51
|
Hong CR, Zurakowski D, Fullerton BS, Ariagno K, Jaksic T, Mehta NM. Nutrition Delivery and Growth Outcomes in Infants With Gastroschisis. JPEN J Parenter Enteral Nutr 2018; 42:913-919. [DOI: 10.1002/jpen.1022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/20/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Charles R. Hong
- Department of Surgery; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts USA
| | - David Zurakowski
- Department of Surgery; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts USA
- Department of Anesthesia; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - Brenna S. Fullerton
- Department of Surgery; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts USA
| | - Katelyn Ariagno
- Center for Nutrition; Division of Gastroenterology; Hepatology and Nutrition; Boston Children's Hospital; Boston Massachusetts USA
| | - Tom Jaksic
- Department of Surgery; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts USA
| | - Nilesh M. Mehta
- Center for Nutrition; Division of Gastroenterology; Hepatology and Nutrition; Boston Children's Hospital; Boston Massachusetts USA
- Division of Critical Care Medicine; Department of Anesthesiology Perioperative and Pain Medicine; Boston Children's Hospital; Boston Massachusetts USA
- Center for Nutrition Boston Children's Hospital; Harvard Medical School Boston; Boston Massachusetts USA
| |
Collapse
|
52
|
Moreno YMF, Hauschild DB, Martins MD, Bechard LJ, Mehta NM. Feasibility of Enteral Protein Supplementation in Critically Ill Children. JPEN J Parenter Enteral Nutr 2017; 42:61-70. [PMID: 29350400 DOI: 10.1002/jpen.1018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/06/2017] [Accepted: 08/24/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND We describe the protein type and concentration in standard enteral nutrition (EN) formulas and the effect of protein supplementation on the osmolality of standard formulas. We also aimed to examine factors associated with optimal protein delivery in critically ill children. METHODS Protein content and other characteristics of pediatric EN formulas used worldwide were recorded. Factors associated with achievement of recommended protein delivery and tolerance of protein-supplemented formulas were recorded prospectively in a cohort of critically ill children. A range of protein supplement doses was added to 2 standard formulas and water, and the osmolality was recorded by cryoscopy in a bench experiment. RESULTS We reviewed 125 formulas used in a multicenter study including sites from >13 countries. A majority of the EN formulas (73.6%) were polymeric, with a nonprotein calorie/nitrogen ratio of 182 ± 66 and protein content of 3.53 ± 2.00 g/100 mL. In the cohort of critically ill children, 28.5% achieved protein intake goal within 4 days, with no intolerance. In addition to optimal protein prescription (P < 0.001), protein supplementation (P = 0.018) and early EN initiation (P = 0.006) were associated with significantly higher odds of achieving goal protein intake. Formulas supplemented with up to 8 g/100 mL polymeric protein had osmolality <450 mOsm/kg. CONCLUSIONS The protein content of current pediatric formulas may be inadequate to meet the needs of critically ill children. Protein supplementation of formulas allows early achievement of goal and is likely to be safe.).
Collapse
Affiliation(s)
- Yara M F Moreno
- Department of Nutrition and Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Daniela B Hauschild
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Mayara D Martins
- Department of Nutrition and Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Lori J Bechard
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
53
|
Goday PS, Mehta NM. Response to "Pediatric Intensive Care Nutrition Guidelines 2017: Key Questions Remain Unanswered". JPEN J Parenter Enteral Nutr 2017; 42:10-11. [PMID: 29505148 DOI: 10.1002/jpen.1016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Praveen S Goday
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Nilesh M Mehta
- Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
54
|
Martinez EE, Smallwood CD, Quinn NL, Ariagno K, Bechard LJ, Duggan CP, Mehta NM. Body Composition in Children with Chronic Illness: Accuracy of Bedside Assessment Techniques. J Pediatr 2017; 190:56-62. [PMID: 29144272 PMCID: PMC5718170 DOI: 10.1016/j.jpeds.2017.07.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/12/2017] [Accepted: 07/21/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the accuracy of estimated fat mass and fat-free mass from bedside methods compared with reference methods in children with chronic illnesses. STUDY DESIGN Fat mass and fat-free mass values were obtained by skinfold, bioelectrical impedance analysis (BIA), dual-energy x-ray absorptiometry (DXA), and deuterium dilution method in children with spinal muscular atrophy, intestinal failure, and post hematopoietic stem cell transplantation (HSCT). Spearman's correlation and agreement analyses were performed between (1) fat mass values estimated by skinfold equations and by DXA and (2) fat-free mass values estimated by BIA equations and by DXA and deuterium dilution methods. Limits of agreement between estimating and reference methods within ±20% were deemed clinically acceptable. RESULTS Fat mass and fat-free mass values from 90 measurements in 56 patients, 55% male, and median age of 11.6 years were analyzed. Correlation coefficients between the skinfold-estimated fat mass values and DXA were 0.93-0.94 and between BIA-estimated fat-free mass values and DXA were 0.92-0.97. Limits of agreement between estimated and DXA values of fat mass and fat-free mass were greater than ±20% for all equations. Correlation coefficients between estimated fat-free mass values and deuterium dilution method in 35 encounters were 0.87-0.91, and limits of agreement were greater than ±20%. CONCLUSION Estimated body composition values derived from skinfold and BIA may not be reliable in children with chronic illnesses. An accurate noninvasive method to estimate body composition in this cohort is desirable.
Collapse
Affiliation(s)
- Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Craig D Smallwood
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Nicolle L Quinn
- Center for Nutrition, Boston Children's Hospital, Boston, MA
| | - Katelyn Ariagno
- Center for Nutrition, Boston Children's Hospital, Boston, MA
| | - Lori J Bechard
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Christopher P Duggan
- Harvard Medical School, Boston, MA; Center for Nutrition, Boston Children's Hospital, Boston, MA; Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Center for Nutrition, Boston Children's Hospital, Boston, MA.
| |
Collapse
|
55
|
Mehta NM, Skillman HE, Irving SY, Coss-Bu JA, Vermilyea S, Farrington EA, McKeever L, Hall AM, Goday PS, Braunschweig C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr 2017; 41:706-742. [DOI: 10.1177/0148607117711387] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Heather E. Skillman
- Clinical Nutrition Department, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Sharon Y. Irving
- Division of Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Jorge A. Coss-Bu
- Section of Critical Care, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah Vermilyea
- Division of Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Elizabeth Anne Farrington
- Department of Pharmacy, Betty H. Cameron Women’s and Children’s Hospital, New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - Liam McKeever
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amber M. Hall
- Biostatistics, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Praveen S. Goday
- Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Carol Braunschweig
- Division of Epidemiology and Biostatistics, Department of Kinesiology and Nutrition, University of Illinois, Chicago, Illinois, USA
| |
Collapse
|
56
|
Hauschild DB, Ventura JC, Mehta NM, Moreno YMF. Impact of the structure and dose of protein intake on clinical and metabolic outcomes in critically ill children: A systematic review. Nutrition 2017; 41:97-106. [PMID: 28760436 DOI: 10.1016/j.nut.2017.04.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/10/2017] [Accepted: 04/24/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The aim of this study was to describe the effects of structure/type and total amount of protein intake on protein balance and clinical outcomes in critically ill children. METHODS We conducted a systematic review of relevant literature on Embase, PubMed/Medline, Web of Science, Scopus, and Latin American and Caribbean Health Sciences. A partial gray literature search was undertaken and the reference lists of the selected articles were searched manually. Observational and clinical trials that evaluated the total protein intake, structure of the protein source, or both, in critically ill children were included. Nitrogen balance and clinical outcomes (mortality, length of stay, and duration of mechanical ventilation) were the main outcomes of interest. RESULTS We found 18 eligible studies, of which 17 assessed the quantity and one described protein structure in relation to the outcomes. In all, 2118 pediatric critically ill patients <18 y of age were included. The total daily protein intake ranged from 0.67 to 4.7 g/kg. Average daily total protein intake >1.1 g/kg, especially >1.5 g/kg, was associated with positive protein balance and lower mortality. CONCLUSION In critically ill children, total daily protein intake >1.1 g/kg was associated with positive effects on clinical outcomes and protein balance. The existing data are not sufficient for determining the optimal structure of protein delivered by enteral route in critically ill children.
