Nutrition therapy in a pediatric intensive care unit: indications, monitoring, and complications

Background: Nutrition therapy (NT) is essential for the care of critically ill children. Inadequate feeding leads to malnutrition and may increase the patient's risk of morbidity and mortality. The aim of this study was to describe the NT used in a tertiary pediatric intensive care unit (PICU). Methods: The authors evaluated NT administered to 90 consecutive patients who were hospitalized for 7 days in the PICU of Instituto da Criança, Hospital das Clínicas, Universidade de São Paulo, Brazil. NT was established according to the protocol provided by the institution's NT team. NT provided a balance of fluids and nutrients and was monitored with a weekly anthropometric nutrition assessment and an evaluation of complications. Results: NT was initiated, on average, within 72 hours of hospitalization. Most children (80%) received enteral nutrition (EN) therapy; of these, 35% were fed orally and the rest via nasogastric or postpyloric tube. There were gastrointestinal complications in patients (5%) who needed a postpyloric tube. Parenteral nutrition (PN) was used in only 10% of the cases, and the remaining 10% received mixed NT (EN + PN). The average calorie and protein intake was 82 kcal/kg and 2.7 g/kg per day. Arm circumference and triceps skinfold thickness decreased. Conclusions: The use of EN was prevalent in the tertiary PICU, and few clinical complications occurred. There was no statistically significant change in most anthropometric indicators evaluated during hospitalization, which suggests that NT probably helped patients maintain their nutrition status.     

Challenges to Optimal Enteral Nutrition in a Multidisciplinary Pediatric Intensive Care Unit

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.     

A randomized controlled trial comparing three different techniques of nasojejunal feeding tube placement in critically ill children

BACKGROUND: The goal of this study was to compare 3 different techniques used to place nasojejunal (NJ) feeding tubes in the critically ill or injured pediatric patients. This was a randomized, prospective trial in a university-affiliated 12-bed pediatric intensive care unit. Patients were critically ill children requiring placement of an NJ feeding tube. Patient age, weight, medications, use of mechanical ventilation, and patient tolerance were recorded. An abdominal radiograph obtained immediately after the placement determined correct placement. The final placement was recorded, as was the number of placement attempts. METHODS: Patients were randomized to 1 of 3 groups: standard technique, standard technique facilitated with gastric insufflation, and standard technique facilitated with the use of preinsertion erythromycin. To ensure equal distribution, all patients were stratified by weight (<10 kg vs > or =10 kg) before randomization. All NJ tubes were placed by one of the investigators. If unsuccessful, a second attempt by the same investigator was allowed. Successful placement of the NJ tube was defined by confirmation of the tip of the tube in the first part of the duodenum or beyond by a pediatric radiologist blinded to the treatment groups. RESULTS: Seventy-five pediatric patients were enrolled in the study; 94.6% (71/75) of tubes were passed successfully into the small bowel on the first or second attempt. Evaluation of the data revealed no significant association with a specific technique and successful placement (p = .1999). CONCLUSIONS: When placed by a core group of experienced operators, the majority of NJ feeding tubes can be placed in critically ill or injured children on the first or second attempt, regardless of the technique used.     

Volume‐Based Feeding in the Critically Ill Patient

Introduction: Critically ill patients placed on enteral nutrition (EN) are usually underfed. A volume‐based feeding (VBF) protocol designed to adjust the infusion rate to make up for interruptions in delivery should provide a greater volume of EN than the more common fixed hourly rate‐based feeding (RBF) method. Methods: This single‐center, randomized (3:1; VBF/RBF) prospective study evaluated critically ill patients on mechanical ventilation expected to receive EN for ≥3 days. Once goal rate was achieved, the randomized feeding strategy was implemented. In the VBF group, physicians used a total goal volume of feeds to determine an hourly rate. For the RBF group, physicians determined a constant hourly rate of infusion to meet goal feeds. Results: Sixty‐three patients were enrolled in the study with a mean age of 52.6 years (60% male). Six patients were excluded after randomization because of early extubation. The VBF group (n = 37) received 92.9% of goal caloric requirements with a mean caloric deficit of ?776.0 kcal compared with the RBF group (n = 20), which received 80.9% of goal calories (P = .01) and a caloric deficit of ?1933.8 kcal (P = .01). Uninterrupted EN was delivered for 51.7% of all EN days in VFB patients compared with 54.5% in RBF patients. On days when feeding was interrupted, VFB patients overall received a mean 77.6% of goal calories (while RBF patients received 61.5% of goal calories, P = .001). No vomiting, regurgitation, or feeding intolerance occurred due to VBF. Conclusions: A VBF strategy is safe and improves delivery to better meet caloric requirements than the standard more commonly used rate‐based strategy.     

