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Dr Arun Aggarwal Gastroenterologist: - TOTAL PARENTERAL NUTRITION

Effective nutritional support of premature and critically ill infants is largely dependent on parenteral nutrition. Initiate parenteral nutrition with in first 24 hrs, continue until enteral nutrition supplies at least 75 % of total protein and energy requirements.<br>

DrArunAggarwalGastroenterologist
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Dr Arun Aggarwal Gastroenterologist: - TOTAL PARENTERAL NUTRITION

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  1. TOTAL PARENTERAL NUTRITION BY: Dr. ARUN AGGARWAL GASTROENTEROLOGIST

  2. Parenteral nutrition is a means of providing either partially or completely the nutritional requirements (fluid, calories and vitamins) of renal metabolism and growth to an infant incapable of tolerating them enterally. By: Dr. Arun Aggarwal Gastroenterologist

  3. INDICATIONS 1. congenital GI anomalies preventing the use of enteral feeds. Post surgical patient unable to feed enterally for an extended period of time. Newborn with intractable diarrhea. Preterm infants who are unable to tolerate enteral feedings or unable to feed adequate amount of enteral feedings. By: Dr. Arun Aggarwal Gastroenterologist

  4. Effective nutritional support of premature and critically ill infants is largely dependent on parenteral nutrition. • Initiate parenteral nutrition with in first 24 hrs, continue until enteral nutrition supplies at least 75 % of total protein and energy requirements. By: Dr. Arun Aggarwal Gastroenterologist

  5. COMPONENTS OF PARENTERAL NUTRITION • Proteins • Energy • Glucose • Lipids • Electrolytes, minerals, trace elements and vitamins By: Dr. Arun Aggarwal Gastroenterologist

  6. PROTEINS • Initial goal of TPN is to minimize losses and preserve existing body stores. • 26 week gestation infant lose 1.5g/kg/day of body protein; protein losses in term infants are ~0.7 g/kg/day. • If extremely premature infants are provided with no AA (amino acid) supply, they lose over 1.5% of their body protein per day when they should be accumulating protein at a rate of 2% per day. By: Dr. Arun Aggarwal Gastroenterologist

  7. AA intakes of 1.1-2.3 g/kg/day at caloric intakes of 30-50 kcal/kg/day change the protein balance from significantly negative to neutral or positive in sick VLBW infants. • In multiple controlled trials evaluating the effect of early AA intake in premature infants, no differences in ammonia concentrations, acid base status or BUN levels were observed b/w infants who recd AA and those who did not. By: Dr. Arun Aggarwal Gastroenterologist

  8. Currently available data suggest that 70-80 kcal/kg/day may be sufficient to maximize protein accretion. • Based on a variety of studies measuring protein losses and balance, 3.5-4.0 g/kg/day of AA is a reasonable estimate of parenteral nutrition requirements in ELBW. By: Dr. Arun Aggarwal Gastroenterologist

  9. Cysteine is not included in the most AA solutions because it is not stable for long periods. • A Cysteine supplement that can be added to the PN solution just prior to delivery is commercially available. • The addition of Cysteine also improves the solubility of Ca and PO4 in PN solutions and also may improve the status of antioxidant glutathione. By: Dr. Arun Aggarwal Gastroenterologist

  10. For above mentioned reasons, addition of Cysteine (40 mg/g of AA, up to a max of 120 mg/kg) is recommended. • Cysteine can result in a metabolic acidosis, but this possibility can be appropriately countered by the use of acetate in the PN solutions as a buffer. By: Dr. Arun Aggarwal Gastroenterologist

  11. SUGGESTED DAILY PARENTERAL INTAKE FOR ELBW By: Dr. Arun Aggarwal Gastroenterologist

  12. SUGGESTED DAILY PARENTERAL INTAKE FOR VLBW By: Dr. Arun Aggarwal Gastroenterologist

  13. ENERGY • To support normal rates of growth, a positive energy balance of 20-25 kcal/kg/day must be achieved. • Please see table on previous slide. • Most of the parenteral calories are best supplied by a balanced caloric intake of lipids and glucose. By: Dr. Arun Aggarwal Gastroenterologist

  14. GLUCOSE • Maintaining glucose concentration of >40 mg/dL and < 150-200 mg/dL is a reasonable clinical goal. • GIR of 4-7 mg/kg/min is an appropriate starting point for most infants. • For ELBW, a rate of 8-10 mg/kg/min is required to match endogenous glucose production. • A gradual increase in glucose intake over 2-7 days, up to 13-17 g/kg/day, is usually tolerated when the glucose is combined with amino acid intake. By: Dr. Arun Aggarwal Gastroenterologist

