Transcript REE (kcal/kg/day)

‫بسم هللا الرحمن الرحيم‬
‫‪1‬‬
Pediatric parenteral
nutrition
M.safarian,MSc,MD, PhD
Mashhad University of Medical Sciences,
Nutrition Department
Indication:
 Unsafe or non functional GI
 Malnurished children
 Increased risk of malnutrition:
 They include infants who have gone: 2-3 days without
adequate intake
 older children who have gone 4-5 days
Peripheral parenteral nutrition:
• the patient is not fluid-restricted
• nutrient needs can be met, and
• central PN is not feasible.
Central parenteral nutrition:
 the patient is fluid-restricted
 peripheral access is limited, and
 nutritional needs cannot be met
by peripheral PN.
PPN vs. TPN
 PPN
 TPN
 Peripheral access
 Central access
 <900 mOsm/L
 No osmolarity limitations
 Max D12.5%
 Typical max dextrose
 Can go up to D15% with
non-central PICC
 Usually requires
increased fluid allowance
ASPEN (2010)
usually D25% however
can go up to D30% prn
Nutritional requirements
 Energy: less than EN
 In children & infants approximately 7-15%
 In neonate approximately ~25%
Nutritional requirements
 Energy: increased when :
 compromised respiratory status,
 sepsis,
 thermal burns,
 cardiac failure,
 chronic growth failure,
 who are recovering from surgery
Nutritional requirements
 Energy: Assessment:
 Weight change for short periods
 Growth pattern for long term
 Also : other anthropometrics
Parenteral Nutrition Kcal
 Goal kcal dictate macronutrient goals
 Extubated: provide ~10% < DRIs due to lack of
thermogenesis
 Intubated: REE or ~80% DRI (dependent on pt’s age)
usually appropriate
Fung (2000)
Resting Energy Expenditure
Age (years)
REE (kcal/kg/day)
0–1
55
1–3
57
4 –6
48
7 –10
40
11-14 (Male/Female)
32
15-18 (Male/Female)
27
Factors adding to REE
Maintenance
Activity
Fever
Simple Trauma
Multiple Injuries
Burns
Sepsis
Growth
Multiplication factor
0.2
0.1-0.25
0.13/per degree > 38ºC
0.2
0.4
0.5-1
0.4
0.5
Nutritional requirements
 Protein:
 AA in parenteral nutrition
Age
Initiate
Advance
Maximum
<1yr
1-2g/kg/day
1g/kg/day
4g/kg/day
1-10yr
1-2g/kg/day
1g/kg/day
1.5-3g/kg/day
>10yr
(adolescents)
1g/kg/day
1g/kg/day
0.8-2.5g/kg/day
***Goal aa correspond to ASPEN protein guidelines for critical
illness
***4kcal/g aa
ASPEN (2010)
Nutritional requirements
 Protein:
 Assessment:
 There is no good marker
Nutritional requirements
 Carbohydrate:
 Solutions greater than 12.5% dextrose should not be
infused
 should be initiated in a stepwise fashion
 Assessment:
 evaluation of serum glucose levels
Age
Initiate
Advance
Maximum
<1yr
~6-9mg/kg/min
1-2mg/kg/min
1-10yr
1-2mg/kg/min
1-2mg/kg/min
Goal: 1012mg/kg/min
Max: 14mg/kg/min
Max: 8-10mg/kg/min
>10yr (adolescents)
1-2mg/kg/min
1-2mg/kg/min
Max: 5-6mg/kg/min
ASPEN (2010)
Nutritional requirements
 Fat:
 Assessment:
 Tolerance is measured by an Intralipid level, a measure of
unmetabolized intravenous fat or artificial chylomicrons.
A level <1.0 g/L indicates acceptable clearance.
Do not give intravenous lipids to patients
with an allergy to egg or soy due to the
presence of egg and soy protein in the
intravenous preparation.
Parenteral Lipids
Age
Initiate
Advance
Maximum
<1yr
1g/kg/day
1g/kg/day
3g/kg/day
1-10yr
1g/kg/day
1g/kg/day
2-3g/kg/day
>10yr
(adolescents)
1g/kg/day
1g/kg/day
1-2.5g/kg/day
-goals dependent on total kcal goals
-do not exceed 60% kcal via lipid (ketosis)
-maximum lipid clearance 0.15g/kg/H
Coss-Bu et al. (2001), ASPEN (2010)
Fat Emulsion

What TG level is appropriate?