Gastric vs Small Bowel Feeding in Critically Ill Neurologically Injured Patients

Background: To evaluate gastric compared with small bowel feeding on nutrition and clinical outcomes in critically ill, neurologically injured patients. Materials and Methods: International, prospective observational studies involving 353 intensive care units (ICUs) were included. Eligible patients were critically ill, mechanically ventilated with neurological diagnoses who remained in the ICU and received enteral nutrition (EN) exclusively for at least 3 days. Sites provided data, including patient characteristics, nutrition practices, and 60‐day outcomes. Patients receiving gastric or small bowel feeding were compared. Covariates including age, sex, body mass index, and Acute Physiology and Chronic Health Evaluation II score were used in the adjusted analyses. Results: Of the 1691 patients who met our inclusion criteria, 1407 (94.1%) received gastric feeding and 88 (5.9%) received small bowel feeding. Adequacy of calories from EN was highest in the gastric group (60.2% and 52.3%, respectively, unadjusted analysis; P = .001), but this was not significant in the adjusted model (P = .428). The likelihood of EN interruptions due to gastrointestinal (GI) complications was higher for the gastric group (19.6% vs 4.7%, unadjusted model; P = .015). There were no significant differences in the rate of discontinuation of mechanical ventilation (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.66–1.12; P = .270) or the rate of being discharged alive from the ICU (HR, 0.94; 95% CI, 0.72–1.23; P = .641) and hospital (HR, 1.16; 95% CI, 0.87–1.55; P = .307) after adjusting for confounders. Conclusions: Despite a higher likelihood of EN interruptions due to GI complications, gastric feeding may be associated with better nutrition adequacy, but neither route is associated with better clinical outcomes.     

Pre-pyloric versus post-pyloric feeding

Optimal management of the critically ill patient involves the initiation and rapid advancement of early enteral nutrition (EN). Compared to parenteral nutrition or no nutritional support, early enteral feeding favorably impacts patient outcome by reducing infectious morbidity and shortening hospital length of stay. Controversy exists over the true risks and benefits of pre-pyloric versus post-pyloric feeding. Placement of nasogastric tubes is easier than nasojejunal tubes, initiation of EN is more expedient, and intragastric feeds may provide greater physiologic benefits. Post-pyloric feeding, on the other hand, is associated with fewer interruptions once EN has been started, may reach goal calorie provision sooner, and may reduce risk for gastroesophageal reflux and aspiration. Overall differences in outcome between the two methods of feeding, however, are minimal. Thus, the final choice for the practicing clinician on the level of infusion of enteral feeding is based on institutional factors (related to protocols and available expertise) and the degree of risk and potential tolerance of the individual patient.     

床旁放置经鼻小肠管的新方法

胃排空障碍是影响危重患者肠内营养实施的重要问题,经小肠喂养是解决方法之一。放置小肠营养管的非手术方法主要包括内镜引导和X线辅助,但这两种方法均需要一定的设备和场所,不利于对危重患者进行床旁实施。近年来出现了多种辅助盲探放置小肠管的新方法,本文对这些方法进行综述。     

A randomized trial of endoscopic and fluoroscopic placement of postpyloric feeding tubes in critically ill patients

