Transcript tpn-dr imani

TPN
BY:DR.B .IMANI
ASSISTANT PROF OF PEDIATRICS
Introduction
 Total parenteral nutrition (TPN)
 The goal of TPN is to initially provide
sufficient nutrients to prevent negative
energy and nitrogen balance and essential
fatty acid deficiency and support normal
growth of appropriate composition without
increased significant morbidity.
Introduction
 short-term outcomes : lower
propensity to infection and shortened
hospital stay
 longer-term outcomes :decreased
growth deficits, improved
neurodevelopment, and overall
morbidity
Clinical Indications
•Gastrointestinal surgery(gastroschisis, meconium
and paralytic ileus, short bowel syndrome )
•Extreme prematurity
•Necrotizing enterocolitis
•severe illness such as septicemia or cardiac failure –
often with ileus.
 malabsorption
•respiratory distress
 (Preterm who will not reach full feeds in 3-4 days or
term babies where oral feeds not possible for 7 days).
General indications
 TPN therapy is indicated for patients:
 Requiring long-term (>10 days) supplemental nutrition.
 Requiring total nutrition because of severe gut
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dysfunction or inability to tolerate enteral feedings.
When enteral feeding cannot be established, TPN is
usually helpful:
After major surgery.
In patients with enterocutaneous fistulas, both high and
low.
In patients with inflammatory bowel disease.
Specific indications
 TPN therapy is part of routine care in:
 Patients who cannot eat or absorb nutrients through the GI
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tract because of:
Massive bowel resection
Diseases of the small bowel
Radiation enteritis
Malnourished patients undergoing high-dose chemotherapy
or radiation therapy.
Patients with severe necrotizing pancreatitis when enteral
feeding is not possible.
Patients with severe malnutrition and nonfunctional gut.
Severely catabolic patients whose gut cannot be used within 5
to 7 days.
Clinical Considerations
 NEONATE: <1500 grams should be started on TPN
by 48 hours of age unless they are expected to be
tolerating full feeds within 24-48 hours.
 NEONATE>1500 grams should be started on TPN by
72 hours of age if they are not expected to be
enterally fed by day 5.
INFUSION ROUTES
 1. Peripheral route is used for partial or supplemental
PN. This route is usually used for short-term nutritional
support. Peripheral PN solutions cannot exceed 12.5%
dextrose or 3.5% amino acids due to the risk of
thrombophlebitis and should not contain calcium
because of the serious complications resulting from
extravasation of calcium.
 2. Central PN is delivered by a venous catheter with the
tip in a central location (DW30%) .This route is used for
patients who require long-term nutritional support,
usually TPN.
Components of TPN Solutions
 TPN provides some or all nutrients of
basal metabolism and growth for:
 fluid, energy, macronutrients (protein,
carbohydrate, and fat) and
micronutrients (electrolytes, major
minerals, trace minerals, and vitamins).
Daily Energy Requirements (Nonprotein kcal/kg)
 Age
 Preterm
 Term
 < 6 months
 6-12 months
 1-7 yr
 7-12
 >12-18
Non-protein(kcal/kg)
120-140
100-120
90-120
80-100
75-90
60-75
30-60
Increase caloric requirements
 Fever
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above 37oC
Cardiac Failure
Major Surgery
Burns
Long term growth failure
Protein calorie malnutrition
12% for each degree
5-25%
20-50%
up to 100%
50-100%
50-100%
Fluid
Fluid requirements Increased in
Decreased in
Fever
Fistulas
Renal failure
Diarrhea
Congestive heart failure
NG suction Pulmonary disease
Pulmonary disease
Cirrhotic ascites
Maintenance requirements for fluid
 Body weight
1-10 kg.
11-20 kg.
> 20 kg.
Fluid requirements per
day
100ml/kg
1000 mls plus 50 ml/kg for
each kg > 10 kg.
1500 mls plus 20 ml/kg for
each kg > 20 kg.
