Parenteral%20Nutrition

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Parenteral Nutrition
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Parenteral Nutrition (Definition)

• Components are in elemental or pre-digested
  form
• Protein as amino acids
• CHO as dextrose
• Fat as lipid emulsion
• Electrolytes, vitamins and minerals

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Parenteral Nutrition (PN) Definition

• Delivery of nutrients intravenously, e.g. via the
  bloodstream.
• Central Parenteral Nutrition often called Total
  Parenteral Nutrition (TPN) delivered into a
  central vein
• Peripheral Parenteral Nutrition (PPN) delivered
  into a smaller or peripheral vein

A.S.P.E.N. Nutrition Support Practice Manual, 2nd
edition, 2005, p. 97
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Indications for PN (ASPEN)

• When Specialized Nutrition Support (SNS) is
  indicated, EN should generally be used in
  preference to PN. (B)
• When SNS is indicated, PN should be used when the
  gastrointestinal tract is not functional or
  cannot be accessed and in patients who cannot be
  adequately nourished by oral diets or EN. (B)
• The anticipated duration of PN should be gt7 days

ASPEN Board of Directors. JPEN 2619SA, 2002.
ASPEN Nutrition Support Practice Manual, 2005, p.
108
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EN vs PN in Critical Care (EAL)

• R.1. If the critically ill ICU patient is
  hemodynamically stable with a functional GI
  tract, then EN is recommended over PN.
• Patients who received EN experienced less septic
  morbidity and fewer infectious complications than
  patients who received PN. Strong, Conditional

ADA Evidence Analysis Library, accessed 8/07
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EN vs PN in Critical Care (EAL)

• In the critically ill patient, EN is associated
  with significant cost savings when compared to
  PN. There is insufficient evidence to draw
  conclusions about the impact of EN or PN on LOS
  and mortality. Strong, Conditional

ADA Evidence Analysis Library, accessed 8/07
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Common Indications for PN

• Patient has failed EN with appropriate tube
  placement
• Severe acute pancreatitis
• Severe short bowel syndrome
• Mesenteric ischemia
• Paralytic ileus
• Small bowel obstruction
• GI fistula unless enteral access can be placed
  distal to the fistula or where volume of output
  warrants trial of EN

Adapted from Mirtallo in ASPEN, The Science and
Practice of Nutrition Support A Case-Based Core
Curriculum. 2001.
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Contraindications

• Functional and accessible GI tract
• Patient is taking oral diet
• Prognosis does not warrant aggressive nutrition
  support (terminally ill)
• Risk exceeds benefit
• Patient expected to meet needs within 14 days

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PN Central Access

• May be delivered via femoral lines, internal
  jugular lines, and subclavian vein catheters in
  the hospital setting
• Peripherally inserted central catheters (PICC)
  are inserted via the cephalic and basilic veins
• Central access required for infusions that are
  toxic to small veins due to medication pH,
  osmolarity, and volume

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Venous Sites for Access to the Superior Vena Cava
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PICC Lines (peripherally inserted central
catheter)

• PICC lines may be used in ambulatory settings or
  for long term therapy
• Used for delivery of medication as well as PN
• Inserted in the cephalic, basilic, median
  basilic, or median cephalic veins and threaded
  into the superior vena cava
• Can remain in place for up to 1 year with proper
  maintenance and without complications

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PN Peripheral Access

• PN may be administered via peripheral access when
  
• Therapy is expected to be short term (10-14 days)
• Energy and protein needs are moderate
• Formulation osmolarity is lt600-900 mOsm/L
• Fluid restriction is not necessary

A.S.P.E.N. Nutrition Support Practice Manual,
2005 p. 94
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Parenteral Nutrition

• Macronutrients
• Micronutrients

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Macronutrients Carbohydrate

• Source Monohydrous dextrose
• Properties Nitrogen sparing Energy source
• 3.4 Kcal/g
• Hyperosmolar
• Recommended intake
• 2 5 mg/kg/min
• 50-65 of total calories

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Macronutrients Carbohydrate

• Potential Adverse Effects
• Increased minute ventilation
• Increased CO2 production
• Increased RQ
• Increased O2 consumption
• Lipogenesis and liver problems
• Hyperglycemia

