Ultrasound Assessment of Quadriceps Femoris Muscle Thickness in Critically Ill Children.

OBJECTIVES: Evaluate the reliability of ultrasound to measure quadriceps femoris muscle thickness in critically ill children and to describe serial changes in quadriceps femoris muscle thickness in relation to fluid balance and nutritional intake. DESIGN: Prospective observational study. SETTING: Tertiary care children's hospital. PATIENTS: Inpatients age 3 months to 18 years recently admitted to the ICU who were sedated and mechanically ventilated at the time of the first ultrasound scan. METHODS: Prospective observational study to examine the reliability of averaged ultrasound measurements of quadriceps femoris muscle thickness. Change in average quadriceps femoris muscle thickness over time was correlated with fluid balance and nutritional intake. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Averaged quadriceps femoris muscle thickness demonstrated good to excellent reliability when comparing pediatric critical care providers to pediatric radiologists and when comparing between different pediatric critical care providers. We found no significant association between fluid balance over 1 or 3 days and change in quadriceps femoris muscle thickness over the same time frame. However, there was a significant association between percent of goal calories (p < 0.001) or percent of goal protein (p < 0.001) over 6 days and change in quadriceps femoris muscle thickness over the same time frame. CONCLUSIONS: Averaged ultrasound measurements of quadriceps femoris muscle thickness demonstrate good to excellent reliability, are not confounded by fluid balance, and are useful for tracking changes in muscle thickness that are associated with nutritional intake. Ultrasound-based assessment of quadriceps femoris is a clinically useful tool for evaluating muscle mass and may be a proxy for nutritional status.

Feasibility of bioimpedance spectroscopy and long-term functional assessment in critically ill children.

BACKGROUND & AIMS: Lean body mass loss due to critical illness in childhood could be detrimental to long term outcomes, including functional status and quality of life. We describe the feasibility of body composition assessment by bioimpedance spectroscopy (BIS) in the pediatric intensive care unit (PICU), and functional status and quality of life assessments up to 6 months following admission in a cohort of mechanically ventilated, critically ill children. METHODS: We conducted a prospective, observational pilot study in a multidisciplinary PICU. Children aged 1 month to 18 years who required mechanical ventilation, with expected stay in the PICU of at least 5 days were included. We examined the feasibility of consenting, enrolling, and completing baseline and 6-month assessments of BIS variables, Functional Status Scale (FSS), and Pediatric Quality of Life (Peds QL), in eligible patients. RESULTS: Of 32 patients approached, 23 (72%) completed baseline assessments [median (IQR) age 3.4 (1.0, 7.8) years, 14 (61%) male]; 6-month assessments were completed in 15 (65%) enrolled patients. Mean (SD) phase angle at study enrollment was 2.95 (0.93) and the impedance ratio was 0.90 (0.03). Phase angle (rs = -0.58, p = 0.03) and impedance ratio (rs = 0.61, p = 0.02) by BIS were significantly correlated with total FSS at PICU discharge. Median total FSS and FSS tech (feeding and respiratory domains of FSS) scores improved from enrollment [16 (13, 26) and 8 (7, 10)] to 6 months [6 (6, 9) and 2 (2, 4), respectively, p < 0.001]. Median Peds QL total, physical summary and psychosocial summary scores were not significantly different between PICU discharge and 6 months after PICU admission. Correlations between the total 6-month FSS and a) phase angle (-0.45, p = 0.197) and b) impedance ratio (0.56, p = 0.096) at PICU discharge were not significant. CONCLUSIONS: We have demonstrated the feasibility of obtaining bedside BIS measurements in the PICU, and functional and quality of life assessments remotely following PICU discharge. Body composition and long-term assessment of functional outcomes and quality of life must be incorporated in nutrition trials in critically ill children.

Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit.

BACKGROUND: Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program. METHODS: In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined. RESULTS: The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction. CONCLUSION: Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.

Energy and Protein Delivery in Overweight and Obese Children in the Pediatric Intensive Care Unit.

BACKGROUND: Early and optimal energy and protein delivery have been associated with improved clinical outcomes in the pediatric intensive care unit (PICU). Overweight and obese children in the PICU may be at risk for suboptimal macronutrient delivery; we aimed to describe macronutrient delivery in this cohort. METHODS: We performed a retrospective study of PICU patients ages 2-21 years, with body mass index (BMI) ≥85th percentile and >48 hours stay. Nutrition variables were extracted regarding nutrition screening and assessment, energy and protein prescription, and delivery. RESULTS: Data from 83 patient encounters for 52 eligible patients (52% male; median age 9.6 [5-15] years) were included. The study cohort had a longer median PICU length of stay (8 vs 5 days, P < .0001) and increased mortality rate (6/83 vs 182/5572, P = .045) than concurrent PICU patient encounters. Detailed nutrition assessment was documented for 60% (50/83) of patient encounters. Energy expenditure was estimated primarily by predictive equations. Stress factor >1.0 was applied in 44% (22/50). Median energy delivered as a percentage of estimated requirements by the Schofield equation was 34.6% on day 3. Median protein delivered as a percentage of recommended intake was 22.1% on day 3. CONCLUSIONS: The study cohort had suboptimal nutrition assessments and macronutrient delivery during their PICU course. Mortality and duration of PICU stay were greater when compared with the general PICU population. Nutrition assessment, indirect calorimetry-guided energy prescriptions, and optimizing the delivery of energy and protein must be emphasized in this cohort. The impact of these practices on clinical outcomes must be investigated.