‫بسم هللا الرحمن الرحيم‬

NUTRITIONAL
STRATEGIES IN PICU

Mahmoud Tarek Abdelmonim, MD

Professor of Pediatrics, Faculty Of Medicine,
Ain Shams University, Cairo, Egypt.
 LEARNING GOALS

 Impact of Critical Illness

 Enteral vs Parenteral nutrition in the PICU
Patient
 Importance of Nutrition & Goals of
nutritional support
 Monitoring of the nutritional status
 Nutritional requirements in the PICU
Patient
Why Is Nutrition Important ?

CRITICAL ILLNESS + POOR NUTRITION

=
 Prolonged ventilator dependency
 Prolonged ICU stay
 Heightened susceptibility to nosocomial
infections MSOF
 Increased mortality
 Critical illness

Nutritional Deficient intake

disorder & starvation
Impact of critical illness

Catabolic phase

•Increased energy expenditure : ( Pain,

Anxiety, Fever, Muscular effort-WOB &
shivering)
• Inadequate intake wasting of endogenous
protein stores and increased muscle-protein breakdown &
gluconeogenesis
Impact of starvation

• Negative nitrogen balance

• Morphological changes in the gut (Mucosal
thickness, Cell proliferation and Villus height)
• Functional changes (Increased permeability &
Decreased absorption of amino acids)
• Enzymatic/Hormonal changes (Decreased
sucrase and lactase…etc)
Impact of starvation

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)
Bed side questions
When What How

?????
 ENTERAL
OR PARENTERAL
??????????
ENTERAL or PARENTERAL?

Enteral Nutrition: Superior to Parenteral

•Trophic effects on intestinal villus
•Supports Gut-associated Lymphoid Tissue
•Promotes secretory IgA secretion and
function
•Lower cost
•No needs for IV access
•Lower Infectious risk
P
E
ENTERAL FEEDING
WHEN TO INITIATE ENTERAL NUTRITION ?

• ASAP-usually within 24 hours even in

severe states

CONTRAINDICATIONS TO ENTERAL NUTRITION

• Nonfunctional gut, anatomic disruption, gut

ischemia
• Severe peritonitis
• Severe shock states
 ROUTE OF FEEDING

•Nasogastric
Requires gastric
motility/emptying
•Transpyloric
Effective in gastric atony/ ileus
•Percutaneous/surgical
placement
-Gastrostomy if > 4 weeks
nutritional support anticipated
-Jejunostomy if GE reflux,
gastroparesis, pancreatitis
POTENTIAL DRAWBACKS OF
ENTERAL FEEDS

 Gastric emptying impairments

 Aspiration of gastric contents
 Diarrhea
 Sinusitis
 Esophagitis /erosions
 Displacement of feeding tube
PARENTERAL
FEEDING
 Indications :

• Intractable vomiting, ileus, short bowel syndrome

• Severe diarrhea
• Severe malnourishment
• After gastrointestinal surgery
• Severe mucositis, exacerbation of inflammatory
bowel disease, Necrotizing enterocolitis …etc
• Respiratory illness until enteral feeding is
established
ENTERAL OR PARENTRAL
????
It is best to feed the patient
through the enteral route
whenever possible.
“If the GI tract works, use it”
Nutrition formulation
• Fluid Requirements
• Energy Requirements
• Protein, Fat and CHO Requirements
• Vitamins
• Trace elements
 Fluid Requirements:
• Fluid requirements = maintenance + repair of
dehydration + replacement of ongoing losses.
• Maintenance Fluid Requirements
1 - 10 kg = 100 ml/kg/day
10 - 20kg = 1000 ml + 50 ml for each kg > 10 kg
20 kg = 1500 ml + 20ml for each kg > 20 kg
• Remember to consider medications, flushes, drips,
transfusion therapy and other IV fluids in your
calculations.
Energy Requirements

Total Daily Energy Requirements (kcal/day)

=
Resting Energy Expenditure (REE)
+
REE  (Total stress Factors)
Energy Requirements

Resting Energy Expenditure (REE)

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
Factors adding to REE :
Factor 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
 Example
• A critically ill child aged 2.5 years, body
weight is 14 kg. The patient is active but has
fever 39°C and evidence of sepsis.

