1. Nutrition in Pediatric Cardiac Intensive Care
QUALITY IMPROVEMENT
INITIATIVE
Nutrition in Pediatric Cardiac Intensive Care
María Balestrini, MD
Pediatric Cardiac Intensive Care Unit
Pediatric Hospital J. P. Garrahan
Buenos Aires
Argentina

2. PCICU – PEDIATRIC HOSPITAL J. P. GARRAHAN
21 BEDS, 2 EXCLUSIVE OPERATING ROOMS, 5 SENIOR SURGEONS,
CARDIOLOGISTS AND PEDIATRIC CARDIAC INTENSIVISTS

3. PCICU - HOSPITAL GARRAHAN
New patients admitted for surgery 2014
563
Total assignable RACHS-1 patients
514
Neonatal surgeries 67
By pass
85%
Mortality rate 5%
Other programs
ECMO, Chronic ventricular support and heart transplant

4. PILLARS OF NUTRITIONAL SUPPORT IN THIS PERIOD
Preserve the function of vital organs, minimizing the loss of lean body mass, although it can not completely prevent catabolism.
Achieve positive nitrogen balance, which is crucial to growth
Avoid over feeding, leading to CO2 retention, difficulty in weaning ventilator and impaired immune function.

5. METABOLIC CHANGES IN THE IMMEDIATE POST SURGICAL
Limited glycogen storage
Cytokine mobilization
Mobilization of amino acids for gluconeogenesis
METABOLIC RESPONSE TO STRESS
More important in neonates
Returns to baseline values between 12 and 24 hours
INCREASED METABOLIC RATE
Generalized edema
Capillaritis (capillary leak syndrome)
Multiorgan failure.
INCREASED INFLAMMATORY RESPONSE

6. NUTRITIONAL SUPPORT PROGRAM DEVELOPEMENT
Discuss common feeding issues in patients with complex congenital heart disease
We reviewed previous practices and made a new feeding protocol
We examined preliminary data after the initiation of the new protocol at Garrahan Hospital.

7. FAILURE OF GROWTH
Common among infants with complex CHD: • Inefficient circulation • High metabolic demand during post-operative healing • Alterations in growth factors and growth hormone • Genetic syndromes • Poor oral skills • Gastrointestinal pathology • Associated with worse outcomes in CHD patients

8. PERIOPERATIVE FEEDING CONSIDERATIONS
Preoperatively
• Cyanosis and compromised systemic output
• Cardiac disease Prostaglandin (PGE) dependent
• Need of Umbilical Catheters
 Postoperatively
• Clinical weakness 
• High respiratory support 
• Inotropic support 
• Poor oral skills 
• Gastric dysmotility 
• Vocal cord paralysis

9. PREOPERATIVE FEEDING IN PGE DEPENDENT PATIENTS
• No increased risk of necrotizing enterocolitis (NEC) with early feeding in hemodynamically stable, cyanotic infants
 • No increase in adverse events with enteral feeding
 • No increased risk of NEC with umbilical artery catheters

10. BENEFITS OF EARLY ENTERAL FEEDING
• Improved nutritional status and growth prior to surgery
• Improved surgical outcome
• Enhanced intestinal maturation
• Improved feeding tolerance post-operatively
• Decreased length of parental nutrition
• Increased immunity

11. CONSENSUS FEEDING GUIDELINE
National Pediatric Cardiology Quality Improvement Collaborative
• Created in 2009 to improve outcomes among single ventricle patients
• Multidisciplinary Feeding Work Group
• Devised first consensus feeding guidelines for single ventricle infants
• Released guidelines in 2011

12. OUR FEEDING GUIDELINES
Previous guidelines 
• No recommendations on timing of pre or post-operative feed initiation 
• Post-operative feeds started continuously at
2 ml/hr 
• Increased by 1 ml/hr every 6 hours 
• Once at goal volume, caloric density slowly increased 
• Once at goal calories, progression to bolus schedule 

13. OUR FEEDING GUIDELINES
Previous guidelines
Parenteral nutrition was not initiated within 24 hours of surgery
Parenteral nutrition had significant deficit of nutrients
We invited a multidisciplinary committee to revise feeding guidelines 
New protocol implemented in January 2013

14. NEW FEEDING GUIDELINES
Focus of new guidelines
Early initiation of enteral feeds pre and post-operatively 
Oral feeding and breast feeding when possible 
Vocal cord paralysis assessment after aortic arch interventions 
Nasogastric tube bolus as preferred postoperative enteral feeding choice
Rapid full protein-caloric requirements achievement
A standard parenteral nutrition formula for infants with congenital heart disease was developed.

