PEDIATRIC

NUTRITION IN ICU
Saptadi Yuliarto

Pediatric Intensive Care Unit

Department of Pediatric
Saiful Anwar Hospital - Medical Faculty University of Brawijaya
Malang
th (%) 4.30 prescription was causedfor
)
Clinical Nutrition (2008) 27, 65–71 prescribed
by delayed
180
start of en nutri-delivered
Prescription nutrition1
tion (Figure 2), limited use of PN (Figure 2), and too Delivery
38.8
little amounts of protein means7SD.
(Figure 3D).
160 Goal 1
20

In fact...
140 1
3.5 Only approximately 40% and 70% of
120
our patients *
*
1
3.5 received nutritionhttp:/
on/intl.elsevierhealth.com/journals/clnu
day 1 and 2, respectively.100
This
* 1

%
23
10.6 was also found in a study by Hulst and 80 coworkers
*
ORIGINAL
23.5
ARTICLE
who showed that inadequate Table feeding 60
2 during
* Percentages
the of patien
7.1
Nutritional first few daysand
goals, prescription of admission
delivery quate,in a 40 under-,
accounted for almost and over-nutritio
50% of cumulative
$ caloric and protein deficits.
However, there is increasingmacronutrients.
pediatric
dian (inter intensive
quartile range), unless care unit evidence
20
0 that early
a,! (o12–24 h after
a admission)
Marjorie de Neef , Vincent G.M. Geukers , Aafke Dral , b EN in acutely
1 2 3
ill
4 5 6 7 8 9 10

o90%
Day of admission
c
Robert Lindeboom , Hans P. Sauerwein , Albert P. Bos d a
Percentage of target Fat 9
combi Figure 3 Prescribed and delivered percentages of targets for
a
Pediatric Intensive Care Unit, G8-131, Emma Children’s Hospital/Academic Medical Center,
for prescribed en delivered nutrition is significant at pp0.05l
b
PN %
P.O. Box 22700, 1100DE Amsterdam, The Netherlands
Department of Clinical Nutrition, Academic Medical
Energy
means7SD.
Center, Amsterdam, The Netherlands
49.9 2
EN %
Fat 66.0 1
c
Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam,
The Netherlands
d 100
Department of Endocrinology and Metabolism, Academic Medical Center, Amsterdam, The 2 Percentages of patient days with ade-
Netherlands
Table b
Protein 84.5
quate, under-, and over-nutrition of calories and n1
80 22 August 2007; accepted 26 October 2007
Received f
Carbohydrates
macronutrients.
56.1 1
60 Percentage of target o90% 90–110% 4110% i
%

KEYWORDS Summary w
40 Energy
Background & aims: The aim of this study was to compare prescription and delivery
49.9 23.6 26.5
Child;
Fat associated
of nutrition to predefined nutritional targets, and identify risk factors 66.0 14.6 19.4 e
Nutritional support;
20
Malnutrition; with inadequate nutritional intake. Protein 84.5 10.7 4.8 t
Methods: In 84 mechanically ventilated critically ill children with length of stay on
Pediatric intensive
the PICU of at least 3 days, we observed prescribed and delivered Carbohydrates
percentages of 56.1 18.7 25.1 v
care units;
0 p
Observational
studies 1 2 3 4 period.
study 5 Factors
6 associated
7 with8 inadequate patients can effectively increase
predefined targets for intake of calories and macronutrients during a 10-months
9 intake10 were identified.
Results: On the third day of admission 92.9% of the patients received nutritional
n
DayThe ofcaloric
admission f
therapy.
intake, and reduce infectious
goal was reached on day 5, mainly supplied by fat and carbo-
hydrates. Mean actual daily protein delivery was about 75% of the target during the
patients canentire
effectively increase cumulative energy h
Figure 2 Percentagesstudy ofperiod.
patients receivingornutrition.
Use of catecholamines neuromuscular blocking agents was a risk factor
25,26
LOS. de Neef,
In the
Clinicalfirst
intake,
for caloric undernutrition, whereas there were no specific risk factors
Conclusions: Nutritional therapy should be started in the early LOS.
days
2008afte
and reduce infectious complications and
for overnutrition.
Nutrition
25,26
In the first days after admission, early
phase of critical
n
illness, including adequate supply of protein. In order to prevent deficits to

needs cannot be met by enteral nutrition.

administration of additional PNt
accumulate, parenteral nutrition should be added in an earlyadministration
phase, if nutritional of additional PN can increase total
15
Nutritional practice in pediatric intensive care 69

Prescription Prescribed
Delivery Delivered
180 180
Goal Goal
160 160 *
140 140 *
* *
120 120 *
*
100
* 100
%

