Care of child requiring long term ventilation

Care of child requiring long term ventilation

1. Care of child requiring long term ventilation/nutritional needs of critically ill child

2. MECHANICAL VENTILATION: Mechanical ventilation is a method to mechanically assist or replace spontaneous breathing

3. PHYSIOLOGY OF MECHANICAL VENTILATION

4. RESPIRATORY SYSTEM MECHANICS

5. Common medical indications for use include: Acute lung injury (including ARDS, trauma) Apnea with respiratory arrest, including cases from intoxication Chronic obstructive pulmonary disease (COPD) Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 50 mmHg and pH < 7.25, which may be due to paralysis of the diaphragm due to Guillain-Barré syndrome, Myasthenia Gravis, spinal cord injury, or the effect of anaesthetic and muscle relaxant drugs

6. Increased work of breathing as evidenced by significant tachypnea , retractions, and other physical signs of respiratory distress Hypoxemia with arterial partial pressure of oxygen ( Pa O2) < 55 mm Hg with supplemental fraction of inspired oxygen ( Fi O2) = 1.0 Hypotension including sepsis, shock, congestive heart failure Neurological diseases such as Muscular Dystrophy and Amyotrophic Lateral Sclerosis

7. Other Indications for Mechanical Ventilation Established or imminent respiratory failure resulting from the following: Pulmonary disease Hypoventilation/apnea caused by central nervous system pathology. Defective ventilatory pump: neuromuscular disease, chest wall trauma.

8. Post-resuscitation for circulatory arrest. Reduction of work of breathing: in children with shock. Hyperventilation for reducing raised intracranial pressure. Prophylactic indications: during and after surgery.

9. MECHANICAL VENTILATORS Transport ventilators Intensive-care ventilators Neonatal ventilators Positive airway pressure ventilators Negative pressure ventilator

10. Transport ventilators — These ventilators are small, more rugged, and can be powered pneumatically or via AC or DC power sources.

11. Intensive-care ventilators — These ventilators are larger and usually run on AC power (though virtually all contain a battery to facilitate intra-facility transport and as a back-up in the event of a power failure). This style of ventilator often provides greater control of a wide variety of ventilation parameters (such as inspiratory rise time). Many ICU ventilators also incorporate graphics to provide visual feedback of each breath

12. Neonatal ventilators — Designed with the preterm neonate in mind, these are a specialized subset of ICU ventilators which are designed to deliver the smaller, more precise volumes and pressures required to ventilate these patients.

13. Positive airway pressure ventilators (PAP) — These ventilators are specifically designed for non-invasive ventilation. This includes ventilators for use at home for treatment of chronic conditions such as sleep apnea or COPD

14. Negative pressure ventilator-----The iron lung, also known as the Drinker and Shaw tank, was developed in 1929 and was one of the first negative-pressure machines used for long-term ventilation. It was refined and used in the 20th century largely as a result of the polio epidemic that struck the world in the 1940s. The machine is effectively a large elongated tank, which encases the patient up to the neck. The neck is sealed with a rubber gasket so that the patient's face (and airway) are exposed to the room air.

15. CATEGORIES/METHODS OF MECHANICAL VENTILATION

16. MODES OF VENTILATION

17. CONTROLLED SUPPORTED MODES COMBINED MODES SPONTANEOUS MODES BREATHING VC PS AUTOMODE: CPAP VC-VS PC VS AUTOMODE: Nasal CPAP PC-PS PRVC NIV-PS AUTOMODE: PRVC- VS NIV-PC SIMV: VC+PS SIMV: PC+PS

18. PC (Pressure Controlled Ventilation) In this controlled mode of ventilation, the ventilator delivers a breath to a set pressure, and at a set rate. This is primarily used when the patient has no spontaneous breathing but will support the patient if they are able to trigger a breath. If the pressure is set at PC 16 above PEEP of 4, then the ventilator will deliver a top pressure (peak pressure) of 20 (PC level of 16 plus PEEP) with an end pressure of 4. This keeps the airways slightly open, making it easier to inflate them, and help prevent collapse and consolidation.