  15. LIPIDS • Lipids are made up of triglycerides, phospholipids from egg yolk to emulsify and glycerol, which is added to achieve isotonicity. • Iv lipids contain long chain triglycerides. • Essential fatty acid deficiency can be avoided if 0.5 -1.0 g/kg/day of iv lipids is provided. • Additional lipid is necessary if energy requirements of preterm infants are to be met. By: Dr. Arun Aggarwal Gastroenterologist

  16. Meta analysis of studies confirmed that early iv lipid administration (on day 1 of life) is a recommended clinical practice. • Lipid infusion rates in excess of 0.25 g/kg/hr are associated with decrease in PO2. • Triglyceride concentration are most often used as an indication of lipid intolerance. • Maintaining triglycerides levels <150-200 mg/dL seems desirable. By: Dr. Arun Aggarwal Gastroenterologist

  17. Numerous studies have documented superiority of 20% over 10% lipid emulsions. • At present, withholding iv lipids from jaundiced premature infants does not seem warranted. • Carnitine facilitates transport of long chain fatty acids through the myocardial membrane and thereby plays an imp role in their oxidation. • At present, insufficient information is available to support a recommendation for the routine supplementation of parenterally fed neonates with carnitine. By: Dr. Arun Aggarwal Gastroenterologist

  18. ELECTROLYTES, MINERALS, TRACE ELEMENTS AND VITAMINS • For ELBW infants, addition of Na to the PN solution may not be necessary until about day 3 of life. • Frequently measure Na conc and water balance. • ELBW babies sometimes require > 2-4 meq/kg/day to compensate for larger renal sodium losses. • Chloride requirements follow the same time course as for Na requirements. By: Dr. Arun Aggarwal Gastroenterologist

  19. Once electrolytes are added to the PN solution, Cl intake should not be less than 1 meq/kg/day and all Cl should not be omitted when NaHCO3 or acetate is given to correct metabolic acidosis. • K intakes of 2-3 meq/kg/day are usualle adequate to maintain normal serum K conc. By: Dr. Arun Aggarwal Gastroenterologist

  20. Current recommendations are to use PN solutions containing 50-60 mg/dL of elemental Ca and 40-47 mg/dL of phosphorus. • A Ca to phosphorus ratio of 1.7:1 by wt appears to be optimal for bone mineralization. • PO4 is not usually provided to the premie during the first 3 days when abnormalities of Ca balance are most common. • Mg should be supplied at 3-7.2 mg/kg/day. By: Dr. Arun Aggarwal Gastroenterologist

  21. Recommended parenteral intake of trace elements for term and preterm infants By: Dr. Arun Aggarwal Gastroenterologist

  22. Zn should be included early in PN solutions. Other trace elements probably are not needed until after the first 2 weeks of life. • Pediatric trace metal solutions containing Cu, Mn and Cr are usually provided at 0.2 ml/kg/day. • Supplementation with Se is suggested after 2 weeks of age. By: Dr. Arun Aggarwal Gastroenterologist

  23. Parenteral iron is recommended only when preterm infants are nourished exclusively by parenteral solutions for the first 2 months of life. • Currently only one pediatric multivitamin preparation is available and it is delivered with a standard dosage of 2 ml/kg/day (max 5 ml/day) in preterm infants and 5 ml/day in term infants. By: Dr. Arun Aggarwal Gastroenterologist

  24. COMPLICATIONS OF PARENTERAL NUTRITION • Cholestasis : ~ 50% of ELBW exhibits cholestasis after 2 weeks of parenteral nutrition. • Precise cause of cholestasis is unknown and probably is multifactorial (hypoxia, hemodynamic instability, infection). • Enteral feedings even at low caloric intakes can reduce the incidence of cholestasis. By: Dr. Arun Aggarwal Gastroenterologist

  25. Clinical manifestations of cholestasis are hyperbilirubinemia and jaundice. • A sensitive but non specific indicator of early cholestasis is an increase in GGT. • Elevation of AST and ALT occurs later. • Cholestasis most often resolves after discontinuation of parenteral nutrition and initiation of enteral feeds. • At present routine use of ursodeoxycholic acid or Phenobarbital in PN associated cholestasis cant be recommended. By: Dr. Arun Aggarwal Gastroenterologist