Collapse
Affiliation(s)
- Daniela B Hauschild
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Julia C Ventura
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Yara M F Moreno
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil.
| |
Collapse
|
57
|
Affiliation(s)
- Craig D Smallwood
- Division of Critical Care Medicine Department of Anesthesiology Perioperative and Pain Medicine Boston Children's Hospital
| | - Nilesh M Mehta
- Division of Critical Care Medicine Department of Anesthesiology Perioperative and Pain Medicine Boston Children's Hospital; Center for Nutrition Boston Children's Hospital Harvard Medical School Boston, Massachusetts.
| |
Collapse
|
58
|
Abstract
PURPOSE OF REVIEW To review the current literature evaluating clinical outcomes of early and delayed parenteral nutrition initiation among critically ill children. RECENT FINDINGS Nutritional management remains an important aspect of care among the critically ill, with enteral nutrition generally preferred. However, inability to advance enteral feeds to caloric goals and contraindications to enteral nutrition often leads to reliance on parenteral nutrition. The timing of parenteral nutrition initiation is varied among critically ill children, and derives from an assessment of nutritional status, energy requirements, and physiologic differences between adults and children, including higher nutrient needs and lower body reserves. A recent randomized control study among critically ill children suggests improved clinical outcomes with avoiding initiation of parenteral nutrition on day 1 of admission to the pediatric ICU. SUMMARY Although there is no consensus on the optimal timing of parenteral nutrition initiation among critically ill children, recent literature does not support the immediate initiation of parenteral nutrition on pediatric ICU admission. A common theme in the reviewed literature highlights the importance of accurate assessment of nutritional status and energy expenditure in deciding when to initiate parenteral nutrition. As with all medical interventions, the initiation of parenteral nutrition should be considered in light of the known benefits of judiciously provided nutritional support with the known risks of artificial, parenteral feeding.
Collapse
Affiliation(s)
- Lissette Jimenez
- aDivision of Gastroenterology, Hepatology and Nutrition bDivision of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | |
Collapse
|
59
|
Smallwood CD, Kheir JN, Walsh BK, Mehta NM. Accuracy of Oxygen Consumption and Carbon Dioxide Elimination Measurements in 2 Breath-by-Breath Devices. Respir Care 2017; 62:475-480. [PMID: 28096476 DOI: 10.4187/respcare.05115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although accurate quantification of oxygen consumption (V̇O2 ) and carbon dioxide elimination (V̇CO2 ) provides important insights into a patient's nutritional and hemodynamic status, few devices exist to accurately measure these parameters in children. Therefore, we assessed the accuracy and agreement of 2 devices currently on the market using a pediatric in vitro model of gas exchange. METHODS We utilized a Huszczuk simulation model, which simulates oxygen consumption and carbon dioxide production using gas dilution, to examine the accuracy of two FDA-cleared respiratory modules (E-COVX and E-sCAiOVX-00). V̇O2 and V̇CO2 were set at 20, 40, 60, and 100 mL/min, ranges typical for infant and pediatric patients. Bland-Altman analysis was used to calculate the bias and limits of agreement of each device relative to simulated values for V̇O2 and V̇CO2 . RESULTS The E-COVX mean percentage bias (limits of agreement) was -26.3% (-36.1 to -16.6%) and -39.3% (-47.5 to -31.1%) for V̇O2 and V̇CO2 , respectively. The mean bias (limits of agreement) for the E-aCAiOVX-00 was -0.5% (-13.3 to 12.3%) and -6.0% (-13.8 to 1.7%) for V̇O2 and V̇CO2 , respectively. CONCLUSIONS The E-COVX demonstrated bias and limits of agreement that were not clinically acceptable; therefore, application of this module to pediatric patients would not be recommended. The new module, E-sCAiOVX, demonstrated acceptable bias and limits of agreement for the V̇O2 and V̇CO2 in the range 40-100 mL/min (which corresponds to patients in the range of ∼5-16 kg).
Collapse
Affiliation(s)
- Craig D Smallwood
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine .,Harvard Medical School, Boston, Massachusetts
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Brian K Walsh
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine.,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
60
|
Lee JH, Rogers E, Chor YK, Samransamruajkit R, Koh PL, Miqdady M, Al-Mehaidib AI, Pudjiadi A, Singhi S, Mehta NM. Optimal nutrition therapy in paediatric critical care in the Asia-Pacific and Middle East: a consensus. Asia Pac J Clin Nutr 2017; 25:676-696. [PMID: 27702711 DOI: 10.6133/apjcn.012016.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Current practices and available resources for nutrition therapy in paediatric intensive care units (PICUs) in the Asia Pacific-Middle East region are expected to differ from western countries. Existing guidelines for nutrition management in critically ill children may not be directly applicable in this region. This paper outlines consensus statements developed by the Asia Pacific-Middle East Consensus Working Group on Nutrition Therapy in the Paediatric Critical Care Environment. Challenges and recommendations unique to the region are described. METHODS AND STUDY DESIGN Following a systematic literature search from 2004-2014, consensus statements were developed for key areas of nutrient delivery in the PICU. This review focused on evidence applicable to the Asia Pacific-Middle East region. Quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. RESULTS Enteral nutrition (EN) is the preferred mode of nutritional support. Feeding algorithms that optimize EN should be encouraged and must include: assessment and monitoring of nutritional status, selection of feeding route, time to initiate and advance EN, management strategies for EN intolerance and indications for using parenteral nutrition (PN). Despite heterogeneity in nutritional status of patients, availability of resources and diversity of cultures, PICUs in the region should consider involvement of dieticians and/or nutritional support teams. CONCLUSIONS Robust evidence for several aspects of optimal nutrition therapy in PICUs is lacking. Nutritional assessment must be implemented to document prevalence and impact of malnutrition. Nutritional support must be given greater priority in PICUs, with particular emphasis in optimizing EN delivery.
Collapse
Affiliation(s)
- Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, and Office of Clinical Sciences, Duke-NUS School of Medicine, Singapore.
| | - Elizabeth Rogers
- Department of Nutrition and Food Services, Royal Children's Hospital, Melbourne, Australia
| | | | - Rujipat Samransamruajkit
- Division of Paediatric Pulmonary and Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pei Lin Koh
- Paediatric Critical Care and Paediatric Haematology- Oncology Divisions of Department of Paediatrics, Khoo Teck Puat- National University Children's Medical Institute, National University Hospital, Singapore
| | - Mohamad Miqdady
- Paediatric Gastroenterology, Hepatology and Nutrition, Sheikh Khalifa Medical City, United Arab Emirates
| | - Ali Ibrahim Al-Mehaidib
- Paediatric Gastroenterology and Nutrition, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Antonius Pudjiadi
- Paediatric Critical Care Division, Department of Child Health, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Sunit Singhi
- Department of Paediatrics, Advanced Paediatrics Center, Postgraduate Institute of Medical Education and Research, India
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital Boston, United States
| |
Collapse
|
61
|
Martinez EE, Pereira LM, Gura K, Stenquist N, Ariagno K, Nurko S, Mehta NM. Gastric Emptying in Critically Ill Children. JPEN J Parenter Enteral Nutr 2017; 41:1100-1109. [PMID: 28061320 DOI: 10.1177/0148607116686330] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delayed gastric emptying (GE) impedes enteral nutrient (EN) delivery in critically ill children. We examined the correlation between (a) bedside EN intolerance assessments, including gastric residual volume (GRV); (b) delayed GE; and (c) delayed EN advancement. MATERIALS AND METHODS We prospectively enrolled patients ≥1 year of age, eligible for gastric EN and without contraindications to acetaminophen. Gastric emptying was determined by the acetaminophen absorption test, specifically the area under the curve at 60 minutes (AUC60). Slow EN advancement was defined as delivery of <50% of the prescribed EN 48 hours after study initiation. EN intolerance assessments (GRV, abdominal distension, emesis, loose stools, abdominal discomfort) were recorded. RESULTS We enrolled 20 patients, median 11 years (4.4-15.5), 50% male. Sixteen (80%) patients had delayed GE (AUC60 <600 mcg·min/mL) and 7 (35%) had slow EN advancement. Median GRV (mL/kg) for patients with delayed vs normal GE was 0.43 (0.113-2.188) vs 0.89 (0.06-1.91), P = .9635. Patients with slow vs rapid EN advancement had median GRV (mL/kg) of 1.02 mL/kg (0.20-3.20) vs 0.27 mL/kg (0.06-1.62), P = .3114, and frequency of altered EN intolerance assessments of 3/7 (42.9%) vs 5/13 (38.5%), P = 1. Median AUC60 for patients with slow vs rapid EN advancement was 91.74 mcg·min/mL (53.52-143.1) vs 449.5 mcg·min/mL (173.2-786.5), P = .0012. CONCLUSIONS A majority of our study cohort had delayed GE. Bedside EN intolerance assessments, particularly GRV, did not predict delayed GE or rate of EN advancement. Delayed gastric emptying predicted slow EN advancement. Novel tests for delayed GE and EN intolerance are needed.