19. VC (Volume Control Ventilation) In volume control mode a preset tidal volume is delivered at a set rate, primarily used when the patient has no spontaneous breathing. If the volume is set at 4.5 lit res and a rate of 20, then the volume delivered with each breath will be 225mls per breath (4500mls/20=225mls). The air is delivered during the inspiratory phase, held in the lungs during the pause phase, and then released during the expiratory phase.

20. Peak pressure can vary from breath to breath depending on the patient's compliance and resistance. If the patient's compliance reduces or resistance increases the peak pressures will increase to ensure the set tidal volume is achieved. This volume would be delivered with each breath regardless of the pressure required so it is very important to check the upper pressure alarm setting is at a suitable value to protect the patient's lungs. (If the upper pressure limit is reached inspiration will stop and change to expiration.)

21. PRVC (Pressure Regulated Volume Control) PRVC is a controlled mode of ventilation which combines pressure and volume controlled ventilation. A preset tidal volume is delivered at a set rate, similar to VC, but it is delivered with the lowest possible pressure. It is very important to check the upper airway pressure preset alarm limits as this is the only factor that limits the pressures from increasing to potentially damaging levels. The maximum available pressure limit is 5cmH20 below the preset upper pressure alarm limit. If this is reached the ventilator will alarm "regulation pressure limited", switch to expiration, and will not be able to deliver the preset tidal volume

22. AUTOMODE All three of these controlled modes of ventilation have an option called automode which automatically controls the transition between controlled (ventilator triggered) and support (Patient triggered) mode in accordance with the patient's breathing efforts. Automode allows the patient to go into a support mode automatically if they trigger the ventilator:

23. Pressure Control ~ Pressure Support Volume Control ~ Volume Support PRVC ~ Volume Support If the patient does not make any respiratory effort, the ventilator will remain in the controlled mode or revert back to the controlled mode from the support mode.

24. SIMV ( Synchronised Intermittent Mandatory Ventilation) This mode is used to assist patient's who have some, but not sufficient breathing and can be used for weaning. The ventilator provides mandatory breaths which are synchronised with the patient's spontaneous efforts at a pre-set rate. There are three different SIMV modes : SIMV Volume control and Pressure support SIMV Pressure Control and Pressure Support SIMV PRVC and Pressure Support

25. The mandatory breath is defined by the basic settings (control mode), the SIMV rate is the rate of mandatory breaths per minute, and the spontaneous/supported breath is defined by setting the pressure support level above PEEP

26. Pressure Support Ventilation (PS) Pressure Support provides support for every patient triggered breath and is used for patients who do not have sufficient capacity or to facilitate weaning. The patient initiates the breath and the ventilator delivers support with the preset pressure level above PEEP. With the support of the ventilator, the patient regulates the respiratory rate and tidal volume. Although there is no respiratory rate set on this mode there is a safety back-up ventilation function on the servo i if the patient becomes apnoeic . (This may not be the case with other ventilators).

27. Volume Support (VS) Volume support works in a very similar way to pressure support but the tidal volume and PEEP are set rather than the pressure. The patient initiates the breath and the ventilator delivers support in proportion to the inspiratory effort and the target volume. The set tidal volume is delivered to the patient with different support from the ventilator depending on the patient's activity.

28. Continuous Positive Airway Pressure (CPAP) When PEEP is applied without other forms of ventilation it is called CPAP. Continous Positive Airway Pressure is maintained in the airways preventing collapse, but the patient regulates all other respiratory functions. CPAP works in the same way as PS but the PS level is set to zero, and if the apnoea alarm is triggered it will switch to backup ventilation.

