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Persaud S, Hron BM, Rudie C, Mantell P, Kahlon PS, Ariagno K, Ozonoff A, Trivedi S, Yugar C, Mehta NM, Raymond M, Duggan CP, Huh SY. Improving anthropometric measurements in hospitalized children: A quality-improvement project. Nutr Clin Pract 2024; 39:685-695. [PMID: 38153693 PMCID: PMC11068491 DOI: 10.1002/ncp.11112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/04/2023] [Revised: 10/16/2023] [Accepted: 11/24/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND The objective of this quality-improvement project was to increase documentation rates of anthropometrics (measured weight, length/height, and body mass index [BMI], which are critical to identify patients at malnutrition (undernutrition) risk) from <50% to 80% within 24 hours of hospital admission for pediatric patients. METHODS Multidisciplinary champion teams on surgical, cardiac, and intensive care (ICU) pilot units were established to identify and iteratively test interventions addressing barriers to documentation from May 2016 to June 2018. Percentage of patients with documented anthropometrics <24 h of admission was assessed monthly by statistical process control methodology. Percentage of patients at malnutrition (undernutrition) risk by anthropometrics was compared by χ2 for 4 months before and after intervention. RESULTS Anthropometric documentation rates significantly increased (P < 0.001 for all): BMI, from 11% to 89% (surgical), 33% to 57% (cardiac), and 16% to 51% (ICU); measured weight, from 24% to 88% (surgical), 69% to 83% (cardiac), and 51% to 67% (ICU); and length/height, from 12% to 89% (surgical), 38% to 57% (cardiac), and 26% to 63% (ICU). Improvement hospital-wide was observed (BMI, 42% to 70%, P < 0.001) with formal dissemination tactics. For pilot units, moderate/severe malnutrition (undernutrition) rates tripled (1.2% [24 of 2081] to 3.4% [81 of 2374], P < 0.001). CONCLUSION Documentation of anthropometrics on admission substantially improved after establishing multidisciplinary champion teams. Goal rate (80%) was achieved within 26 months for all anthropometrics in the surgical unit and for weight in the cardiac unit. Improved documentation rates led to significant increase in identification of patients at malnutrition (undernutrition) risk.
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Affiliation(s)
- Sabrina Persaud
- Clinical Education, Informatics, Quality and Professional Practice Department, Boston Children’s Hospital, Boston, Massachusetts, USA
- Center for Nutrition and Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Bridget M. Hron
- Center for Nutrition and Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Coral Rudie
- Center for Nutrition and Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Patricia Mantell
- Clinical Education, Informatics, Quality and Professional Practice Department, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Prerna S. Kahlon
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Katelyn Ariagno
- Center for Nutrition and Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Al Ozonoff
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Shrunjal Trivedi
- Center for Applied Pediatric Quality Analytics, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Carlos Yugar
- Center for Applied Pediatric Quality Analytics, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Nilesh M. Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Michelle Raymond
- Center for Nutrition and Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Christopher P. Duggan
- Center for Nutrition and Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Susanna Y. Huh
- Center for Nutrition and Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Ironwood Pharmaceuticals, Boston, Massachusetts, USA
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Akhondi-Asl A, Ariagno K, Fluckiger L, Jotterand Chaparro C, Martinez EE, Moreno YMF, Ong C, Skillman HE, Tume L, Mehta NM, Bechard LJ. Changes in global nutrition practices in critically ill children and the impact of emerging evidence: a secondary analysis of the Pediatric International Nutrition Studies (PINS), 2009-2018. J Acad Nutr Diet 2024:S2212-2672(24)00203-X. [PMID: 38679383 DOI: 10.1016/j.jand.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 04/21/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND The timeline of the three Pediatric International Nutrition Studies (PINS) coincided with the publication of 2 major guidelines for the timing of parenteral nutrition (PN) and recommended energy and protein delivery dose. OBJECTIVE The study's main objective was to describe changes in the nutrition delivery practice recorded in PINS 1 and 2 (conducted in 2009 and 2011, pre-exposure epoch) versus PINS 3 (conducted in 2018,post-exposure epoch), in relation to the published practice guidelines. DESIGN This study is a secondary analysis of data from a multi-center prospective cohort study. PARTICIPANTS /setting. Data from 3650 participants, aged 1 month to 18 years, admitted to 100 unique hospitals that participated in three PINS was used for this study. MAIN OUTCOME MEASURES The time in days from PICU admission to the initiation of PN and enteral nutrition (EN) delivery were the primary outcomes. Prescribed energy and protein goals were the secondary outcomes. STATISTICAL ANALYSES PERFORMED A frailty model with a random intercept per hospital with stratified baseline hazard function by region for the primary outcomes and a mixed-effects negative binomial regression with random intercept per hospital for the secondary outcomes. RESULTS The proportion of patients receiving EN (88.3% vs. 80.6%, p-value<0.001) was higher, and those receiving PN (20.6% vs. 28.8%, p-value<0.001) was lower in the PINS3 cohort compared to PINS1-2. In the PINS3 cohort, the odds of initiating PN during the 1st 10 days of PICU admission were lower, compared to the PINS1-2 cohort (HR=0.8, CI=[0.67-0.95], p-value=0.013); and prescribed energy goal was lower compared to the PINS1-2 cohort (IRR=0.918, CI=[0.874-0.965], p=0.001). CONCLUSIONS The likelihood of initiation of PN delivery significantly decreased in the first ten days post-admission in the PINS3 cohort compared to PINS1-2. Energy goal prescription in mechanically ventilated children significantly decreased in the post-guidelines epoch compared to the pre-guidelines epoch.
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Affiliation(s)
- Alireza Akhondi-Asl
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katelyn Ariagno
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Center for Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Larissa Fluckiger
- Critical Care Dietitian; Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Switzerland
| | - Enid E Martinez
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Yara M F Moreno
- Graduate Program in Nutrition, Health Sciences Center, Federal University of Santa Catarina, Santa Catarina, Brazil
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore
| | - Heather E Skillman
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, CO, USA
| | - Lyvonne Tume
- Faculty of Health, Social care & Medicine, Edge Hill University, Ormskirk, UK
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Center for Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Lori J Bechard
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Nutrition and Dietetics, Johnson & Wales University, College of Health & Wellness, Providence, RI
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Seleman M, Mehta NM, Yang Y. Medication Errors: Detection Methodology Matters. J Patient Saf 2024; 20:e6-e7. [PMID: 38240643 DOI: 10.1097/pts.0000000000001201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
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Akhondi-Asl A, Yang Y, Luchette M, Burns JP, Mehta NM, Geva A. Comparing the Quality of Domain-Specific Versus General Language Models for Artificial Intelligence-Generated Differential Diagnoses in PICU Patients. Pediatr Crit Care Med 2024:00130478-990000000-00310. [PMID: 38329382 DOI: 10.1097/pcc.0000000000003468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 02/09/2024]
Abstract
OBJECTIVES Generative language models (LMs) are being evaluated in a variety of tasks in healthcare, but pediatric critical care studies are scant. Our objective was to evaluate the utility of generative LMs in the pediatric critical care setting and to determine whether domain-adapted LMs can outperform much larger general-domain LMs in generating a differential diagnosis from the admission notes of PICU patients. DESIGN Single-center retrospective cohort study. SETTING Quaternary 40-bed PICU. PATIENTS Notes from all patients admitted to the PICU between January 2012 and April 2023 were used for model development. One hundred thirty randomly selected admission notes were used for evaluation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Five experts in critical care used a 5-point Likert scale to independently evaluate the overall quality of differential diagnoses: 1) written by the clinician in the original notes, 2) generated by two general LMs (BioGPT-Large and LLaMa-65B), and 3) generated by two fine-tuned models (fine-tuned BioGPT-Large and fine-tuned LLaMa-7B). Differences among differential diagnoses were compared using mixed methods regression models. We used 1,916,538 notes from 32,454 unique patients for model development and validation. The mean quality scores of the differential diagnoses generated by the clinicians and fine-tuned LLaMa-7B, the best-performing LM, were 3.43 and 2.88, respectively (absolute difference 0.54 units [95% CI, 0.37-0.72], p < 0.001). Fine-tuned LLaMa-7B performed better than LLaMa-65B (absolute difference 0.23 unit [95% CI, 0.06-0.41], p = 0.009) and BioGPT-Large (absolute difference 0.86 unit [95% CI, 0.69-1.0], p < 0.001). The differential diagnosis generated by clinicians and fine-tuned LLaMa-7B were ranked as the highest quality in 144 (55%) and 74 cases (29%), respectively. CONCLUSIONS A smaller LM fine-tuned using notes of PICU patients outperformed much larger models trained on general-domain data. Currently, LMs remain inferior but may serve as an adjunct to human clinicians in real-world tasks using real-world data.
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Affiliation(s)
- Alireza Akhondi-Asl
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Perioperative and Critical Care-Center for Outcomes (PC-CORE), Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Youyang Yang
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Perioperative and Critical Care-Center for Outcomes (PC-CORE), Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Perioperative and Critical Care-Center for Outcomes (PC-CORE), Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Jeffrey P Burns
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Perioperative and Critical Care-Center for Outcomes (PC-CORE), Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Perioperative and Critical Care-Center for Outcomes (PC-CORE), Boston Children's Hospital, Boston, MA
| | - Alon Geva
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Perioperative and Critical Care-Center for Outcomes (PC-CORE), Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
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Mills KI, Albert BD, Bechard LJ, Chu S, Duggan CP, Kaza A, Rakoff-Nahoum S, Sleeper LA, Newburger JW, Priebe GP, Mehta NM. Stress Ulcer Prophylaxis Versus Placebo-A Blinded Pilot Randomized Controlled Trial to Evaluate the Safety of Two Strategies in Critically Ill Infants With Congenital Heart Disease. Pediatr Crit Care Med 2024; 25:118-127. [PMID: 38240536 PMCID: PMC10829532 DOI: 10.1097/pcc.0000000000003384] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 01/23/2024]
Abstract
OBJECTIVES The routine use of stress ulcer prophylaxis (SUP) in infants with congenital heart disease (CHD) in the cardiac ICU (CICU) is controversial. We aimed to conduct a pilot study to explore the feasibility of performing a subsequent larger trial to assess the safety and efficacy of withholding SUP in this population (NCT03667703). DESIGN, SETTING, PATIENTS Single-center, prospective, double-blinded, parallel group (SUP vs. placebo), pilot randomized controlled pilot trial (RCT) in infants with CHD admitted to the CICU and anticipated to require respiratory support for greater than 24 hours. INTERVENTIONS Patients were randomized 1:1 (stratified by age and admission type) to receive a histamine-2 receptor antagonist or placebo until respiratory support was discontinued, up to 14 days, or transfer from the CICU, if earlier. MEASUREMENTS AND MAIN RESULTS Feasibility was defined a priori by thresholds of screening rate, consent rate, timely drug allocation, and protocol adherence. The safety outcome was the rate of clinically significant upper gastrointestinal (UGI) bleeding. We screened 1,426 patients from February 2019 to March 2022; of 132 eligible patients, we gained informed consent in 70 (53%). Two patients did not require CICU admission after obtaining consent, and the remaining 68 patients were randomized to SUP (n = 34) or placebo (n = 34). Ten patients were withdrawn early, because of a change in eligibility (n = 3) or open-label SUP use (n = 7, 10%). Study procedures were completed in 58 patients (89% protocol adherence). All feasibility criteria were met. There were no clinically significant episodes of UGI bleeding during the pilot RCT. The percentage of patients with other nonserious adverse events did not differ between groups. CONCLUSIONS Withholding of SUP in infants with CHD admitted to the CICU was feasible. A larger multicenter RCT designed to confirm the safety of this intervention and its impact on incidence of UGI bleeding, gastrointestinal microbiome, and other clinical outcomes is warranted.
