74 Questions
What is the primary benefit of measuring prealbumin in hospitals?
To monitor the visceral protein pool
What happens to serum acute-phase protein levels in children with burn injury within 12–24 hours of the stress?
They rise in response to injury
What is the relationship between serum prealbumin and CRP concentrations during the acute response period?
They are inversely related
Why is it important to assess energy expenditure in critically ill children?
To prevent overfeeding and underfeeding
What is the result of increased serum counter-regulatory hormone concentrations in critically ill children?
Catabolism of endogenous stores of protein, carbohydrate, and fat
What is the average metabolic state in mechanically ventilated children in the PICU?
Variable metabolic state
Why may standard equations underestimate the measured REE in children with severe burn injury?
Because they do not account for the severity of injury
What is the risk of overfeeding critically ill children who are sedated and mechanically ventilated?
Lower risk due to decreased energy expenditure
What is the effect of dietary glucose provision on gluconeogenesis in injured and septic adults?
It has no effect on gluconeogenesis
What is the recommended approach to estimating energy requirements in critically ill children?
Using indirect calorimetry to measure energy expenditure
What is the primary source of energy in metabolically stressed children?
Fatty acids
What is the recommended concentration of linoleic acid in the diet of critically ill or injured infants?
4.5% of total calories
What is the significance of decreases in serum CRP values to levels < 2 mg/dL in infants after surgery?
Indicates the return of anabolic metabolism
What is the maximum percentage of total calories recommended for IVFE administration in critically ill children?
30%-40%
Why is enteral nutrition preferred over parenteral nutrition in critically ill children?
All of the above
What is the risk of not providing essential fatty acids in critically ill children?
All of the above
What is the recommended initiation time for enteral feeding in critically ill children?
Within 48-72 hours after admission
What is the effect of IVFE supplementation on CO2 production and metabolic rate in critically ill children?
It has no significant effect on CO2 production and metabolic rate
What is the advantage of post-pyloric feeding in critically ill children?
It reduces the risk of aspiration
What is the current practice in many centers for initiating enteral feeding in critically ill children?
Initiation of enteral feeding within 48-72 hours after admission
What is the primary characteristic of protein metabolism during critical illness and recovery from trauma or surgery?
Increased protein catabolism and turnover
What is the advantage of high protein turnover during critical illness?
A continuous flow of amino acids is available for synthesis of new proteins
What is the ultimate limitation of the catabolism of muscle protein during critical illness?
Limited protein reserves available in children and neonates
Why is the provision of dietary carbohydrate alone ineffective in reducing endogenous glucose production during critical illness?
Because of the metabolically stressed state
What is the primary nutrition intervention in critically ill children?
Provision of dietary protein sufficient to optimize protein synthesis
What is the recommended protein intake for critically ill neonates and children?
0-2 years, 2-3 g/kg/day; 2-13 years, 1.5-2 g/kg/day; and 13-18 years, 1.5 g/kg/day
What is the effect of high protein administration (4-6 g/kg/day) on critically ill children?
Adverse effects such as azotemia, metabolic acidosis, and neurodevelopmental abnormalities
What is the primary energy source used by the brain, erythrocyte, and renal medulla?
Carbohydrate
What is the consequence of the depletion of glycogen stores during illness or injury?
Need for gluconeogenesis
What is the effect of protein administration on net protein synthesis and overall protein balance in critically ill patients?
Similar beneficial effects on net protein synthesis and overall protein balance
What was the outcome of the study by Gurgueira et al on the implementation of a specialized NST?
An increase in EN rate from 25% to 67% with a significant decrease in PN rates
What was the finding of Lambe et al's study on the implementation of a specialized NST?
No significant difference in nutrition outcomes
What is the role of the NST in patient care?
To provide expert advice and help during rounds
What was the outcome for children who received EN during >50% of their LOS in Gurgueira et al's study?
They had a 83% lower risk of death
What is the current understanding of the role of NST in the PICU?
The role of NST is evolving and the clear benefit on patient outcomes is debatable
What is a characteristic of recent surveys on the presence of NST during rounds?
