Enteral Nutrition Algorithm for Critically Ill Children
Enteral Nutrition Algorithm for Critically Ill Children
A stepwise, evidence-based algorithm for initiating, advancing, and maintaining EN in critically ill children was developed using a multidisciplinary consensus approach. A full description of the process is beyond the scope of this article and will be described separately. In brief, representatives from critical care nursing, critical care medicine, respiratory therapy, nutrition, gastroenterology, surgery, and pharmacy were among the key stakeholders who participated in the algorithm development process. Working groups were assigned eight major areas of inquiry: 1) nutritional assessment and screening, 2) indications and contraindications to EN, 3) advancement strategies for EN, 4) risk factors and strategies to prevent aspiration of gastric contents, 5) definition of EN intolerance and management strategies, 6) role of EN adjuncts such as antacids and promotility agents, 7) bowel management strategies to prevent and treat constipation, and 8) recommendations for fasting time around procedures. The designated groups examined the literature using a systematic approach for searching, grading, and reporting the evidence on each area and made recommendations based on the available evidence. These recommendations were translated into stepwise decision points in the EN algorithm.
The final guideline was drafted in the form of a stepwise algorithm and included 1) nutritional assessment and establishing nutrient intake goals, 2) selection of the mode of nutrition (EN vs PN) and selecting route of EN (gastric vs postpyloric), 3) initiation of EN, and 4) maintenance of EN. Figure 1 shows a condensed/simplified version of our full EN algorithm. (Screening procedures for nutritional status and contraindications to EN are described in Appendices 1 and 2 [Supplemental Digital Content 1, http://links.lww.com/PCC/A107], respectively. The criteria for "feeding intolerance" and "risk of aspiration" are available in Appendices 3 and 4 [Supplemental Digital Content 1, http://links.lww.com/PCC/A107], respectively.) The institutional nutritional advisory committee approved the guideline. An initial pretest administered to physicians and nurses allowed identification of areas of knowledge deficits and need for education. A computerized learning module, one-on-one education, and weekly nutrition rounds performed by members of the guideline development committee were included in the educational phase prior to dissemination of the guidelines via paper and electronic format to all personnel. We also incorporated reminders to review the nutrition algorithm and EN goals during daily bedside rounds.
(Enlarge Image)
Figure 1.
Stepwise algorithm for initiating and advancing enteral nutrition (EN) in the PICU. AG = abdominal girth, GRV = gastric residual volume, PN = parenteral nutrition.
The impact of this intervention was examined by an audit of bedside nutrition practices over a 4-week period that mimicked the preintervention audit in patients who received EN with a length of stay more than 24 hours in the medical/surgical PICU at Boston Children's Hospital. After obtaining approval from the institutional review board, we prospectively recorded nutrient delivery, actual amount and route of nutrient intake, interruptions to EN, PN usage, and adequacy of energy delivery in this cohort. Clinical characteristics, details of enteral nutrient delivery, EN interruptions, PN use, and the ability and time to reach energy goal via the enteral route, were compared between the pre- and postimplementation cohorts. A dedicated nutrition team defined individual daily energy and volume goals for each patient. Standard energy equations (either the Schofield or World Health Organization [WHO]) were used to determine basal energy requirement. Clinical status was taken into account to determine the need for any additional "stress factors" as appropriate. For subjects more than 18 years old, the WHO equation was used when an accurate height or length was not available. The Schofield equation was preferred when both weight and height were reliably obtained. Nutrient delivery goals were reassessed regularly by the nutrition team during the course of illness and adjusted as necessary.
Primary outcomes for the study included 1) total and avoidable interruptions to EN (number and duration of each episode), 2) time to initiate EN after PICU admission, 3) time to reach prescribed energy goal, and 4) PN use in patients with EN interruption. All episodes of interruption to EN delivery were examined, and avoidable episodes were identified a priori by consensus among the multidisciplinary group of investigators. Nurses completed the nutrition audit twice daily at the end of each 12-hour shift. These documents were examined daily by nursing investigators to allow for capture of any missing data. The accuracy of each nutrition audit was crosschecked with the existing electronic medical record. Clinical data, such as duration of mechanical ventilation support and length of PICU stay, were abstracted retrospectively from patient charts following completion of enrollment.
Patient characteristics were described using frequency tables for categorical variables and using measures of central tendency with spread for noncategorical variables. Variables that were reasonably normally distributed were described using mean and SD, whereas those displaying a high degree of skew were characterized by their median and interquartile range (IQR). Comparisons in patient characteristics were made between the cohorts before and after implementation of the nutrition algorithm. Tests of significance for two-group comparisons included Fisher exact test for categorical variables and Student t test and the Mann-Whitney rank sum test for normal and skewed distributions, respectively. Kaplan-Meier curves were generated for the two cohorts to compare the proportion of patients achieving energy delivery goal during the PICU course, censored to 12 days. The log rank sum test and hazards ratio were used to test the significance of difference between these cohorts.
