Total enteral nutrition versus total parenteral nutrition during pediatric extracorporeal membrane oxygenation

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Abstract
Objective: To evaluate the adequacy, tolerance, and complications of enteral nutrition, compared with parenteral nutrition, in pediatric patients requiring extracorporeal membrane oxygenation (ECMO). Design: A retrospective chart review of all patients placed on extracorporeal life support from January 1991 through December 1995. Setting: Medical/surgical pediatric intensive care unit at Egleston Children's Hospital, a tertiary care pediatric center. Patients: Twenty-nine consecutive pediatric patients who required ECMO and were provided nutritional support, either enterally or parenterally. Group A consisted of 14 patients who were provided nutritional support using total parenteral nutrition. Group B consisted of 15 patients. Two patients were excluded from group B because their ECMO run was <36 hrs, leaving insufficient data for analysis. The remaining 13 patients were provided total enteral nutrition during ECMO. Interventions: None. Measurements and Main Results: Both groups were similar in age, weight, pre-ECMO oxygenation index, alveolar-arterial oxygen difference, type, and duration of ECMO (p = NS). Comparison of percent ideal body weight on admission did not show a statistical difference between groups A and B (p = .883). There was no difference between the two groups in the time needed to achieve caloric goal (p = .536) from the initiation of ECMO. No complications were associated with the utilization of enteral feedings. Savings for the nutritional supplement was estimated to be $170 per day for the enterally fed group. The percentage of patients surviving was higher in the enterally fed patients compared with the parenterally fed group (79% vs. 100%), although this difference was not statistically significant (p = .47). Conclusions: Enteral nutrition in patients receiving either venoarterial or venovenous ECMO is well tolerated, provides adequate nutrition, is cost effective, and is without complications, as compared with parenteral nutrition. These data suggest that total enteral nutrition can be safely administered for nutritional support in pediatric patients undergoing either venoarterial or venovenous ECMO. (Crit Care Med 1998; 26:358-363) Extracorporeal membrane oxygenation (ECMO) is recognized as an advanced therapy for use in pediatric respiratory and/or cardiac failure [1,2]. Although ECMO is frequently applied to the pediatric population, the most experience with this technique has come from neonates with respiratory failure [3,4]. Concerns regarding necrotizing enterocolitis and the possible effect of hypoxia on the gut have led to the use of total parenteral nutrition as the main source of nutritional support in the neonatal population [5]. Approximately 90% of neonates who develop necrotizing enterocolitis were enterally fed and were born at <36 wks gestational age [6]. Although gestational age is not an issue when considering pediatric ECMO, the effect of a prior hypoxic/ischemic insult on the gut must be considered. Typically, pediatric patients placed on ECMO have not been enterally fed because of the theoretical concerns associated with prior hypoxic/ischemic insults, potentially resulting in intestinal ischemia. Additional concerns regarding the initiation of enteral feedings have centered around the use of vasopressors and their contribution to intestinal ischemia. Withholding intestinal feedings while providing nutritional support using total parenteral nutrition results in hypoplasia of the intestinal villi, reduction of intestinal absorptive function, increased bacterial translocation, and total parenteral nutrition-associated cholestasis[7-14]. Conversely, the reported advantages of total enteral nutrition include improved gastrointestinal immunologic function, a reduction of sepsis-associated morbidity, decreased frequency of total parenteral nutrition cholestasis, and reduced cost [15-18]. In 1994, based on the evidence supporting the advantages of enteral feedings, we began a concerted effort to enterally feed all critically ill patients in the pediatric intensive care unit at our institution. This change in practice was expanded to include patients placed on ECMO, a population that had typically received parenteral nutrition alone. The purpose of this study was to evaluate and report our experience with enteral nutrition in pediatric patients requiring ECMO.