Total Parenteral Nutrition

1

Total Parenteral Total Parenteral NutritionNutritionMohamed KhashabaMohamed Khashaba

Professor of Professor of Pediatrics/NeonatologyPediatrics/Neonatology

Head of NICU, MUCHHead of NICU, MUCH

2

Parenteral NutritionParenteral Nutrition

Learning ObjectivesLearning Objectives Know the indications of parenteral Know the indications of parenteral

nutrition.nutrition. Recognize the complications of Recognize the complications of

parenteral feeding.parenteral feeding.

3

Learning ObjectivesLearning Objectives Know the components of parenteral Know the components of parenteral

nutrition.nutrition. Fluid volumeFluid volume CaloriesCalories GlucoseGlucose ProteinsProteins LipidsLipids Electrolytes, minerals and vitaminsElectrolytes, minerals and vitamins

Monitor infants on parenteral nutrition.Monitor infants on parenteral nutrition. Proceed to oral feeding.Proceed to oral feeding.

4

INTRODUCTIONINTRODUCTION

Nutritional management of the neonate in Nutritional management of the neonate in

health and disease states is one the most health and disease states is one the most

important parts of the general management important parts of the general management

of these babies during hospitalization and of these babies during hospitalization and

after their dischargeafter their discharge..

The nutritional status of the newborn The nutritional status of the newborn

interferes positively or negatively with the interferes positively or negatively with the

outcome of many disorders as: jaundice, outcome of many disorders as: jaundice,

sepsis, respiratory distress, anemia, bleeding, sepsis, respiratory distress, anemia, bleeding,

etc…etc…

5

This nutritional This nutritional management should be management should be thought of on daily basis thought of on daily basis during hospitalization and during hospitalization and assessed at regular intervals on assessed at regular intervals on subsequent outpatient follow subsequent outpatient follow up.up.

6


Intravenous delivery of energy Intravenous delivery of energy and nutrients required for the and nutrients required for the infant’s growth.infant’s growth.

PartiallyPartially CompletelyCompletely

Infants incapable of tolerating Infants incapable of tolerating enteral feedingenteral feeding

7


Central lineCentral line

Peripheral veinPeripheral vein

8


Indications:Indications:1.1. Preterm infants: not expected to tolerate Preterm infants: not expected to tolerate

enteral feeds within 3-7 days.enteral feeds within 3-7 days.

2.2. NEC (suspected or confirmed): NEC (suspected or confirmed):

NPO for an extended period.NPO for an extended period.

3.3. Post-Surgical infants: unable to feed for an Post-Surgical infants: unable to feed for an

extended period.extended period.

4.4. Congenital GI anomalies.Congenital GI anomalies.

5.5. Infants failing to gain weight on enteral Infants failing to gain weight on enteral

feeds.feeds.

9

practical hints for TPNpractical hints for TPN

Do not starve babies! The ones who don’t Do not starve babies! The ones who don’t complain are the ones who need it the most.complain are the ones who need it the most.

Use birthweight to calculate intake till Use birthweight to calculate intake till birthweight regained, then use daily wtbirthweight regained, then use daily wt

Start TPN on 2nd or 3rd day if the baby will Start TPN on 2nd or 3rd day if the baby will not be on full feeds by a weeknot be on full feeds by a week

Start with proteins (1 g/kg/d) and increase Start with proteins (1 g/kg/d) and increase slowly. slowly.

After a few days (3rd or 4th day), add lipids After a few days (3rd or 4th day), add lipids (0.5 kg/kg/d)(0.5 kg/kg/d)

Aim for 90-100 Cal/kg/day with 2.5-3 g/kg/d Aim for 90-100 Cal/kg/day with 2.5-3 g/kg/d Protein Protein

10

Parenteral NutritionParenteral Nutrition Complications:Complications:

