Daily interruption of sedation in critically ill children

Abstract

Objective: Adequate nutrition support is considered important to recovery after pediatric traumatic brain injury. The 2003 Pediatric Guidelines recommend initiation of nutrition within 72 hrs after traumatic brain injury. We examined our local experience with nutritional support in severe pediatric traumatic brain injury patients (cases) and non-traumatic brain injury patients (controls). Design: A retrospective review of pediatric patients with severe traumatic brain injury over an 11-yr period (1997–2009) and without traumatic brain injury over a 3-yr period (2007–2009). Setting: Level I pediatric trauma center pediatric intensive care unit. Patients: Patients with severe pediatric traumatic brain injury (age <15 yrs, Glasgow Coma Scale score of <9) and admitted to the pediatric intensive care unit for >7 days and patients without traumatic brain injury (age <15 yrs, head Abbreviated Injury Scale score of 0) and admitted to pediatric intensive care unit. Interventions: None. Measurements and Main Results: Data from 101 severe traumatic brain injury and 92 non-traumatic brain injury patients were analyzed. Traumatic brain injury patients: All received enteral nutrition while 13 (12%) also received parenteral nutrition. Nutrition was started 53 ± 20 hrs (range 12–162) after pediatric intensive care unit admission. Fifty patients (52%) received nutrition within the first 48 hrs, and 83 (82%) received nutrition support within the first 72 hrs. Caloric and protein intakes were 47% and 40% of the goals on pediatric intensive care unit day 7 and 76% and 70% of the goals on pediatric intensive care unit day 14. Caloric and protein goals were met in 26% ± 16% and 18% ± 19% of pediatric intensive care unit stay, respectively. Patients whose intake met nutritional goals on pediatric intensive care unit day 7 had earlier initiation of nutrition support at admission than patients who never met the goals (calorie goal met vs. unmet by day 7, 44 ± 23 hrs vs. 67 ± 31 hrs; p < .001; protein goal met vs. unmet by day 7, 43 ± 17 hrs vs. 65 ± 29 hrs; p = .001). Patients gained 0.6% ± 11% weight by pediatric intensive care unit day 7 and lost 7% ± 11% weight by pediatric intensive care unit day 14. Non-traumatic brain injury patients: The time to start of nutrition for the non-traumatic brain injury group was earlier only for patients with isolated orthopedic injuries (24 ± 6 hrs; p = .02). The average caloric and protein intakes were less for the traumatic brain injury (n = 20) group (caloric 52% ± 16% of goal and protein 42% ± 18% of goal) than for the non-traumatic brain injury (n = 23) group (65% ± 11% of goal and protein 51% ± 20% of goal; both p < .01) for pediatric intensive care unit days 0–7. For pediatric intensive care unit days 8–14, there was no difference in average caloric (82% ± 22% vs. 79% ± 18% of goal) or protein (77% ± 6% vs. 79% ± 7% of goal) between the traumatic brain injury (n = 12) and non-traumatic brain injury (n = 10) groups. Addition of a nutritionist was associated with earlier time to nutrition start (p = .02). Conclusions: Nutritional support was initiated in most patients within 72 hrs of pediatric intensive care unit admission. Although daily caloric and protein goals were not achieved in the first 2 wks of pediatric intensive care unit stay and nutritional deficiencies were common, earlier start of nutritional support was associated with involvement of a nutritionist and with meeting both caloric and protein goals by pediatric intensive care unit day 7.