Nutrition care for the 14+ year old admitted to an adult ICU 

Overall nutrition approach for the 14+ year old population can be very similar to the adult population. Nutritional requirements mainly depend on primary acute diagnosis. We have been advised populations most likely to be transferred to adult ICUs will be Asthma, DKA, Asthma, Overdose, Septic/toxic shock, Trauma. 

Nutrition Considerations 

Dietitian clinical practice recommendations 

Diagnosis 

Asthma: 

  • RD to see when EN (NG feeds) are indicated.   

  • Most patients start PO clears within 24-48hrs of PICU admission. Then diet is advanced as tolerated.   

  • If EN is required due to inability to PO feed (i.e., on Non-invasive ventilation or work of breathing – WOB), please follow EN guidelines below.  

        Energy requirements: See below 

        Protein: DRI for age or a minimum 1.0 g/kg/d  

DKA:  

  • Dietitian services are not indicated.  Within 24-48hrs, patients are weaned off dextrose and insulin infusions and started on PO diet, with subcutaneous insulin. 

  • Patients are transferred to the ward or peripheral hospital where diabetic teaching begins. 

Overdose:   

  • Most patients start PO clears within 24-48hrs of PICU admission. Then diet advanced as tolerated.  

  • RD is involved when NG feeds indicated, see EN guidelines below for guidance.   

       Energy requirements: See below 

       Protein: DRI for age or a minimum 1.0 g/kg/d  

Shock:   

  • EN is usually initiated within first 12-48hrs of admission.  See EN section below for guidance.  

  • Patients commonly require a routine bowel regime (see below).   

  • PN is rarely indicated unless unable to establish EN (see PN guidelines below).     

       Energy requirements: See below  

       Protein: 1.5 – 2.0 g/kg/d  

Trauma:  

  • EN is usually initiated within first 12-48hrs of admission, see EN section below for guidance.  

  • Patients commonly require a routine bowel regime (see below).   

  • PN is rarely indicated unless injury involves the GI tract.  

       Energy requirements: See below 

       Protein: 1.5 – 2.0 g/kg/d  

Energy requirements 

Measuring REE with indirect calorimetry is the gold standard. If not available, apply estimated calculation to determine BMR using the Schofield equation.   

Schofield’s equation for calculating BMR (kcal/d): 

Age  

Boys  

Girls  

10-18 years 

17.7 x (weight in kg) + 658  

13.4 x (weight in kg) + 692  

Estimated energy goals: 

  • Muscle relaxed: BMR x 0.8-1.0 

  • Intubated: BMR 

  • Extubated: BMR x 1.1-1.3 (depending on additional expenditure i.e., mobility, WOB, etc).  

Fluids 

At SickKids, TFI is 80% of maintenance fluids using the 4-2-1 rule to a max of 80mL/hr.   

  • TFI limit includes infusions of medications and nutrition.   

  • All intermittent medications and flushes are not included in TFI.  

  • If more fluid is required for EN, it is usually granted by the team.   

  • ‘4-2-1 rule’ maintenance fluid requirement calculation 

Weight  

mL/kg/h 

A: the first 10kg 

4 

B: weight between 10 - 20 kg 

+2mL/extra kg/h 

C: weight above 20 kg 

+1mL/extra kg/h 

Sum total requirements 

A+B+C 

EN 

We encourage early EN within 48hrs of admission.  

Determining readiness to initiate EN consists of: 

1) soft abdomen 

2) bowel sounds present 

3) hemodynamically stable  

  • demonstrates acceptable oxygen utilization 

              - lactate ≤ 5mmol/L and not increasing 

              - good prefusion on exam 

  • maintained on low dose pressor (< 0.1 mcg/kg/min of norepinephrine) 

Formula modality 

We typically feed our patients continuously via NG. 

Feeding selection 

Any adult formula may be used as per your usual practice 

Feeding rate 

We typically advance feeds to meet goal rate/volume within 24-36hrs. 

Example: Peptamen 1.0kcal/mL at 10mL/hr via NG. Increase by 10mL Q4H to 60mL/hr.  

Make up remaining TFI with IV maintenance fluids as required.  

EN tolerance 

  • EN is tolerated well in the adolescent population.  

  • The most common feeding concern is constipation. When EN is started and no bowel movement >48 hours, initiate PEG 3350 daily. 

  • If no bowel movement continues for 3-4 days, increase PEG to BID and give a bisacodyl suppository x 1.  

PN 

PN is not commonly required for the adolescent population.  

Indication for PN: Unable to provide a minimum of 50% of caloric goal from EN by day 7 of admission.    

Macronutrient 

Initial dose 

Target dose 

Comments 

Lipids 

0.2-0.5g/kg/d 

0.5-1.0g/kg/d as needed to meet total 25-35% of calories from fat 

We use SMOF however can use Intralipid 

Protein 

1.0g/kg/d 

1.0-2.0g/kg/d 

Any AA solution acceptable 

Glucose (dextrose) 

1.5-3mg/kg/min 

3-6mg/kg/min as needed to meet caloric needs 

Typically, PN containing 100g/L is sufficient  

  

If you think PN is indicated for your adolescent patient, please feel free to email us for guidance (contact below). 

SK PICU dietitian contacts 

lori.tuira@sickkids.ca 

 anna.tedesco-bruce@sickkids.ca 

Last revised: Nov 8, 2022 

Contributors: Lori Tuira, Joann Herridge, Anna Tedesco-Bruce, Haifa Mtaweh