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ENTERAL AND ENTERAL AND PARENTERAL NUTRITION PARENTERAL NUTRITION
IN CRITICALLY ILL IN CRITICALLY ILL CHILDRENCHILDREN
Mudit Mathur, M.D.
SUNY Downstate Medical Center
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LEARNING GOALSLEARNING GOALSImpact of Critical IllnessImportance of NutritionGoals of nutritional supportNutritional requirementsEnteral vs Parenteral When and how to initiate and advance NutritionMonitoring
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IMPACT OF CRITICAL ILLNESS-1IMPACT OF CRITICAL ILLNESS-1Physiologic stress response :
Catabolic phaseincreased caloric needs, urinary nitrogen lossesinadequate intake wasting of endogenous
protein stores, gluconeogenesismass reduction of muscle-protein breakdown
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IMPACT OF CRITICAL ILLNESS-2IMPACT OF CRITICAL ILLNESS-2
Increased energy expenditure– Pain– Anxiety– Fever– Muscular effort-WOB, shivering
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RESPONSE TO INJURYRESPONSE TO INJURY
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WHY IS NUTRITION IMPORTANTWHY IS NUTRITION IMPORTANT
CRITICAL ILLNESS + POOR NUTRITION =CRITICAL ILLNESS + POOR NUTRITION =
Prolonged ventilator dependencyProlonged ICU stayHeightened susceptibility to nosocomial
infections MSOFIncreased mortality with mild/moderate or
severe malnutrition
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NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALSACCP Consensus statement, 1997ACCP Consensus statement, 1997
Provide nutritional support appropriate for the individual patient’s– Medical condition– Nutritional status– Available routes for administration
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NUTRITION: OVERALL GOALSNUTRITION: OVERALL GOALS
Prevent/treat macro/micronutrient deficiencies
Dose nutrients compatible with existing metabolism
Avoid complicationsImprove patient outcomes
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ENTERAL ENTERAL OR OR
PARENTERALPARENTERAL
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IMPACT OF STARVATION-1IMPACT OF STARVATION-1
Negative nitrogen balance, further wt lossMorphological changes in the gut
– Mucosal thickness– Cell proliferation– Villus height
Functional changes– Increased permeability– Decreased absorption of amino acids
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IMPACT OF STARVATION-2IMPACT OF STARVATION-2Enzymatic/Hormonal changes
– Decreased sucrase and lactase
Impact on immunity– Cellular: Decreased T cells, atrophied germinal
centers, mitogenic proliferation, differentiation,
Th cell function, altered homing– Humoral: Complement, opsonins, Ig, secretory IgA– (70-80% of all Ig produced is secretory IgA)– Increased bacterial translocation
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ENTERAL or PARENTERAL?ENTERAL or PARENTERAL?Enteral Nutrition: Superior to Parenteral
– Trophic effects on intestinal villus – Reduces bacterial translocation– Supports Gut-associated Lymphoid Tissue– Promotes secretory IgA secretion and function– Lower cost
Parenteral Nutrition– IV access– Infectious risk
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ENTERAL WITH PARENTERALENTERAL WITH PARENTERALIS THE COMBINATION BETTERIS THE COMBINATION BETTER
120 adult patients, (medical and surgical)Combination vs enteral feeds aloneProspective, randomized, double blind, controlledRBP, pre albumin increased significantly D 0-7No reduction in ICU morbidityNo reduction in ICU LOS/ vent, MSOF, dialysisReduced hospital stay (by 2 days)Mortality at 90 days and 2 years was identicalBauer et al, Intensive care med. 2000: 26, 893-900
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A PRACTICAL APPROACH-1A PRACTICAL APPROACH-1
Nutritional assessment– History-preexisting malnutrition, underlying
disease, recent wt loss (> 5% in 3 wks or >10% in 3 months)
– Physical-anthropometrics, BMI, evidence of wasting
– Labs-albumin (t ½ 18-21 d),
transferrin (t ½ 8 d), prealbumin (t ½ 2 d), RBP (t ½ 0.5 d)
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A PRACTICAL APPROACH-2A PRACTICAL APPROACH-2Assessment of the present illness
Hypermetabolism-burns, sepsis, MSOF, trauma
GI surgical procedures-prolonged NPOEnd-organ failure (Hepatic/renal etc)
Metabolic Cart-facilitates assessment of energy expenditure, Respiratory Quotient
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WHEN TO INITIATE WHEN TO INITIATE ENTERAL NUTRITION:ENTERAL NUTRITION:
ASAP-usually within 24 hours in severe trauma, burns and catabolic states
Contraindications to enteral nutrition:– Nonfunctional gut, anatomic disruption, gut
ischemia– Severe peritonitis– Severe shock states
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ROUTE OF FEEDINGROUTE OF FEEDINGNasogastric
– Requires gastric motility/emptyingTranspyloric
