associated with decreased mortality. CONCLUSIONS There is a substantial variability among clinicians' perceptions regarding indications for delay to initiate enteral feeding in critically ill children, especially after the first 6 h of PICU admission. ERTEN, but not EIF, is associated with a significantly lower mortality rate in critically ill children.
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Affiliation(s)
- Soyhan Baǧci
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
| | - Elif Keleş
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Gazi, Ankara, Turkey
| | - Feyza Girgin
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Marmara, Istanbul, Turkey
| | - Dinçer R Yıldızdaş
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Cukurova, Adana, Turkey
| | - Özden Ö Horoz
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Cukurova, Adana, Turkey
| | - Nilüfer Yalındağ
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Marmara, Istanbul, Turkey
| | - Murat Tanyıldız
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Hacettepe, Ankara, Turkey
| | - Benan Bayrakçi
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Hacettepe, Ankara, Turkey
| | - Gökhan Kalkan
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Gazi, Ankara, Turkey
| | - Başak N Akyıldız
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Erciyes, Kayseri, Turkey
| | - Alper Köker
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Dokuz Eylül, Izmir, Turkey
| | - Tolga Köroğlu
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Dokuz Eylül, Izmir, Turkey
| | - Ayşe B Anıl
- Pediatric Intensive Care Unit, Department of Pediatrics, Izmir Tepecik Hospital, Izmir, Turkey.,Pediatric Intensive Care Unit, Department of Pediatrics, University of Izmir Katip Celebi, Izmir, Turkey
| | - Neslihan Zengin
- Pediatric Intensive Care Unit, Department of Pediatrics, Izmir Tepecik Hospital, Izmir, Turkey
| | - Ener Ç Dinleyici
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Osmangazi, Eskisehir, Turkey
| | - Eylem Kıral
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Osmangazi, Eskisehir, Turkey
| | - Oğuz Dursun
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Akdeniz, Antalya, Turkey
| | | | - Peter Bartmann
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
| | - Andreas Müller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
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Mikhailov TA, Gertz SJ, Kuhn EM, Scanlon MC, Rice TB, Goday PS. Early Enteral Nutrition Is Associated With Significantly Lower Hospital Charges in Critically Ill Children. JPEN J Parenter Enteral Nutr 2018; 42:920-925. [PMID: 30001462 DOI: 10.1002/jpen.1025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 09/28/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Previous studies have shown that early enteral nutrition (EEN) is associated with lower mortality in critically ill children. The purpose of this study was to determine the association between EEN (provision of 25% of goal calories enterally over the first 48 hours) and pediatric intensive care unit (PICU) and hospital charges in critically ill children. METHODS We conducted a supplementary study to our previous multicenter retrospective study of nutrition and outcomes in critically ill patients who had a PICU length of stay (LOS) ≥96 hours for the years 2007-2008. From 2 centers, we obtained additional data for all charges incurred during the PICU and hospital stay, respectively, from administrative data sets at each institution. RESULTS We obtained data for 859 patients who met the inclusion criteria (615 from the first center and 244 from the second center). In the combined data from both centers, total (P = .0006, adjusted for Pediatric Index of Mortality-2 [PIM-2] and center) and daily hospital charges (P < .001, adjusted for PIM-2 and center) were significantly lower in patients who met the EEN goal than in patients who did not. Hospital LOS did not differ between patients who met the EEN goal and patients who did not. A significant interaction between EEN and centers prevented any comparison of PICU charges, daily PICU charges, and PICU LOS between those patients who met the EEN goal and those who did not. CONCLUSION In critically ill children who stay in the PICU >96 hours, EEN is associated with significantly lower hospital charges.
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Affiliation(s)
- Theresa A Mikhailov
- Critical Care Division, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Shira J Gertz
- St. Barnabas Medical Center, Livingston, New Jersey, USA
| | - Evelyn M Kuhn
- Business Intelligence and Data Warehousing, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew C Scanlon
- Critical Care Division, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thomas B Rice
- Critical Care Division, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Praveen S Goday
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Creamer KM, Chan DS, Sutton C, DeLeon C, Moreno C, Shoupe BA. A Comprehensive Pediatric Inpatient Nutrition Support Package: A Multi-disciplinary Approach. Nutr Clin Pract 2016. [DOI: 10.1177/088453360101600409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Sánchez C, López-Herce J, de Guerra MM, Carrillo A, Moral R, Sancho L. The Use of Transpyloric Enteral Nutrition in the Critically Ill Child. J Intensive Care Med 2016. [DOI: 10.1177/088506660001500503] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To assess the use and complications of transpyloric enteral nutrition (TEN) in the critically ill child we evaluated prospectively all children who received TEN in a pediatric intensive care unit (PICU) of a tertiary university hospital. The type of nutrition used, its duration, medication administered, tolerance, gastrointestinal complications (vomiting, abdominal distension or excessive gastric residue, diarrhea, and pulmonary aspiration), nongastrointestinal complications, and mortality were assessed. A comparative analysis was made between the first 2 years of the study and the remaining period. Over a period of 4.5 years, 152 patients between the ages of 3 days and 17 years received TEN for a duration of 19 ± 32.3 days (range 1–240 days). Forty-one patients received TEN during the first 2 years; 100 patients received TEN in the postoperative period after cardiac surgery (66%). One hundred seventeen patients (77%) received sedation and 65 (43%) received muscle relaxants, presenting no extra complications. Twenty-four patients (15.8%) presented with gastrointestinal complications: abdominal distension and/or excessive gastric residue in 17 and diarrhea in 11. Gastrointestinal intolerance was associated with pulmonary infection ( p < 0.05), altered hepatic function ( p < 0.001), and hypokalemia or hypocalcemia ( p < 0.05). Diarrhea was more frequent in patients with shock ( p < 0.05), altered hepatic function ( p < 0.05), excessive gastric residue ( p < 0.001), and hypokalemia or hypocalcemia ( p < 0.05). In the second study period, the number of patients on TEN and the doses of sedatives, muscle relaxants, and vasoactives were higher ( p < 0.05), with no increase in the incidence of complications. TEN is a useful method of nutrition with few complications in the critically ill child.
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Affiliation(s)
- César Sánchez
- From the Pediatric Intensive Care Unit, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Jesús López-Herce
- From the Pediatric Intensive Care Unit, Gregorio Marañón University General Hospital, Madrid, Spain
| | - María Moreno de Guerra
- From the Pediatric Intensive Care Unit, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Angel Carrillo
- From the Pediatric Intensive Care Unit, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Ramón Moral
- From the Pediatric Intensive Care Unit, Gregorio Marañón University General Hospital, Madrid, Spain
| | - Luis Sancho
- From the Pediatric Intensive Care Unit, Gregorio Marañón University General Hospital, Madrid, Spain
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7
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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 We aimed to review gastric dysmotility in critically ill children: 1) its pathophysiology, with a focus on critical care diseases and therapies that affect gastric motility, 2) diagnostic methodologies, and 3) current and future potential therapies. DATA SOURCES Eligible studies were identified from PubMed and MEDLINE. STUDY SELECTION Literature search included the following key terms: "gastric emptying," "gastric motility/dysmotility," "gastrointestinal motility/dysmotility," "nutrition intolerance," and "gastric residual volume." DATA EXTRACTION Studies since 1995 were extracted and reviewed for inclusion by the authors related to the physiology, pathophysiology, diagnostic methodologies, and available therapies for gastric emptying. DATA SYNTHESIS Delayed gastric emptying, a common presentation of gastric dysmotility, is present in up to 50% of critically ill children. It is associated with the potential for aspiration, ventilator-associated pneumonia, and inadequate delivery of enteral nutrition and may affect the efficacy of enteral medications, all of which may be result in poor patient outcomes. Gastric motility is affected by critical illness and its associated therapies. Currently available diagnostic tools to identify gastric emptying at the bedside have not been systematically studied and applied in this cohort. Gastric residual volume measurement, used as an indirect marker of delayed gastric emptying in PICUs around the world, may be inaccurate. CONCLUSIONS Gastric dysmotility is common in critically ill children and impacts patient safety and outcomes. However, it is poorly understood, inadequately defined, and current therapies are limited and based on scant evidence. Understanding gastric motility and developing accurate bedside measures and novel therapies for gastric emptying are highly desirable and need to be further investigated.