Collapse
Affiliation(s)
- Enid E Martinez
- 1 Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,3 Harvard Medical School, Boston, Massachusetts, USA
| | - Luis M Pereira
- 2 Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,3 Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen Gura
- 4 Department of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicole Stenquist
- 1 Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Katelyn Ariagno
- 4 Department of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,5 Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samuel Nurko
- 3 Harvard Medical School, Boston, Massachusetts, USA.,4 Department of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- 1 Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,3 Harvard Medical School, Boston, Massachusetts, USA.,5 Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
62
|
Velazco CS, Zurakowski D, Fullerton BS, Bechard LJ, Jaksic T, Mehta NM. Nutrient delivery in mechanically ventilated surgical patients in the pediatric critical care unit. J Pediatr Surg 2017; 52:145-148. [PMID: 27856012 DOI: 10.1016/j.jpedsurg.2016.10.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/20/2016] [Indexed: 01/28/2023]
Abstract
PURPOSE Inadequate nutrient intake is associated with poor outcomes in critically ill children. We examined macronutrient delivery in surgical patients in the pediatric intensive care unit (PICU). METHODS In a prospective international cohort study of mechanically ventilated children (1month to 18years), we recorded adequacy of cumulative nutrient delivery in the PICU. Surgical patients enrolled in this study were included in the current analysis. Protein intake <60% of the prescribed goal was deemed inadequate. RESULTS Five hundred nineteen surgical patients, 45% female, median age 2years (IQR 0.5, 8), BMI z score -0.26, with 9-day median PICU stay and 60-day mortality 5.8% were enrolled. Three hundred forty-one (66%) patients received enteral nutrition (EN), and median time of initiation was PICU day 2. EN delivery was interrupted in 68% of these patients for a median duration of 9hours. Median enteral protein delivery was <15% of the prescribed goal and was <60% in two-thirds of the cohort. Patients with inadequate enteral protein delivery had longer time to EN initiation (p<0.001) and longer duration of EN interruptions (p<0.001) compared to those with adequate delivery. CONCLUSION Enteral protein delivery in critically ill pediatric surgical patients is inadequate. Early EN initiation and minimizing interruptions may increase protein delivery and potentially improve outcomes in this population. LEVEL OF EVIDENCE I. TYPE OF STUDY Prospective study.
Collapse
Affiliation(s)
- Cristine S Velazco
- Department of Surgery, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital; Division of Critical Care Medicine; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115
| | - Brenna S Fullerton
- Department of Surgery, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115
| | - Lori J Bechard
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital
| | - Tom Jaksic
- Department of Surgery, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115
| | - Nilesh M Mehta
- Division of Critical Care Medicine; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital; Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115.
| |
Collapse
|
63
|
De Cosmi V, Mehta NM, Boccazzi A, Milani GP, Esposito S, Bedogni G, Agostoni C. Nutritional status, metabolic state and nutrient intake in children with bronchiolitis. Int J Food Sci Nutr 2016; 68:378-383. [PMID: 27790933 DOI: 10.1080/09637486.2016.1245714] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Nutrition has a coadjuvant role in the management of children with acute diseases. We aimed to examine nutritional status, macronutrient requirements and actual macronutrient delivery in bronchiolitis. The nutritional status was classified according to WHO criteria and resting energy expenditure (MREE) was measured using an indirect calorimeter. Bland-Altman analysis was used to examine the agreement between MREE and estimated energy expenditure (EEE) with standard equations. Based on the ratio MREE/EEE in relation to Schofield equation on admission, we defined the subjects' metabolic status. A total of 35 patients were enrolled and 46% were malnourished on admission, and 25.8% were hypermetabolic, 37.1% hypometabolic and 37.1% normometabolic. We performed a 24-h recall in 10 children and 80% were overfed (AEI: MREE >120%). Mean bias (limits of agreement) with MREE was 8.9 (-73.9 to 91.8%) for Schofield; 61.0 (-41 to 163%) for Harris-Benedict; and 9.9 (-74.4 to 94.2%) for FAO-WHO equation. Metabolism of infants with bronchiolitis is not accurately estimated by equations.
Collapse
Affiliation(s)
- V De Cosmi
- a Pediatric Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Laboratorio di Statistica Medica, Biometria ed Epidemiologia 'G.A. Maccacaro' Department of Clinical Sciences and Community Health , University of Milan , Milan , Italy
| | - N M Mehta
- b Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine , Boston Children's Hospital, Boston, Massachusetts; Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School , Boston , MA , USA
| | - A Boccazzi
- c Pediatric Intermediate Care Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , University of Milan , Milan , Italy
| | - G P Milani
- d Pediatric Emergency Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - S Esposito
- e Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , University of Milan , Milan , Italy
| | - G Bedogni
- c Pediatric Intermediate Care Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , University of Milan , Milan , Italy
| | - C Agostoni
- c Pediatric Intermediate Care Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , University of Milan , Milan , Italy
| |
Collapse
|
64
|
Martinez EE, Ariagno KA, Stenquist N, Anderson D, Muñoz E, Mehta NM. Energy and Protein Delivery in Overweight and Obese Children in the Pediatric Intensive Care Unit. Nutr Clin Pract 2016; 32:414-419. [PMID: 28490231 DOI: 10.1177/0884533616670623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Early and optimal energy and protein delivery have been associated with improved clinical outcomes in the pediatric intensive care unit (PICU). Overweight and obese children in the PICU may be at risk for suboptimal macronutrient delivery; we aimed to describe macronutrient delivery in this cohort. METHODS We performed a retrospective study of PICU patients ages 2-21 years, with body mass index (BMI) ≥85th percentile and >48 hours stay. Nutrition variables were extracted regarding nutrition screening and assessment, energy and protein prescription, and delivery. RESULTS Data from 83 patient encounters for 52 eligible patients (52% male; median age 9.6 [5-15] years) were included. The study cohort had a longer median PICU length of stay (8 vs 5 days, P < .0001) and increased mortality rate (6/83 vs 182/5572, P = .045) than concurrent PICU patient encounters. Detailed nutrition assessment was documented for 60% (50/83) of patient encounters. Energy expenditure was estimated primarily by predictive equations. Stress factor >1.0 was applied in 44% (22/50). Median energy delivered as a percentage of estimated requirements by the Schofield equation was 34.6% on day 3. Median protein delivered as a percentage of recommended intake was 22.1% on day 3. CONCLUSIONS The study cohort had suboptimal nutrition assessments and macronutrient delivery during their PICU course. Mortality and duration of PICU stay were greater when compared with the general PICU population. Nutrition assessment, indirect calorimetry-guided energy prescriptions, and optimizing the delivery of energy and protein must be emphasized in this cohort. The impact of these practices on clinical outcomes must be investigated.
Collapse
Affiliation(s)
- Enid E Martinez
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Harvard Medical School, Boston, Massachusetts, USA
| | - Katelyn A Ariagno
- 3 Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicole Stenquist
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Daniela Anderson
- 4 University of São Paulo-Ribeirao Preto School of Medicine, São Paulo, Brazil
| | - Eliana Muñoz
- 5 Universidad de Chile, Hospital Dr. Luis Calvo Mackenna, Providencia, Chile
| | - Nilesh M Mehta
- 1 Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Harvard Medical School, Boston, Massachusetts, USA.,3 Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
65
|
Moreno YMF, Hauschild DB, Barbosa E, Bresolin NL, Mehta NM. Problems With Optimal Energy and Protein Delivery in the Pediatric Intensive Care Unit. Nutr Clin Pract 2016; 31:673-80. [DOI: 10.1177/0884533616639125] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Yara M. F. Moreno
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Daniela B. Hauschild
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Eliana Barbosa
- Joana de Gusmão Children’s Hospital, Florianópolis, Brazil
| | | | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
66
|
Strychowsky JE, Albert D, Chan K, Cheng A, Daniel SJ, De Alarcon A, Garabedian N, Hart C, Hartnick C, Inglis A, Jacobs I, Kleinman ME, Mehta NM, Nicollas R, Nuss R, Pransky S, Russell J, Rutter M, Schilder A, Thompson D, Triglia JM, Volk M, Ward B, Watters K, Wyatt M, Zalzal G, Zur K, Rahbar R. International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Routine peri-operative pediatric tracheotomy care. Int J Pediatr Otorhinolaryngol 2016; 86:250-5. [PMID: 27132195 DOI: 10.1016/j.ijporl.2016.03.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 03/21/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To develop consensus recommendations for peri-operative tracheotomy care in pediatric patients. METHODS Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group. RESULTS Consensus recommendations including pre-operative, intra-operative, and post-operative considerations, as well as sedation and nutrition management are described. These recommendations are based on the collective opinion of the IPOG members and are targeted to (i) otolaryngologists who perform tracheotomies on pediatric patients, (ii) intensivists who are involved in the shared-care of these patients, and (iii) allied health professionals. CONCLUSION Pediatric peri-operative tracheotomy care consensus recommendations are aimed at improving patient-centered care in this patient population.
