Topic Discussions

Feeding in PICU

  • Kids are at inc risk for developing nutritional deficiencies
  • Adults BMR (basal metabolic rate) = ~20cal/kg/day
  • Infants BMR = 50-60 cal/kg/day
  • ~1/3 of baby’s calories ==> growth
  • ~15% of teen’s calories ==> growth
  • Window for how long you can leave NPO is shorter in peds
  • Under-nutrition is associated with:
    • —Increased morbidity and mortality
    • —Increased LOS
    • —Increased days on ventilator
    • —Decreased weight and muscle mass
    • —Higher risk of infection
    • —Worsened immune function
    • —Delayed wound healing

GOT:

  • A goal is typically NOT to have weight gain in ICU (assuming they are still acutely ill) since when they are ill they won’t grow (not the case if its a “live-in” patient whose been in ICU for months)
  • To preserve lean body mass and prevent muscle catabolism following acute injury or stress
  • Maintain fluid, electrolyte and glucose homeostasis

Fluids:

  • 4-2-1 rule –> take 60-80% for feeds & meds
    • The Holliday-Segar overestimates fluid needs in ICU
  • Inc ADH in trauma/post-op/etc. = dec. Na+
  • Mg in blood = 1% of total body Mg

Glucose infusion rate:

  • Neonates GIR: 5-6 mg/kg/min
  • Kids GIR: 4-6 mg/kg/min needed to prevent hypoglycemia
  • GIR = rate/hr * 24hr * dextrose [ ] (10g/100mL) / wt(kg) / 1.44 = mg/kg/min

How much to feed:

  • If I&V aim to feed ~BMR+10% (=REE: resting energy expenditure)
    • 1-10kg = 75% maintenance
    • 10-30kg = 65% maintenance
    • >30kg = 50% maintenance
  • Note while kcal needs are less than usual in an acuity state, protein needs are 1.5-2x normal. –> sol’n = protein powder to feeds (if expecting longer LOS)
  • Feeding when NPO can be a risk
    • ~4 hr before procedures needing general anaesthetics
      • <1 y/o = D10NS
      • > 1 y/o = D5NS
    • Exception: burn pts (no NPO pre-op), get feeds NJ (only NPO at time of OR)

TPN:

  • TPN – cholestasis can appear w/in 2 weeks
  • Access:
    • Peripheral lines <900 mOsm/L –> so only used as bridging until central line is in
      • ADRs: thromboplebitis, extravasation, catheter occlusion
    • Central lines preferred – but there’s an OR wait for them
  • Macronutrients recommendations to prevent cholestasis
  • In PICU TPN aims are usually “days 1-2” not 3 becuase only need resting energy expenditure
  • No insulin added to our TPNs (@BCCH)
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