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Macronutrients Amino Acids

• Source Crystalline amino acids standard or
  specialty
• Properties 4.0 Kcal/g
• EAA 4050 NEAA 50- 60
• Glutamine / Cysteine
• Recommended intake
• 0.8-2.0 g/kg/day
• 15-20 of total calories

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Macronutrients Amino Acids

• Potential Adverse Effects
• Increased renal solute load
• Azotemia

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Macronutrients Amino Acids

• Specialized Amino Acid Solutions
• Branched chain amino acids (BCAA)
• Essential amino acids (EAA)
• Not shown to improve patient outcome
• More expensive than standard solutions

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Macronutrients Lipid

• Source Safflower and/or soybean oil
• Properties Long chain triglycerides
• Isotonic or hypotonic
• Stabilized emulsions 10 Kcals/g
• Prevents essential fatty acid
  deficiency
• Recommended intake
• 0.5 1.5 g/kg/day (not gt2 g/kg) 12 24 hour
  infusion rate

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Macronutrients Lipids

• Requirements
• 4 to 10 kcals given as lipid meets EFA
  requirements or 2 to 4 kcals given as linoleic
  acid
• Generally 500 mL of 10 fat emulsion given two
  times weekly or 500 mL of 20 lipids given once
  weekly will prevent EFAD
• Usual range 25 to 35 of total kcals
• Max. 60 of kcal or 2 g fat/kg

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Macronutrients Lipids

• Potential Adverse Effects
• Egg allergy
• Hypertriglyceridemia
• Decreased cell-mediated immunity (limit to lt1
  g/kg/day in critically ill immunosuppressed
  patients)
• Abnormal LFTs

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Parenteral Base Solutions

• Carbohydrate
• Available in concentrations from 5 to 70
• D30, D50 and D70 used for manual mixing
• Amino acids
• Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20
  solutions
• 8.5 and 10 generally used for manual mixing
• Fat
• 10 emulsions 1.1 kcal/ml
• 20 emulsions 2 kcal/ml
• 30 emulsions 3 kcal/ml (used only in mixing
  TNA, not for direct venous delivery)

The A.S.P.E.N. Nutrition Support Practice Manual,
2nd edition, 2005, p. 97 Barber et al. In ASPEN,
The Science and Practice of Nutrition Support A
Case-Based Core Curriculum. 2001.
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Other Requirements

• Fluid30 to 50 ml/kg (1.5 to 3 L/day)
• Sterile water is added to PN admixture to meet
  fluid requirements
• Electrolytes
• Use acetate or chloride forms to manage metabolic
  acidosis or alkalosis
• Vitamins multivitamin formulations
• Trace elements

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Electrolytes/Vitamins/Trace Elements

• Because parenterally-administered vitamins and
  trace elements do not go through
  digestion/absorption, recommendations are lower
  than DRIs
• Salt forms of electrolytes can affect acid-base
  balance

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Adult Parenteral Multivitamins

• New FDA requirements published in 2000 replacing
  NAG-AMA guidelines
• Increased B1, B6, vitamin C, folic acid, added
  Vitamin K
• MVI Adult (Mayne Pharma) and Infuvite (MVI-13)
  from Baxter contain Vitamin K and are consistent
  with the new FDA guidelines
• MVI-12 (Mayne Pharma) does not contain Vitamin K

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Parenteral Nutrition Vitamin Guidelines
Vitamin FDA Guidelines
A IU 3300 IU
D IU 200 IU
E IU 10 IU
K mcg 150 mcg
C mg 200
Folate mcg 600
Niacin mg 40
Vitamin FDA Guidelines
B2 mg 3.6
B1 mg 6
B6 mg 6
B12 mg 5.0
Biotin mcg 60
B5 dexpanthenol mg 15
Federal Register 66(77) April 20, 2000
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Daily Trace Element Supplementation for Adult PN
TRACE ELEMENT INTAKE
Chromium 10-15 mcg
Copper 0.3-0.5 mg
Manganese 60-100 mcg
Zinc 2.5-5.0 mg
ASPEN Safe practices for parenteral nutrition
formulations. JPEN 22(2) 49, 1998
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Daily Electrolyte Requirements Adult PN
Electrolyte PN Equiv RDA Standard Intake
Calcium 10 mEq 10-15 mEq
Magnesium 10 mEq 8-20 mEq
Phosphate 30 mmol 20-40 mmol
Sodium N/A 1-2 mEq/kg replacement
Potassium N/A 1-2 mEq/kg
Acetate N/A As needed for acid-base
Chloride N/A As needed for acid-base
ASPEN Safe practices for parenteral nutrition
formulations. JPEN 22(2) 49, 1998
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PN Contaminants