Collapse
Affiliation(s)
- Julie E Strychowsky
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, United States; Department of Otolaryngology-Head and Neck Surgery, Children's Hospital at London Health Sciences Centre, Western University, London, Ontario, Canada.
| | - David Albert
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Kenny Chan
- Children's Hospital Colorado, Aurora, Colorado, United States
| | - Alan Cheng
- Department of Pediatric Otolaryngology, The Sydney Children's Hospital Network-Westmead Campus, The University of Sydney, Sydney, NSW, Australia
| | - Sam J Daniel
- Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | | | - Noel Garabedian
- Pediatric ENT Department, Hôpital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | - Catherine Hart
- Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | - Christopher Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, United States
| | - Andy Inglis
- Seattle Children's Hospital, Seattle, Washington, United States
| | - Ian Jacobs
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Monica E Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Richard Nicollas
- Aix-Marseille Université, Department of Pediatric Otolaryngology, La Timone Children's Hospital, Marseille, France
| | - Roger Nuss
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - Seth Pransky
- Rady Children's Hospital, San Diego, California, United States
| | - John Russell
- Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Mike Rutter
- Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | - Anne Schilder
- evidENT, UCL Ear Institute, Royal National Throat, Nose and Ear Hospital, London, United Kingdom
| | - Dana Thompson
- Division of Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Jean-Michel Triglia
- Aix-Marseille Université, Department of Pediatric Otolaryngology, La Timone Children's Hospital, Marseille, France
| | - Mark Volk
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - Bob Ward
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Medical Center, New York, NY, United States
| | - Karen Watters
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| | - Michelle Wyatt
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - George Zalzal
- Department of Otolaryngology, Children's National Hospital, Washington, DC, United States
| | - Karen Zur
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, United States; Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
67
|
Grippa RB, Silva PS, Barbosa E, Bresolin NL, Mehta NM, Moreno YMF. Nutritional status as a predictor of duration of mechanical ventilation in critically ill children. Nutrition 2016; 33:91-95. [PMID: 27364223 DOI: 10.1016/j.nut.2016.05.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/06/2016] [Accepted: 05/01/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Critically ill children admitted to the pediatric intensive care unit (PICU) often are malnourished. The aim of this study was to determine the role of nutritional status on admission as a predictor of the duration of mechanical ventilation in critically ill children. METHODS This was a single-center, prospective cohort study, including consecutive children (ages 1 mo to 15 y) admitted to a PICU. Demographic characteristics, clinical characteristics, and nutritional status were recorded and patients were followed up until hospital discharge. Nutritional status was evaluated by anthropometric parameters and malnutrition was considered if the Z-scores for the parameters were ≤-2. Adjusted Cox's regression analysis was used to determine the association between nutritional status and duration of mechanical ventilation. RESULTS In all, 72 patients were included. The prevalence of malnutrition was 41.2%, according to height-for-age Z-score, 18.6% according to weight-for-height Z-score, and 22.1% according body mass index-for-age Z-score. Anthropometrical parameters that predicted the duration of mechanical ventilation were weight-for-age (hazard ratio [HR], 2.73; 95% confidence interval [CI], 1.44-5.18); height-for-age (HR, 2.49; 95% CI, 1.44-4.28); and upper arm muscle area-for-age (HR, 5.22; 95% CI, 1.19-22.76). CONCLUSION Malnutrition, based on a variety of anthropometric variables, was associated with the duration of mechanical ventilation in this cohort of critically ill children. Assessment of nutritional status by anthropometry should be performed on admission to the PICU to allow targeted nutritional rehabilitation for the subset of children with existing malnutrition.
Collapse
Affiliation(s)
- Rafaela B Grippa
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Paola S Silva
- Undergraduate Nutrition Course, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Eliana Barbosa
- Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | | | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Yara M F Moreno
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil.
| |
Collapse
|
68
|
Wong JJM, Ong C, Han WM, Mehta NM, Lee JH. Survey of contemporary feeding practices in critically ill children in the Asia-Pacific and the Middle East. Asia Pac J Clin Nutr 2016; 25:118-25. [PMID: 26965770 DOI: 10.6133/apjcn.2016.25.1.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Nutrition is a fundamental component of care of critically ill children. Determining variation in nutritional practices within paediatric intensive care units (PICUs) allows for review and improvement of nutrition practices. METHODS AND STUDY DESIGN The aim was to survey the nutrition practices and perspectives of paediatric intensivists and dieticians in Asia-Pacific and the Middle East. A questionnaire was developed to collect data on (1) the respondent's and institution's characteristics, (2) nutritional assessments and nutrient delivery practices, and (3) the perceived importance and barriers to optimal enteral feeding in the PICU. RESULTS We analysed 47 responses from 35 centres in 18 different countries. Dedicated dietetic services were only present in 13 (37%) centres and regular nutrition assessments were conducted in only 12 (34%) centres. In centres with dedicated dieticians, we found greater use of carbohydrate, fat additives and special formulas. Two thirds [31 (66%)] of respondents used total fluids to estimate energy requirements. Only 11 (31%) centres utilized feeding protocols. These centres had higher use of small bowel feeding, acid suppressants, laxatives and gastric residual volume thresholds. When dealing with feed intolerance, they were also more likely to start a motility agent. There was also a lack of consensus on when feeding should start and the use of adjuncts. CONCLUSIONS Nutrition practices and barriers are unique in Asia-Pacific and the Middle East and strongly reflect a lack of dietetic services. Future effort should focus on developing a uniform approach on nutrition practices to drive paediatric critical care nutrition research in these regions.
Collapse
Affiliation(s)
- Judith J M Wong
- Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Chengsi Ong
- Department of Dietetics and Nutrition, KK Women's and Children's Hospital, Singapore
| | - Wee Meng Han
- Department of Dietetics and Nutrition, KK Women's and Children's Hospital, Singapore
| | - Nilesh M Mehta
- Critical Care Medicine, Boston Children's Hospital, Boston, United States of America
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore. .,Office of Clinical Sciences, Duke-NUS School of Medicine, Singapore
| |
Collapse
|
69
|
Compher C, Mehta NM. Diagnosing Malnutrition: Where Are We and Where Do We Need to Go? J Acad Nutr Diet 2016; 116:779-84. [DOI: 10.1016/j.jand.2016.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/29/2016] [Indexed: 01/04/2023]
|
70
|
Affiliation(s)
- Nilesh M Mehta
- From Harvard Medical School and the Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital - both in Boston
| |
Collapse
|
71
|
Smallwood CD, Martinez EE, Mehta NM. A Comparison of Carbon Dioxide Elimination Measurements Between a Portable Indirect Calorimeter and Volumetric Capnography Monitor: An In Vitro Simulation. Respir Care 2015; 61:354-8. [PMID: 26715770 DOI: 10.4187/respcare.04282] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Gas exchange measurements for carbon dioxide elimination (V̇CO2 ) and oxygen consumption (V̇O2 ) have been used to derive resting energy expenditure and guide energy prescription. Volumetric capnography is used in intensive care units and provides V̇CO2 measurements that could be used for titrating respiratory and nutritional support. We have recently suggested that measuring V̇CO2 may be sufficient to obtain a reasonable estimate of energy expenditure. However, data describing the accuracy of gas exchange measurement devices are limited. METHODS We used an in vitro simulation model to test the accuracy of gas exchange measurements by 2 devices: the CCM Express indirect calorimeter and the NM3, a volumetric capnography monitor. A Huszczuk gas injection system combined with a high-fidelity lung simulator was used to simulate V̇O2 and V̇CO2 values in the pediatric and adult range. Bland-Altman analysis was used to examine the agreement between the measured and simulated values across a range of tidal volumes and gas exchange values. Additionally, agreement between the 2 devices was examined. RESULTS During the adult simulation with the CCM Express, the mean bias (95% CI) for V̇CO2 values was -12.6% (-16.4 to -8.8%) and -17.5% (-19.9 to -15.1%) for V̇O2 values. For the pediatric simulation with the CCM Express, mean bias for V̇O2 was -14.7% (-16.4 to -13.0%) and V̇CO2 was -10.9% (-13.5 to -8.3%). For the adult and pediatric simulations with the NM3, the bias for V̇CO2 was -8.2% (-15.7 to -0.7%) and -8.3% (-19.4 to -2.8%), respectively. Between the 2 devices, the mean bias was -4.4% (-10.2 to 1.3%) and -2.3% (-11.4 to 6.8%) for the adult and pediatric V̇CO2 simulations, respectively. CONCLUSIONS Currently available portable gas exchange monitors demonstrated acceptable agreement with reference V̇O2 and V̇CO2 values in an in vitro simulation. The devices demonstrated good agreement with each other.
