Knight Dawn E, Larmour Kelly, Wellman Paul, Mulvey Nicki, Hopkins Julia, Tibby Shane M
Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK.
JPEN J Parenter Enteral Nutr. 2021 Nov;45(8):1720-1728. doi: 10.1002/jpen.2077. Epub 2021 Mar 26.
On a 20-bed, mixed cardiac and general, UK pediatric intensive care unit (PICU), we aimed to determine if a physiologically based enteral feeding guideline for critically ill children, using feed frequency tailored to individual gastric emptying times, resulted in earlier establishment of full feeds (when 100% of fluid allowance (FA) available to be given as intravenous maintenance fluid or feed, defined as free FA [FFA], is given as enteral nutrition [EN]) and an increase in FFA given as EN.
Four prospective audits (totaling 331 patients and 19,771 hours) were conducted at 1 year before guideline introduction and 1, 5, and 10 years after. Patient feeding data were collected from admission until day 4 or discharge, including reasons why feed was withheld.
The median time from admission to establishing full feeds decreased from 18 to 10 hours preguideline and postguideline and was sustained over 10 years. After adjustment for 5 confounders, this represented a reduction in the geometric mean time to full feeds of 30% (2009), 29% (2013), and 48% (2019) compared with 2007 (all P < .01). Nil-per-oral (NPO) hours were categorized as due to modifiable and nonmodifiable factors. Preguideline and postguideline NPO hours from modifiable factors decreased from 21 (2007) to 10 (2009) per 100 audit hours, which was sustained across 10 years (all P < .01). Conversely, NPO hours from nonmodifiable factors ranged from 27 to 36 per 100 audit hours throughout the audits, with no consistent trend over time. Similar inconsistency was shown in the proportion of FFA given as EN: 48% (2007), 71% (2009), 51% (2013), and 64% (2019). Continuous nasogastric and hourly bolus feeds decreased over time; they comprised 66% of feeds in 2007 but only 4%-11% in subsequent periods, being replaced with more 2-6 hour bolus, on-demand, or continuous nasojejunal feeds.
The guideline was associated with sustained reduction in the time to establishing full feeds and NPO hours due to modifiable factors and more or no less FFA being given as EN.
在英国一家拥有20张床位的儿科重症监护病房（PICU），该病房同时收治心脏疾病和其他病症的患儿，我们旨在确定一项针对危重症儿童的基于生理的肠内喂养指南，即根据个体胃排空时间调整喂养频率，是否能使全量喂养更早开始（当可作为静脉维持液或喂养给予的全部液体量（FA），定义为自由FA [FFA]，全部作为肠内营养[EN]给予时），以及增加作为EN给予的FFA量。
在引入指南前1年以及引入后1年、5年和10年进行了四项前瞻性审计（总计331例患者，19771小时）。收集从入院到第4天或出院的患者喂养数据，包括喂养中断的原因。
从入院到开始全量喂养的中位时间在引入指南前为18小时，引入后为10小时，并在10年内保持这一水平。在对5个混杂因素进行调整后，与2007年相比，这代表全量喂养的几何平均时间减少了30%（2009年）、29%（2013年）和48%（2019年）（所有P <.01）。禁食（NPO）小时数按可改变和不可改变因素分类。由于可改变因素导致的引入指南前和引入指南后的NPO小时数从每100审计小时21小时（2007年）降至10小时（2009年），并在10年内保持这一水平（所有P <.01）。相反，在整个审计过程中，由于不可改变因素导致的NPO小时数每100审计小时在27至36小时之间，且没有随时间变化的一致趋势。作为EN给予的FFA比例也显示出类似的不一致性：2007年为48%，2009年为71%，2013年为51%，2019年为64%。持续鼻胃管喂养和每小时推注喂养随时间减少；它们在2007年占喂养方式的66%，但在随后时期仅占4%-11%，被更多的2-6小时推注、按需或持续鼻空肠喂养所取代。
该指南与全量喂养开始时间的持续减少以及由于可改变因素导致的NPO小时数减少相关，并且作为EN给予的FFA量增加或至少没有减少。
