36
Preoperative Trophic Feeds in Neonates with Hypoplastic Left Heart Syndrome Rune Toms, MD,*† Kimberly W. Jackson, MD,* Robert J. Dabal, MD,‡ Cristina H. Reebals, NNP,† and Jeffrey A. Alten MD* *Department of Pediatrics, Division of Critical Care, Section of Cardiovascular Intensive Care, University of Alabama at Birmingham, Birmingham, Ala, USA; †Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, Ala, USA; ‡Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Ala, USA ABSTRACT
Objective. The aim of this is study is to determine if preoperative trophic feeds (TFs) can improve outcomes after Norwood palliation. Design. This is a retrospective cohort study. Setting. The setting is a pediatric cardiovascular intensive care unit in a tertiary hospital. Patients. The patients were 50 consecutive patients with hypoplastic left heart, excluding 5 patients with prematurity or other significant comorbidities. Thirty-one patients that received preoperative TFs (20–30 mL/kg) were compared with 14 that remained nothing by mouth. Decision to initiate feeds was based on attending preference. All patients had protocolized feeds postoperatively, with initiation via transpyloric tube when patient was on minimal inotropes. Outcome Measures. Demographic, feeding, and other clinical outcome data were collected retrospectively from the patient medical record. Results. There were no differences in demographics or preoperative risk factors (mechanical ventilation and lowest pH) between the two groups. Overall survival to discharge was 78% (25/31 TF, 10/14 nothing by mouth, P = .7). Neonates receiving TFs had less fluid administration in the cardiovascular operating room (P = .002), a more negative 48-hour postoperative fluid balance (P = .03), and median 3 days shorter duration of mechanical ventilation (P = .006). Trophic feeds patients also had a nonsignificant trend toward lower peak lactic acid (P = .06), lower inotropic score (P = .15), shorter hospital length of stay (P = .19), and faster time to tolerance of full enteral and oral feeds by 3 and 8 days, respectively (P = .06 and .01). There were no episodes of necrotizing enterocolitis in either group. Conclusions. Preoperative TFs before Norwood palliation appear safe and are associated with shorter duration of mechanical ventilation, a trend toward more stable postoperative hemodynamics, less fluid overload, and earlier postoperative feeding tolerance. Key Words. Trophic Feeds; Congenital Heart Disease; Hypoplastic Left Heart Syndrome; Necrotizing Enterocolitis; Neonates
Introduction
N
eonates with congenital heart disease have increased risk of developing necrotizing enterocolitis (NEC), and those with hypoplastic left heart syndrome (HLHS) are at particularly high risk.1 Clinicians often choose not to feed patients with HLHS before the Norwood palliation (NP), fearing potential complications related to intestinal ischemia. However, when considering Congenit Heart Dis. 2015;10:36–42
all congenital heart disease lesions, the development of NEC does not seem to be associated with a history of previous enteral feeding or the timing of such feeds.1 Enteral feeds have been shown to have several potential benefits. In premature infants, bowel rest (nothing by mouth [NPO]) leads to intestinal atrophy, while trophic feeds (TFs) aid in intestinal mucosa development and maturation of its associated immune system.2 Premature infants © 2014 Wiley Periodicals, Inc.
37
Preoperative Feeds in Hypoplastic Left Heart Table 1.
Patient Characteristics
Variable
No Pre-Op Feeds (n = 14)
Yes Pre-Op Feeds (n = 31)
P
Weight, kg Gestational age, weeks Diagnosis, n (%) Mitral stenosis, aortic stenosis Mitral atresia, aortic stenosis Mitral stenosis, aortic atresia Mitral atresia, aortic atresia Other single ventricle Race, n (%) Caucasian African American Other Sex, n (%) Male Female Age at surgery, days Preoperative ventilation, n (%) Preoperative catecholamines, n (%) Preoperative infection Lowest preoperative arterial pH
3.10 ± 0.48 39 (39, 39)
3.15 ± 0.57 39 (39, 39)
.77 1 .88
1 (7) 2 (14) 3 (21) 6 (43) 2 (14)
3 (10) 3 (10) 5 (16) 16 (52) 4 (13)
10 (71) 3 (21) 1 (7)
14 (45) 15 (48) 2 (6)
.47
1 10 (71) 4 (29) 7 (5, 8) 2 (14) 1 (7) 0 7.32 (7.19, 7.33)
who receive TFs also have better feeding tolerance, improved growth, decreased hospital length of stay, decreased incidence of infection, and decreased incidence of NEC.2 Necrotizing enterocolitis in premature infants and those with HLHS share some similar pathogenic pathways.3 In other critically ill pediatric populations, early enteral feeding has been shown to decrease infection, promote wound healing, improve organ function, decrease hospital length of stay, and improve other clinical outcomes.4–6 We designed this retrospective review to test our hypothesis that preoperative TFs in patients with HLHS is not only safe and well tolerated but also shortens time to full feeds and may be associated with improved postoperative outcomes— potentially related to amelioration of the intestinal inflammatory response from cardiopulmonary bypass.
