Fellow Boston Children's Hospital Boston, Massachusetts, United States
Abstract:
Introduction: Extracorporeal membrane oxygenation (ECMO) is utilized in critically ill children with heart disease. The provision of nutrition while on ECMO can be challenging due to perceived limitations and complications. Our objective was to explore the relationship between nutritional adequacy – both energy and protein – and change in the pediatric sequential organ function assessment (pSOFA) score, as a marker of end organ dysfunction.
Methods: Children (≤21yo) admitted to our institution with heart disease and requiring ECMO between 1/1/2013 and 12/31/2020 were included. Energy adequacy was defined as actual intake divided by goal intake, as determined by the Schofield equation. Protein adequacy was defined as actual intake divided by goal intake based on consensus-based, age-related guidelines published by ASPEN. pSOFA scores were calculated for each patient at ECMO cannulation and decannulation.
Results: There were 259 ECMO runs in 252 patients evaluated over the 8-year time period; 54% (n=140) were male with a median age at admission of 5.3 [0, 33.6] months. A majority had complex biventricular (n=102) or single ventricle (n=98) cardiac disease and were admitted postoperatively (n=173 surgical versus n=86 medical) with a median PRISM score of 9 [5, 13] on admission. Veno-arterial (VA) ECMO was almost universally used (n=255) with a mean duration of support of 6.7 ± 12.3 days. Seventy-four patients (29%) received EN and 205 (79%) received PN while on ECMO. Median EN energy adequacy was 0 [0, 1]% and EN protein adequacy was 0 [0, 0]%. Median PN energy adequacy was 55.6 [17.5, 94.0]% and median PN protein adequacy 41.0 [12, 62.6]%. Total (EN + PN) energy adequacy was 57.3 [19.6, 95.4]% and protein adequacy was 41.6 [13.8, 63.6]%. Median pSOFA score at cannulation was 8 [3,13] and at decannulation 12 [9, 15.5]. Improved total energy and protein adequacy (p=0.0007 and p=0.006, respectively), as well as PN energy adequacy (p=0.001) were associated with decreased change in pSOFA score (Figure 1). Additionally, achieving energy adequacy >80% was associated with a decreased change in pSOFA (p=0.022). There were 28 patients with hospital-acquired infections and there was no association with the prescription of PN and hospital-acquired infections (p=0.18).
Conclusion: Improved energy and protein adequacy are associated with preservation of end organ function for critically ill children with heart disease supported on ECMO. Achieving caloric adequacy was associated with a decreased change in pSOFA, although both energy and protein adequacy remain suboptimal. The provision of PN is required in our patient population to ensure the provision of nutrition and was not associated with an increased risk for hospital-acquired infections. Future studies need to determine strategies to optimize the safe provision of enteral nutrition for children with heart disease supported on ECMO.
