Safety of Enteral Feedings in Critically Ill Children Receiving Vasoactive Agents.

BACKGROUND: The objective of this retrospective study was to evaluate the safety of enteral feeding in children receiving vasoactive agents (VAs). METHODS: Patients aged 1 month to 18 years with a pediatric intensive care unit stay for ≥96 hours during 2007 and 2008 who received any VA (epinephrine, norepinephrine, vasopressin, milrinone, dopamine, and dobutamine) were included and categorized into fed and nonfed groups. Their demographics, clinical characteristics, type and dose of VA, and presence of gastrointestinal (GI) outcomes were obtained. GI outcomes were compared between the groups by the χ(2) test, Mann-Whitney test, and logistic regression. RESULTS: In total, 339 patients were included. Of these, 55% were in the fed group and 45% in the nonfed group. Patients in the fed group were younger (median age, 1.05 vs 2.75 years, respectively; P < .001) and tended to have a lower Pediatric Index of Mortality 2 (PIM2) risk of mortality (ROM) than those in the nonfed group (median, 3.33% vs 3.52%, respectively; P = .106). Mortality was lower in the fed group than the nonfed group (6.9% vs 15.9%, respectively; odds ratio [OR], 0.39; 0.18-0.84; P < .01, 95% CI), while GI outcomes did not differ between the groups. The vasoactive-inotropic score (VIS) did not differ between the groups except on day 1 (P = .017). The ROM did not differ between the groups after adjusting for age, PIM2 ROM, and VIS on day 1 (OR, 0.58; 0.26-1.28; P = .18, 95% CI). CONCLUSIONS: Enteral feeding in patients receiving VAs is associated with no difference in GI outcomes and a tendency towards lower mortality. Prospective studies are required to confirm the safety of enteral feedings in patients receiving VAs.

Early enteral nutrition is associated with lower mortality in critically ill children.

BACKGROUND: The purpose of this study was to examine the association of early enteral nutrition (EEN), defined as the provision of 25% of goal calories enterally over the first 48 hours of admission, with mortality and morbidity in critically ill children. METHODS: We conducted a multicenter retrospective study of patients in 12 pediatric intensive care units (PICUs). We included patients aged 1 month to 18 years who had a PICU length of stay (LOS) of ≥96 hours for the years 2007-2008. We obtained patients' demographics, weight, Pediatric Index of Mortality-2 (PIM2) score, LOS, duration of mechanical ventilation (MV), mortality data, and nutrition intake data in the first 4 days after admission. RESULTS: We identified 5105 patients (53.8% male; median age, 2.4 years). Mortality was 5.3%. EEN was achieved by 27.1% of patients. Children receiving EEN were less likely to die than those who did not (odds ratio, 0.51; 95% confidence interval, 0.34-0.76; P = .001 [adjusted for propensity score, PIM2 score, age, and center]). Comparing those who received EEN to those who did not, adjusted for PIM2 score, age, and center, LOS did not differ (P = .59), and the duration of MV for those receiving EEN tended to be longer than for those who did not, but the difference was not significant (P = .058). CONCLUSIONS: EEN is strongly associated with lower mortality in patients with PICU LOS of ≥96 hours. LOS and duration of MV are slightly longer in patients receiving EEN, but the differences are not statistically significant.

Registered dietitians making a difference: early medical record documentation of estimated energy requirement in critically ill children is associated with higher daily energy intake and with use of the enteral route.

BACKGROUND: Establishing a caloric requirement or energy target is a recommended part of any nutrition care plan. OBJECTIVE: Our objective was to describe early documentation of a caloric requirement in critically ill children, and to determine if this would have any effect on daily energy intake and route of nutrition. DESIGN: We used a descriptive chart review of a subgroup of patients included as part of a larger, retrospective multicenter study. Variables of interest included nutritional intake information, as well as presence/absence and amount of a documented caloric requirement within 48 hours of admission. PARTICIPANTS: Five of the original 12 study centers collected the required supplementary data. Enrolled patients were those who were admitted to our pediatric intensive care unit (PICU) from January 1, 2007, through December 31, 2008; were between ages 30 days and 18 years; and had a length of stay in the PICU ≥ 96 hours. STATISTICAL ANALYSIS: Energy intake among patients with and without a documented caloric requirement was analyzed using Mann-Whitney U tests. The difference of receiving enteral nutrition among patients with and without a caloric requirement was analyzed using a χ(2) test. RESULTS: We studied 1,349 patients, of whom 644 (47.7%) had a caloric requirement documented (95.6% of caloric requirements were entered by a registered dietitian) in the medical record; these patients had higher total daily energy intake and were more likely to be fed enterally during the first 4 days of PICU admission than those without a documented caloric requirement (P<0.001 for all comparisons). CONCLUSIONS: Less than half of critically ill children studied had a caloric requirement documented in the medical record; when a caloric requirement was documented in the medical record of a critically ill child, a registered dietitian had likely made the note. Having a caloric requirement documented in the medical record is associated with a higher energy intake and the use of the enteral route.