Nutrition Initiation and Advancement Clinical Pathway — PICU/PCU

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Provider Resources

Related Pathways

All PICU Patients Requiring Nutrition Support EXCEPT:

Patients already on oral feeds/home feeding regimen or those with a plan to start oral feeds/home feeding regimen
General surgery/trauma patients
Patients with a known metabolic disorder
Intestinal rehabilitation program patients
Patients requiring a ketogenic diet

Ordering Provider to Initiate Pathway No Later Than 48 Hours After PICU Admission

Utilize PICU/PCU Pathway for Initiation and Advancement of Nutrition in Children Order Set
Obtain Anthropometry Measurements
per PICU Policy
Place Nutrition Consult Order in EPIC

Barriers to Enteral Nutrition (EN)
Start Parenteral Nutrition (PN)

Known/Presumed Gut Ischemia
Persistent Hemodynamic Instability
Gut Graft vs. Host Disease (GVHD)
Malabsorptive State
(e.g.: Short Gut)
Intra-abdominal Hypertension/Abdominal Compartment Syndrome
Intractable Emesis
Planned NPO Time > 72 Hours (Includes Post-surgical Patients)

Monitor for
Tolerance

Barriers to Initiating Enteral Nutrition (EN)

Yes

1. Start Enteral Feeds/Formula Selection
2. Initiate Bowel Regimen to Prevent Constipation

Consider Trophic Feeds

Yes

Tolerating Feeds

Initiate Trophic Feeds

Parenteral Nutrition (PN)
via CVL

Yes

Advance to
Prescribed Goal

Hold Feeds
x6 hours

Evaluate Daily

Advance PN per RD Recommendation to Prescribed Goal

Tolerating Feeds

Investigate & Resolve Intolerance

Yes

Resume Feeds to Last Tolerated Rate

Consider Parenteral Nutrition (PN) via CVL

Conservative Advance to Prescribed Goal

Investigate & Resolve Intolerance

Advance to Prescribed Goal

Yes

Consider Stopping Trophic Feeds – Consider or Continue PN

Re-evaluate
Trophic Feed
Ability Daily

Posted: December 2014
Revised: December 2022
Authors: S. Irving, PhD, CRNP*; V. Srinivasan, MD*; M. Mascarenhas, MD; S. Seiple, RD; M. Nagle, RD; K. Berry, RD; N. Tabatabaei, RD; B. Blowey, PharmD; *co-leads

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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PICU/PCU Clinical Pathway for Initiation and Advancement of Nutrition in Children

Evidence