– Effective in gastric atony/ colonic ileus– Silicone/polyurethane tubing – Positioning, Prokinetic agents/ fluoroscopic/ pH/
endoscopic guidancePercutaneous/surgical placement
– PEG if > 4 weeks nutritional support anticipated– Jejunostomy if GE reflux, gastroparesis, pancreatitis
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POTENTIAL DRAWBACKS POTENTIAL DRAWBACKS OF ENTERAL FEEDSOF ENTERAL FEEDS
Gastric emptying impairmentsAspiration of gastric contentsDiarrheaSinusitisEsophagitis /erosionsDisplacement of feeding tube
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NUTRITIONAL REQUIREMENTSNUTRITIONAL REQUIREMENTS25-30 non protein Kcal/kg/d adult males20-25 non protein Kcal/kg/d adult femalesChildren: BMR 37-55 Kcal/kg/d (50% of EE)
+ Activity + growthFactors increasing EE
– Fever 12%– Burns upto 100%– Sepsis 40-50 %– Major surgery 20-30%
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Resting Energy Expenditure Resting Energy Expenditure
Age (years) REE (kcal/kg/day)
0 – 1 55
1 – 3 57
4 –6 48
7 –10 40
11-14 (Male/Female) 32/28
15-18 (Male/Female) 27/25
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Factors adding to REEFactors adding to REE
Multiplication factor
Maintenance 0.2
Activity 0.1-0.25
Fever 0.13/per degree > 38ºC
Simple Trauma 0.2
Multiple Injuries 0.4
Burns 0.5-1
Sepsis 0.4
Growth 0.5
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NUTRITIONAL REQUIREMENTSNUTRITIONAL REQUIREMENTSInitial protein intake 1.2-1.5 gram/kg/dMicronutrients-added if feeds are small in
volume or patient has excessive losses
Tailor individually, 24-30 cal/oz formulaUsually continuous feeds are tolerated betterAdd for catch up growth upon recoveryAdequate calories = adequate growth
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FORMULA COMPOSITIONFORMULA COMPOSITION
Carbohydrates: 60-70% of non protein calories– Polysaccharides/disaccharides/monosaccharides– Glucose polymers better absorbed
Lipids: 30-40% of non protein calories– Source of EFA– Concentrated calories-but poorer absorption– MCT direct portal absorption-better
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FORMULA COMPOSITIONFORMULA COMPOSITIONProteins
– -polymeric (pancreatic enzymes required) or peptides
– Small peptides from whey protein hydrolysis absorbed better than free AA
Fibers– Insoluble-reduce diarrhea, slower transit-better
glycemic control– Degraded to SCFA-trophic to colon
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COMPOSITION-SPECIAL COMPOSITION-SPECIAL FORMULASFORMULAS
Pulmonary: High fat( 50%), Low CHOHepatic: High BCAA, low aromatic AA,
<0.5 gm/kg/d protein in encephalopathyRenal: Low protein, calorically dense, low
PO4 , K, Mg
GFR >25: 0.6-0.7 g/kg/d
GFR <25: 0.3 g/kg/dImmune-enhancing
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IMMUNE MODULATIONIMMUNE MODULATIONGlutamineArginine Fatty acids (w-3)NucleotidesVitamins and minerals
Pediatric burn patients: Arginine & w-3 fatty acid supplements reduce infections, LOS
( Gottslisch: J Parenter. Ent. Nutr. 14: 225, 1990)
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IMMUNE MODULATIONIMMUNE MODULATION
Glutamine+arginine+Branched chain AA (Immunaid)
Arginine+omega-3 Fatty acids+RNA (Impact)– EN started within 36 hrs– Mortality, bacteremic episodes reduced– More pronounced effect in APACHE II 10-15
Galban et al, CCM, 2000; 28: 3, (643-48)
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IMMUNE MODULATIONIMMUNE MODULATION MECHANISMS ARE UNCLEARMECHANISMS ARE UNCLEARReduction of duration and magnitude of
inflammatory responseWill this disrupt the balance between pro
and anti-inflammatory processes??Of the multiple ingredients in these special
formulas: which is “the” oneBeneficial effects seen in patients achieving
early EN
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Conclusive studies, clear indications
&
Cost-benefit analysis are still needed
IMMUNE MODULATIONIMMUNE MODULATION
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Maintains nutritional statusPrevents catabolismProvides resistance to infectionPotential effect on immune
modulation
ENTERAL NUTRITION IN CRITICAL ILLNESS:
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PARENTERAL NUTRITION PARENTERAL NUTRITION (PN)(PN)
The PN formulation is based on:
Fluid RequirementsEnergy Requirements VitaminsTrace elementsOther additives-Heparin, H2 blocker etc
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Fluid RequirementsFluid RequirementsFluid requirements = maintenance + repair of dehydration +
replacement of ongoing losses. Maintenance Fluid Requirements
1 - 10 kg = 100 ml/kg/day10 - 20kg= 1000 ml + 50 ml for each kg > 10 kg20 kg = 1500 ml + 20ml for each kg > 20 kg
PN generally should be used for the maintenance needs. Deficit and replacement of losses should be provided separately. Remember to consider medications, flushes, drips, pressures lines
and other IV fluids in your calculations.
