Total parenteral nutrition

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PARENTERALNUTRITION Dr Somashekhar Chikkanna Department of Pediatrics LLRM, Medical College, Meerut

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“The provision of nutrients orally, enterally, or parenterally with therapeutic intent. This includes, but is not limited to, provision of total enteral or parenteral nutrition support, and provision of therapeutic nutrients to maintain and /or restore optimal nutrition status and health.” ASPEN, 2002

Why nutrition ? : 

Why nutrition ? NICHD 4000 infants 500-1500g - 97% of VLBW <10th centile - 99% of ELBW < 10th centile Pediatrics 1999 Sridhar et al IJP 2002 < 1250 g and < 31weeks lag at 1 year length & weight

What if malnutrition ? : 

What if malnutrition ? Consequences of malnutrition - Impaired CNS development exp - Cognition and development affected animal - Decreased somatic growth data Lucas et al RCT preterm infants – lower IQ at 7 yrs in malnourished babies in first month of life Outcome of VLBW babies – 10-15% poor - Nutritional factors ? - Degree and duration ?

An overview : 

An overview Indications Components & requirements Monitoring Complications Precautions & practical approach

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All ELBW babies VLBW babies if feeds delayed Enteral nutrition is contraindicated GI anomalies Gastroschisis & omphalocele Small bowel atresia Meconium peritonitis Hirschsprungs disease Anorectal malformations GI fistula & Tof

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TPN Components : 

TPN Components Fluids Energy Protein Fat Electrolytes Vitamins Minerals

Fluids : 

Fluids Fluid balance should be monitored meticulously in sick new born babies Preterm infants adapt poorly to inadequate or excessive fluid intake Requirements - Radiant warmers, phototherapy - double walled incubators, plastic blankets & humidity

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Restricted fluid approach reduces the risks of PDA , NEC & death (Cochrane rev) Restrict the water intake to premature babies initially , while avoiding dehydration Serial assessment of hydration status is mandatory

What to do bedside..? : 

What to do bedside..? Start with 80ml/kg in <1200gm and 60ml/kg in >1200gm Assess weight loss , urine output , serum urea & electrolytes 12th hrly during 1st week of life Increment by 15-20 ml/kg/day based on above values; no rules of thumb


ENERGY Provide sufficient energy & nitrogen to prevent catabolism & to achieve Positive N2 balance In a preterm infant Energy expenditure is 50-60kcal/kg /day Energy cost of growth is 5 kcal/gm (15gm/kg-75kcal/kg) To support normal growths during PN 90-120kcal/kg/day, most supplied by Lipid & Glu Parenteral energy requirements< Enteral Nutrition; No energy is lost in stools

Estimation of energy requirement of LBW infant : 

Estimation of energy requirement of LBW infant

Carbohydrate : 

Carbohydrate Goal-To maintain Euglycemia & promote optimal growth & composition Glucose production rate in term neonates is 3-5mg/kg/min & in preterm is 7.7-7.9mg/kg/min Infusions commenced @ 4mg/kg/min GIR can be increased gradually to 12-14mg/kg/min in the 2nd week Monitor Hyperglycemia

Basic composition of dextrose fluid : 

Basic composition of dextrose fluid 5% Dextrose 5 gm of dextrose/100ml 10% Dextrose 10 gm of dextrose/100ml 25% Dextrose 25 gm of dextrose/100ml 50% Dextrose 50 gm of dextrose/100ml

Venous lines for glucose administration : 

Venous lines for glucose administration <12.5% dextrose solutions are best administered >12.5% dextrose solutions are best administered Peripheral Central

Calculation of Glucose Infusion Rate (GIR) : 

Calculation of Glucose Infusion Rate (GIR) Dextrose % conc. X ml/kg/day GIR in mg/kg/min = ------------------------------ 144 Example : D10W at 120 ml/kg/day 10 X 120 GIR in mg/kg/min = -------------- 144 = 8.3 mg/kg/min

Desired conc. of glucose from available glucose conc. : 

Desired conc. of glucose from available glucose conc. Example 1: 12.5% dextrose 25% dextrose 10% dextrose 25 – 12.5 = 12.5 12.5 – 10=2.5 ( 5 : 1 ) 1 part of 25% D 5 part of 10%D 17 ml 25% D (in100ml) 83ml 10% D (in100ml)

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Example 2: 9% dextrose 5% dextrose 10% dextrose 9 – 5 = 4 10 – 9 = 1 ( 4 : 1 ) 1 part of 5% D 4 parts of 10% D 20ml 5% D (in 100ml) 80ml 10% D(in 100ml)