Collapse
Affiliation(s)
- Craig D Smallwood
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts.
| | - Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts. Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts
| |
Collapse
|
72
|
Martinez EE, Bechard LJ, Smallwood CD, Duggan CP, Graham RJ, Mehta NM. Impact of Individualized Diet Intervention on Body Composition and Respiratory Variables in Children With Respiratory Insufficiency: A Pilot Intervention Study. Pediatr Crit Care Med 2015; 16:e157-64. [PMID: 25944746 PMCID: PMC4497837 DOI: 10.1097/pcc.0000000000000428] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Diet modification may improve body composition and respiratory variables in children with respiratory insufficiency. Our objective was to examine the effect of an individualized diet intervention on changes in weight, lean body mass, minute ventilation, and volumetric CO2 production in children dependent on long-term mechanical ventilatory support. DESIGN Prospective, open-labeled interventional study. SETTING Study subjects' homes. PATIENTS Children, 1 month to 17 years old, dependent on at least 12 hr/d of transtracheal mechanical ventilatory support. INTERVENTIONS Twelve weeks of an individualized diet modified to deliver energy at 90-110% of measured energy expenditure and protein intake per age-based guidelines. MEASUREMENTS AND MAIN RESULTS During a multidisciplinary home visit, we obtained baseline values of height and weight, lean body mass percent by bioelectrical impedance analysis, actual energy and protein intake by food record, and measured energy expenditure by indirect calorimetry. An individualized diet was then prescribed to optimize energy and protein intake. After 12 weeks on this interventional diet, we evaluated changes in weight, height, lean body mass percent, minute ventilation, and volumetric CO2 production. Sixteen subjects, mean age 9.3 years (SD, 4.9), eight male, completed the study. For the diet intervention, a majority of subjects required a change in energy and protein prescription. The mean percentage of energy delivered as carbohydrate was significantly decreased, 51.7% at baseline versus 48.2% at follow-up, p = 0.009. Mean height and weight increased on the modified diet. Mean lean body mass percent increased from 58.3% to 61.8%. Minute ventilation was significantly lower (0.18 L/min/kg vs 0.15 L/min/kg; p = 0.04), and we observed a trend toward lower volumetric CO2 production (5.4 mL/min/kg vs 5.3 mL/min/kg; p = 0.06) after 12 weeks on the interventional diet. CONCLUSIONS Individualized diet modification is feasible and associated with a significant decrease in minute ventilation, a trend toward significant reduction in CO2 production, and improved body composition in children on long-term mechanical ventilation. Optimization of respiratory variables and lean body mass by diet modification may benefit children with respiratory insufficiency in the ICU.
Collapse
Affiliation(s)
- Enid E Martinez
- 1Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA. 2Harvard Medical School, Boston, MA. 3Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | | | | | | | | | | |
Collapse
|
73
|
Mehta NM, Bechard LJ, Zurakowski D, Duggan CP, Heyland DK. Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study. Am J Clin Nutr 2015; 102:199-206. [PMID: 25971721 PMCID: PMC4480666 DOI: 10.3945/ajcn.114.104893] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 04/15/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The impact of protein intake on outcomes in pediatric critical illness is unclear. OBJECTIVE We examined the association between protein intake and 60-d mortality in mechanically ventilated children. DESIGN In a prospective, multicenter, cohort study that included 59 pediatric intensive care units (PICUs) from 15 countries, we enrolled consecutive children (age: 1 mo to 18 y) who were mechanically ventilated for ≥48 h. We recorded the daily and cumulative mean adequacies of energy and protein delivery as a percentage of the prescribed daily goal during the PICU stay ≤10 d. We examined the association of the adequacy of protein delivery with 60-d mortality and determined variables that predicted protein intake adequacy. RESULTS We enrolled 1245 subjects (44% female) with a median age of 1.7 y (IQR: 0.4, 7.0 y). A total of 985 subjects received enteral nutrition, 354 (36%) of whom received enteral nutrition via the postpyloric route. Mean ± SD prescribed energy and protein goals were 69 ± 28 kcal/kg per day and 1.9 ± 0.7 g/kg per day, respectively. The mean delivery of enteral energy and protein was 36 ± 35% and 37 ± 38%, respectively, of the prescribed goal. The adequacy of enteral protein intake was significantly associated with 60-d mortality (P < 0.001) after adjustment for disease severity, site, PICU days, and energy intake. In relation to mean enteral protein intake <20%, intake ≥60% of the prescribed goal was associated with an OR of 0.14 (95% CI: 0.04, 0.52; P = 0.003) for 60-d mortality. Early initiation, postpyloric route, shorter interruptions, larger PICU size, and a dedicated dietitian in the PICU were associated with higher enteral protein delivery. CONCLUSIONS Delivery of >60% of the prescribed protein intake is associated with lower odds of mortality in mechanically ventilated children. Optimal prescription and modifiable practices at the bedside might enhance enteral protein delivery in the PICU with a potential for improved outcomes. This trial was registered at clinicaltrials.gov as NCT02354521.
Collapse
Affiliation(s)
- Nilesh M Mehta
- Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, and Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and
| | - Lori J Bechard
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and
| | - David Zurakowski
- Department of Anesthesiology, Perioperative and Pain Medicine, and Harvard Medical School, Boston, MA; and Kingston General Hospital, Kingston, Canada
| | - Christopher P Duggan
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and
| | | |
Collapse
|
74
|
Smallwood CD, Gouldstone A, Mehta NM. Validation of the V
max
Metabolic Cart in a Simulated Pediatric Model. JPEN J Parenter Enteral Nutr 2015; 39:387-8. [DOI: 10.1177/0148607114536444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
75
|
Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
76
|
Martinez EE, Ariagno K, Arriola A, Lara K, Mehta NM. Challenges to Nutrition Therapy in the Pediatric Critically Ill Obese Patient. Nutr Clin Pract 2015; 30:432-9. [DOI: 10.1177/0884533615569887] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Enid E. Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Katelyn Ariagno
- Center for Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Aldis Arriola
- Universidad Francisco Marroquin, Guatemala City, Guatemala
| | - Kattina Lara
- Universidad Francisco Marroquin, Guatemala City, Guatemala
| | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Center for Nutrition, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
77
|
Martinez EE, Smallwood CD, Bechard LJ, Graham RJ, Mehta NM. Metabolic assessment and individualized nutrition in children dependent on mechanical ventilation at home. J Pediatr 2015; 166:350-7. [PMID: 25444009 DOI: 10.1016/j.jpeds.2014.09.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/14/2014] [Accepted: 09/19/2014] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the nutritional and metabolic status and body composition of children on long-term mechanical ventilation using a home-based model. STUDY DESIGN Children on home mechanical ventilation, for at least 12 hours a day, were eligible. We performed anthropometry, bioelectrical impedance analysis (BIA), actual energy intake (AEI), and indirect calorimetry in the subject's home. Agreement between measured energy expenditure (MEE) from indirect calorimetry, and estimated energy expenditure by the Schofield equation and a novel volumetric carbon dioxide production-based equation was examined. Agreement between fat mass estimates from anthropometry and BIA was examined and compared with population norms. RESULTS We enrolled 20 children, 11 (55%) male; mean age 8.4 years (SD 4.8). Mean weight for age z-score was -0.26 (SD 1.48); 9/20 had z-scores <-1 or >+1. Thirteen were underfed (AEI:MEE <90%) or overfed (AEI:MEE >110%); 11 of 19 had protein intake that was less than recommended by guidelines. Fifteen subjects were hypo- or hypermetabolic. Mean (SD) fat mass % was 33.6% (8.6) by anthropometry, which was significantly greater than matched population norms (mean 23.0%, SD 6.1, P < .001). The estimated energy expenditure by a volumetric carbon dioxide production-based equation was in stronger agreement with the MEE than the Schofield equation (mean bias 0.06%, limits -15.98% to 16.16% vs mean bias -1.31%, limits -74.3% to 72%, respectively). BIA and anthropometric fat mass values were not in agreement. CONCLUSION A majority of children on home ventilation are characterized by malnutrition, altered metabolic status, and suboptimal macronutrient intake, in particular low protein intake. A multidisciplinary home-based model facilitates individualized energy and protein delivery and may improve outcomes in this cohort.