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Energy RequirementsEnergy Requirements
Total Daily Energy Requirements (kcal/day) = Resting Energy Expenditure (REE) + REE
(Total Factors)
Factors = Maintenance + Activity + Fever + Simple Trauma + Multiple Injuries + Burns + Growth
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PN-suggested guidelines for PN-suggested guidelines for Initiation and Maintenance Initiation and Maintenance
Substrate Initiation Advancement
Goals Comments
Dextrose 10% 2-5%/day 25% Increase as tolerated.
Consider insulin if hyperglycemic
Amino acids
1 g/kg/day 0.5-1 g/kg/day
2-3 g/kg/day
Maintain calorie:nitrogen ratio at approximately 200:1
20% Lipids
1 g/kg/day 0.5-1 g/kg/day
2-3 g/kg/day
Only use 20%
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Resting Energy Expenditure Resting Energy Expenditure
Age (years) REE (kcal/kg/day)
0 – 1 55
1 – 3 57
4 –6 48
7 –10 40
11-14 (Male/Female) 32/28
15-18 (Male/Female) 27/25
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Factors adding to REEFactors adding to REE
Multiplication factor
Maintenance 0.2
Activity 0.1-0.25
Fever 0.13/per degree > 38ºC
Simple Trauma 0.2
Multiple Injuries 0.4
Burns 0.5-1
Sepsis 0.4
Growth 0.5
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Suggested monitoring ProtocolSuggested monitoring Protocol
Weight Urine dip for glucose
Bedside glucose
Labs
First week Daily Q shift Q shift Daily SMA-7, Ca, Mg, Phos, triglycerides
Q OD LFTs
Subsequently Daily Q shift Q shift SMA-7, Ca, Mg, Phos 2x/wk
CBC, LFTs weekly
Triglycerides 2x/wk
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CalculationsCalculations
Dextrose____g/100ml Dextrose ____ml/day =
____grams/day_____g/day (weight 1.44) = _____mg/kg/min_____g/kg/day 3.4 kcal/g = _____ kcal/kg/day
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CalculationsCalculations
Fat 20 grams/100ml Fat _____ml/day =
_____grams/day_____g/kg/day 9 kcal/g = _____
kcal/kg/day
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CalculationsCalculations
grams Protein 6.25 = _____ NitrogenNon-protein calories Nitrogen =
Calorie:Nitrogen ratio
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DANGERS OF OVERFEEDINGDANGERS OF OVERFEEDINGSecretory diarrhea (with EN)Hyperglycemia, glycosuria, dehydration,
lipogenesis, fatty liver, liver dysfunctionElectrolyte abnormalities: PO4 , K, MgVolume overload, CHF CO2 production- ventilatory demand O2 consumptionIncreased mortality (in adult studies)
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MONITORINGMONITORINGPrevent OverfeedingPrevent Overfeeding
Carbohydrate: High RQ indicates CHO excess, stool reducing substances
Protein: Nitrogen balanceFat: triglycerideVisceral protein monitoringElectrolytes, vitamin levelsCaloric requirement assessment by metabolic cart
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CONCLUSIONSCONCLUSIONS
Start nutrition earlyEnteral route is preferred when availableSet goals for the individual patientDose nutrients compatible with existing
metabolismAppropriate monitoring is essentialAvoid overfeeding
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QUESTION 1QUESTION 1
When should nutritional support be initiated in critically ill patients?– Only after extubation– After 3 days of NPO status– After 5 days of NPO status– After 7 days of NPO status– ASAP, preferrably within 24 hours of
admission
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QUESTION 2QUESTION 2What would be the preferred mode for nutritional
support in a 10 year old boy with head injury, raised ICP and aspiration pneumonia that developed after he vomited during intubation in the field.– Parenteral nutrition– Enteral nutrition– A combination of enteral and parenteral nutrition– IV fluids alone until ICP is better controlled.
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QUESTION 3QUESTION 3
What would be the initial TPN composition for a 10 kg 18 month year old child– Glucose 10%, Protein 20 g/day, lipids 5g/d– Glucose 10%, Protein 10 g/day, lipids 15g/d– Glucose 15%, Protein 5 g/day, lipids 20g/d– Glucose 12.5%, Protein 20 g/day, lipids 10g/d– Glucose 10%, Protein 10 g/day, lipids 10g/d