Simone Brasil de Oliveira Iglesias

Enteral nutrition in critically ill children: are prescription and delivery according to their energy requirements?

BACKGROUND The purpose of this study was to compare the differences between prescribed and delivered energy among critically ill children and to identify the factors that impede the optimal delivery of enteral nutrition in the first 5 days of nutrition support. METHODS In a prospective cohort study, we evaluated 55 critically ill children aged 8.2 ± 11.4 months (0-162.3 months), who were fed for ≥2 days through a gastric or postpyloric tube. The patients were followed from admission until day 10 of enteral nutrition. Prescribed and delivered energy were recorded daily and compared with each other and with the estimated basal metabolic rate (BMR). The Paediatric Index of Mortality 2 (PIM 2) was used to estimate illness severity. RESULTS The ratio of delivered:required energy was <90% in 55.7% of the enteral nutrition days. Low prescription was the main reason for not achieving the energy goal in the first 5 days of enteral nutrition. Discrepancies between prescribed and delivered: energy were attributable to interruptions in feeding caused by clinical instability, airway management, radiologic and surgical procedures, and accidental feeding tube removal. The other factors associated with the delivery of less than required energy were PIM 2 ≥15%, gastrointestinal complications, dialysis, and use of α-adrenergic vasoactive drugs. The latter was the only variable in multivariate analysis that was associated with not ultimately achieving energy goal. CONCLUSIONS The prescription and delivery of energy were not adequate in >50% of enteral nutrition days. The gap between the effective administration and energy requirements can be explained by both underprescription and underdelivery. Administration of vasoactive drugs was the only variable independently associated with a low energy supply.

Malnutrition May Worsen the Prognosis of Critically Ill Children With Hyperglycemia and Hypoglycemia

OBJECTIVES To determine whether hyperglycemia and hypoglycemia are associated with higher mortality, longer length of intensive care unit (ICU) stay, and fewer ventilator-free days in critically ill children while taking into account the clinical severity and nutrition status. PATIENTS AND METHODS A prospective observational cohort study was conducted on 221 children admitted to the ICU. Blood glucose levels were analyzed in the first 72 hours. Potential exposure variables for adverse prognosis included hyperglycemia (blood glucose >150 mg/dL), hypoglycemia (blood glucose ≤60 mg/dL), age <1 year, sex, nutrition status, the revised Pediatric Index of Mortality (PIM 2), and the Pediatric Logistic Organ Dysfunction (PELOD). RESULTS Of the patients, 47.1% were malnourished. Controlling for nutrition status, both hyperglycemia and hypoglycemia increased the risk of mortality in the malnourished patients compared with the well-nourished ones. Adjusting for clinical severity, the odds ratio of mortality was higher in malnourished patients with hyperglycemia (odds ratio [OR], 3.98; 95% confidence interval [CI], 1.14-13.94; P = .03), whereas no significant associations were detected in the well-nourished patients. After controlling for nutrition status, hypoglycemia was associated with longer length of ICU stay (OR, 6.5; 95% CI, 1.30-32.57; P < .01) and fewer ventilator-free days (OR, 4.11; 95% CI, 1.26-13.40; P < .01) only in the malnourished group of patients. CONCLUSIONS Compared with the well nourished, malnourished patients with hyperglycemia are at a greater risk of mortality, independent of clinical severity. Hypoglycemia was shown to be associated with mortality, longer length of ICU stay, and fewer ventilator-free days only in malnourished patients.

Procedural sedation for insertion of central venous catheters in children: comparison of midazolam/fentanyl with midazolam/ketamine

Background:  There is a lack of studies evaluating procedural sedation for insertion of central venous catheters (CVC) in pediatric patients in emergency departments or pediatric intensive care units (PICU). This study was designed to evaluate whether there is a difference in the total sedation time for CVC insertion in nonintubated children receiving two sedation regimens.

