Transcript Neonatal Infections

Neonatal parenteral nutrition
Dr HOMA BABAEI
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In VLBW newborn full enteral feedings
are generally delayed because of the
severity of medical problems associated
with prematurity, such as immature lung
function (which often requires
endotracheal intubation and mechanical
ventilation), hypothermia, infections,
and hypotension
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As a result, the nutritional requirements
of VLBW infants are rarely met by
enteral feeds in the first two weeks after
birth
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inadequate nutrition in the first weeks of life of premature infants
results in growth failure and may lead to permanent mental
effects.
The early use of adequate PN minimizes weight loss , improves
growth and neurodevelopmental outcome, and appears to
reduce the risk of mortality and later adverse outcomes, such as
necrotizing enterocolitis and bronchopulmonary dysplasia ..
In one study of 148 extremely low birth weight (ELBW)
survivors (birth weight below 1000 g), increasing caloric and
protein intakes during the first week of life were associated with
increases in the Bayley Mental Development Index (MDI) scores
at 18 months of corrected
Indication for initiating PN
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Infant with birth weight < 1500 gr
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Infant with birth weight > 1500 gr that
significant enteral intake is not expected
for>3 days
GI abnormality , NEC
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INFUSION ROUTES:
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Peripheral
– AAP recommends osmolarity between 300
and 900 mosm/l.
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Centeral (svc,ivc)
– >7 days inability for enteral feeding
PN for premature infant
includes:
– Adequate calories for Energy expenditure
and Growth
- Carbohydrate to prevent hypoglycemia
- Adequate protein intake
- Fatty acids
- Mineral , electrolyte,Vitamins , trace elements
Energy Needs
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Expenditure
– Resting metabolic rate
– Activity
– Thermoregulation
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Growth
Energy requirments in the
parenteraly fed infant
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Energy requirments:
– BMR :
40-60
– Thermoregulation
0-5 %
– (Thermal stresses increase Energy E by100%)
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Activity
Energy cost of growth
Energy stored
Energy extered
Total energy requirement :
0- 5%
15
20-30
15
90-120kcal/kg/d
Component of parenteral nutrition
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Fluid
Carbohydrate
Lipids
Protein
Electrolytes
Vitamins and
Trace elements
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Carbohydrate and fat provide the
calories(40-45%)
Pr for positive nitrogen balance and
tissue growth
Studies shown: higher distribution of
carbohydrate –adverse effects on
respiratory metabolism
glucose conversion to fat .. Rise pco2
& oxygen consumption
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Intake of glucose (without lipid): protein
oxidation
A study reported that preterm infants
who received a PN solution contain
higher energy from glucose without
amino acid had frequent episodes of
hyperglycemia .
With a greater AA supply associated
with higher insulin secretion and
normoglycemia.
Intravenous carbohydrate
requirements
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Neural tissue make up agreater proportion of
BW( higher brain to body ratio)
Glycogenolysis &gluconeogenesis are
minimal in VLBW(decresed fat stores).
Term 3-5mg/kg/day
Srart with 6 -8 mg/kg/min ,advance by 12mg/kg/min daily to amaximum of
12mg/kg/min(15mg/kg/min in selected cases)
Dextrose yields 3.4kcal/g.
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ELBW need to be started on a 5%
glucose solution
Intravenous carbohydrate
requirements
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Complication :
– Hyperglycemia(ELBW) = BS>150
BS <200 do not intervention
Treatment:
( D/W 5%)
Insulin :0.05 -0.1 u /kg /h
INTRAVENOUS LIPID
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Lipid solution are made up of :neutral
triglycerides,egg yolk phospholipids,
glycerol, soybean,
Prevent essential fatty acid deficiency
– Linoleic and linolenic acids essential fatty
acids.
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Serve as energy source
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In VLBW : risk of essential fatty acid
deficiency within 72 h of life ( dermatitis,
thrombocytopenia ).
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Intitiated within 24-48 h of life
INTRAVENOUS LIPID
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Intravenous lipids are available
as:10% ,20%,30% .