Macronutrients
 Energy needs may be increased with:
 infection, chronic lung disease, healing, growth, and
in babies who have experienced intrauterine growth
restriction (IUGR).
 Energy needs may be decreased with:
 sedation, mechanical ventilation, and after
tracheostomy placement.
Micronutrients
 Electrolytes. Sodium, potassium,
and chloride are essential to life
and requirements are dependent on
obligatory losses, abnormal losses,
and amounts necessary for growth.
Major Minerals
 Calcium, phosphorus, and
magnesium are the most abundant
minerals in the body. They are
closely interrelated to each other in
metabolism, the formation of tissue
structure, and function.
 Preterm infants and term infants receiving
long-term parenteral nutrition are at
increased risk for bone demineralization and
fractures. Calcium (Ca) and phosphorus
 (P) delivery should be maximized for all
infants receiving PN.
 (approximately 1 mEq Ca=2mg Calcium
gluconate)
Clinical Considerations
 1. Sodium: Very small infants with poor renal
tubular function may need as much as 8-10
mmol/kg/day. In premature infants who suffer from
persistent metabolic acidosis due to urinary loss of
bicarbonate it may be helpful to give 50% of the
sodium as acetate.
 2. Potassium: May require adjustment if the infant
is on diuretics or has poor urine output.
 3. Chloride: Ordinarily this amount is delivered
automatically as a side effect of the usual doses of
NaCL and KCL in the IV.
Clinical Considerations
 4. Magnesium: An abnormally high magnesium level may be
due to maternal treatment with magnesium sulfate. * Remove
Mg from TPN if serum Mg is greater than 1.25 mmol/L.
Resume Mg when levels normalize. The renal clearance of
magnesium is poor during the first few days and infants may
accumulate magnesium given in the TPN solution and reach
even higher levels with no warning.
 Do not start magnesium until the serum level is <2.5 mg/dL.
 5. Calcium: Higher risk infants may require higher doses of
calcium.
 *Ensure Ca:Phos molar ratio is 1:1 – 1.3:1 for optimal mineral
retention.
Major Minerals
 Element
 Sodium
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Daily Amount
2-5 meq/kg
Potassium
2-5 meq/kg
Chloride
2-5 meq/kg
Magnesium
0.25-0.5 mEq/kg
Calcium gluconate*
0.5-2.5 mEq/kg
Phosphorous
1-2 mmol/kg
* 110 mg is used in standard pediatric TPN; gluconate is
the recommended Calcium salt in Parenteral Nutrition
solutions since this salt dissociates less than chloride salt.
Trace Minerals
 Copper, selenium, molybdenum, and iron can be
delivered separately also.
 .Copper and manganese are discontinued
from TPN solutions with the complication of
cholestasis, and amounts of chromium,
selenium, and molybdenum are reduced or
omitted when renal output is low. Minimal
enteral feedings are also a source of copper within
the first two weeks.
Iron
 Parenteral iron supplementation may be delayed
until two months of age in premature infants and
three months of age in term infants and
considered for those infants who do not receive
regular blood. Iron - is not a standard part of TPN
solutions, but may be added to solutions as Iron
Dextran when oral iron therapy is precluded by GI
problems. Monitor serum ferritin levels. A test dose
of iron dextran must be given.
Trace Elements
 1. Cholestatic Liver Disease: Conjugated Bilirubin >
2.5 mg/dL reduce trace elements to twice weekly. If
receiving enteral nutrition, discontinue trace
elements.
 2. Persistent diarrhea and GI loss: Increase Zinc
Trace elements
Trace elements are recommended as 0.2 mL/kg/d of trace element solution
containing zinc, manganese, copper, and chromium.
Preterm infants need additional zinc (300 mcg/kg/d) and selenium (2
mcg/kg/d).
Term infants need additional zinc (200 mcg/kg/d) and selenium (2
 mcg/kg/d).