They demonstrate the presence of NST during rounds in many centers around the world
What was the main outcome measure examined in the study by Horn et al?
Tolerance of enteral feedings
What was the percentage of patients who received full estimated energy requirements in a review of 42 patients in a tertiary-level PICU?
50%
What was the main reason for suboptimal enteral nutrient delivery in critically ill children?
All of the above
What is the recommended strategy to achieve estimated energy goals in critically ill children?
Protocols for feeding use of transpyloric feeding tubes and changing from bolus to continuous EN during brief periods of intolerance
What was the percentage of children who received early post-pyloric nutrition in the study by Sanchez et al?
38%
What was the reason for the inability to achieve daily caloric goal in the study by Sanchez et al?
Intolerance to EN due to hemodynamic instability
What was the outcome of the unblinded RCT that did not show a difference in microaspiration, enteral access device displacement, and feed intolerance between the gastric or post-pyloric fed groups?
The post-pyloric fed group had a higher percentage of subjects achieving their daily caloric goal
What is the recommended approach to enteral feeding in critically ill children?
Standardized approach to optimizing benefits and minimizing risks with EN delivery
What is the reason for the absence of beneficial effect in multiple studies and meta-analysis of the efficacy of immunonutrition in preventing infection?
Consistently underachieved EN goals
What is the limitation of postpyloric or transpyloric feeding in critically ill children?
Limited expertise and resources in individual PICUs
What is the recommendation for the use of prokinetic medications or motility agents in critically ill children?
They are not recommended for EN intolerance or to facilitate enteral access device placement
What is the grade of recommendation for the routine use of immunonutrition or immune-enhancing diets/nutrients in critically ill children?
Grade D
What is the primary factor contributing to malnutrition in critically ill patients?
Failure to provide optimal nutrition support therapy during ICU stay
Which of the following nutrients has been shown to have beneficial effects in adults with burn injury and trauma?
Glutamine
What is the consequence of underfeeding and overfeeding in the pediatric intensive care unit (PICU)?
Large energy imbalances
What is the goal of nutrition support therapies in pediatric critical care?
To augment the short-term benefits of the pediatric stress response while minimizing the long-term harmful consequences
What is the outcome of the study by Briassoulis et al on the use of immunonutrition in children admitted to the PICU?
No outcome differences were found
What is the effect of a specialized nutrition support team in the PICU on patient outcomes?
No effect on patient outcomes
Why is it important to determine energy requirements accurately in pediatric critical care?
To reduce the risk of malnutrition
What is the consequence of malnutrition in hospitalized children?
Increased resource utilization
What is the purpose of a dedicated nutrition support team in the PICU?
To implement optimal nutrition practices
What is the key to providing optimal nutrition support therapy in pediatric critical care?
Making an individualized determination of nutrient requirements
What is the result of using a specialized adult immune modulating enteral formula in pediatric burn victims?
An improvement in oxygenation and pulmonary compliance
What is the reason for the variability in the practice of providing EN in the PICU?
A multitude of reasons
Why is it important to monitor the success of the feeding strategy in pediatric critical care?
To ensure the provision of optimal nutrition support therapy
What is the primary goal of nutrition support therapy in pediatric critical care?
To provide optimal nutrition support therapy through the appropriate route
What is the outcome of the study by Briassoulis et al on the use of immunonutrition in children admitted to the PICU in terms of transient diarrhea?
An increase in transient diarrhea
What is the grade of recommendation for the use of a specialized nutrition support team in the PICU and aggressive feeding protocols?
Grade E
What is the primary goal of nutrition assessment in critically ill children?
To identify children with existing malnutrition
What is the correlation observed by Hulst et al in a mixed population of critically ill children?
Between energy deficits and deterioration in anthropometric parameters
What is the primary limitation of using albumin as a marker of visceral protein status?
Its serum concentration is affected by albumin infusion, dehydration, sepsis, trauma, and liver disease
What is the role of prealbumin in nutrition assessment?
It is involved in the transport of thyroxine and retinol
What is the significance of nutrition assessment in critically ill children?
It has implications on hospital length of stay, illness course, and morbidity
What is the recommended approach to nutrition assessment in critically ill children?
