Proefschrift Kerklaan

Summary

Therefore this approach should be implemented in current nutritional practice on PICUs worldwide.

Chapter 8 This chapter provides a general discussion in which the main findings of this thesis are evaluated and substantiated by speculations on underlying mechanisms. Based on the findings and available literature, current gaps in knowledge of nutritional support in critically ill children are highlighted and are followed by future perspectives on clinical practice and nutritional research.

Table 1. Main findings of this thesis Findings Chapter 1 Introduction

Understanding the stress response of critical illness and its phases is essential to provide recommendations on amount, timing and route of nutrition in critically ill children Current nutritional practices vary widely between PICUs worldwide, especially on macronutrient targets, estimation of energy requirements and threshold for the use of (supplemental) PN. Applied nutritional practice deviated from local protocols or strategies on multiple occasions. There appears to be wide-spread consensus on the preference for the enteral route and its early initiation measurements by the Servo-I® ventilator is a feasible and more precise method to determine REE in mechanically ventilated children >15 kg than predictive equations. It may be a promising method to compensate for the limited availability of indirect calorimetry in the future The number of children identified as overfed ranges widely depending on the definition used. Current definitions of overfeeding fail to take into account several factors associated with critical illness and are therefore not generally applicable to the PICU population There is currently no evidence to support any of the current PN practices for critically ill children. Available RCTs focus on surrogate outcome measures instead of hard clinical outcomes. The evidence from high quality RCTs in critically ill adults no longer supports the early use of PN Withholding PN for one week in the PICU is clinically superior to early provision of PN, with fewer new infections, shorter duration of intensive care dependency and a shorter hospital stay Use of VCO 2

Chapter 2 Worldwide survey of nutritional practices in PICUs

Chapter 3 Ventilator-derived VCO 2 determine REE Chapter 4 Use of indirect calorimetry to detect overfeeding Chapter 5 Evidence for the use of PN in the PICU measurements to

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Chapter 6 and 7 PEPaNIC trial

PICU= Paediatric Intensive Care Unit, REE= Resting Energy Expenditure, PN= Parenteral Nutrition, RCT= Randomised Controlled Trial

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