Clinical Pathway for Management of Nutrition in the Traumatically Injured Child Requiring ICU Care for ≥ 3 Days
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Goal
- Initiate nutrition within 72 hrs
- Achieve calorie goal by post-injury day 7
- Avoid prolonged recovery time and increased morbidity and mortality associated with inadequate nutrition
Multidisciplinary Team Assessment
- Tertiary survey completed by Trauma team w/in 24 hrs of admission
- Assess/identify pre-existing risk factors and malnutrition
- Measure weight
- Review patient growth chart
- Update dosing weight
- Plan nutrition with Trauma team, Trauma dietitian (RD)
- Anticipate route — NJ, NG or CVC for parenteral nutrition (PN)
- Frequent OR Considerations
Post-injury Day
Day 0
Day 1-2
Plan, Execute Access
Nutrition Considerations
- Initiate nutrition as soon as hemodynamically stable
- Transition between enteral and parenteral nutrition is expected
Days 2-4
Begin Feeds
Enteral Nutrition
Parenteral Nutrition
Optimal route if not contraindicated
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Gastric
- Order NG/OG tube placement
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Jejunal
- PICU/IR/OR coordination for NJ placement with or without bridle
- Review with Trauma dietitian
- Discuss patient-specific goals
- Select Appropriate Formula
- Start Trophic Feeds
- Advance feeds to reach goal in 24-36 hrs
- Arrange for appropriate access for PN
- OR/PICU/IR for central access as indicated
- Review with Trauma dietician
- Patient-specific goals
- Order PN
- PN panel morning after starting
- Advance rate to reach goal w/in 36 hrs
Day 5
Reassess
Nutrition Not Initiated
- Escalate to Trauma, PICU attending for review
- Assess Barriers to Nutrition
- Consider transition to parenteral nutrition
Days 6-7
Monitor
Nutrition at Patient-specific Goal
Monitor Nutrition During PICU Care
- Biweekly weight checks (Monday/Thursday)
- Weekly nutrition assessment completed by Trauma dietitian
- Daily discussion between PICU and Trauma teams
- % of estimated nutrition needs received
- Address barriers if receiving < 90% of goal
- Daily reassessment of ability to start/advance enteral feeds in children receiving PN
Evidence
- Effect of Early Nutritional Support on Intensive Care Unit Length of Stay and Neurological Status at Discharge in Children With Severe Traumatic Brain Injury
- Nutritional Support of the Pediatric Trauma Patient
- Enteral Nutrition Initiation in Children Admitted to Pediatric Intensive Care Units After Traumatic Brain Injury
- Improving the Quality of Nutrition in Pediatric Trauma
- Controversies of Enteral Nutrition in Select Critically-ill Surgical Patients: Traumatic Brain Injury, Extracorporeal Life Support, and Sepsis
- Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition
- Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)
- Allometric Prediction of Energy Expenditure in Infants and Children
- Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition)
- Dutch National Survey to Test the STRONGkids Nutritional Risk Screening Tool in Hospitalized Children