1.1. Catheter related:Catheter related:

Local skin infectionLocal skin infection

SloughsSloughs

SepsisSepsis

ThrombosisThrombosis

11

2.2. Metabolic complications:Metabolic complications:

HyperglycemiaHyperglycemia

Electrolyte imbalanceElectrolyte imbalance

AcidosisAcidosis

Liver damage and Liver damage and cholestasischolestasis

OsteopeniaOsteopenia

12

Parenteral NutritionParenteral Nutrition Components:Components:

Fluid volumeFluid volume CaloriesCalories GlucoseGlucose ProteinProtein LipidsLipids ElectrolytesElectrolytes Minerals & VitaminsMinerals & Vitamins

13


Fluid VolumeFluid Volume

Depends upon the daily fluid Depends upon the daily fluid

requirements at different days of life requirements at different days of life

in different days of life in different in different days of life in different

birth weights groups.birth weights groups.

14

Fluid requirements day of Fluid requirements day of Life # 1-3 Life # 1-3

IV Fluid requirements ( cc /kg/day )IV Fluid requirements ( cc /kg/day ) Birth Birth

weightweight1000g1000g 1000-1000-

1500g1500g1500-1500-2500g2500g

>2500g>2500g

Day # 1Day # 1 120 D120 D55 W W 100 D100 D7.57.5 WW

80 D80 D1010 W W 80 D80 D1010 W W

Day # 2Day # 2 140 D140 D55 W W 120 D120 D7.57.5 WW

100 D100 D1010 W W 90 D90 D1010 W W

Day # 3Day # 3 170 D170 D55 W W 130 D130 D7.57.5 WW

110 D110 D1010 W W 100 D100 D1010 W W

N.B. Subtract 20 CC/kg/day if the infant suffers from N.B. Subtract 20 CC/kg/day if the infant suffers from R.D.R.D.

15

Parenteral NutritionParenteral Nutrition CaloriesCalories

--The ultimate goal:The ultimate goal:

90-100 K Cal./Kg/day90-100 K Cal./Kg/day

-For the VLBW infants should be -For the VLBW infants should be advanced slowly:advanced slowly:

Day of life 1-3 =Day of life 1-3 = 50-55 k cal./kg/day50-55 k cal./kg/day



16


CaloriesCalories

From From PROTEINPROTEIN not to exceed 15% not to exceed 15%

From From LIPIDSLIPIDS not to exceed 50% not to exceed 50%

of the total caloriesof the total calories

17

Parenteral NutritionParenteral Nutrition GlucoseGlucose

I gm. I gm. 3.4 k cal.3.4 k cal. Start with:Start with:

4-6 mg./kg./min. (in VLBW)4-6 mg./kg./min. (in VLBW)

8-10 mg./kg./min. (in full term)8-10 mg./kg./min. (in full term)

Advance in daily increments ofAdvance in daily increments of1-2 mg./kg./min.1-2 mg./kg./min.

(to (to risk of Hyperglycemia) risk of Hyperglycemia)

18

GlucoseGlucose IV: IV:

Dextrose 3.4 Cal/g = 34 Cal/100 cc of D10W. Dextrose 3.4 Cal/g = 34 Cal/100 cc of D10W. Tiny babies are less able to tolerate dextrose. Tiny babies are less able to tolerate dextrose.

If < 1 kg, start at 6 mg/kg/min. If 1-1.5 kg, If < 1 kg, start at 6 mg/kg/min. If 1-1.5 kg, start at 8 mg/kg/min. start at 8 mg/kg/min.

If blood levels >150-180 mg/dL, If blood levels >150-180 mg/dL, glucosuria=> osmotic diuresis, dehydrationglucosuria=> osmotic diuresis, dehydration

Insulin can control hyperglycemiaInsulin can control hyperglycemia Hyper- or hypo-glycemia => early sign of Hyper- or hypo-glycemia => early sign of

sepsissepsis Avoid Dextrose>12.5% through peripheral IVAvoid Dextrose>12.5% through peripheral IV

19

GIR (mg/ kg /min) = GIR (mg/ kg /min) =

Fluid rate (cc/hr) x Dextrose Fluid rate (cc/hr) x Dextrose ConcentrationConcentration

6 x weight (kg)6 x weight (kg)

