Jason Kerstein, MD
Boston Children's Hospital
Boston, Massachusetts
Disclosure information not submitted.
Emily Finnan, MS, RD, LDN, CNSC
Clinical Nutrition Specialist, Division of Gastroenterology, Hepatology and Nutrition
Boston Children's Hospital, United States
Disclosure information not submitted.
Ravi Thiagarajan, MD, MPH
Chief, Division of Cardiac Critical Care
Boston Children's Hospital, United States
Disclosure information not submitted.
Nilesh Mehta, MD
Senior Associate in Critical Care Medicine
Boston Children's Hospital, United States
Disclosure information not submitted.
Kimberly Mills, MD
Pediatric Cardiac Intensive Care Staff Physician
Boston Children's Hospital, United States
Disclosure information not submitted.
Title: Nutrition support in children with heart disease receiving extracorporeal membrane oxygenation
Introduction: ECMO is utilized in children with congenital or acquired heart disease for cardiopulmonary support, acutely during cardiac arrest (E-CPR) and post-cardiotomy. Consensus nutrition guidelines for children on ECMO are limited and generalized. Enteral nutrition (EN) remains underutilized during ECMO due to the concern for intestinal malperfusion. Our objective was to describe EN delivery for children on ECMO in the cardiac intensive care unit (CICU) and examine its association with clinical outcomes.
Methods: We retrospectively reviewed electronic health records and our institutional surgical database of children (≤21yo) with congenital or acquired heart disease requiring ECMO at Boston Children’s Hospital’s CICU from 1/1/2013 to 12/31/2020. Illness severity was considered based on underlying cardiac diagnosis and STAT score.
Results: Data from 272 eligible patients were analyzed. The median age was 5 [0, 34] months, weight 5.7 [3.2, 12.5] kilograms, 94 (34.6%) were neonates and 127 (46.7%) were female. Surgical patients comprised 181 patients (66.5%), 162 of whom were post cardiopulmonary bypass. Most patient diagnoses were complex biventricular (108, 39.7%) or single ventricle (101, 37.1%). 76 (27.9%) patients received EN while on ECMO. EN was initiated on day 3 [2, 4] of ECMO support with 1.7 [0.9, 3.4] kcal/kg/d and 0.04 [0, 0.1] g/kg/d of energy and protein delivered, respectively. EN energy adequacy was 3.8 [1.9, 8.1] % while on ECMO. EN use was associated with male gender (p< 0.01), older age (p< 0.01), higher admission weight (p=0.015), cardiac diagnosis classification (p< 0.01), lower STAT score (p=0.012) and longer duration of ECMO (p< 0.01). By univariate analysis, EN was associated with improved survival, but increased CICU and hospital length of stay (LOS). However, after adjusting for important confounders, these were no longer significant (CICU LOS OR 1.1 [0.9, 1.4], p=0.76; hospital LOS OR 1.2 [0.95, 1.4], p=0.55; survival OR 0.86 [0.5, 1.5], p=0.6).
Conclusions: Many factors are considered when prescribing EN on ECMO. In our cohort, a quarter of patients received limited EN without associated improvement in clinical outcomes. Further research is needed to understand how to safely advance EN, the impact of enteral adequacy on outcomes and its potential effect on end organ function.