Formal nutrition assessment with the development of a nutrition care plan
What is the significance of monitoring weight in critically ill children?
It is a valuable index of nutrition status
What is the prevalence of malnutrition in hospitalized children?
It has remained unchanged over several years
What is the significance of prealbumin in liver disease?
Its serum concentration is diminished
What is the rationale for nutrition assessment in critically ill children?
To prevent malnutrition and its associated morbidities
Study Notes
Malnutrition in Critically Ill Children
- The prevalence of malnutrition in hospitalized children has remained unchanged over several years, affecting hospital length of stay, illness course, and morbidity.
- Critically ill children are at risk of longstanding altered nutrition status and anthropometric changes, which may be associated with morbidity.
Nutrition Assessment
- Children admitted to the PICU should undergo nutrition screening to identify those with existing malnutrition or those who are nutritionally at-risk.
- Formal nutrition assessment with the development of a nutrition care plan is required, especially in those children with premorbid malnutrition.
- Nutrition assessment can be achieved by measuring nitrogen balance, resting energy expenditure (REE), and anthropometric measurements such as weight, mid-arm circumference, and skin fold thickness.
Energy Requirement in Critically Ill Children
- Energy expenditure should be assessed throughout the course of illness to determine the energy needs of critically ill children.
- Accurate measurement of energy expenditure using indirect calorimetry (IC) is desirable in a subgroup of patients with suspected metabolic alterations or malnutrition.
- Estimates of energy expenditure using available standard equations are often unreliable.
- In mechanically ventilated children in the PICU, a wide range of metabolic states has been reported, with an average early tendency towards hypermetabolism.
Macronutrient Intake During Critical Illness
- There are insufficient data to make evidence-based recommendations for macronutrient intake in critically ill children.
- The rational partitioning of the major substrates should be based on basic understanding of protein metabolism and carbohydrate- and lipid-handling during critical illness.
- Critical illness and recovery from trauma or surgery are characterized by increased protein catabolism and turnover.
- The provision of dietary carbohydrate alone is ineffective in reducing the endogenous glucose production via gluconeogenesis in the metabolically stressed state.
Route of Nutrient Intake (Enteral Nutrition)
- In critically ill children with a functioning gastrointestinal tract, enteral nutrition (EN) should be the preferred mode of nutrient provision, if tolerated.
- A variety of barriers to EN exist in the PICU, and clinicians must identify and prevent avoidable interruptions to EN in critically ill children.
- Post-pyloric or transpyloric feeds may improve caloric intake when compared to gastric feeds, but there is no clear evidence to support the superiority of one route of feeding over the other.
- Despite the absence of sound evidence, the enteral route has been successfully used for nutrition support of the critically ill child.### Energy Expenditure in Critically Ill Children
- Only 25% of children with meningococcal sepsis achieve goal nutrition.
- In a PICU, patients received a median of 58.8% of their estimated energy requirements.
- EN was interrupted 264 times for clinical procedures in one review.
- Only 50% of patients received full estimated energy requirements after a median of 7 days in the ICU.
Strategies to Achieve Energy Goals
- Using transpyloric feeding tubes and changing from bolus to continuous EN during brief periods of intolerance can help achieve energy goals.
Immunonutrition in the PICU
- The routine use of immunonutrition or immune-enhancing diets/nutrients in critically ill children is not recommended due to lack of evidence.
- Studies on immunonutrition are flawed by poor methodology and small sample size, making it difficult to detect significant differences in clinical outcomes.
Nutrients Studied for Immune Modulation
- Arginine, glutamine, aminopeptides, ω-3 fatty acids, and antioxidants are some of the nutrients studied for their immune modulation effects.
Nutrition Support Team and Feeding Protocols
- A specialized nutrition support team in the PICU and aggressive feeding protocols may enhance the delivery of nutrition.
- The effect of these strategies on patient outcomes has not been demonstrated.
- A dedicated nutrition support team can increase EN rate and decrease PN rates.
This quiz assesses your knowledge of malnutrition in critically ill patients, its prevalence, and the factors contributing to it. Learn about the metabolic response to critical illness and the importance of optimal nutrition support therapy.
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