Judith Ju-Ming Wong

Protocol-Driven Enteral Nutrition in Critically Ill Children A Systematic Review

Enteral nutrition (EN) protocols are thought to improve clinical outcomes in the pediatric intensive care unit (PICU); however, critical evaluation of their efficacy is limited. We conducted a systematic review with the aim of assessing the effect of EN protocols on important clinical outcomes in these children. We searched MEDLINE, Cochrane Database for Reviews, Embase, and CINAHL using predetermined keywords and MESH terms. We included randomized controlled trials (RCTs) and observational studies that involved EN protocols in children admitted to the PICU for >24 hours. We included studies that reported at least 1 of our outcomes of interest. Studies that exclusively studied premature neonates or adults were excluded. Primary outcomes were PICU or hospital mortality, PICU or hospital length of stay (LOS), duration of mechanical ventilation, gastrointestinal (GI) complications, and infective complications. Secondary outcomes were time to initiate feeds and time to achieve goal feeds. In total, we included 9 studies (total 1564 children) in our systematic review (1 RCT, 4 before-and-after studies, 1 single-arm cohort study, 1 prospective descriptive study, and 2 audits). There is low-level evidence that the use of EN protocols is associated with a reduction in GI and infective complications and improved timeliness of feed initiation and achievement of goal feeds. Current medical literature does not have compelling data on the effects of an EN protocol on clinical outcomes among critically ill children. Future clinical trials should look into using standardized interventions and outcome measures to strengthen the existing evidence.

Epidemiology of pediatric acute respiratory distress syndrome in singapore: risk factors and predictive respiratory indices for mortality.

Aim: Acute respiratory distress syndrome (ARDS) represents the most severe form of acute lung injury. The aim of our study is to describe the epidemiology of pediatric ARDS in Singapore and compare the outcomes of ARDS using the following respiratory indices: PaO2/FiO2 ratio (P/F ratio), SpO2/FiO2 ratio (S/F ratio), oxygenation index (OI), and oxygen saturation index (OSI). Methods: We examined medical records of patients admitted to the Children’s Intensive Care Unit in KK Women’s and Children’s Hospital from 2009 to 2012. Those who fulfilled criteria for the American-European Consensus Conference definition for ARDS were identified. Demographic, clinical, and radiographic information were extracted and analyzed. Results: We identified 70 patients with ARDS. Median age (interquartile range) was 6.2 (1.4, 10.4) years. The most common risk factor was pneumonia [50 (71%)]. Overall mortality was 44 (63%) patients. Thirty-two (56%) patients had an underlying chronic comorbidity; 18 (46%) were hematology–oncology conditions. Fifty-six (80%) patients had multiorgan dysfunction. Adjunct therapies used in our patients included inhaled nitric oxide [5 (7%)], prone position [22 (31%)], steroids [26 (37%)], and neuromuscular blockade [26 (37%)]. A high OI and low PF ratio after 24 h of diagnosis of ARDS were associated with mortality. From day 3 onward, all four respiratory indices appropriately differentiated survivors from non-survivors. Severity based on the S/F ratio and OSI demonstrated association with decreased ventilator free days and ICU free days. Conclusion: Risk factors for mortality included having an underlying comorbidity, multiorgan dysfunction, a low PF ratio, and high OI at 24 h of ARDS. Abnormal SpO2-based measurements were reliable markers of poor outcomes in pediatric ARDS.

Nutrition Delivery Affects Outcomes in Pediatric Acute Respiratory Distress Syndrome