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Affiliation(s)
- Kimberly I. Mills
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Ben D. Albert
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Perioperative and Critical Care Center for Outcomes (PC-CORE), Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Lori J. Bechard
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Perioperative and Critical Care Center for Outcomes (PC-CORE), Boston Children’s Hospital, Boston, MA
| | - Stephen Chu
- Department of Pharmacy, Boston Children’s Hospital, Boston, MA
| | - Christopher P. Duggan
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Aditya Kaza
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Seth Rakoff-Nahoum
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Gregory P. Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Nilesh M. Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Perioperative and Critical Care Center for Outcomes (PC-CORE), Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
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Jotterand Chaparro C, Pabion C, Tume L, Mehta NM, Valla FV, Moullet C. Determining energy and protein needs in critically ill pediatric patients: A scoping review. Nutr Clin Pract 2023; 38 Suppl 2:S103-S124. [PMID: 37721467 DOI: 10.1002/ncp.11060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/27/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION In critically ill pediatric patients, optimal energy and protein intakes are associated with a decreased risk of morbidity and mortality. However, the determination of energy and protein needs is complex. The objective of this scoping review was to understand the extent and type of evidence related to the methods used to determine energy and protein needs in critically ill pediatric patients. METHODS An international expert group composed of dietitians, pediatric intensivists, a nurse, and a methodologist conducted the review, based on the Johanna Briggs Institute methodology. Two researchers searched for studies published between 2008 and 2023 in two electronic databases, screened abstracts and relevant full texts for eligibility, and extracted data. RESULTS A total of 39 studies were included, mostly conducted in critically ill children undergoing ventilation, to assess the accuracy of predictive equations for estimating resting energy expenditure (REE) (n = 16, 41%) and the impact of clinical factors (n = 22, 56%). They confirmed the risk of underestimation or overestimation of REE when using predictive equations, of which the Schofield equation was the least inaccurate. Apart from weight and age, which were positively correlated with REE, the impact of other factors was not always consistent. No new indirect calorimeter method used to determine protein needs has been validated. CONCLUSION This scoping review highlights the need for scientific data on the methods used to measure energy expenditure and determine protein needs in critically ill children. Studies using a reference method are needed to validate an indirect calorimeter.
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Affiliation(s)
- Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Bureau d'Echange des Savoirs pour des praTiques exemplaires de soins (BEST): A JBI Centre of Excellence, Lausanne, Switzerland
| | - Céline Pabion
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Lyvonne Tume
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frédéric V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Clémence Moullet
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
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Geva A, Akhondi-Asl A, Mehta NM. Validation and Extension of the Association Between Potentially Excess Oxygen Exposure and Death in Mechanically Ventilated Children. Pediatr Crit Care Med 2023; 24:e434-e440. [PMID: 37668503 DOI: 10.1097/pcc.0000000000003261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
OBJECTIVES "Cumulative excess oxygen exposure" (CEOE)-previously defined as the mean hourly administered Fio2 above 0.21 when the corresponding hourly Spo2 was 95% or above-was previously shown to be associated with mortality. The objective of this study was to examine the relationship among Fio2, Spo2, and mortality in an independent cohort of mechanically ventilated children. DESIGN Retrospective cross-sectional study. SETTING Quaternary-care PICU. PATIENTS All patients admitted to the PICU between 2012 and 2021 and mechanically ventilated via endotracheal tube for at least 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 3,354 patients, 260 (8%) died. Higher CEOE quartile was associated with increased mortality (p = 0.001). The highest CEOE quartile had an 87% increased risk of mortality (95% CI, 7-236) compared with the first CEOE quartile. The hazard ratio for extended CEOE exposure, which included mechanical ventilation data from throughout the patients' mechanical ventilation time rather than only from the first 24 hours of mechanical ventilation, was 1.03 (95% CI, 1.02-1.03). CONCLUSIONS Potentially excess oxygen exposure in patients whose oxygen saturation was at least 95% was associated with increased mortality.
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Affiliation(s)
- Alon Geva
- Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Alireza Akhondi-Asl
- Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Nilesh M Mehta
- Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
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LaRovere KL, Luchette M, Akhondi-Asl A, DeSouza BJ, Tasker RC, Mehta NM, Geva A. Heart Rate Change as a Potential Digital Biomarker of Brain Death in Critically Ill Children With Acute Catastrophic Brain Injury. Crit Care Explor 2023; 5:e0908. [PMID: 37151893 PMCID: PMC10158912 DOI: 10.1097/cce.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
Bedside measurement of heart rate (HR) change (HRC) may provide an objective physiologic marker for when brain death (BD) may have occurred, and BD testing is indicated in children. OBJECTIVES To determine whether HRC, calculated using numeric HR measurements sampled every 5 seconds, can identify patients with BD among patients with catastrophic brain injury (CBI). DESIGN SETTING AND PARTICIPANTS Single-center, retrospective study (2008-2020) of critically ill children with acute CBI. Patients with CBI had a neurocritical care consultation, were admitted to an ICU, had acute neurologic injury on presentation or during hospitalization based on clinical and/or imaging findings, and died or survived with Glasgow Coma Scale (GCS) less than 13 at hospital discharge. Patients meeting BD criteria (BD group) were compared with those with cardiopulmonary death (CD group) or those who survived to discharge. MAIN OUTCOMES AND MEASURES HRC was calculated as the interquartile range of HR divided by median HR using 5-minute windows with 50% overlap for up to 5 days before death or end of recording. HRC was compared among the BD, CD, and survivor groups. RESULTS Of 96 patients with CBI (69% male, median age 4 years), 28 died (8 BD, 20 CD) and 20 survived (median GCS 9 at discharge). Within 24 hours before death, HRC was lower in BD compared with CD patients or survivors (0.01 vs 0.03 vs 0.04, p = 0.001). In BD patients, HRC decreased at least 1 day before death. HRC discriminated BD from CD patients and survivors with 90% sensitivity, 70% specificity, 44% positive predictive value, 96% negative predictive value (area under the receiver operating characteristic curve 0.88, 95% CI, 0.80-0.93). CONCLUSIONS AND RELEVANCE HRC is a novel digital biomarker that, with further validation, may be useful as a classifier for BD in the overall course of patients with CBI.
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Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
| | - Matthew Luchette
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
| | - Alireza Akhondi-Asl
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
| | - Bradley J DeSouza
- Department of Critical Care Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
| | - Alon Geva
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Boston Children's Hospital, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
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Martinez EE, Melvin P, Callif C, Turner AD, Hamilton S, Mehta NM. Postpyloric vs gastric enteral nutrition in critically ill children: A single-center retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:494-500. [PMID: 36722708 PMCID: PMC10464611 DOI: 10.1002/jpen.2482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/07/2022] [Revised: 12/30/2022] [Accepted: 01/27/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND We aimed to describe enteral nutrition (EN) delivery in patients receiving postpyloric EN (PPEN) vs gastric EN (GEN). METHODS Single-center retrospective study including patients aged <21 years admitted to an intensive care unit in a pediatric quaternary care hospital for ≧48 h who received PPEN or GEN as a first approach, as guided by a nutrition algorithm. PPEN patients were 1:1 propensity score matched to GEN patients on demographics, clinical characteristics, and disease severity. Days to EN initiation from admission, percentage of EN adequacy (delivered EN volume/prescribed EN volume) on days 1-3 and 7 after EN initiation, and time to achieving 60% of prescribed EN volume were compared between the two groups using Wilcoxon Mann-Whitney tests and a Cox proportional hazards model. Data are presented as median (IQR1, IQR3). RESULTS Forty-six PPEN and 46 GEN patients were matched. Median time to EN initiation was 3.25 (2, 6.8) days for PPEN and 4.15 (1.5, 7.1) days for GEN (P = 0.6). Percentage of EN adequacy was greater for PPEN than GEN patients (day 1 PPEN 59.4% [18.8, 87.5] vs GEN 21.1% [7.8, 62.8], day 2 PPEN 54.3% [16.7, 95.8] vs GEN 24% [5.4, 56.7], day 3 PPEN 65.4% [14.7, 100] vs GEN 16% [0, 64.6], day 7 PPEN 77.8% [11.1, 100] vs GEN 13.8% [0, 74.5]; P < 0.05). PPEN patients had greater likelihood of achieving 60% of their prescribed EN volume than GEN patients (hazard ratio 1.84, 95% CI 1.07-3.15; P = 0.028). CONCLUSION PPEN was associated with greater EN delivery compared with GEN.
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Affiliation(s)
- Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care, Center for Outcomes Research & Evaluation (PC-CORE), Boston Children’s Hospital, Boston MA
| | - Patrice Melvin
- Office of Health Equity and Inclusion, Boston Children’s Hospital, Boston, MA
| | - Charles Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Ashley D Turner
- Department of Medicine, Boston Children’s Hospital, Boston, MA
| | - Susan Hamilton
- Department of General Surgery, Boston Children’s Hospital, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care, Center for Outcomes Research & Evaluation (PC-CORE), Boston Children’s Hospital, Boston MA
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10
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O'Hara JE, Buchmiller TL, Bechard LJ, Akhondi-Asl A, Visner G, Sheils C, Becker R, Studley M, Lemire L, Mullen MP, Vitali S, Mehta NM, Dickie B, Zalieckas JM, Albert BD. Long-Term Functional Outcomes at 1-Year After Hospital Discharge in Critically Ill Neonates With Congenital Diaphragmatic Hernia. Pediatr Crit Care Med 2023:00130478-990000000-00185. [PMID: 37098788 DOI: 10.1097/pcc.0000000000003249] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVES Congenital diaphragmatic hernia (CDH) is a birth defect associated with long-term morbidity. Our objective was to examine longitudinal change in Functional Status Scale (FSS) after hospital discharge in CDH survivors. DESIGN Single-center retrospective cohort study. SETTING Center for comprehensive CDH management at a quaternary, free-standing children's hospital. PATIENTS Infants with Bochdalek CDH were admitted to the ICU between January 2009 and December 2019 and survived until hospital discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred forty-two infants (58% male, mean birth weight 3.08 kg, 80% left-sided defects) met inclusion criteria. Relevant clinical data were extracted from the medical record to calculate FSS (primary outcome) at hospital discharge and three subsequent outpatient follow-up time points. The median (interquartile range [IQR]) FSS score at hospital discharge was 8.0 (7.0-9.0); 39 patients (27.5%) had at least moderate impairment (FSS ≥ 9). Median (IQR) FSS at 0- to 6-month (n = 141), 6- to 12-month (n = 141), and over 12-month (n = 140) follow-up visits were 7.0 (7.0-8.0), 7.0 (6.0-8.0), and 6.0 (6.0-7.0), respectively. Twenty-one patients (15%) had at least moderate impairment at over 12-month follow-up; median composite FSS scores in the over 12-month time point decreased by 2.0 points from hospital discharge. Median feeding domain scores improved by 1.0 (1.0-2.0), whereas other domain scores remained without impairment. Multivariable analysis demonstrated right-sided, C- or D-size defects, extracorporeal membrane oxygenation use, cardiopulmonary resuscitation, and chromosomal anomalies were associated with impairment. CONCLUSIONS The majority of CDH survivors at our center had mild functional status impairment (FSS ≤ 8) at discharge and 1-year follow-up; however, nearly 15% of patients had moderate impairment during this time period. The feeding domain had the highest level of functional impairment. We observed unchanged or improving functional status longitudinally over 1-year follow-up after hospital discharge. Longitudinal outcomes will guide interdisciplinary management strategies in CDH survivors.