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Ang B, Han WM, Wong JJM, Lee AN, Chan YH, Lee JH. Impact of a nurse-led feeding protocol in a pediatric intensive care unit. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815610139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: To determine effectiveness of a nurse-led, volume-based feeding protocol in our pediatric intensive care unit (PICU), we evaluated patients’ nutrition adequacy pre- and post-protocol implementation. Methods: We conducted an observational study of patients admitted for more than three days in the PICU during pre- and post-feeding protocol periods. We recorded energy and protein intake and feed interruptions in patients started on enteral nutrition over the first seven days of admission. We excluded patients with septic shock requiring more than two inotropes, post-cardiac and post-gastrointestinal surgeries. To determine nutrition adequacy, actual energy and protein intakes were compared with calculated requirements, expressed as percentages. Results: We had a total of 40 patients (20 in the pre- and post-protocol groups, respectively) with median age of 9.4 (interquartile range (IQR) 2.8, 57) months. Median time to feed initiation was similar between groups (20.0 (IQR 17.0, 37.5) vs. 21.5 (IQR 10.5, 27.0) hours, p = 0.516). There was no difference in median energy (55 (IQR 12, 102) vs. 59 (IQR 25, 85) %, p = 0.645) and protein intake (53 (IQR 16, 124) vs. 73 (IQR 22, 137) %, p = 0.069) over the seven-day period between groups; the proportion of patients meeting their energy (10 vs. 35%, p = 0.127) and protein goal (15 vs. 30%, p = 0.451) by day three also did not differ significantly pre- and post-protocol implementation. The most common reasons for feed interruption were intubation/extubation and radiological procedures. Conclusion: Our current feeding protocol did not improve nutrient adequacy. The effectiveness of a more aggressive protocol in units where enteral nutrition is initiated within 24 hours should be investigated.
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Affiliation(s)
- Bixia Ang
- Department of Nutrition and Dietetics, KK Women’s and Children’s Hospital, Singapore
| | - Wee Meng Han
- Department of Nutrition and Dietetics, KK Women’s and Children’s Hospital, Singapore
| | - Judith Ju-Ming Wong
- Department of Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Ang Noi Lee
- Division of Nursing, KK Women’s and Children’s Hospital, Singapore
| | - Yoke Hwee Chan
- Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore
| | - Jan Hau Lee
- Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore
- Office of Clinical Sciences, Duke-NUS Graduate School of Medicine, Singapore
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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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Ramakrishnan N, Daphnee DK, Ranganathan L, Bhuvaneshwari S. Critical care 24 × 7: But, why is critical nutrition interrupted? Indian J Crit Care Med 2014; 18:144-8. [PMID: 24701064 PMCID: PMC3963197 DOI: 10.4103/0972-5229.128704] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background and Aims: Adequate nutritional support is crucial in prevention and treatment of malnutrition in critically ill-patients. Despite the intention to provide appropriate enteral nutrition (EN), meeting the full nutritional requirements can be a challenge due to interruptions. This study was undertaken to determine the cause and duration of interruptions in EN. Materials and Methods: Patients admitted to a multidisciplinary critical care unit (CCU) of a tertiary care hospital from September 2010 to January 2011 and who received EN for a period >24 h were included in this observational, prospective study. A total of 327 patients were included, for a total of 857 patient-days. Reasons and duration of EN interruptions were recorded and categorized under four groups-procedures inside CCU, procedures outside CCU, gastrointestinal (GI) symptoms and others. Results: Procedure inside CCU accounted for 55.9% of the interruptions while GI symptoms for 24.2%. Although it is commonly perceived that procedures outside CCU are the most common reason for interruption, this contributed only to 18.4% individually; ventilation-related procedures were the most frequent cause (40.25%), followed by nasogastric tube aspirations (15.28%). Although GI bleed is often considered a reason to hold enteral feed, it was one of the least common reasons (1%) in our study. Interruption of 2-6 h was more frequent (43%) and most of this (67.1%) was related to “procedures inside CCU”. Conclusion: Awareness of reasons for EN interruptions will aid to modify protocol and minimize interruptions during procedures in CCU to reach nutrition goals.
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Affiliation(s)
| | - D K Daphnee
- Department of Dietetics, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Lakshmi Ranganathan
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - S Bhuvaneshwari
- Department of Dietetics, Apollo Hospitals, Chennai, Tamil Nadu, India
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12
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Mikhailov TA, Kuhn EM, Manzi J, Christensen M, Collins M, Brown AM, Dechert R, Scanlon MC, Wakeham MK, Goday PS. Early enteral nutrition is associated with lower mortality in critically ill children. JPEN J Parenter Enteral Nutr 2014; 38:459-66. [PMID: 24403379 DOI: 10.1177/0148607113517903] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The purpose of this study was to examine the association of early enteral nutrition (EEN), defined as the provision of 25% of goal calories enterally over the first 48 hours of admission, with mortality and morbidity in critically ill children. METHODS We conducted a multicenter retrospective study of patients in 12 pediatric intensive care units (PICUs). We included patients aged 1 month to 18 years who had a PICU length of stay (LOS) of ≥96 hours for the years 2007-2008. We obtained patients' demographics, weight, Pediatric Index of Mortality-2 (PIM2) score, LOS, duration of mechanical ventilation (MV), mortality data, and nutrition intake data in the first 4 days after admission. RESULTS We identified 5105 patients (53.8% male; median age, 2.4 years). Mortality was 5.3%. EEN was achieved by 27.1% of patients. Children receiving EEN were less likely to die than those who did not (odds ratio, 0.51; 95% confidence interval, 0.34-0.76; P = .001 [adjusted for propensity score, PIM2 score, age, and center]). Comparing those who received EEN to those who did not, adjusted for PIM2 score, age, and center, LOS did not differ (P = .59), and the duration of MV for those receiving EEN tended to be longer than for those who did not, but the difference was not significant (P = .058). CONCLUSIONS EEN is strongly associated with lower mortality in patients with PICU LOS of ≥96 hours. LOS and duration of MV are slightly longer in patients receiving EEN, but the differences are not statistically significant.