Glucose concentration : 

Glucose concentration

GIR with different conc. of dextrose : 

GIR with different conc. of dextrose

Hyperglycemia & Insulin in TPN : 

Hyperglycemia & Insulin in TPN Hyperglycemia: 1. osmotic diuresis & subsequent dehydration 2. ICH & high mortality If BSL >200mg/dl ,Start insulin @ 0.05-0.1U/kg/hr

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Potential benefits- higher glucose delivery anabolic effect (not proven) release LPL & stimulates lipolysis Potential harms: decreased protein synthesis & metabolic acidosis Routine use in ELBW babies is not recommended

Proteins : 

Proteins Goal-To achieve nitrogen retention at in utero rates without causing metabolic disturbance Fetus in utero accretes 1.8-2.2g/kg /day IUGR babies lose 1.2g/kg/day if glucose alone is given(1%-2% of body protein stores) Early PN amino acids with calorie intake at least 50kcal/kg results in positive N2 balance

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Early AA of 3gm/kg/day appears to be safe Early AA may help reduce the incidence of hyperglycemia in ELBW babies To optimize nutrition, conditionally EAA are necessary- cysteine, tyrosine, arginine, glycine & histidine Monitor BUN & plasma aminograms for toxicity ↑ Catabolism with sepsis, surgery, dexona

Special amino acids : 

Special amino acids 1. Glutamine is a major energy substrate for Small Intestinal mucosa & reduces the incidence of fatty infiltration of liver - ?prevents NEC, ?sepsis 2. Taurine might influence ABER & lowers the incidence of cholestasis 3. Cysteine lowers pH of final solution- metabolic acidosis

Lipids (10%, 20%) : 

Lipids (10%, 20%) Goal- To prevent early EFA deficiency, provide lipid soluble vitamins, promote optimal growth & body composition Made up of 1. neutral TGs, 2. egg yolk PL to emulsify & 3. glycerol to adjust tonicity 20% sol (Preferred): has lower Phospholipid: TG ratio & lower liposomal content than 10%

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Initiated @ 1-3g/kg/day infusions < 0.25g/kg/hr TGs between 150-200mg/dl Early use: ?? CLD, impaired oxygenation & kernicterus – FFA displace bil from albumin binding sites (FFA: S.Alb ratio<4=safe; >6) TG levels used as an indicator for lipid tolerance Do not withhold lipids from jaundiced pre-term

Special points : 

Special points Continuous infusion regimen is better than intermittent regimen No definite advantage to protect the tubing with aluminium foil (to prevent lipid peroxidation) Peripheral Vs Central: Peripheral adequate for <14days

Proportionate TPN : 

Proportionate TPN Nutrient & Protein retention is maximal if non-protein calorie balance b`n Carbohydrate: lipid is 60:40 Infant with ELBW babies need 80-90 kcal/kg/day for non-protein energy supplies

Comparision of commercial(20%) IV lipid emulsions & human milk : 

Comparision of commercial(20%) IV lipid emulsions & human milk

How to taper and stop TPN? : 

How to taper and stop TPN? No scientific guidelines Taper the one with complications With increasing feeds (as tolerated) and constant total fluid requirement, use of IVF is decreased concomitantly/proportionately.  GIR, Aminoplasma together Lipids untouched as often not counted in TFR Stop TPN once feed intake is 90-100ml/kg/day

Electrolyte Requirements : 

Electrolyte Requirements Element Infant Child > 1 yr Na (mEq/kg) 2-4 2-4 K (mEq/kg) 2-3 2-3 Cl (mEq/kg) 2-3 2-3 Phos (mM/kg) 0.5-1 0.5-1 Ca (mEq/kg) 1-2 1 Mg (mEq/kg) 0.5 0.5

Fat soluble vitamins : 

Fat soluble vitamins

Water soluble vitamins : 

Water soluble vitamins

MVI available in india(composition) : 

MVI available in india(composition)

Trace elements : 

Trace elements Zinc – 400mcg/kg/d – rapidity of growth, high output renal failure, GI disease Copper – 20mcg/kg/d – not required in short term. Not with cholestasis Chromium – def not described in pediatr population. Reco 0.2mcg/kg/d Mo – 0.25mcg/kg/d Mn - 1mcg/kg/d Iodine - 1mcg/kg/d ( skin absorption ) TMA- not available now