%
*
80 80
60 60
40 40
20 20
0 0
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Day of admission Day of admission
Energy Carbohydrate

Prescription Prescription
180 Delivery 180 Delivery
160 Goal 160 Goal
140 140
*
120 * 120
*
100 * 100 *
%

* *
80 80
*
60 * 60
*
40 40
20 20
0 0
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10
Day of admission Day of admission
Fat Protein

de Neef, Clinical Nutrition 2008

Figure 3 Prescribed and delivered percentages of targets for calories and macronutrients. *Wilcoxon signed-rank test
for prescribed en delivered nutrition is significant at pp0.05 level. Targets are represented as dotted lines. Values are
proteins were not correlated to either of the above week, and th
variables. stay were th

5000
3000 Target Delivery *p < 0.001 0

Energy – daily mean (kcal)

–5000

tot energy balance

2000
–10000
* –15000
1000 *
–20000
0 –25000
–30000
–1000 Balance
–35000
n = 48 16 11 7
–2000 –40000
1 2 3 4 –1
Weeks after admission

Figure 1 Progression of energy delivery compared to Figure 2 Rel

energy target over 4 weeks: the figure shows that energy energy balanc
delivery increases with time, reducing daily deficit. tions.

Table 3 Plasma proteins.

Villet, Clinical Nutrition 2005
 Why is it happen?
• Lack of data about caloric goal/target in critical
ill
• Influence of therapeutic intervention (MV,
sedation, NMB)
• Fluid restriction
• Difficulty of nutrition routes
• High residual volume
• Waiting for bowel sound
 ARTICLE IN PRESS
with FClinical
¼ 4:14, and P ¼
Nutrition (2005) 24, 502–509 hypocaloric feeding was associated with increasing
pectively). Table 4 shows blood stream infections. Another study including

What’s the impact?

the total energy deficit 200 medical ICU patients, observed a reduction
complications during the in length of mechanical ventilation associated
were also strong with the http://intl.elsevierhealth.com/journals/clnu22
with improved nutritional support. The negative
ilation,ORIGINAL
the total ARTICLE number energy balance was strongly correlated with
ctious complications, the complications,feeding and particularly with the infectious
Negative impact of hypocaloric and energy
ength of ICU stay. Energy complications. The multiple regression analysis
balance
d with mortality. Plasma
on clinical outcome in ICU patients
showed that energy balance at the end of the first
ed to either
Stéphane of Villet
the aabove week,
, René L. Chiolero b
, and
Marcthe cumulated
D. Bollmann b
, energy balance of the ICU
b b
Jean-Pierre Revelly , Marie-Christine Cayeux RN ,
Jacques Delaruec, Mette M. Bergerb,!
stay were the strongest predictors of prolonged ICU

a
Anesthésiologie, Centre Hospitalier Universitaire5000
Vaudois (CHUV), 1011 Lausanne, Switzerland
b
Soins Intensifs Chirurgicaux et Centre des Brûlés CHUV-BH 08.660, CH 1011 Lausanne, Switzerland
c
EA-948 Oxylipides, Laboratoire Régional de Nutrition Humaine,
elivery *p < 0.001 0 CHU de Brest, 29200 Brest, France

Received 29 January 2005; accepted 30 March 2005 –5000

tot energy balance

–10000
* KEYWORDS Summary
–15000
Nutritional support; Background and aims: Critically ill patients with complicated evolution are
Enteral nutrition; frequently hypermetabolic, catabolic, and at risk of underfeeding. The study aimed
Critically ill; –20000
at assessing the relationship between energy balance and outcome in critically ill
Malnutrition; patients.
Outcome; Methods: Prospective observational study conducted in consecutive patients
Infection
–25000
stayingX5 days in the surgical ICU of a University hospital. Demographic data, time
to feeding, route, energy delivery, and outcome were recorded. Energy balance was
–30000
calculated as energy delivery minus target. Data in means7SD, linear regressions
Balance between energy balance and outcome variables.
Results: Forty eight patients aged 57716 years were investigated; complete data
–35000
are available in 669 days. Mechanical ventilation lasted 1178 days, ICU stay 1579
6 11 7 was days, and 30-days mortality was 38%. Time to feeding was 3.172.2 days. Enteral
–40000
nutrition was the most frequent route with 433 days. Mean daily energy delivery was
3 4 10907930 kcal. Combining enteral and parenteral nutrition achieved highest energy
–1 0 1 2 3 4 5 6 7 8 9 10
delivery. Cumulated energy balance was between !12,600710,520 kcal, and
after admission correlated with complications ðPo0:001Þ, already after 1 week. infec tot
Conclusion: Negative energy balances were correlated with increasing number
of complications, particularly infections. Energy debt appears as a promising tool
ergy delivery compared to Figure 2 Relation between the progressive negative
for nutritional follow-up, which should be further tested. Delaying initiation
of nutritional support exposes the patients to energy deficits that cannot be
the figure shows that energy energy balance and the number of infectious complica-
compensated later on.
reducing daily deficit. tions.
& 2005 Elsevier Ltd. All rights reserved.

