Protocol for treatment of constipation with polyethylene glycol 3350 plus electrolytes in critically ill children.

INTRODUCTION AND OBJECTIVES: No studies have analysed the effectiveness of treatment for constipation in critically ill children. The aim of this study was to assess the implementation, efficacy and safety of a treatment protocol using polyethylene glycol 3350 with electrolytes (PEG 3350 + E) for constipation in critically ill children. METHODS: We conducted a single-centre prospective study in children admitted to the paediatric intensive care unit for a minimum of 72 h and who developed constipation. Children with previous gastrointestinal disorders or diseases were excluded. The patients were treated with rectal enemas or with the oral PEG 3350 + E protocol at the discretion of the treating physician. We compared clinical and demographic variables as well as adverse events (diarrhoea, abdominal distension and electrolyte imbalances). RESULTS: The sample included 56 patients with a mean age of 48.2 ±â€¯11.9 months, of who 55.4% were male. Forty-four patients (78.6%) were treated with PEG 3350 + E and 12 (21.4%) with rectal enemas. The proportion of patients that responded well to treatment was greater in the PEG 3350 + E group (79.5%) compared to the enema group (58.3%), but the difference was not statistically significant (P = .151). There were no significant differences between the groups in any of the adverse effects. Treatment with PEG 3350 + E was more effective in children aged less than 2 years (100%) compared to older children (100% vs 65.4%; P < .01), with no significant differences in the development of adverse events. CONCLUSIONS: The PEG 3350 + E treatment protocol for constipation in critically ill children was effective and associated with few adverse events, even in children aged less than 2 years.

Comparison of the effect of three different protein content enteral diets on serum levels of proteins, nitrogen balance, and energy expenditure in critically ill infants: study protocol for a randomized controlled trial.

BACKGROUND: Nutritional support is essential in the care of critically ill children since malnutrition in this population is associated with increased morbidity and mortality. Injury in patients admitted to pediatric intensive care units (PICU) results in a catabolic state and augmented protein breakdown, leading to a negative protein balance. Current recommendations about protein prescription in the PICU are fundamentally based on expert opinions, and the minimum threshold is 1.5 g/kg per day of protein, although protein needs could be higher in certain subgroups of patients. The main objectives of the present study are to examine whether the administration of a protein-enriched infant formula increases the serum levels of total proteins, albumin, prealbumin, transferrin, and retinol and improves nitrogen balance and to analyze the effect of the high-protein diet on energy expenditure. A secondary objective is to register possible secondary effects of the protein-enriched diet. METHODS: A multicenter prospective randomized controlled trial (RCT) will be performed in three hospitals. Patients meeting inclusion criteria will be randomly allocated to one of three enteral feeding formulae with different protein contents. Blood and urine test, nitrogen balance assessment, and energy expenditure testing by indirect calorimetry will be performed at the beginning of the nutrition regimen and at 24 h, 72 h and 5-7 days after initiation. The sample size for this trial is estimated to be 90 participants (about 30 participants in each group). The data analysis will be by intention to treat. DISCUSSION: This RCT will provide new data about the amount of protein needed to improve levels of serum protein and nitrogen balance, a surrogate of protein balance, in critically ill infants receiving enteral nutrition. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03901742 . Registered April 1, 2019 - Retrospectively registered.

Adrenaline, terlipressin, and corticoids versus adrenaline in the treatment of experimental pediatric asphyxial cardiac arrest.

OBJECTIVE: To analyze if treatment with adrenaline (epinephrine) plus terlipressin plus corticoids achieves higher return of spontaneous circulation than adrenaline in an experimental infant animal model of asphyxial cardiac arrest. DESIGN: Prospective randomized animal study. SETTING: Experimental department in a University Hospital. SUBJECTS: Forty-nine piglets were studied. INTERVENTIONS: Cardiac arrest was induced by at least 10 minutes of removal of mechanical ventilation and was followed by manual external chest compressions and mechanical ventilation. After 3 minutes of resuscitation, piglets that did not achieve return of spontaneous circulation were randomized to two groups: adrenaline 0.02 mg kg every 3 minutes (20 animals) and adrenaline 0.02 mg kg every 3 minutes plus terlipressin 20 µg kg every 6 minutes plus hydrocortisone 30 mg kg one dose (22 animals). Resuscitation was discontinued when return of spontaneous circulation was achieved or after 24 minutes. MEASUREMENT AND MAIN RESULTS: Return of spontaneous circulation was achieved in 14 piglets (28.5%), 14.2% with only cardiac massage and ventilation. Return of spontaneous circulation was achieved in 25% of piglets treated with adrenaline and in 9.1% of those treated with adrenaline plus terlipressin plus hydrocortisone (p = 0.167). Return of spontaneous circulation was achieved in 45.4% of animals with pulseless electric activity, 20% with asystole, and 0% with ventricular fibrillation (p = 0.037). Shorter duration of cardiac arrest, higher mean blood pressure and EtCO2 and lower PaCO2 before resuscitation, and higher mean blood pressure during resuscitation were associated with higher return of spontaneous circulation. CONCLUSIONS: Treatment with adrenaline plus terlipressin plus corticoids does not achieve higher return of spontaneous circulation than that with adrenaline in an infant animal model of asphyxial cardiac arrest.