Background: Malnutrition is prevalent in critically ill children. We aim to describe nutrition received by children with acute respiratory distress syndrome (ARDS) and to determine whether provision of adequate nutrition is associated with improved clinical outcomes. Materials and Methods: We studied characteristics and outcomes of 2 groups of patients: (1) those who received adequate calories (defined as ≥80% of predicted resting energy expenditure) and (2) those who received adequate protein (defined as ≥1.5g/kg/d of protein). Outcomes of interest were mortality, ventilator-free days (VFDs), intensive care unit (ICU)–free days, multiorgan dysfunction, and need for extracorporeal membrane oxygenation. Categorical variables were analyzed using the Fisher exact test, and continuous variables were analyzed using the Mann-Whitney U test. Univariate and multivariate logistic regression models were used to identify associated risk factors related to these outcomes of interest. Results: In total, 107 patients with ARDS were identified. There was a reduction in ICU mortality in patients who received adequate calories (34.6% vs 60.5%, P = .025) and adequate protein (14.3% vs 60.2%, P = .002) compared with those that did not. Patients with adequate protein intake also had more VFDs (median [interquartile range], 12 [3.0–19.0] vs 0 [0.0–14.8] days; P = .005). After adjusting for severity of illness, adequate protein remained significantly associated with decreased mortality (adjusted odds ratio [95% confidence interval], 0.09 [0.01–0.94]; P = .044). Conclusion: Our study demonstrated that adequate nutrition delivery in children with ARDS was associated with improved clinical outcomes. Protein delivery may have potentially more impact than overall caloric delivery.

Mortality in Pediatric Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis

Objective: Sparse and conflicting evidence exists regarding mortality risk from pediatric acute respiratory distress syndrome (ARDS). We aimed to determine the pooled mortality in pediatric ARDS and to describe its trend over time. Data Sources and Study Selection: MEDLINE, EMBASE, and Web of Science were searched from 1960 to August 2015. Keywords or medical subject headings (MESH) terms used included “respiratory distress syndrome, adult,” “acute lung injury,” “acute respiratory insufficiency,” “acute hypoxemic respiratory failure,” “pediatrics,” and “child.” Study inclusion criteria were (1) pediatric patients aged 0 days to 18 years, (2) sufficient baseline data described in the pediatric ARDS group, and (3) mortality data. Randomized controlled trials (RCTs) and prospective observational studies were eligible. Data Extraction and Synthesis: Data on study characteristics, patient demographics, measures of oxygenation, and mortality were extracted using a standard data extraction form. Independent authors conducted the search, applied the selection criteria, and extracted the data. Methodological quality of studies was assessed. Meta-analysis using a random-effects model was performed to obtain pooled estimates of mortality. Meta-regression was performed to analyze variables contributing to change in mortality over time. Eight RCTs and 21 observational studies (n = 2274 patients) were included. Pooled mortality rate was 24% (95% confidence interval [CI]: 19-31). There was a decrease in mortality rates over 3 epochs (≤2000, 2001-2009, and ≥2010: 40% [95% CI: 24-59], 35% [95% CI: 21-51], and 18% [95% CI: 12-26], respectively, P < .001). Observational studies reported a higher mortality rate than RCTs (27% [95% CI: 24-29] versus 16% [95% CI: 12-20], P < .001). Earlier year of publication was an independent factor associated with mortality. Conclusion: Overall mortality rate in pediatric ARDS is approximately 24%. Studies conducted and published later were associated with better survival.

Survey of contemporary feeding practices in critically ill children in the Asia-Pacific and the Middle East

BACKGROUND AND OBJECTIVES Nutrition is a fundamental component of care of critically ill children. Determining variation in nutritional practices within paediatric intensive care units (PICUs) allows for review and improvement of nutrition practices. METHODS AND STUDY DESIGN The aim was to survey the nutrition practices and perspectives of paediatric intensivists and dieticians in Asia-Pacific and the Middle East. A questionnaire was developed to collect data on (1) the respondents and institutions characteristics, (2) nutritional assessments and nutrient delivery practices, and (3) the perceived importance and barriers to optimal enteral feeding in the PICU. RESULTS We analysed 47 responses from 35 centres in 18 different countries. Dedicated dietetic services were only present in 13 (37%) centres and regular nutrition assessments were conducted in only 12 (34%) centres. In centres with dedicated dieticians, we found greater use of carbohydrate, fat additives and special formulas. Two thirds [31 (66%)] of respondents used total fluids to estimate energy requirements. Only 11 (31%) centres utilized feeding protocols. These centres had higher use of small bowel feeding, acid suppressants, laxatives and gastric residual volume thresholds. When dealing with feed intolerance, they were also more likely to start a motility agent. There was also a lack of consensus on when feeding should start and the use of adjuncts. CONCLUSIONS Nutrition practices and barriers are unique in Asia-Pacific and the Middle East and strongly reflect a lack of dietetic services. Future effort should focus on developing a uniform approach on nutrition practices to drive paediatric critical care nutrition research in these regions.