29. TROUBLESHOOTING Remember DOPE: D: Displaced Tube? 0: Obstruction? P: Pneumothorax ? E: Equipment Failure?

30. POSSIBLE COMPLICATIONS DURING THE PERIOD OF MECHANICAL VENTILATION

31. accidental extubation blockage [secretions / blood] aspiration tracheal damage [ ett /suction] infection intubation of right bronchus barotrauma [ pneumothorax ]

32. hypo/hyperventilation ventilator dependancy /inability to wean stress ulceration of the gi tract hypotension rise in cvp decrease in renal function mechanical equipment failure

33. Ventilator and Ventilator Alarm Setting In the PICU the Medical staff are responsible for programming all ventilator setting and alarm limits. Nursing staff should not alter ventilator settings or alarm limits but are responsible for checking them and informing the medical staff or senior nursing staff if they are not appropriately set and need changed. In the case of faults, alarms should not be continuously overridden. The nurse in charge and the bioengineering department should be informed.

34. All monitoring equipment should be checked by the nurse and documented at the beginning of each shift (as part of the safety checks) and ventilator settings should be checked every hour and documented.

35. Non Invasive Ventilation (NIV) Non-Invasive Ventilation refers to the delivery of mechanical ventilation using a face mask or similar device, rather than an Endotracheal intubation. It is important that the following criteria are met before commencing NIV: The patient must be conscious and breathing spontaneously The patient must have an adequate gag and cough reflex.

36. NIV Pressure Control In this controlled mode of ventilation, the ventilator delivers a flow to maintain the preset pressure at a set respiratory rate and inspiratory time (similar to invasive pC ). The patient can also trigger a patient controlled breath. NIV Pressure Support NIV PS is a spontaneous mode of ventilation where the patient initiates the breath and the ventilator delivers support with the preset pressure level. The patient regulates the respiratory rate and tidal volume so the alarm parametersmust be set appropriately.

37. Nasal CPAP Nasal CPAP can be delivered on the servo i by nasopharyngeal tube, nasal mask or nasal prongs on infants from 5OOg to 10kg. The CPAP Level (cmH20) and oxygen concentration is set and the ventilator will deliver the flow necessary to maintain the desired pressure compensating for the leak. (The max flow is 33L/min) During all NIV the ventilator automatically adapts to the variation of leakage in order to maintain the set pressures. However, if the leakage is excessive or the patient is disconnected the ventilator will alarm and pause the ventilation.

38. Non Invasive BiPAP , or SiT (Spontaneous Trigger) Mode, works in a similar way to PS. In normal respiration each breath consists of two phases: an inspiratory and an expiratory phase. BiPAP works by providing assistance during the inspiratory phase of respiration and preventing airway closure during the expiratory phase. Assistance during the inspiratory phase ( Inspiratory Positive Airway Pressure- IPAP) is in the form of pressure support. At the end of each inspiratory phase a continuous positive pressure (CPAP) is maintained and is termed expiratory positive airway pressure (EPAP) The BiPAP ventilator alternates between IPAP and EPAP synchronising with the patient's breathing pattern or at a set synchronised rate.

39. Viasys Infant Flow SiPAP (CPAP Driver) The Infant Flow SiPAP provides non-invasive respiratory support via nasal prongs or nasal mask. The 02 and Flow (pressure flow) is set (usually 8-10 I/min) and the level of CPAP achieved is dependent on the leak. Generally a CPAP of 4-6cmH20 is required to be effective. An apnoea sensor can be attached to the machine for monitoring and alarms .

40. WEANING Discontinuation of mechanical ventilation is a two step process, consisting of readiness testing and weaning: Readiness testing – Readiness testing is the evaluation of objective criteria to determine whether a patient might be able to successfully and safely wean from mechanical ventilation.

41. Weaning – Weaning is the process of decreasing the amount of support that the patient receives from the mechanical ventilator, so the patient assumes a greater proportion of the ventilatory effort. The purpose is to assess the probability that mechanical ventilation can be successfully discontinued. Weaning may involve either an immediate shift from full ventilatory support to a period of breathing without assistance from the ventilator or a gradual reduction in the amount of ventilator support .Weaning has also been referred to as the discontinuation of mechanical ventilation or liberation from the mechanical ventilator.

42. Patients who wean successfully have less morbidity, mortality, and resource utilization than patients who require prolonged mechanical ventilation or the reinstitution of mechanical ventilation . The most successful weaning strategies include a daily assessment of the patient’s readiness to wean and the careful use of sedatives .

