TOTAL PARENTERAL NUTRITION

Transcription

1 TOTAL PARENTERAL NUTRITION Indication See algorithm. Timing Start TPN as indicated on algorithm 1. There is no need to build up TPN volume. The volume of TPN (including lipids) should equate to the total daily available fluid volume after exclusion of other infusions and feeds. All Parenteral Nutrition (Babiven bags without lipids) can be used for a maximum of 48 h. The maximum volume of a bag is 500 ml. Lipids should be always given over approx. 24 h. Route Central lines should be exclusively used for TPN and drugs that require central access delivery (i.e. inotropes, except dobutamine) (for further information on choice of central access see CPAP Guideline). TPN is not routinely given peripherally. Discuss with Consultant. Prescription Please refer to attached charts for content, prescription volume and weaning TPN as a general guidance: o Babiven Start-up (no trace elements): first 48 h of life o Babiven Maintenance (with trace elements): > 48 h of life o Babiven Concentrate Maintenance: fluid restriction < 120 ml/kg/d > 48 h, severe growth restriction and poor growth on enteral feeds, surgical patients with stoma Increase TPN as much as possible with total volume requirements (see Renal and Fluid Management Guideline), i.e ml/kg/day total daily TPN volume on admission, but keep the ratio between Babiven bag and lipid syringe. Concentrated TPN is to be exclusively used for persistent poor nutritional intake, not for short term fluid management. Aim for a minimum total of 100 kcal/kg/day (50 kcal/kg/day of non-protein calories or 25 kcal of non-protein calories per 1 g of protein intake) once on steady state intake. Aim for 10 mg/kg/min glucose intake to avoid iatrogenic hyperglycaemia. Aim for 3.5 g/kg/day of protein intake (max. 4 g/kg/day) that is ml/kg/day Babiven Maintenance or 90.2 ml/kg/day Babiven Maintenance Concentrate. Aim for 3.6 g/kg/d (max. 4 g/kg/d) of lipid intake that is 20 ml/kg/d (max ml/kg/d) of lipid syringe once on steady state. Lipid intake needs to be reduced irrespective of protein and carbohydrate intake, if triglyceride levels exceed 3.5 mmol/l please indicate on the prescription sheet. If a sidearm is required prescribe Dextrose 5 % or 10 % according to total carbohydrate intake and glucose levels plus additional Na, K and Ca. Calcium can only be given centrally except in emergencies. Monitoring Daily nutritional intake (fluid, protein, fat, carbohydrates, electrolytes, energy), blood glucose, triglycerides, urine analysis and blood pressure measurement until on full TPN. Weekly nutritional intake, blood glucose and triglycerides (once parenteral intake not increasing), liver function. Monthly trace minerals (copper, zinc, selenium). Complications Catheter related problems like occlusion, infection and accidental removal. 1

2 Compatibility related problems check stability matrix in unit drug folder. Parenteral nutrition related problems, e.g. hyperglycaemia, conjugated hyperbilirubinaemia, acidosis. Algorithm 1. 2

3 Composition of Available Formulas (Babiven ) Composition Start-up Bag Maintenance Bag (with trace elements) Maintenance Bag Maintenance Bag (Concentrate) Volume per 100ml per 100ml per 100ml per 66ml Nitrogen(g) Amino acids(g) Glucose (g) Non protein kcal Sodium (mmol) Potassium (mmol) Calcium (mmol) Magnesium (mmol) Phosphate (mmol) Chloride (mmol) Acetate (mmol) Zinc (micromol) Parenteral Nutrition Prescription Excluding Lipids (Start-up Bag) Volume of parenteral nutrition Non-protein calories in kcal/kg Carbohydrates in mg/kg/min Protein in g/kg/day Parenteral Lipid Infusion Volume of lipid infusion Non-protein calories in kcal/kg Lipids in g/kg/day

4 Volume of normal volume PN Parenteral Nutrition Prescription Excluding Lipids (Maintenance Bag No Trace Elements) Non-protein calories Carbohydrates Protein In kcal/kg in mg/kg/min in /kg/day Volume of normal volume PN Parenteral Nutrition Prescription Excluding Lipids (Maintenance Bag with Trace Elements) Non-protein calories Carbohydrates Protein In kcal/kg in mg/kg/min in /kg/day Volume of concentrated PN Volume of concentrated PN BOLD Recommended Acceptable Not recommended (in majority of cases) Target Range Establishing Infusion Rate 4

5 Formula 1. Total daily fluid intake in ml/day = Total daily fluid intake x weight 2. Total daily TPN volume in ml/day = Total daily fluid intake in ml/day oral intake and/or infusions in ml/day 3. Total daily lipid volume in ml/day = Total daily TPN volume / Lipid volume in ml/h = Total daily lipid volume/24 h 5. Total daily Babiven volume (PN Bag) = Total daily TPN volume - total daily lipid volume 6. Babiven volume (PN Bag) in ml/h = Total daily Babiven volume (PN Bag)/24 h 7. Total daily lipid volume in ml/day if receiving Babiven Concentrate = Total daily TPN volume/5.5 5

6 Infusion Rate per Hour Infusion Rate Graph TPN Volume Concentrated PN Bag TPN Volume with Normal PN Bag PN Bag Lipid syringe PN Bag Concentrate 6

7 Infusion Rate Chart (Normal Volume PN) TPN Volume ml/day PN ml/h Lipid ml/h Change of Bag h TPN Volume ml/day PN ml/h Lipid ml/h Change of Bag h TPN Volume ml/day PN ml/h Lipid ml/h Change of Bag h TPN Volume ml/day PN ml/h Lipid ml/h Change of Bag h TPN Volume ml/day PN ml/h Lipid ml/h Change of Bag h

8 Infusion Rate Chart (Concentrated Volume PN) TPN Volume ml/day PN Concentrate ml/h Lipid ml/h Change of Bag h TPN Volume ml/day PN Concentrate ml/h Lipid ml/h Change of Bag h TPN Volume ml/day PN Concentrate ml/h Lipid ml/h Change of Bag h TPN Volume ml/day PN Concentrate ml/h Lipid ml/h Change of Bag h TPN Volume ml/day PN Concentrate ml/h Lipid ml/h Change of Bag h