Risk Stratification in Pediatric Acute Respiratory Distress Syndrome: A Multicenter Observational Study*

Objectives: The Pediatric Acute Lung Injury Consensus Conference developed a pediatric specific definition for acute respiratory distress syndrome (PARDS). In this definition, severity of lung disease is stratified into mild, moderate, and severe groups. We aim to describe the epidemiology of patients with PARDS across Asia and evaluate whether the Pediatric Acute Lung Injury Consensus Conference risk stratification accurately predicts outcome in PARDS. Design: A multicenter, retrospective, descriptive cohort study. Setting: Ten multidisciplinary PICUs in Asia. Patients: All mechanically ventilated children meeting the Pediatric Acute Lung Injury Consensus Conference criteria for PARDS between 2009 and 2015. Interventions: None. Measurements and Main Results: Data on epidemiology, ventilation, adjunct therapies, and clinical outcomes were collected. Patients were followed for 100 days post diagnosis of PARDS. A total of 373 patients were included. There were 89 (23.9%), 149 (39.9%), and 135 (36.2%) patients with mild, moderate, and severe PARDS, respectively. The most common risk factor for PARDS was pneumonia/lower respiratory tract infection (309 [82.8%]). Higher category of severity of PARDS was associated with lower ventilator-free days (22 [17–25], 16 [0–23], 6 [0–19]; p < 0.001 for mild, moderate, and severe, respectively) and PICU free days (19 [11–24], 15 [0–22], 5 [0–20]; p < 0.001 for mild, moderate, and severe, respectively). Overall PICU mortality for PARDS was 113 of 373 (30.3%), and 100-day mortality was 126 of 317 (39.7%). After adjusting for site, presence of comorbidities and severity of illness in the multivariate Cox proportional hazard regression model, patients with moderate (hazard ratio, 1.88 [95% CI, 1.03–3.45]; p = 0.039) and severe PARDS (hazard ratio, 3.18 [95% CI, 1.68, 6.02]; p < 0.001) had higher risk of mortality compared with those with mild PARDS. Conclusions: Mortality from PARDS is high in Asia. The Pediatric Acute Lung Injury Consensus Conference definition of PARDS is a useful tool for risk stratification.

Abstract P-610: EPIDEMIOLOGY OF PAEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME IN A SINGLE CENTRE IN SINGAPORE

Unauthorized reproduction of this article is prohibited Pediatric Critical Care Medicine 2018 • Volume 19 • Number 6 (Suppl.) 4 Cinica Alemana-Universidad del Desarrollo, Centro de Investigacion e Inovacion en Informatica Medica, Santiago de Chile, Chile 5 Hospital Sotero del Rio. Unidad de Cuidados intesivos Pediatricos, Unidad de Cuidados Intensivos Pediatricos, SAntiago de Chile, Chile 6 Hospital El Carmen de Maipu, Unidad de Cuidados Intensivos Pediatricos, Maipu, Chile 7Caja Nacional de Salud, Unidad de Cuidados Intesivos Pediatricos, La Paz, Bolivia 8 Hopital de Los Angeles, Unidad de Cuidados Intensivos Pediatricos, Los Angeles BIO BIO, Chile 9 Medica Uruguaya Coorporacion Asistencia Medica MUCAM, Pediatric Intensive Unit PICUCINP, Montevideo, Uruguay 10Hospital de Salto, Unidad de Cuidados Intensivos Pediatricos, Salto, Uruguay 11 Centro de Asistencia Medica de Lavalleja, Unidad de Cuidados Intensivos Pediatricos, Lavalleja, Uruguay 12 Hospital Evangelico, Unidad de Cuidados Intensivos Pediatricos, Montevideo, Uruguay 13 Circulo Catolico de Obreros del Uruguay, Unidad de Cuidados Intensivos Pediatricos, Montevideo, Uruguay 14 Circulo Catolicos de Obreros del Uruguay, Unidad de Cuidados Intensivos Pediatricos, Montevideo, Uruguay 15 Hospital de Tacuarembo, Unidad de Cuidados Intensivos Pediatricos, Tacuarembo, Uruguay 16Hospital Policial, Unidad de Cuidados Intensivos Pediatricos, Montevideo, Uruguay