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13
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Wakeham M, Christensen M, Manzi J, Kuhn EM, Scanlon M, Goday PS, Mikhailov TA. Registered Dietitians Making a Difference: Early Medical Record Documentation of Estimated Energy Requirement in Critically Ill Children Is Associated with Higher Daily Energy Intake and with Use of the Enteral Route. J Acad Nutr Diet 2013; 113:1311-6. [DOI: 10.1016/j.jand.2013.04.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 04/22/2013] [Indexed: 10/26/2022]
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Wong JJM, Ong C, Han WM, Lee JH. Protocol-driven enteral nutrition in critically ill children: a systematic review. JPEN J Parenter Enteral Nutr 2013; 38:29-39. [PMID: 24072738 DOI: 10.1177/0148607113502811] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Enteral nutrition (EN) protocols are thought to improve clinical outcomes in the pediatric intensive care unit (PICU); however, critical evaluation of their efficacy is limited. We conducted a systematic review with the aim of assessing the effect of EN protocols on important clinical outcomes in these children. We searched MEDLINE, Cochrane Database for Reviews, Embase, and CINAHL using predetermined keywords and MESH terms. We included randomized controlled trials (RCTs) and observational studies that involved EN protocols in children admitted to the PICU for >24 hours. We included studies that reported at least 1 of our outcomes of interest. Studies that exclusively studied premature neonates or adults were excluded. Primary outcomes were PICU or hospital mortality, PICU or hospital length of stay (LOS), duration of mechanical ventilation, gastrointestinal (GI) complications, and infective complications. Secondary outcomes were time to initiate feeds and time to achieve goal feeds. In total, we included 9 studies (total 1564 children) in our systematic review (1 RCT, 4 before-and-after studies, 1 single-arm cohort study, 1 prospective descriptive study, and 2 audits). There is low-level evidence that the use of EN protocols is associated with a reduction in GI and infective complications and improved timeliness of feed initiation and achievement of goal feeds. Current medical literature does not have compelling data on the effects of an EN protocol on clinical outcomes among critically ill children. Future clinical trials should look into using standardized interventions and outcome measures to strengthen the existing evidence.
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Affiliation(s)
- Judith Ju-Ming Wong
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore
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15
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Akuzawa N, Takeuchi AM, Tsukagoshi J, Kaneko R, Naito H, Mizuno T, Sunaga Y, Tashiro M. Enteral Nutrition Related Complications Relevant to Alteration of Formulas in Two Critically Ill Pediatric Patients. Gastroenterology Res 2013; 6:156-160. [PMID: 27785247 PMCID: PMC5074815 DOI: 10.4021/gr568w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2013] [Indexed: 11/26/2022] Open
Abstract
The early institution of enteral nutrition is associated with beneficial outcomes and intestinal growth in pediatric patients. However, the number, frequency, and types of unfavorable events occurring with particular formulas are undefined. We experienced unexpected complications in two cases following a change in formula. One case diagnosed with myotubular myopathy experienced highly-increased gastric residuals and watery diarrhea leading to decreased calorie intake and weight loss. The second case with campomelic dysplasia suffered liver dysfunction and fever. In both cases, symptoms developed soon after of the change in formula and improved after resumption of the previous formula. Both cases had undergone tracheostomy and artificial ventilation, and had a history of feeding the same formula for an extended period of time. In chronic care patients such as ours, a change in formula may cause unexpected adverse events; therefore, caution is warranted.
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Affiliation(s)
- Nobuhiro Akuzawa
- Nutrition Support Team, Social Insurance Gunma Chuo General Hospital, 1-7-13 Koun-cho, Maebashi, Gunma 371-0025, Japan
| | - Aya Murata Takeuchi
- Nutrition Support Team, Social Insurance Gunma Chuo General Hospital, 1-7-13 Koun-cho, Maebashi, Gunma 371-0025, Japan; Nutrition Support Team, Social Insurance Gunma Chuo General Hospital, 1-7-13 Koun-cho, Maebashi, Gunma 371-0025, Japan
| | - Jun Tsukagoshi
- Nutrition Support Team, Social Insurance Gunma Chuo General Hospital, 1-7-13 Koun-cho, Maebashi, Gunma 371-0025, Japan
| | - Ryoko Kaneko
- Nutrition Support Team, Social Insurance Gunma Chuo General Hospital, 1-7-13 Koun-cho, Maebashi, Gunma 371-0025, Japan
| | - Hiroshi Naito
- Nutrition Support Team, Social Insurance Gunma Chuo General Hospital, 1-7-13 Koun-cho, Maebashi, Gunma 371-0025, Japan
| | - Takahisa Mizuno
- Department of Pediatrics, Social Insurance Gunma Chuo General Hospital, 1-7-13 Koun-cho, Maebashi, Gunma 371-0025, Japan
| | - Yasuo Sunaga
- Department of Pediatrics, Social Insurance Gunma Chuo General Hospital, 1-7-13 Koun-cho, Maebashi, Gunma 371-0025, Japan
| | - Masahiko Tashiro
- Department of Pediatrics, Social Insurance Gunma Chuo General Hospital, 1-7-13 Koun-cho, Maebashi, Gunma 371-0025, Japan
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Lee H, Koh SO, Kim H, Sohn MH, Kim KE, Kim KW. Avoidable causes of delayed enteral nutrition in critically ill children. J Korean Med Sci 2013; 28:1055-9. [PMID: 23853489 PMCID: PMC3708077 DOI: 10.3346/jkms.2013.28.7.1055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 05/03/2013] [Indexed: 01/15/2023] Open
Abstract
To evaluate the incidence of delayed enteral nutrition (EN) and identify avoidable causes of delay, we retrospectively reviewed medical records of 200 children (median age [range]; 37.5 [1-216] months) who stayed in the intensive care unit (ICU) for a minimum of 3 days. Among 200 children, 115 received EN following ICU admission with a median time of EN initiation of 5 days after admission. Of these, only 22 patients achieved the estimated energy requirement. A significant decrease in the final z score of weight for age from the initial assessment was observed in the non-EN group only (-1.3±2.17 to -1.57±2.35, P<0.001). More survivors than non-survivors received EN during their ICU stay (61.2% vs 30.0%, P=0.001) and received EN within 72 hr of ICU admission (19.8% vs 3.3%, P=0.033). The most common reason for delayed EN was gastrointestinal (GI) bleeding, followed by altered GI motility and hemodynamic instability. Only eight cases of GI bleeding and one case of altered GI motility were diagnosed as active GI bleeding and ileus, respectively. This study showed that the strategies to reduce avoidable withholding EN are necessary to improve the nutrition status of critically ill children.
