ICU Pathway for the Evaluation/Treatment of Infants > 28 Days and Children with Severe Sepsis/Septic Shock

Nutrition > 24 Hours

BEGIN WITHIN 24-48 HRS OF ADMISSION

ENTERAL NUTRITION (EN)

Contact RD for choice of formula and calorie goal
Begin at 0.5 ml/kg/hr or maximum of 25 ml/hr UNLESS:

Conditions exist that have significant effect on GI tract including:

Severe ischemic injury, necrotizing enterocolitis, acute pancreatitis, peritonitis, GI obstruction or bleeding, trauma or surgery to the bowel, abdominal compartment syndrome, hemodynamic instability (defined as ongoing fluid resuscitation (> 60ml/kg over 1 hour)) or initiation/escalation of vasoactive medications within the last 8 hours.

Follow initiation by consistent advancement to full feeds UNLESS demonstrated intolerance

< 7 years or < 25kg increase 1 ml/kg/hr every 4-8 hrs
> 7 years or ≥ 25kg increase 25 ml/hr every 4-8 hrs

Minimize delivery interruptions. If feeding not tolerated, restart at last tolerated rate
Consider delivering EN by NJ tube, has been shown to improve the amount of nutrition successfully delivered versus gastric tubes

PARENTERAL NUTRITION (PN)

Consult RD for PN composition and calorie goal
PN may be substituted or combined with EN.
Initiate PN as a bridge to EN within 72 hours of admission if one of the following conditions is met:

EN is not indicated (for reasons identified above)
Feeding intolerance is established
Deliver PN via central line (peripheral parenteral nutrition not preferable)

A dextrose/amino acid solution should be paired with lipids to provide essential fatty acids

Dextrose

Begin with D5-D10 and advance as advised by RD

Amino acid solution

Provide adequate protein to support positive nitrogen balance, wound healing, and preserve skeletal muscle mass.

Guidelines for protein goals are:

0-2 yrs2-3 g/kg/day
2-13 yrs 1.5-2 g/kg/day
13-18 yrs 1.5 g/kg/day
Patient condition may require a deviation from guidelines – consult RD

Lipids

Initiate at 0.5-2 gm/kg/day, advance as advised by RD

0-2 yrsmax 3g/kg
> 2 yrs max 2g/kg

PN panel (TPN panel)

Obtain at initiation, twice weekly (Mon/Thu) for duration of PN
Monitor triglyceride level

Essential Vitamins, Minerals and Trace Elements

Consult RD for starting recommendations for age
Ongoing monitoring of growth and laboratory studies as recommended by RD


Nutrition – References