43. Modes of weaning Traditional methods of weaning include spontaneous breathing trials (SBTs), progressive decreases in the level of pressure support during pressure support ventilation (PSV), and progressive decreases in the number of ventilator-assisted breaths during intermittent mandatory ventilation (IMV). Newer weaning methods include computer-driven automated PSV weaning and early extubation with immediate use of post- extubation noninvasive positive pressure ventilation (NPPV).

44. Common reasons for weaning failure: Chronic hypercapnic state Decreased CNS drive Weaning to exhaustion and inadequate rest of respiratory muscles Reduced respiratory pump capacity Poor nutritional status Electrolyte disturbances (decreased calcium, magnesium and phosphate levels Polyneuropathy of critical illness Corticosteroid therapy Prolonged neuromuscular blockade Auto-Peep

45. Increased airway resistance ( bronchospasm , endotracheal tube obstruction) Decreased lung or chest wall compliance High ventilation requirements due to increased dead space Overfeeding Myocardial ischaemia , left heart failure Infection/fever Major organ system failure

46.  Points to remember: 1.Ensure an appropriate mix of work and rest periods, assurance of proper sleep andnutrition are helpful. 2. Patients who fail a spontaneous breathing trial (SBT) should have the cause for the failed SBT determined. Once reversible causes for failure are corrected, subsequent SBT should be performed every 24 hours. 3. Patients who fail an SBT should receive a stable, non-fatiguing, comfortable form ofventilatory support.

47. 4. Protocols to decrease the use of continuous intravenous sedation reduce the durationof weaning. 5. Tracheostomy should be considered when it is apparent that the patient requiresprolonged ventilator assistance. Even though the timing of tracheostomy is still controversial, it is recommended to consider tracheostomy if anticipated ventilationis going to be > 7 days. Advantages of tracheostomy include decrease need forsedation , more secure airway enabling greater patient mobility, improved efficiencyof airway suctioning, faster weaning from mechanical ventilation and reducedlength of stay in the ICU.

48. 6.Unless there is evidence for clearly irreversible disease (e.g. high spinal cord injury,advanced amyotrophic lateral sclerosis), a patient requiring prolonged mechanical ventilatory support for respiratory failure should not be considered permanently ventilator dependent until 3 months of failed weaning attempts. 7. Weaning strategy in the prolonged mechanically ventilated patient should be slow paced,and include gradually lengthening spontaneous breathing trials.

49. CARE OF CHILD REQUIRING MECHANICAL VENTILATION

50. Assessment of the Child chest movements/expansion, air entry, breath sounds, color of the skin. Pulse oximetry is useful adjunct. ABG

51. Supportive Care and Synchronization When the goal is full control of patient's ventilation, sedation and muscle paralysis may be required. on-synchronized ventilation can result in ineffective ventilation, increase in work of breathing, patient discomfort and barotrauma . The modes used to improve the synchronization are assist- control ventilation,SIMV (pressure/volume) and PSv . Various triggers can be used for synchronization of ventilator breaths with the onset of child's respiratory effort.

52. The machine should be able to detect a minor change in pressure or flow and respond fast enough for adequate synchronization. Either a pressure or a flow trigger may be used; the latter may be superior. Controlled humidification of the inspired gases, regular sterile endotracheal suctioning and meticulous nursing care is must for any child on ventilator.

53. Care of endotracheal tube E T care should be performed at least every shift, and as needed as ordered by the patient’s Physician. The patient should always be pre-oxygenated with 100% oxygen prior to suctioning. Saline should not be routinely instilled into the airway. Saline installation has been shown to increase infection rates and to cause decreased oxygen levels for longer periods of time than suctioning without it.

54. Good pulmonary hygiene Oropharyngeal Suctioning Suction every 12 hours to remove secretions from the oropharyngeal area above the vocal cords Suction the oral cavity Swab the oral cavity every 4 hours and PRN to cleanse and maintain oral mucosal integrity Moisturize oral cavity every 4 hours

55. Nutrition and hydration Enteral nutrition to support the patient’s metabolic needs and defend against infection. Avoid high carbohydrate diet during weaning. NG tube if necessary – relieves gastric distension and prevents aspiration

56. Continuing Ventilatory Support Most children need ventilatory support for a few days only; however, a small number require mechanical ventilation for prolonged periods. After starting mechanical ventilation, subsequent adjustment are made after evaluating the child's disease status, spontaneous effort, and ABG .

