Indirect Calorimetry Reveals That Better Monitoring of Nutrition Therapy in Pediatric Intensive Care Is Needed

Dokken, Mette; Rustøen, Tone; Stubhaug, Audun

doi:10.1177/0148607113511990

Cited by 34 publications

(31 citation statements)

References 47 publications

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“…Energy needs can be measured by indirect calorimetry 28 , 29 or estimated through the use of standard equations 30 . Each of the methods to estimate energy needs is just that: an estimation.…”

Section: Consensus Recommendationsmentioning

confidence: 99%

“…Ideally, clinicians should perform indirect calorimetry to measure a child's actual energy requirements. Indirect calorimetry is the most precise method for the determination of energy expenditure because predictive equations do not accurately determine energy expenditure or account for the variability of a child's metabolic state during the course of an illness 28 , 29 . The Food and Agriculture Organization (FAO)/WHO 31 and Schofield 32 equations, although imprecise and developed to estimate the energy utilization of healthy children, are the most widely used formulas to estimate energy needs.…”

Section: Consensus Recommendationsmentioning

confidence: 99%

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Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition

et al. 2014

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The Academy of Nutrition and Dietetics (the Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), utilizing an evidence-informed, consensus-derived process, recommend that a standardized set of diagnostic indicators be used to identify and document pediatric malnutrition (undernutrition) in routine clinical practice. The recommended indicators include z scores for weight-for-height/length, body mass index-for-age, or length/height-for-age or mid-upper arm circumference when a single data point is available. When 2 or more data points are available, indicators may also include weight gain velocity (<2 years of age), weight loss (2-20 years of age), deceleration in weight for length/height z score, and inadequate nutrient intake. The purpose of this consensus statement is to identify a basic set of indicators that can be used to diagnose and document undernutrition in the pediatric population ages 1 month to 18 years. The indicators are intended for use in multiple settings (eg, acute, ambulatory care/outpatient, residential care). Several screening tools have been developed for use in hospitalized children. However, identifying criteria for use in screening for nutritional risk is not the purpose of this paper. Clinicians should use as many data points as available to identify and document the presence of malnutrition. The universal use of a single set of diagnostic parameters will expedite the recognition of pediatric undernutrition, lead to the development of more accurate estimates of its prevalence and incidence, direct interventions, and promote improved outcomes. A standardized diagnostic approach will also inform the prediction of the human and financial responsibilities and costs associated with the prevention and treatment of undernutrition in this vulnerable population and help to further ensure the provision of high-quality, cost-effective nutritional care.

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Section: Consensus Recommendationsmentioning

confidence: 99%

Section: Consensus Recommendationsmentioning

confidence: 99%

Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition

et al. 2014

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“…MREE may be decreased during deep sedation, neuromuscular blockade, or severe hypothyroidism, or increased with temperature >38°C and distress/activity 30 , 31 , 33 . In cohort studies, MREE did not significantly vary within the same patient over time 21 , 28 , 35 . After the baseline MREE is performed (ideally during the first week of critical illness), repeat measurements may be obtained in patients with significant changes in clinical status 27 , 35 .…”

Section: Introductionmentioning

confidence: 99%

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition

Mehta

Skillman

Irving

et al. 2017

J Parenter Enteral Nutr

373

515

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This document represents the first collaboration between 2 organizations-the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine-to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric critically ill patient (>1 month and <18 years) expected to require a length of stay >2-3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2032 citations were scanned for relevance. The PubMed/MEDLINE search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1661 citations. In total, the search for clinical trials yielded 1107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We used the GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluation) to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

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“…Todo ello explica por qué las ecuaciones predictivas del gasto energético basal (GEB) no presentan buena correlación con el gasto energético en reposo (GER) calculado por calorimetría indirecta (CI), especialmente en lactantes (29)(30)(31). Estudios transversales en pacientes pediátricos ingresados en Unidades de Cuidados Intensivos (UCI) que utilizaron CI para medir el gasto energético en reposo, muestran que más del 80% de los pacientes recibían un aporte inadecuado a sus necesidades reales, bien por defecto (en torno al 21%) o por exceso (en más del 60% de los pacientes) (32,33). La desnutrición es un predictor independiente de morbilidad en el paciente crítico (34), pero el exceso de aporte también se asocia a peor evolución (35)(36)(37).…”

