Basis of nutritional support in pediatrics

OBJECTIVE: To present an update and systematic review of the basis of nutritional support in pediatrics, emphasizing the importance of nutrition in critically ill patient. METHODS: Relevant studies were selected from databases (Medline, Scielo, Lilacs, etc.). Textbooks and theses were analyzed, and the authors personal experience was also considered. RESULTS: Nutritional therapy is part of the treatment. In order to reach the objective, it is important to determine specific nutritional requirements of water, calories, proteins, macro and micronutrients. So, nutritional evaluation should consist of clinical, anthropometric, and laboratory assessment, so that the best nutritional therapy (parenteral and/or enteral) is chosen. Patient monitoring is also indicated in order to prevent complications. CONCLUSION: Nutritional therapy is essential for the treatment. When well indicated and well monitored, it helps in the patient s recovery, and in the decrease of morbidity and mortality.     

Extracorporeal life support

Extracorporeal life support (ECLS) denotes the use of prolonged extracorporeal cardiopulmonary bypass in patients with acute, reversible cardiac or respiratory failure. As technology has advanced, organ support functions other than gas exchange, such as liver, renal, and cardiac support, have been provided by ECLS, and others, such as immunologic support, will be developed. The future of ECLS will include improvements in devices accompanied by circuit simplification and auto-regulation. Such enhancements in technology will allow application of ECLS to populations currently excluded from such support; for example, thromboresistant circuits will eliminate the need for systemic anticoagulation and lead to the use of this technique in premature newborns. As the ECLS technique becomes safer and simpler, and as morbidity and mortality are minimized, criteria for application of ECLS will be relaxed. New approaches to ECLS, such as pumpless arteriovenous bypass, the artificial placenta, arteriovenous CO(2) removal (AVCO(2)R), and intravenous oxygenators (IVOX), will become more commonly applied. Such advances in technology will allow broader and more routine application of ECLS for lung and other organ system failure.     

Extracorporeal life support in paediatrics

Extracorporeal membrane oxygenation (ECMO) is a life support technique based on modifications of heart-lung bypass technology. It is used to support severe but potentially reversible pulmonary or cardiopulmonary failure. There is increasing use of the technique for neonates and a return of interest in its use for adults. The number of non-neonatal paediatric patients receiving pulmonary support with ECMO worldwide is, however, small, and survival rates average less than 50%. Initial experience in 15 patients aged 3 months to 5 years with a high survival and low morbidity is reported.     

Pediatric advanced life support

Advanced life support (ALS) includes all the procedures and maneuvers used to restore spontaneous circulation and breathing, thus minimizing brain injury. The fundamental steps of ALS are airway control with adjuncts, ventilation with 100% oxygen, vascular access and fluid and drug administration, and monitoring to diagnose and treat arrhythmias. Airway control can be achieved by means of oropharyngeal airway, endotracheal intubation, and alternative methods (laryngeal mask and cricothyroidotomy). Vascular access can be achieved by the peripheral venous, intraosseous, central venous, and tracheal routes. The most frequent rhythms found in children with cardiorespiratory arrest are nonshockable (asystole, severe bradycardia, pulseless electrical activity, and complete atrioventricular block). In these cases, adrenaline continues to be the essential drug. Currently, low adrenaline doses (0.01 mg/kg IV and 0.1 mg/kg intratracheal administration) are recommended throughout the resuscitation period. Amiodarone (5 mg/kg) is the drug of choice in cases of ventricular fibrillation refractory to electric shock. The treatment sequence for shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia) is one 4 J/kg electric shock, followed by cardiopulmonary resuscitation (chest compressions and ventilation) for 2 minutes with subsequent reassessment of the electrocardiographic rhythm. Adrenaline must be administered immediately before the third electric shock and subsequently every 3-5 minutes. Amiodarone must be administered immediately before the fourth shock.     

Extracorporeal life support in paediatrics.

Extracorporeal membrane oxygenation (ECMO) is a life support technique based on modifications of heart-lung bypass technology. It is used to support severe but potentially reversible pulmonary or cardiopulmonary failure. There is increasing use of the technique for neonates and a return of interest in its use for adults. The number of non-neonatal paediatric patients receiving pulmonary support with ECMO worldwide is, however, small, and survival rates average less than 50%. Initial experience in 15 patients aged 3 months to 5 years with a high survival and low morbidity is reported.     

Advanced paediatric life support in practice

Paediatric resuscitation guidelines provide a framework allowing resuscitation teams to work in a coordinated fashion to provide timely resuscitation to the collapsed child. Effective resuscitation systems include early recognition of sick children, communication systems, training of parents and healthcare professionals, provision of equipment and direct clinical care to the critically ill child. Clinical outcomes may be improved by early recognition and timely intervention to prevent further deterioration. If collapse has occurred effective and timely management is essential to optimize outcomes.