A Stepwise Enteral Nutrition Algorithm for Critically Ill Children Helps Achieve Nutrient Delivery Goals*

Abstract

Objective To evaluate the impact of implementing an enteral nutrition (EN) algorithm on achieving optimal EN delivery in the Pediatric Intensive Care Unit (PICU). Design Prospective pre/post implementation audit of EN practices. Setting One 29-bed medical/surgical PICU in a free standing, university affiliated children’s hospital. Patients Consecutive patients admitted to the PICU over two 4-week periods pre and post implementation, with a stay of > 24 hours who received EN. Interventions Based on the results of our previous study, we developed and systematically implemented a stepwise, evidence and consensus-based algorithm for initiating, advancing and maintaining EN in critically ill children. Three months after implementation, we prospectively recorded clinical characteristics, nutrient delivery, EN interruptions, parenteral nutrition (PN) use, and ability to reach energy goal in eligible children over a 4-week period. Clinical and nutritional variables were compared between the pre and post-intervention cohorts. Time to achieving energy goal was analyzed using Kaplan Meier statistical analysis. Measurements and Main Results Eighty patients were eligible for this study and were compared to a cohort of 80 patients in the pre-implementation audit. There were no significant differences in median age, gender, need for mechanical ventilation, time to initiating EN, or use of post-pyloric feeding between the 2 cohorts. We recorded a significant decrease in the number of avoidable episodes of EN interruption (3 vs. 51, p0.0001) and the incidence and duration of PN dependence in patients with avoidable EN interruptions in the post-intervention cohort. Median time to reach energy goal decreased from 4 days to 1 (p<0.0001), with a higher proportion of patients reaching this goal (99% vs. 61%, p = 0.01). Conclusions The implementation of an EN algorithm significantly improved EN delivery and decreased reliance on PN in critically ill children. Energy intake goal was reached earlier in a higher proportion of patients.

Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study

“…A significant proportion of these interruptions may be avoidable (6,23). A variety of strategies have been used to avoid unintended EN interruptions in the intensive care unit, including the use of the postpyloric route, stepwise algorithms, and volume-based feeding (24)(25)(26). Compared with gastric feeding, postpyloric feeding did not improve outcomes in a randomized controlled trial in the PICU environment (27).…”

“…Our results suggest that postpyloric feeding deserves additional examination in welldesigned trials conducted in centers with local expertise and resources for the placement of specialized enteral access. The use of stepwise EN-delivery algorithms was shown to improve EN delivery in single centers (20,26). A uniform approach to EN delivery at the bedside may help identify candidates for EN adjuncts such as postpyloric feeding, decrease unintended interruptions, improve the management of EN intolerance, and facilitate the early identification of cumulative nutrient imbalances.…”

A review of feeding intolerance in critically ill children

“…Used a preterm definition: GRV > 2 ml/kg or ½ the amount fed over the prior 3 h, a change in the color of the aspirate top green or red, abdominal distention with tenderness or a change in stool consistency to brown or red Hamilton et al 2014 [9] Before and after study…”

Resultados de la implementación de un protocolo de soporte nutricional en grandes quemados pediátricos internados en la Unidad de Cuidados Intensivos

“…Existe vasta evidencia bibliográfica a favor de su utilización para aumentar el éxito del soporte nutricional. 2 Hamilton y col. 10 encontraron un descenso significativo de las interrupciones en la alimentación enteral y en el tiempo para alcanzar el requerimiento energético al implementar un protocolo a tal fin.…”