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Affiliation(s)
- Hosun Lee
- Department of Nutrition and Dietetics, Severance Hospital, Yonsei University Health System, Seoul, Korea
| | - Shin Ok Koh
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Seoul, Korea
| | - Hyungmi Kim
- Department of Nutrition and Dietetics, Severance Hospital, Yonsei University Health System, Seoul, Korea
| | - Myung Hyun Sohn
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Earn Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Won Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
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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: 292] [Impact Index Per Article: 24.3] [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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Geukers VG, de Neef M, Dijsselhof ME, Sauerwein HP, Bos AP. Effect of a nurse-driven feeding algorithm and the institution of a nutritional support team on energy and macronutrient intake in critically ill children. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.eclnm.2011.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Sánchez C, López-Herce J, García C, Rupérez M, García E. The effect of enteral nutrition on nutritional status in the critically ill child. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/09563070500061414] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mehta NM, McAleer D, Hamilton S, Naples E, Leavitt K, Mitchell P, Duggan C. Challenges to optimal enteral nutrition in a multidisciplinary pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2009; 34:38-45. [PMID: 19903872 DOI: 10.1177/0148607109348065] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To describe nutrient intake in critically ill children, identify risk factors associated with avoidable interruptions to enteral nutrition (EN), and highlight opportunities to improve enteral nutrient delivery in a busy tertiary pediatric intensive care unit (PICU). Design, Setting, and Measurements: Daily nutrient intake and factors responsible for avoidable interruptions to EN were recorded in patients admitted to a 29-bed medical and surgical PICU over 4 weeks. Clinical characteristics, time to reach caloric goal, and parenteral nutrition (PN) use were compared between patients with and without avoidable interruptions to EN. RESULTS Daily record of nutrient intake was obtained in 117 consecutive patients (median age, 7 years). Eighty (68%) patients received EN (20% postpyloric) for a total of 381 EN days (median, 2 days). Median time to EN initiation was less than 1 day. However, EN was subsequently interrupted in 24 (30%) patients at an average of 3.7 +/- 3.1 times per patient (range, 1-13), for a total of 88 episodes accounting for 1,483 hours of EN deprivation in this cohort. Of the 88 episodes of EN interruption, 51 (58%) were deemed as avoidable. Mechanically ventilated subjects were at the highest risk of EN interruptions. Avoidable EN interruption was associated with increased reliance on PN and impaired ability to reach caloric goal. CONCLUSIONS EN interruption is common and frequently avoidable in critically ill children. Knowledge of existing barriers to EN such as those identified in this study will allow appropriate interventions to optimize nutrition provision in the PICU.
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Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care, Department of Anesthesia, Department of Nursing, Division of Gastroenterology, and Nutrition and Clinical Research Program, Biostatistics Core, at Children's Hospital Boston, Boston, Massachusetts 02115, USA.
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Meyer R, Harrison S, Sargent S, Ramnarayan P, Habibi P, Labadarios D. The impact of enteral feeding protocols on nutritional support in critically ill children. J Hum Nutr Diet 2009; 22:428-36. [PMID: 19743981 DOI: 10.1111/j.1365-277x.2009.00994.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Studies have shown that feeding protocols may assist in achieving optimal nutritional care in critically ill children. The present study aimed to assess the impact of enteral feeding protocols on nutritional support practices through a continuous auditing process over a defined period. MATERIALS AND METHODS A prospective audit on nutritional practice was initiated in 1994-1995 on all ventilated patients who were admitted for more than a complete 24-h period in the paediatric intensive care unit. The audit was repeated 1997-1998, 2001 and 2005. The collection of data on outcomes included the time taken to initiate nutritional support, the proportion of patients fed via the enteral versus parenteral route, and the proportion of children reaching 50% and 70% of the estimated average requirement (EAR) by day 3. Feeding algorithms and protocols were introduced after each audit with a view to improving practices. RESULTS Over the study period, time taken to initiate nutrition support was reduced from 15 h (1994-1995), 8 h (1997-1998), 5.5 h (2001) to 4.5 h (2005). The proportion of patients on parenteral feeds was reduced from 11% (1994-1995) to 4% (2005). An increase was also documented in the percentage of patients receiving a daily energy provision of 50% and 70% of the EAR by day 3 after the initiation of nutritional support (6% in 1994-1995 to 21% in 2005 for 70% of EAR). CONCLUSION The present study demonstrates that feeding protocols improve nutritional practices in a paediatric intensive care unit. However, protocol introduction needs to be monitored regularly through audit.
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Affiliation(s)
- R Meyer
- Department of Paediatric, Imperial College NHS Trust, [corrected] London, UK.
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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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Clinical severity scores do not predict tolerance to enteral nutrition in critically ill children. Br J Nutr 2009; 102:191-4. [PMID: 19586569 DOI: 10.1017/s0007114508159049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The objective of the present study was to analyse whether there is a relationship between the clinical severity at the time of starting transpyloric enteral nutrition (TEN) and the onset of digestive tract complications in critically ill children. Between May 2005 and December 2007, we performed a prospective, observational study with the participation of 209 critically ill children aged between 3 d and 17 years and who received TEN. The characteristics of the nutrition and its tolerance were compared with the paediatric risk of mortality (PRISM), the paediatric index of mortality (PIM) and the paediatric logistic organ dysfunction index (PELOD) at the time of starting the nutrition. Higher PRISM and PELOD scores correlated with a later time of starting enteral nutrition, a longer time to reach the maximum daily energy delivery and a longer duration of the TEN. However, the severity scores did not correlate with the maximum energy delivery achieved. Abdominal distension or excessive gastric residues were observed in 4.7 % of the patients and diarrhoea in 4.3 %. The ability of the severity scores to predict diarrhoea was of 0.67 for PRISM, 0.63 for PELOD and 0.60 for PIM-2.The severity scores were not able to predict other digestive tract complications. Higher scores of clinical severity at the time of starting enteral nutrition correlate with a later initiation of the nutrition, a longer time to reach the maximum energy delivery and a longer duration of TEN. However, their ability to predict digestive tract complications is low.
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Abstract
BACKGROUND Infants with hypoplastic left heart syndrome (HLHS) experience a high incidence of growth failure in the postoperative period following stage I palliation. Because of an increased risk of necrotizing enterocolitis in this population, clinicians may be reluctant to initiate early enteral feedings. Published guidelines for initiating and advancing enteral feedings in this population are limited. OBJECTIVE To test the safety and efficacy of an enteral feeding algorithm in infants with HLHS following stage I palliation. DESIGN Single-center, prospective case series with historical comparisons. SETTING Pediatric cardiovascular intensive care unit in tertiary care children's hospital. PATIENTS The study group consisted of consecutive patients > or =35 wks gestational age and weight > or =2 kg admitted to our cardiac intensive care unit over an 18-month period following stage I palliation of HLHS (n = 36). Excluded were nonsurvivors, patients supported on extracorporeal membrane oxygenation or those with a history of NEC or fetal intervention. These data were compared with a similar cohort of patients admitted to the cardiac intensive care unit over an 18-month period before the implementation of the feeding algorithm (n = 27). INTERVENTION A feeding algorithm was implemented in the study group in the postoperative period for initiation and advancement of enteral nutrition. MEASUREMENTS AND MAIN RESULTS The median duration of total parenteral nutrition was significantly higher in the control group (116 vs. 51 hrs; p = 0.03) compared with the study group. The median time to achieve recommended daily allowance of calories defined as 108 kcal/kg per day was significantly reduced in the study group (9 vs. 13 days; p = 0.01). Despite the rapid advancement of enteral feedings on the algorithm, there was no incidence of NEC in the study group compared with 11% in the control group. CONCLUSION The use of an enteral feeding algorithm is a safe and effective means of initiating and advancing enteral nutrition in infants with HLHS following stage I palliation.
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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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Affiliation(s)
- Urban Flaring
- Department of Paediatric Anaesthesia and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska Hospital, Stockholm, Sweden.
