الفهرس 
Nutritional assessment and nutrition support in PICUOnly 14 pages are availabe for public view
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Abstract
Nutrition is an important component of patient management in the Pediatric Intensive Care Unit (PICU). Critically ill infants and children may have an increased metabolic need, which predisposes them to nutritional deterioration during illness.
Despite increasing awareness of nutrition support, malnutrition is still prevalent in Pediatric ICU patients, with reports in the range of 25 to 45 % at the time of admission.
Also, malnutrition has been identified as an independent factor for higher rate of nosocomial infections, which has become one of the most severe clinical outcomes associated with substantial morbidity and mortality and prolonged hospital stay.
Malnutrition screening has been advocated as part of patient’s standard care. This recommendation is because malnutrition on admission or deterioration of nutritional status during hospitalization has been associated with a prolonged hospital stay and adverse outcomes. The early identification of nutritional risk followed by an appropriate nutritional management were proposed as part of routine clinical practice.
The aim of our study was to assess the optimal timing of initiation of TPN among Critically ill children admitted into Pediatric Intensive Care Unit and its correlation with PICU stay, ventilator-free days, vasoactive infusion days, incidence of new infections, and mortality.
Our study was conducted on 140 critically ill children admitted to PICU of Menoufia University Hospital from February 2019 to January 2020.71 patients belonged to the early parenteral nutrition group while the late parenteral nutrition included 69 patients.
All patients were assessed by full history taking, thorough clinical examination, anthropometric measurements plotted on WHO Z score, PYMS score to assess nutritional risk, PRISM and PSOFA scores to assess disease severity and mortality then the following laboratory investigations were done: complete blood count (CBC), blood gas analysis, random blood sugar, serum electrolytes: Na, K,Ca, Po4 and Mg, serum creatinine, liver function tests(ALT and AST), and C reactive protein(CRP).
Early parenteral nutrition was given in the 1st 24 hours of admission while late parenteral nutrition was initiated after 6 days of admission. For children with moderate/severe undernutrition, early parenteral nutrition was started in the 1st day while late parenteral nutrition was begun 3 days after admission. This was done after hemodynamic stability, clinical and laboratory evaluation, nutrition assessment and determination of risk of mortality.
Follow up of patients was performed clinically, anthropometry and laboratory weekly and evaluation of outcome as regard: PICU stay, ventilator-free days, vasoactive infusion days, incidence of new infections, and mortality.
Our results demonstrated that patients who received early parenteral nutrition were able to start enteral feeding earlier; had lower risk of feeding intolerance; took
Summary
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shorter time to reach full calories; had shorter PICU stay; lower vasoactive-infusion days; lower central venous catheter days and lower nosocomial infection rate compared with those given late parenteral nutrition.
The most common cause of admission was respiratory system diseases (31.4%) followed by central nervous system diseases (29.3%). Cases with complex chronic condition represented 45% of all patients.
Anthropometric measurements were performed at 1st day of admission, repeated weekly and on discharge. Therefore malnutrition was detected in 30.7% of all cases according to z-score ≤ -2 SD. For children > 36 months, weight/age z score ≤ -2 SD was used.
For assessment of malnutrition risk, we used PYMS score which ranged from (1 – 7) on admission and (0 – 7) on discharge.
Incidence of mechanical ventilation represented 45% of all cases of admission. There was significant increase of mechanical ventilation rate among patients of the late PN group compared with the early group (p-value= 0.018).
The mortality rate ranged from (0.8 – 46.7) in our results. We used PRISM score which was a good predictor of mortality between the two studied groups. Other predictors of outcome included PICU stay (among survivors), ventilator-free days, and vasoactive infusion days, and incidence of new infections.
According to the results of our study, we concluded that early initiation of parenteral nutrition is associated with ability to start enteral feeding earlier; had lower risk of feeding intolerance; and took shorter time to reach full calories. No significant difference between the two groups in the total duration of parenteral nutrition. Early PN also improves outcome as regard PICU stay, vasoactive-infusion days, central venous catheter days and lower nosocomial infection rate compared with late PN.
from this study, we recommend early initiation of parenteral nutrition within 24 hours of admission in critically ill pediatric patients after thorough evaluation.