Download Total Parental Nutrition

Total Parental Nutrition
Infusion Routes:
1. Central: TPN delivered with catheter tip in central location ending in large vessel (IVC/SVC). Can be
Broviac, Cook, UAC, UVC, PICC. This route used for patients who require longterm nutritional support,
usually TPN.
2. Peripheral: Route used for partial or supplemental PN, usually for short-term nutritional support.
Peripheral PN solutions cannot exceed 12.5% dextrose (D12.5) or 3% amino acids due to risk of
thrombophlebitis and should not contain calcium b/c of serious complications of extravasation of calcium.
Can be PICC lines, IV lines.
Total Fluid Intake
1. Typical volume (ml/kg/d) varies with age
a. Newborns: (start with below, then advance over next 5 days by 10-20 ml/kg/d to 100-150
ml/kg/d)
Term newborn: 60-80 ml/kg/d
> 1000 g: 80 ml/kg/d
< 1000 g: 100 ml/kg/d
b. Older children:
For the first 10 kg: 100 ml/kg/day
plus, for 11-20 kg: add 50 ml/kg/day
plus, for > 20 kg: add 20 ml/kg/day
CALORIES
Requirements
0-1 year
90-120 kcal/kg/day
1-7 years
75-90 kcal/kg/day
7-12 years 60-75 kcal/kg/day
12-18 years 30-60 kcal/kg/day
Sources
Dextrose= 4 kcal/gm
Protein = 4 kcal/gm
Fat = 9 kcal/gm
(Intralipid = 2kcal/ml *)
Dextrose Calorie Density
D5 = 0.17 kcal/ml
D7.5 = 0.25 kcal/ml
D10 = 0.34 kcal/ml
D12.5 = 0.43 kcal/ml
D15 = 0.51 kcal/ml
D17 = 0.58 kcal/ml
D20 = 0.69 kcal/ml
(Note: The caloric density for breast milk and infant formulas is 20kcal/ounce =20kcal/30ml = 0.68kcal/ml)
* 20% intralipid (20g fat/100ml fluid) solution has a caloric density of 2kcal/ml
INTRALIPIDS – for cell membrane, myelination, skin formation and hormone production.
Intralipid is not added directly to the parental nutrition solution, but rather is given separately by constant infusion.
Relatively contraindicated in severe pulmonary failure/sepsis and severe hyperbilirubinemia.
Usually start with 1 g/kg/d (premies start 0.5 g/kg/d) and increase by 0.5 g/kg/d to max 3 g/kg/d.
Monitor the effect of infusion by measuring the serum triglyceride level (goal <250 mg/dl).
AMINO ACIDS
Start at 1g/kg/d – advance by 0.5-1 g/kg/d to target 3-4 g/kg/d
DEXTROSE (premie usu 4-6 mg/kg/min; term usu 6-8 mg/kg/d)
Goal ~70% of total calories (~ 70 cals/kg/d)
Usually start with D10 and increase by 10-20% per day to typical maximum D20
Exception: maximal for peripheral IV is D12.5%
Calculation: Glucose delivery (mg/kg/min ):
Fluid volume (ml/kg/day) x [Dextrose]*
24 x 60
or
Fluid rate (ml/hr) x [Dextrose]*
weight (kg) x 6
[Dextrose]* = dextrose concentration (e.g. D10)
90
ADDITIVES
Trace elements and Vitamins
Pediatric trace elements (chromium, copper, manganese, selenium, zinc)
-if <20 kg = 0.2 ml/kg/d
-if >20 kg = 5ml/kg/d
-if patient has direct hyperbilirubinemia, discontinue trace elements
Vitamins
-if <2.5 kg = 2 ml/kg/d
-if >2.5 kg and kids up to 11 yo = 5 ml/day
Electrolytes and Minerals
1. Phosphate (0.5-2 mmol/kg/d)
- daily maintenance Phosphorus 1 mmol/kg/d
2. Sodium (2-4 mEq/kg/d)
- daily maintenance 3 mEq/kg/d
3. Potassium (2-3 mEq/kg/d)
-daily maintenance 2 mEq/kg/d
-may require adjustment if on diuretics or has poor urine output
4. Acetate (1-4 mEq/kg/d)
-positive cations (Na+, K+) are balanced with either acetate or Cl- anions
-acetate is metabolized to HCO3-can be ordered as “maximize” “minimize” or “balance” with chloride depending upon pH
• write “max” on acetate line if patient has low serum bicarb so pharm will give more of this base
• write “min” on acetate line if pt hypochloremic so pharmacy will give mostly chloride in TPN
• write “balance” on acetate line if pt stable so pharmacy will balance acetate and chloride
5. Magnesium (0.25-0.5 mEq/kg/d)
-check a serum magnesium level before starting magnesium on any small infant whose mother was treated
for hypertension or pre-eclampsia. The serum levels in these babies are often 3 or greater at birth, and
since their renal clearance of magnesium is poor during the first few days of life, they may accumulate
magnesium given in the TPN solution and reach even higher levels with no warning
6. Calcium (50-500 mg/kg/d)
-daily maintenance Calcium gluconate 400 mg/kg/d
-some patients may need extra Ca, like pts with cardiac disease (important for optimal contractility),
frequent blood product transfusion (Ca bound by anticoagulants in blood), or documented hypocalcemia
(iCa <1)
-incompatible with many meds (esp. bicarbonate), so don’t add Ca to any line unless sure it is compatible
-adding extra Ca to TPN (after pharmacy prepared it) is dangerous b/c may cause precipitation w/phos
7. Heparin – maintains catheter patency (total heparin delivery not to exceed 5 units/kg/hr)
• PICC – no heparin
• UAC/UVC, Hickman/Broviac – 1 unit/ml
• PICC – if TPN running <3 ml/hr then 2 units/ml; if >3 m/hr then 1 unit/ml
Other: Ranitidine (written on “other” line) (2 mg/kg/d)
-not to be ordered routinely for stress ulcer prophylaxis
-reserved for patients w/coagulopathy, severe resp failure, gastritis, GE reflux, steroids
Other: Selenium (written on “other” line) (2 mcg/kg/d)
-If patient on TPN >1 month
TPN Cholestasis
-pts on TPN at risk for developing cholestasis and direct hyperbilirubinemia
-Tx: Phenobarbital or Actigall; remove trace elements (Cu and Mn excreted thru bile and will build up in
tissue)
91