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Parenteral Nutrition
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Partial or total parenteral nutrition is routinely used and is an integral part of neonatal intensive care. Advances in delivery systems and development of long-term, double or triple lumen intravenous catheters have allowed greater utilization of parenteral nutrition. In contrast to human infants, foals should gain a significant amount of weight daily (1-3 lbs, ≈1 kg) following birth.
Editor's Comment - For quick start of formula used at UC Davis see TPN Straight Talk - simple set up.
I. Indications
- Neonatal foals that have not been able to consume at least 10% of their body weight in milk for a 48-72 hour period.
- Neonatal foals that have daily weight loss (even just 1 pound) for 24-48 hours and cannot consume at least 10% of their body weight in milk during next 24 hrs.
- Premature foals or critically ill foals with gastric reflux and minimal gut motility on day 1 or 2 of life.
Editor's Comment - Don't wait for weight loss, start TPN and feed only when GI motility returns - All neonatal foals that are not gaining daily weight while receiving maximal tolerated amounts of enteral nutrition.
- Base line, maintenance caloric requirements are 100-150 Kcal/kg/day [1].
- Resting caloric requirements are (premature or recumbent foal) lower because of the low activity level (50 Kcal/kg/day).
- Conditions which may require TPN.
- Prematurity.
- Severe, persistent diarrhea.
- Septicemia with secondary ileus.
- Respiratory distress with secondary ileus.
- Post-gastrointestinal surgery
- Persistent gastric obstruction.
- Effects of protein malnutrition.
- Decreased immune function.
- Weakness - Depression - Incoordination.
- Decubital sores.
- Angular limb deformities.
- Failure to grow.
II. General Principles of Parenteral Nutrition
- Dextrose alone won't meet energy demands.
- Dextrose provides 3.4 Kcal/gm [1]. 5% dextrose contains 170 Kcal/L.
- Since resting caloric requirements in a 50 kg foal are approx. 2500 Kcal/day, and 5% dextrose contains 170 Kcal/liter it would take 15 liters of 5% dextrose/day IV to meet this energy demand.
- Dextrose solutions ≥10% can be irritating to veins. Other problems with hypertonic glucose are hyperglycemia, glucosuria, and fatty liver.
- Lipids provide 9.0 Kcal/g and essential fatty acids [1].
- Amino acid solutions can be used as protein source [1].
- Amino acids in "veterinary jugs" have grossly inadequate levels of amino acids for TPN [1].
- Use an 8.5% amino acid solution.
- Must balance ratio of nitrogen with energy; non-protein calories per gm of nitrogen should be 100-200 [1].
- Solutions of dextrose, protein and lipid can be combined for "all in 1 bag" administration and meet energy and protein requirements for maintenance and growth.
- Parenteral nutrition requires minimum of 1 day to get started, 1 day on, and 1 day to wean off.
- Fluid (water) requirements will not be met with these solutions. Foals need approximately 100-120 ml/kg of fluid a day.
- Always try to feed small amounts enterally if possible while using parenteral nutrition.
III. Administration [2]
- A dedicated IV port that is not used for giving any other medications or drawing blood samples is required to prevent infection.
- If medication must be administered through this line, stop TPN solution, wipe injection port with alcohol and 2% iodine and flush with heparinized saline before and after medication administration.
- Jugular Catheter (See Placement and Management of Intravascular Catheters)
- Teflon catheters are not recommended and should be avoided for TPN administration. This catheter coupled with a hyperosmotic fluid like TPN carry high risk for thrombosis and catheter-induced sepsis.
- Polyurethane Single, double or triple lumen Mila®, Arrow®, Cook®, Jorvet® IV catheters with a guidewire or peel away introducers can be used in a size of 4-7FR X 5-10'' (12-25 cm).
Editor's Comment - Our NICU uses this type preferably triple or at least double lumen catheters. - Silicone elastomer catheters (Mila®, Braun®, Arrow®, Cook®) with single or double lumen (60 cm X 5-7Fr) have minimal thrombogenicity and can be left in a central vein for up to 30+ days.
- Rate of Administration needs to be carefully controlled.
- A constant flow rate is required.
- Infusion pumps are essential.
- A buretral system without pump can be employed but not recommended for extended periods.
- Target rate should be calculated to meet resting requirements (50 Kcal/kg/day)
- Start at 25% of the goal rate to allow the physiology to adjust, then gradually increase every 4-6 hours while monitoring blood glucose levels every 4-6 hrs.
- Solutions are generally increased in volume over 24 hours to reach the target level.