!Corresponding author. Tel.: +41 21 31 42 095; fax: +41 21 31 43 045.

Villet, Clinical Nutrition 2005
E-mail address: mette.berger@chuv.hospvd.ch (M.M. Berger).
pact of hypocaloric feeding on ICU outcome 0 0
10 20 30 40 50 60 70 80 90 15 20 25
50 50 50
Energy Balance:Cumulated 3 Multiple
FigureEnergy regression
Balance: weekanalysis showing the
1st N influence of
organ failures
40
P<.0001 SOFA
40 score on length P=0.0134
of ICU stay. 40 P=0,653
ICU stay (d)

30 30 30

20 20 Table 4 Relationship between20complications and st

cumulated energy deficit by regression analysis. pr
10 10 10 Re
ARTICLE IN PRESS Variables F P ab
0 0 0
ICU outcome
-40 -30 -20 -10 0-5 -3
Length -2
of stay -1 0 .5 507125.182 0.0001
3 4 5 ge
Complications 15.15 0.0003
th
Kcal/1000 Kcal/1000 N
Infections 9.14 0.0042 flu
50 50
ated 50 Energy Balance: 1st week N organ failures
50 Days on antibiotics 50 17.48 0.0003 na
001
40 Age (years) P=0.0134
40 Start of nutrition
P=0,6534
BMI 17.17 0.0002 en
SOFA score
40 P=0.2984 P=0.2622 P=0,899
40
Days of mechanical ventilation 40 17.12 0.0002 im
ICU stay (d)

30
30
30 in
30 30
se
20 20
20 20 20 du
10 stay.
10 Correlation does still not mean causality. It is ac
10 obvious
10 for any ICU specialist, 10 that the longer the lim
’’
0
0 -3
stay,
0 the likelier a patient is to have experienced d
0-5 -2 -1 0 .5 0 1 2 3 4 5 6 0
10 20 30 40 50 60 70 80 90 complications and
15 20 25 30 35 40to have received0
antibiotics
5 10
at 15
Kcal/1000 some stage: the N most severe Villet, Clinical are
patients Nutrition 2005 nu
also the
ure 3 Multiple regression analysis showing the influence of energy balance, number of organ failure, age
 See corresponding editorial on page 527.