Trace elements ASCN-American society of clinical nutrition : 

Trace elements ASCN-American society of clinical nutrition

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Daily body weight ,weekly body length & HC Grading up & periods of Metabolic instability -strict fluid balance -6-12hrly urine & blood glucose -Daily Plasma Na , K, Ca, urea & ABG -Twice weekly TGs

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Full PN & metabolic steady state -strict fluid balance -12-24hrly urine/blood glucose -Once/Twice weekly Na , k, Ca, urea & ABG Weekly -Plasma Mg, Ph, ALK-P, albumin,TGs & bilirubin Trace elements monthly & coagulation as indicated Plasma AA & ammonia not usually monitored

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Metabolic Catheters related General

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Metabolic -Hyperglycemia -Hyperchloremic acidosis -Metabolic bone disease of prematurity -Abnormal aminogram -Hyperlipidemia

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Catheters related -Infection-Staph.aureus & S epidermidis(mc) -Candida & Malassezia frfur(fungal) -Thrombosis & Tissue necrosis -Pleural effusions & Pericardial tamponade General -cholestasis -Gut mucosal atrophy

TPN induced Cholestasis : 

TPN induced Cholestasis A major pediatric TPN problem Combo- sepsis + TPN + nil orally Earliest marker is serum bile acids Hypo caloric enteral feeding combined with PN improves hepatic function Phenobarbitone & ursodeoxycholic acid Do not overfeed or provide too much protein Have a “balanced solution”

Precautions taken to minimize sepsis : 

Precautions taken to minimize sepsis Surgical wash and OT attire Prepare TPN in laminar flow Never reuse once used solutions(even in one setting) Preparations of individual aliquots of PN Avoid manipulations after connecting to baby

Precautions…… : 

Precautions…… Use Silastic catheters instead of PE/PV catheters Place CV catheters under Aseptic conditions Proper care of the site ,all the connectors & tubings essential Never brake TPN line for drug administration Clean skin exit site of catheter meticulously

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Practical approach

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Peripheral line If <14 days & central line if >14 days Glucose infusion using 10% solution Term-3-4mg/kg/min preterm-6-8mg/kg/min Use 5% solution if weight < 1000gms Start Lipids as early as 1st day of life @1g/kg/day using 20% sol & increase @3g/kg/min gradually

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Initiate AA @3mg/kg/day at the earliest Consider glucose conc. >12.5% only if Low BSL Electrolytes ,minerals & vitamins should be introduced in the standard PN solution Avoid heparin Continue PN until enteral feedings supply energy @100-110kcal/kg/day

Caloric value of Parenteral nutrition : 

Caloric value of Parenteral nutrition Carbohydrate= 3.4 kcal/gm Aminoplasma= 4 kcal/gm Lipids= 9 kcal/gm of 20% lipids

Calculating caloric value of TPN : 

Calculating caloric value of TPN @140ml/kg/day Total fluid x % of dextrose in decimal= gm/kg Eg 140ml/kg/d of 12.5 % Dx= 140X 0.125= 17.5 gm Eg 140 ml/kg/d of 10% Dx= 140 X 0.1= 14 gm

Stock solution : 

Stock solution In a 50ml syringe, 10% Dextrose – 30 ml 25% Dextrose- 5ml 10% Aminoplasma- 15ml

Conclusions : 

Conclusions Early use of PN minimize losses & improve growth outcome Along with Minimal enteral nutrition (MEN) and early feeding reduces growth failure PN is life saving in neonatal GI failure & is an essential facet of modern intensive care Aggressive PN has no major adverse effects Benefits max if started early

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Central vein Catheterization

Umbilical vein Catheterization : 

Umbilical vein Catheterization A life-saving procedure in neonates who require vascular access for medication and resuscitation Required for CV pressure monitoring & exchange blood transfusion It remains patent and viable for cannulation until approximately 1 week after birth Size- 5fr <3.5kg, 8fr >3.5Kg

Point of Emphasis… : 

Point of Emphasis… Catheter tip should lie in ductus venosus or IVC Once fixed,do not advance catheter Avoid infusion of hypertonic sol when tip is not in IVC Don`t leave catheter open to atmosphere because of air embolism Avoid use of CVP monitoring catheter for concomitant infusion of PN due to risk of sepsis

Identify @ periphery of umb stump between 11 & 12 O` clock position : 

Identify @ periphery of umb stump between 11 & 12 O` clock position

Technique : 


Complications : 