20

Example: Example:

What is the GIR in an infant What is the GIR in an infant weighting 2 kg on a total fluid of weighting 2 kg on a total fluid of 120 cc/kg/day using the D120 cc/kg/day using the D1010WW

solution?solution?Hourly rate is:Hourly rate is:

2 (kg) x 120 (cc /kg /day) ÷ 24 = 2 (kg) x 120 (cc /kg /day) ÷ 24 = 10 cc/hr10 cc/hr

GIR = 10 x 10% ( DGIR = 10 x 10% ( D1010W) ÷ (6x2) = W) ÷ (6x2) = 8.3 mg/kg/min 8.3 mg/kg/min

21

Parenteral NutritionParenteral Nutrition ProteinProtein

((6% Amino acid solution containing taurine)6% Amino acid solution containing taurine)

1 gm1 gm 4.0 kcal4.0 kcal

Start with : 0.5 – 1 gm./kg./dayStart with : 0.5 – 1 gm./kg./day

Advance in daily increments of 1.5 – Advance in daily increments of 1.5 –

1gm./kg./day1gm./kg./day

Maximum of 3.0 – 3.5 gm./kg./dayMaximum of 3.0 – 3.5 gm./kg./day

22

Parenteral NutritionParenteral Nutrition ProteinProtein

Reduce the protein load, if serum Reduce the protein load, if serum BUN is raising, or with metabolic BUN is raising, or with metabolic acidosis.acidosis.

The ratio of protein (gm.) : non-The ratio of protein (gm.) : non-protein calories.protein calories.

Should not exceed 1 : 25Should not exceed 1 : 25

23

Parenteral NutritionParenteral Nutrition LipidsLipids

Intralipid 20% (soybean oil, egg Intralipid 20% (soybean oil, egg phosphlipid and 2.25 % glycerol)phosphlipid and 2.25 % glycerol)

1 gm. 1 gm. 10 kcal (2 kcal/ml.)10 kcal (2 kcal/ml.) Start with : 0.5 – 1 gm./kg./dayStart with : 0.5 – 1 gm./kg./day Advance in daily increments of Advance in daily increments of 0.5gm./kg./day0.5gm./kg./day

Maximum of 3.0 – 4.0 gm./kg./dayMaximum of 3.0 – 4.0 gm./kg./day

24


LipidsLipids

If serum Triglycerid level is:If serum Triglycerid level is:

> 200 mg> 200 mg stop stop Intralipids.Intralipids.

> 150 mg> 150 mg decrease the decrease the infusion rate.infusion rate.

25

Intralipids should be used at Intralipids should be used at minimum rate (0.5 – 1 minimum rate (0.5 – 1 gm./kg./day) in:gm./kg./day) in:SepsisSepsisSevere lung diseaseSevere lung diseaseHepatic diseaseHepatic diseaseJaundiceJaundiceThrombocytopeniaThrombocytopenia

26


Macro nutrientsMacro nutrients

StartStart Daily Daily AdvanceAdvance

MaximumMaximum

GlucoseGlucose

(3.4 (3.4 kcal.)kcal.)

4-6 4-6 mg./kg./min.mg./kg./min.

1-2 1-2 mg./kg./min.mg./kg./min.

12.5% solution 12.5% solution in peripheral in peripheral veinvein

ProteinProtein

(4.0 (4.0 kcal.)kcal.)

0.5-1 0.5-1 gm./kg./daygm./kg./day


3.0-3.5 3.0-3.5 gm./kg./daygm./kg./day

(6% solution)(6% solution)

LipidsLipids

(10 (10 kcal.)kcal.)


