Download Parentral nutrition in neonate

Parenteral nutrition in
neonate
Goals
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•
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minimizes weight loss
improves growth and neurodevelopmental outcome
reduce the risk of mortality and NEC
Caloric concentration
A. Dextrose: 3.4 kcal/g.
B. Protein:
4 kcal/g.
C. Fat:
9 kcal/g.
Carbohydrates
 5 to 6 mg/kg per minute be required in the preterm infant
to prevent hypoglycemia
 In ELBW neonate glucose starting at 3.5 mg/kg per
minute (5 g/kg day) and slowly increasing to 12
mg/kg/min over several days
 Dextrose is provided to maintain blood sugar between
45 - 125 mg/dl
In the presence of hyperglycemia, glucose infusion
rate should not be reduced below 4 mg/kg/min.
Insulin may be required to maintain adequate blood
glucose levels, although its routine use is not
recommended
proteins
Inadequate protein intake : Failure to thrive(lose 1
g/kg per day)
Hypoalbuminemia
Edema
Amino acid intake produced positive nitrogen
balance and appropriate growth
 Glutathione, an antioxidant concentrations rise with
early amino acid administration
Early amino acid supplementation may help
decrease hyperglycemia and hyperkalemia
Amino Acid Solations
The ideal mixture of amino acids for PN in premature
infants is unknow
TrophAmine, Aminosyn PF, Aminoven are available
that contain less of those potentially neurotoxic
amino acids
In preterm ELBW and VLBW infants, 3.5 g/kg/d of
amino acids should be started on day 1 and is
associated with better linear growth and
neurodevelopmental outcomes.
Term infants who are likely to have delayed
initiation of enteral nutrition should be started on 1.5
g/kg/d of proteins
Lipid
 Intravenous lipid administration provides essential
fatty acids
 provides needed energy for tissue healing and
growth
 combination of lipids and amino acids reduce
episodes of hyperglycemia
Starting lipids at 0.5–1 g/kg/d within 24 hours of birth is safe.
 Advance by 0.5–1.0 g/kg/d as tolerated up to 3.0 g/kg/d.
 The infusion is given continuously over 20–24 hours.
 The rate should not exceed 0.12–0.15 g/kg/h
The use of 20% emulsions is preferred over 10%
Lipids should be administered separately from
amino acids
 caution may be needed in hyperbilirubinemia
New lipid formulation(omegaven,smoflipid)

Vitamins
 minerals
 Trace elements
 Heparin
Monitoring
Weight
Daily
Length
Weekly
Head circumference
Weekly
Intake and output
Daily
Glucose 2–3 times per day ; then as needed
Calcium, phosphorus, 2–3 times per week; then
every 1–2 weeks
Electrolytes (Na, Cl, K, CO2) Daily , then 2–3 times
per week.
BUN and creatinine 2–3 per week; then every 1–2
weeks
Bilirubin Weekly
Ammonia Weekly if using high protein
 Total protein and albumin every 2–3 weeks
 AST/ALT every 2–3 weeks
 Triglycerides 1–2 per week
 Vitamins and trace minerals as indicated
 Urine
 Specific gravity and glucose 1–3 times per day initially;
then as needed
Intravenous routes used in PN
A. Central PN. Central PN is usually reserved for
patients requiring long-term(>2 weeks administration
of most calories).
 Basically, this type of nutrition involves infusion of a
hypertonic nutrient solution (15–30% dextrose)
B. Peripheral PN. The maximum concentration of dextrose
that can be administered is12.5%
C. Umbilical catheters. PN can be given through an umbilical
artery catheter but it is not preferred and should be used with
caution. Maximum dextrose in UAC is 15%.
cmplications
nutrient-related :
hypoglycemia (plasma sugar < 50 mg%)
 hyperglycemia (plasma sugar > 150 mg)
Hyperammonemia
metabolic acidosis (protein related);
hypertriglyceridemia (triglyceride > 200mg/dl)
Cholestasis
`
Risk factors cholestasis :
prematurity
sepsis
hypoxia
hemodynamic instability
duration of PN
delayed entral feeding
Catheter-related : malposition and infection
pneumothorax
pneumomediastinum,
chylothorax
Infection:
Staphylococcus
Pseudomonas spp,
Klebsiella spp
Candida albicans.