• REE = 14 X 57 = 798 Kcal/day

• Stress factors = 0.2 + 0.2 + 0.26 +0.4 = 0.86
(0.86 X 798 = 686 Kcal/day )

• Total Daily Energy Requirement = 798 +

686 = 1484 Kcal/day
Energy Requirements

- Caloric values : 3.4 Kcal/g for dextrose & amino

acids - 9 Kcal/g for fat
-At least 80% of necessary calories should be provided.
-A positive nitrogen balance can be achieved by 60
Kcal/kg /day of IV glucose + 2.5 g/kg/day of a.a.
-Higher energy intakes improve nitrogen retention and
spare fat reserves
 PN-suggested guidelines for Initiation
and Maintenance
Substrate Initiation Advancement Goals
Dextrose 10% 2-5%/day 25%

Amino acids 1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day

20% Lipids 1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day

•Dextrose Concentrations of 10-12.5 % can be used in peripheral

veins. Higher concentration (up to 25%) can be used in central
veins.
Minerals:
 Sodium : 3 – 3.8 mEq/kg/day
 Potassium : 1-1.2 mEq/kg/day
 Chloride : 2 mEq/kg/day
 Calcium : 80 mg/kg/day (20 mg/dl=0.5
mmol/dl=1 mEq/dl)
 Magnesium : 6 mg/kg/day (12 mg/dl=0.5
mmol/dl=1mEq/dl)
 Phosphhrus : 60 mg/kg/day
 Trace elements
Zinc : 300-450 ug / dl
Copper : 20-30 ug/dl
Chromium:0.2-0.3 ug/dl
Manganese: 5-7 ug/dl
Selenium: 1.5-2 ug/dl

Trace elements should be stopped or given less frequently

in severe cholestasis (copper & Mg are eleminated in bile)
or in renal failure (Se & chromium accumulations).
However in both situations Zn should be given the same
 Monitoring:
 Daily weight
 Routine nursing observations
 Laboratory investigations :
-CBC
-Urine (sugar, acetone)
-Electrolytes
-Transaminases, alkaline phosphatase and bilirubin levels
-Urea & creatinine
-Lipid levels
Fat infusion should be stopped 2-4 hours before taking blood
samples (8 hours for lipid tests)
Complications :
 Infection
 Hepatic dysfunction
 Metabolic complications: hyperglycemia,
hypoglycemia, acidosis, hypomagnesemia,
hyperlipidemia, hypocalcemia
 Trace metal deficiencies
 Mechanical complications: dysrrhythmias, venous
thrombosis, air embolism & skin sloughs
 Bilirubin displacement by intralipid
OVERFEEDING
Dangers of overfeeding:

• Secretory diarrhea (with EN)

• Hyperglycemia, glycosuria, dehydration, lipogenesis,
fatty liver, liver dysfunction
• Electrolyte abnormalities: PO4 , K, Mg
• Volume overload, CHF
• CO2 production- ventilatory demand
• O2 consumption
Nutrition support of the
critically ill patient
with
Organ Failure
Respiratory Failure
General treatment goals for respiratory failure

 Treat underlying condition

 Support physiologic function
– Maintain tissue oxygen delivery
– Minimize pulmonary edema
– Give nutrition support
– Prevent/manage infection
Nutrient Requirements in Pulmonary Failure

 Calories: don’t overfeed when weaning to prevent

increased CO2 production
(Provide 25-30 kcal/kg or resting energy expenditure)
 Respiratory Quotient (RQ)
 RQ is the ratio of carbon dioxide produced to
oxygen consumed.
 RQ is an indicator of fuel utilization
 Normal (physiologic) range is 0.5 to 1.5
 High RQ in a ventilator patient may make it
difficult to wean the patient from the respirator
 Respiratory Quotient Values for
Various Fuel Substrates
Fat 0.7
Protein 0.8
Carbohydrate 1.0
Mixed Diet ~0.85
Underfed <0.8
Overfed >1.0
Nutrient Requirements in Pulmonary Failure

 Protein: 1.5-2 g/kg

– Amino acids may increase ventilation, increase O2
consumption.
 Fat: OMEGA 3 FA may be anti-inflammatory
and alter immune status in sepsis/ARDS
Liver Failure
Nutrient Requirements in liver Failure

 Calories: caloric requirements affected by

acuteness of disease, seriousness of injury,
absorption, other organ failure, sepsis; accurate
calculation of REE & total energy nereds.
 CHO: ~70% non-protein calories; in acute
failure, may need continuous glucose infusion
– Chronic: may have diabetes/altered glucose
levels requiring controlled CHO and insulin.
Nutrient Requirements in liver Failure

