Nutrition support in the neonatal ICU with

Congenital Heart Disease

Oleh :
dr. Reni Fitriasari SpA.(K)., M.Kes
National Cardiovascular Center Harapan Kita
Pediatric Cardiac Intensive Care Unit (PCICU)
Learning Objectives

Feeding guidelines for patients with critical illness

01

Recognize potential medical complications that compromise nutrition

02

Parenteral nutrition with appropriate protein, fat, and glucose goals

03

Diagnostic tools and treatment post-intervention feeding dysfunction

04
 Background
• Malnutrition in criticall ill 20%-30% Morbidity and mortality
[Jessie H dkk., 2006, Marcheto da Silva F dkk., 2013]

• About 50% CHD patients  malnutrition before surgery

[Vaidyanathan B dkk., 2009]

• 27% CHD  persistent malnutrition after surgery

[Vaidyanathan B dkk., 2008]
Nutritional requirements for critically Ill
• Metabolic response to stress
• Increased risk energy & protein imbalance
Consideration in • Ongoing nutritional assessment
critical care requirements
• Early enteral nutrition

• Increases Morbidity and mortality

Effect malnutrition • Decreases immunity
and nutrient • Impairs wound healing
deficiencies • Increases muscle breakdown
• Lengthens hospital stay

• Improves nutritional intake and promotes

Enteral feeding consistent delivery
protocol • Improves feeding tolerance
• Optimize patient growth
Feeding protocol on post-CHD surgery?
The effect CPB on fluid balance
Total circulating volume (TCV) = Patient’s blood
volume + priming volume
 Fluid shifting

 Fluid shifting is not only an intraoperative

problem but a postoperative problem.
 Peak of fluid shifting at 5 hrs after trauma and
persists up to 72 hrs depending on location
and duration of surgery.

Robarts WM: Nature of the disturbance in the body fluid compartements during
and after surgical operations. Br J Surg 1979; 66:691-5
Positive fluid balance
• Lung Edema

Gut edema and burst

abdomen
Fluid balance
•Fluid balance target
CPB : day 0 – 2: negatif 10 – 30 ml/kg/day
Non CPB: 0 ± 10 ml/kg/day

•Diuretic
Furosemid intermiten day 1 after stabil hemodynamic
combined with spironolactone(K sparing diuretic)

•Acute Kidney Injury :

Furosemid drip continue 0,5 - 1 mg/kg/h, PD and CVVH
Darrow Formula
Nutrition
•Enteral feeding ASAP, 12 hours post procedure
(Without contraindication), Gut feeding ASI/PASI
10-20 ml/kg/day devided 8 times.
•Glucose target > 40 mg/dl (non-neonatus), > 60
mg/dl (neonatus).
• If Glucose level < 100 mg, still NPO, GIR
evaluation and start TPN on day 2.
• If glucose level > 200 mg/dl, evaluate of
hemodynamic, pain, temperature, adrenalin,
steroid before considering insulin
Nutrition
GIR (glucose concentration x cc /h)
(6 x BW)

•GIR target 6 -8 mg/kg/min

•Protein 1-2 g/kg/day
•Fat 1 – 2 g/kg/day
Nutrition Algorithms

Julie Slicker et al, Congenit Heart Dis. 2013

• Julie Slicker et al, Congenit Heart Dis. 2013
Julie Slicker et al, Congenit Heart Dis. 2013
Julie Slicker et al, Congenit Heart Dis. 2013
 Protokol pemberian formula:

Penilaian asupan paska operasi

Evaluasi pemberian asupan Penilaian hemodinamik Evaluasi Dokter/Dietisian

 Cardiac Output
 Apakah gastrointestinal  Saturasi ScVO2
berfungsi?  Urin output

Iniasiasi pemberian
enteral

Mode pemberian asupan enteral: Jenis Formula:

 Melalui NGT  Formula padat kalori

 Mulai 20 ml/kg/hari (dibagi 8 kali  Formula standar
pemberian)

Toleransi asupan?

Toleransi baik

*) *) Intoleransi ?
Penambahan Volume: Penambahan Kalori:
 Cardiac Output /GI ?
 Target 120-140  Target 120-150  Gastric residu> 50%
ml/kg/hari kcal/kg/hari  Distensi abdomen
 Penambahan 20  Ketika volume  Diare
ml/kg/hari optimal tercapai
naikan kalori 2
kcal/oz/hari

Eksklusi
Recognize potential medical
complications that compromise nutrition

Fluid restriction
Gastrointestinal
Feeding
Infection
Bleeding
SIRS
interuption
Intolerance

Eur Soc for Clin Nutr and Metab. 2009

J Hum Nutr Dietet 2006
 Enteral feeding

Parenteral Nutrition
Parenteral nutrition with appropriate protein,
fat, and glucose goals
Balance TPN and Lipid infusion
• 50-55% carbohydrate
• 25-30% fat
• 20-25% protein
Adjustment with hyperbilirubinemia
following prolong TPN use

• Decrease the lipids to 1 mg/kg

• Infuse only 12 hours
• Consider an omega-3 fatty acid emulsion or lipid
containing soya beans oil, MCT, olive oil, fish oil
(SMOF lipids)
Diagnostic tools and treatment post
intervention feeding dysfunction
• Vocal cord dysfunction
 Diagnosis tools: Barium swallow, Otolaryngology
 Intervention: Thickened feed, side lying positioning

• Chylothorax:
 Diagnosis tools:Chest Xray, USG, Laboratory: Trigliseride>120 mg/L, jumlah
sel > 1000/microliter
 Intervention: Changed formula MCT if not effective TPN

• NEC
 Diagnosis tools: Abdomen X Ray
 Intervention: NPO TPN
Take Home Message
• Enteral feeding is safe in hemodynamically stable
• Oral feeds should be initiated following feeding
evaluation
• Continued assessment of growth and nutrition is
critical for CHD patients
• Parenteral Nutrition (PN) should be initiated early
and advanced to full calorie and protein goals
(When the patients not be considered candidates
for enteral feeding)
Terima kasih

Terimakasih