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Skillman HE, Wischmeyer PE. Nutrition Therapy in Critically Ill Infants and Children. JPEN J Parenter Enteral Nutr 2008; 32:520-34. [DOI: 10.1177/0148607108322398] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Heather E. Skillman
- From the Department of Clinical Nutrition, The Children's Hospital, Aurora, Colorado; and the Department of Anesthesiology, University of Colorado Health Sciences Center, Aurora, Colorado
| | - Paul E. Wischmeyer
- From the Department of Clinical Nutrition, The Children's Hospital, Aurora, Colorado; and the Department of Anesthesiology, University of Colorado Health Sciences Center, Aurora, Colorado
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López-Herce J, Mencía S, Sánchez C, Santiago MJ, Bustinza A, Vigil D. Postpyloric enteral nutrition in the critically ill child with shock: a prospective observational study. Nutr J 2008; 7:6. [PMID: 18237381 PMCID: PMC2262901 DOI: 10.1186/1475-2891-7-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 01/31/2008] [Indexed: 12/26/2022] Open
Abstract
Background Tolerance to enteral nutrition in the critically ill child with shock has not been studied. The purpose of the study was to analyze the characteristics of enteral nutrition and its tolerance in the critically ill child with shock and to compare this with non-shocked patients. Methods A prospective, observational study was performed including critically ill children with shock who received postpyloric enteral nutrition (PEN). The type of nutrition used, its duration, tolerance, and gastrointestinal complications were assessed. The 65 children with shock who received PEN were compared with 461 non-shocked critically ill children who received PEN. Results Sixty-five critically ill children with shock, aged between 21 days and 22 years, received PEN. 75.4% of patients with shock received PEN exclusively. The mean duration of the PEN was 25.2 days and the maximum calorie intake was 79.4 kcal/kg/day. Twenty patients with shock (30.7%) presented gastrointestinal complications, 10 (15.4%) abdominal distension and/or excessive gastric residue, 13 (20%) diarrhoea, 1 necrotising enterocolitis, and 1 duodenal perforation due to the postpyloric tube. The frequency of gastrointestinal complications was significantly higher than in the other 461 critically ill children (9.1%). PEN was suspended due to gastrointestinal complications in 6 patients with shock (9.2%). There were 18 deaths among the patients with shock and PEN (27.7%). In only one patient was the death related to complications of the nutrition. Conclusion Although most critically ill children with shock can tolerate postpyloric enteral nutrition, the incidence of gastrointestinal complications is higher in this group of patients than in other critically ill children.
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Affiliation(s)
- Jesús López-Herce
- Pediatric intensive care unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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Lambe C, Hubert P, Jouvet P, Cosnes J, Colomb V. A nutritional support team in the pediatric intensive care unit: Changes and factors impeding appropriate nutrition. Clin Nutr 2007; 26:355-63. [PMID: 17442464 DOI: 10.1016/j.clnu.2007.02.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Revised: 02/13/2007] [Accepted: 02/19/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND & AIMS The aims of this study were to determine the impact of a nutritional support team (NST) intervention in a pediatric intensive care unit (PICU) and to identify the factors at admission that were associated to a delay to achieve a sustained optimal caloric intake (SOCI). METHODS Caloric and protein intake and nutritional parameters were compared in 82 children in 2000 and 2003, respectively before and after the introduction of a NST. Predictive factors of a delay to achieve the SOCI were identified using multivariate analysis. RESULTS There was no difference in 2000 and 2003, respectively, regarding cumulative caloric deficits (19+/-15.7 vs. 20.7+/-14.8 kcal/kg day), cumulative protein deficits (0.26+/-0.31 vs. 0.22+/-0.20 g/kg day), time to achieve a SOCI (7 vs. 7 days). Factors at admission associated with a delay to achieve a SOCI were a pediatric risk of mortality (PRISM) score > 10 (hazard ratio 0.58; 95% CI 0.44-0.77), a CRP > 50 mg/L (hazard ratio 0.49; 95% CI 0.35-0.70), a fluid restriction (hazard ratio 0.51; 95% CI 0.37-0.71), and a weight for age > 3rd centile (hazard ratio 0.54; 95% CI 0.41-0.72). CONCLUSIONS The intervention of a NST has not modified significantly the nutritional management. In pediatric intensive care, many factors identified at admission are associated with impairing appropriate nutrition.
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Affiliation(s)
- Cecile Lambe
- Réanimation Pédiatrique, Hôpital Necker-Enfants Malades, APHP, Université René Descartes, Paris, France.
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de Oliveira Iglesias SB, Leite HP, Santana e Meneses JF, de Carvalho WB. Enteral nutrition in critically ill children: are prescription and delivery according to their energy requirements? Nutr Clin Pract 2007; 22:233-9. [PMID: 17374797 DOI: 10.1177/0115426507022002233] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare the differences between prescribed and delivered energy among critically ill children and to identify the factors that impede the optimal delivery of enteral nutrition in the first 5 days of nutrition support. METHODS In a prospective cohort study, we evaluated 55 critically ill children aged 8.2 +/- 11.4 months (0-162.3 months), who were fed for > or =2 days through a gastric or postpyloric tube. The patients were followed from admission until day 10 of enteral nutrition. Prescribed and delivered energy were recorded daily and compared with each other and with the estimated basal metabolic rate (BMR). The Paediatric Index of Mortality 2 (PIM 2) was used to estimate illness severity. RESULTS The ratio of delivered:required energy was <90% in 55.7% of the enteral nutrition days. Low prescription was the main reason for not achieving the energy goal in the first 5 days of enteral nutrition. Discrepancies between prescribed and delivered: energy were attributable to interruptions in feeding caused by clinical instability, airway management, radiologic and surgical procedures, and accidental feeding tube removal. The other factors associated with the delivery of less than required energy were PIM 2 > or =15%, gastrointestinal complications, dialysis, and use of alpha-adrenergic vasoactive drugs. The latter was the only variable in multivariate analysis that was associated with not ultimately achieving energy goal. CONCLUSIONS The prescription and delivery of energy were not adequate in >50% of enteral nutrition days. The gap between the effective administration and energy requirements can be explained by both underprescription and underdelivery. Administration of vasoactive drugs was the only variable independently associated with a low energy supply.
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Affiliation(s)
- Simone Brasil de Oliveira Iglesias
- Pediatric Intensive Care Unit, Department of Pediatrics, Federal University of São Paulo, Rua Loefgreen 1647, 04040-032, São Paulo SP, Brazil
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Sánchez C, López-Herce J, Carrillo A, Mencía S, Vigil D. Early transpyloric enteral nutrition in critically ill children. Nutrition 2007; 23:16-22. [PMID: 17189086 DOI: 10.1016/j.nut.2006.10.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Revised: 10/03/2006] [Accepted: 10/08/2006] [Indexed: 01/15/2023]
Abstract
OBJECTIVE We compared the tolerance of early (within the first 24 h after admission to the pediatric intensive care unit) and late transpyloric enteral nutrition in critically ill children. METHODS We performed a prospective observational study including all critically ill children fed using transpyloric enteral nutrition. The clinical characteristics, energy intake, tolerance, and complications of nutritional delivery between the children with early (first 24 h) and late (after 24 h, range 1-43 d) transpyloric enteral nutrition were compared. RESULTS Transpyloric nutrition was started within the first 24 h in 202 (38.5%) of the 526 children. There were no differences in the diagnoses, incidence of organ disturbances, doses of vasoactive drugs, or mortality between the two groups. There were no differences in the maximum number of calories delivered or in the duration of the nutrition between children with early and late transpyloric nutrition. The incidence of abdominal distention was lower in the children receiving early transpyloric nutrition (3.5%) than in those receiving nutrition at a later date (7.8%; P < 0.05). Moreover, 6.3% of patients presented diarrhea, with no difference being found between the two groups. CONCLUSION Early transpyloric enteral nutrition is well tolerated in critically ill children and is not associated with an increase in incidence of complications.