BACKGROUND: Early postpyloric feeding is considered the accepted method of nutrition support in critically ill patients. Endoscopic and fluoroscopic techniques are associated with the highest percentage of successful placement. The purpose of this study was to compare endoscopic vs fluoroscopic placement of postpyloric feeding tubes in critically ill patients. METHODS: This is a randomized prospective clinical trial. Forty-three patients were randomized to receive feeding tubes by endoscopic or fluoroscopic technique. All procedures were performed at the bedside in the critical care unit. A soft small-bore nonweighted feeding tube was used in all cases. Successful placement was confirmed by either an abdominal x-ray for endoscopic technique or a fluoroscopic radiograph for fluoroscopic technique. RESULTS: Postpyloric feeding tubes were successfully placed in 41 of 43 patients (95%). The success rate using endoscopic technique was 96% (25 of 26), whereas the rate using fluoroscopy was 94% (16 of 17). The average time of successful placement was 15.2 +/- 2.9 (mean +/- SEM) minutes for endoscopic placement and 16.2 +/- 3.2 minutes for fluoroscopic placement, which was not statistically significant (p > .05). CONCLUSIONS: Endoscopic and fluoroscopic placement of postpyloric feeding tubes can safely and accurately be performed at the bedside in critically ill patients. Our results showed no significant difference in the success rate or time of placement between endoscopic vs fluoroscopic placement of postpyloric feeding tubes.     

Nutrition Therapy for the Critically Ill Surgical Patient With Aortic Aneurysmal Rupture

Background: Our goal is to define nutrition therapy in critically ill patients after surgical repair of acute ruptured or dissecting aortic aneurysm to identify opportunities for quality improvement. Methods: International, prospective studies in 2007–2009 and 2011 were combined. Sites provided institutional and patient characteristics including from intensive care units (ICUs) admission to ICU discharge for a maximum of 12 days. We selected patients with aortic aneurysmal rupture or acute dissection staying in the ICU for ≥ 3 days. Results: There were 104 eligible patients from 72 distinct ICUs analyzed. Overall, 86.5% received artificial nutrition. There were 50.0% patients who received enteral nutrition (EN) only, 29.8% patients received a combination of EN and parenteral nutrition (PN), 6.7% patients received PN only, and 13.5% did not receive any nutrition. The mean time from admission to initiation of EN was 3.0 days (SD ± 2.4 days). The adequacy of calories from nutrition support was 46.8% (range 0%‐111%) with a mean of 10.0 kcal/kg/day. Of the total of 83 patients who received EN, 53 patients (63.8%) had interruption of EN. The reasons included fasting, intolerance, patients deemed too sick for enteral feeding, and loss of enteral feeding route. For patients with gastrointestinal intolerance, 3/30 patients (10%) received small bowel feeding and 23/30 patients (76.7%) of patients received motility agents. Conclusion: Postoperative critically ill patients with aortic aneurysmal rupture or acute dissection are at high risk for inadequate nutrition therapy, and there may be inadequate utilization of strategies to improve nutrition uptake.     

When early enteral feeding is not possible in critically ill patients: results of a multicenter observational study

Background: Early enteral nutrition (EN) is the preferred strategy for feeding the critically ill; however, it is not always possible to initiate EN within the recommended 24 to 48 hours. When these situations arise, controversy exists whether to start feeding early via the parenteral route or to delay feeding until EN can be provided. Methods: A multicenter, international, observational study examined nutrition practices in intensive care units (ICUs). Eligible patients were critically ill patients with a medical diagnosis who remained in the ICU for >72 hours and received EN >48 hours after admission. Data were collected on site, including patient characteristics, daily nutrition practices, and outcomes at 60 days. Nutrition and clinical outcomes were compared between 3 groups of patients: (1) early parenteral nutrition (PN) (<48 hours after admission) and late EN (>48 hours after admission), (2) late PN and late EN, and (3) late EN and no PN. Results: Of the 703 patients who met our inclusion criteria, 541 (77.0%) medical patients received late EN and no PN. In patients receiving late EN and PN, 83 (11.8%) received early PN and 79 (11.2%) received late PN. Adequacy of calories and protein from total nutrition was highest in the early PN group (74.1% ± 21.2% and 71.5% ± 24.9%, respectively) and lowest in the late EN group (42.9% ± 21.2% and 38.7% ± 21.6%) (P < .001). The proportion of patients dead or remaining in hospital was significantly higher for early PN compared with late EN and PN (unadjusted hazard ratio for early PN = 0.55; 95% confidence interval, 0.37–0.83, P = .015). However, this difference did not remain significant (P = .65) after adjustment for baseline characteristics. Conclusions: The results suggest that initiating PN early, when it is not possible to feed enterally early, may improve provision of calories and protein but is not associated with better clinical outcomes compared with late EN or PN.     

