Nutrition in Pediatric Cardiac Intensive Care

1. Nutrition in Pediatric Cardiac Intensive Care QUALITY IMPROVEMENT INITIATIVE María Balestrini, MD PediatricCardiacIntensiveCareUnit Pediatric Hospital J. P. Garrahan Buenos Aires Argentina

2. PCICU – PEDIATRIC HOSPITAL J. P. GARRAHAN 21 BEDS, 2 EXCLUSIVE OPERATING ROOMS, 5 SENIOR SURGEONS, CARDIOLOGISTS AND PEDIATRIC CARDIAC INTENSIVISTS

3. PCICU - HOSPITAL GARRAHAN

4. PILLARS OF NUTRITIONAL SUPPORT IN THIS PERIOD • Preserve the function of vital organs, minimizing the loss of lean body mass, although it can not completely prevent catabolism. • Achieve positive nitrogen balance, which is crucial to growth • Avoid over feeding, leading to CO2 retention, difficulty in weaning ventilator and impaired immune function.

5. METABOLIC CHANGES IN THE IMMEDIATE POST SURGICAL

6. NUTRITIONAL SUPPORT PROGRAM DEVELOPEMENT • Discuss common feeding issues in patients with complex congenital heart disease • We reviewed previous practices and made a new feeding protocol • We examined preliminary data after the initiation of the new protocol at Garrahan Hospital.

7. FAILURE OF GROWTH Common among infants with complex CHD: • Inefficient circulation • High metabolic demand during post-operative healing • Alterations in growth factors and growth hormone • Geneticsyndromes • Poor oral skills • Gastrointestinal pathology • Associated with worse outcomes in CHD patients

8. PERIOPERATIVE FEEDING CONSIDERATIONS Preoperatively • Cyanosis and compromised systemic output • Cardiac disease Prostaglandin (PGE) dependent • Need of Umbilical Catheters Postoperatively • Clinical weakness  • High respiratory support  • Inotropic support  • Poor oral skills  • Gastric dysmotility  • Vocal cord paralysis

9. PREOPERATIVE FEEDING IN PGE DEPENDENT PATIENTS • No increased risk of necrotizing enterocolitis (NEC) with early feeding in hemodynamically stable, cyanotic infants  • No increase in adverse events with enteral feeding  • No increased risk of NEC with umbilical artery catheters

10. BENEFITS OF EARLY ENTERAL FEEDING • Improved nutritional status and growth prior to surgery • Improved surgical outcome • Enhanced intestinal maturation • Improved feeding tolerance post-operatively • Decreased length of parental nutrition • Increased immunity

11. CONSENSUS FEEDING GUIDELINE National Pediatric Cardiology Quality Improvement Collaborative • Created in 2009 to improve outcomes among single ventricle patients • Multidisciplinary Feeding Work Group • Devised first consensus feeding guidelines for single ventricle infants • Released guidelines in 2011

12. OUR FEEDING GUIDELINES Previous guidelines • No recommendations on timing of pre or post-operative feed initiation  • Post-operative feeds started continuously at 2 ml/hr  • Increased by 1 ml/hr every 6 hours  • Once at goal volume, caloric density slowly increased  • Once at goal calories, progression to bolus schedule 

13. OUR FEEDING GUIDELINES Previous guidelines • Parenteral nutrition was not initiated within 24 hours of surgery • Parenteral nutrition had significant deficit of nutrients • We invited a multidisciplinary committee to revise feeding guidelines  • New protocol implemented in January 2013

14. NEW FEEDING GUIDELINES Focus of new guidelines • Early initiation of enteral feeds pre and post-operatively  • Oral feeding and breast feeding when possible  • Vocal cord paralysis assessment after aortic arch interventions  • Nasogastric tube bolus as preferred postoperative enteral feeding choice • Rapid full protein-caloric requirements achievement • A standard parenteral nutrition formula for infants with congenital heart disease was developed.

15. IMPLEMENTATION OF NUTRITIONAL SUPPORT IN THE IMMEDIATE POSTOPERATIVE PERIOD

16. PARENTERALNUTRITIONALSUPPORT

17. ENTERAL NUTRITION SUPPORT

18. NUTRITIONAL SUPPORT PROGRAM IMPACT EVALUATION • We conducted a prospective clinical study from 1 January 2013 to 31 December 2014 • Less than 3 months perioperative patients, were included.

19. CLINICAL STUDY Anthropometric: Weight, height, head circumference. (mean and SD) Laboratory: Glucose, albumin, total and ionized calcium, total magnesium, phosphorus, electrolytes, triglycerides Resting energy expenditure (REE) assessment: using Schoffield and WHO equations. Feeding characteristics: volume, formula, calories, proteins, lipids; enteral and parenteral

20. CLINICAL STUDY • Diagnoses assignable RACHS-1 patients • N 70 patients • Female 55% • Median age 17 days (r1-120). • 95% neonates • All term infants • Median weight 3,2 Kg (r1,9-5) • LOS 13 day (r1-160) • Survival 93%

21. CLINICAL STUDY

22. PREOPERATIVE

23. POST OPERATIVE 72 HS • The sum of enteral and parenteral gives 66 kcal/ kg/day (r 27 -117) • 70% arrived at suggested target

24. DISCHARGE • 78% discharge with oral feeding, • 22% by nasogastric tube. • 13 patients with exclusive breast feeding • 9 patients combined breast feeding and formula • 42 patients formula

25. CONCLUSION • Cardiovascular TPN standard was safely implemented. • Parenteral and enteral nutrition, alone or in combination exceeded REE requeriments, during perioperative course in all patients. • There were no patients with NEC • There was an increase in weight. Head circumference and height remained stable.

26. SUMMARY • Nutrition is a major focus in improving the outcome of children with complex CHD • Early pre-operative enteral feeding in this patient population is safe. • Standardized approach in nutritional support is likely to improve outcomes in patients with congenital heart surgery, specially neonates and small infants.

27. THANK YOU VERY MUCH