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Affiliation(s)
- Jill E O'Hara
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Terry L Buchmiller
- Harvard Medical School, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Lori J Bechard
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Alireza Akhondi-Asl
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Gary Visner
- Harvard Medical School, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
| | - Catherine Sheils
- Harvard Medical School, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
| | - Ronald Becker
- Harvard Medical School, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Mollie Studley
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Lindsay Lemire
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Mary P Mullen
- Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Sally Vitali
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Nilesh M Mehta
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Belinda Dickie
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Jill M Zalieckas
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Ben D Albert
- Harvard Medical School, Boston, MA
- Perioperative and Critical Care-Center for Outcomes, Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Surgery, Boston Children's Hospital, Boston, MA
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, MA
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
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Liauchonak S, Hamilton S, Franks JD, Callif C, Akhondi-Asl A, Ariagno K, Mehta NM, Martinez EE. Impact of implementing an evidence-based definition of enteral nutrition intolerance on nutrition delivery: A prospective, cross-sectional cohort study. Nutr Clin Pract 2023; 38:376-385. [PMID: 36541429 PMCID: PMC10023272 DOI: 10.1002/ncp.10941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/30/2022] [Revised: 10/28/2022] [Accepted: 11/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Enteral nutrition (EN) interruptions because of EN intolerance impede nutrient delivery. We aimed to examine whether revising the EN intolerance definition of an algorithm would decrease EN interruptions and improve nutrient delivery in critically ill children. METHODS We performed a cross-sectional cohort study including patients who were admitted to our intensive care unit (ICU) for >24 h and received EN. The EN intolerance definition in our nutrition algorithm was modified to include two symptoms of EN intolerance. We compared time to 60% EN adequacy (EN delivered/EN prescribed x 100) and EN interruptions before and after this intervention. RESULTS We included 150 eligible patients, 78 and 72 patients in the preimplementation and postimplementation cohorts, respectively. There were no significant differences in demographics and clinical characteristics. The preimplementation and postimplementation cohorts achieved 60% EN adequacy 4 (2-5) days and 3 (2-5) days after ICU admission, respectively (P = 0.59). The preimplementation cohort had a median of 1 (1-2) interruption per patient and the postimplementation cohort 2 (1-3; P = 0.08). The frequency of interruptions because of EN intolerance within the first 8 days of ICU admission was 17 in the preimplementation and 10 in the postimplementation cohorts. CONCLUSION Modifying the EN intolerance definition of a nutrition algorithm did not change the time to 60% EN adequacy or total number of EN interruptions in critically ill children. EN intolerance and interruptions continue to limit nutrient delivery. Research on the best definition for EN intolerance and its effect on nutrition outcomes is needed.
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Affiliation(s)
- Siarhei Liauchonak
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Susan Hamilton
- Department of Surgery, Boston Children’s Hospital, Boston, MA
| | - Jennifer D. Franks
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Charles Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Alireza Akhondi-Asl
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Katelyn Ariagno
- Center for Nutrition, Department of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Center for Nutrition, Department of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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12
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Farr BJ, Bechard LJ, Rice-Townsend SE, Mehta NM. Bio-impedance spectroscopy for total body water assessment in pediatric surgical patients: A single center pilot cohort study. J Pediatr Surg 2022; 57:962-966. [PMID: 35940939 DOI: 10.1016/j.jpedsurg.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/15/2022] [Revised: 06/23/2022] [Accepted: 07/12/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Excess peri‑operative fluid administration is associated with higher morbidity and mortality. We aimed to examine the feasibility of bio-impedance spectroscopy (BIS) to record serial peri‑operative fluid volumes in the pediatric surgical population. METHODS Children who underwent major elective general surgery from March 2019 to March 2020 were included. Total body water (TBW) assessment by BIS was recorded prior to surgery and on subsequent post-operative days (POD). We recorded the duration, tolerance and completion of each BIS assessment. We used Spearman coefficient and Bland Altman analysis to examine correlation and agreement between fluid balance (FB) in ml/kg calculated from intake/output (IO) recording and measured by BIS. RESULTS 20 (87%) of 23 consented patients, median age 2.5 (1-17) years and 13 (65%) male, completed pre-operative and post-operative measurements, and were included in the analysis. Median time required for BIS assessments was 10 (5-15) minutes, and there were no recorded side effects or intolerance. The correlation coefficient for fluid balance measurements on POD 1 between BIS and IO methods was 0.59 (p = 0.01); mean bias (limits) of agreement was 26 (111 to 163) mL/kg. The trend in TBW measured by BIS declined from POD 1-3, while the recorded FB increased. CONCLUSION Bedside BIS is feasible and well-tolerated. Despite moderate correlation between fluid balance assessment by BIS and IO on POD 1, the wide limits of agreement between values from these methods preclude their use interchangeably. The role of BIS in assessment of fluid status in the pediatric surgical population should be further examined. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Bethany J Farr
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States.
| | - Lori J Bechard
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Samuel E Rice-Townsend
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States; Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, United States
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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13
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Martinez EE, Bechard LJ, Brown AM, Coss-Bu JA, Kudchadkar SR, Mikhailov TA, Srinivasan V, Staffa SJ, Verbruggen SSCAT, Zurakowski D, Mehta NM. Intermittent versus continuous enteral nutrition in critically ill children: A pre-planned secondary analysis of an international prospective cohort study. Clin Nutr 2022; 41:2621-2627. [PMID: 36306567 PMCID: PMC9722589 DOI: 10.1016/j.clnu.2022.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/15/2022] [Revised: 09/14/2022] [Accepted: 09/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Intermittent enteral nutrition (EN) may have physiologic benefits over continuous feeding in critical illness. We aimed to compare nutrition and infection outcomes in critically ill children receiving intermittent or continuous EN. METHODS International, multi-center prospective observational study of mechanically ventilated children, 1 month to 18 years of age, receiving EN. Percent energy or protein adequacy (energy or protein delivered/prescribed × 100) and acquired infection rates were compared between intermittent and continuous EN groups using adjusted-multivariable and 4:1 propensity-score matched (PSM) analyses. Sensitivity analyses were performed after excluding patients who crossed over between intermittent and continuous EN. RESULTS 1375 eligible patients from 66 PICUs were included. Patients receiving continuous EN (N = 1093) had a higher prevalence of respiratory illness and obesity, and lower prevalence of neurologic illness and underweight status on admission, compared to those on intermittent EN (N = 282). Percent energy or protein adequacy, proportion of patients who achieved 60% of energy or protein adequacy in the first 7 days of admission, and rates of acquired infection were not different between the 2 groups in adjusted-multivariable and propensity score matching analyses (P > 0.05). CONCLUSION Intermittent versus continuous EN strategy is not associated with differences in energy or protein adequacy, or acquired infections, in mechanically ventilated, critically ill children. Until further evidence is available, an individualized feeding strategy rather than a universal approach may be appropriate.
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Affiliation(s)
- Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, MA, USA; Perioperative and Critical Care - Center for Outcomes Research (PC-CORE), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Lori J Bechard
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, MA, USA; Perioperative and Critical Care - Center for Outcomes Research (PC-CORE), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Jorge A Coss-Bu
- Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Austin, TX, USA
| | - Sapna R Kudchadkar
- Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Theresa A Mikhailov
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Vijay Srinivasan
- Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Steven J Staffa
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA
| | - S Sascha C A T Verbruggen
- Pediatric Intensive Care Unit, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, NL, USA
| | - David Zurakowski
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, MA, USA; Perioperative and Critical Care - Center for Outcomes Research (PC-CORE), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.
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14
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Schults JA, Rickard CM, Charles K, Rahiman S, Millar J, Baveas T, Long D, Kleidon TM, Macfarlane F, Mehta NM, Runnegar N, Hall L. Quality measurement and surveillance platforms in critically ill children: A scoping review. Aust Crit Care 2022:S1036-7314(22)00097-2. [PMID: 36117039 DOI: 10.1016/j.aucc.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/24/2022] [Accepted: 07/31/2022] [Indexed: 10/14/2022] Open
Abstract
BACKGROUND/AIM The objective of this study was to describe current surveillance platforms which support routine quality measurement in paediatric critical care. METHOD Scoping review. The search strategy consisted of a traditional database and grey literature search as well as expert consultation. Surveillance platforms were eligible for inclusion if they collected measures of quality in critically ill children. RESULTS The search strategy identified 21 surveillance platforms, collecting 57 unique outcome (70%), process (23%), and structural (7%) quality measures. Hospital-associated infections were the most commonly collected outcome measure across all platforms (n = 11; 52%). In general, case definitions were not harmonised across platforms, with the exception of nationally mandated hospital-associated infections (e.g., central line-associated blood stream infection). Data collection relied on manual coding. Platforms typically did not provide an evidence-based rationale for measures collected, with no identifiable reports of co-designed, consensus-derived measures or consumer involvement in measure selection or prioritisation. CONCLUSIONS Quality measurement in critically ill children lacks uniformity in definition which limits local and international benchmarking. Current surveillance activities for critically ill children focus heavily on outcome measurement, with process, structural, and patient-reported measures largely overlooked. Long-term outcome measures were not routinely collected. Harmonisation of paediatric intensive care unit quality measures is needed and can be achieved using prioritisation and consensus/co-design methods.
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Affiliation(s)
- Jessica A Schults
- School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; Metro North Hospital and Health Service, Queensland, Australia; Child Health Research Centre, Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia; School of Nursing and Midwifery Griffith University, Queensland, Australia; Paediatric Intensive Care Unit Queensland Children's Hospital, South Brisbane, Queensland, Australia.
| | - Claire M Rickard
- School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; Metro North Hospital and Health Service, Queensland, Australia; School of Nursing and Midwifery Griffith University, Queensland, Australia
| | - Karina Charles
- School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; Child Health Research Centre, Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia; School of Nursing and Midwifery Griffith University, Queensland, Australia; Paediatric Intensive Care Unit Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Sarfaraz Rahiman
- Paediatric Intensive Care Unit Queensland Children's Hospital, South Brisbane, Queensland, Australia; School of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Johnny Millar
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Australia
| | - Thimitra Baveas
- Paediatric Intensive Care Unit Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Debbie Long
- Paediatric Intensive Care Unit Queensland Children's Hospital, South Brisbane, Queensland, Australia; School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Tricia M Kleidon
- School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; School of Nursing and Midwifery Griffith University, Queensland, Australia; Department of Anaesthesia and Pain Management, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Fiona Macfarlane
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Nilesh M Mehta
- Perioperative & Critical Care Center for Outcomes Research (PC-CORE), USA; Department of Anesthesiology, Critical Care & Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, USA; Harvard Medical School, Boston, USA
| | - Naomi Runnegar
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia; Infection Management, Princess Alexandra Hospital, Woolloongabba, Qld, Australia
| | - Lisa Hall
- School of Public Health, Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
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15
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Affiliation(s)
- Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital for Children, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alessio Fasano
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, Massachusetts General Hospital for Children, Boston, MA
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16
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Yang Y, Geva A, Madden K, Mehta NM. Implementation Science in Pediatric Critical Care - Sedation and Analgesia Practices as a Case Study. Front Pediatr 2022; 10:864029. [PMID: 35859943 PMCID: PMC9289107 DOI: 10.3389/fped.2022.864029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022] Open
Abstract
Sedation and analgesia (SA) management is essential practice in the pediatric intensive care unit (PICU). Over the past decade, there has been significant interest in optimal SA management strategy, due to reports of the adverse effects of SA medications and their relationship to ICU delirium. We reviewed 13 studies examining SA practices in the PICU over the past decade for the purposes of reporting the study design, outcomes of interest, SA protocols used, strategies for implementation, and the patient-centered outcomes. We highlighted the paucity of evidence-base for these practices and also described the existing gaps in the intersection of implementation science (IS) and SA protocols in the PICU. Future studies would benefit from a focus on effective implementation strategies to introduce and sustain evidence-based SA protocols, as well as novel quasi-experimental study designs that will help determine their impact on relevant clinical outcomes, such as the occurrence of ICU delirium. Adoption of the available evidence-based practices into routine care in the PICU remains challenging. Using SA practice as an example, we illustrated the need for a structured approach to the implementation science in pediatric critical care. Key components of the successful adoption of evidence-based best practice include the assessment of the local context, both resources and barriers, followed by a context-specific strategy for implementation and a focus on sustainability and integration of the practice into the permanent workflow.
