Dr Arun Aggarwal Gastroenterologist: - TOTAL PARENTERAL NUTRITION

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TOTAL PARENTERAL NUTRITION

• BY Dr. ARUN AGGARWAL GASTROENTEROLOGIST

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• 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
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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
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• 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
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COMPONENTS OF PARENTERAL NUTRITION

• Proteins
• Energy
• Glucose
• Lipids
• Electrolytes, minerals, trace elements and
  vitamins

By Dr. Arun Aggarwal Gastroenterologist
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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
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• 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
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• 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
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• 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
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• 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
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SUGGESTED DAILY PARENTERAL INTAKE FOR ELBW
COMPONENTS DAY 0 TRANISITION GROWING
Energy (kcal) 40-50 75-85 105-115
Protein (g) 2 3.5 3.5-4
Glucose (g) 7-10 8-15 13-17
Fat (g) 1 1-3 3-4
Na (meq) 0-1 2-4 3-7
K (meq) 0 0-2 2-3
Cl (meq) 0-1 2-4 3-7
Ca (mg) 20-60 60 60-80
Phosphorus (mg) 0 45-60 45-60
Mg (mg) 0 3-7.2 3-7.2
By Dr. Arun Aggarwal Gastroenterologist
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SUGGESTED DAILY PARENTERAL INTAKE FOR VLBW
COMPONENTS DAY 0 TRANISITION GROWING
Energy (kcal) 40-50 70-80 90-100
Protein (g) 2 3.0-3.5 3.0-3.5
Glucose (g) 7-10 8-15 13-17
Fat (g) 1 1-3 3
Na (meq) 0-1 2-4 3-5
K (meq) 0 0-2 2-3
Cl (meq) 0-1 2-4 3-7
Ca (mg) 20-60 60 60-80
Phosphorus (mg) 0 45-60 45-60
Mg (mg) 0 3-7.2 3-7.2
By Dr. Arun Aggarwal Gastroenterologist
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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
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GLUCOSE

• Maintaining glucose concentration of gt40 mg/dL
  and lt 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
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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
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• 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 lt150-200 mg/dL
  seems desirable.

By Dr. Arun Aggarwal Gastroenterologist
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• 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
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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 gt 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
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• 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
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• 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 1.71 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
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Recommended parenteral intake of trace elements
for term and preterm infants
Trace element Term (µg/kg/day) Preterm (µg/kg/day)
Chromium 0.20 0.2
Copper 20 20
Iron - -
Fluoride - -
Iodide 1 1
Manganese 1 1
Molybdenum 0.25 0.25
Selenium 2 2
zinc 250 400
By Dr. Arun Aggarwal Gastroenterologist
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• 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
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• 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
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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
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• 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
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• 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
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• Hyperglycemia which can cause osmotic diuresis
  and dehydration.
• Hyperaminoacidemia.
• Hyperammonemia.

By Dr. Arun Aggarwal Gastroenterologist
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CONTRAINDICATION TO LIPID USE

• Infants with liver disease.
• Blood coagulopathies.
• Hyperbilirubinemia.
• Use with caution in very low birth weight infants
  with severe pulmonary diseaselt1 wk old because of
  pulmonary deposition and transitory lower PO2
  levels.

By Dr. Arun Aggarwal Gastroenterologist
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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 _at_ 40mg/g of AA.

By Dr. Arun Aggarwal Gastroenterologist
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• 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 _at_ 100 ml/kg/day provides a GIR of
  7mg/kg/min.

By Dr. Arun Aggarwal Gastroenterologist
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• 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 lt 200mg/dL.

By Dr. Arun Aggarwal Gastroenterologist
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• 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 6040

By Dr. Arun Aggarwal Gastroenterologist
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• 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
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• 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 lt1500 g and 3 g/kg/day for babies gt1500 g.
  monitor BUN and NH3 levels.
• Intralipid (20) started on day 1-2
  _at_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
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HOLD ENTERAL FEEDS IF

• Abdominal distention with increased abdominal
  girth gt2 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
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STOCK SOLUTION

• To be started immediately after birth for babies
  lt1500g and for sick babies gt1500g
• For babies lt1000g stock solution proportion will
  be 80 ccD5W 1.5 g AA 1.5 mEq (30 mg) elemental
  calcium.
• For babies gt1000g stock solution proportion will
  be 80 ccD10W 1.5 g AA 1.5 mEq (30 mg) elemental
  calcium.
• Solution should be given _at_ 80cc/kg/day
• Any extra vol should be given separetely.

By Dr. Arun Aggarwal Gastroenterologist
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• 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