• Components of PN formulations have been found to
  be contaminated with trace elements
• Most common contaminants are aluminum and
  manganese
• Aluminum toxicity a problem in pts with renal
  compromise on long-term PN and in infants and
  neonates
• Can cause osteopenia in long term adult PN
  patients

ASPEN Nutrition Support Practice Manual 2005 p.
109
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PN Contaminants

• FDA requires disclosure of aluminum content of PN
  components
• Safe intake of aluminum in PN is set at 5
  mcg/kg/day

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PN Contaminants

• Manganese toxicity has been reported in long term
  home PN patients
• May lead to neurological symptoms
• Manganese concentrations of 8 to 22 mcg/daily
  volume have been reported in formulations with no
  added manganese
• May need to switch to single-unit trace elements
  that dont include manganese

ASPEN Nutrition Support Practice Manual 2005 p.
98-99
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Calculating Nutrient Needs

• Provide adequate calories so protein is not used
  as an energy source
• Avoid excess kcal (gt35 kcal/kg)
• Determine energy and protein needs using usual
  methods (kcals/kg, Ireton-Jones 1992,
  Harris-Benedict)
• Use specific PN dosing guides for electrolytes,
  vitamins, and minerals

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Protein Requirements

• 1.2 to 1.5 g protein/kg IBW mild or moderate
  stress
• Up to 2.5 g protein/kg IBW burns or severe trauma

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Peripheral Parenteral Nutrition

• Hyperosmolar solutions cause thrombophlebitis in
  peripheral veins
• Limited to 800 to 900 mOsm/kg (MHS uses 1150
  mOsm/kg w/ lipid in the solution)
• Dextrose limited to 5-10 final concentration and
  amino acids 3 final concentration
• Electrolytes may also be limited
• Use lipid to protect veins and increase calories

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Peripheral Parenteral Nutrition

• New catheters allow longer support via this
  method
• In adults, requires large fluid volumes to
  deliver adequate nutrition support (2.5-3L)
• May be appropriate in mild to moderate
  malnutrition (lt2000 kcal required or lt14 days)
• More commonly used in infants and children
• Controversial

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Contraindications to Peripheral Parenteral
Nutrition

• Significant malnutrition
• Severe metabolic stress
• Large nutrition or electrolyte needs (potassium
  is a strong vascular irritant)
• Fluid restriction
• Need for prolonged PN (gt2 weeks)
• Renal or liver compromise

From Mirtallo. In ASPEN, The Science and Practice
of Nutrition Support A Case-Based Core
Curriculum. 2001, 222.
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Compounding Methods

• Total nutrient admixture (TNA) or 3-in-1
• Dextrose, amino acids, lipid, additives are mixed
  together in one container
• Lipid is provided as part of the PN mixture on a
  daily basis and becomes an important energy
  substrate
• 2-in-1 solution of dextrose, amino acids,
  additives
• Typically compounded in 1-liter bags
• Lipid is delivered as piggyback daily or
  intermittently as a source of EFA

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Advantages of TNA

• Decreased nursing time
• Decreased risk of touch contamination
• Decreased pharmacy prep time
• Cost savings
• Easier administration in home PN
• Better fat utilization in slow, continuous
  infusion of fat
• Physiological balance of macronutrients

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Disadvantages of TNA

• Diminished stability and compatibility
• IVFE (IV fat emulsions) limits the amount of
  nutrients that can be compounded
• Limited visual inspection of TNA reduced ability
  to detect precipitates

ASPEN Nutrition Support Practice Manual 2005 p.
98-99
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Two-in-One PN
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PN Compounding Machines Automix
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PN Compounding Machines Micromix
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PN SOLUTION COMPONENTSA
Central Peripheral ---Solutions--- Solutions
Lipid- Dextrose- based based
Dextrose 14.5 35.0 lt10.0 Amino Acids 5.5 5.0 lt4.25 Fat 5.0 250 ml/ 3.0 - 8.0 20 fat q M,Th a Final Concentration Courtesy of Marian, MJ.
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Initiation of PN

