PROTOCOL FOR PARENTERAL NUTRITION

Transcription

1 PROTOCOL FOR PARENTERAL NUTRITION Based on; Roberton s textbook of neonatology. 4 th edition Sudha Chaudari and Sandeep Kumar.TPN in neonates. Indian Paediatrics. November 2006 Deepak Chawla, Anu Thukral, Ramesh Agrawal, Ashok Deorari, Vinod Paul. Parenteral Nutrition. AIIMS protocol in neonatology. Indian Journal of Paediatrics. April 2008 William W Hay Jr.Strategies for feeding the preterm infant. Neonatology. October 2008 Indications Gestation < 30wks, birth weight < 1.5Kg without nutrition for more than 1 day Gestation > 30wks, without nutrition for 5 days due to respiratory distress etc.. Neonates who are not receiving 50% of their calory requirement by day 7 of life Nectrotizing enterocolitiis Post surgical trachea-esophagial fistula, malrotation with volvulus etc. Calory requirement Preterm Kcal/Kg/day Term Kcal/Kg/day CHO 55-60% Protein 10 15% Lipid 30% Fluid requirement Start at 60ml/kg/day for term neonates 1

2 Start at 70 80ml/kg/day for preterm neonates Gradually increase by 10-20ml/kg/day Maximum for a ventilated neonate 150ml/kg/day Monitoring schedule Blood sugar-2-3 times/day while increasing glucose infusion, daily while on a stable infusion rate Urine sugar daily Serum electrolytes twice a week initially, then weekly Blood urea - twice a week initially, then weekly Ca, PO 4, Mg weekly Serum albumin weekly PCV weekly Liver function tests weekly Serum triglycerides weekly Weight daily at same time Length weekly OFC weekly Fluid - ml/kg/day daily Nutrient intake calculation Energy in Kcal/kg/day, Protein in g/kg/day Protein supplementation Maximum of 15% of calory requirement Protein requirement according to gestational age Gestational age Protein requirement wks g/kg/day wks 2-3 g/kg/day 37wks g/kg/day Vaminolact 0.24Kcal/ml, 5.8g/100ml Day 2 1g/kg/day 17ml/kg/day Day 3 1.5g/kg/day 25ml/kg/day 2

3 Day 4 2g/kg/day 34ml/kg/day Day 5 2.5g/kg/day 43ml/kg/day Day 6 3g/kg/day 50ml/kg/day Can be increased to 3.5g/kg/day (Roberton) An elevated blood urea in face of a normal creatinine is suggestive of underhydration. Reduce amino acid intake to 2.5g/kg/day in such situations. In the absence of renal disease a rising urea or acidosis is unlikely to be due to amino acid infusion. NEVER use arterial line NEVER give Ca / HCO 3 in same line Contraindicated in liver failure / renal failure / heart failure Lipid supplementation Maximum of 30% of calory requirement Intralipid 20% - 2Kcal/ml Day 3 1g/kg/day 5ml/kg/day Day 4 2g/kg/day 10ml/kg/day Day 5 3g/kg/day 15ml/kg/day Can go upto 3.5g/kg/day if the baby has very poor growth May interfere with biochemical tests, it may cause spurious : o Conjugated hyperbilirubinemia o Hypercalcemia o Hyponatraemia Lipid infusion lines should be covered by carbon paper or foil to protect it from light. (Exposure to light forms toxic lipid peroxides) Should be given via a separate line 3

4 Should be given as a slow infusion <150mg/kg/hr Dose may be reduced in o Acute episode of sepsis o Respiratory distress o Thrombocytopenia o Severe hyperbilirubinemia TPN associated cholestasis o Onset of hyperbilirubinemia within 2 weeks of starting PN. o Direct bilirubin > 2mg/dl (34µmol/l) o Liver function normalizes within 1-4 months of stopping PN o Ursodeoxycholic acid 20-30mg/kg/day is used in the therapy o Prevention Minimize duration of therapy Prevent and treat early sepsis Start enteral feeds as early as possible Sugar control in the neonate (Roberton 4 th ed) 10% dextrose 0.34Kcal/ml Glucose infusions should be commenced at 4-6mg/kg/min (10% dextrose 60-90ml/kg/day) Chart for conversion of rate of glucose (ml/kg/24h) to (mg/kg/min) depending on strength of dextrose solution Rate of infusion Strength of dextrose solution mg/kg/min ml/kg/24h ml/kg/h 5% 10% 12.5% 15% 20% If preterm babies <1000g need more than dextrose 80ml/kg/day 5% dextrose should be used to avoid hyperglycemia 4

5 Hypoglycemia - < 2.6mmol/l (<45mg/dl) CBS <2mmol/l (<36mg/dl) on 2 occasions without any clinical signs line) On parenteral nutrition and already on 10% dextrose increase infusion rate or concentration (12.5% dextrose is the maximum concentration that can be given via a peripheral On enteral feeds- express and give breast milk or formula feeds in increased volume and frequency to keep CBS >2mmol/l CBS <1 mmol/l (<18mg/dl) or fits/coma Take sample for RBS before treatment IV 10% dextrose bolus 3ml/kg, repeat till signs resolve Follow immediately by IV glucose infusion 3ml/kg/hour, increase rate according to signs CBS hourly until >2mmol/l (hyperinsulism >3mmol/l) Hyperglycemia - > 8mmol/l (>150mg/dl) ) Look for underlying cause infection / pain Reduce glucose infusion rate to 5mg/kg/min (10% dextrose 75ml/kg/day) If still CBS > 20mmol/l (>360mg/dl) or osmotic diuresis - start on insulin U/kg/h Moderate hyperglycemia may be tolerated if not associated with osmotic diuresis. (Check urine sugar) Vitamin supplementation Water soluble vitamins Soluvit N Dosage - 1ml/kg/day to a maximum dose of 10ml/day Can be added to the carbohydrate/amino acid solution or to Intralipid. Fat soluble vitamins Vitalipid N Dosage - 4ml/kg/day to a maximum dose of 10ml/day. Should only be added to Intralipid. 5

6 Early reports suggest that addition of both Soluvit N and Vitalipid N to the Intralipid solution may help conserve fat soluble vitamins A and E. Comparison between the vitamin content of Soluvit N,Vitalipid N and MVI-Paediatric (Austrailan) VITAMIN MVI-Paediatric 2ml/kg/day Soluvit N 1ml/kg/day Vitalipid N 4ml/kg/day Vitamin A IU Vitamin D IU Vitamin E IU Vitamin K mcg Vitamin C mg Thiamin (B1) mg Riboflavin (B2)mg Niacin (B3) mg Pantothenic Acid (B4) mg Pyridoxine (B6) mg Cynanocobalamin (B12) mcg Biotin mcg Folic Acid mcg AuSPEN Guidelines