Perceived barriers to effective enteral and parenteral nutrition in pediatric intensive care units in Ecuador: a multicenter survey study.

Santiago Campos-Miño; María Carolina Velasco; Paúl Moscoso; Xavier Páez; María de Lourdes Alvear; Cristóbal Alvarado; Bayron Guillen

doi:10.47464/MetroCiencia/vol29/4/2021/27-35

Authors

Santiago Campos-Miño Hospital Metropolitano https://orcid.org/0000-0003-4686-7358
María Carolina Velasco Latin American Center for Clinical Research https://orcid.org/0000-0002-8482-9865
Paúl Moscoso Hospital Metropolitano https://orcid.org/0000-0001-9018-7611
Xavier Páez Hospital Roberto Gilbert Elizalde https://orcid.org/0000-0003-0399-1949
María de Lourdes Alvear Hospital Roberto Gilbert Elizalde https://orcid.org/0000-0003-3491-0726
Cristóbal Alvarado Hospital Verdi Cevallos Balda https://orcid.org/0000-0002-8052-0959
Bayron Guillen Hospital Universitario del Río https://orcid.org/0000-0003-4406-2943

DOI:

https://doi.org/10.47464/MetroCiencia/vol29/4/2021/27-35

Keywords:

Pediatric critical care, enteral nutrition, parenteral nutrition, pediatric, nutritional support, barriers

Abstract

Aims: To identify the main barriers perceived by pediatric intensive care healthcare professionals in delivering enteral and parenteral nutrition to critically ill children in Ecuador. Methods: An online cross-sectional survey was sent electronically from May 2020 to July 2020 to PICU intensivists, pediatricians, nurses, and dieticians across Ecuador. The questionnaire consisted of 27 questions on the barriers to enteral nutrition (EN) and 10 questions on the barriers to parenteral nutrition (PN). Respondents were asked to rate each barrier based on a 7-point Likert scale that ranged from 0 = “it is not a barrier at all” to 6 = “it has a great influence as a barrier”. Each barrier was classified into three categories according to the Likert scale score: no barrier (0), moderate barrier (1-3), and important barrier (4-6). Results: A total of 119 responses from 16 hospitals were obtained. 34% of respondents were pediatricians, 21% pediatric intensivists, 39% nurses, and 6% dieticians. The top 5 perceived barriers for EN were: 1) Feeding being held too far in advance of procedures or operating room visits, 2) Not enough time dedicated to education and training, 3) No or not enough dietician coverage during evenings, weekends, and holidays 4) Dietician not routinely present on weekday patient rounds, 5) Lack of familiarity with current guidelines for nutrition. For PN the top three perceived barriers were: 1) Waiting for physician to place a central venous catheter and then request and review X-ray to confirm its correct placement, 2) There is no PN protocol in place or it is not applied, 3) There is no catheter or catheter lumen available for PN purposes only. Conclusions: Our study shows that many perceived barriers to EN in Ecuadorian PICUs are like those found internationally. Barriers to the implementation of PN were also evaluated, finding organizational problems to be one of the main limitations. Most of the identified barriers can be overcome through practical strategies such as the development of specific protocols for enteral and parenteral nutrition and the conformation of multidisciplinary teams. It is essential to implement continuous training programs in nutrition for all health personnel in charge of critically ill pediatric patients.

Downloads

Download data is not yet available.

Author Biographies

Santiago Campos-Miño, Hospital Metropolitano

Attending Pediatric Intensivist, Pediatric Intensive Care Unit, Hospital Metropolitano; Latin American Center for Clinical Research. Quito – Ecuador
María Carolina Velasco, Latin American Center for Clinical Research

Biostatistician, Latin American Center for Clinical Research. Quito – Ecuador
Paúl Moscoso, Hospital Metropolitano

Attending Pediatrician, Pediatric Nutritionist, Hospital Metropolitano. Quito – Ecuador
Xavier Páez, Hospital Roberto Gilbert Elizalde

Attending Pediatric Intensivist, Pediatric Intensive Care Unit, Hospital Roberto Gilbert Elizalde. Guayaquil – Ecuador
María de Lourdes Alvear, Hospital Roberto Gilbert Elizalde

Attending Pediatric Intensivist, Pediatric Intensive Care Unit, Hospital Roberto Gilbert Elizalde. Guayaquil – Ecuador
Cristóbal Alvarado, Hospital Verdi Cevallos Balda

Attending Pediatric Intensivist, Pediatric Intensive Care Unit, Hospital Verdi Cevallos Balda. Portoviejo – Ecuador
Bayron Guillen, Hospital Universitario del Río

Attending Physician, Pediatric and Neonatal Intensive Care Unit, Hospital Universitario del Río. Cuenca – Ecuador

References

Campos-Miño S, Figueiredo-Delgado A. Failure to thrive in the PICU: An overlooked real problem. Pediatr Crit Care Med. 2019;20(8):776–7.

