Assessment Of Energy And Protein Requirement In Relation With Nutritional And Clinical Outcomes In Children Receiving Early Enteral Feeding In Children With Congenital Heart Disease After Cardiopulmonary Bypass

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The energy and protein balance between requirement and supply in congenital heart disease children after cardiopulmonary bypassBackground and objective:Congenital heart disease(CHD)is one of the most common congenital malformations,and most of these children need surgical treatment.However,Paucity of data exists about actual protein and energy requirements which are profoundly altered as a result of systemic inflammatory and complex neuroendocrine responses.The energy formulas are based on the normal healthy children,and can only represent the general level of a specific group.The American Society of Enteral and Parenteral Nutrition(ASPEN)recommends indirect calorimetry to monitor energy consumption in critically ill children and nitrogen balance to monitor protein supply and demand to guide nutritional therapy.Adequate supply of protein and energy is crucial,yet challenging,in postoperative management in children after cardiopulmonary bypass(CPB).The present study aimed to assess resting energy expenditure(REE)and nitrogen loss in comparison with caloric and protein supply in the current clinical practice in children following CPB.Methods:From April 2015 to January 2017,CHD infants were performed CPB in the Children's Hospital Affiliated to the Capital Institute of Pediatrics were inclusive.REE was measured using indirect calorimetry and calculated by Schofield equations,White equations and FAO/WHO/UNU equations.Data of clinical caloric and protein supply was collected.Nitrogen losses include total urinary nitrogen and faecal/miscellaneous.Total urinary nitrogen was defined as 1.25 times the urinary urea nitrogen.The nitrogen balance was nitrogen intake minus total nitrogen loss.The nitrogen-to-protein conversion factor was 6.25.Results:28 children(aged 1-60 months,median 4 months)were studied in the first 24 hours after CPB.In these patients,REE was 66±10 kcal/kg/d,and there is no good correlation between REE and calculated value of energy equations.Caloric supply was 11±4 kcal/kg/d,only 17%of REE.Nitrogen balance was-0.91±0.54 g/kg/d.Conclusions:Energy and protein supply is substantially less than requirements in children early after CPB.There is large inter-individual variation in energy and protein requirements among these patients.Our data represent the current situation in nutritional management worldwide.Further studies are warranted to obtain better understanding of individual nutrition requirements in different groups of children in the early postoperative days after different cardiac surgeries in order to provide adequate and individualized nutrition treatment.Part ? Efficacy and safety evaluation of enteral optimum protein intake in infants with complex congenital heart disease during the early postoperative period after cardiopulmonary surgeryBackground and objective:Adequate nutrition is an integral component of postoperative treatment in infants with congenital heart disease(CHD)following Cardiopulmonary bypass(CPB).CPB surgery induces profound metabolic alterations characterized by hypo-anabolism and hyper-catabolism that releases amino acids for protein synthesis to support tissue repair,immune defense and inflammatory responses.Adequate energy and protein provision may help to offset the catabolic burden imposed by critical illness,preventing nutritional deterioration and improving outcomes.We aimed to determine protein requirement and nitrogen kinetics based on the adequate energy supply guided by directly measured REE via early EN in relation to nutritional,organ functional and clinical outcomes in infants with complex CHD during the early period after CPB.Methods:Patients in the controlled trial were randomized into control group(standard protein formula,1.5 g/kg/day),medium protein group(MP,2.5 g/kg/day)or high protein group(HP,4 g/kg/day).Daily energy supply was based on measurements of REE using indirect calorimetry.The nutrition protocol was designed to control dose of protein intake by adding pure whey protein,and fed via enteral feeding,commenced at 6 hours after CPB and throughout the 5 days in all the patients.Accurately calculate the daily doses of carbohydrates,fat,and protein administered.Renal,hepatic myocardial functional measures and other laboratory tests at each designated point were collected on time.Daily nitrogen balance and nitrogen waste were calculated by laboratory test results as follows:nitrogen balance is nitrogen intake minus nitrogen loss;nitrogen waste is internal nitrogen pool plus nitrogen excretion.Evaluated the safety of the intervention of higher proportion of protein intake after CPB by renal,hepatic myocardial functional measures and clinical outcomes.A combination of inflammatory markers and bacterial culture was used to diagnose new infections.Results:From May,2017 to September,2018,157 complex CHD infants aged between 1 month and 12 months were assessed for eligibility and 116 patients were excluded.38 patients completed the experiment.These infants were randomly assigned to control group(n=11),MP group(n=14)and HP group(n=13).REE and energy intakes were not significantly different in 3 groups in the 5 days(P>0.1).With increasing doses of protein,nitrogen balance was slightly improved,and was positive except for postoperative day 1 and day 2 in HP group,while it remained negative in the other two groups in the 5 days(P<0.001).The nitrogen waste in MP and HP groups was higher than control group(P=0.03 and 0.001 respectively),and all three groups had higher levels in the first two days after CPB.However,compared with the dose of protein intake in each group,the waste nitrogen/nitrogen intake was significantly lower in HP group than in control group(P=0.02),and the nitrogen for ureagenesis,nitrogen excretion and internal nitrogen pool were significantly higher in the HP group(P=0.04,0.009 and 0.01 respectively).The incidence of intolerable events was not significantly different in 3 groups.There were no significant differences in renal,hepatic and myocardial functional measures among 3 groups except for postoperative blood and urine urea nitrogen.None of the children developed acute liver or kidney damage.In addition,there were no significant differences in new infections,reintubation rate,poor wound healing and prolonged ICU stay(P>0.23 for all).Conclusions:In infants with complex CHD during the early period after CPB,protein requirement is about 4g/kg/day and energy requirement is about 55 kcal/kg/day.Early EN of adequate composition of energy and protein is not associated with adverse effects on vital organ function despite increased ureagenesis,and rather,with favorable effects in amino acids and anthropometric measures.Further studies are warranted to examine the effects of such formula on clinical endpoints in this special group of patients.These data may have implications for nutritional intervention in critically ill patients in general.