15. IMPLEMENTATION OF NUTRITIONAL SUPPORT IN THE IMMEDIATE POSTOPERATIVE PERIOD
Day 1
Standard Total Parenteral Nutrition
Day 2-3
Standard Total Parenteral Nutrition+Start enteral feeding
Onwards
Decrease in Total Parenteral Nutrition and progression of enteral feeding

16. PARENTERAL NUTRITIONAL SUPPORT
Volume: 60 ml/kg/day
Glucose flow: 7mg/kg /min
Amino acids: 3 g/kg/day
Lipids: 3 g/kg/day
Preparation 2 in 1
Central Line
Provides: 1 kcal/ml
Calories: Kcal / kg / day
Goal Calories: 90 – 100 Kcal/kg/day
Increase volumen
Glucose Peak flow 10 mg/kg/min
Check glycosuria
Suspend the TPN only if managed to obtain 75% of the total calories by enteral feeding

17. ENTERAL NUTRITION SUPPORT
Trophic mode feeding
Nasogastric tube (NG)
20-30 ml/Kg/day
Feeding mode
- NG
- Oral
- Bolus
- Continuous enteral feeding
Feeding options
- Human milk preferred
- Standard formula
- Hydrolyzed formula
Volume and Calories Goal
- Volume
ml/Kg/d
- Calories
Kcal/kg/d

18. NUTRITIONAL SUPPORT PROGRAM IMPACT EVALUATION
We conducted a prospective clinical study from 1 January 2013 to 31 December 2014
Less than 3 months perioperative patients, were included.

19. Initial evaluation Clinical, Anthropometric Laboratory, Feeding REE
72hs
Clinical, Laboratory, Feeding.
7th day
Clínical, Laboratory, Feeding
Hospital Discharge
Clinical, Anthropometric Laboratory, Feeding
CLINICAL STUDY
Anthropometric: Weight, height, head circumference. (mean and SD)
Laboratory: Glucose, albumin, total and ionized calcium, total magnesium, phosphorus, electrolytes, triglycerides
Resting energy expenditure (REE) assessment: using Schoffield and WHO equations.
Feeding characteristics: volume, formula, calories, proteins, lipids; enteral and parenteral

20. Diagnoses assignable RACHS-1 patients
CLINICAL STUDY
N 70 patients
Female 55%
Median age 17 days
(r1-120).
95% neonates
All term infants
Median weight 3,2 Kg (r1,9-5)
LOS 13 day (r1-160)
Survival 93%
Diagnoses assignable RACHS-1 patients
RACHS- 1 % 2
14,3 3
34,2 4 43 6
8,5

21. 5 deaths - 9 early Discharge
CLINICAL STUDY
Initial evaluation
70 Patients
72 hs
68 patients 2 deaths
7th Day
5 deaths - 9 early Discharge
Hospital Discharge
64 PATIENTS
COMPLETED THE STUDY

22. PREOPERATIVE VOLUME ML/KG 78,2 ± 21 CALORIES KCAL/KG 59 ± 10 TPN
MEDIAN
STANDARD DEVIATION
VOLUME
ML/KG
78,2
± 21
CALORIES
KCAL/KG 59
± 10
PREOPERATIVE
ENTERAL
MEDIAN
STANDARD
DESVIATION
VOLUME
ML/KG 77
± 43
CALORIES
KCAL/KG 62
± 38
% REE
MEDIAN SD
Schoffield
162
±86
WHO
163
±78

23. TPN 55%
MEDIAN
RANGE
VOLUME ML/KG 55
30-80
CALORIES KCAL/KG 60
30-76
POST OPERATIVE
72 HS
The sum of enteral and parenteral gives 66 kcal/ kg/day (r )
70% arrived at suggested target
ENTERAL 49%
MEDIAN
RANGE
VOLUME ML/KG 60
20-140
CALORIES KCAL/KG 50
% REE
MEDIAN
RANGE/SD
Schoffield
 127.7
41-328
WHO
137
±51

24. DISCHARGE ENTERAL MEDIAN RANGE 78% discharge with oral feeding,
VOLUME
ML/KG
140
60-160
CALORIES
KCAL/KG
120
DISCHARGE
78% discharge with oral feeding,
22% by nasogastric tube.
13 patients with exclusive breast feeding
9 patients combined breast feeding and formula
42 patients formula
WEIGHT (kg)
MEDIAN SD
ADMISSION
3,32
± 0,68
DISCHARGE
3,5
± 0,78

25. CONCLUSION Cardiovascular TPN standard was safely implemented.
Parenteral and enteral nutrition, alone or in combination exceeded REE requeriments, during perioperative course in all patients.
There were no patients with NEC
There was an increase in weight. Head circumference and height remained stable.

26. SUMMARY Nutrition is a major focus in improving the
outcome of children with complex CHD
Early pre-operative enteral feeding in this
patient population is safe.
Standardized approach in nutritional support is
likely to improve outcomes in patients with
congenital heart surgery, specially neonates and
small infants.

27. THANK YOU VERY MUCH