57. In case of worsening, the settings have to be increased . Usually one variable is modified at a time and then its effect seen on ABGs. However, if worsening to severe/acute - multiple variables e.g., Fi0 2 , rate, PEEP, etc. may have to be adjusted to achieve improvement in oxygenation and/or ventilation.

58. Care of common complication Injury during Mechanical Ventilation possibility of ventilator associated lung injury, baro -trauma, tracheal necrosis etc have to be detected in time and take appropriate action. Oxygen toxicity -Try and maintain a SpO2 of > 90% and PaO2 of 60 – 90 mmHg with minimum possible FiO2 to prevent O2 toxicity. Especially for COPD patients : Maintain SpO2 of 85 – 90% and PaO2 of 55 – 70 mmHg

59. Complications of Mechanical Ventilation - Positive Pressure Ventilation can cause:  hypotension decreased venous return decreased cardiac output. Other complications:  pneumothorax subcutaneous emphysema air embolus localized pulmonary hyperinflation nosocomial infections increased intracranial pressure (cerebral edema) Nebulization - It is advisable to put all the patients on bronchodilators on regular basis. Nebulize as per the doctor’s order

60. Weaning from the Ventilator Weaning is the process decreasing the ventilatory support, as the child improves. Reduction in ventilatory support has to keep pace with the child's condition; decreasing support earlier than indicated imposes greater work of breathing while delaying this would delay extubation . Weaning from mechanical ventilation depends not only on the child's respiratory status but also on recovery of the other systems such as circulation (hemodynamic tability ) and the brain (level of consciousne ).

61. Discontinuation of mechanical ventilation can be considered when: The child is stable ( hemodynamics , neurologic status). The underlying disease and its complications have improved. The ventilator support is minimal compared with the patient's spontaneous breathing. The Fi0 2 is low (~0.4).

62. Documentation Record and document Rate & Volume Make sure to assess and document the patient’s spontaneous respiratory rate and tidal volume. This information tells you a lot about the patient’s respiratory functioning. Note any changes in this area, and report significant findings to the child’s Physician.

63. Continuous and Periodic documentation of Vital parameters such as temperature,SpO2, Pulse, BP,ECG pattern, breath rate etc. Ventilator settings: All settings should be recorded – as per the doctors order Sensorium Intake and output Level of comfort Arterial blood gases.

64. Emotional care Reassurance and support the child and the family during the period of anxiety, frustration and hopelessness.

65. NURSING DIAGNOSIS FOR A CHILD UNDER MECHANICAL VENTILATION Ineffective Airway Clearance related to intubation, obstruction, secretions, or pain Deficient Fluid Volume related to fever, decreased appetite, and intubation Impaired Skin Integrity related to mechanical trauma Ineffective Coping related to separation from family and home Bathing/Hygiene/Feeding/Toileting Self-Care Deficit related to long term ventilation Fatigue related to increased work of breathing

66. Anxiety related to respiratory distress and mechanical ventilation Parental Role Conflict related to hospitalization of the child Impaired Physical Mobility related to therapeutic regimen Delayed Growth and Development related to the nature and extent of ventilation Interrupted Family Processes related to the nature of the ventilation, the demands of daily management, and resultant changes in family life Risk for Injury related to deficit in motor activity and coordination Risk for infection related to poor aseptic practices

67. COMPLICATIONS OF MECHANICAL VENTILATION Damage to teeth, lips, or tongue Damage to trachea (windpipe), resulting in pain, hoarseness, and sometimes difficulty breathing after the tube is removed Esophageal intubation (when the tube is accidentally inserted into the esophagus and stomach rather than the trachea) Low blood pressure Pneumonia Lung injury Infection

