Enteral and parenteral nutrition of newborns. Protocol for infusion therapy and parenteral nutrition of newborns

The date: 29.06.2020

“CLINICAL RECOMMENDATIONS PARENTERAL NUTRITION OF NEWBORN CLINICAL RECOMMENDATIONS edited by Academician of the Russian Academy of Sciences N.N. Volodin Prepared by: Russian Association of Specialists...»

IIAPEHTERALHOE IITANIE OF THE BORNBORN

under the editorship of Academician of the Russian Academy of Sciences N.N. Volodin

Prepared by: Russian Association of Perinatal Medicine Specialists

in collaboration with the Association of Neonatologists

Approved by: Union of Pediatricians of Russia

Prutkin Mark Evgenievich Chubarova Antonina Igorevna Kryuchko Daria Sergeevna Babak Olga Alekseevna Balashova Ekaterina Nikolaevna Grosheva Elena Vladimirovna Zhirkova Yulia Viktorovna Ionov Oleg Vadimovich Lenyushkina Anna Alekseevna Kitrbaya Anna Revazievna Kucherov Yury Ivanovich Monakhova Oksana Anatolyevna Remizov Mikhail Valerievich Ryumina Irina Ivanovna Terlyakova Olga Yuryevna Mikhail Shtatnov

Department of Hospital Pediatrics No. 1 of the Russian National Research Medical University. N. I. Pirogov;

State Budgetary Healthcare Institution "City Hospital No. 8" of the Moscow Department of Health;

GGBUZ SO CSTO No. 1 in Yekaterinburg;

OFGBU NTsAGP them. Academician V.I. Kulakov;

Department of Pediatric Surgery, Russian National Research Medical University. N.I. Pirogov;

FFNKTs DGOI them. Dmitry Rogachev;

GGBUZ "Tushino Children's City Hospital" of the Department of Health

Russian Medical Academy of Postgraduate Education.

Introduction

1. Liquid

2. Energy

5. Carbohydrates

6. Need for electrolytes and trace elements

6.2. Sodium

6.3. calcium and phosphorus

6.4. Magnesium

7. Vitamins

8. Monitoring during the PP

9. Complications of parenteral nutrition

10. Procedure for calculating PP in premature babies

10.1. Liquid

10.2. Protein

10.4. electrolytes

10.5. vitamins

10.6. Carbohydrates

11. Control of the received concentration of glucose in

12. Calorie control

13. Drawing up an infusion therapy sheet

14. Calculation of the infusion rate

15. Venous access during parenteral nutrition

16. Technology for the preparation and administration of solutions for PP

17. Maintaining enteral nutrition. Features of calculating partial PP

18. Cessation of parenteral nutrition Appendix with tables

INTRODUCTION

Extensive population studies in recent years prove that the health of the population in different age periods significantly depends on the nutritional security and growth rate of a given generation in the prenatal and early postnatal periods. The risk of developing such common diseases as hypertension, obesity, type 2 diabetes, osteoporosis, increases in the presence of nutritional deficiency in the perinatal period.

Intellectual and mental health are also dependent on the state of nutrition during this period of an individual's development.

Modern techniques make it possible to ensure the survival of the majority of children born prematurely, including the improvement in the survival rates of children born on the verge of viability. Currently, the most urgent task is to reduce disability and improve the health status of children born prematurely.

Balanced and properly organized nutrition is one of the most important components of nursing premature babies, which determine not only the immediate, but also the long-term prognosis.

The terms "balanced and properly organized nutrition" mean that the appointment of each of the nutritional components should be based on the needs of the child for this ingredient, taking into account that the ratio of nutritional ingredients should contribute to the formation of a correct metabolism, as well as special needs for certain diseases of the perinatal period, and that nutritional technology is optimal for its full assimilation.

To unify approaches to parenteral nutrition of newborns in profile

Provide understanding of the need for a differentiated approach to parenteral nutrition, healthcare facilities;

Minimize the number of complications during parenteral nutrition.

depending on gestational age and post-conceptual age;

Parenteral (from the Greek para - around and enteron - intestine) nutrition is a type of nutritional support in which nutrients are introduced into the body, bypassing the gastrointestinal tract.

Parenteral nutrition can be complete, when it completely compensates for the need for nutrients and energy, or partial, when part of the need for nutrients and energy is compensated by the gastrointestinal tract.

Indications for parenteral nutrition:

Parenteral nutrition (full or partial) is indicated for newborns if enteral nutrition is not possible or insufficient (does not cover 90% of nutrient requirements).

