Obesity and Mortality Risk in Critically Ill Children

Ross, Patrick; Newth, Christopher J L; Leung, Denis H. Y.; Wetzel, Randall C.; Khemani, Robinder G.

doi:10.1542/peds.2015-2035

Cited by 67 publications

(66 citation statements)

References 19 publications

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“…Since the first pediatric critical care nutrition guidelines (ASPEN) published in 2009, there has been a substantial increase in research and publications related to this subject. The impact of nutrition status and nutrient delivery during critical illness has been demonstrated on clinical outcomes such as mortality, infectious complications, and LOS 4 – 10 . Thus, careful planning and monitoring of nutrient delivery at the bedside is attempted in most intensive care units (ICUs).…”

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

371

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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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

371

515

View full text Add to dashboard Cite

show abstract

“…The lack of height measurement can be pervasive in PICUs. In a retrospective study of US PICUs only 39.2% of 325,325 admissions had height recorded (11). Potentially, if we find a way to measure or estimate height more readily it may be measured more frequently.…”

Section: Discussionmentioning

confidence: 99%

Predicting Body Height in a Pediatric Intensive Care Unit Using Ulnar Length

et al. 2018

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Objective: To determine if ulnar length obtained by the bedside nurse can be used to estimate patient length. To compare our findings to previous predictive equations of height and ulnar length. To evaluate the performance of predictive equations for height and ulnar length on patients with syndromes that affect height.Design: Retrospective observational study of prospectively collected data.Settings: Multidisciplinary Pediatric Intensive Care Unit in a university teaching hospital.Patients: 1,177 patients, ages 1 month to 23 years. Mean age was 79.7 months (1,3 IQR 19.5, 164.5 months) and 55.4% male.Measurements: Ulnar length was obtained using digital calipers by bedside nurses in PICU as well as height and weight. The electronic health care record was used to extract patient information.Main Results: The predictive equation for height for the entire group is: height (cm) = 0.59*ulnar length (mm) + 13.1 (r2 = 0.93). Bland Altman analysis of the derivation formula applied to the testing group did not show any systematic bias.Conclusions: Our study shows that ulnar length measurements can be used to predict height with a simple linear formula in a PICU setting. Not having specific individuals or specific training for ulnar measurement did not seem to alter the accuracy (r2 = 0.93). The robust nature of the measurement and ease of use may make this an unconventional but reasonable alternative to obtaining height when that cannot be measured directly.

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“…In a recent study of 325,325 PICU patients’ height was recorded only 39% of the time(22). In our study it appeared that ABW was used to calculate exhaled VT and other variables, since height was recorded in only two-thirds of cases.…”

Section: Discussionmentioning

confidence: 99%

Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?*

Newth

Sward

Khemani

et al. 2017

Pediatric Critical Care Medicine

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Objective Although pediatric intensivists philosophically embrace lung protective ventilation for Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS), we hypothesized that ventilator management varies. We assessed ventilator management by evaluating changes to ventilator settings in response to blood gases, pulse oximetry or end tidal CO2. We also assessed the potential impact that a pediatric mechanical ventilation (MV) protocol adapted from NHLBI ARDSNet protocols could have on reducing variability by comparing actual changes in ventilator settings to those recommended by the protocol. Design Prospective observational study. Setting Eight tertiary care US PICUs, October 2011 – April 2012. Patients 120 patients (age range 17 days to 18 years) with ALI/ARDS. Measurements and Main Results 2100 arterial and capillary blood gases, 3964 SpO2 and 2757 PETCO2 values were associated with 3983 ventilator settings. Ventilation mode at study onset was Pressure Control (PC) 60%, Volume Control (VC) 19%, Pressure-regulated Volume Control (PRVC) 18%, High Frequency Oscillatory Ventilation (HFOV) 3%. Clinicians changed FiO2 by ±5 or ±10% increments every 8 hours. PEEP was limited at ~10 cmH20 as oxygenation worsened, lower than would have been recommended by the protocol. In the first 72 hours of MV, maximum tidal volume/kg using predicted versus actual body weight was 10.3 ml/kg; 8.5–12.9 (median; IQR) versus 9.2 ml/kg; 7.6–12.0 (p<0.001). Intensivists made changes similar to protocol recommendations 29% of the time, opposite the protocol’s recommendation 12% of the time and no changes 56% of the time. Conclusions Ventilator management varies substantially in children with ARDS. Opportunities exist to minimize variability and potentially injurious ventilator settings by utilizing a pediatric mechanical ventilation protocol offering adequately explicit instructions for given clinical situations. An accepted protocol could also reduce confounding by MV management in a clinical trial.

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Obesity and Mortality Risk in Critically Ill Children

Cited by 67 publications

References 19 publications

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

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

Predicting Body Height in a Pediatric Intensive Care Unit Using Ulnar Length

Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?*

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