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- 2. Parenteral Nutrition in Neonates Prepared By Neveen Hassan Abdel Aal Clinical Pharmacist at NICU Assuit University
- 3. Parenteral Nutrition: Definition & Goals. Types of PN Admixtures. Routes of Administration of PN. Nutritional Components
- 4. Parenteral Nutrition PN is the administration of intravenous nutrition in patients with a Non- functioning or
- 5. Parenteral Nutrition Goals (1) Weight maintenance or promoting growth. (2) Preservation of lean body mass& visceral
- 6. Types of PN Admixtures 2 in 1 3 in 1 all nutrients are mixed in the
- 7. Routes of Administration of PN
- 8. Central Access Advantages : No restrictions on the osmolarity of central PN, so Hypertonic solutions can
- 9. Central Access Indications: For patients who require long-term nutritional support. have large nutrient requirements , poor
- 10. Criteria for Peripheral Administration Osmolarity must not exceed 900 mOsm/L. Final dextrose concentration should be ˂10%
- 11. Nutritional Components of PN Formulation PN should provide a balanced nutritional intake of 1) Macronutrients including
- 12. Estimating the Osmolarity of Parenteral nutrients ● Peripheral TPN: ● Central TPN: 1500 - 2800 mOsm/L
- 13. Calculating the Osmolarity of a Parenteral Nutrition Solution Multiply the grams of dextrose per liter by
- 14. Developing a Regimen for PN Administration Through Central Line
- 15. I. Evaluation of patient case PN components should be adjusted individually to each patient according to:
- 16. I. Evaluation of patient case First of all Review: Patient Age, weight ( Kg). Make sure
- 17. Evaluation of patient case continue 4. Assessment of degree of hydration. Signs of dehydration: Reduced urine
- 18. II. Start Calculating Components of PN Formula Steps of Calculation Fluid need/tolerated (Subtract drugs, Blood, O.R.S,
- 19. 1.Determine Fluid Requirements
- 20. Daily maintenance of fluids intake on body weight basis AACN Advanced Critical Care Volume 23, Number
- 21. The Neonatal adaptation processes after birth may be divided into three major phases: Phase I: transition.
- 22. Recommended Parenteral fluid intake (ml/kg /day) During the first postnatal week During the intermediate phase prior
- 23. Variations in Fluid Requirements Do not use PN for fluid replacement but for maintenance fluid only.
- 24. Suggested initial adjustment in specific situations Fever…..+12% for each degree >37 c. High humidity…..0.7 × maintenance.
- 25. Adjustment of Fluid Requirements in case of Kidney Dysfunction TFR= I.W.L + U.O.P Insensible water loss
- 26. 2. Determine Caloric Requirements
- 27. Parenteral energy needs may be roughly estimated using the following ranges J Pediatr Gastroenterol Nutr, Vol.
- 28. Further aspects need to be taken into account according to clinical parameters: Weight gain in regard
- 29. Variations in Caloric Requirements Patient require increased caloric needs in case of fever, inflammation, sepsis, burn,
- 30. Factors that increase caloric requirements
- 31. The Caloric balance of PN Formula Caloric needs are met by a proper balance of carbohydrates,
- 32. 3.Determine Protein Requirements Proteins are the major structural and functional components of all cells in the
- 33. Protein requirements of neonates and children depend on age and weight J Pediatr Gastroenterol Nutr, Vol.