 For infants with cholestasis discontinue the trace element solution and
give:
􀂃 Zinc 400 mcg/kg/d TOTAL (preterm infants)
􀂃 300 mcg/kg/d TOTAL (term infants)
􀂃 Chromium 0.2 mcg/kg/d
􀂃 Selenium 2 mcg/kg/d
􀂃 Discontinue selenium with patients on renal dialysis.
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Vitamins
 . MVI Pediatric is the only parenteral multivitamin
solution designed for pediatric .
 The standard dose of 2 mL/kg/d with a maximum
intake of 5 mL/d provides lower amounts of vitamin
A and higher amounts of most of the B vitamins.
Furthermore, intravenous vitamin delivery may be
less due to photodegradation of vitamins A, D, E, K,
B2, B6, B12, C, and folic acid and absorption of
vitamins A, D, and E into the vinyl delivery bags and
tubing.
Heparin (1 unit/mL) is added to
all central venous lines and to
all peripheral infusions running
at <2 mL/hr in order to
maintain catheter patency.
Initiation and Advancement of Macronutrients in
TPN Solutions
 Provision of greater than 70
kcal/kg/d and 2.7 to 3.5 g
protein/kg/d has been
demonstrated to support growth
and positive nitrogen balance in
preterm infants.
Carbohydrate
 Carbohydrate is delivered in 2.5 to 30% dextrose
solutions that provide 3.4 kcal/g. Glucose is the
energy source for all cells and is essential for the
central nervous system (CNS), erythrocytes, and
other tissues.
 4 to 6 mg/kg/min; 8 to 10 mg/kg/min in ELBW
infants provides 40 to 50 kcal/kg/d and preserves
carbohydrate stores. Advance by 1-3 mg/kg/min
daily to a maximum of 12 mg/kg/min (up to
 15 mg/kg/min in selected cases).
Carbohydrates
 Dextrose
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mg/kg/ min
g/kg/day
Initial dose 6 – 8
7
Avg. daily increase 1 – 3
0.5 – 1
Maximum dose 12 – 14
10 – 17
Energy value 3.4 kcal/g; 2.8 kJ/mmol (14.3 kJ)
Conversions 1 mmol = 0.2 g = 200 mg = 2.8 kJ (0.67
kcal)
 Adjust the percent dextrose daily according to the
infant's tolerance as measured by glucometer, blood
sugars and urine dipsticks.
 Note: The maximum percent dextrose should not
exceed 12.5% when delivered peripherally or 30%
centrally.
 2. If plasma glucose concentration is greater than 8.3
mmol/L sepsis should be evaluated and treated.
 Potential complications/risks include:
 Hyperglycemia or hypoglycemia
 Glycosuria and potential osmotic diuresis
 Excess co2 production
 Cholestasis and/or hepatic steatosis with
high caloric intake usually from long-term
high concentration infusion.
protein
 Amino acid solutions provide 4.0 kcal/g of protein.
provision of at least 1 g/kg/d of amino acids can decrease
catabolism.
 ELBW infants can generally receive 2 g/kg/d of amino
acids on the first day of life. Protein requirements may be
increased to counter catabolic or excretory losses in
clinical conditions such as postoperative woundhealing, chronic lung disease treated with
steroids, lymphatic injury with a sustained chyle
leak, and/or during sustained periods when
infants require limited or withheld enteral
feeding or higher amounts of protein for catchup growth.
New ESPGHAN Guidelines 2010
 Recommendation of two different
protein intakes:
 Preterm babies <1000 g :
 3.6 – 4.1 g/100 kcal
 Preterm babies 1000-1800 g:
 3.2 – 3.6 g/100 kcal
Protein
 Protein
 Initial dose (by 48 hrs)
 Avg. daily increase
 Max usual dose
g/kg/day
1.5
0.5
3.8
 Energy Value: 4 Kcal/g (16.8 kJ/g)
 1. Restrict protein dose in renal failure and hepatic
failure to 0.5-1.5 g/kg/day.