Campos Miño S. Gastrointestinal complications in the PICU: Is disease the only culprit? Pediatr Crit Care Med. 2015;16(9):882–3.

Mehta NM, Bechard LJ, Cahill N, Wang M, Day A, Duggan CP, et al. Nutritional practices and their relationship to clinical outcomes in critically ill children--an international multicenter cohort study. Crit Care Med. 2012;40(7):2204–11.

Campos-Miño S, López-Herce Cid J, Figueiredo Delgado A, Muñoz Benavides E, Coss-Bu JA, Nutrition Committee, Latin American Society of Pediatric Intensive Care (SLACIP). The Latin American and Spanish survey on nutrition in Pediatric Intensive Care (ELAN-CIP2). Pediatr Crit Care Med. 2019;20(1):e23–9.

Tume LN, Eveleens RD, Verbruggen SCAT, Harrison G, Latour JM, Valla FV, et al. Barriers to delivery of enteral nutrition in pediatric intensive care: A world survey: A world survey. Pediatr Crit Care Med. 2020;21(9):e661–71.

Country Nutrition Profiles [Internet]. Globalnutritionreport.org. [cited 2021 jan 7]. Available from: https://globalnutritionreport.org/resources/nutrition-profiles/latin-america-and-caribbean/south-america/ecuador/

Campos-Miño S, Sasbón JS, von Dessauer B. Los cuidados intensivos pediátricos en Latinoamérica. Med Intensiva. 2012;36(1):3–10.

Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, et al. An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Anaesthesia. 2020;75(3):374–85.

Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures an updated report by the American society of anesthesiologists task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology. 2017;126(3):376–93.

Segaran E, Barker I, Hartle A. Optimising enteral nutrition in critically ill patients by reducing fasting times. J Intensive Care Soc. 2016;17(1):38–43.

Elliott EM, Isserman RS, Stricker P, Yaddanapudi S, Subramanyam R. Fasting for anaesthesia: Less is more! Indian J Anaesth. 2020;64(2):87–9.

Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major adverse events and relationship to nil per Os status in pediatric sedation/anesthesia outside the operating room: A report of the Pediatric Sedation Research Consortium. Anesthesiology. 2016;124(1):80–8.

Borland LM, Sereika SM, Woelfel SK, Edward W Saitz MD, Carrillo PA, Lupin JL, et al. Pulmonary aspiration in pediatric patients during general anesthesia: Incidence and outcome. J Clin Anesth. 1998;10(2):95–102.

Andersson H, Schmitz A, Frykholm P. Preoperative fasting guidelines in pediatric anesthesia: Are we ready for a change? Curr Opin Anaesthesiol. 2018;31(3):342–8.

McCracken GC, Smith AF. Breaking the fast for procedural sedation: changing risk or risking change? Anaesthesia. 2020;75(8):1010–3.

McCracken GC, Montgomery J. Postoperative nausea and vomiting after unrestricted clear fluids before day surgery: A retrospective analysis. Eur J Anaesthesiol. 2018;35(5):337–42.

Smith AF, Vallance H, Slater RM. Shorter preoperative fluid fasts reduce postoperative emesis. BMJ. 1997;314(7092):1486.

Simpao AF, Wu L, Nelson O, Gálvez JA, Tan JM, Wasey JO, et al. Preoperative fluid fasting times and postinduction low blood pressure in children. Anesthesiology. 2020;133(3):523–33.

Carvalho CAL de B, Carvalho AA de, Preza ADG, Nogueira PLB, Mendes KBV, Dock-Nascimento DB, et al. Benefícios Metabólicos e Inflamatórios da Abreviação do Jejum Pré-operatório em Cirurgia Pediátrica. Rev Col Bras Cir. 2020;47:e20202353.