• Adults should be hemodynamically stable, able to
  tolerate the fluid volume necessary to deliver
  significant support, and have central venous
  access
• If central access is not available, PPN should be
  considered (more commonly used in neonatal and
  peds population)
• Start slowly(1 L 1st day 2 L 2nd day)

ASPEN Nutrition Support Practice Manual 2005 p.
98-99
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Initiation of PN formulation

• As protein associated with few metabolic side
  effects, maximum amount of protein can be given
  on the first day, up to 60-70 grams/liter
• Maximum CHO given first day 150-200 g/day or a
  15-20 final dextrose concentration
• In pts with glucose intolerance, 100-150 g
  dextrose or 10-15 glucose concentration may be
  given initially

ASPEN Nutrition Support Practice Manual 2005 p.
98-99
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Initiation of PN Formulation

• Generally energy and protein needs can be met in
  adults by day 2 or 3
• In neonates and peds, time to reach full support
  relates inversely to age, may be 3-5 days

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Initiation of PN Formulation

• Dextrose content of PN can be increased if
  capillary blood glucose levels are consistently
  lt180 mg/dL
• IVFE in PN can be increased if triglycerides are
  lt400 mg/dL

ASPEN Nutrition Support Practice Manual 2005 p.
109
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PN AdministrationTransition to Enteral Feedings
in Adults

• Controversial
• In adults receiving oral or enteral nutrition
  sufficient to maintain blood glucose, no need to
  taper PN
• Reduce rate by half every 1 to 2 hrsor switch to
  10 dextrose IV) may prevent rebound hypoglycemia
  (not necessary in PPN)
• Monitor blood glucose levels 30-60 minutes after
  cessation

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PN AdministrationTransition to Enteral Feedings
in Pediatrics

• Generally tapered more slowly than in adults as
  oral or enteral feedings are introduced and
  advanced
• Generally PN is continued until 75-80 of energy
  needs are met enterally

ASPEN Nutrition Support Practice Manual 2005 p.
109
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Medications That May Be Added to Total Nutrient
Admixture (TNA)

• Phytonadione
• Selenium
• Zinc chloride
• Levocarnitine
• Insulin

• Metoclopromide
• Ranitidine
• Sodium iodide
• Heparin
• Octreotide

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Parenteral Nutrition

• Infusion Schedules

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Infusion Schedules

• Continuous PN
• Non-interrupted infusion of a PN solution over
  24 hours via a central or peripheral venous access

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Continuous PN

• Advantages
• Well tolerated by most patients
• Requires less manipulation
• decreased nursing time
• decreased potential for touch contamination

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Continuous PN

• Disadvantages
• Persistent anabolic state
• altered insulin glucagon ratios
• increased lipid storage by the liver
• Reduces mobility in ambulatory patients

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Infusion Schedules

• Cyclic PN
• The intermittent administration of PN via a
  central or peripheral venous access, usually over
  a period of 12 18 hours
• Patients on continuous therapy may be converted
  to cyclic PN over 24-48 hours

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Cyclic PN

• Advantages
• Approximates normal physiology of intermittent
  feeding
• Maintains
• Nitrogen balance
• Visceral proteins
• Ideal for ambulatory patients
• Allows normal activity
• Improves quality of life

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Cyclic PN

• Disadvantages
• Incorporation of N2 into muscle stores may be
  suboptimal
• Nutrients administered when patient is less
  active
• Not tolerated by critically ill patients
• Requires more nursing manipulation
• Increased potential for touch contamination
• Increased nursing time

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Parenteral Nutrition

• Home TPN

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Home TPN

• Safety and efficacy
• depend on
• Proper selection of patients
• Adequate discharge planning/education
• Home monitoring protocols

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Home TPN

• Patient selection
• Reasonable life expectancy
• Demonstrates motivation, competence, compliance
• Home environment conducive to sterile technique

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Home TPN Discharge Planning

• Determination whether patient meets payer
  criteria for PN completion of CMN forms
• Identification of home care provider and DME
  supplier
• Identification of monitoring team for home
• Conversion of 24-hour infusion schedule to cyclic
  infusion with monitoring of patient response