 2. For infants with sepsis, high cardio-pressor
support, or significant birth asphyxia, start at
1g/kg/day and advance as tolerated.
Daily protein requirements (g/kg)
 Neonates
 Infants
 Children
 Adolescents
 Critically Ill
2.5-3 gm/kg
2.0-2.5 gm/kg
1.5-2.0 gm/kg
0.8-2.0 gm/kg
1.5-2.0 gm/kg
Complications of Excess Protein Administration
 Azotemia
 Abnormal Plasma Aminograms
 Acidosis
 Elevated BUN
 Hyperammonemia
 Cholestasis with prolonged administration
Fat
 Fat is delivered as lipid emulsions of neutral
triglycerides (TG), primarily polyunsaturated fatty
acids (PUFA) that are essential for normal growth
and development, retinal development and
function, brain development, and cell
structure and function. Lipid emulsions provide
a concentrated source of energy, 10 kcal/g of fat.
Adequate administration of lipids prevents
essential fatty acid deficiency, promotes positive
nitrogen balance, and optimizes energy utilization.
Fat
 The lipid emulsion is advanced as tolerated in
incremental rates of 0.5 to 1 g/kg/d to a typical
maximum of 3 g/kg/d.In a balanced TPN solution,
this generally approximates about 30% of total
calories from fat.
 Fluid-restricted, growth-compromised patients or
those limited to peripheral line access may require as
high as 3.5 to 4 grams fat/kg/d to achieve adequate
energy for growth and protein sparing.
Lipids
 Lipids
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Initiate by 48h of Age_
Initial dose (g/kg/day)
1 g/kg/day
Increase every 2-3 days
0.5 g/kg/day
Maximum dose (g/kg/day)
3-4 g/kg/day _
Energy Value 20% - 2 kcal/mL; 8.4 kJ/mL and 0.2
g/mL
 Check TG level after each incremental increase in IV
lipid.
 2. Maintain serum TG level below 2.26 mmol/L.
 *If TG > 2.26 mmol/L reduce or discontinue IV lipid
and ensure at least
 0.5-1 g/kg/day of fat to prevent essential fatty acid
deficiency (EFAD).
Clinical Considerations
 3. Infants with sepsis or with severe compromise in oxygenation
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and/or severe hyperbilirubinema should be maintained at 0.5 – 1
g/kg/day.
4. Initiate IV lipids within the first 3 days of life to prevent essential
fatty acid deficiency (EFAD). Minimum intake to prevent EFAD is
0.5 – 1 g/kg/day.
**Reported complications of high lipid levels
a) Enhancement of RBC and platelet clumping.
b) Competition of free fatty acids with bilirubin for albumin binding
sites.
c) An adverse effect of the oxygen diffusion capacity in the lungs.
d) Deposition on intravenous lipids in the RES (reticuloendothelial
system) and potential blocking of RES function.
 lipid infusion rates less than or equal to 0.15 g/kg/h
are recommended to span over 24 hours. The
delivery of 3 g/kg/d of a 20% lipid emulsion equates
to an infusion rate of 0.125 g/kg/h.Premature infants
have limited fat stores and lipoprotein lipase
concentrations that may hinder their ability to clear
plasma lipids following infusions of intravenous fat.
Fat:
 There are potential safety concerns regarding
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administration of lipid emulsions to very low birth
weight infants and infants with hyperbilirubinemia,
pulmonary hypertension and serious pulmonary
disease.
To maximize benefits of lipids and minimize their
adverse effects, use the following guidelines:
(a) provide sufficient lipids to prevent essential fatty
acid deficiency;
(b)monitor for evidence of lipid intolerance;
(c) adjust lipid dose based on clinical status.