Contraindications to parenteral nutrition:

Parenteral nutrition is not carried out against the background of resuscitation and begins immediately after stabilization of the condition against the background of the selected therapy. Surgery, mechanical ventilation and the need for inotropic support will not be a contraindication to parenteral nutrition.

1. FLUID Evaluation of the volume of fluid required by the newborn is an extremely important parameter when prescribing parenteral nutrition. Features of fluid homeostasis are determined by the redistribution between the intercellular space and the vascular bed, which occur in the first few days of life, as well as possible losses through immature skin in children with extremely low body weight.

1. Ensuring urine excretion for the elimination of metabolic products,

The need for water for nutritional purposes is determined by the need to:

2. Compensation for imperceptible water losses (with evaporation from the skin and during breathing, losses from

3. An additional amount to ensure the formation of new tissues: there is practically no build-up of sweat in newborns), a mass of 15-20 g/kg/day will require 10 to 12 ml/kg/day of water (0.75 ml/g of new tissues).

In addition to providing nutrition, fluid may also be required to replenish the BCC in the presence of arterial hypotension or shock.

The postnatal period, depending on changes in water and electrolyte metabolism, can be divided into 3 periods: a period of transient weight loss, a period of weight stabilization and a period of stable weight gain.

During the transitional period, there is a decrease in body weight due to water loss, it is desirable to minimize the amount of body weight loss in preterm infants by preventing fluid evaporation, but it should not be less than 2% of birth weight. The exchange of water and electrolytes in the transient period in preterm infants, compared with full-term infants, is characterized by: (1) high losses of extracellular water and an increase in the concentration of plasma electrolytes due to evaporation from the skin, (2) less stimulation of spontaneous diuresis, (3) low tolerance to fluctuations in BCC and plasma osmolarity.

During the period of transient weight loss, the sodium concentration in the extracellular fluid increases. Sodium restriction during this period reduces the risk of some diseases in newborns, but hyponatremia (125 mmol/l) is unacceptable due to the risk of brain damage. Fecal sodium loss in healthy term infants is estimated at 0.02 mmol/kg/day. The appointment of liquid is advisable in an amount that allows you to keep the concentration of sodium in the blood serum below 150 mmol / l.

The period of weight stabilization, which is characterized by the preservation of a reduced volume of extracellular fluid and salts, but further weight loss stops. Diuresis remains reduced to a level of 2 ml / kg / h to 1 or less, fractional excretion of sodium is 1-3% of the amount in the filtrate. During this period, fluid losses with evaporation decrease, therefore, a significant increase in the volume of fluid administered is not required, it becomes necessary to compensate for the loss of electrolytes, the excretion of which by the kidneys is already increasing. The increase in body weight in relation to birth weight during this period is not a priority task, provided that proper parenteral and enteral nutrition is provided.

Kidney function is still reduced during this period, so additional amounts of fluid are required to administer sufficient amounts of nutrients for growth (high-osmolar foods cannot be administered as nutrition). Plasma sodium concentration remains constant when sodium is supplied from outside in the amount of 1.1-3.0 mmol/kg/day. The growth rate does not significantly depend on sodium intake when providing liquid in the amount of 140 ml/kg/day.

Fluid balance

The volume of liquid in the composition of parenteral nutrition is calculated taking into account:

Volume of enteral nutrition (enteral nutrition up to 25 ml/kg does not include diuresis when calculating the required fluid and nutrients) Dynamics of body weight Sodium level Sodium level should be maintained at 135-145 mmol/l.

An increase in sodium levels indicates dehydration. In this situation, the volume of fluid should be increased, not excluding sodium preparations. Decreased sodium levels are most often an indication of overhydration.

Children with ENMT are characterized by the syndrome of "late hyponatremia", associated with impaired renal function and increased sodium intake against the background of accelerated growth.

The volume of fluid in children with ELBW should be calculated in such a way that the daily weight loss does not exceed 4%, and weight loss in the first 7 days of life does not exceed 10% in full-term and 15% in preterm infants. Indicative figures are presented in Table 1 Table 1.

Estimated fluid requirements for newborns

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Full coverage of all components of energy intake should be strived for through parenteral and enteral nutrition. Only in the case of indications for total parenteral nutrition, all needs should be provided by the parenteral route. In other cases, the amount of energy that is not received by the enteral route is administered parenterally.