Enteral nutrition in the critically ill child: comparison of standard and protein-enriched diets.

OBJECTIVE: To compare a standard diet and a protein-enriched diet in critically ill children. STUDY DESIGN: In this prospective randomized controlled trial in critically ill children, all patients received enteral nutrition exclusively and were randomly assigned to a standard diet or a protein-enriched diet (1.1 g protein/100 mL of feeding formula). Blood and urine tests, nitrogen balance assessment, and energy expenditure testing by indirect calorimetry were performed before the beginning of the nutrition regimen and at 24 hours, 72 hours, and 5 days after initiation. Demographic data and pediatric mortality risk scores were recorded. RESULTS: Fifty-one children were randomized, and 41 completed the study. Of these, 21 patients received standard formula and 20 received a protein-enriched formula. There were no between-group differences in terms age, sex, diagnosis, or mortality risk scores. There was a greater positive trend in levels of prealbumin, transferrin, retinol-binding protein, and total protein in the protein-enriched diet group. These differences were significant only for retinol-binding protein. The positive nitrogen balance trend was also higher in the protein-enriched diet group; however, this difference did not reach statistical significance. No adverse effects or hyperproteinemia were detected in the protein-enriched diet group. CONCLUSIONS: The standard diet provides insufficient protein delivery to critically ill children. Enteral protein supplementation is safe and can improve some biochemical parameters of protein metabolism.

Stability of continuous renal replacement therapy solutions after phosphate addition: an experimental study.

The incidence of hypophosphatemia is high in critically ill children on continuous renal replacement therapy (CRRT) and the addition of phosphate supplements to the replacement and dialysis fluids reduces the frequency of hypophosphatemia. The objective of this study was to determine the in vitro stability of the CRRT solutions after phosphate addition. Three different concentrations of phosphate, 2.5, 4.6 and 7.7 mg/dL, in the replacement and dialysis fluids were analyzed. The pH, glucose, total calcium, phosphate, and magnesium were determined before adding the phosphate and at 2, 24, and 48 h after its addition. The bags were macroscopically observed for possible precipitation. After addition of the phosphate, its concentration remained stable and there were no significant changes in the concentrations of the other components. There were no visible signs of precipitation up to 48 h. The addition of phosphate to the CRRT fluids at concentrations of up to 7.7 mg/dL does not cause problems with precipitation or instability of the mixture.

Hypophosphatemia and phosphate supplementation during continuous renal replacement therapy in children.

Severe hypophosphatemia can cause generalized muscle weakness, paralysis of the respiratory muscles, myocardial dysfunction, reduced peripheral vascular resistance, and encephalopathy. Here we conducted a prospective study to determine the incidence of hypophosphatemia in 47 children on continuous renal replacement therapy and to evaluate the efficacy and safety of adding phosphate to the replacement and dialysate solutions of 38 pediatric patients. During continuous renal replacement therapy, 68% of patients were found to have hypophosphatemia, significantly more than the 12% of patients at the beginning of therapy. There was no higher incidence of hypophosphatemia among patients requiring insulin, diuretics, parenteral nutrition, or high doses of vasoactive drugs. In the children to whom phosphate was not added to replacement and dialysate solutions, 85% presented with an incidence of hypophosphatemia and 36% required intravenous phosphate replacement, rates significantly higher than in those patients where phosphate was added to the solutions. Phosphate supplementation did not cause any instability of the mixtures or other complications. We show here that the incidence of hypophosphatemia in children on continuous renal replacement therapy is very high. Further, we show that the addition of phosphate to replacement and dialysate solutions is safe and that it reduces the incidence of hypophosphatemia and the need for intravenous phosphate treatment.