The Role of the Enteral Route and the Composition of Feeds in the Nutritional Support of Malnourished Surgical Patients

In surgical patients, malnutrition is an important risk factor for post-operative complications. In undernourished patients undergoing major gastrointestinal procedures, preoperative enteral nutrition (EN) should be preferred whenever feasible. It may be given either orally or by feeding tubes, depending on patient compliance. Early oral intake after surgery should be encouraged, but if an insufficient postoperative oral intake is anticipated, tube feeding should be initiated as soon as possible. The use of immunomodulating formulas offers significant advantages when compared to standard feeds and the positive results on postoperative complications seem independent from the baseline nutritional status. In malnourished patients, the optimal timing and dose of immunonutrition is unclear, but consistent data suggest that they should be treated peri-operatively for at least two weeks.     

Nutrition entérale en réanimation : le point de vue du pédiatre

Malnutrition at admission is frequent in critically ill children and associated with impaired outcomes. Profound metabolic and hormonal shifts occur during critical illness; they are responsible for faltering growth, leading to pediatric intensive care acquired weakness with long-term consequences. Nutritional support is essential in this setting; enteral nutrition should be favored, with rare contra-indications and good tolerance in most children. Nutritional goals should be set using indirect calorimetry or Schofield equations. Early enteral nutrition is recommended, through a gastric tube. Enteral nutrition should be increased over a few days to meet the predefined goals, following local written guidelines. Polymeric products should be first choice, and iso- versus hyper-caloric solutions should be chosen depending on fluid restriction requirements. Tolerance should be closely monitored, but the use of gastric residual volume needs to be further studied.     

Serum paracetamol concentration: an alternative to X-rays to determine feeding tube location in the critically ill

BACKGROUND: Placement of enteral feeding tubes is an important clinical issue. Previous studies suggest that paracetamol absorption is very fast after jejunal administration. The aim was to determine whether paracetamol serum concentration measured by immunoassay can determine the tip position of the feeding tube. METHODS: Thirty-three critically ill patients requiring enteral nutrition with either gastric or post-pyloric feeding tubes were enrolled prospectively in the surgical intensive care unit of a university hospital. Paracetamol was administered in the feeding tube (15 mg/kg) after a baseline blood sample (T0). Thereafter, 8 blood samples were taken between 2.5 and 240 minutes. Paracetamol was analyzed using an automated homogenous immunoassay. RESULTS: The patients did not differ with respect to age or severity of disease. Peak paracetamol concentrations were significantly higher after post-pyloric administration with 42.6 +/- 13.5 versus 20.5 +/- 7.5 mg/L (p < .0001). Time-to-peak paracetamol concentration was significantly shorter with post-pyloric tubes (median, 5 versus 60 minutes; p < .0001). The receiver operating characteristic (ROC) curves showed the highest sensitivity and specificity at 5 minutes with 94.1% and 100%, respectively, for discriminating between gastric and post-pyloric location. CONCLUSIONS: Because of paracetamol's rapid absorption after jejunal administration, the test seems to be a safe and inexpensive alternative to X-ray control for assessment of the enteral feeding tube location. Its value in clinical practice remains to be established.     

Nutrition support in the critically ill: a physician survey

Background: Current clinical practice guidelines delineate optimal nutrition management in the intensive care unit (ICU) patient. In light of these existing data, the authors identify current physician perceptions of nutrition in critical illness, preferences relating to initiation of feeding, and management practices specific to nutrition after initiation of feeding in the ICU patient. Methods: The authors electronically distributed a 12‐question survey to attending physicians, fellows, and residents who routinely admit patients to medical and surgical ICUs. Results: On a scale ranging from 1 to 5 (1 = low, 5 = high), the attending physician's mean rating for importance of nutrition in the ICU was 4.60, the rating for comfort level with the nutrition support at the authors' institution was 3.70, and the rating for the physician's own understanding of nutrition support in critically ill patients was 3.33. Attending physicians, fellows, and residents reported waiting an average of 2.43, 1.79, and 2.63 days, respectively, before addressing nutrition status in an ICU patient. Fifty‐two percent of attending physicians chose parenteral nutrition as the preferred route of nutrition support in a patient with necrotizing pancreatitis. If a patient experiences enteral feeding intolerance, physicians most commonly would stop tube feeds. There was no significant difference in responses to any of the survey questions between attending physicians, fellows, and residents. Conclusions: This study demonstrates a substantial discordance in physician perceptions and practice patterns regarding initiation and management of nutrition in ICU patients, indicating an urgent need for nutrition‐related education at all levels of training.     