Collapse
Affiliation(s)
- Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | - Lori J Bechard
- Center for Nutrition, Boston Children's Hospital, Boston, MA
| | - Robert J Graham
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Center for Nutrition, Boston Children's Hospital, Boston, MA.
| |
Collapse
|
78
|
Bairdain S, Khan FA, Fisher J, Zurakowski D, Ariagno K, Cauley RP, Zalieckas J, Wilson JM, Jaksic T, Mehta NM. Nutritional outcomes in survivors of congenital diaphragmatic hernia (CDH)-factors associated with growth at one year. J Pediatr Surg 2015; 50:74-7. [PMID: 25598097 DOI: 10.1016/j.jpedsurg.2014.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/06/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Malnutrition is prevalent among congenital diaphragmatic hernia (CDH) survivors. We aimed to describe the nutritional status and factors that impact growth over the 12-months following discharge from the pediatric intensive care unit (PICU) in this cohort. METHODS CDH survivors, who were discharged from the PICU from 2000 to 2010 with follow-up of at least 12months, were included. Nutritional intake, anthropometric, and clinical variables were recorded. Multivariable linear regression was used to determine factors associated with weight-for-age Z-scores (WAZ) at 12months. RESULTS Data from 110 infants, 67% male, 50% patch repair, were analyzed. Median (IQR) WAZ for the cohort was -1.4 (-2.4 to -0.3) at PICU discharge and -0.4 (-1.3 to 0.2) at 12-months. The percentage of infants with significant malnutrition (WAZ<-2) decreased from 26% to 8.5% (p<0.001). Patch repair (p=0.009), protein intake<2.3g/kg/day (p=0.014), and birth weight (BW)<2.5kg (p<0.001) were associated with lower WAZ at 12-months. CONCLUSIONS CDH survivors had a significantly improved nutritional status in the 12-months after PICU discharge. Patch repair, lower BW, and inadequate protein intake were significant predictors of lower WAZ at 12-months. A minimum protein intake in the PICU of 2.3g/kg/day was essential to ensure optimal growth in this cohort.
Collapse
Affiliation(s)
- Sigrid Bairdain
- Department of Pediatric Surgery, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States
| | - Faraz A Khan
- Department of Pediatric Surgery, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States
| | - Jeremy Fisher
- Department of Pediatric Surgery, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Department of Pediatric Surgery, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States; Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States
| | - Katelyn Ariagno
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States
| | - Ryan P Cauley
- Department of Pediatric Surgery, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States
| | - Jill Zalieckas
- Department of Pediatric Surgery, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States
| | - Jay M Wilson
- Department of Pediatric Surgery, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States
| | - Tom Jaksic
- Department of Pediatric Surgery, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States
| | - Nilesh M Mehta
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States; Division of Critical Care Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
79
|
Abstract
BACKGROUND Accurate measurement of carbon dioxide elimination (V̇CO2 ) and oxygen consumption (V̇O2 ) at the bedside may help titrate nutritional and respiratory support in mechanically ventilated patients. Continuous V̇CO2 monitoring is now available with many ventilators. However, because normative data are sparsely available in the literature, we aimed to describe the range of V̇CO2 and V̇O2 values observed in mechanically ventilated children. We also aimed to examine the characteristics of V̇CO2 values that are associated with standard steady state (5-min period when V̇CO2 and V̇O2 variability are < 10%). METHODS Mechanically ventilated patients who underwent indirect calorimetry testing were eligible for inclusion, and subjects who achieved standard steady state were included. Normalized V̇CO2 and V̇O2 values (mL/kg/min) were modeled against subject height, and correlation coefficients were computed to quantify the goodness of fit. A steady-state definition using only V̇CO2 was developed (V̇CO2 variability of < 5% for a 5-min period) and tested against standard steady state using sensitivity and specificity. RESULTS Steady-state data from 87 indirect calorimetry tests (in 70 subjects) were included. For age groups < 0.5, 0.5-8, and > 8 y, the mean V̇CO2 values were 7.6, 5.8, and 3.5 mL/kg/min. Normalized V̇CO2 and V̇O2 values were inversely related to subject height and age. The relationships between normalized gas exchange values and height were demonstrated by the models: V̇CO2 = 115 × (height in cm)(-0.71) (R = 0.61, P < .001) and V̇O2 = 130 × (height in cm)(-0.72) (R = 0.61, P < .001). Steady-state V̇CO2 predicted standard steady state (sensitivity of 0.84, specificity of 1.0, P < .01). CONCLUSIONS V̇CO2 and V̇O2 measurements correlated with subject height and age. Smaller and younger subjects produced larger amounts of CO2 and consumed more O2 per unit of body weight. The use of a 5-min period when V̇CO2 varied by < 5% predicted standard steady state. Our observations may facilitate greater utility of V̇CO2 at the bedside in the pediatric ICU and thereby extend the benefits of metabolic monitoring to a larger group of patients.
Collapse
Affiliation(s)
- Craig D Smallwood
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine Harvard Medical School, Boston, Massachusetts.
| | - Brian K Walsh
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine Harvard Medical School, Boston, Massachusetts
| | - Lori J Bechard
- Department of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
80
|
Martinez EE, Bechard LJ, Mehta NM. Nutrition algorithms and bedside nutrient delivery practices in pediatric intensive care units: an international multicenter cohort study. Nutr Clin Pract 2014; 29:360-7. [PMID: 24740498 DOI: 10.1177/0884533614530762] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Enteral nutrition (EN) delivery is associated with improved outcomes in critically ill patients. We aimed to describe EN practices, including details of algorithms and individual bedside practices, in pediatric intensive care units (PICUs). METHODS Available EN algorithm details from 31 international PICUs were obtained. Daily nutrient intake data from 524 mechanically ventilated patients, 1 month to 18 years old, were prospectively documented, including EN delivery, adjunct therapies, and energy prescription. Practices associated with higher percentage adequacy of EN delivery were determined by regression analysis. RESULTS Nine EN algorithms were available. All algorithms defined advancement and EN intolerance; 7 of 9 defined intolerance by gastric residual volume; 3 of 9 recommended nutrition screening and fasting guidelines. Few elements were in agreement with the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition guidelines. Of the 341 patients who received EN exclusively 32.9% received ≥66.6% of prescribed energy on day 7. Percentage adequacy of EN delivered was inversely associated with days to EN initiation (-8.92; P < .001) and hours per EN interruption (-1.65; P = .001) and was not associated with the use of algorithms, promotility agents, or postpyloric feeding. CONCLUSIONS A minority of PICUs employ EN algorithms; recommendations were variable and not in agreement with national guidelines. Optimal EN delivery was achieved in less than one-third of our cohort. EN adjunct therapies were not associated with increased EN delivery. Studies aimed at promoting early EN and decreasing interruptions may optimize energy delivery in the PICU.
Collapse
Affiliation(s)
- Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | | | |
Collapse
|
81
|
Abstract
Delivery of adequate nutrients during illness to counteract the metabolic stress response and facilitate healing and tissue repair is an important goal in the care of critically ill children. With recent advances in technology, accurate minute-to-minute gas exchange and energy expenditure measurements are now available in intensive care units. The bedside availability of these devices may allow a titrated approach to energy delivery for patients, ushering in a new era of individualized nutrition therapy. Basic concepts, available monitoring devices, indications, pitfalls, and bedside application of metabolic monitoring are discussed in this article.
Collapse
Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anaesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | | | |
Collapse
|
82
|
Mehta NM, Smallwood CD, Joosten KFM, Hulst JM, Tasker RC, Duggan CP. Accuracy of a simplified equation for energy expenditure based on bedside volumetric carbon dioxide elimination measurement--a two-center study. Clin Nutr 2014; 34:151-5. [PMID: 24636151 DOI: 10.1016/j.clnu.2014.02.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 02/11/2014] [Accepted: 02/12/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND & AIMS Accurate assessment of resting energy expenditure (REE) and metabolic state is essential to optimize nutrient intake in critically ill patients. We aimed to examine the accuracy of a simplified equation for predicting REE using carbon dioxide elimination (VCO2) values. METHODS We conducted a two-center study of metabolic data from mechanically ventilated children less than 18 years of age. Mean respiratory quotient (RQ) from the derivation set (n = 72 subjects) was used to modify the Weir equation to obtain a simplified equation based on VCO2 measurements alone. This equation was then applied to subjects at the second institution (validation dataset, n = 94) to predict resting energy expenditure. Bland-Altman analysis was used to assess the agreement between measured REE values, and REE estimated by the new equation as well as the Schofield equation. We also examined the accuracy of the new equation in classifying patients according to their metabolic state. RESULTS Mean respiratory quotient (± SD) of 0.89 ± 0.09 in the derivation set was used to obtain a simplified equation, REE (kcal/day) = 5.534*VCO2 (L/min)*1440. In relation to the measured REE in the validation set, the mean bias (limits of agreement) for the REE predicted by this equation was -0.65% (-14.4-13.1%); and the overall diagnostic accuracy for classifying subjects as hypometabolic or hypermetabolic was 84%. Mean bias (limits) of agreement between measured and Schofield equation estimated REE was -0.1% (-40.5-40.7%). CONCLUSIONS A simplified metabolic equation using VCO2 values was superior to the standard equation in estimating REE, and provided a reasonably accurate metabolic classification in mechanically ventilated children. In the absence of indirect calorimetry, bedside VCO2 monitoring could provide valuable continuous metabolic information to guide optimal nutrient intake.
