Trauma Nutrition Clinical Pathway — ICU | Children's Hospital of Philadelphia

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Related Pathway
Perioperative Care, Anesthesia/ Sedation, ED and Inpatient

Traumatically Injured Child Requiring ICU Care for ≥ 3 Days

Goal
- Initiate nutrition within 72 hrs
- Achieve calorie goal by post-injury day 7
- Avoid prolonged recovery time and increased morbidity and mortality associated with inadequate nutrition

Multidisciplinary Team Assessment

Tertiary survey completed by Trauma team w/in 24 hrs of admission
Assess/identify pre-existing risk factors and malnutrition
Measure weight
- Review patient growth chart
- Update dosing weight
Plan nutrition with Trauma team, Trauma dietitian (RD)
- Anticipate route — NJ, NG or CVC for parenteral nutrition (PN)
Frequent OR Considerations
- General NPO Guidelines

Post-injury Day

Day 0

Day 1-2
Plan, Execute Access

Nutrition Considerations

Initiate nutrition as soon as hemodynamically stable
Transition between enteral and parenteral nutrition is expected

Days 2-4
Begin Feeds

Enteral Nutrition

Parenteral Nutrition

Optimal route if not contraindicated

Gastric
- Order NG/OG tube placement
Jejunal
- PICU/IR/OR coordination for NJ placement with or without bridle
Review with Trauma dietitian
- Discuss patient-specific goals
- Select Appropriate Formula
- Start Trophic Feeds
Advance feeds to reach goal in 24-36 hrs

Arrange for appropriate access for PN
- OR/PICU/IR for central access as indicated
Review with Trauma dietician
- Patient-specific goals
- Order PN
- PN panel morning after starting
- Advance rate to reach goal w/in 36 hrs

Day 5
Reassess

Nutrition Not Initiated

Escalate to Trauma, PICU attending for review
Assess Barriers to Nutrition
Consider transition to parenteral nutrition

Days 6-7
Monitor

Nutrition at Patient-specific Goal

Monitor Nutrition During PICU Care

Biweekly weight checks (Monday/Thursday)
Weekly nutrition assessment completed by Trauma dietitian
Daily discussion between PICU and Trauma teams
- % of estimated nutrition needs received
- Address barriers if receiving < 90% of goal
Daily reassessment of ability to start/advance enteral feeds in children receiving PN

Posted: September 2021
Revised: June 2024, Revisions

Authors:
- R. Cook, RD;
- J. Kloss, CRNP;
- G. Nace, MD;
- B. Bruins, MD;
- S. Irving, CRNP

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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Clinical Pathway for Management of Nutrition in the Traumatically Injured Child Requiring ICU Care for ≥ 3 Days

Evidence