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Affiliation(s)
- Youyang Yang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Alon Geva
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
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Hames DL, Sleeper LA, Ferguson MA, Mehta NM, Salvin JW, Mills KI. Fluid Restriction Contributes to Poor Nutritional Adequacy in Patients With Congenital Heart Disease Receiving Renal Replacement Therapy. J Ren Nutr 2022; 32:78-86. [PMID: 34625332 PMCID: PMC8991421 DOI: 10.1053/j.jrn.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/24/2021] [Accepted: 08/10/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Critically ill patients receiving renal replacement therapy (RRT) in the pediatric cardiac intensive care unit (CICU) are at high risk for inadequate nutrition delivery. The objective of this study is to evaluate barriers to adequate energy and protein delivery in critically ill patients with congenital heart disease receiving RRT. METHODS This is a single-center retrospective cohort study of patients receiving RRT in the CICU from 2011 to 2019. Energy and protein adequacy was recorded over the first 7 days of RRT. Adequacy was defined as delivery of >80% of the energy and protein targets during this time period. Patients who achieved adequacy were compared to those who did not. Multivariable logistic regression models were constructed to determine factors independently associated with energy and protein adequacy while receiving RRT. RESULTS Sixty patients were included for analysis. Fifty-five patients (92%) achieved energy adequacy and 37 patients (62%) achieved protein adequacy. A higher weight-for-age z-score (WAZ) on admission to the CICU was the only independent predictor of inadequate energy intake (odds ratio 0.07, 95% confidence interval 0.01-0.58, P = .014); median WAZ was -1.17 versus +1.24 for those with adequate versus inadequate energy intake, respectively. Fluid restriction to <80% of maintenance fluid at the time of RRT initiation was more likely in patients with higher WAZ. Fluid restriction was the only independent predictor of inadequate protein intake (odds ratio 0.13, 95% confidence interval 0.02-0.7, P = .018); 5% versus 30% were fluid restricted in those with adequate versus inadequate protein intake, respectively. Azotemia was not associated with inadequate protein intake. Initiation of RRT did not allow for liberalization of fluid intake over the time period evaluated. CONCLUSIONS Protein delivery was inadequate in 38% of children undergoing RRT in the CICU. Fluid restriction was associated with inadequate protein intake and higher WAZ was associated with inadequate energy intake.
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Affiliation(s)
- Daniel L. Hames
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Michael A. Ferguson
- Division of Nephrology, Department of Medicine, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital
| | - Joshua W. Salvin
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberly I. Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
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Martinez EE, Dang H, Franks J, Callif CG, Tasker RC, Madden K, Mehta NM. Association Between Anticholinergic Drug Burden and Adequacy of Enteral Nutrition in Critically Ill, Mechanically Ventilated Pediatric Patients. Pediatr Crit Care Med 2021; 22:1083-1087. [PMID: 34560773 DOI: 10.1097/pcc.0000000000002840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Enteral nutrition delivery is limited by intolerance and interruptions in critically ill children. Anticholinergic properties of frequently administered medications may contribute to altered gastric motility and enteral nutrition intolerance in this population. We examined the association between the anticholinergic burden of administered medications using the Anticholinergic Drug Scale and adequacy of enteral nutrition delivery. DESIGN Secondary analysis of data from a previously characterized PICU cohort. SETTING Multidisciplinary PICU in a quaternary academic medical center. PATIENTS Younger than or equal to 18 years, on mechanical ventilation and received enteral nutrition within the first 3 days of PICU admission. MEASUREMENTS AND MAIN RESULTS Daily Anticholinergic Drug Scale score, demographic data, and clinical data were obtained from the primary study. Percent enteral energy adequacy ([kcal delivered ÷ kcal prescribed] × 100) during the first 3 days of PICU admission was calculated. Forty-two patients received enteral nutrition, with median age (interquartile range) 5 years (1.09-12.54 yr), and 62% were male. Median Anticholinergic Drug Scale score was inversely correlated with energy adequacy, with a median 9% decline in energy adequacy per 1-point increase in Anticholinergic Drug Scale score (coefficient, -9.3; 95% CI, -13.43 to -5.27; R2 = 0.35; p < 0.0001). Median hours of enteral nutrition interruptions directly correlated with Anticholinergic Drug Scale score (coefficient, 1.5; 95% CI, 0.531-2.54; R2 = 0.19; p = 0.004). Severity score was greater in patients with less than or equal to 25% enteral energy adequacy and directly correlated with median Anticholinergic Drug Scale score. CONCLUSIONS Anticholinergic burden from medications administered in the PICU is a potentially modifiable factor for suboptimal enteral nutrition delivery.
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Affiliation(s)
- Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jennifer Franks
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Charles G Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Center for Nutrition, Boston Children's Hospital, Boston, MA
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19
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Harrington AW, Riebold J, Hernandez K, Staffa SJ, Svetanoff WJ, Zurakowski D, Hamilton T, Jennings R, Mehta NM, Zendejas B. Nutrition delivery and growth outcomes in infants with long-gap esophageal atresia who undergo the Foker process. J Pediatr Surg 2021; 56:2133-2139. [PMID: 34366132 DOI: 10.1016/j.jpedsurg.2021.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 06/01/2021] [Revised: 07/01/2021] [Accepted: 07/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Predictors of growth outcomes in patients with long-gap esophageal atresia (LGEA) are not known. We examined nutrition and growth in-hospital and post-discharge in LGEA patients who underwent the Foker Process (FP). METHODS Single-center, retrospective cohort study of infants with LGEA undergoing primary (non-rescue) FP from 2014 to 2020. Weight-for-age z scores (WAZ, 0 = average), macronutrient prescription, anthropometry, and clinical variables were collected. Longitudinal median regression evaluated differences in WAZ over time. Multivariable median regression examined variables associated with change in WAZ at 1 year. RESULTS 45 patients met criteria, with median (IQR) age at repair of 4 (2, 5.8) months and WAZ of -0.96 (-1.55, -0.40). On admission, 11% were moderately (WAZ < -2) and 9% were severely (WAZ < -3) malnourished. Lower admission WAZ was significantly associated with improvement in WAZ at 1-year follow-up (p = 0.002); EA type (59% type A), esophageal leak (16%), median days paralyzed (13), ventilated (21), on parenteral nutrition (35), or to full enteral nutrition (35) were not associated with change in WAZ. Median WAZ remained stable while in-hospital, and patients maintained their growth curves through 3-year follow-up. CONCLUSION Throughout infancy, most primary FP LGEA patients have weight for age that is below average. Using targeted nutritional intervention, those who present with malnutrition can still achieve adequate growth despite prolonged and complicated hospital courses.
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Affiliation(s)
- Amanda W Harrington
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Jane Riebold
- Boston Children's Hospital, Division of Gastroenterology, Hepatology and Nutrition, Boston, MA, United States
| | - Kayla Hernandez
- Boston Children's Hospital, Division of Gastroenterology, Hepatology and Nutrition, Boston, MA, United States
| | - Steven J Staffa
- Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, United States
| | - Wendy Jo Svetanoff
- Department of General and Thoracic Surgery, Children's Mercy Hospital, Kansas City, MO, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States; Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, United States
| | - Thomas Hamilton
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Russell Jennings
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States
| | - Nilesh M Mehta
- Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, MA, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States.
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20
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Bechard LJ, Staffa SJ, Zurakowski D, Mehta NM. Time to achieve delivery of nutrition targets is associated with clinical outcomes in critically ill children. Am J Clin Nutr 2021; 114:1859-1867. [PMID: 34320161 DOI: 10.1093/ajcn/nqab244] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/29/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Optimal nutrition in critically ill children involves a complex interplay between the doses, route, and timing of macronutrient delivery. OBJECTIVES We aimed to examine the association between the time to achieve delivery of 60% of the prescribed energy and protein targets and clinical outcomes in mechanically ventilated children. METHODS We conducted a prospective, observational cohort study of mechanically ventilated children admitted to pediatric intensive care units (PICUs) worldwide. Daily energy and protein delivery were recorded for up to 10 d in the PICU. We calculated "adequacy" as the percentage of the prescribed energy or protein goal delivered by enteral nutrition (EN), parenteral nutrition (PN), and total nutrition (EN + PN). Based on the days required to reach 60% energy or protein adequacy after PICU admission, we categorized patients into 3 groups: early (≤3 d), pragmatic (4 to 7 d), and late (more than 7 d). The primary outcome was 60-d all-cause mortality; secondary outcomes were the incidence of acquired infections and 28-d ventilator-free days (VFDs). RESULTS From 77 participating PICUs, 1844 patients, with a median age of 1.64 y (IQR, 0.47-7.05), were included; the 60-d mortality rate was 5.3% (n = 97). The average adequacies of delivery via EN + PN was 49% (IQR, 26-70) for energy and 66% (IQR, 44-89) for protein. In multivariable models adjusted for confounders, mortality was significantly lower in patients who achieved targets within 7 d, for energy (adjusted HR, 0.48; 95% CI: 0.28-0.82; P = 0.007) or protein (adjusted HR, 0.55; 95% CI: 0.33-0.94; P = 0.027) delivery. There were no clinically significant differences in infections or VFDs between groups. CONCLUSIONS Achieving 60% of energy or protein delivery targets within the first 7 d after PICU admission is associated with lower 60-d mortality in mechanically ventilated children, and is not associated with a greater incidence of infections or a reduction in VFDs compared to later achievement of targets. This trial was registered at clinicaltrials.gov as NCT03223038.