Collapse
Affiliation(s)
- Nilesh M Mehta
- Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Craig D Smallwood
- Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | | | - Jessie M Hulst
- Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Robert C Tasker
- Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Christopher P Duggan
- Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| |
Collapse
|
83
|
Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care, Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital, Boston, Massachusetts
| |
Collapse
|
84
|
Smallwood CD, Mehta NM. Gas exchange measurement during pediatric mechanical ventilation – Agreement between gas sampling at the airway and the ventilator exhaust. Clin Nutr 2013; 32:988-92. [DOI: 10.1016/j.clnu.2013.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 03/13/2013] [Accepted: 03/15/2013] [Indexed: 12/01/2022]
|
85
|
Abstract
IMPORTANCE Obesity is prevalent among hospitalized children. Knowledge of the relationship between obesity and outcomes in hospitalized children will enhance nutrition assessment and provide opportunities for interventions. OBJECTIVE To systematically review the existing literature concerning the impact of obesity on clinical outcomes in hospitalized children. EVIDENCE ACQUISITION PubMed, Web of Science, and EMBASE databases were searched for studies of hospitalized children aged 2 to 18 years with identified obesity and at least 1 of the following clinical outcomes: all-cause mortality, incidence of infections, and length of hospital stay. Cohort and case-control studies were included. Cross-sectional studies, studies of healthy children, and those without defined criteria for classifying weight status were excluded. The Newcastle-Ottawa Scale was used to assess study quality. RESULTS Twenty-eight studies (26 retrospective; 24 cohort and 4 case-control) were included. Of the 21 studies that included mortality as an outcome, 10 reported a significant positive relationship between obesity and mortality. The incidence of infections was assessed in 8 of the 28 studies; 2 reported significantly more infections in obese compared with nonobese patients. Of the 11 studies that examined length of stay, 5 reported significantly longer lengths of hospital stay for obese children. Fifteen studies (53%) had a high quality score. Larger studies observed significant relationships between obesity and outcomes. Studies of critically ill, oncologic or stem cell transplant, and solid organ transplant patients showed a relationship between obesity and mortality. CONCLUSIONS AND RELEVANCE The available literature on the relationship between obesity and clinical outcomes is limited by subject heterogeneity, variations in criteria for defining obesity, and outcomes examined. Childhood obesity may be a risk factor for higher mortality in hospitalized children with critical illness, oncologic diagnoses, or transplants. Further examination of the relationship between obesity and clinical outcomes in this subgroup of hospitalized children is needed.
Collapse
Affiliation(s)
- Lori J Bechard
- Center for Nutrition, Divisions of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA 02115, USA.
| | | | | | | | | |
Collapse
|
86
|
Affiliation(s)
| | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine at Children’s Hospital
- Harvard Medical School, Boston, MA
| |
Collapse
|
87
|
Mehta NM, Corkins MR, Lyman B, Malone A, Goday PS, Carney LN, Monczka JL, Plogsted SW, Schwenk WF. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr 2013; 37:460-81. [PMID: 23528324 DOI: 10.1177/0148607113479972] [Citation(s) in RCA: 365] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English-language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non-illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness-related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence-based nutrition practices.
Collapse
Affiliation(s)
- Nilesh M Mehta
- Department of Anesthesiology, Pain and Perioperative Medicine, Boston Children's Hospital, MSICU Office, Bader 634 Children’s Hospital, Boston, Massachusetts 2115, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
88
|
Mehta NM. The Goldilocks conundrum for optimal macronutrient delivery in the PICU--too much, too little, or just right? JPEN J Parenter Enteral Nutr 2012; 37:178-80. [PMID: 22961724 DOI: 10.1177/0148607112459906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Massachusetts, USA.
| |
Collapse
|
89
|
Bechard LJ, Parrott JS, Mehta NM. Systematic review of the influence of energy and protein intake on protein balance in critically ill children. J Pediatr 2012; 161:333-9.e1. [PMID: 22402566 DOI: 10.1016/j.jpeds.2012.01.046] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 01/05/2012] [Accepted: 01/20/2012] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To examine the influence of protein and energy intakes on protein balance in children receiving mechanical ventilation in the pediatric intensive care unit. STUDY DESIGN We hypothesized that higher energy and protein intakes are correlated with positive protein balance. We performed a systematic literature search to identify studies reporting protein balance in children requiring mechanical ventilation. Factors contributing to protein balance, including protein and energy intake, age, illness severity, study design, and feeding routes, were analyzed using a qualitative approach. RESULTS Nine studies met the entry criteria and were included in the final analysis. Positive nitrogen balance was reported in 6 of the studies, with a wide range of associated energy and protein intakes. Measures of central tendency for daily energy and protein intakes were significantly correlated with positive protein balance. A minimum intake of 57 kcal/kg/day and 1.5 g protein/kg/day were required to achieve positive protein balance. CONCLUSION We found a correlation between higher energy and protein intakes and achievement of positive protein balance in children receiving mechanical ventilation in the pediatric intensive care unit. However, there is a paucity of interventional studies, and a variety of protocols have been used to determine nitrogen balance. Larger clinical trials with uniform methodology are needed to further examine the effect of energy and protein intake on protein balance, lean body mass, and clinical outcomes in children on mechanical ventilation.
Collapse
Affiliation(s)
- Lori J Bechard
- Division of Gastroenterology, Children's Hospital Boston, Boston, MA 02115, USA.
| | | | | |
Collapse
|
90
|
Mehta NM, Costello JM, Bechard LJ, Johnson VM, Zurakowski D, McGowan FX, Laussen PC, Duggan CP. Resting energy expenditure after Fontan surgery in children with single-ventricle heart defects. JPEN J Parenter Enteral Nutr 2012; 36:685-92. [PMID: 22539159 DOI: 10.1177/0148607112445581] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data on resting energy expenditure (REE) and oxygen consumption (VO(2)) after pediatric cardiopulmonary bypass (CPB) will facilitate optimal nutrient prescription. METHODS The authors measured continuous REE and VO(2), using an in-line indirect calorimetery (IC) in 30 consecutive children with single-ventricle physiology immediately after Fontan surgery. REE during steady state at 8 hours after surgery was compared with standard equation-estimated energy expenditure (EEE). Patients were classified into 3 groups: hypermetabolic (measured REE [MREE]/EEE ratio >1.2), hypometabolic (MREE/EEE ratio <0.8), and normometabolic (MREE/EEE ratio 0.8-1.2). Demographic, anthropometric, and perioperative clinical characteristics were examined for their correlation with metabolic status. RESULTS In 26 of 30 patients with completed IC, mean REE at 8 hours after surgery was 57 ± 20 kcal/kg/d, and mean VO(2) was 110 ± 35 mL/min. Mean values of VO(2) and REE did not change within the first 24 hours after surgery. There was poor correlation between MREE at 8 hours and the EEE using the World Health Organization equation (r = 0.32, P = .11). Most patients (n = 19, 73%) were either normometabolic or hypometabolic. Lack of hypermetabolism was significantly associated with higher intraoperative serum lactate level and positive fluid balance compared with the rest of the group. CONCLUSIONS The authors report a low prevalence of hypermetabolism in children with single-ventricle defects after Fontan surgery. Measured REE had poor correlation with equation-estimated energy expenditure in a majority of the cohort. The absence of increased energy expenditure after CPB will influence energy prescription in this group.
Collapse
Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care Medicine/Anesthesia, Department of Anesthesiology, Pain and Perioperative Medicine, Children's Hospital Boston, Harvard Medical School, Bader 634, MSICU Office, 300 Longwood Ave, Boston, MA 02115, USA.
| | | | | | | | | | | | | | | |
Collapse
|
91
|
Smallwood CD, Mehta NM. Accuracy of abbreviated indirect calorimetry protocols for energy expenditure measurement in critically ill children. JPEN J Parenter Enteral Nutr 2012; 36:693-9. [PMID: 22510266 DOI: 10.1177/0148607112441948] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Accurate measurement of resting energy expenditure (REE) using indirect calorimetry (IC) facilitates optimal energy prescription. Steady-state (SS) REE obtained using a 5-minute protocol (SS5) has been used as a surrogate for 24-hour REE measurement. However, SS5 conditions are difficult to achieve in critically ill children on mechanical ventilatory support. METHODS The authors prospectively examined factors associated with successful IC testing using the standard SS5 protocol in mechanically ventilated children. They examined the agreement of REE between SS5 and 2 abbreviated SS protocols: 4-minute (SS4) and 3-minute (SS3) protocols as well as the Schofield prediction equation, using Bland-Altman analysis. RESULTS IC testing (n = 45) was completed in 34 children. SS was achieved during 25 (56%), 31 (69%), and 42 (93%) tests, using the SS5, SS4, and SS3 protocols, respectively. Intratest variability in respiratory rate, endotracheal tube leak, and inspiratory time was associated with failed IC by the SS5 protocol. The mean bias (limits of agreement) for REE was 2.8 (-47 to 65), 5.8 (-71 to 72), and -127 (-418 to 1176) kcal/d using SS4, SS3, and Schofield, respectively. A stronger agreement was observed when means of all abbreviated SS REE values during a 30-minute test were used. CONCLUSION In mechanically ventilated children, 4-minute and 3-minute SS protocols allowed REE measurements to be obtained in most patients with reasonable accuracy. Abbreviated protocols may decrease the need to rely on inaccurate equations when assessing energy expenditure in children who fail IC testing by standard SS criteria.
