Frontier Lifeline Hospital , Chennai , India Peri-operative Nutrition Supplementation in Congenital Heart Surgery- A clinical audit and plan for Quality Improvement Frontier Lifeline Hospital , Chennai , India

Background Malnutrition- a major problem in developing countries More prevalent among children with congenital heart diseases, particularly ones with Increased Pulmonary blood flow and Cardiac failure Other contributing factors: Low birth weight, Anemia, Recurrent Infections

More than 30 per cent of children in Tamil Nadu aged under 5 years are underweight More than 30 per cent of adolescent girls (15–19 years) and half of pregnant women (15-19 years) are anemic

Congenital Heart Disease is indeed a major cause of Neonatal and Infant Mortality The Infant Mortality Rate (IMR) in Tamil Nadu is 22 deaths per 1000 live births Almost three quarters of infant deaths in the state occur within 28 days of birth and 77 per cent of neonatal deaths occur within the first seven days of life (Early Neonatal Mortality) -

Among children undergoing Cardiac Surgery: Neonates: 30 % are Low birth weight Infants: 60 % are malnourished

Poor preoperative nutritional state -often exacerbated postoperatively by the metabolic response – altered energy demands, a complex inflammatory state, and protein catabolism Greater risk for developing infection and poor wound healing All these can have impact on post operative outcomes.

Factors affecting Postop Nutrition Increased metabolic demands Inefficient nutrient absorption Postsurgical fluid restriction oropharyngeal dysfunction Frequent interruptions of enteral feeding for procedures

Finding a balance of appropriate nutritional intake to cover metabolic demands in infants and young children postoperatively remains a frequent challenge So our aim was to conduct an audit on the efficiency of our nutrition protocols to meet the necessary demands.

Objectives of the audit To review our Peri-operative nutrition protocols , and to assess how they meet the demands To assess the extent of documentation in case records, so that outcomes could be measured To propose modifications in protocols and ensure adequate documentation To implement the protocols and re audit at the end of 6 months

Methods A retrospective chart review of patients admitted postoperatively to the intensive care unit at Frontier Lifeline Hospital 30 case records of children < 24 months of age were reviewed

The following variables were obtained: Age, gender, admission weight, and length of admission. Weights were recorded at the time of admission (pre op ) and at discharge from the hospital when available.

Medical records were reviewed for the following data All forms of dextrose-containing intravenous fluids, enteral nutritional intake received in the ICU Nutritional support data obtained included postoperative day that enteral or parenteral nutrition was initiated,and quantity of nutrition As the study focused on patients younger infants, majority of oral intake was in the form of breast milk, infant and pediatric formulas

The patient’s daily energy and protein intake was calculated until discharge from ICU To determine caloric requirements, a stress factor of 1.5 was added The total caloric and protein requirements met with each day was calculated

Dietary Protocol Calculations based on standard formula (National Institute of Nutrition , Hyderabad , India ) Stress factor of 0.5 was added Early enteric feeding always preferred Concentration of feed : 1-1.2 cals / ml

Results: Total no. of patients reviewed: 30 Males: 21 Females: 9 Age distribution: Neonates- 4 1mo – 1 year - 23 > 1 year - 3

Pre op Malnutrition Weight for age < 50 Th centile: 26/30(80%) Height for age < 50 th centile: 21/30 ( 67 %) Weight for Height < 50 th centile -21/30 (67 %) Reference: Indian Academy of Pediatrics Growth Charts

Median ICU stay for malnourished children: 66 hours

0-30 days

1mo-1 year

>1 year

Observations 2/3 subjects had Pre op Chronic and Acute on Chronic Malnutrition Nearly 80 % had acute malnutrition pre op

Observations Maximum amount of calorie and protein needs met during ICU stay has been upto 60-70 % of estimated needs There has been a constant step up day by day in meeting the needs

The nutritional needs are upto 60 % in spite of adding a stress factor to calculate needs Inability to deliver required amounts is due to: 1Fluid restriction 2. Feed withdrawal due to various reasons 3. Feed Intolerance due to gut edema etc.

Observation on Documentation Many charts had missing data on feed administration and reason for withdrawal Daily weight recording in ICU and discharge from ICU absent in many charts

Prolonged ICU stays We have not reviewed patients with prolonged ICU stay , beyond 7 days Need for Total Parenteral /Enteral nutrition/ supplements of multi vitamins and minerals need to be looked into.

Recommendations ASPEN –American Society for Parenteral and Enteral Nutrition guidelines

Nutritional support guidelines in critically ill child 1 A- Children admitted with critical illness should undergo nutrition screening to identify those with existing malnutrition and those at risk. A formal nutritional assessment with development of nutrition care plan esp in children with premorbid malnutrition. Energy expenditure should be assessed throughout the course of illness to determine the energy needs of critically ill children.

Malnutrition or metabolic alterations- accurate measurement of energy expenditure using indirect calorimetry or normograms. Insufficient data to make evidence based recommendations for macro nutrition intake in critically ill children.

Functioning GIT, enteral nutrition (EN) should be the preferred mode of nutrition. Prevent avoidable interruptions to EN Routine use of immunonutrition or immune enhancing diets –NOT recommended. Specialised nutrition support group with appropriate protocols

From our protocols and audit A reasonable dietary plan has been made Have achieved upto 60-70 % of requirements, comparable to major studies Certain shortcomings in documentation.

Recommendations in the proposed project Better Pre op Nutritional assessment including Serum Albumin level if possible Pre op nutritional supplementation wherever possible Daily weight recording in ICU and until discharge

Better documentation of Enteral feeding Correlation of nutritional status with ICU stay, hospital outcomes

A prospective collection of data regarding nutritional supplementation to be done for 6 months A re audit and study at the end of 6 months to assess outcomes To propose a standard protocol of perioperative Nutrition which can be used across various units as a part of the IQIC

Acknowledgements Department of Paediatric Cardiology and Cardiac Surgery Department of Dietetics Physician Assistants

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