Lipid intake of 0.5-1 gr/kg/d is
required to prevent essential fatty
acid deficiency
Started at 1g/kg/d and increased to
3g/kg/d (3.5g/kg/d in the ELBW)
INTRAVENOUS LIPID
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Do not allow lipids to exceed 60% of
total caloric intake.
Lipid infusion rates >0.25g/kg/h
associated with decreases in po2 .
Infusion during 24 h (change syrings)
Jaundice requiring phototherapy
:concentration >2gr/kg/day shoud be
avoided.
INTRAVENOUS LIPID
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Triglyceride concentration below 150200mg/dl
Lipid peroxidation result in formation of
organic free radicals ---- tissue injury
– Light ,especially phototherapy
INTRAVENOUS LIPID
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Complication:
– Pulmonary hypertention(PPHN)(free
radical)
– Hyperlipidemia
– Kernicterus
– Impaird lymph drainage –edema
INTRAVENOUS LIPID
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Monitoring:
– Lipid infusion reaches
– Lipid infusion reaches
– weekly
1.5g/kg/d
3g/kg/d
AMINOACID REQUIREMENT
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VLBW with no AA --- lose 1g/kg/d of
protein every day
– 1-2% total endogenous body protein stores
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Combined use of early AA & glucose
within first 24 h replaces urinary
nitrogen loss.
In premature infants : 3.5 to 4 g/kg/day
is needed to meet intrauterine accretion.
≥4 g/kg/day with lower rate of BPD but
failed to improvement in growth
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Administer AA intake 3.5 g/kg on day of
birth .
This level of AA in PN reduce risk of
hyperglycemic episodes versus lower
AA concentration.
calcium
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Reduce intake,
impaird response to PTH
Increased calcitonin level
Increased urinary loss
Inadequate of calcium
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Osteopenia of prematurity
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Fracture
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Affect chest wall stability ----atelectasia
&chronic lung disease
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Immediately after birth PN should
include enough ca ( elemental 25-75
mg/kg/d)
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P : not needed in 1 -2 first day.
Added if P<5mg/dl
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Calcium:80 mg/kg/d
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Phosphorus:40-70 mg/kg/d
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Ca/p ratio =1.7/1 optimal for bone
mineralization
Vitamin
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1cc/kg/d in preterm(max 5cc)
5cc/d in term
Vit A
Electrolytes
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Sodium need is 2-3mEq/kg/d in term &45mEq/kg/d in the preterm
Potassium need is 2-3mEq/kg/d in both term
&preterm.
Magnesium:3-7.2mg/kg/d
mineral, trace element
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Zinc :
– 250 microg/kg/d for term
– 400microg/kg/d for preterm
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Other trace elements
Only trace elemnt recommended from
the first day PN are zinc and selenium
Other trace elemnt after 2 weeks of age
Iron :parenteral iron only after 1 month
TPN WEANING
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Milk >50CC/kg/d –TPN gradually
tapered off
Milk >100-120CC/kg/d—TPN stopped
Dextrose stopped with tapering
Lipid may be stopped without tapering
COMPLICATIONS OF PN
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Electrolyte imbalance
Hypoglycemia,hyperglycemia,hypocalce
mia,hypercalcemia,….
Cholestasis
Complication related to the infusion line
cholestasis
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Multifactorial
– Sepsis, hypoxia,..
– Prolonged lack of enteral nutrition
– Aminoacid toxicity
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Serum bile acids
Gamma –glutamyltranspeptidase
Hepatic transaminases
Venous line complication
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Thrombosis
Infection
– Staphylococcus epidermidis
– Candida albicans
LAB TEST
test
Initial
When stable
Electrolytes,
BUN/Cr
Daily
2-3X/week
glucose
Q6hr-daily
Daily&when
changing CHO
Ca,ionized
Daily
2-3X/week
P,mg,bili,ALT,A baseline
LKP,ALb
weekly
Triglycerid
weekly
CBC.PLT
1.5g/fat/kg/d,
3g/fat/kg/d
weekly
example
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FLUID at 140ml/kg/d
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D12.5%------17.5g/kg------60kcal/kg
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AMINOACIDS---3g/kg -----12kcal/kg
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LIPID 20%-- --3g/kg -----27kcal/kg
TOTAL 99 kcal/kg
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