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Affiliation(s)
- Lori J Bechard
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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21
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Spolidoro GCI, D’Oria V, De Cosmi V, Milani GP, Mazzocchi A, Akhondi-Asl A, Mehta NM, Agostoni C, Calderini E, Grossi E. Artificial Neural Network Algorithms to Predict Resting Energy Expenditure in Critically Ill Children. Nutrients 2021; 13:nu13113797. [PMID: 34836053 PMCID: PMC8618974 DOI: 10.3390/nu13113797] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Accurate assessment of resting energy expenditure (REE) can guide optimal nutritional prescription in critically ill children. Indirect calorimetry (IC) is the gold standard for REE measurement, but its use is limited. Alternatively, REE estimates by predictive equations/formulae are often inaccurate. Recently, predicting REE with artificial neural networks (ANN) was found to be accurate in healthy children. We aimed to investigate the role of ANN in predicting REE in critically ill children and to compare the accuracy with common equations/formulae. STUDY METHODS We enrolled 257 critically ill children. Nutritional status/vital signs/biochemical values were recorded. We used IC to measure REE. Commonly employed equations/formulae and the VCO2-based Mehta equation were estimated. ANN analysis to predict REE was conducted, employing the TWIST system. RESULTS ANN considered demographic/anthropometric data to model REE. The predictive model was good (accuracy 75.6%; R2 = 0.71) but not better than Talbot tables for weight. After adding vital signs/biochemical values, the model became superior to all equations/formulae (accuracy 82.3%, R2 = 0.80) and comparable to the Mehta equation. Including IC-measured VCO2 increased the accuracy to 89.6%, superior to the Mehta equation. CONCLUSIONS We described the accuracy of REE prediction using models that include demographic/anthropometric/clinical/metabolic variables. ANN may represent a reliable option for REE estimation, overcoming the inaccuracies of traditional predictive equations/formulae.
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Affiliation(s)
- Giulia C. I. Spolidoro
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (G.C.I.S.); (V.D.C.); (G.P.M.)
| | - Veronica D’Oria
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, 20122 Milan, Italy; (V.D.); (E.C.)
| | - Valentina De Cosmi
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (G.C.I.S.); (V.D.C.); (G.P.M.)
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gregorio Paolo Milani
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (G.C.I.S.); (V.D.C.); (G.P.M.)
- Pediatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Alessandra Mazzocchi
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Alireza Akhondi-Asl
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (A.A.-A.); (N.M.M.)
| | - Nilesh M. Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (A.A.-A.); (N.M.M.)
- Center for Nutrition, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
| | - Carlo Agostoni
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (G.C.I.S.); (V.D.C.); (G.P.M.)
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Correspondence:
| | - Edoardo Calderini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, 20122 Milan, Italy; (V.D.); (E.C.)
| | - Enzo Grossi
- Villa Santa Maria Foundation, Neuropsychiatric Rehabilitation Center, Autism Unit, 22038 Tavernerio, Italy;
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Ventura JC, Silveira TT, Bechard L, McKeever L, Mehta NM, Moreno YMF. Nutritional screening tool for critically ill children: a systematic review. Nutr Rev 2021; 80:1392-1418. [PMID: 34679168 DOI: 10.1093/nutrit/nuab075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/13/2022] Open
Abstract
CONTEXT Nutritional screening tools (NSTs) are used to identify patients who are at risk of nutritional status (NS) deterioration and associated clinical outcomes. Several NSTs have been developed for hospitalized children; however, none of these were specifically developed for Pediatric Intensive Care Unit (PICU) patients. OBJECTIVE A systematic review of studies describing the development, application, and validation of NSTs in hospitalized children was conducted to critically appraise their role in PICU patients. DATA SOURCES PubMed, Embase, Web of Science, Scopus, SciELO, LILACS, and Google Scholar were searched from inception to December 11, 2020. DATA EXTRACTION The review included 103 studies that applied NSTs at hospital admission. The NST characteristics collected included the aims, clinical setting, variables, and outcomes. The suitability of the NSTs in PICU patients was assessed based on a list of variables deemed relevant for this population. DATA ANALYSIS From 19 NSTs identified, 13 aimed to predict NS deterioration. Five NSTs were applied in PICU patients, but none was validated for this population. NSTs did not include clinical, NS, laboratory, or dietary variables that were deemed relevant for the PICU population. CONCLUSION None of the available NSTs were found to be suitable for critically ill children, so a new NST should be developed for this population. AQ6. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42020167898.
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Affiliation(s)
- Julia C Ventura
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Taís T Silveira
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Lori Bechard
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Liam McKeever
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Nilesh M Mehta
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Yara M F Moreno
- Julia C. Ventura, Taís T. Silveira, and Yara M. F. Moreno are with the Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil. L. Bechard and N. M. Mehta are with the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. L. McKeever is with the Perelman School of Medicine, at the University of Pennsylvania, Philadelphia, Pennsylvania, USA. N. M. Mehta is with the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Yara M. F. Moreno is with the Department of Nutrition, Federal University of Santa Catarina, Florianópolis, SC, Brazil
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Yang Y, Akhondi-Asl A, Geva A, Dwyer D, Stickney C, Kleinman ME, Madden K, Sanderson A, Mehta NM. Implementation of an Analgesia-Sedation Protocol Is Associated With Reduction in Midazolam Usage in the PICU. Pediatr Crit Care Med 2021; 22:e513-e523. [PMID: 33852546 PMCID: PMC8490269 DOI: 10.1097/pcc.0000000000002729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/26/2022]
Abstract
OBJECTIVES Examine the association of a revised analgesia-sedation protocol with midazolam usage in the PICU. DESIGN A single-center nonrandomized before-after study. SETTING PICU at a quaternary pediatric hospital (Boston Children's Hospital, Boston, MA). PATIENTS Children admitted to the PICU who were mechanically ventilated for greater than 24 hours. The preimplementation cohort included 190 eligible patients admitted between July 29, 2017, and February 28, 2018, and the postimplementation cohort included 144 patients admitted between July 29, 2019, and February 28, 2020. INTERVENTIONS Implementation of a revised analgesia-sedation protocol. MEASUREMENTS AND MAIN RESULTS Our primary outcome, total dose of IV midazolam administered in mechanically ventilated patients up to day 14 of ventilation, decreased by 72% (95% CI [61-80%]; p < 0.001) in the postimplementation cohort. Dexmedetomidine usage increased 230% (95% CI [145-344%]) in the postimplementation cohort. Opioid usage, our balancing metric, was not significantly different between the two cohorts. There were no significant differences in ventilator-free days, PICU length of stay, rate of unplanned extubations, failed extubations, cardiorespiratory arrest events, and 24-hour readmissions to the PICU. CONCLUSIONS We successfully implemented an analgesia-sedation protocol that primarily uses dexmedetomidine and intermittent opioids, and it was associated with significant decrease in overall midazolam usage in mechanically ventilated patients in the PICU. The intervention was not associated with changes in opioid usage or prevalence of adverse events.
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Affiliation(s)
- Youyang Yang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Alireza Akhondi-Asl
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Alon Geva
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Danielle Dwyer
- Division of Medical Critical Care, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Carolyn Stickney
- Division of Medical Critical Care, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Monica E Kleinman
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Amy Sanderson
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA
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Hoffmann RM, Ariagno KA, Pham IV, Barnewolt CE, Jarrett DY, Mehta NM, Kantor DB. Ultrasound Assessment of Quadriceps Femoris Muscle Thickness in Critically Ill Children. Pediatr Crit Care Med 2021; 22:889-897. [PMID: 34028373 DOI: 10.1097/pcc.0000000000002747] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evaluate the reliability of ultrasound to measure quadriceps femoris muscle thickness in critically ill children and to describe serial changes in quadriceps femoris muscle thickness in relation to fluid balance and nutritional intake. DESIGN Prospective observational study. SETTING Tertiary care children's hospital. PATIENTS Inpatients age 3 months to 18 years recently admitted to the ICU who were sedated and mechanically ventilated at the time of the first ultrasound scan. METHODS Prospective observational study to examine the reliability of averaged ultrasound measurements of quadriceps femoris muscle thickness. Change in average quadriceps femoris muscle thickness over time was correlated with fluid balance and nutritional intake. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Averaged quadriceps femoris muscle thickness demonstrated good to excellent reliability when comparing pediatric critical care providers to pediatric radiologists and when comparing between different pediatric critical care providers. We found no significant association between fluid balance over 1 or 3 days and change in quadriceps femoris muscle thickness over the same time frame. However, there was a significant association between percent of goal calories (p < 0.001) or percent of goal protein (p < 0.001) over 6 days and change in quadriceps femoris muscle thickness over the same time frame. CONCLUSIONS Averaged ultrasound measurements of quadriceps femoris muscle thickness demonstrate good to excellent reliability, are not confounded by fluid balance, and are useful for tracking changes in muscle thickness that are associated with nutritional intake. Ultrasound-based assessment of quadriceps femoris is a clinically useful tool for evaluating muscle mass and may be a proxy for nutritional status.
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Affiliation(s)
- Robert M Hoffmann
- Department of Medicine, Boston Children's Hospital, Boston, MA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Katelyn A Ariagno
- Department of Medicine, Boston Children's Hospital, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Ivy V Pham
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | | | - Delma Y Jarrett
- Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA
| | - David B Kantor
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA
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Geva A, Albert BD, Hamilton S, Manning MJ, Barrett MK, Mirchandani D, Harty M, Morgan EC, Kleinman ME, Mehta NM. eSIMPLER: A Dynamic, Electronic Health Record-Integrated Checklist for Clinical Decision Support During PICU Daily Rounds. Pediatr Crit Care Med 2021; 22:898-905. [PMID: 33935271 PMCID: PMC8490208 DOI: 10.1097/pcc.0000000000002733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/27/2022]
Abstract
OBJECTIVES Design, implement, and evaluate a rounding checklist with deeply embedded, dynamic electronic health record integration. DESIGN Before-after quality-improvement study. SETTING Quaternary PICU in an academic, free-standing children's hospital. PATIENTS All patients in the PICU during daily morning rounds. INTERVENTIONS Implementation of an updated dynamic checklist (eSIMPLER) providing clinical decision support prompts with display of relevant data automatically pulled from the electronic health record. MEASUREMENTS AND MAIN RESULTS The prior daily rounding checklist, eSIMPLE, was implemented for 49,709 patient-days (7,779 patients) between October 30, 2011, and October 7, 2018. eSIMPLER was implemented for 5,306 patient-days (971 patients) over 6 months. Checklist completion rates were similar (eSIMPLE: 95% [95% CI, 88-98%] vs eSIMPLER: 98% [95% CI, 92-100%] of patient-days; p = 0.40). eSIMPLER required less time per patient (28 ± 1 vs 47 ± 24 s; p < 0.001). Users reported improved satisfaction with eSIMPLER (p = 0.009). Several checklist-driven process measures-discordance between electronic health record orders for stress ulcer prophylaxis and user-recorded indication for stress ulcer prophylaxis, rate of venous thromboembolism prophylaxis prescribing, and recognition of reduced renal function-improved during the eSIMPLER phase. CONCLUSIONS eSIMPLER, a dynamic, electronic health record-informed checklist, required less time to complete and improved certain care processes compared with a prior, static checklist with limited electronic health record data. By focusing on the "Five Rights" of clinical decision support, we created a well-accepted clinical decision support tool that was integrated efficiently into daily rounds. Generalizability of eSIMPLER's effectiveness and its impact on patient outcomes need to be examined.
