Transcript Parenteral Nutrition

Parenteral
Nutrition
Dr Monidipa Banerjee
Dr Papiya Khawas
Parenteral Vs Enteral
Total vs Partial
Whom to give?
Can not feed - gut anomalies, GI surgery,
NEC
 Can not feed enough –Prematurity, renal
disease, cardiac disease, growth failure of
chronic disease
 Should not feed – intestinal obstruction
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Inability to tolerate minimum 60 kcal/kg/d by
enteral route
Whom not to give?
Metabolic acidosis
 Acute renal failure – oliguria, ↑urea, ↑creat
 Cholestatic jaundice
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How to wean?
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Oral feed to start as soon as baby is ready
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Go up on oral feeds as tolerated
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Keep total daily volume constant (TPN+
oral)
Infusion Routes
Umbilical vein- upto D7
 Long line – placed percutaneously - expensive
 Broviac – placed surgically - expensive
 Confirm proper line placement by x-ray
 Peripheral vein
can’t give higher conc.of dextrose,max12.5%
problem with asepsis in prolonged TPN
Ca, amino acid damages veins
Used 80% of the time in our unit
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Infrastructure
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Place : OT, NICU, lamellar flow ( ideal )
Prepared by: Doctor, trained nurse
Asepsis: person preparing should be fully
scrubbed, using all new disposables every day
Delivery: syringe pump, infusion pump, High
pressure infusion lines, chamber drip set,3 way
connector/ BD connector
Monitoring: Trained nurse to monitor lines and
baby
Composition - 1
Protein: as crystalline amino acids
 Available: 6%&10% Aminoven, Primene.
Each 100 ml of 10% Aminoven contains 10g of
a.acid.(1ml contains 0.1g of a.acid)
 Calorie: 1g Protein = 4 kcal (prot:non-prot=1:6)
 Start: Can be started on Day 1
 Dose: Starting with 0.5-1 g/kg/d, increment of
0.5g/kg/d, upto 3-3.5 g/kg/d.
1.5-2g/kg/d avoids catabolism
Infusion: continuous over 24 hrs, mixed with dextrose
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Composition - 2
Lipid: emulsions with soybean oil preferred
 Available: 10%&20% Intralipid, Clipped.
Each 100 ml contains 10g or 20g of lipid. (1ml
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contains 0.1g or .2g of lipid)
Calorie: 1g Lipid = 9 kcal, 30%-40% of total calories
 Start: Usually started on Day 3 of TPN
 Dose: Starting with 0.5-1 g/kg/d, increment of
0.5g/kg/d, upto 3 g/kg/d.
0.5-1g/kg/d provides essential F.acids
Infusion: continuous over 20-24 hrs, given separately
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Composition - 3
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Carbohydrate: As dextrose, forms main substrate
(% tailored acc. to req. by combining 50% D &
5%D).
Available:
5% Dext/IsoP - 5g/100ml = 50mg/ml
10% Dext
50% Dext
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-10g/100ml =100mg/ml
-50g/100ml = 500mg/ml
Calorie: 1g Carbohydrate= 4 kcal
Dose: Starting 6mg/kg/min,↑10-12mg/kg/min
Monitor: keep CBG 60-150 mg/dl
Composition - 4
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Multivitamins
Trace elements - usually added after 2 weeks of
TPN
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Heparin: if indicated ( e.g. UVC, central lines)
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0.5-1 unit heparin/ml of TPN
Electrolytes
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Normal daily requirement
Na+
2-4 mmol/kg/d add >48 hrs
K+
2 mmol/kg/d add >48 hrs &
normal urinary flow
Ca++
1 mmol/kg/d or add Day 1
2 mEq/kg/d or
75mg/kg/d
Mg++
0.3mEq/kg/d
(0.25 ml/kg/d of 50% MgSO4 –maintenance dose)
PO4
isolated P preparation not available
Dextrose Na+
g/100ml mmol/lit
K+
mmol/lit
Ca++
mmol
Mg++
mmol
5% D
50
(50mg
per ml)
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50%D
500(500
mg/ml)
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IsoP
5%
26
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3 mEq/l
½ DNS
5%
77
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19
NS
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150
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3%Nacl
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0.5per ml
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KCI
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2 per ml
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7.5%
NaHCO3
10% Ca
gluconate
1 per ml
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2.2/10ml
0r 9.2mg Ca / ml
elemental
How much?
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Total fluid req. >day 5 = 150-180ml/kg/d
Volume for TPN= total fluid – other infusions
Volume for TPN = Lipid + AA + Dext +
Electrolytes + MVI
Total calorie req. = ~ 100 kcal/kg/d
Calories from Non-protein:Protein source
maintained at a ratio above 6:1 to prevent
catabolism.
Parenteral nutrition
Intralipid
(separately by
syringe pump
via a 3-way
connector)
Aminoven +
Isolyte-P/ 5% Dextrose
50% Dextrose +
MVI +
Heparin (0.5 - 1unit/ml)
+
Add. electrolytes, as reqd.
Remember!!!
Strict asepsis
 24-hr TPN prepared at a time
 Changing infusion sets daily (ideal)
 New amino acid, lipid bottles daily (ideal)
 Separate IV access for other drugs
 Serum Na, K on alt. days;
urea, creatinie,Ca biweekly;
P, Mg, LFT, triglycerides weekly (ideal)
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Complications
Mechanical: thrombosis, embolism, skin
slough
 Infectious: particularly staph epidermidis,
candida
 Metabolic: hypoglycaemia,
hyperglycaemia, cholestasis
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Thank you