- Once the target level is tolerated, the rate can be increased to provide 75 Kcal/kg/day.
- Change all IV lines associated with the TPN solution once daily.
- Change hanging solutions once daily.
IV. Solutions and Administration [2-4].
Parenteral nutrition solutions should be mixed under a hood, wearing sterile gloves and mask. Alternatively with the Baxter All in One Bag® solutions can be mixed on a disinfected counter in a draft free environment.
- Partial parenteral nutrition formula.
- 500 ml of 50% dextrose - Energy.
- 500 ml 8.5% amino acid solution, 100 ml contains 14.3 gm nitrogen.
- Provides 1 Kcal/ml.
- Start at 25 ml/hr and work up to 100 ml/hr over a 24 hour period.
- Withdraw over 12-24 hours to avoid sudden hypoglycemia.
- Monitor.
- Serum glucose BID
- Urine glucose frequently.
- Serum K+; watch for hypokalemia.
- BUN once daily - To assess tolerance to nitrogen.
- All in one parenteral nutrition - Amino acids, glucose
- Energy from: 1000 ml of 50% dextrose
- 500 ml of 20% lipid emulsion.
- Nitrogen from 1500 ml of 8.5% amino acid solutions.
- Mix dextrose and amino acids first; then add lipid when using Baxter All in One Bag; or can piggyback lipid solution on Dextrose-AA line.
- All in One Bag has 3 leads for plugging into each stock solution of amino acids, dextrose and lipids.
- Start at 25 ml/hr and work up to 100 ml/hr over 24 hours. It provides 1.07 Kcal/ml.
- Electrolytes can be added to the solutions.
- I prefer not to add the electrolytes, but drip a KCl solution in another vein and add Na+ and other electrolytes as needed. Severe hypernatremia has developed with adding recommended electrolytes to the TPN.
- Vitamins and Minerals need to be added to the PN formula
V. TPN Straight Talk-simple Set Up: (Gary Magdesian's favorite TPN recipe)
1 L of 50 % dextrose
1.5 L of 8.5 % amino acids
0.5 L of 20 % lipids
Total volume: 3.0 L of PN. Caloric content is approximately 1.13 kcal/ml. Put it all in one bag.
To provide 50 kcal/kg to a 50 kg foal, approximately 2200 ml are required per day, equating to 91 ml/h. As this is tolerated the PN can be increased to provide approximately 75 kcal/kg/day, or 140 ml/h.
If the animal has lipid derangements, then I leave out the lipids and do:
1 L of 50 % dextrose
1 L of 8.5 % amino acids
This has an energy content of 1.02 kcal/ml
I also supplement vitamins and minerals - B-complex in fluids and a commercial human TPN vitamin mineral mix in the PN solution.
Potassium and calcium and phosphorus can be added as needed. I usually supplement Mg through the use of Mg containing fluids at a maintenance rate. Plasmalyte and Normosol have 4 meq/l of Mg.
Potassium is added to fluids (or PN) at 20-30 meq/l.
Phosphorus can be added at 0.01 mmol/kg/L for an 8-12 h period per day.
VI. Common Problems - Complications [4]
- Hyperglycemia [1]
- During the initial 24 hour adaptation, elevated blood sugars of < 200 mg/dl (11 mmol/l) are tolerated.
- Prolonged hyperglycemia (glucose > 180 mg/dl; 10 mmol/l) can cause fluid loss and other problems. Glucose becomes converted to fat within liver.
- With severe infection such as septicemia, glucose may not be metabolized at normal rates. Decrease infusion rate of TPN and initiate insulin therapy.
- May increase metabolism of glucose and cause increased production of CO2 and increase work of breathing.
- Hyperlipidemia [1]
- May be observed as gross lipemia.
- Serum triglyceride (>200 mg/dl; 2.3 mmol/l) and cholesterol may increase.
- Slow rate and concentration of lipid emulsion from 20% to 10%.
- Metabolic Acidosis
- Principal cause is excess chloride in electrolyte solution. As chloride anion increases, HCO3-anion decreases and have base deficit.
- Lower chloride in supplemental fluids.
- If acidosis is severe - Correct as described (See Fluid and Electrolyte Balance).
- Hypokalemia
- Associated with hyperglycemia (K+ moves intracellularly), or with losses from diarrhea.
- Supplement with potassium chloride solution in 10-30 mEq/L KCl solutions.
- Do not exceed flow rates of 0.5 mEq/kg of potassium/hour.
- Infection
- Catheter associated or solution contamination.
- With careful attention to detail this is infrequent.
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School of Veterinary Medicine, University of California-Davis, CA, USA.
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