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Affiliation(s)
- César Sánchez
- Paediatric Intensive Care Unit, Gregorio Marañón General University Hospital, Madrid, Spain
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López-Herce J, Santiago MJ, Sánchez C, Mencía S, Carrillo A, Vigil D. Risk factors for gastrointestinal complications in critically ill children with transpyloric enteral nutrition. Eur J Clin Nutr 2007; 62:395-400. [PMID: 17327861 DOI: 10.1038/sj.ejcn.1602710] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To study the risk factors for gastrointestinal complications related to enteral nutrition in critically ill children. DESIGN A prospective, observational study. SETTING Pediatric intensive care unit. SUBJECTS Five hundred and twenty-six critically ill children who received transpyloric enteral nutrition(TEN). METHODS Univariate and multivariate logistic regression analysis were used to identify risk factors for gastrointestinal complications. RESULTS Sixty six patients (11.5%) presented gastrointestinal complications, 33 (6.2%) abdominal distension and/or excessive gastric residue, 34 (6.4%) diarrhea, one gastrointestinal bleeding, three necrotizing enterocolitis and one duodenal perforation. Enteral nutrition was definitively suspended because of gastrointestinal complications in 11 (2.1%) patients. Fifty patients (9.5%) died. Gastrointestinal complications were more frequent in the patients who died. Death was related to complications of the nutrition in only one patient. The frequency of gastrointestinal complications was significantly higher in children with shock, acute renal failure, hypokalemia, hypophosphatemia and in those receiving dopamine, epinephrine and vecuronium. The stepwise multivariate logistic regression analysis showed that the most important factors associated with gastrointestinal complications were shock, epinephrine at a rate higher than 0.3 microg/kg/min and hypophosphatemia. CONCLUSIONS The tolerance of TEN in critically ill children is good, although the incidence of gastrointestinal complications is higher in patients with shock, acute renal failure, hypokalemia, hypophosphatemia, and those receiving epinephrine, dopamine, and vecuronium.
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Affiliation(s)
- J López-Herce
- Pediatric Intensive Care Unit, Preventive and Quality Control Service (DV), Gregorio Marañón General University Hospital, Madrid, Spain.
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López-Herce J, Sánchez C, Carrillo A, Mencía S, Santiago MJ, Bustinza A, Vigil D. Transpyloric enteral nutrition in the critically ill child with renal failure. Intensive Care Med 2006; 32:1599-605. [PMID: 16826386 DOI: 10.1007/s00134-006-0271-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 06/08/2006] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To study the efficacy and tolerance of transpyloric enteral nutrition (TEN) in the critically ill child with acute renal failure (ARF). DESIGN Prospective observational study. SETTING Paediatric intensive care unit. PATIENTS Critically ill children with ARF who received TEN were included in the study. They were compared with the remaining 473 critically ill children receiving TEN in this period. Tolerance of nutrition and gastrointestinal complications were assessed. INTERVENTION Transpyloric enteral nutrition. MEASUREMENTS AND RESULTS Fifty-three critically ill children with ARF aged between 3 days and 17 years received TEN. Children with ARF more frequently received parenteral nutrition before TEN (56.6%) than the other patients (17.5%). The incidence of shock, hepatic alterations and mortality was significantly higher in patients with ARF than in the remaining children. In children with ARF the mean duration of the TEN was 16.5-27.3 days and the maximum caloric intake was 77-26.7 kcal/kg/day. Thirteen patients (24.5%) presented gastrointestinal complications, 9 (17%) abdominal distension and/or excessive gastric residue, 5 (9.4%) diarrhoea, 1 necrotising enterocolitis and 1 duodenal perforation. The frequency of gastrointestinal complications was significantly higher in children with ARF. TEN was definitive suspended in five patients due to gastrointestinal complications. Four of these patients were treated with continuous renal replacement therapy. Thirty percent of patients died during TEN. In only one patient was the death related to complications of the nutrition. CONCLUSIONS Critically ill children with ARF tolerate TEN, although the incidence of gastrointestinal complications is higher than in other critically ill children.
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Affiliation(s)
- Jesús López-Herce
- Gregorio Marañón General University Hospital, Paediatric Intensive Care Unit, Dr Castelo 47, 28009 Madrid, Spain.
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Petrillo-Albarano T, Pettignano R, Asfaw M, Easley K. Use of a feeding protocol to improve nutritional support through early, aggressive, enteral nutrition in the pediatric intensive care unit. Pediatr Crit Care Med 2006; 7:340-4. [PMID: 16738503 DOI: 10.1097/01.pcc.0000225371.10446.8f] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate the effects of instituting a feeding protocol with inclusive bowel regimen on tolerance and time to accomplish goal feeding in the pediatric intensive care unit. DESIGN Retrospective comparison chart review before and after the initiation of a feeding protocol. PATIENTS A total of 91 patients in the year 2000, before the initiation of the protocol, who received nasogastric feedings and 93 patients in year 2002 after the protocol was initiated. MEASURES AND MAIN RESULTS Patients were selected for review if they received nasogastric tube feedings while in the pediatric intensive care unit. The data were reviewed from time of admission in the pediatric intensive care unit through 7 days of goal feedings or discharge from the pediatric intensive care unit. Data examined included: days in the pediatric intensive care unit and hospital, time to goal feedings, concomitant use of cardiovascular medications, sedation, analgesia, episodes of feedings held, vomiting, diarrhea, and constipation. The protocol group achieved goal nutrition in an average of 18.5 hrs and a median of 14 hrs. The retrospective group achieved goal feedings at an average of 57.8 hrs and a median of 32 hrs (p < .0001). Also noted were a reduction in the percentage of patients vomiting from 20% to 11% and a reduction in constipation from 51% to 33%. CONCLUSION This comparison study suggests that the institution of a feeding protocol will not only achieve goal feedings at a substantially reduced time but also improve tolerance of enteral feedings in patients admitted to the pediatric intensive care unit.
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Pritchard C, Duffy S, Edington J, Pang F. Enteral nutrition and oral nutrition supplements: a review of the economics literature. JPEN J Parenter Enteral Nutr 2006; 30:52-9. [PMID: 16387900 DOI: 10.1177/014860710603000152] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND We sought to review the economics literature on enteral nutrition (EN) and oral nutrition supplements (ONS) against the background of an ongoing clinical guideline development. METHODS We searched the Health Economic Evaluations Database, the NHS Economic Evaluation Database, and the Cochrane Database of Systematic Reviews. RESULTS Enteral vs parenteral nutrition was found to be the most common comparison undertaken. The randomized trial evidence suggests that, in some groups of patients, EN is better in terms of clinical endpoints and/or length of hospital stay. This should translate into a lower mean cost for EN, given the reduced daily cost. These studies should be treated with caution because of their small sample size and poor quality. Costing was often crude and poorly reported, tending to focus on the narrow costs of the nutrition supplements. Only 1 study of a nutrition supplement in the community setting was found. CONCLUSIONS There is some evidence to indicate economic advantages of enteral over parenteral nutrition and of immune-enhancing supplements relative to control diet. There is a lack of well-designed studies taking a broad view of relevant comparators, costs, and outcomes. The cost-effectiveness of different forms of nutrition in different patient groups remains to be established.