Materials and Methods
Study Population Approval from the University of Alabama at Birmingham Institutional Review Board was obtained. All neonates with diagnosis of HLHS from 2008 to 2012 were eligible for inclusion. Fifty consecutive neonates with HLHS were identified retrospectively from our cardiac intensive care unit clinical database (patient characteristics listed in Table 1). Patients
Preoperative Trophic Feeds in Neonates with Hypoplastic Left Heart Syndrome Rune Toms, MD,*† Kimberly W. Jackson, MD,* Robert J. Dabal, MD,‡ Cristina H. Reebals, NNP,† and Jeffrey A. Alten MD* *Department of Pediatrics, Division of Critical Care, Section of Cardiovascular Intensive Care, University of Alabama at Birmingham, Birmingham, Ala, USA; †Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, Ala, USA; ‡Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Ala, USA ABSTRACT
Objective. The aim of this is study is to determine if preoperative trophic feeds (TFs) can improve outcomes after Norwood palliation. Design. This is a retrospective cohort study. Setting. The setting is a pediatric cardiovascular intensive care unit in a tertiary hospital. Patients. The patients were 50 consecutive patients with hypoplastic left heart, excluding 5 patients with prematurity or other significant comorbidities. Thirty-one patients that received preoperative TFs (20–30 mL/kg) were compared with 14 that remained nothing by mouth. Decision to initiate feeds was based on attending preference. All patients had protocolized feeds postoperatively, with initiation via transpyloric tube when patient was on minimal inotropes. Outcome Measures. Demographic, feeding, and other clinical outcome data were collected retrospectively from the patient medical record. Results. There were no differences in demographics or preoperative risk factors (mechanical ventilation and lowest pH) between the two groups. Overall survival to discharge was 78% (25/31 TF, 10/14 nothing by mouth, P = .7). Neonates receiving TFs had less fluid administration in the cardiovascular operating room (P = .002), a more negative 48-hour postoperative fluid balance (P = .03), and median 3 days shorter duration of mechanical ventilation (P = .006). Trophic feeds patients also had a nonsignificant trend toward lower peak lactic acid (P = .06), lower inotropic score (P = .15), shorter hospital length of stay (P = .19), and faster time to tolerance of full enteral and oral feeds by 3 and 8 days, respectively (P = .06 and .01). There were no episodes of necrotizing enterocolitis in either group. Conclusions. Preoperative TFs before Norwood palliation appear safe and are associated with shorter duration of mechanical ventilation, a trend toward more stable postoperative hemodynamics, less fluid overload, and earlier postoperative feeding tolerance. Key Words. Trophic Feeds; Congenital Heart Disease; Hypoplastic Left Heart Syndrome; Necrotizing Enterocolitis; Neonates
Introduction
N
eonates with congenital heart disease have increased risk of developing necrotizing enterocolitis (NEC), and those with hypoplastic left heart syndrome (HLHS) are at particularly high risk.1 Clinicians often choose not to feed patients with HLHS before the Norwood palliation (NP), fearing potential complications related to intestinal ischemia. However, when considering Congenit Heart Dis. 2015;10:36–42
all congenital heart disease lesions, the development of NEC does not seem to be associated with a history of previous enteral feeding or the timing of such feeds.1 Enteral feeds have been shown to have several potential benefits. In premature infants, bowel rest (nothing by mouth [NPO]) leads to intestinal atrophy, while trophic feeds (TFs) aid in intestinal mucosa development and maturation of its associated immune system.2 Premature infants © 2014 Wiley Periodicals, Inc.
37
Preoperative Feeds in Hypoplastic Left Heart Table 1.
Patient Characteristics
Variable
No Pre-Op Feeds (n = 14)
Yes Pre-Op Feeds (n = 31)
P
Weight, kg Gestational age, weeks Diagnosis, n (%) Mitral stenosis, aortic stenosis Mitral atresia, aortic stenosis Mitral stenosis, aortic atresia Mitral atresia, aortic atresia Other single ventricle Race, n (%) Caucasian African American Other Sex, n (%) Male Female Age at surgery, days Preoperative ventilation, n (%) Preoperative catecholamines, n (%) Preoperative infection Lowest preoperative arterial pH
3.10 ± 0.48 39 (39, 39)
3.15 ± 0.57 39 (39, 39)
.77 1 .88
1 (7) 2 (14) 3 (21) 6 (43) 2 (14)
3 (10) 3 (10) 5 (16) 16 (52) 4 (13)
10 (71) 3 (21) 1 (7)
14 (45) 15 (48) 2 (6)
.47
1 10 (71) 4 (29) 7 (5, 8) 2 (14) 1 (7) 0 7.32 (7.19, 7.33)
who receive TFs also have better feeding tolerance, improved growth, decreased hospital length of stay, decreased incidence of infection, and decreased incidence of NEC.2 Necrotizing enterocolitis in premature infants and those with HLHS share some similar pathogenic pathways.3 In other critically ill pediatric populations, early enteral feeding has been shown to decrease infection, promote wound healing, improve organ function, decrease hospital length of stay, and improve other clinical outcomes.4–6 We designed this retrospective review to test our hypothesis that preoperative TFs in patients with HLHS is not only safe and well tolerated but also shortens time to full feeds and may be associated with improved postoperative outcomes— potentially related to amelioration of the intestinal inflammatory response from cardiopulmonary bypass.
Materials and Methods
Study Population Approval from the University of Alabama at Birmingham Institutional Review Board was obtained. All neonates with diagnosis of HLHS from 2008 to 2012 were eligible for inclusion. Fifty consecutive neonates with HLHS were identified retrospectively from our cardiac intensive care unit clinical database (patient characteristics listed in Table 1). Patients