 Protein: well nourished/low stress: 0.8 g/kg;

malnourished/with metabolic stress: up to 1.5
g/kg
 FAT: 30% non-protein calories.
 Evaluate and compensate for vitamins and
mineral deficiencies especially fat soluble
vitamins
Nutrition in Pediatric
Acute Renal Failure
Nutrition Implications of ARF
• ARF causes anorexia, nausea, vomiting, bleeding
• ARF causes rapid nitrogen loss and lean body mass loss
(hypercatabolism)
• ARF causes ↑ gluconeogenesis with insulin resistance
• Dialysis causes loss of amino acids and protein
• Uremia toxins cause impaired glucose utilization and protein
synthesis
 Nutrition Implications of ARF

-Impaired a.a metabolism : impaired conversion and resultant

deficiencies of Gly, Ala (Tubular protectant) & Arg
(Preserves renal perfusion)
……..AA Supplementation helps renal perfusion and GFR and
diuresis.

- Impaired Lipolysis
Lipase Activity ~50%
impaired Lipoprotein Lipase
impaired Hepatic Triglyceride Lipase
Nutrition Implications of ARF

Vitamins
 Vitamin A: elevated vitamin A levels are
known to occur with RF
 Vitamin B – prevent B6 deficiency by giving
10 mg pyridoxine hydrochloride/day
 Vitamin C: <200 mg/day to prevent ↑ oxalate
 Activated vitamin D
 SIRS
&
Multiple Organ Failure
Nutrition/Metabolism Considerations

• 3-5 times higher catabolism

• Increased skeletal muscle proteolysis
• Higher shift of amino acids for
gluconeogenesis
 Nutrient Needs in MODS
 Calories: Adequate intake
 Protein: up to 1.5-2.0 g/kg
 Fat: 30% nonprotein calories
 Micronutrients: evaluate individually
 Fluid: based on fluid status
 CONCLUSIONS
 Start nutrition early
 Enteral route is preferred when available
 Set goals for the individual patient
 Appropriate monitoring is essential
 Avoid overfeeding
 Critically ill patients with organ failure
present special challenges to the nutrition
care professional and medical team
Thank you
Initiation and advancement of Macronutrients:

 Dextrose - Begin PN at 10 - 15% dextrose depending on whether

the line is peripheral or central and the clinical status and age of
the child. Advance by 2.5 - 5% in older infants and children and
by 5 - 10% per day in adolescents until an endpoint of D12.5%
dextrose for PPN or generally between 20 - 25% dextrose for
CPN, as needed to meet nutritional needs.
 Provision of excess carbohydrate calories may lead to the
following adverse effects: hyperglycemia, hepatotoxicity,
cholestasis, glycosuria, osmotic diuresis
 Insulin Use - Critically ill pediatric patients experiencing
hyperglycemia from stress or medical management may need to
have insulin added to the TPN.
Initiation and advancement of Macronutrients:

 Protein - Infants under 2 years of age should be started on a

pediatric parenteral amino acid solution such as TrophAmine
(B. Braun, Irvine, CA). This amino acid formulation for
pediatric patients provides numerous advantages including:
provides essential amino acids for infants, promotes plasma
amino acid profiles within normal neonatal target range,
decreases the tendency for development of cholestasis, and
decreases the pH of the solution thus improving calcium and
phosphorus solubility (7.2 mEq of Ca + Phos per 100 ml of PN
solution).
 Protein Advancement in Infants and Children - Begin at
1.5 - 2 gm/kg per day and advance to endpoint goal by Day 2.
In infants with renal insufficiency or failure may need to limit
protein to 1.0 gm/kg/day on first day of PN.
Initiation and advancement of Macronutrients:

 Lipids - Lipids may be safely used on a daily basis in most

patients. Begin lipids at 1.0 gm/kg and advance by 1.0 gm/kg
per day depending on a child's age and lipid clearance to the
appropriate endpoint goal of 3 gm/kg in infants and 1 - 2.0
gm/kg in older children and adolescents, depending on clinical
status.

 Essential Fatty Acid (EFA) Requirements - 20% Intralipid

(2 kcal/cc) should be provided at a minimum dose of 0.5 - 1.0
gm/kg per day for provision of essential fatty acid (EFA)
requirements. Signs of EFA deficiency include: reduced
growth rate, impaired wound healing, increased susceptibility
to infections, thromobocytopenia, and flaky dry skin .