K. A. Ohman1, T. CreveCouer1, A. M. Vogel2 1Washington University,Department Of Surgery,St. Louis, MO, USA 2Washington University,Division Of Pediatric Surgery,St. Louis, MO, USA
Introduction: Nutritional adequacy (NA) in intensive care unit patients is low and inversely correlated with morbidity and mortality. Neonatal and pediatric patients requiring extracorporeal life support (ECLS) represent a subset of critically ill patients whose nutritional delivery by enteral (EN) and parenteral (PN) routes has not been well characterized. Barriers to providing nutrition, particularly EN, exist although multiple studies document the feasibility and safety and current guidelines recommend EN for neonates on ECLS. This study describes nutritional delivery in neonatal and pediatric patients who received ECLS with a focus on NA and outcome.
Methods: A single-center, retrospective review of all neonatal and pediatric patients who underwent ECLS from January 1, 2013 through December 31, 2014 was performed. Demographic, clinical, and outcome data was abstracted. Daily energy and protein prescriptions and amount administered were recorded. NA for energy and protein was defined as the mean percentage of what was prescribed and defined as low (<50%), moderate (50-80%), and high (>80%). Patients whose duration of ECLS was < 48 hours were excluded. Congenital diaphragmatic hernia patients were excluded from EN analysis. Descriptive statistical analyses were performed.
Results: We identified 70 patients; 57.1% were male and median age was 4 months (IQR 72 months). 54 (77.1%) were initiated on venoarterial and 16 (22.9%) on venovenous ECLS. Overall survival was 62.9%. Mean ECLS duration was 220.1 hours; mean duration of mechanical ventilation was 20 days. Categories included: 12 (17.1%) neonatal respiratory, 14 (20.0%) pediatric respiratory, 16 (22.9%) neonatal cardiac, and 28 (40.0%) pediatric cardiac. 23 (32.9%) received nutrition prior to ECLS, but only 8 (11.4%) achieved goal EN prior to ECLS. Mean time to initiation of nutrition was 1.1 ± 1.3 days; mean time to initiation of EN was 4.2 ± 3.4 days. Mean time without any nutritional prescription was 1.4 ± 1.4 days; when nutrition was prescribed, mean energy NA was 92% of the daily goal for energy and 100% for protein. Energy NA, when prescribed, for neonatal respiratory, pediatric respiratory, neonatal cardiac, and pediatric cardiac was 89%, 88%, 95%, and 92%, respectively. However, EN only accounted for 24% of the NA goal. However, when all ECLS days are accounted for, including days without nutrition, only 27.1% achieve high NA. There was no direct correlation with survival. Gastrointestinal complications occurred in 13.6% of survivors and 26.7% of non-survivors.
Conclusion: NA in this neonatal and pediatric ECLS population is poor and utilization of enteral nutrition is low. When nutrition is prescribed, NA is met, but overall NA remains poor due to delayed onset and days without nutrition. Survival was not directly associated with NA as there are confounding variables, but improving NA may represent an opportunity to improve outcome in these critically ill patients.