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Affiliation(s)
- Alon Geva
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Ben D. Albert
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Susan Hamilton
- Department of Cardiovascular and Critical Care Nursing, Medical-Surgical Intensive Care Unit, Boston Children’s Hospital, Boston, MA
| | - Mary-Jeanne Manning
- Department of Cardiovascular and Critical Care Nursing, Medical-Surgical Intensive Care Unit, Boston Children’s Hospital, Boston, MA
| | - Megan K. Barrett
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Dimple Mirchandani
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Matthew Harty
- Anesthesia Information Services, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Erin C. Morgan
- Anesthesia Information Services, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA
| | - Monica E. Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
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Yang Y, Mehta NM. "Closing the chasm" - guidelines bridge the gap from evidence to implementation. Pediatr Investig 2021; 5:163-166. [PMID: 34589672 PMCID: PMC8458711 DOI: 10.1002/ped4.12296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Youyang Yang
- Department of AnesthesiologyCritical Care and Pain MedicineBoston Children’s Hospital, and Harvard Medical SchoolBostonMA
- Perioperative & Critical CareCenter for Outcomes ResearchBoston Children’s HospitalBostonMA
| | - Nilesh M. Mehta
- Department of AnesthesiologyCritical Care and Pain MedicineBoston Children’s Hospital, and Harvard Medical SchoolBostonMA
- Perioperative & Critical CareCenter for Outcomes ResearchBoston Children’s HospitalBostonMA
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27
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Martinez EE, Mehta NM. Nutrition therapy and outcomes in hospitalized children. JPEN J Parenter Enteral Nutr 2021; 45:1392-1394. [PMID: 34406666 DOI: 10.1002/jpen.2253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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Abstract
Optimal nutrition therapy can positively influence clinical outcomes in critically ill children. Accurate assessment of nutritional status, metabolic state, macronutrient requirements and substrate utilization allows accurate prescription of nutrition in this population. In response to stress and injury, the body undergoes adaptive physiologic changes leading to dysregulation of the inflammatory response and hyperactivation of the inflammatory cascade. This results in a global catabolic state with modification in oxygen consumption and macronutrient metabolism. A comprehensive understanding of the metabolic response is essential when prescribing nutritional interventions aimed to offset the burden of this adaptive stress response in the critically ill. In this narrative review we aim to provide a comprehensive review of the physiologic basis, recent literature and some emerging concepts related to energy expenditure and the practical aspects of energy delivery in the critically ill child. Based on the unique metabolic characteristics of the critically ill child, we aim to provide a pragmatic approach to providing nutrition therapy.
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Affiliation(s)
- Ben D Albert
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Cambridge, MA, USA
| | - Giulia C Spolidoro
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA - .,Harvard Medical School, Cambridge, MA, USA.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Center for Nutrition, Boston Children's Hospital, Boston, MA, USA
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Ventura JC, Oliveira LDDA, Silveira TT, Hauschild DB, Mehta NM, Moreno YMF. Admission factors associated with nutritional status deterioration and prolonged pediatric intensive care unit stay in critically ill children: PICU-ScREEN multicenter study. JPEN J Parenter Enteral Nutr 2021; 46:330-338. [PMID: 33818806 DOI: 10.1002/jpen.2116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Early identification of patients in the pediatric intensive care unit (PICU) at risk of nutritional status (NS) deterioration and poor outcomes is desirable. We aimed to identify factors associated with NS deterioration and prolonged PICU stay. METHODS Prospective cohort study in eight Brazilian PICUs with children <18 years with a PICU stay >72h. We used multivariable logistic regression to identify the clinical, laboratory, and nutrition variables at admission that were associated with outcomes. NS deterioration was defined as the reduction in weight-for-age, body mass index-for-age or mid-upper arm circumference-for-age z-score ≥1 during PICU stay. Prolonged PICU stay was defined as ≥13 days. RESULTS We enrolled 363 eligible patients, median age 11.3 months (interquartile range:3.1-45.6) and 46% had at least one complex chronic condition (CCC). NS deterioration was observed in 23% of participants and was associated with CCC (odds ratio [OR]:2.71; 95% confidence interval [CI]:1.44-5.09), after adjusting for severity risk score, leukocyte count, obesity, and PICU site. Prolonged PICU stay was associated with age <2 years (OR:1.95; 95%CI:1.03-3.66), fluid overload (>10%) over the first 72h (OR:2.66; 95%CI:1.50-4.73), and hypoalbuminemia (<3.0 g/dL) (OR:2.05; 95%CI:1.12-3.76), after adjusting for CCC, severity risk score, undernutrition, early nutrition therapy, and PICU site. CONCLUSIONS CCC at admission was associated with NS deterioration. Age <2 years, fluid overload, and hypoalbuminemia at PICU admission were associated with prolonged PICU stay. These factors must be further evaluated as part of an admission nutrition screening tool for critically ill children.
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Affiliation(s)
| | | | - Taís Thomsen Silveira
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | | | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Yara Maria Franco Moreno
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil.,Department of Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
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30
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Ariagno K, Bechard L, Quinn N, Rudie C, Finnan E, Arena A, Sun T, Hale J, Duggan CP, Mehta NM. Timing of parenteral nutrition is associated with adequacy of nutrient delivery and anthropometry in critically ill children: A single-center study. JPEN J Parenter Enteral Nutr 2021; 46:190-196. [PMID: 33605456 DOI: 10.1002/jpen.2079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 01/25/2021] [Accepted: 01/29/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The optimal timing of supplemental parenteral nutrition (PN) use in the pediatric intensive care unit (ICU) is unclear. We aimed to describe patterns of PN use in the ICU and the association between the timing of PN initiation and macronutrient delivery and anthropometry. METHODS We enrolled patients (aged <18 years) with an ICU stay >3 days were started on PN in the ICU. Initiation within 48 hours of admission was deemed as early, and duration <5 days was deemed as short. We used multivariable analysis to examine the association between PN timing and macronutrient delivery adequacy (percentage of the prescribed target that was actually delivered) and weight-for-age z-score (WAZ) over hospital stay. RESULTS Ninety-five patients were included. Median (interquartile range [IQR]) time to initiate PN was 4 (1, 6) days, and in 33%, PN was initiated early. Median (IQR) PN duration was 8 (5, 14) days, and in 16.8%, duration was short. Median (IQR) adequacies for total energy and protein delivery were 55% (40, 74) and 72% (44, 81) in the early PN group compared with 29% (3, 50) and 31% (4, 47), respectively, in the late PN group (P < .001). The late PN group had a 0.50-unit greater decline in mean WAZ compared with the early PN group (95% CI, 0.11-0.89; P = .012). CONCLUSION Late PN initiation was associated with significantly lower adequacy of macronutrient delivery and greater decline in WAZ in critically ill children. The relationship between PN timing patient outcomes must be further examined.
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Affiliation(s)
- Katelyn Ariagno
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lori Bechard
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nicolle Quinn
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Coral Rudie
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Emily Finnan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anastasia Arena
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tina Sun
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jaqueline Hale
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christopher P Duggan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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31
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Mehta NM. Pediatric Sarcopenia: Hidden in Plain Sight? J Pediatr Gastroenterol Nutr 2021; 72:181-183. [PMID: 33003170 DOI: 10.1097/mpg.0000000000002959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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32
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46:10-67. [PMID: 32030529 PMCID: PMC7095013 DOI: 10.1007/s00134-019-05878-6] [Citation(s) in RCA: 266] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objectives To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. Design A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. Methods The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, “in our practice” statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. Results The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, “in our practice” statements were provided. In addition, 52 research priorities were identified. Conclusions A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, UK
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, UK
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | | | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, Singapore.,Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Nunnally
- New York University Langone Medical Center, New York, NY, USA
| | | | - Raina M Paul
- Advocate Children's Hospital, Park Ridge, IL, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,College of Nursing, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-Sur-Yvette, France
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Abstract
The goal of nutrition support is to provide the substrates required to match the bioenergetic needs of the patient and promote the net synthesis of macromolecules required for the preservation of lean mass, organ function, and immunity. Contemporary observational studies have exposed the pervasive undernutrition of critically ill patients and its association with adverse clinical outcomes. The intuitive hypothesis is that optimization of nutrition delivery should improve ICU clinical outcomes. It is therefore surprising that multiple large randomized controlled trials have failed to demonstrate the clinical benefit of restoring or maximizing nutrient intake. This may be in part due to the absence of biological markers that identify patients who are most likely to benefit from nutrition interventions and that monitor the effects of nutrition support. Here, we discuss the need for practical risk stratification tools in critical care nutrition, a proposed rationale for targeted biomarker development, and potential approaches that can be adopted for biomarker identification and validation in the field.
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Affiliation(s)
- Christian Stoppe
- 3CARE—Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Sebastian Wendt
- 3CARE—Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
| | - Nilesh M. Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Charlene Compher
- Department of Biobehavioral Health Science, University of Pennsylvania and Clinical Nutrition Support Service, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Jean-Charles Preiser
- Erasme University Hospital, Université Libre de Bruxelles, 808 route de Lennik, B-1070 Brussels, Belgium
| | - Daren K. Heyland
- Department of Critical Care Medicine, Queen’s University, Angada 4, Kingston, ON K7L 2V7 Canada
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, Kingston, ON K7L 2V7 Canada
| | - Arnold S. Kristof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, Faculty of Medicine, Departments of Medicine and Critical Care, Research Institute of the McGill University Health Centre, 1001 Décarie Blvd., EM3.2219, Montreal, QC H4A 3J1 Canada
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Mills KI, Albert BD, Bechard LJ, Duggan CP, Kaza A, Rakoff-Nahoum S, Vlamakis H, Sleeper LA, Newburger JW, Priebe GP, Mehta NM. Stress ulcer prophylaxis versus placebo-a blinded randomized control trial to evaluate the safety of two strategies in critically ill infants with congenital heart disease (SUPPRESS-CHD). Trials 2020; 21:590. [PMID: 32600393 PMCID: PMC7322718 DOI: 10.1186/s13063-020-04513-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/15/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Critically ill infants with congenital heart disease (CHD) are often prescribed stress ulcer prophylaxis (SUP) to prevent upper gastrointestinal bleeding, despite the low incidence of stress ulcers and limited data on the safety and efficacy of SUP in infants. Recently, SUP has been associated with an increased incidence of hospital-acquired infections, community-acquired pneumonia, and necrotizing enterocolitis. The objective of this pilot study is to investigate the feasibility of performing a randomized controlled trial to assess the safety and efficacy of withholding SUP in infants with congenital heart disease admitted to the cardiac intensive care unit. METHODS A single center, prospective, double-blinded, randomized placebo-controlled pilot feasibility trial will be performed in infants with CHD admitted to the cardiac intensive care unit and anticipated to require respiratory support for > 24 h. Patients will be randomized to receive a histamine-2 receptor antagonist (H2RA) or placebo until they are discontinued from respiratory support. Randomization will be performed within 2 strata defined by admission type (medical or surgical) and age (neonate, age < 30 days, or infant, 1 month to 1 year). Allocation will be a 1:1 ratio using permuted blocks to ensure balanced allocations across the two treatment groups within each stratum. The primary outcomes include feasibility of screening, consent, timely allocation of study drug, and protocol adherence. The primary safety outcome is the rate of clinically significant upper gastrointestinal bleeding. The secondary outcomes are the difference in the relative and absolute abundance of the gut microbiota and functional microbial profiles between the two study groups. We plan to enroll 100 patients in this pilot study. DISCUSSION Routine use of SUP to prevent upper gastrointestinal bleeding in infants is controversial due to a low incidence of bleeding events and concern for adverse effects. The role of SUP in infants with CHD has not been examined, and there is equipoise on the risks and benefits of withholding this therapy. In addition, this therapy has been discontinued in other neonatal populations due to the concern for hospital-acquired infections and necrotizing enterocolitis. Furthermore, exploring changes to the microbiome after exposure to SUP may highlight the mechanisms by which SUP impacts potential microbial dysbiosis of the gut and its association with hospital-acquired infections. Assessment of the feasibility of a trial of withholding SUP in critically ill infants with CHD will facilitate planning of a larger multicenter trial of safety and efficacy of SUP in this vulnerable population. TRIAL REGISTRATION ClinicalTrials.gov , NCT03667703. Registered 12 September 2018, https://clinicaltrials.gov/ct2/show/NCT03667703?term=SUPPRESS+CHD&draw=2&rank=1 . All WHO Trial Registration Data Set Criteria are met in this manuscript.