Evolution of the nutritional support pattern in Pediatric Intensive Care

OBJECTIVES To evaluate patterns of usage and monitoring of nutritional support in a Pediatric ICU of a teaching hospital and the role of an education program in nutritional support given throughout the resident physician training. DESIGN In a historical cohort study, records from children who received nutritional support during the year 1992 were analyzed. Thereafter a continuing education program in Nutritional Support was conveyed to the residents. In a second phase of the study, the same parameters were reevaluated in children who received nutritional support throughout the year 1995. SETTING Pediatric Intensive Care Unit of Department of Pediatrics, Escola Paulista de Medicina. PATIENTS All the children who were given nutritional support during a period of five days or more. Based on this criteria 37 children were selected for the first phase of this study, and 35 for the second one. INTERVENTION The education program included theoretical lectures about basic themes of nutritional support and journal article reading sessions. It was given to successive groups of residents on a weekly schedule. MEASUREMENTS Daily records of fluid, protein, caloric and micronutrient supply, nutritional assessment and metabolic monitoring. RESULTS In the first phase of the study, an exclusively parenteral route was utilized for 80.5%, and a digestive route 19.5% of the time period. Nutritional assessment was performed on 3 children; no patient had the nutritional goals set. The nitrogen to nonprotein calories ratio and the vitamin supply were inadequate, whilst the supply of trace elements was adequate except for zinc. Nutritional monitoring was performed on almost all patients but without uniformity. In the second phase, the exclusive parenteral route was used for 69.7% and the digestive route for 30.3% of the time period; no significant increase in the use of the digestive route was detected. The nonprotein calories to nitrogen ratio and micronutrient supply were adequate. The frequency of nutritional assessment increased, but deficiency in nutritional monitoring and infrequent enteral feeding were still detected. CONCLUSION There were deficiencies in the implementation of nutritional support, which were partially corrected in the second phase of the study by the training of the residents. Reinforcement of the education program, which should be applied to the whole medical staff, and the organization of a multidisciplinary team in charge of coordinating the provision of nutritional support are suggested.

Comparison of two different severity scores (Paediatric Risk of Mortality [PRISM] and the Glasgow Meningococcal Sepsis Prognostic Score [GMSPS]) in meningococcal disease: preliminary analysis

Summary Two different illness severity scores, Pediatric Risk of Mortality (PRISM) and the Glasgow Meningococcal Sepsis Prognostic Score (GMSPS), were evaluated and compared in meningococcal disease in two paediatric intensive care units. Forty-nine children with a median age of 36 months who had meningococcal sepsis confirmed by laboratory data were evaluated. Overall mortality was 18%. The median GMSPS was 3 in survivors and 8 in non-survivors. A GMSPS ≥ 8 was significantly associated with death (p = 0.0001) with a mortality predictivity and specificity of 70% and 92.5%, respectively. The median PRISM score in survivors was 5.5 and 23 in non-survivors. A PRISM score of ≥ 11 was significantly related to death (p < 0.0001). The Kendal correlation co-efficient between GMSPS and PRISM showed τ = 0.6859 (p = 0.0000). It is concluded that GMSPS and PRISM are useful methods for identifying and classifying children into low and high risk categories. GMSPS ≥ 8 or a PRISM score ≥ 11 are significantly predictive of mortality.

The product of platelet and neutrophil counts (PN product) at presentation as a predictor of outcome in children with meningococcal disease

Abstract Background: Despite improvement in the treatment of Neisseria meningitidis infection, meningococcal diseases (MD) are still an important cause of morbidity and mortality around the world. This study assessed the performance of the product of platelet and neutrophil counts (PN product) at the time of presentation to hospital as a predictor of outcome in children with MD. Methods: Retrospective evaluation of children with clinical MD admitted to two paediatric intensive care units in Brazil. Results: Seventy-two children aged 2–156 months were studied. Overall mortality was 19.7%. The PN product, the Glasgow Meningococcal Septicaemia Prognostic Score and the Paediatric Risk of Mortality score discriminated between survivors and non-survivors. A PN ≤ 113 had a sensitivity of 28.6% (95% CI 8.6–58.1), specificity of 96.6% (95% CI 88.1–99.5) and positive and negative predictive values of 66.7% and 84.8%. The area under the receiver operating characteristic curve was 0.85 (95% CI 0.74–0.92). Conclusion: The PN product had a lower performance than reported in previous studies from a developed country. The PN product, however, is a good indicator of mortality in MD but needs to be validated for the population to which it is being applied.