Background

There are many myths and misconceptions around enteral nutrition in the critically ill child.

Objectives

This talk will review common myths and misconceptions and prevent evidence to disprove these

Methods

Interactive evidence based session

Results

Common misconcpetions and myths will be presented and discussed with the audience amnd then the evidence for these presented with a final conclusion

Conclusion

Common myths and misconceptions are enteral feeding after contribute to underfeeding or inadquate nutrition in the critically ill neoante and child

Background

Despite little evidence, the practice of routine measurement of gastric residual volume to guide both the initiation and delivery of enteral feeding in pediatric intensive care units is widespread internationally. In light of increased scrutiny of the evidence surrounding this practice, and as part of a trial feasibility study,

Objectives

To determine enteral feeding and Gastric Residual Volume (GRV) measurement practices in United Kingdom (UK) Pediatric Intensive Care Units (PICUs).

Methods

On-line cross-sectional survey to all UK PICUs in our network.

Results: 24/27 (89%) units approached completed the survey. Twenty-three units (95.8% 23/24) had written feeding guidelines and 19 units (19/23 83%) sent their guidelines for review. More units fed continuously (15/24 62%) than intermittently (9/24 37%) via the gastric route as their primary feeding method. All but one PICU routinely measured GRV, regardless of the method of feeding. Eighteen units had an agreed definition of feed tolerance, and all these included GRV. GRV thresholds for feed tolerance were either volume based (ml/kg body weight) (11/21 52%) or a percentage of the volume of feed administered (6/21 29%). Yet only a third of units provided guidance about the technique of GRV measurement.

Conclusion

Routine GRV measurement is part of standard practice in UK PICUs, with little guidance provided about the technique, which can influence the accuracy of GRV. All PICUs that defined feed tolerance included GRV in the definition.

Background

Hyperbaric oxygenation (HBO) has proved itself as an effective way of treatment in different cases, for example in hypoxia. However, the exact in vivo biochemical mechanisms of HBO are to be revealed.

Objectives

We used ³¹P and ¹H magnetic resonance spectroscopy (MRS), as well as resting state functional magnetic resonance imaging (rs-fMRI) in order to find the effects of one HBO session on human brain in vivo.

Methods

MRI scanner 3.0T and hyperbaric chamber Sechrist 3200 were used in the study. Seventeen subjects participated in ³¹P MRS part, and 12 subjects - in ¹H and rs-fMRI part. The data were collected in MRI scanner during ~20 minutes before HBO session and right after it. Spectroscopy data were processed in jMRUI (in case of ³¹P) and LCModel (¹H). The concentrations of creatine phosphate (PCr), ATP and NAD (indirectrly) in whole brain, and of N-acetylaspartate (NAA) in voxels, (see fig.1) after HBO were normalized on the corresponding values after HBO, these values were compared with the value=1 (Mann-Whitney). Rs-fMRI data were processed in CONN (Matlab), the effect of HBO on MPFC-PCC connectivity was found.

Results

After HBO session decreased: PCr (by 3%), NAA in MPFC and PCC (by 4%), NAD increased (by 6%), ATP remained unchanged. The MPFC-PCC connectivity increased (fig.2)

Conclusion

Decrease in PCr and NAA manifestates energy metabolism activation. Together with the increase in NAD and functional connectivity this is the confirmation of HBO effectiveness even at low pressures, that may help to overcome the effect of such diseases as acute ischemia or TBI.

Background

Optimisation of early nutrition in very preterm infants prevents postnatal growth failure. Limitations from individualised parenteral nutrition (PN) include delay in starting PN which can compromise nutrition. Standardised concentrated PN based on the ‘SCAMP’ regimen was introduced in University Hospitals of Leicester (UHL) in December 2017, replacing individualised PN.

Objectives

Assess the feasibility and impact on growth due to standardised concentrated PN

Methods

Infants born between September to November 2017 receiving PN within 24 hours old at UHL were compared with those in 2018. Retrospective and prospective data collection of growth parameters and cost analysis were carried out for both cohorts. Growth parameters were converted to z scores using LMS method. Continuous data were compared using Mann Whitney test.

Results

21 and 20 infants were included for the 2017 and 2018 periods with a mean gestation of 29.6 and 28.0 weeks respectively. PN was started earlier after introduction of standardised concentrated PN (median 8 hours (n=20) in 2018 vs 25 hours (n=19) in 2017, P<0.0001). No statistical difference in change of weight z score was seen at 28 days of age (median -0.43 (n=18) in 2018 vs -0.66 (n=19) in 2017, p=0.6) and at discharge/36 weeks corrected (median -0.7 (n=12) in 2018 vs -0.86 (n=21) in 2017, p=0.4). Standardised concentrated PN reduced procurement costs by 29% compared with individualised PN.

Conclusion

Standardised concentrated PN is feasible and reduces the time to start PN and cost. The small sample size may account for the lack of statistical significance in improvement of weight z score seen.

Background

Children with an inborn error of metabolism (IEM) requiring PICU admission are a challenge. Acute infections can cause severe metabolic decompensation and hasten underlying disease progression. Metabolic team is of immense value in optimal management . These patients also present ethical challenges as reorientation of care or long term ventilation may need discussed.

Objectives

a) Record PICU management of four patients with different rare IEM who were critically unwell, required extensive multidisciplinary team involvement, made good recovery and discharged home.

b) Highlight specialist team involvement; special dietary management and raise ethical issues arising during long PICU course.

Methods

Patients with known or newly diagnosed IEM admitted to PICU had clinical data collected prospectively over 6 months. Literature reviews were performed on each diagnoses using Ovid with mesh terms of ‘paediatric,’ in addition to relevant diagnosis.

Results

Leigh Syndrome; Proprionic Acidemia; Mitochondrial disorder and Riboflavin transporter defect were the 4 different metabolic conditions managed in PICU in the 6 month time period. Mortality rates for these conditions in literature review were up to 50%. In our PICU all 4 required multi-organ support and extensive MDT involvement and successfully recovered - 2 patients required tracheostomy and long term home ventilation support.

Conclusion

Patients with IEM admitted to PICU have lengthy admissions , require prompt intensive care management and can have a high mortality. These four cases demonstrate that although their journey through PICU is long and difficult , a multidisciplinary team working together for the child can lead to satisfactory outcomes.