保留空肠营养管在胃癌术后化疗期间的应用价值

目的 探讨保留空肠营养管在胃癌术后化疗期间的应用价值.方法 总结42例胃癌根治术后行辅助化疗患者的临床资料,术中常规放置空肠营养管,将所有病例按术后病理分期及肿瘤部位随机分为A、B两组,每组各21例,A组保留空肠营养管并在化疗期间经空肠营养管行肠内营养,B组不保留空肠营养管在化疗期间按日常进食,分别比较两组化疗前后营养及免疫指标,比较两组患者呕吐的发生率.观察长期保留空肠营养管的并发症.结果 化疗后A组营养及免疫指标较B组明显提高,两组比较差异有统计学意义(P＜0.05).A组呕吐发生率为18.3%,显著低于B组发生率(35.7%)(X2=9.75,P＜0.01).长期保留空肠营养管未发生严重并发症.结论 保留空肠营养管在胃癌术后化疗期间行肠内营养能显著改善患者的营养及免疫状况,且安全可靠,值得推广.     

Treating Delayed Gastric Emptying in Critical Illness

Background: We describe experience using the Cortrak nasointestinal feeding tube and prokinetics in critically ill patients with delayed gastric emptying. Methods: Patient cohorts fed via a Cortrak electromagnetically guided nasointestinal tube (EGNT) or 14 French‐gauge nasogastric tube plus prokinetics were retrospectively compared. Results: Of 69 EGNT placements in 62 patients, 87% reached the small intestine. The median percentage of the enteral nutrition goal increased from 19% pre‐EGNT to 80%–100% between days 1 and 10 post‐insertion and was greater than in 58 patients prescribed metoclopramide (40%–87%: days 1–2, 5–7, P ≤ .018) or 38 patients prescribed erythromycin (48%–98%; days 1 and 5, P < .0084). Up to day 10, the cumulative feeding days lost were lower for EGNT (1.06) than for metoclopramide (2.6, P < .02) or erythromycin (3.1, P < .02). The EGNT group had a lower use of prokinetics and lower treatment cost. Conclusion: Most bedside EGNT placements succeed and, compared to nasogastric feeding plus prokinetics, increase enteral nutrition delivery and reduce both cumulative feeding days lost and prokinetic use.     

Nutrition therapy for the critically ill surgical patient: we need to do better!

Background: To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described. Methods: International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared. Results: A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy. Conclusions: Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.     

重症患者肠内营养及生长激素治疗的疗效观察

目的 探讨早期肠内营养(EN)和生长激素(GH)对危重病患者救治的效果.方法 70例危重患者随机分为EN组和EN+GH组.两组营养支持均等热量、等氮量.分别于营养支持前后检测血生化、营养状态指标及肠道黏膜通透性.营养支持治疗10 d后测定两组的免疫学指标与T细胞亚群.营养支持期间每天测定氮平衡,并计算累计氮平衡.结果 EN+GH组体重、白蛋白、转铁蛋白水平的改善优于EN组,但差异无显著性(P＞0.05),而EN+GH组前白蛋白、纤维连接蛋白显著高于EN组(P＜0.05).EN+GH组IgA水平显著低于EN组,而CD4、NK水平显著高于EN组(P＜0.05).EN+GH组肠道通透性显著低于EN组(P＜0.05).EN+GH组累计氮平衡为正氮平衡,而EN组为负氮平衡,二者之间差异具有显著性(P＜0.05).结论 早期EN支持能迅速改善危重患者营养状态,减少并发症,适量应用GH能增强免疫功能,降低致残率和死亡率.