68. Neck or cervical spine injury Pre-existing lung disease ( eg , emphysema ) Poor condition of teeth Recent meal Dehydration

69. NUTRITIONAL NEEDS OF CRITICALLY ILL CHILD

70. IMPACT OF CRITICAL ILLNESS Increased energy expenditure Pain Anxiety Fever Muscular effort, shivering

71. METABOLIC RESPONSE TO CRITICAL ILLNESS:

72. NEED FOR NUTRITION IN CRITICALLY ILL CHILD Physiologic stress response: Catabolic phase increased caloric needs, urinary nitrogen losses inadequate intake wasting of endogenous protein stores, gluconeogenesis mass reduction of muscle-protein breakdown

73. NUTRIENT METABOLISM AND THE METABOLIC CONSEQUENCES OF THE STRESS RESPONSE

74. Protein Metabolism Amino acids are the key building blocks required for growth and tissue repair. The vast majority (98%) is found in existing proteins, with the remainder residing in the free amino acid pool. Proteins themselves are not static as they are continually degraded and synthClinically significant negative protein balance is characterized by skeletal muscle wasting, weight loss, and immune dysfunction. Apart from the need for acute-phase protein production in the inflammatory response, another driving force for increased protein catabolism is the obligate production of glucose from amino acids through the process of gluconeogenesisesized in the process of protein turnover

75. ENERGY METABOLISM During critical illness, increases in the metabolic turnover of protein, carbohydrate, and lipid result in an increased basal energy requirement for the pediatric patient. Conversely, the dietary provision of excess calories from glucose results in an increased production of carbon dioxide (CO2), with no change in loss of lean body mass. Administration of high-caloric (glucose load) diets in the early phase of critical illness may exacerbate hyperglycemia, increase carbon dioxide generation with increased load on the respiratory system, promote hyperlipidemia resulting from increased lipogenesis , and result in a hyperos -molar state.

76. CARBOHYDRATE METABOLISM Analogous to protein and carbohydrate metabolism, lipid turnover is generally accelerated by critical illness, surgery, and trauma. Because of the increased demand for lipid use in critical illness coupled with the limited lipid stores in the pediatric patient, critically ill children are susceptible to the evolution of biochemically detected essential fatty acid defi ciency if administered a fat-free diet.66,67 In infants, linoleic and linolenic acid are considered essential, whereas arachidonic acid and docosahexaenoic acid are thought to be conditionally essential. The provision of commercially available lipid solutions to parenterally fed critically ill children reduces the risk of essential fatty acid deficiency, results in improved protein use, and does not sig- nifi cantly increase CO2 production or metabolic rate. There are disadvantages, however, with lipid administration, including hypertriglyceridemia , increased rates, of infection, and decreased alveolar oxygen diffusion capacity.

77. ELECTROLYTE METABOLISM Requirements for the basic electrolytes—Na, K, Cl , HCO3, and Ca2—must be evaluated frequently in the critically ill patient. In addition to routine electrolyte monitoring, careful attention to phosphate and magnesium levels is recom -mended. Hypophosphatemia may lead to hemolytic anemia and respiratory muscle dysfunction and may also be seen with refeeding syndrome in the ill child. Renal failure can result in the reten-tion of phosphate, and nutritional allotments must be reduced accordingly. Defi ciency of magne-sium can cause fatal cardiac arrhythmia. Abnormalities of acid–base physiology in the critically ill child can also influence the nutritional regi -men.   alkalemia tends to inhibit the respiratory drive, shift potassium intracellularly , and decrease ionized calcium concentrations by increasing the affinity of albumin for calcium.

78. VITAMIN AND TRACE MINERAL METABOLISM Vitamin and trace mineral metabolism in critically ill and postoperative patients has not been extensively studied. For the neonate and the child required vitamins include fat-soluble vitamins (A, D, E, and K) and water-soluble vitamins (ascorbic acid, thiamin, ribofl avin , pyridoxine, niacin, pantothenate , biotin, folate , and vitamin B12), and these are routinely administered. Required vitamins include fat-soluble vitamins (A, D, E, and K) and water-soluble vitamins (ascorbic acid, thiamin, riboflavin, pyridoxine, niacin, pantothenate , biotin, folate , and vitamin B12), and these are routinely administered. In children with severe hepatic failure, copper and manganese accumulation can occur; thus, parenteral trace mineral supplementation should be reduced.  

