Proefschrift Kerklaan

General discussion

Admission to PICU

≥1 exclusion criteria?

1. STRONGkids score <2, and/or expected stay <24 hr, and/or oral intake 2. Transfer from another NICU or PICU after stay >7 days 3. Preterm infant 4. Short bowel syndrome or other condition requiring PN 5. (Suspicion of) Inborn metabolic diseases 6. Ketoacidotic or hyperosmolar coma

Yes

Diagnosis/patient specific protocols

Readmission <48 hr: restart day count from 1st day of previous admission

No

Blood glucose < 2.6 mmol/L: 1. Bolus glucose 10% 2 ml/kg 2. Double glucose intake 3. Blood glucose 2x > 4.5 mmol/L Æ back to gluc 3%/NaCl 0.36%

Newborn?

Yes

No

On admission (day 1): 1. Infusion gluc 3%/NaCl 0.36% with calcium gluconate 0.011 mmol/L according to maintenance fluid requirements neonates 2. After 6 hr initiate EN, if possible

On admission (day 1): 1. Infusion gluc 3%/NaCl 0.36% according to maintenance

fluid requirements older children 2. After 6 hr initiate EN, if possible

NB: consider NaCl 0.9% in case of traumatic brain injury, sepsis, bronchiolitis, excessive diarrhoea or CNS infection

8

Day 2-7: 1.Infusion gluc 3%/NaCl 0.36% with elektrolytes * 2.Infusion vitamins/trace elements * until EN covers ≥80% of caloric goal

From day 8 onwards: Switch to regular PN, if EN covers <80% of caloric goal

Figure 1. Flowchart for nutritional support in critically ill children after admission to the PICU *Composition age-dependent, based on ESPEN/ESPGHAN guidelines 2 Critically ill children at nutritional risk (STRONGkids score≥2) 76 , with an expected PICU stay of at least 24 hours without oral intake, and not fulfilling any of the exclusion criteria 84 , will be provided with an infusion of glucose 3% /NaCl 0.36% upon admission. For newborns, this infusion will be supplemented with extra calcium to meet the higher requirements in this population. If possible, enteral nutrition (EN) is initiated after 6 hours, preferably by post-pyloric tube, using commercially available formulas. If placement of a post-pyloric tube fails, gastric feedings should be attempted. The aim of EN administration is to reach caloric and protein goals by day 3: use of caloric and protein enriched formulas may be necessary to achieve this. Details of the local EN protocol have been described previously 85 . From the morning following admission (day 2) up to day 8, pharmacy-made parenteral nutrition (PN) solutions for different weight categories, containing glucose 3%/NaCl 0.36%and electrolytes, are provided at rates based on maintenance fluid requirements proposed by Holliday-Segar 86 , or lower in case of fluid restriction or concomitant enteral nutrient administration, according to the judgement of the attending physician. No parenteral lipids or amino acids are to be administered during the first week of PICU stay. Vitamins and trace elements are provided by a continuous parenteral infusion (neonates-children 30 kg)

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