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Home TPN

• Cost effective
• Quicker discharge from hospital
• Improved rehabilitation in the home
• Reduced hospital readmissions

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Common Indications for PN in Peds

• Surgical GI disorders
• Intractable diarrhea of infancy
• Short bowel syndrome
• Inflammatory bowel disease
• Intractable chylothorax
• Intensive cancer treatment

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Pediatric Energy Needs in PN

• No consensus exists as to how to determine energy
  needs of hospitalized children
• RDAs are intended for healthy children but can
  use for healthy/acutely ill children and monitor
  response
• Can estimate REE using WHO equation and add
  stress factors, monitor clinical course
• Indirect calorimetry recommended in difficult
  cases

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RDAs for Energy and Protein
Category Age (yr) Energy (kcal/kg/d) Protein (g/kg/d)
Infants 0.0-0.5 108 2.2
Children 1-3 102 1.2
4-6 90 1.1
7-10 70 1.0
Females 11-14 47 1.0
15-18 40 0.8
Males 11-14 44 1.0
15-18 45 0.9
Recommended Dietary Allowances, 10th ed. 1989.
National Academy Press, Washington, DC
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WHO Equations to predict REE from body weight
Sex/Age Range (years) Equation to Derive REE (kcal/d)
Males 0-3 (60.0 x wt) 54
Males 3-10 (22.7 x wt) 495
Males 10-18 (17.5 x wt) 651
Females 0-3 (6.1 x wt) 51
Females 3-10 (22.5 x wt) 499
Females 10-18 (12.2 x wt) 746
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Increase WHO REE by stress factors
Fever Increase 13 per degree C
Cardiac Failure 15-25
Traumatic Injury 20-30
Severe respiratory distress or broncho-pulmonary dysplasia 25-30
Severe sepsis 45-50
Olson, D. Pediatric Parenteral Nutrition. In
Sharpening your skills as a nutrition support
dietitian. DNS, 2003.
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Trauma/Critically Ill Peds
Age in years Kcals/kg G/pro/kg
0-1 90-120 2.0-3.5
1-6 75-90 1.8-3.0
7-12 50-75 1.5-2.5
13-18 30-60 1.0-2.0
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Pediatric PN Fluids

• Standard calculation
• 100 kcal/kg for infant 3-10 kg
• 1000 kcal 50 kcal/kg for every kg over 10 kg
  for a child 10-20 kg
• 1500 kcal 20 kcal/kg for every kg over 20 kg
  for a child over 20 kg
• 1 mL fluid/kcal/d adjustments for fever,
  diarrhea, stress, etc.

ASPEN BOD Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric
patients. JPEN 2626SA, 2001
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Pediatric PN Carbohydrate

• Carbohydrate should comprise 45-50 of caloric
  intake in infants and children (C)
• For neonates, CHO delivery in PN should begin at
  6-8 mg/kg/minute of dextrose and advanced to
  10-14 mg/kg/minute. (B)

ASPEN BOD Guidelines for the use of parenteral
and enteral nutrition in adult and pediatric
patients. JPEN 2628-29SA, 2001
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Pediatric PN Lipid

• Preterm start at .5 g/kg/day and increase by
  .5g/kg q day
• Infants Start at 1 g/kg and increase by .5
  g/kg/day until the maximum or desired dose is
  reached need 0.5 to 1 g/kg/day for EFA needs
• Maximum is 3 g/kg for lt24 months old and 2.5g/kg
  for 24 months and older

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Daily Electrolyte and Mineral Requirements for
Peds Pts
Electrolyte Infants/Children Adolescents
Sodium 2-6 mEq/kg Individualized
Chloride 2-5 mEq/kg Individualized
Potassium 2-3 mEq/kg Individualized
Calcium 1-2.5 mEq/kg 10-20 mEq
Phosphorus 0.5-1 mmol/kg 10-40 mmol
Magnesium 0.3-0.5 mEq/kg 10-30 mEq
National Advisory Group. Safe practices for
parenteral nutrition formulations JPEN
19982249-66
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Document in Chart

• Type of feeding formula and tube
• Method (bolus, drip, pump)
• Rate and water flush
• Intake energy and protein
• Tolerance, complications, and corrective actions
  
• Patient education