Abstract O-40: HIGH FREQUENCY VENTILATION IN PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME; A PROPENSITY SCORE ADJUSTED STUDY

HIGH FREQUENCY VENTILATION IN PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME; A PROPENSITY SCORE ADJUSTED STUDY J.J.M. Wong1, S. Liu2, S. Qian3, J.S.M. Ong4, C.S. Gan5, N. Anantasit6, Y.K. Chor7, R. Samransamruajkit8, H.P. Phan9, S. Phumeetham10, X. Feng11, M. Feng2, J.H. Lee1 1KK Women’s and Children’s Hospital, Pediatric Medicine, Singapore, Singapore 2National University of Singapore, Saw Swee Hock School of Public Health, Singapore, Singapore 3Beijing Children’s Hospital, Pediatric Intensive Care Unit, Beijing, China 4National University of Singapore, Pediatric Intensive Care Unit, Singapore, Singapore 5University Malaya Medical Centre, Department of Pediatrics, Kuala Lumpur, Malaysia 6Ramathibodi Hospital, Pediatric Department, Bangkok, Thailand 7Sarawak General Hospital, Department of Pediatrics, Kuching, Malaysia 8King Chulalongkorn Memorial Hospital, Department of Pediatrics, Bangkok, Thailand 9National Children’s Hospital, Pediatric Intensive Care Unit, Hanoi, Vietnam 10Siriraj Hospital, Department of Pediatrics, Bangkok, Thailand 11Children’s Hospital of Chongqing Medical University, Pediatric Intensive Care Unit, Chongqing, China

Impact of a nurse-led feeding protocol in a pediatric intensive care unit:

Background: To determine effectiveness of a nurse-led, volume-based feeding protocol in our pediatric intensive care unit (PICU), we evaluated patients’ nutrition adequacy pre- and post-protocol implementation. Methods: We conducted an observational study of patients admitted for more than three days in the PICU during pre- and post-feeding protocol periods. We recorded energy and protein intake and feed interruptions in patients started on enteral nutrition over the first seven days of admission. We excluded patients with septic shock requiring more than two inotropes, post-cardiac and post-gastrointestinal surgeries. To determine nutrition adequacy, actual energy and protein intakes were compared with calculated requirements, expressed as percentages. Results: We had a total of 40 patients (20 in the pre- and post-protocol groups, respectively) with median age of 9.4 (interquartile range (IQR) 2.8, 57) months. Median time to feed initiation was similar between groups (20.0 (IQR 17.0, 37.5) vs. 21.5 (IQR 10.5, 27.0) hours, p = 0.516). There was no difference in median energy (55 (IQR 12, 102) vs. 59 (IQR 25, 85) %, p = 0.645) and protein intake (53 (IQR 16, 124) vs. 73 (IQR 22, 137) %, p = 0.069) over the seven-day period between groups; the proportion of patients meeting their energy (10 vs. 35%, p = 0.127) and protein goal (15 vs. 30%, p = 0.451) by day three also did not differ significantly pre- and post-protocol implementation. The most common reasons for feed interruption were intubation/extubation and radiological procedures. Conclusion: Our current feeding protocol did not improve nutrient adequacy. The effectiveness of a more aggressive protocol in units where enteral nutrition is initiated within 24 hours should be investigated.