 GUIDELINES FOR ADMINISTERING 20% LIPID EMULSION (2)(6)
 Premature
 SGA Infants
 Initial Dose
Full-Term
AGA Infants
0.5 gm/kg/day
Older
Children
1gm/kg/day
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(2.5ml/kg/day)
(5ml/kg/day)
1gm/kg/day
(5ml/kg/day)
 Increase Daily
 Dose by
1gm/kg/day
 (1.25ml/kg/day)
0.25 gm/kg/day
0.5 gm/kg/day
(2.5ml/kg/day)
(5ml/kg/day)
 Maximum Dose
3 gm/kg/day
4 gm/kg/day
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 (10 ml/kg/day)
(15 ml/kg/day)
(20 ml/kg/day)
2 gm/kg/day
Complication
 Hyperlipidemia
 Potential risk of kernicterus at low levels of
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unconjugated bilirubin because of displacement of
bilirubin from albumin binding sites by free fatty acids.
As a general rule, do not advance lipids beyond 0.5
g/kg/d until bilirubin is below threshold for
phototherapy
Potential increased risk or exacerbation of chronic lung
disease
Potential exacerbation of Persistent Pulmonary
Hypertension (PPHN)
Lipid overload syndrome with coagulopathy and liver
failure
Clinical Monitoring of Nutrient Adequacy,
Compatibility, and Tolerance of TPN Solutions
 Accurate and routine monitoring of growth measures
is necessary to prevent over- or undernutrition from
TPN support. Further, routine monitoring of
solution compatibility and tolerance is required to
prevent morbidity.
requires 0.4 cc of blood in each of 2 microtainer tubes (i.e., 0.8 cc total). It is usually drawn on
mondays with additional individual labs as needed or suggested above.
Test
Initial
When stable
Electrolytes,
BUN/creatinine
Daily
2-3x/week
Chemstrip/glucose
q6hr-daily
Daily, more frequently when
changing CHO
Calcium, ionized
daily
2-3x/week
Total calcium, phosphorus,
magnesium, bilirubin (T/D),
ALT, alkaline phosphatase, GGT,
albumin
Baseline
weekly
Triglycerides
When lipid infusion reaches 1.5 g
fat/kg/d and
3 g fat/kg/d
weekly
CBC/Diff and platelets
Growth Monitoring
 Weekly lengths and head measurements, in addition to
daily weights, are important to ensure that overall
growth is occurring and not simply weight gain.
 Although accurate and reproducible lengths are more
difficult to obtain among clinicians, they are a better
indicator of lean body mass and not influenced
significantly by edema.
 For infants to grow optimally, ongoing assessment of
growth in relation to daily estimates of nutrient intake is
necessary. It is critical for practitioners to be cognizant of
the actual amount of TPN that is delivered to a patient
and not to assume that it approximates 100% of what is
ordered.
TPN WEANING GUIDELINES
 When the patient is tolerating >50
ml/kg/day of feedings, the TPN
should be gradually tapered off.
DISCONTINUING PARENTERAL NUTRITION:
PN may be stopped when the infant is tolerating ≥100-120
cc/kg of enteral feedings or is receiving ≤25 cc/kg/d of PN.
 The rate of dextrose administration should be tapered to
prevent rebound hypoglycemia.
 Chemstrips should be done q6h. Newborns need a slower
tapering than older children and require continued
monitoring of glucose after the solution has been
stopped. Lipids may be stopped without tapering. If the
PN catheter clots or infiltrates, start another IV with
dextrose concentration ≤12.5% depending on the current
glucose concentration
Transitional Feeds
 Reduce IV Lipid by 50% when infant tolerates > 50%
of TFI as enteral feeds
 Discontinue TPN when an infant is tolerating 75% of
full enteral feeds.
CONTRAINDICATIONS
 Contraindications to the initiation of enteral
nutrition include bowel obstruction, severe and
protracted ileus, major upper
gastrointestinal bleeding, intractable
vomiting or diarrhea, hemodynamic
instability, significant bowel wall edema,
gastrointestinal ischemia, a high output
fistula, and a gastrointestinal anastomosis
distal to the infusion site. Contraindications to
parenteral feeding include severe hyperglycemia,
hyperosmolality, and severe fluid and
electrolyte abnormalities.