3 Whom to give? Can not feed - gut anomalies, GI surgery, NEC Can not feed enough –Prematurity, renal disease, cardiac disease, growth failure of chronic diseaseShould not feed – intestinal obstructionInability to tolerate minimum 60 kcal/kg/d by enteral route
4 Whom not to give? Metabolic acidosis Acute renal failure – oliguria, ↑urea, ↑creatCholestatic jaundice
5 How to wean? Oral feed to start as soon as baby is ready Go up on oral feeds as toleratedKeep total daily volume constant (TPN+ oral)
6 Infusion Routes Umbilical vein- upto D7 Long line – placed percutaneously - expensiveBroviac – placed surgically - expensiveConfirm proper line placement by x-rayPeripheral veincan’t give higher conc.of dextrose,max12.5%problem with asepsis in prolonged TPNCa, amino acid damages veinsUsed 80% of the time in our unit
7 Infrastructure Place : OT, NICU, lamellar flow ( ideal ) Prepared by: Doctor, trained nurseAsepsis: person preparing should be fully scrubbed, using all new disposables every dayDelivery: syringe pump, infusion pump, High pressure infusion lines, chamber drip set,3 way connector/ BD connectorMonitoring: Trained nurse to monitor lines and baby
8 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 1Dose: Starting with g/kg/d, increment of g/kg/d, upto g/kg/d.1.5-2g/kg/d avoids catabolismInfusion: continuous over 24 hrs, mixed with dextrose
9 Composition - 2 Lipid: emulsions with soybean oil preferred Available: 10%&20% Intralipid, Clipped.Each 100 ml contains 10g or 20g of lipid. (1ml contains 0.1g or .2g of lipid)Calorie: 1g Lipid = 9 kcal, 30%-40% of total caloriesStart: Usually started on Day 3 of TPNDose: Starting with g/kg/d, increment of g/kg/d, upto 3 g/kg/d.0.5-1g/kg/d provides essential F.acidsInfusion: continuous over hrs, given separately
10 Composition - 3 Carbohydrate: As dextrose, forms main substrate (% tailored acc. to req. by combining 50% D & 5%D).Available: 5% Dext/IsoP g/100ml = 50mg/ml10% Dext g/100ml =100mg/ml50% Dext g/100ml = 500mg/mlCalorie: 1g Carbohydrate= 4 kcalDose: Starting 6mg/kg/min,↑10-12mg/kg/minMonitor: keep CBG mg/dl
11 Composition - 4 Multivitamins Trace elements - usually added after 2 weeks of TPNHeparin: if indicated ( e.g. UVC, central lines) unit heparin/ml of TPN
12 Electrolytes Normal daily requirement Na+ 2-4 mmol/kg/d add >48 hrs K mmol/kg/d add >48 hrs & normal urinary flowCa mmol/kg/d or add Day 12 mEq/kg/d or75mg/kg/dMg mEq/kg/d(0.25 ml/kg/d of 50% MgSO4 –maintenance dose)PO4 isolated P preparation not available
13 Dextroseg/100mlNa+mmol/litK+Ca++mmolMg++5% D50 (50mgper ml)-50%D500(500mg/ml)IsoP5%26193 mEq/l½ DNS77NS1503%Nacl0.5per mlKCI2 per ml7.5% NaHCO31 per ml10% Ca gluconate2.2/10ml0r 9.2mg elementalCa / ml
14 How much? Total fluid req. >day 5 = 150-180ml/kg/d Volume for TPN= total fluid – other infusionsVolume for TPN = Lipid + AA + Dext Electrolytes + MVITotal calorie req. = ~ 100 kcal/kg/dCalories from Non-protein:Protein source maintained at a ratio above 6:1 to prevent catabolism.
15 Parenteral nutrition Intralipid Aminoven + (separately by syringe pumpvia a 3-wayconnector)Aminoven +Isolyte-P/ 5% Dextrose50% Dextrose +MVI +Heparin ( unit/ml)+Add. electrolytes, as reqd.
16 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 drugsSerum Na, K on alt. days;urea, creatinie,Ca biweekly;P, Mg, LFT, triglycerides weekly (ideal)