79. ASSESMENT OF NUTRITIONAL STATUS Nutritional assessment of the critically ill child is challenging and clinicians use a combination of anthropometric and laboratory data to diagnose undernourishment.

80. Laboratory Tests Serum albumin is frequently used as a tool for nutritional assessment in the ICU. Levels <2.2 g/ dL refl ect malnutrition. However, the long half-life of albumin (14 to 20 days) makes it less responsive to acute changes in nutritional status. Serum albumin concentrations may be affected by albumin infusion, dehydration, sepsis, trauma, and liver disease, independent of nutritional status. Chemistry profile should be monitored on admission and repeated periodically. Other proteins used for nutritional assessment include, RBP, transferrin , fi bronectin , and insulin-like growth factor 1 (IGF-1) Other laboratory tests that help in overall nutritional assessment include serum electrolytes, blood urea nitrogen, glucose, coagulation profi le, iron, magnesium, calcium, and phosphate. The adequacy of cellular immunity can be estimated through the measurement of total lymphocyte count (TLC) and by delayed-type hypersensitivity testing with a series of common antigens ( eg , Candida, trichophyton , tuberculin).

81. NEED FOR NUTRITION IN CRITICALLY ILL CHILD

82. INDICATIONS Prolonged ventilator dependency Prolonged ICU stay Heightened susceptibility to nosocomial infections Increased mortality with mild/moderate or severe malnutrition

83. Prevent/treat macro/micronutrient deficiencies Dose nutrients compatible with existing metabolism Avoid complications Improve patient outcomes

84. ENTERAL NUTRITION

85. usually within 24 hours in severe trauma, burns and catabolic states Contraindications to enteral nutrition: Nonfunctional gut, anatomic disruption, gut ischemia Severe peritonitis Severe shock states

86. ROUTE OF FEEDING Transpyloric Effective in gastric atony / colonic ileus Silicone/polyurethane tubing Nasogastric Requires gastric motility/emptying uoroscopic / pH/ endoscopic guidance Percutaneous /surgical placement PEG if > 4 weeks nutritional support anticipated Jejunostomy if GE reflux, gastroparesis , pancreatitis

87. POTENTIAL DRAWBACKS OF ENTERAL FEEDS Gastric emptying impairments Aspiration of gastric contents Diarrhea Sinusitis Esophagitis /erosions Displacement of feeding tube

88. PARENTERAL NUTRITION The PN formulation is based on: Fluid Requirements Energy Requirements Vitamins Trace elements Other additives-Heparin, H2 blocker etc

89. Alternative Names IV fluids - infants; TPN - infants; Intravenous fluids - infants; Hyperalimentation - infants

90. Purposes of TPN preventing unwanted weight loss and skin breakdown, promoting positive nitrogen balance, and maintaining visceral and somatic protein stores. To promote adequate nutrition. TPN reduces morbidity and mortality, promotes tissue repair, and enhances the immune response

91. Indications Paralytic ileus Intestinal obstruction Acute pancreatitis Malabsorption Persistent vomiting Severe diarrhea Congenital anomalies Major abdominal surgery

92. Cancer patients undergoing chemotherapy or radiation therapy Alcoholic hepatitis Mild acute pancreatitis Acute colitis Crohn's disease (steroid therapy is indicated as being more effective) Acquired immunodeficiency syndrome (AIDS) Pulmonary disease

93. Types Central total parentral nutrition Total nutrient admixture (TNA) is a highly concentrated form of parenteral nutrition that is given through a central vein. It contains a dextrose solution of 20% or higher. Higher glucose concentration should be administered through a central venous line because the high venous flow rate rapidly dissipates the high osmolarity . TNA is indicated for parenteral nutrition needed for more than 7 days.