Section: Paciente Críticamente Enfermo Necesidades Energéticasunclassified

Nutrición parenteral en situaciones clínicas especiales

Martínez¹,

Giner

2017

Nutr Hosp

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RECIÉN NACIDO PREMATUROLa nutrición parenteral (NP) constituye un pilar fundamental en la nutrición del recién nacido (RN) prematuro, especialmente en el RN muy prematuro (< 32 semanas de gestación) y RN prematuro extremo (< 28 semanas de gestación) (1). En estos pacientes, la administración de una NP balanceada y precoz se considera de elección (2). Dos metaanálisis han demostrado que la NP precoz en el RN prematuro < 1.500 g es segura, sin aumentar el riesgo de efectos adversos (3,4), y ha mostrado beneficios en relación con un balance nitrogenado positivo (ver aporte proteico) y mayor ganancia ponderal respecto a controles, aunque no se ha observado mayor longitud o perímetro craneal al alta en el grupo de intervención (3). Cabe destacar que los ensayos clínicos analizados cuentan con pequeño tamaño muestral y son heterogéneos (3,4). NECESIDADES ENERGÉTICASLa evidencia sobre las necesidades energéticas del RN prematuro es muy escasa, pues desde una aproximación empírica es muy difícil desligar el efecto de la energía administrada del obtenido por el aporte proteico y resto de nutrientes. Por tanto, las recomendaciones energéticas del RN prematuro se basan en el método factorial, asumiendo que su composición corporal es similar a la del feto y que el crecimiento debería ser similar al que ocurre intraútero (5). Actualmente, se recomienda un aporte inicial de 60 kcal/kg/día, con aumento rápido y progresivo hasta las 90-100 kcal/kg/día en la primera semana (1). Posteriormente se irá incrementado en función del peso de RN (2,6), con el objetivo de conseguir un crecimiento lo más próximo al crecimiento fetal (ver capítulo de "Requerimientos en nutrición parenteral pediátrica" en las tablas II y III). MODIFICACIONES EN EL DISEÑO DEL PREPARADO DE NP Requerimientos proteicosEl aporte proteico mínimo para conseguir un balance nitrogenado positivo en el RN prematuro es 1,5 g/kg/día (6). No obstante, en los últimos años se ha demostrado seguro el aporte inicial de 2,4 g/kg/ día el primer día de vida (4,7,8). Los resultados dependen no solo de la dosis de aminoácidos (AA) sino del aporte concomitante de calorías no proteicas. Así, en el RN prematuro < 1.500 g el aporte proteico inicial de 2,4 g/kg/día junto a lípidos (2 g/kg/día el primer día, incrementando a 3 g/kg/día el segundo) mejoró el balance nitrogenado respecto al mismo aporte proteico sin lípidos (7). Aportes iniciales superiores (3,6 g/kg/día junto a lípidos) no han demostrado mejorar el balance nitrogenado y se asocian a aumento de urea plasmática que refleja una mayor oxidación de AA (7,9). En un reciente ensayo clínico con RN prematuros < 1.500 g se demostró mayor síntesis de albúmina en 12 pacientes con aporte precoz proteico de 3,6 g/ kg/día junto a lípidos comparados con 9 pacientes que recibieron 2,4 g/kg/día junto a lípidos (8), datos que deben ser refrendados en estudios de mayor tamaño muestral (ver capítulo de "Requerimientos en nutrición parenteral pediátrica" para incrementos posteriores).La fórmula de AA a administrar debe contener cisteína, tiro...

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Indirect Calorimetry Reveals That Better Monitoring of Nutrition Therapy in Pediatric Intensive Care Is Needed

Abstract: The high percentage of children (~61%) who were overfed emphasizes the need to measure energy needs by using indirect calorimetry.

Cited by 34 publications

References 47 publications

Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition

Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition

Nutrición parenteral en situaciones clínicas especiales

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