iversity of Technology on July 28, 2013

versus 20.7%, respectively).
The fat-mass index was significantly higher in men hospital-
ized 1–2 d and # 12 d than in male control subjects (Table 1) and
ree- Nutritional assessment: lean body mass depletion at hospital
significantly higher in female patients hospitalized 1–2 d and # 7
1–3
the
spi-
admission is associated with an increased length of stay
d than in female control subjects. Higher fat-mass index was
associated with greater LOS in women (trend test, P $ 0.03) but
free not in men. These results show that the patients had lower fat-free
sso- Claude Pichard,
mass and higher Ursula
body fat G Kyle,
than Alfredo
did the controlMorabia,
subjects. Arnaud Perrier, Bernard Vermeulen, and Pierre Unger
616 PICHARD ET A
ABSTRACT highly predictive of hospital readmission (5, 6), whereas
TABLE 3 concentrations and lymphocyte counts are speci 25.9
by Background: Low fat-free mass may be an independent risk factor protein
Odds ratios (OR) and 95% CIs for length of hospital stay (LOS) by fat-
for malnutrition that results in an increased length of hospital stay of h
sensitive
free-mass indexindicators of postoperative
at hospital admission in men and women complications
1 (7).Sim
A
otal
(LOS). and hematocrit were shown toNormal predict longer LOS and6.7) m
Objectives: The objectives were to compare differences in fat-free (8). The Subjective Global Assessment
Low fat-free- fat-free-mass (SGA) questionn 0.4)
predictor ofwas
2
mass and fat mass at hospital admission between patients and healthy determining nutritional mass index
status isindex
an accurateOR (95% CI)
co
1) 1.2,
control subjects and to determine the association between these tions, such as infections n (%) and poor wound healing (9), and
n (%) is
incr
6) Men 3
differences and the LOS. ated with longer LOS in severely malnourished
9) Control subjects 50 (16.1) 261 (83.9) 1 patientsCI: (1
6) Design: Patients (525 men, 470 women) were prospectively re- Patients
Patients (n % 393)with # 2 abnormal nutritional markers mas
(we
4) cruited at hospital admission. Height-corrected fat-free mass and fat LOS 1–2 d 93 (37.7) 154 (62.3) 3.3 (2.2, 5.0)4
height,
LOS 3–6 d
percentage9weight (32.1)
loss, arm muscle
19 (67.9)
circumferen
2.3 (1.0, 5.5) Len
8) mass (fat-free-mass index or fat-mass index; in kg/m2) were deter-
1)
serum
LOS 7–11 albumin)
d had more serious
22 (52.4) complications
20 (47.6) than
5.9 (3.0, 11.6) 4
didLp
mined in patients at admission by bioelectrical impedance analysis LOS "12 d
with a normal 31 (55.4)
nutritional status 25 (44.6)
(11). 5.6 (3.1, 10.4)
Schols
4
et al (12) showfree
4.3) Women 5
and were compared with values for sex-, age-, and height-matched depletion of muscle mass, reflected massfat-f
1) Control subjects 129 (38.1) 210 (61.9)by lean body1 or
7) control subjects. Patients were classified as well-nourished, moder- larly
mass,
Patients (n % 380)occur in patients who maintained their wei
could
2.2 (1.6, 3.1)4 ques
7) ately FIGURE
depleted,1. or severely
Prevalence of depleted on the
low (!), normal (■),basis of a(u)
and high Subjective
fat-free- LOS 1–2 d
that
151 (56.8) 115 (43.2)
massAssessment
index in control subjects and patients LOSfat-free
3–6 d mass20depletion
(71.4) contributed
8 (28.6) 3.8to impaired
(1.6, 8.9)4 fun
8.2
Global questionnaire and ahospitalized
body massforindex
1–2, 3–
(in6,kg/m
7–11,2)
status. Thus, low fat-free
25 (83.3) mass 5may (16.7)be an
7.1independent
(2.6, 19.0)4 test:
ris
0.5) and # 12 d. The prevalence of low fat-free-mass index progressively in- LOS 7–11 d
! or " 20. "12 d 4 A
8.2) creased with an increased length of hospital stay (LOS) and was highest in forLOSlonger LOS. 43 (76.8) 13 (23.2) 4.4 (2.3, 8.7)
asso
Results:
patientsLow fat-free
with the longestmass was noted
LOS (55% in 37%
compared andin55.6%
with 18% controlof patients
subjects). 1
There was a significant interaction for sex. See Subjects and Methods
00.0) Kyle et al (13) found, with the SGA questionnaire, that tien
hospitalized 1–2&d158.5,
Chi-square test and " df & $ 0.001.
129,d,P respectively. The odds ratios were for definition of normal and low fat-free-mass index.
mass
2 is significantly
Adjusted for age. lower in malnourished patients mas
significant for fat-free-mass index and were higher in patients with 3
test % subjects
62.9, df % 4,and
P ! that seve
healthy control
Chi-square 0.001.fat mass is greater in chro
a LOS of " 12 d [men (odds ratio: 5.6; 95% CI: 3.1, 10.4), women 4
P ! 0.001. ciate
ill5patients aged " 55 y at hospital
Chi-square test % 58.4, df % 4, P ! 0.001. admission, despite low
inde
(4.4; 2.3, 8.7)] than in those with a LOS of 1–2 d [men (3.3; 2.2, 5.0), 2
mass indexes (BMIs; in kg/m ), than in age- and height-m sign
women (2.2; 1.6, 3.1)]. Severe nutritional depletion was signifi-
healthy adults
for a (14). Furthermore, of patients fellsign
33% index be
cantly associated only with a LOS " 12 d.
Risk
10th
factors
Patientspercentile
Pichard,
low and
were moreoflikelyfat-free
Am
than mass
J
were the
Clin
high fat-free-mass
Nutr
compared
2004
with only
control subjects to
(OR
10%
Conclusion: Fat-free mass and fat-free-mass index were signifi- asso
 What we’ve to do?
• Stabilize first!
• Prompt resuscitasion for early
stabilization (6 hrs - EGDT)
• Early nutrition after stabilization
• Reach 100% of target in the 1 st day
• EN, or PN, or combine
What’s the nutritional
goal?
• Body weight?
• MUAC?
• Albumin? Pre-albumin? Retinol-binding
protein?
• Completness of delivery?
• INDIRECT CALORIMETRY
THANK YOU