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< 200 if a trial period off
< 300-350 if continuously infusing
Lipid calories should not exceed dextrose
calories
Do not exceed 0.15 g/kg/hr infusion
PN Electrolyte Dosing Guidelines
Electrolyte
Preterm
Neonates
Infants/
Children
Adolescents/
Children >50kg
Na
2-5meq/kg
2-5meq/kg
1-2meq/kg
K
2-4meq/kg
2-4meq/kg
1-2meq/kg
Ca
2-4meq/kg
0.5-4meq/kg
10-20meq/day
Phos
1-2mmol/kg
0.5-2mmol/kg
10-40mmol/day
Mg
0.3-0.5meq/kg
0.3-0.5meq/kg
10-30meq/day
Acetate
As needed to maintain acid-base balance
Chloride
As needed to maintain acid-base balance
ASPEN (2010)
PNALD

PNALD
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Avoid macronutrient overfeeding in general
Decrease lipids
GIR ≤ 12.5mg/kg/min
Cholestatic trace elements
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Decreased Cu; no Mn
Cycle TPN as able
Initiate EN asap (even trophic feeds)
Btaiche and Khalidi (2002), Kaufman (2002)
PN-suggested guidelines for
Initiation and Maintenance
Substrate Initiation
Advance Goals
ment
Comments
Dextrose
10%
2-5%/day
Amino
acids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
20%
Lipids
1 g/kg/day 0.5-1
g/kg/day
2-3
g/kg/day
Increase as tolerated.
Consider insulin if
hyperglycemic
Maintain
calorie:nitrogen ratio
at approximately
200:1
Only use 20%
25%
Monitoring
 Initial: weight, height, Total protein/Albumin
(TP/Alb), Transthyretin (TTR);
 Daily Chem until stable
 Stable: weekly Chem and bimonthly TG, LFT’s,
TB/DB
 Chronic: bimonthly Chem and monthly TG, LFT’s,
TP/Alb/TTR
Calculations
Dextrose
 ____g/100ml Dextrose  ____ml/day = ____grams/day
 _____g/day  (weight  1.44) = _____mg/kg/min
 _____g/kg/day  3.4 kcal/g = _____ kcal/kg/day
Calculations
Fat
 20 grams/100ml Fat  _____ml/day = _____grams/day
 _____g/kg/day  9 kcal/g = _____ kcal/kg/day
Calculations
 grams Protein  6.25 = _____ Nitrogen
 Non-protein calories  Nitrogen = Calorie:Nitrogen
ratio
Key points
 There may not exhibit significant hyper catabolism
post-injury
 Their energy need may be decreased due to:
 Decreased physical activity,
 Transient absence of growth during the acute illness
Key points
 Overfeeding:
 Impair liver function by inducing steatosis/cholestasis
 Increase risk of infection
 Hyperglycemia
 Prolonged mechanical ventilation
 Prolonged icu LOS
 No benefit to the maintenance of lean body mass
(LBM)
Agus and Jaksic (2002)
Overfeeding complications
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Hyperglycemia
glycosuria
dehydration
Lipogenesis
fatty liver
liver dysfunction
Electrolyte abnormalities: PO4 , K, Mg
Volume overload, CHF
CO2 production- ventilatory demand
O2 consumption
Increased mortality (in adult studies)
MONITORING
Prevent Overfeeding
 Carbohydrate: High RQ indicates CHO excess, stool
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reducing substances
Protein: Nitrogen balance
Fat: triglyceride
Visceral protein monitoring
Electrolytes, vitamin levels
Other complications
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CHOLESTASIS
elevated conjugated bilirubin and other liver function tests.
Patients most at risk to develop cholestasis:
• overfeeding
• lack enteral nutrition
• long-term parenteral nutrition
• gastrointestinal surgery
• were preterm
• a history of recurrent sepsis
• peak conjugated bilirubin may occur up to one month
after cessation of PN
Other complications
 Chylothorax
 Elevated serum urea
 Hyperglycemia
 Glycosuria
 Hyperbilirobinemia
 Hyperlipidemia
 Hypoglycemia
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Thank you