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Sánchez C, López-Herce J, Carrillo A, Bustinza A, Sancho L, Vigil D. Transpyloric enteral feeding in the postoperative of cardiac surgery in children. J Pediatr Surg 2006; 41:1096-102. [PMID: 16769341 DOI: 10.1016/j.jpedsurg.2006.02.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of this study is to assess the utility of transpyloric enteral nutrition in the postoperative period of cardiac surgery in children. METHODS A prospective, observational study was performed on children receiving transpyloric enteral nutrition in the postoperative period of cardiac surgery. The type of nutrition, duration, tolerance, and complications were studied. RESULTS Children (212) between the ages of 3 days and 17 years received transpyloric enteral nutrition in the postoperative period of cardiac surgery. The duration of the transpyloric feeding was 16 +/- 23.8 days, and the maximum calorie delivery was 85.1 +/- 25.7 kcal/kg/d. Tolerance to nutrition was good and was not affected by the infusion of vasoactive drugs, sedatives, or muscle relaxants. Of the study population, 14.6% presented with gastrointestinal complications, 9.4% with abdominal distension and/or excessive gastric residue, and 7.5% with diarrhea. Nutrition was withdrawn in 2.4% of the patients because of gastrointestinal complications. Mortality was not related to any characteristic of the nutrition or to gastrointestinal complications. CONCLUSIONS Transpyloric enteral nutrition is useful and is a simple feeding method that enables a high calorie delivery to be provided with few complications in the postoperative period of cardiac surgery in children, including those receiving high doses of sedatives and muscle relaxants.
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Affiliation(s)
- César Sánchez
- Pediatric Gastroenterology Section, Gregorio Marañón Hospital, 28007 Madrid, Spain
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Abstract
Enteral feeding is desirable when the gastrointestinal tract is functional because it allows better use of nutrients, is safer, and is more cost-effective than parenteral nutrition. Feeding through a gastric tube, however, is often not feasible in severely ill adults and children because of gastric paresis leading to recurrent episodes of gastroesophageal reflux with the risk of subsequent aspiration. Feeding into the small intestine (duodenum or jejunum) through a nasointestinal tube, therefore, is preferred. Unfortunately, no method of enteral feeding is risk free. This literature review addresses the following 10 topics: (a) the reasons why nasointestinal tube feeding is better tolerated by some patients, (b) candidates for nasointestinal tube feeding, (c) options for selecting nasointestinal tubes, (d) recommended methods for predicting the distance to insert nasointestinal tubes, (e) recommended methods for placing nasointestinal tubes, (f) how promotility medications work and whether they facilitate nasointestinal tube placement, (g) nasointestinal tube placement error rate, (h) methods of determining the internal location of nasointestinal tubes, (i) complications associated with nasointestinal tube use, and (j) other pertinent issues surrounding feeding through nasointestinal tubes. The available research evidence is summarized and recommendations for future work are suggested.
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Ista E, Joosten K. Nutritional Assessment and Enteral Support of Critically Ill Children. Crit Care Nurs Clin North Am 2005; 17:385-93, x. [PMID: 16344208 DOI: 10.1016/j.ccell.2005.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Critical care nurses play an important role in feeding of critically ill children. Many procedures and caregiving interventions, such as placement of feeding tubes, registration of gastric retention, observation and care of the mouth, and administration of nutrition (enteral or parenteral), are within the nursing domain. This article discusses nutritional assessment techniques and enteral nutrition in critically ill children.
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Affiliation(s)
- Erwin Ista
- Department of Pediatrics, Erasmus MC--Sophia Children's Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands.
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Pérez-Navero JL, Dorao Martínez-Romillo P, López-Herce Cid J, Ibarra de la Rosa I, Pujol Jover M, Hermana Tezanos MT. Nutrición artificial en las unidades de cuidados intensivos pediátricos. An Pediatr (Barc) 2005; 62:105-12. [PMID: 15701304 DOI: 10.1157/13071305] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To perform an epidemiologic study of artificial nutrition in critically-ill pediatric patients. PATIENTS AND METHODS A multicenter, prospective and descriptive study was conducted in 23 Spanish intensive care units (ICU) (18 pediatric ICUs and five pediatric/neonatal ICUs) over a 1-month period. Artificial nutrition (AN) was required by 165 critically-ill patients (21.4 %). Data on diagnosis, severity, treatment, type of nutrition administered and complications were analyzed. RESULTS A total of 54.4 % of the participants were younger than 1 year, 19.4 % were aged between 1 and 5 years old, 15.7 % between 5 and 10 years old and 13.4 % were older than 10 years. ICU mean length stay was 11 days. One hundred six patients were administered enteral nutrition (EN): 67.9 % continuous nasogastric EN, 27.4 intermittent nasogastric EN, 16 % nasojejunal EN, 2.8 % gastrostomy EN. Eighty patients required parenteral nutrition (PN): 86.3 % central PN, 20 % peripheral PN. No significant differences were found between patients with EN and PN in mean energy intake, days receiving AN, diagnosis at admission to the ICU, disease severity (measured by PRISM III) or intensive support techniques. The EN group required greater inotropic support. Patients undergoing mechanical ventilation had equal mortality independent of the type of AN. The most common complications in EN were: 17.9 % emesis, 13.2 % abdominal distension, 11.3 % diarrhea, 4.7 % gastric residual volumes, and 6.6 % hypokalemia. In PN complications consisted of: 5 % catheter related infection, 1.3 % thrombophlebitis, 7.5 % hyponatremia, 3.8 % hypoglycemia, 6.3 % hypophosphatemia and 3.8 % hypertriglyceridemia. CONCLUSIONS EN provides critically-ill children with adequate energy intake and is well tolerated. Therefore, if there are no contraindications, EN should be the system of choice in the critically-ill patient requiring AN.
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Affiliation(s)
- J L Pérez-Navero
- Unidades de Cuidados Intensivos Pediátricos, Grupo de Trabajo de Nutrición de la Sociedad Española de Cuidados Intensivos Pediátricos, Spain.
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Verger JT, Bradshaw DJ, Henry E, Roberts KE. The pragmatics of feeding the pediatric patient with acute respiratory distress syndrome. Crit Care Nurs Clin North Am 2004; 16:431-43, x. [PMID: 15358390 DOI: 10.1016/j.ccell.2004.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Acute respiratory distress syndrome (ARDS) represents the ultimate pulmonary response to a wide range of injuries, from septicemia to trauma. Optimal nutrition is vital to enhancing oxygen delivery, supporting adequate cardiac contractility and respiratory musculature, eliminating fluid and electrolyte imbalances, and supporting the proinflammatory response. Research is providing a better understanding of nutrients that specifically address the complex physiologic changes in ARDS. This article highlights the pathophysiology of ARDS as it relates to nutrition, relevant nutritional assessment, and important enteral and parenteral considerations for the pediatric patient who has ARDS.