- 34. Regimen of Protein Administration Start with 1.5 gm/kg/d and then increase by 1 gm/kg/d to maximum
- 35. Protein requirements Variations Increased amount of amino acids are required in case of patients with short
- 36. Potential complications and risks of providing IV amino acids 1- Acidosis 2- Elevated BUN 3- Hyper-
- 37. Caloric Value of Proteins Calories from protein (4 kcal/g) Inadequate supplementation of energy from carbohydrates and
- 38. 4.Determine Lipid Requirements Providing fat is essential to Achieve adequate caloric intake in TPN Utilize amino
- 39. The lipid requirements of neonates and children depending on age J Pediatr Gastroenterol Nutr, Vol. 41,
- 40. Regimen of Lipid Administration Starting dose of 1 g/kg/day Titrate toward the goal as tolerated by
- 41. Caloric Value of Lipids Calories from Lipid (10 kcal/g) Maximum fat oxidation occurs when intravenous lipid
- 42. Precautions For Neonates Restrict the dose of lipids in minimum amounts that will provide only the
- 43. Potential complications and risks of providing IV Lipids Hyperlipidemia. Potential increased risk or exacerbation of chronic
- 44. Monitoring Plasma clearance of infused triglycerides can be assessed by measurement of plasma triglyceride concentrations. Checking
- 45. J Pediatr Gastroenterol Nutr, Vol. 41, Suppl. 2, November 2005
- 46. 5. Determine Carbohydrates Requirements Dextrose is major immediate energy source . Several body tissues depend mainly
- 47. Recommended parenteral glucose supply (g/kg/day) Estimation of carbohydrates requirements It is important, especially when prescribing PN
- 48. Carbohydrates Requirements need to be adapted according to Age and clinical situation (e.g. malnutrition, acute illness,
- 49. Regimen of Carbohydrate Administration For neonates: Begin with GIR 4-8 mg/kg/min in preterm 4-6 mg/kg/min in
- 50. Caloric Value of Dextrose Dextrose yields 3.4 kcal/ g Peripheral line: maximum dextrose concentration 12.5%. Central
- 51. Potential complications Hyperglycemia or hypoglycemia. Glycosuria and potential osmotic diuresis. Cholestasis and/or hepatic steatosis (usually from
- 52. Managing Hyperglycemia in Neonates If hyperglycemia develops: ↓GIR insulin may improve glucose tolerance . Do not
- 53. 6. Estimate a Daily Maintenance amount of Electrolytes Vitamins & Trace elements
- 54. A) Electrolytes Initial PN solutions may be started without added electrolytes. Add electrolytes gradually as the
- 55. Electrolytes Requirements If Magnesium Sulfate was administered prior to delivery then leave Mg out of PN
- 56. Recommended Parenteral electrolyte intake *Careful adjustment of water and electrolyte administration is needed in ELBW infants
- 57. Phosphate Normal Ranges by Age Normal values of Phosphate are age related as a result of
- 58. B) Trace Elements Standard trace elements contain selenium, chromium, copper , manganese , and zinc. Neonates
- 59. Trace Elements Requirements
- 60. Pediatrace® Dose: 1 ml/ kg/ day for Premature, Infant & Children with a weight
- 61. C) Vitamins Requirements Similar to trace elements, multivitamins are often standard in PN unless requested otherwise.
- 62. Medication Additives in PN Generally, medications should not be added to PN if it can be
- 63. PN Complications Short term Complications 1- Catheter-related infections 2- Catheter insertion complications 3-Peripheral Thrombophlebitis 4-Gut atrophy
- 64. Short term Complications Continue 7. Refeeding syndrome can occur in acutely or chronically malnourished patients by
- 65. Long term Complications 1-Hepatobiliary Disorders (includes steatosis, cholestasis, and gallbladder stones) 2-Osteoporosis & osteomalacia associated with
- 66. Monitoring PN Administration 1- Infection: Temperature ,WBC , IV access site 2- Peripheral vein thrombophlebitis (if
- 67. Monitoring Continue 5-Glycemic control(Hyperglycemia and hypoglycemia.) Goal : 150 mg/dl or less 6- Monitor for electrolyte
- 68. Monitoring Laboratory measurement
- 69. Transition to Oral or Enteral Nutrition When initiating enteral or oral nutrition , monitor for glucose,
- 71. A- Patient data: Age: 2year, weight: 10 kg, Phase: acute B- Calculations: 1- Total fluid intake
- 72. 3- Lipids: Dose 1.0 gm/kg/day. Volume =10×1×(100/20)=50 ml/d Calories= [10gm lipids×10kcal/gm]/10(weight)=10 Kcal/kg/d. 4- Electrolytes: Na (0.9%)
- 73. 7- Calculation of glucose % Total fluid intake 1000 ml/d. Volume of glucose = TF- (2+3+4+5+6)=
- 74. Preterm and Term Infants During the Transition Phase Sodium, chloride and potassium should be supplemented in
- 75. Electrolytes Function
- 76. Trace Elements Function
- 77. Special consideration
- 79. Medication Additives Continue Heparin: may be added to the TPN solutions in (0.5 - 1 unit/mL
- 80. There is no proven benefit of heparin for the prevention of thrombotic occlusion of CVC’s under
- 81. Medication Additives Continue Carnitine Should be added if a patient continues to require PN after 10
- 82. Medication Additives Continue H2 antagonist such as famotidine or ranitidine, may be added to the daily
- 83. Illustrative case A 5-day-old neonate, with gestational age of 28 weeks and birth weight of 900
- 84. Answer Step I: Total fluids 150 mL/kg = 135 mL Step II: Amino acid (10%) 1
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