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Affiliation(s)
- Kimberly I. Mills
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Ben D. Albert
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Lori J. Bechard
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Christopher P. Duggan
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Center for Nutrition, Boston Children’s Hospital, Boston, MA USA
| | - Aditya Kaza
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA USA
| | - Seth Rakoff-Nahoum
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Hera Vlamakis
- grid.66859.34Broad Institute of MIT and Harvard, Boston, MA USA
| | - Lynn A. Sleeper
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Jane W. Newburger
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Gregory P. Priebe
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Nilesh M. Mehta
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA ,grid.2515.30000 0004 0378 8438Center for Nutrition, Boston Children’s Hospital, Boston, MA USA
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Martinez EE, Zurakowski D, Pereira L, Freire R, Emans JB, Nurko S, Duggan CP, Fasano A, Mehta NM. Interleukin-10 and Zonulin Are Associated With Postoperative Delayed Gastric Emptying in Critically Ill Surgical Pediatric Patients: A Prospective Pilot Study. JPEN J Parenter Enteral Nutr 2020; 44:1407-1416. [PMID: 32386238 PMCID: PMC7754495 DOI: 10.1002/jpen.1874] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 11/20/2022]
Abstract
Background Impaired gastric emptying (GE) is associated with morbidity in surgical critically ill children. The relationship between inflammation, gut barrier integrity (lipopolysaccharide binding protein [LBP]; zonulin), and GE has not been described in this cohort. Methods Children ≥2 years of age and requiring critical care after surgery were enrolled. Preoperative and postoperative levels of serum cytokines, LBP, and zonulin, and GE by the acetaminophen absorption test, were measured, allowing patients to serve as their own controls. Postoperative delayed GE was defined as a decrease in GE by ≥20% compared with preoperative GE. The following were examined : comparison between postoperative andpreoperative values, correlations between fold change (postoperative/preoperative) in study variables, and fold change in study variables between patients with and without postoperative delayed GE. Results Twenty patients, median age 14 years (12.25, 18), 12 female, were included. Eight of 20 patients had postoperative delayed GE. Postoperative interleukin‐6 (IL‐6), IL‐8, IL‐10, and LBP were increased, and zonulin was decreased (P‐values < .05). Fold change in IL‐10 and zonulin were inversely correlated (ρ −0.618, P = .004). Patients with postoperative delayed GE had greater fold increase in IL‐10 (P = .0159) and fold decrease in zonulin (P = .0160). Five of 7 (71%) patients with both fold increase in IL‐10 and decrease in zonulin had delayed GE. Conclusion Postoperative changes in IL‐10 and zonulin were associated with delayed GE in surgical critically ill children, which might suggest a mechanism to for delayed GE in postoperative inflammation and gut barrier dysregulation after surgery.
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Affiliation(s)
- Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Luis Pereira
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel Freire
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts, USA
| | - John B Emans
- Harvard Medical School, Boston, Massachusetts, USA.,Orthopedic Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samuel Nurko
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christopher P Duggan
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alessio Fasano
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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36
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Mehta NM. Forty-Third ASPEN Presidential Address: "Our Time Is Now-Challenges and Strategies for the Field of Nutrition". JPEN J Parenter Enteral Nutr 2020; 44:567-580. [PMID: 32185809 DOI: 10.1002/jpen.1810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/22/2020] [Indexed: 12/12/2022]
Abstract
I am grateful for this opportunity to address the ASPEN community and the international colleagues gathered at the ASPEN 2019 Nutrition Science and Practice Meeting. I have used this platform to revisit some of the historical beginnings of our field and our organization, and illustrate some of the lessons learned. I have outlined 5 challenges facing the field of nutrition during our times and discussed strategies that might help navigate them. These challenges are, healthcare finance, biotechnology disruption, safety, research, and knowledge transfer. These challenges will require nutrition providers to adapt to changing times. We must be prepared to show the "value" of the care provided. The impact of nutrition therapies must be unequivocally demonstrated on meaningful patient outcomes, thereby emphasizing the relevance and value of the services we provide. As clinical nutrition professionals, we must embrace the rapid pace of biotechnology advance and harness its power to assist us and our patients. The provision of safe nutrition care to our patients is the fundamental aspect of the ASPEN vision. I remain confident in our collective strengths, our sense of purpose, and our ability to rise above the challenges we face. Together with our global partners we will deliver on the promise of safe, efficacious, low-cost, and high-quality nutrition that will improve patient outcomes and population health.
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Affiliation(s)
- Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
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Mehta NM. Long-term outcomes related to timing of parenteral nutrition in critically ill children. Lancet Respir Med 2020; 8:224-226. [PMID: 32085845 DOI: 10.1016/s2213-2600(20)30061-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Nilesh M Mehta
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care, and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA 02115, USA.
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020; 21:e52-e106. [PMID: 32032273 DOI: 10.1097/pcc.0000000000002198] [Citation(s) in RCA: 458] [Impact Index Per Article: 114.5] [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] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | - Akash Deep
- King's College Hospital, London, United Kingdom
| | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, and Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | - Adrienne G Randolph
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Lyvonne N Tume
- University of the West of England, Bristol, United Kingdom
| | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,College of Nursing, University of Iowa, Iowa City, IA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-sur-Yvette, France
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Turner AD, Hamilton SM, Callif C, Ariagno KA, Arena AE, Mehta NM, Martinez EE. Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit. Nutr Clin Pract 2020; 35:299-305. [PMID: 31990093 DOI: 10.1002/ncp.10452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 01/15/2023] Open
Abstract
BACKGROUND Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program. METHODS In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined. RESULTS The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction. CONCLUSION Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.
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Affiliation(s)
| | - Susan M Hamilton
- Department of Cardiovascular/Critical Care Nursing, Boston, Massachusetts, USA
| | - Charles Callif
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA
| | - Katelyn A Ariagno
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anastasia E Arena
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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40
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Bechard LJ, Mehta NM. From body habitus to body composition-Predicting outcomes in the PICU. J Pediatr 2019; 213:248. [PMID: 31331654 DOI: 10.1016/j.jpeds.2019.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 06/18/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Lori J Bechard
- Pediatric Critical Care Nutrition, Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nilesh M Mehta
- Pediatric Critical Care Nutrition, Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Ventura JC, Hauschild DB, Barbosa E, Bresolin NL, Kawai K, Mehta NM, Moreno YMF. Undernutrition at PICU Admission Is Predictor of 60-Day Mortality and PICU Length of Stay in Critically Ill Children. J Acad Nutr Diet 2019; 120:219-229. [PMID: 31522971 DOI: 10.1016/j.jand.2019.06.250] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 06/23/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND There are few studies that assess the role of different nutritional assessment variables at pediatric intensive care unit (PICU) admission in predicting clinical outcomes. OBJECTIVE To identify nutritional variables in the first 4 days of PICU stay that predict 60-day mortality and time to discharge alive from the PICU. DESIGN Single-center prospective study in Southern Brazil, conducted between July 2013 and February 2016. At PICU admission, children with z scores <-2 for body mass index (BMI)-for-age, mid-upper arm circumference (MUAC)-for-age, and triceps skinfold thickness (TSF)-for-age were considered as undernourished. PARTICIPANTS/SETTING There were 199 patients, aged <15 years, with PICU stay >48 hours. MAIN OUTCOME MEASURES Sixty-day mortality and time to discharge alive from the PICU. STATISTICAL ANALYSIS PERFORMED Cox regression model was applied to determine predictors of 60-day mortality and time to discharge alive from the PICU. RESULTS Median age was 23.1 months (interquartile range=3.9 to 89.1), and 63% were male, with 18% prevalence of undernutrition at admission by BMI-for-age. Median PICU stay was 7 days (interquartile range=4 to 12), and 60-day mortality was 12%. After adjusting for sex, age, Pediatric Index of Mortality 2, and presence of complex chronic conditions, undernutrition based on BMI-for-age (hazard ratio [HR]=3.75; 95% CI=1.41 to 9.95; P=0.008), MUAC-for-age (HR=7.62; 95% CI=2.42 to 23.97; P=0.001), and TSF-for-age (HR=4.01; 95% CI=1.14 to 14.15; P=0.031) was associated with higher risk of 60-day mortality. Based on MUAC-for-age with the same adjustment model, undernourished children had longer time to discharge alive from the PICU (HR=0.45; 95% CI=0.21 to 0.98; P=0.045). CONCLUSIONS Undernutrition at PICU admission based on different anthropometric variables was predictive of 60-day mortality and longer time to discharge alive from the PICU.
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Martinez EE, Panciotti C, Pereira LM, Kellogg MD, Stylopoulos N, Mehta NM. Gastrointestinal Hormone Profiles Associated With Enteral Nutrition Tolerance and Gastric Emptying in Pediatric Critical Illness: A Pilot Study. JPEN J Parenter Enteral Nutr 2019; 44:472-480. [PMID: 31304610 DOI: 10.1002/jpen.1678] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 06/19/2019] [Accepted: 06/28/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Enteral nutrition (EN) intolerance and delayed gastric emptying are prevalent in pediatric critical illness and limit EN delivery. Gastrointestinal (GI) hormones may be associated with EN intolerance and delayed gastric emptying in this cohort. METHODS We determined GI hormone levels, time to achieve 50% of EN goal, and gastric emptying in critically ill children. Total amylin, active ghrelin, total glucagon-like peptide-1 (GLP-1), total gastric inhibitory polypeptide, glucagon, and total peptide-YY (PYY) were measured by multiplex assay and cholecystokinin by ELISA. Lower concentrations of acetaminophen at 1 hour (C1h, µg/mL) using the acetaminophen absorption test defined delayed gastric emptying. Correlation, regression analyses, and a principal component analysis were used to examine the association between GI hormones and time to 50% EN goal and C1h. RESULTS GI hormones were measured in 14 of 21 patients with gastric emptying testing; median age of 11.2 years (6.74-16.3) and 50% male. Increasing hormone levels from GI hormone profile 1 (GLP-1, glucagon, and amylin) correlated with greater time to reach 50% EN goal (R2 = 0.296, P = 0.04). Decreasing hormone levels from GI hormone profile 2 (PYY and ghrelin) correlated with lower C1h and slower gastric emptying (R2 = 0.342, P = 0.02). CONCLUSION GI hormone profiles are associated with time to achieve 50% of EN goal and gastric emptying in critically ill children. We have described a feasible model to study the role of GI hormones in this cohort, including the potential clinical applicability of GI hormone measurement in the management of delayed gastric emptying.