Van Veen MR, van Hasselt PM, de Sain-van der Velden MGM, Verhoeven N, Hofstede FC, de Koning TJ, et al. Metabolic profiles in children during fasting. Pediatrics. 2011;127(4):e1021–7.

Ljungqvist O, Nygren J, Thorell A. Insulin resistance and elective surgery. Surgery. 2000;128(5):757–60.

Jenkins B, Calder PC, Marino LV. Evaluation of implementation of fasting guidelines for enterally fed critical care patients. Clin Nutr. 2019;38(1):252–7.

Passier RHA, Davies AR, Ridley E, McClure J, Murphy D, Scheinkestel CD. Periprocedural cessation of nutrition in the intensive care unit: opportunities for improvement. Intensive Care Med. 2013;39(7):1221–6.

Mehta NM, McAleer D, Hamilton S, Naples E, Leavitt K, Mitchell P, et al. Challenges to optimal enteral nutrition in a multidisciplinary pediatric intensive care unit. JPEN J Parenter Enteral Nutr. 2010;34(1):38–45.

Tume L, Carter B, Latten L. A UK and Irish survey of enteral nutrition practices in paediatric intensive care units. Br J Nutr. 2013;109(7):1304–22.

Leong AY, Cartwright KR, Guerra GG, Joffe AR, Mazurak VC, Larsen BMK. A Canadian survey of perceived barriers to initiation and continuation of enteral feeding in PICUs. Pediatr Crit Care Med. 2014;15(2):e49-55.

Keehn A, O’Brien C, Mazurak V, Brunet-Wood K, Joffe A, de Caen A, et al. Epidemiology of interruptions to nutrition support in critically ill children in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(2):211–7.

Spain D. When Is the Seriously III Patient Ready to Be Fed? J Parenter Enteral Nutr, 2002;26(6):S62 - S68.

Sampos Miño S, Sasbón JS. Encuesta latinoamericana de nutrición en Cuidados Intensivos Pediátricos (ELAN-CIP). An Pediatr (Barc). 2009;71(1):5–12.

Kuppinger DD, Rittler P, Hartl WH, Rüttinger D. Use of gastric residual volume to guide enteral nutrition in critically ill patients: a brief systematic review of clinical studies. Nutrition. 2013;29(9):1075–9.

Rogers EJ, Gilbertson HR, Heine RG, Henning R. Barriers to adequate nutrition in critically ill children. Nutrition. 2003;19(10):865–8.

Vallejo KP, Martínez CM, Matos Adames AA, Fuchs-Tarlovsky V, Nogales GCC, Paz RER, et al. Current clinical nutrition practices in critically ill patients in Latin America: a multinational observational study. Crit Care [Internet]. 2017;21(1). Available from: http://dx.doi.org/10.1186/s13054-017-1805-z

Pérez-Navero JL, Dorao Martínez-Romillo P, López-Herce Cid J, Ibarra de la Rosa I, Pujol Jover M, Hermana Tezanos M aT. Nutrición artificial en las unidades de cuidados intensivos pediátricos. An Pediatr (Barc). 2005;62(2):105–12.

Jacobs A, Verlinden I, Vanhorebeek I, Van den Berghe G. Early supplemental parenteral nutrition in critically ill children: An update. J Clin Med. 2019;8(6):830.

Lau CSM, Chamberlain RS. Ultrasound-guided central venous catheter placement increases success rates in pediatric patients: a meta-analysis. Pediatr Res. 2016;80(2):178–84.

Aggarwal S, Claveria J. 1012: Ultrasound confirmation of pediatric central line placement: Ultrasound confirmation of pediatric central line placement. Crit Care Med. 2020;48(1):485–485.

Etherton PM, Akabas SR, Bales CW, Bistrian B, Braun L, Edwards MS, et al. The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. Am J Clin Nutr. 2014;99(5 Suppl):1153S-66S.

Abad-Jorge A. Nutrition management of the critically ill pediatric patient: Minimizing barriers to optimal nutrition support. Infant Child Adolesc Nutr. 2013;5(4):221–30.

Flottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko M, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci. 2013;8(1):35.

Tume LN, Ista E, Verbruggen S, Chaparro CJ, Moullet C, Latten L, et al. Practical strategies to implement the ESPNIC Nutrition Clinical recommendations into PICU practice. Clin Nutr ESPEN [Internet]. 2021; Available from: http://dx.doi.org/10.1016/j.clnesp.2021.01.005