  26. Catheter related complications: infection. • Two of the most common bacterial pathogens are Staph epidermidis and Staph aureus. Fungal infections also occur (Candida and Malassezia). • An association has been reported b/w the use of iv lipids and CNS bacteremia and M. furfur fungemia. By: Dr. Arun Aggarwal Gastroenterologist

  27. Hyperglycemia which can cause osmotic diuresis and dehydration. • Hyperaminoacidemia. • Hyperammonemia. By: Dr. Arun Aggarwal Gastroenterologist

  28. CONTRAINDICATION TO LIPID USE: • Infants with liver disease. • Blood coagulopathies. • Hyperbilirubinemia. • Use with caution in very low birth weight infants with severe pulmonary disease<1 wk old because of pulmonary deposition and transitory lower PO2 levels. By: Dr. Arun Aggarwal Gastroenterologist

  29. PRACTICAL APPROACH • Urgent need to initiate iv AA shortly after birth. • Goal of early PN should be to limit catabolism and preserve endogenous protein loss. • Start with a min of 1.5-2.0 g/kg/day of AA on day 1 of life. • Advance AA intake by 1g/kg/day until the goal is reached. • Add cysteine to the AA solution @ 40mg/g of AA. By: Dr. Arun Aggarwal Gastroenterologist

  30. Glucose should be supplied in a quantity sufficient to maintain normal plasma glucose concentrations. • Need of premature infants are in the range of 6-8 mg/kg/min. • Giving D10 @ 100 ml/kg/day provides a GIR of 7mg/kg/min. By: Dr. Arun Aggarwal Gastroenterologist

  31. Lipids should be started with in the first 24 hr of life, usually at 1g/kg/day. • Advance by 0.5-1.0 g/kg/day to a usual maximum of 3 g/kg/day while monitoring and maintaining the serum triglyceride < 200mg/dL. By: Dr. Arun Aggarwal Gastroenterologist

  32. Caloric goals during PN are lower than enteral feeds. • To achieve optimal protein retention, ~ 80- 90 kcal/kg/day is a reasonable goal. • To optimize growth, somewhat higher caloric intake may be necessary. • Non protein balance b/w carbohydrate and lipid should be ~ 60:40 By: Dr. Arun Aggarwal Gastroenterologist

  33. PN should be continued until enteral feedings are well established and providing ~ 100-110 kcal/kg/day. • As enteral feeds are advanced, the protein and lipid contents of the PN can be gradually decreased. By: Dr. Arun Aggarwal Gastroenterologist

  34. Carbohydrates: start at 6-9 g/kg/day (4.2-6.2 mg/kg/min) and advance by 1-3 g/kg/day till 17-21 g/kg/day, until they account for 605 of total calories or presence of glucose intolerance. • AA: started on 1st day of life at 1.5g/kg/day and advance by 1g/kg/day to a max of 3.5g/kg/day for babies <1500 g and 3 g/kg/day for babies >1500 g. monitor BUN and NH3 levels. • Intralipid: (20%) started on day 1-2 @0.5-1.0g/kg/day and advance by 0.5-1.0g/kg/day to a max of 3g/kg/day. • Hold intralipids at 1-2 g/kg/day if S. bili is elevated to near exchange transfusion level, baby has severe respiratory compromise or severe sepsis. By: Dr. Arun Aggarwal Gastroenterologist

  35. HOLD ENTERAL FEEDS IF: • Abdominal distention with increased abdominal girth >2 cm from baseline. • Blood in stools or guiac positive stools in the absence of anal fissure, bloody oro or nasopharyngeal secretions or gastric residuals. • Persistent bilious residuals or vomiting.0 • X ray findings suggestive of NEC. By: Dr. Arun Aggarwal Gastroenterologist

  36. STOCK SOLUTION • To be started immediately after birth for babies <1500g and for sick babies >1500g • For babies <1000g stock solution proportion will be 80 ccD5W +1.5 g AA +1.5 mEq (30 mg) elemental calcium. • For babies >1000g stock solution proportion will be 80 ccD10W +1.5 g AA +1.5 mEq (30 mg) elemental calcium. • Solution should be given @ 80cc/kg/day • Any extra vol should be given separetely. By: Dr. Arun Aggarwal Gastroenterologist

  37. Exact vol prepared by pharmacy will be: • 100ccD5W +1.875 g of protein + cal gluconate 375 mg +25unit of heparin Or • 100ccD10W +1.875 g of protein + cal gluconate 375 mg +25unit of heparin • No addition to be made to stock solution bag. By: Dr. Arun Aggarwal Gastroenterologist

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