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Affiliation(s)
- Enid E Martinez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Courtney Panciotti
- Department of Medicine, Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Luis M Pereira
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Mark D Kellogg
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Stylopoulos
- Department of Medicine, Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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43
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Tume LN, Valla FV, Floh AA, Goday P, Jotterand Chaparro C, Larsen B, Lee JH, Moreno YMF, Pathan N, Verbruggen S, Mehta NM. Priorities for Nutrition Research in Pediatric Critical Care. JPEN J Parenter Enteral Nutr 2018; 43:853-862. [DOI: 10.1002/jpen.1498] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 12/03/2018] [Indexed: 01/14/2023]
Affiliation(s)
- Lyvonne N. Tume
- Faculty of Health & Applied SciencesUniversity of the West of England Bristol UK
| | - Frédéric V. Valla
- Pediatric Intensive Care UnitHôpital Femme Mère EnfantHospices Civils de Lyon Lyon‐Bron France
| | - Alejandro A. Floh
- Department of PediatricsUniversity of Toronto Toronto Canada
- Cardiac Critical Care UnitDepartment of Critical CareThe Hospital for Sick Children Toronto Canada
| | - Praveen Goday
- Pediatric GastroenterologyNutrition Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Corinne Jotterand Chaparro
- Department of Nutrition and DieteticsUniversity of Applied Sciences Western Switzerland (HES‐SO) Geneva Switzerland
- Pediatric Intensive Care UnitMedico‐Surgical Department of PediatricsUniversity Hospital of Lausanne Lausanne Switzerland
| | - Bodil Larsen
- Department of ALES (Human Nutrition)University of Alberta Edmonton Canada
| | - Jan Hau Lee
- Children's Intensive Care UnitKK Women's and Children's Hospital Singapore Singapore
- Duke‐NUS Medical School Singapore Singapore
| | - Yara M. F. Moreno
- Department of Nutrition and Postgraduate Program in NutritionSanta Catarina Federal UniversityHealth Sciences Centre Florianópolis Santa Catarina Brazil
| | - Nazima Pathan
- Addenbrooke's HospitalUniversity of Cambridge Cambridge England
| | - Sascha Verbruggen
- Pediatric Intensive Care UnitErasmus MC ‐ Sophia Children's Hospital Rotterdam the Netherlands
| | - Nilesh M. Mehta
- Department of AnesthesiologyCritical Care and Pain MedicineBoston Children's HospitalHarvard Medical School Boston Massachusetts USA
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Abstract
Providing adequate nutrition to critically ill pediatric patients is essential and positively impacts outcomes. Critically ill infants and children receiving extracorporeal membrane oxygenation (ECMO) therapy are nutritionally vulnerable, yet there are challenges to reliable assessment of nutrition requirements and to the delivery of optimal nutrition in this cohort. In this review of the relevant literature, we present the current evidence and guidelines for the optimal prescription and delivery of nutrition for pediatric patients receiving ECMO. We also discuss nutrient delivery considerations in ECMO survivors and identify areas where further study is needed.
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Affiliation(s)
- Bethany J Farr
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel E Rice-Townsend
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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45
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Mehta NM, Bechard LJ. The authors reply. Crit Care Med 2018; 44:e1007-8. [PMID: 27635503 DOI: 10.1097/ccm.0000000000001986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Nilesh M Mehta
- Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA;Center for Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, Department of Nutritional Sciences, Rutgers University School of Health Related Professions, Newark, NJ
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Hauschild DB, Oliveira LDA, Farias MS, Barbosa E, Bresolin NL, Mehta NM, Moreno YMF. Enteral Protein Supplementation in Critically Ill Children: A Randomized Controlled Pilot and Feasibility Study. JPEN J Parenter Enteral Nutr 2018; 43:281-289. [PMID: 29959852 DOI: 10.1002/jpen.1416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/04/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Loss of muscle mass in critically ill children can negatively impact outcomes. The aims of this study were to conduct a pilot randomized control trial (RCT) to examine the difference in protein delivery and nitrogen balance in critically ill children with enteral protein supplementation vs controls. We also aimed to assess the feasibility, safety, and tolerance of the pilot trial. METHODS This is a 3-arm RCT in critically ill children eligible for enteral nutrition (EN) therapy. Patients were randomized to 1 of the 3 groups: (1) control (routine EN), (2) polymeric protein module added to EN to reach protein goal by day 4, or (3) oligomeric protein supplementation. Demographics, clinical characteristics, nutrition status, and daily nutrition intake variables were recorded. Protein delivery, nitrogen balance, feasibility variables, and rate of adverse events were the outcomes. RESULTS After screening 286 consecutive patients admitted to the pediatric intensive care unit over 11 months, we enrolled and randomized 25 patients. Twenty-two patients (88% of the enrolled) completed the study procedures. Significantly higher protein prescription and actual protein intake within the first 5 days was achieved in the intervention groups, compared with the control group. Nitrogen balance was obtained in 15 patients. There was no significant difference between the groups for the rate of adverse effects and clinical outcomes. CONCLUSION In our pilot trial, protein supplementation was safe and well tolerated. Our preliminary results suggest that a larger RCT is potentially feasible, with some modifications of the entry criteria. Trial enrollment was low, likely due to restrictive entry criteria.
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Affiliation(s)
- Daniela B Hauschild
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Luna D A Oliveira
- Postgraduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Mirelle S Farias
- Nutrition, Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | - Eliana Barbosa
- Nutrition, Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | - Nilzete L Bresolin
- Pediatric Intensive Care Unit, Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Yara M F Moreno
- Department of Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
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Mehta NM, Tasker RC. Nutrition for term neonates in the paediatric intensive care unit. Lancet Child Adolesc Health 2018; 2:469-471. [PMID: 30169311 DOI: 10.1016/s2352-4642(18)30147-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA; Center for Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA.
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA; Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Armstrong LB, Ariagno K, Smallwood CD, Hong C, Arbuthnot M, Mehta NM. Nutrition Delivery During Pediatric Extracorporeal Membrane Oxygenation Therapy. JPEN J Parenter Enteral Nutr 2018; 42:1133-1138. [DOI: 10.1002/jpen.1154] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/16/2018] [Indexed: 01/07/2023]
Affiliation(s)
| | | | - Craig D. Smallwood
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine; at Boston Children's Hospital; Boston Massachusetts USA
| | | | | | - Nilesh M. Mehta
- Center for Nutrition
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine; at Boston Children's Hospital; Boston Massachusetts USA
- Harvard Medical School; Boston Massachusetts USA
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Martinez EE, Quinn N, Arouchon K, Anzaldi R, Tarrant S, Ma NS, Griffin J, Darras BT, Graham RJ, Mehta NM. Comprehensive nutritional and metabolic assessment in patients with spinal muscular atrophy: Opportunity for an individualized approach. Neuromuscul Disord 2018; 28:512-519. [PMID: 29699728 DOI: 10.1016/j.nmd.2018.03.009] [Citation(s) in RCA: 15] [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] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 02/05/2018] [Accepted: 03/14/2018] [Indexed: 11/26/2022]
Abstract
Optimal nutrition support is recommended for patients with spinal muscular atrophy (SMA). In a prospective study, we performed comprehensive nutritional assessments with the aim to guide best nutritional strategies for patients with SMA types II and III. We recorded a) anthropometry; b) macro- and micronutrient intakes; c) measured resting energy expenditure by indirect calorimetry; and d) body composition including dual X-ray absorptiometry. We enrolled a cohort of 21 patients aged 3 to 36 years of which 13 were female; 19 had SMA type II and 2 had SMA type III. The body mass index z-score ranged from -3 to 2.4. Forty-five percent of the cohort was either underfed or overfed, based on the difference between actual energy intake and measured resting energy expenditure. Vitamin D, E, K, folate and calcium intakes were low in a majority of the cohort. Forty-five percent of the cohort was either hypometabolic or hypermetabolic. Fat mass index (kg/m2) was significantly higher and lean body mass index (kg/m2) was significantly lower in the study cohort compared to population normalized values. Bone mineral density was low in 13 of 17 patients. In summary, we have described the prevalence of malnutrition, suboptimal feeding and alterations in body composition in children with SMA. A comprehensive nutritional assessment could guide individualized nutrition therapy in this vulnerable population.
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Affiliation(s)
- Enid E Martinez
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Nicolle Quinn
- Clinical Translational Study Unit, Boston Children's Hospital, Boston, MA, USA
| | - Kayla Arouchon
- Clinical Translational Study Unit, Boston Children's Hospital, Boston, MA, USA
| | - Rocco Anzaldi
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, USA
| | - Stacey Tarrant
- Center for Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Nina S Ma
- Harvard Medical School, Boston, MA, USA; Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - John Griffin
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Basil T Darras
- Harvard Medical School, Boston, MA, USA; Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Robert J Graham
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Center for Nutrition, Boston Children's Hospital, Boston, MA, USA.
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Fullerton BS, Sparks EA, Khan FA, Fisher JG, Anzaldi R, Scoville MR, Yu YM, Wagner DA, Jaksic T, Mehta NM. Whole Body Protein Turnover and Net Protein Balance After Pediatric Thoracic Surgery: A Noninvasive Single-Dose 15 N Glycine Stable Isotope Protocol With End-Product Enrichment. JPEN J Parenter Enteral Nutr 2018; 42:361-370. [PMID: 29443397 DOI: 10.1177/0148607116678831] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 07/19/2016] [Accepted: 10/20/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND We used the 15 N glycine urinary end-product enrichment technique to quantify whole body protein turnover following thoracic surgery. MATERIALS AND METHODS A single dose of 15 N glycine (2 mg/kg) was administered orally on postoperative day 1 to children (1-18 years) following thoracic surgery. 15 N enrichment of ammonia and urea was measured in mixed urine after 12 and 24 hours, respectively, and protein synthesis, breakdown, and net balance determined. Nitrogen balance (dietary intake minus urinary excretion) was calculated. Urinary 3-methylhistidine:creatinine ratio was measured as a marker of skeletal muscle protein breakdown. RESULTS We enrolled 19 subjects-median (interquartile range): age, 13.8 years (12.2-15.1); weight, 49.2 kg (38.4-60.8)-who underwent thoracotomy (n = 12) or thoracoscopic (n = 7) surgery. Protein synthesis and breakdown by 15 N enrichment were 7.1 (5.5-9) and 7.1 (5.6-9) g·kg-1 ·d-1 with ammonia (12 hours) as the end product, and 5.8 (3.8-6.7) and 6.7 (4.5-7.6) with urea (24 hours), respectively. Net protein balance by the 15 N glycine and urinary urea nitrogen methods were -0.34 (-0.47, -0.3) and -0.48 (-0.65, -0.28) g·kg-1 ·d-1 , respectively (rs = 0.828, P < .001). Postoperative change in 3-methylhistidine:creatinine ratio did not correlate significantly with protein breakdown or balance. CONCLUSION The single-dose oral administration of 15 N glycine stable isotope with measurement of urinary end-product enrichment is a feasible and noninvasive method to investigate whole body protein turnover in children. After major surgery, children manifest increased protein turnover and net negative balance due to increased protein breakdown.
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Affiliation(s)
- Brenna S Fullerton
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eric A Sparks
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Faraz A Khan
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy G Fisher
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rocco Anzaldi
- Department of Pharmacy, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael R Scoville
- Department of Pharmacy, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Yong-Ming Yu
- Department of Surgery, Shriner Burns Hospital, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Tom Jaksic
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nilesh M Mehta
- Division of Critical Care, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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