| Abstract |
Introduction: Currently, the nutritional status of patients in paediatric ICU (PICU), in combination with their feeding status in PICU and their correlation with outcome endpoints, is a scientific field of special interest. Critically ill patients due to the severity of their disease initially appears to be in a hypercatabolic state. This is due to the activation of neuro-hormonal and immunological mechanisms, resulting in rapid protein degradation, increased amino acid catabolism, and a reduced rate of synthesis of specific proteins. On admission to the PICU, patients' nutritional status is assessed on the basis of their anthropometric measurements. BMI z-score plays a particular role in the assessment. In addition, several rapid nutritional status assessment tools have been developed. In addition, it has been shown that early initiation of enteral feeding is associated with better disease outcome results. The ESPEN/ESPNIC guidelines recommend initiating enteral feeding in the first 24 to 48 hours after admission to the paediatric ICU. The best method of calculating daily requirements for patients with severe disease is indirect calorimetry, but this is often not available. Alternatively, validated prediction equations are used, which calculate resting energy needs based on body metrics and gender. The most used are Schofield and WHO/FAO/UNU. Also, the ESPEN/ESPNIC guidelines recommend 1.5g/kg/d of protein intake to achieve a positive nitrogen balance.
Aim of study: The aim of this retrospective study was to assess the nutritional status of children at admission to the paediatric ICU and to assess whether their nutritional needs were met during their hospitalization. The assessment of the timing, initiation, and achievement of nutritional support for the patients was based on the ESPEN/ESPNIC guidelines. In comparison, clinical indicators such as patients' nutritional status, disease severity, and urea/creatinine catabolism index were compared with patients' caloric and protein coverage on the 1st, 3rd, 5th, and 7th day of hospitalization. Finally, the amounts of calorie and protein intake were compared with those recommended by guidelines and with clinical outcome indicators such as mortality and duration of hospitalization and mechanical ventilation.
Results: The study included a total of 99 patients who were hospitalized in the Paediatric ICU of PAGNI for at least 7 days. The most frequent admission diagnosis was pneumonia. In 59.6% of the patients were in catabolism, in whom the mortality was 10.2%. A positive balance of Ur/Cr catabolism index was achieved by 40.4% of patients, of which only one died (mortality 2.5%). Patients with catabolism at the end of the first week of hospitalization were younger compared to patients who had achieved a positive Ur/Cr ratio balance (p=0.002). The two groups did not differ in terms of gender, BMI z score, diagnosis, length of hospitalization and mechanical ventilation, organ deficiencies, and biochemical markers of nutrition and inflammation. Patients who remained catabolic at the end of the first week of hospitalization had a more negative total caloric and protein balance compared to patients with a positive difference in Ur/Cr ratio (p=0.043). However, the daily caloric and protein intake was significantly below that predicted by the ESPNIC/ESPEN guidelines and the Schofield equation in both groups. The predicted daily intake of calories (Schofield) and protein (ESICM, ESPEN) was significantly higher for the group at risk of undernutrition compared to their counterparts with BMI z score positive (p<0.001). Calorie intake in both groups of nutritionally compromised patients followed a significant upward trend from day 1 to day 7 (p<0.001). Only in patients in good nutritional status the daily protein intake followed a significant increasing trend from day 1 to day 7 (p=0.028). Similar results were found in the group of patients with more severe disease (PeLOD > 10), compared to patients with less organ dysfunction (p<0.001). In patients with a positive outcome, the negative calorie and protein balance decreased from day 1 to day 7 (p<0.001) compared to patients who died (NS). Negative Ur/Cr ratio difference of day 7-1, negative calorie balance, and high CRP value emerged as strong predictors of deterioration of catabolism.
Conclusions: The results of the present study showed the necessity of feeding the hospitalized patients in the Pediatric ICU, as it was shown that the lower the negative caloric and protein balance in the first week of hospitalization, according to the guidelines, the better their outcome. Patients at risk of malnutrition have significantly higher caloric and protein needs. Strong predictors of worsening catabolism in patients are a negative total caloric and protein balance and a negative difference in Ur/Cr ratio on day 7 from day 1. There is a need for further research and adaptation of the applied nutrition protocols to the new guidelines to optimize nutritional support of critically ill patients.
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