1. Dr Monidipa Banerjee Dr Papiya Khawas
Parenteral Nutrition
Dr Monidipa Banerjee
Dr Papiya Khawas

2. Parenteral Vs Enteral
Total vs Partial

3. Whom to give? Can not feed - gut anomalies, GI surgery, NEC
Can not feed enough –Prematurity, renal disease, cardiac disease, growth failure of chronic disease
Should not feed – intestinal obstruction
Inability to tolerate minimum 60 kcal/kg/d by enteral route

4. Whom not to give? Metabolic acidosis
Acute renal failure – oliguria, ↑urea, ↑creat
Cholestatic jaundice

5. How to wean? Oral feed to start as soon as baby is ready
Go up on oral feeds as tolerated
Keep total daily volume constant (TPN+ oral)

6. Infusion Routes Umbilical vein- upto D7
Long line – placed percutaneously - expensive
Broviac – placed surgically - expensive
Confirm proper line placement by x-ray
Peripheral vein
can’t give higher conc.of dextrose,max12.5%
problem with asepsis in prolonged TPN
Ca, amino acid damages veins
Used 80% of the time in our unit

7. Infrastructure Place : OT, NICU, lamellar flow ( ideal )
Prepared by: Doctor, trained nurse
Asepsis: person preparing should be fully scrubbed, using all new disposables every day
Delivery: syringe pump, infusion pump, High pressure infusion lines, chamber drip set,3 way connector/ BD connector
Monitoring: Trained nurse to monitor lines and baby

8. Composition - 1 Protein: as crystalline amino acids
Available: 6%&10% Aminoven, Primene.
Each 100 ml of 10% Aminoven contains 10g of a.acid.(1ml contains 0.1g of a.acid)
Calorie: 1g Protein = 4 kcal (prot:non-prot=1:6)
Start: Can be started on Day 1
Dose: Starting with g/kg/d, increment of g/kg/d, upto g/kg/d.
1.5-2g/kg/d avoids catabolism
Infusion: continuous over 24 hrs, mixed with dextrose

9. Composition - 2 Lipid: emulsions with soybean oil preferred
Available: 10%&20% Intralipid, Clipped.
Each 100 ml contains 10g or 20g of lipid. (1ml contains 0.1g or .2g of lipid)
Calorie: 1g Lipid = 9 kcal, 30%-40% of total calories
Start: Usually started on Day 3 of TPN
Dose: Starting with g/kg/d, increment of g/kg/d, upto 3 g/kg/d.
0.5-1g/kg/d provides essential F.acids
Infusion: continuous over hrs, given separately

10. Composition - 3 Carbohydrate: As dextrose, forms main substrate
(% tailored acc. to req. by combining 50% D & 5%D).
Available: 5% Dext/IsoP g/100ml = 50mg/ml
10% Dext g/100ml =100mg/ml
50% Dext g/100ml = 500mg/ml
Calorie: 1g Carbohydrate= 4 kcal
Dose: Starting 6mg/kg/min,↑10-12mg/kg/min
Monitor: keep CBG mg/dl

11. Composition - 4 Multivitamins
Trace elements - usually added after 2 weeks of TPN
Heparin: if indicated ( e.g. UVC, central lines) unit heparin/ml of TPN

12. Electrolytes Normal daily requirement Na+ 2-4 mmol/kg/d add >48 hrs
K mmol/kg/d add >48 hrs & normal urinary flow
Ca mmol/kg/d or add Day 1
2 mEq/kg/d or
75mg/kg/d
Mg mEq/kg/d
(0.25 ml/kg/d of 50% MgSO4 –maintenance dose)
PO4 isolated P preparation not available

13. Dextrose
g/100ml
Na+
mmol/lit K+
Ca++
mmol
Mg++
5% D
50 (50mg
per ml) -
50%D
500(500
mg/ml)
IsoP 5% 26 19
3 mEq/l
½ DNS 77 NS
150
3%Nacl
0.5per ml
KCI
2 per ml
7.5% NaHCO3
1 per ml
10% Ca gluconate
2.2/10ml
0r 9.2mg elemental
Ca / ml

14. How much? Total fluid req. >day 5 = 150-180ml/kg/d
Volume for TPN= total fluid – other infusions
Volume for TPN = Lipid + AA + Dext Electrolytes + MVI
Total calorie req. = ~ 100 kcal/kg/d
Calories from Non-protein:Protein source maintained at a ratio above 6:1 to prevent catabolism.

15. Parenteral nutrition Intralipid Aminoven + (separately by
syringe pump
via a 3-way
connector)
Aminoven +
Isolyte-P/ 5% Dextrose
50% Dextrose +
MVI +
Heparin ( unit/ml) +
Add. electrolytes, as reqd.

16. Remember!!! Strict asepsis 24-hr TPN prepared at a time
Changing infusion sets daily (ideal)
New amino acid, lipid bottles daily (ideal)
Separate IV access for other drugs
Serum Na, K on alt. days;
urea, creatinie,Ca biweekly;
P, Mg, LFT, triglycerides weekly (ideal)

17. Complications Mechanical: thrombosis, embolism, skin slough
Infectious: particularly staph epidermidis, candida
Metabolic: hypoglycaemia, hyperglycaemia, cholestasis

18. Thank you