0.5 0.5 gm./kg./daygm./kg./day

3.0-4.0 3.0-4.0 gm./kg./daygm./kg./day

(20% solution)(20% solution)

27

VitaminsVitamins Fat soluble vitamins: A, D, E, KFat soluble vitamins: A, D, E, K Water soluble vitamins: Vitamins BWater soluble vitamins: Vitamins B11,B,B22, B, B66, ,

BB1212, Biotin, Niacin, Pantothenate, Folic , Biotin, Niacin, Pantothenate, Folic acid, Vitamin C acid, Vitamin C

All neonates should get vit K at birthAll neonates should get vit K at birth Term neonates: No vitamin supplement Term neonates: No vitamin supplement

required, except perhaps vit Drequired, except perhaps vit D Preterm: Start vitamin supplements once Preterm: Start vitamin supplements once

full feeds established if on human milk full feeds established if on human milk without HMF. No need if on human milk without HMF. No need if on human milk with HMF, or preterm infant formula with HMF, or preterm infant formula (except: add vit D if on SSC24). (except: add vit D if on SSC24).

28

IV Electrolytes and minerals IV Electrolytes and minerals requirementsrequirements

Sodium*Sodium*

(mEq/kg/(mEq/kg/day)day)

Potassium*Potassium*

(mEq/kg/(mEq/kg/day)day)

Calcium Calcium (elemental)(elemental)

(mg/kg/day)(mg/kg/day)

Day # 1Day # 1 00 00 4545

Day # 2Day # 2 2-32-3 1-21-2 4545

Day # 3Day # 3 2-32-3 1-21-2 4545

*Do not add sodium if it > 140 mEq/1*Do not add sodium if it > 140 mEq/1

*Do not add potassium until urine output is *Do not add potassium until urine output is established.established.

29


Electrolytes, Minerals & VitaminsElectrolytes, Minerals & Vitamins

Maintain Ca: P ratio at 2:1Maintain Ca: P ratio at 2:1

1 mmol of P = 31 mg1 mmol of P = 31 mg

30

Trace elementsTrace elements

Zinc, Copper, Selenium, Chromium, Zinc, Copper, Selenium, Chromium, manganese, Molybdenum, Iodinemanganese, Molybdenum, Iodine

Trace elements (except for zinc) Trace elements (except for zinc)

should be deleted if direct should be deleted if direct

bilirubin is > 3 mg/dlbilirubin is > 3 mg/dl

31

Assessment of hydration status Assessment of hydration status of the neonateof the neonate

ParameterParameter FrequencyFrequency CommentsComments

WeightWeight Daily, twice a day if Daily, twice a day if <1000g <1000g

Daily weight loss Daily weight loss should not exceedshould not exceed

1-3% 1-3%

Skin and fontanel Skin and fontanel Daily, Every 8 hrDaily, Every 8 hr

if <1000gif <1000gLook for evidence of Look for evidence of dehydration dehydration

Serum sodium Serum sodium Daily, Every 8-12 hr if Daily, Every 8-12 hr if <1000g<1000g

Restrict fluids if Restrict fluids if <130 <130

Liberalize fluids if Liberalize fluids if >145 >145

UrineUrine

VolumeVolume

Specific Specific

gravitygravity

Glycosuria* Glycosuria*

Each diaper changeEach diaper change N. Volume 2-3 N. Volume 2-3 cc/kg/hrcc/kg/hr

N. Sp. Gr. 1005-N. Sp. Gr. 1005-1010 1010

32

Parenteral NutritionParenteral Nutrition MonitoringMonitoring

Suggested monitoring schedule during parenteral Suggested monitoring schedule during parenteral nutrition:nutrition:

Monitoring variableMonitoring variable First week First week last last periodperiodWeightWeight DailyDaily DailyDaily

Length, Head circumferenceLength, Head circumference WeeklyWeekly WeeklyWeekly

Serum Electrolytes, Ca, P, COSerum Electrolytes, Ca, P, CO2 2 2/week2/week

WeeklyWeekly

Serum BUN, albumin, LFTsSerum BUN, albumin, LFTs Weekly Weekly

WeeklyWeekly

Serum TriglyceridesSerum Triglycerides 2/week 2/week WeeklyWeekly

HemoglobinHemoglobin 2/week 2/week WeeklyWeekly

Total Parenteral Nutrition

Documents

daily increments

parenteral nutrition

nutritional management

extended period

human milk

kg day cal

vitamins

lipids