Collapse
Affiliation(s)
- Craig D Smallwood
- Department of Respiratory Care at Children's Hospital Boston, Boston, Massachusetts, USA
| | | |
Collapse
|
92
|
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: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.
| | | | | | | | | | | | | |
Collapse
|
93
|
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.
Collapse
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
| |
Collapse
|
94
|
Affiliation(s)
- Nilesh M. Mehta
- From the Division of Critical Care Medicine, Children's Hospital, Boston, Massachusetts
| |
Collapse
|
95
|
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
| | | |
Collapse
|
96
|
Mehta NM, Bechard LJ, Leavitt K, Duggan C. Cumulative energy imbalance in the pediatric intensive care unit: role of targeted indirect calorimetry. JPEN J Parenter Enteral Nutr 2009; 33:336-44. [PMID: 19126761 DOI: 10.1177/0148607108325249] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Failure to accurately estimate energy requirements may result in underfeeding or overfeeding. In this study, a dedicated multidisciplinary nutrition team measured energy expenditure in critically ill children. METHODS Steady-state indirect calorimetry was used to obtain measured resting energy expenditure, which was compared with equation-estimated energy expenditure and the total energy intake for each subject. The children's metabolic status was examined in relation to standard clinical characteristics. RESULTS Sixteen measurements were performed in 14 patients admitted to the multidisciplinary pediatric intensive care unit over a period of 12 months. Mean age of subjects in this cohort was 11.2 years (range 1.6 months to 32 years) and included 7 males and 7 postoperative patients. Altered metabolism was detected in 13 of 14 subjects and in 15 of 16 (94%) measurements. There was no correlation between the metabolic status of subjects and their clinical characteristics. Average daily energy balance was 200 kcal/d (range -518 to +859 kcal/d). Agreement between measured resting energy expenditure and equation-estimated energy expenditure was poor, with mean bias of 72.3 +/- 446 kcal/d (limits of agreement -801.9 to + 946.5 kcal/d). CONCLUSIONS A disparity was observed between equation-estimated energy expenditure, measured resting energy expenditure, and total energy intake, with a high incidence of underfeeding or overfeeding. A wide range of metabolic alterations were recorded, which could not be accurately predicted using standard clinical characteristics. Targeted indirect calorimetry on high-risk patients selected by a dedicated nutrition team may prevent cumulative excesses and deficits in energy balance.
Collapse
Affiliation(s)
- Nilesh M Mehta
- Divisions of Critical Care Medicine and Gastroenterology and Nutrition, Children's Hospital, Boston, MA, USA.
| | | | | | | |
Collapse
|
97
|
Mehta NM, Bechard LJ, Leavitt K, Duggan C. Severe Weight Loss and Hypermetabolic Paroxysmal Dysautonomia Following Hypoxic Ischemic Brain Injury: The Role of Indirect Calorimetry in the Intensive Care Unit. JPEN J Parenter Enteral Nutr 2008; 32:281-4. [DOI: 10.1177/0148607108316196] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Nilesh M. Mehta
- From the Division of Critical Care Medicine and Division of Gastroenterology and Nutrition, Children's Hospital, Boston, Massachusetts
| | - Lori J. Bechard
- From the Division of Critical Care Medicine and Division of Gastroenterology and Nutrition, Children's Hospital, Boston, Massachusetts
| | - Kristen Leavitt
- From the Division of Critical Care Medicine and Division of Gastroenterology and Nutrition, Children's Hospital, Boston, Massachusetts
| | - Christopher Duggan
- From the Division of Critical Care Medicine and Division of Gastroenterology and Nutrition, Children's Hospital, Boston, Massachusetts
| |
Collapse
|
98
|
Mehta NM, Halwick DR, Dodson BL, Thompson JE, Arnold JH. Potential drug sequestration during extracorporeal membrane oxygenation: results from an ex vivo experiment. Intensive Care Med 2007; 33:1018-24. [PMID: 17404709 DOI: 10.1007/s00134-007-0606-2] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Accepted: 02/28/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Using an ex vivo simulation model we set out to estimate the amount of drug lost due to sequestration within the extracorporeal circuit over time. DESIGN Simulated closed-loop extracorporeal membrane oxygenation (ECMO) circuits were prepared using a 1.5-m2 silicone membrane oxygenator. Group A consisted of heparin, dopamine, ampicillin, vancomycin, phenobarbital and fentanyl. Group B consisted of epinephrine, cefazolin, hydrocortisone, fosphenytoin and morphine. Drugs were tested in crystalloid and blood-primed circuits. After administration of a one-time dose of drugs in the priming fluid, baseline drug concentrations were obtained (P0). A simultaneous specimen was stored for stability testing at 24 h (P4). Serial post-membrane drug concentrations were then obtained at 30 min (P1), 3 h (P2) and 24 h (P3) from circuit fluid. MEASUREMENTS AND RESULTS One hundred and one samples were analyzed. At the end of 24 h in crystalloid-primed circuits, 71.8% of ampicillin, 96.7% of epinephrine, 17.6% of fosphenytoin, 33.3% of heparin, 17.5% of morphine and 87% of fentanyl was lost. At the end of 24 h in blood-primed extracorporeal circuits, 15.4% of ampicillin, 21% of cefazolin, 71% of voriconazole, 31.4% of fosphenytoin, 53.3% of heparin and 100% of fentanyl was lost. There was a significant decrease in overall drug concentrations from 30 min to 24 h for both crystalloid-primed circuits (p = 0.023) and blood-primed circuits (p = 0.04). CONCLUSIONS Our ex vivo study demonstrates serial losses of several drugs commonly used during ECMO therapy. Therapeutic concentrations of fentanyl, voriconazole, antimicrobials and heparin cannot be guaranteed in patients on ECMO.
Collapse
Affiliation(s)
- Nilesh M Mehta
- Children's Hospital, Farley 517, Division of Critical Care Medicine, 300 Longwood Avenue, Boston 02115, MA, USA.
| | | | | | | | | |
Collapse
|
99
|
|
100
|
Abstract
PURPOSE OF REVIEW Acute respiratory failure requiring mechanical ventilation continues to contribute to mortality and affect long-term functional outcomes in patients admitted to the pediatric intensive care unit (ICU). Studies in adults with acute respiratory distress syndrome (ARDS) far outnumber those conducted in the pediatric age group, and pediatric intensivists are left with the task of carefully selecting and critically appraising relevant adult data and extrapolating results to their domain of practice. RECENT FINDINGS The recent ARDSNet study reinforces the use of low tidal volumes. Administration of surfactant is safe, but once again its beneficial effect was not sustained in a randomized trial. Surfactant proteins A and D have been shown to be of prognostic value in cases of acute lung injury. The effect of inhaled nitric oxide (NO) in patients with ARDS can be enhanced by aggressive lung recruitment strategies such as can be achieved using high-frequency oscillatory ventilation (HFOV). A recent adult trial shows good response rates but no significant long-term outcome benefit from prone positioning in patients with ARDS. Routine scheduled assessments of readiness for weaning and extubation may be more important than specific weaning modes and weaning criteria for children. A recent meta-analysis suggests that prophylactic dexamethasone use may decrease postextubation stridor and possibly reduce the need for reintubation in selected patients. Outcome data in children requiring mechanical support is encouraging, especially for high-risk groups such as bone marrow transplant (BMT) recipients, and may guide ethically challenging decision-making for these patients. SUMMARY Mechanical ventilation strategies aiming for optimal alveolar recruitment with the judicious use of positive end-expiratory pressure (PEEP) and low tidal volumes will remain the mainstay for managing respiratory failure in children. Dexamethasone may prevent postextubation stridor. Prone positioning, surfactant therapy, HFOV, and inhaled NO are used sporadically and need to be evaluated for their effect on mortality and duration of ventilation.
Collapse
Affiliation(s)
- Nilesh M Mehta
- Medical Surgical Intensive Care Unit, Department of Anesthesia Children's Hospital, Boston, Massachusetts, USA.
| | | |
Collapse
|