94. Peripheral Parenteral nutrition Peripheral Parenteral nutrition (PPN) is given through a peripheral vein and has a lower concentration of glucose that should not exceed 12.5%. Higher concentrations of glucose have a high osmolarity that can cause damage to the peripheral venous endothelium, resulting in venous thrombosis and sclerosis. PPN has fewer calories and usually a larger percentage of calories are provided by lipids rather than carbohydrates. PPN is indicated for parenteral nutrition needed for less than 7 days. PPN is not used in some facilities because the risk of infection outweighs the short term nutritional benefits

95. Administration Remove TPN and lipids from the refrigerator at least an hour before hanging. TPN solution should be clear, not cloudy. Lipids will be white. Do not use the fluid if cracking or creaming of the fluid is present because it may indicate fluid separation. TPN must be administered using an IV pump and infused via a dedicated line or lumen of the central venous catheter (CVC). TPN should be filtered with a 0.2 micron filter. Lipids may not be filtered. If so a 1.2 micron filter is needed to avoid clogging up the fluid. Line integrity should not to be compromised except for changing the bag or line. No bolus injections may be given into a TPN line.

96. TPN should be infused at a constant rate over 24 hours unless otherwise ordered . Once a patient is stabilized, cyclic TPN can be provided in a shorter time if appropriate. The facilities procedure for site care and line changes should be followed. When flushing a central line, use a 10 cc syringe or larger. Smaller syringes exert excessive pressure that might break the line. The power flushing technique creates turbulence in the line for more effective clearing of the line. To do this you briskly inject 2 ml of saline, stop very briefly, and then inject another 2 ml. Continue this process until you have completed the flush. As you inject the last 2 ml, clamp the catheter.

97. Saline flush prior to using the line to administer any medication. Heparin is not compatible with other medications. If you inject medication into the line without clearing the heparin flush, the medication may precipitate.   A-Administer the medication.   S-Saline flush to clear the medication from the line before administering the heparin flush.   H- Heparinize the catheter when not in use.

98. Duration Short-term PN may be used if a person's digestive system has shut down (for instance by peritonitis), and they are at a low enough weight to cause concerns about nutrition during an extended hospital stay. Long-term PN is occasionally used to treat people suffering the extended consequences of an accident, surgery, or digestive disorder. PN has extended the life of children born with nonexistent or severely deformed organs.

99. Complications

100. Other complications Total parenteral nutrition increases the risk of acute cholecystitis due to complete disuse of gastrointestinal tract, which may result in bile stasis in the gallbladder. Other potential hepatobiliary dysfunctions include steatosis , steatohepatitis , cholestasis , and cholelithiasis In newborn infants with short bowel syndrome with less than 10% of expected intestinal length, thereby being dependent upon total parenteral nutrition, 5 year survival is approximately 20%. Complications are either related to catheter insertion, or metabolic, including refeeding syndrome.

101. Catheter complications include pneumothorax , accidental arterial puncture, and catheter-related sepsis.. Metabolic complications include the refeeding syndrome characterised by hypokalemia , hypophosphatemia and hypomagnesemia . Hyperglycemia. Hypoglycaemia is likely to occur with abrupt cessation of TPN. Liver dysfunction can be limited to a reversible cholestatic jaundice and to fatty infiltration (demonstrated by elevated transaminases ). Severe hepatic dysfunction is a rare complication. Overall, patients receiving TPN have a higher rate of infectious complications.

102. IMMUNONUTRITION The use of enteral formulae supplemented with immunonutrients such as glutamine, arginine , fatty acids, nucleotides, taurine , cysteine , certaic complex carbohydrates and probiotic bacteria has been demonstrated to modulate gut function, inflammatory and immune responses.

103. This help in reinforcement of mucosal barrier and cellular defence and some down-regulation of local or sy temic inflammatory response, thus reducing morbidity and the risk of infectious complication in critically ill patients)

104. IMMUNE MODULATION Reduction of duration and magnitude of inflammatory response This disrupt the balance between pro and anti-inflammatory processes Of the multiple ingredients in these special formulas: which is “the” one Beneficial effects seen in patients achieving early EN