Energy and Protein Requirements in Children Undergoing Cardiopulmonary Bypass Surgery: Current Problems and Future Direction

Abstract

Congenital heart disease (CHD) is 1 of the most common congenital malformations, and considerable numbers of infants and young children with CHD undergo cardiopulmonary bypass surgery. It has been increasingly realized that perioperative nutrition support plays an important role in improving clinical outcomes. The purpose of this review, by searching PubMed, was to examine the nutrition conditions in perioperative children with CHD and the main problems in nutrition management in the cardiac intensive care unit (CICU), based on which future directions were proposed. We found that preoperative poor nutrition status is common. This limited reserve of energy and protein is further compounded by the complex metabolic alterations with hypermetabolism, hypercatabolism, and hypoanabolism in the early postoperative course. Knowledge about energy and protein metabolism and requirements in children after cardiopulmonary bypass remains very limited. The current nutrition recommendations in the CICU are based on little evidence. Insufficient energy and protein supply to meet demands remains a norm in the immediate postoperative period. The commonly used predictive equations do not provide accurate estimate of energy requirement in individual patients during the highly dynamic postoperative course. Indirect calorimetry can provide the best estimate of energy requirements for children with CHD in the CICU. Measurement of nitrogen balance is the recommended method to determine the minimal protein requirement. During the early postoperative period, daily measurements of resting energy expenditure using indirect calorimetry and nitrogen balance in each individual child are essential to optimize energy and protein supply to meet requirements.

Assessment of Energy and Protein Requirements in Relation to Nitrogen Kinetics, Nutrition, and Clinical Outcomes in Infants Receiving Early Enteral Nutrition Following Cardiopulmonary Bypass

“…36 The current barriers in macronutrient delivery in patients with critical illness are fluid restriction and organ failure. 6,7,11,13,37 The actual REE was lower than the estimated values, 7,9 requiring less volume. The harmful effects of amino acids on renal and hepatic function have recently caused much concern.…”

“…The current barriers in macronutrient delivery in patients with critical illness are fluid restriction and organ failure 6,7,11,13,37 . The actual REE was lower than the estimated values, 7,9 requiring less volume.…”

“…Indirect calorimetry is widely considered as difficult and even impossible, particularly in infants. 13,24 However, in our extensive experience, with certain meticulousness, accurate measurements can be achieved. 25 To date, only 4 studies compared measured REE and energy intake in post-CPB children.…”

“…Our data emphasize the importance of daily measurement of REE in individual patients following CPB. Indirect calorimetry is widely considered as difficult and even impossible, particularly in infants 13,24 . However, in our extensive experience, with certain meticulousness, accurate measurements can be achieved 25 .…”

“…Infants with congenital heart disease (CHD) have poor preoperative nutrition status. 13 Other factors also make nutrition treatment more complex in these patients. First, CPB induces greater metabolic response in infants than in older children and adults.…”