Methods
Algorithm/Guideline Development
A stepwise, evidence-based algorithm for initiating, advancing, and maintaining EN in critically ill children was developed using a multidisciplinary consensus approach. A full description of the process is beyond the scope of this article and will be described separately. In brief, representatives from critical care nursing, critical care medicine, respiratory therapy, nutrition, gastroenterology, surgery, and pharmacy were among the key stakeholders who participated in the algorithm development process. Working groups were assigned eight major areas of inquiry: 1) nutritional assessment and screening, 2) indications and contraindications to EN, 3) advancement strategies for EN, 4) risk factors and strategies to prevent aspiration of gastric contents, 5) definition of EN intolerance and management strategies, 6) role of EN adjuncts such as antacids and promotility agents, 7) bowel management strategies to prevent and treat constipation, and 8) recommendations for fasting time around procedures. The designated groups examined the literature using a systematic approach for searching, grading, and reporting the evidence on each area and made recommendations based on the available evidence. These recommendations were translated into stepwise decision points in the EN algorithm.
The final guideline was drafted in the form of a stepwise algorithm and included 1) nutritional assessment and establishing nutrient intake goals, 2) selection of the mode of nutrition (EN vs PN) and selecting route of EN (gastric vs postpyloric), 3) initiation of EN, and 4) maintenance of EN. Figure 1 shows a condensed/simplified version of our full EN algorithm. (Screening procedures for nutritional status and contraindications to EN are described in Appendices 1 and 2 [Supplemental Digital Content 1, http://links.lww.com/PCC/A107], respectively. The criteria for "feeding intolerance" and "risk of aspiration" are available in Appendices 3 and 4 [Supplemental Digital Content 1, http://links.lww.com/PCC/A107], respectively.) The institutional nutritional advisory committee approved the guideline. An initial pretest administered to physicians and nurses allowed identification of areas of knowledge deficits and need for education. A computerized learning module, one-on-one education, and weekly nutrition rounds performed by members of the guideline development committee were included in the educational phase prior to dissemination of the guidelines via paper and electronic format to all personnel. We also incorporated reminders to review the nutrition algorithm and EN goals during daily bedside rounds.
(Enlarge Image)
Figure 1.
Stepwise algorithm for initiating and advancing enteral nutrition (EN) in the PICU. AG = abdominal girth, GRV = gastric residual volume, PN = parenteral nutrition.
Audit of Nutritional Outcomes Following Implementation of EN Algorithm
The impact of this intervention was examined by an audit of bedside nutrition practices over a 4-week period that mimicked the preintervention audit in patients who received EN with a length of stay more than 24 hours in the medical/surgical PICU at Boston Children's Hospital. After obtaining approval from the institutional review board, we prospectively recorded nutrient delivery, actual amount and route of nutrient intake, interruptions to EN, PN usage, and adequacy of energy delivery in this cohort. Clinical characteristics, details of enteral nutrient delivery, EN interruptions, PN use, and the ability and time to reach energy goal via the enteral route, were compared between the pre- and postimplementation cohorts. A dedicated nutrition team defined individual daily energy and volume goals for each patient. Standard energy equations (either the Schofield or World Health Organization [WHO]) were used to determine basal energy requirement. Clinical status was taken into account to determine the need for any additional "stress factors" as appropriate. For subjects more than 18 years old, the WHO equation was used when an accurate height or length was not available. The Schofield equation was preferred when both weight and height were reliably obtained. Nutrient delivery goals were reassessed regularly by the nutrition team during the course of illness and adjusted as necessary.
Data Recording and Analysis
Primary outcomes for the study included 1) total and avoidable interruptions to EN (number and duration of each episode), 2) time to initiate EN after PICU admission, 3) time to reach prescribed energy goal, and 4) PN use in patients with EN interruption. All episodes of interruption to EN delivery were examined, and avoidable episodes were identified a priori by consensus among the multidisciplinary group of investigators. Nurses completed the nutrition audit twice daily at the end of each 12-hour shift. These documents were examined daily by nursing investigators to allow for capture of any missing data. The accuracy of each nutrition audit was crosschecked with the existing electronic medical record. Clinical data, such as duration of mechanical ventilation support and length of PICU stay, were abstracted retrospectively from patient charts following completion of enrollment.
Patient characteristics were described using frequency tables for categorical variables and using measures of central tendency with spread for noncategorical variables. Variables that were reasonably normally distributed were described using mean and SD, whereas those displaying a high degree of skew were characterized by their median and interquartile range (IQR). Comparisons in patient characteristics were made between the cohorts before and after implementation of the nutrition algorithm. Tests of significance for two-group comparisons included Fisher exact test for categorical variables and Student t test and the Mann-Whitney rank sum test for normal and skewed distributions, respectively. Kaplan-Meier curves were generated for the two cohorts to compare the proportion of patients achieving energy delivery goal during the PICU course, censored to 12 days. The log rank sum test and hazards ratio were used to test the significance of difference between these cohorts.