Complications Infection Hemorrhage Vessel perforation Creation of a false luminal tract Hepatic abscess or necrosis Air embolism Catheter tip embolism Portal venous thrombosis Dysrhythmia and pericardial tamponade or perforation (if the catheter is advanced to the heart)

Multiple versus single lumen umbilical venous catheters for newborn infants : 

Multiple versus single lumen umbilical venous catheters for newborn infants RCT show a decrease in the ML-UVCs group in the number of additional PIVs used in the first week of life [WMD -1.42, (95% CI -1.74, -1.10), p<0.00001, number of infants (n) = 99] No significant effect on the number of additional PIVs used in the first four weeks of life [MD -2.30, (95% CI -6.65, 2.05), n=36] Increase in catheter malfunction in theML-UVCs group [typical RR 3.69 (95% CI 0.99, 13.81), p=0.05; RD 0.15 (95% CI 0.03, 0.27), p=0.01; NNH was 7, 95% CI 4, 33; n=99] No significant difference in clinical sepsis, catheter related blood stream infection, catheter-associated thrombosis, complications related to catheter malposition in heart and great vessels, NEC and early neonatal mortality. ML-UVCs in comparison to SL-UVCs in neonates is associated with decrease in the usage of PIVs in first week of life, but an increase in catheter malfunctions..Large studies still required Cochrane Database of Systematic Reviews 2005

Umbilical arterial Catheterization : 

Umbilical arterial Catheterization UAC allows access for 1.Arterial blood sampling 2.Direct measurement of SBP

Point of Emphasis… : 

Point of Emphasis… Avoid use of feeding tubes as catheters Don`t force past an obstruction Never advance once placed & secured Avoid covering umbilicus as this may delay recognition of bleeding or displacement Confirm position by X-ray Always have catheter fluid filled & attached to closed stopcock prior to insertion Run heparinised saline 0.5-1.0 ml/hr using infusion pump

Complications & Action… : 

Complications & Action… Sudden cyanosis or pallor of a part below umbilicus especially a limb or toes may be related to embolism or spasm Action-warm opposite leg with warm(not hot) towel.If no return to normal colour within 5 min or if gluteal region is involved-remove line

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In addition……

Role of insulin : 

Role of insulin Insulin euglycemia - no concerns increase energy intake RCT insulin infusion J Pediatr 1991 - better energy intake - better weight gain Increase in plasma lactate J Pediatr 1998 Increase in energy – quality ? increase in fat disproportionately

Intravenous a.a. mixtures – 3 stages of development : 

Intravenous a.a. mixtures – 3 stages of development 1. Casein hydrolysates – high conc of glycine, glutamate and aspartate, unwanted peptides, high acidity 2. Crystalline a.a. mix – general purpose (dietary protein high quality) - high glycine - absence of glutamate and aspartate - poor solubility of tyrosine and cysteine

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3. Crsytalline a.a. mixture specially made for infants -neophan ( a.a. human milk) -trophamine (a.a infants receiving IV mix,2hr PP) plasma a.a 95% N  PA,  Tyrosine - Primene ( a.a conc of cord blood) a.a profile compared to cord blood except aspartate and glycine > 2.5 gm/kg/d no clear benefit of one over other

10% v/s 20% lipids : 

10% v/s 20% lipids 20% lipids obvious advantage – less fluid 10% and 20% lipids contain same amount of PL but different TG Ratio PL/TG 10% = 0.12 20% = 0.06

Carnitine and TPN : 

Carnitine and TPN quaternary amino acid role - oxidation of LCFA breast milk and infant formulas contain carnitine but not routine supplementation in TPN Carnitine deficiency may be an etiological factor in the limited ability of premature babies to utilize parenteral lipid

Lipids and unconjugated jaundice : 

Lipids and unconjugated jaundice Andrew et al 1gm/kg/d over 4 hrs – bilirubin binding < 33 wks, SGA, F/A ratio >4 Spear et at 1,2,3 gm/kg/d over 15 hrs – effect seen only < 30 weeks Spear et al preterm 25-32 wks 15 hrs v/s 24 hrs @ 2 gm/kg/d – less elevation in the 24 hrs group High jaundice – lipid infusion max 2 gm/kg/d albumin in our babies ?

Lipids and pulmonary function : 

Lipids and pulmonary function Reported fat emboli – artifact Decreased O2 and pul art hypertension initially thought – hyperlipidemia blocked by indomethacin – PG role Brans et al – 24 hr infusion IV lipid emulsions no effect till 4 gm/kg/d