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Affiliation(s)
- Judy T Verger
- School of Nursing, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Abstract
OBJECTIVE The study assessed the adequacy of nutrition support in critically ill infants and children and identifies barriers impeding the delivery of estimated energy requirement (EER). METHODS Forty-two children (median age, 6.6 mo; range, 0-198) who were admitted to a tertiary-level pediatric intensive care unit (PICU) were studied prospectively over a 6-mo period. Patients staying in the PICU longer than a full 3 d and who received enteral or a combination of enteral and parenteral nutrition were eligible for inclusion. Patients were assigned to one of two groups: patients after cardiac surgery (n = 18) and all other diagnoses (n = 24). EERs were compared with actual energy intake, and clinical information was collected throughout the PICU admission. RESULTS Patients in the PICU received a median of 37.7% (range, 0.2-130.2%) of their EERs. The cardiac group achieved significantly lower energy intakes than did the non-cardiac group (P = 0.02). Only 22 of 42 patients (52%) achieved full EERs at any time during their admission, and this was more likely in non-cardiac patients (67% versus 33%, P = 0.03) Children undergoing cardiac surgery had a significant fall in weight-for-age Z scores (WAZ) from PICU admission to discharge (median WAZ, -1.44 versus -2.14; P < 0.001). In both groups, the major barrier to achieving EER was fluid volume restriction. Interruption of feeding for procedures and feeding intolerance reduced energy intake to a lesser degree. CONCLUSIONS This study highlights the inadequacy of nutrition support in critically ill children in the PICU. Restriction of fluid intake was the main barrier to the delivery of adequate nutrition, particularly in infants undergoing cardiac surgery.
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Affiliation(s)
- Elizabeth J Rogers
- Department of Nutrition and Food Services, Royal Children's Hospital, Melbourne, Australia.
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Sánchez Sánchez C, López-Herce Cid J, Carrillo Alvarez A, Bustinza Arriortúa A, Sancho Pérez L, Vigil Escribano D. [Transpyloric enteral nutrition in critically-ill children (II): complications]. An Pediatr (Barc) 2003; 59:25-30. [PMID: 12887870 DOI: 10.1016/s1695-4033(03)78144-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To study tolerance to transpyloric enteral nutrition (TEN) and the incidence of secondary complications in critically-ill children. PATIENTS AND METHODS We performed a prospective, observational study between 1994 and 2002 of all critically-ill children admitted to our pediatric intensive care unit who received TEN. Tolerance and complications were analyzed. RESULTS Of 286 patients aged between 3 days and 17 years who received TEN, gastrointestinal complications occurred in 13.6 %, abdominal distention and/or excessive gastric residue in 8 % and diarrhea in 6.3 %. Diarrhea was associated with shock (p 0.01), abdominal distension and/ or excessive gastric residue (p 0.008), hypophosphatemia (p 0.001), and duration of TEN (p < 0.001). TEN was discontinued in 2.1 % of the patients because of gastrointestinal complications. Thirty-two patients (11.2 %) died during TEN. No relationship was found between the characteristics of nutrition and complications and mortality. CONCLUSIONS TEN is a well tolerated method of nutrition in critically-ill children that produces few complications.
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Affiliation(s)
- C Sánchez Sánchez
- Sección de Cuidados Intensivos Pediátricos. Hospital General Universitario Gregorio Maranon. Madrid. Spain
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Sánchez Sánchez C, López-Herce Cid J, Carrillo Alvarez A, Bustinza Arriortúa A, Sancho Pérez L, Vigil Escribano D. [Transpyloric enteral nutrition in critically-ill children (I): technic and indications]. An Pediatr (Barc) 2003; 59:19-24. [PMID: 12887869 DOI: 10.1016/s1695-4033(03)78143-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To study the utility and efficacy of transpyloric enteral nutrition (TEN) in critically-ill children by analyzing the factors that determine enteral tolerance. PATIENTS AND METHODS We performed a prospective, observational study between 1994 and 2002 of all critically-ill children admitted to our pediatric intensive care unit who received TEN. The indications for enteral nutrition, type of nutrition and its duration were studied. RESULTS A total of 286 patients (8.4 % of patients admitted to the PICU in the study period), aged between 3 days and 17 years received TEN. Fifty-five children (19.2 %) were aged less than 1 month and 165 (27.7 %) were aged less than 6 months. Seventy percent received TEN exclusively. The most frequent indication for TEN was mechanical ventilation in 255 children (89.2 %). One hundred seventy-six patients (61.5 %) received TEN in the postoperative period after cardiac surgery. The mean duration of TEN was 15.4 25 days, the maximum volume of nutrition was 118.7 41 ml/kg/day, and the maximum caloric intake was 88.6 26.7 kcal/kg/day. During TEN, 227 patients received sedation (79.3 %), and 124 were administered muscle relaxants (43.3 %), with no increase in complications. CONCLUSIONS TEN is a useful method of nutrition in critically-ill children.
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Affiliation(s)
- C Sánchez Sánchez
- Sección de Cuidados Intensivos Pediátricos. Hospital General Universitario Gregorio Maranon. Madrid. Spain
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Abstract
The nutritional management of a critically ill child is not a glamorous subject and seldom receives the attention that it merits despite increasing evidence that appropriate goal-oriented nutritional support is associated with improved outcome. Current nutritional management is based on rapidly emerging knowledge on the very special nutritional requirements related to the "vastly different metabolic and physiologic characteristics of the hypermetabolic and stressed" critically ill child. There has been significant changes in traditional practice particularly in the area of calorie delivery, amount of macronutrients and route of nutrient delivery in the critically ill child. The critically ill child presents with "greatly disordered nutrient metabolism" and successful nutritional support involves an initial "hypocaloric regime" with a precise mix of carbohydrates, proteins and lipids which need periodic review as the child improves. The therapeutic benefits of minimal enteral feeding (MEF) have been clearly established--MEF being associated with diminished morbidity, infection rates as well as reduced ICU and hospital stays. Immune enhancement has also been shown to be of some benefit in the critically ill but the subject needs further study.
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Affiliation(s)
- Parvathi U Iyer
- Division of Pediatric and Congenital Heart Surgery, Escorts Heart Institute and Research Centre, New Delhi, India.
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Ellett ML, Beckstrand J. Predicting the distance for nasojejunal tube insertion in children. JOURNAL OF THE SOCIETY OF PEDIATRIC NURSES : JSPN 2001; 6:123-32. [PMID: 11529601 DOI: 10.1111/j.1744-6155.2001.tb00134.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
ISSUES AND PURPOSE As no consistent predictor of insertion tube distance has been determined for intestinal feeding tubes and fluoroscopic placement is very expensive, this study sought a reliable method of blind placement. DESIGN AND METHODS This cross-sectional study measured the internal distance from the lip to the pylorus in 387 children undergoing upper gastrointestinal endoscopy and compared those measurements to the external distances measured from the nose around the ear to the 10th rib and lip around the ear to the 10th rib. RESULTS Regression equations using height fitted in four age groups were the best predictors of the internal pyloric distances. PRACTICE IMPLICATIONS Predicting this distance with height may help healthcare providers be more successful in blind placement of intestinal feeding tubes. A table of predicted nasointestinal tube insertion distances is included.
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Affiliation(s)
- M L Ellett
- School of Nursing, Indiana University, Indianapolis, USA.
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