The fastest growth rate in the least mature fetuses, so it is necessary to provide the child with energy for growth as early as possible. During the transitional period, make efforts to minimize energy losses (nursing in a thermoneutral zone, limiting evaporation from the skin, protective mode).

As soon as possible (1-3 days of life), ensure the supply of energy equal to the exchange of rest kcal / kg.

Increase parenteral nutrition daily by 10-15 kcal/kg to reach 105 kcal/kg by 7-10 days of age.

With partial parenteral nutrition, increase the total energy intake at the same pace in order to achieve a calorie content of 120 kcal / kg by 7-10 days of life.

Stop parenteral nutrition only when the calorie content of enteral nutrition reaches at least 100 kcal/kg.

After the abolition of parenteral nutrition, continue monitoring anthropometric indicators, make nutritional adjustments.

If it is impossible to achieve optimal physical development with exclusively enteral nutrition, continue parenteral nutrition.

Fats are more energy intensive than carbohydrates.

Proteins in premature babies can also be partly used by the body for energy. Excess non-protein calories, regardless of source, are used for fat synthesis.

3. PROTEINS Modern research shows that proteins are not only an important source of plastic material for the synthesis of new proteins, but also an energy substrate, especially in children with extremely low and very low body weight. About 30% of incoming amino acids can be used for energy synthesis purposes. The priority task is to ensure the synthesis of new proteins in the child's body. With insufficient provision of non-protein calories (carbohydrates, fats), the proportion of protein used for energy synthesis increases, and a smaller proportion is used for plastic purposes, which is undesirable. Amino acid supplementation at a dose of 3 g/kg/day during the first 24 hours after birth in children with VLBW and ELBW is safe and associated with better weight gain.

Albumin preparations, fresh frozen plasma and other blood components are not preparations for parenteral nutrition. When prescribing parenteral nutrition, they should not be taken into account as a source of protein.

In the case of drugs intended for administration to the newborn, metabolic acidosis is an extremely rare complication of the use of amino acids in newborns. Metabolic acidosis is not a contraindication to the use of amino acids.

IT IS NECESSARY TO REMEMBER THAT METABOLIC ACIDOSIS IN MOST

CASES IS NOT AN INDEPENDENT DISEASE, BUT A MANIFESTATION

OTHER DISEASE

Protein requirement The protein requirement is determined based on the amount (1) required for protein synthesis and resynthesis in the body (storage protein), (2) used for oxidation as an energy source, (3) the amount of protein excreted.

The optimal amount of protein or amino acids in the diet is determined by the gestational age of the baby, as body composition changes as the fetus grows. In the least ripe fruits, the rate of protein synthesis is normally higher than in more mature ones; protein occupies a large proportion in newly synthesized tissues. Therefore, the lower the gestational age, the greater the need for protein, a smooth change in the ratio of protein and non-protein calories in the diet from 4 or more g / 100 kcal in the least mature preterm infants to

2.5 g / 100 kcal in more mature ones allows us to model the composition of body weight characteristic of a healthy fetus.

Appointment tactics:

Starting doses, the rate of increase and the target level of protein supplementation depending on gestational age are indicated in Table No. 1 of the Appendix. The introduction of amino acids from the first hours of a child's life is mandatory for newborns with very low and extremely low body weight.

In children with a birth weight of less than 1500 g, parenteral protein dosing should remain unchanged until an enteral feeding volume of 50 ml/kg/day is reached.

1.2 grams of amino acids from parenteral nutrition solutions is equivalent to approximately 1 gram of protein. For routine calculation, it is customary to round this value up to 1 g.

The metabolism of amino acids in newborns has a number of features, therefore, for safe parenteral nutrition, protein preparations should be used that are designed taking into account the characteristics of amino acid metabolism in newborns and are allowed from 0 months (see Table No. 2 of the Appendix). Preparations for parenteral nutrition of adults should not be used in newborns.

Dosage of amino acids can be carried out both through a peripheral vein and through a central venous catheter.

Control of safety and efficacy To date, no effective tests have been developed to monitor the sufficiency and safety of parenteral protein administration. It is optimal to use the indicator of nitrogen balance for this purpose, however, in practical medicine, urea is used for an integral assessment of the state of protein metabolism. Control should be carried out from the 2nd week of life with a frequency of 1 time in 7-10 days. At the same time, a low level of urea (less than 1.8 mmol / l) will indicate an insufficient supply of protein. An increase in the level of urea cannot be unambiguously interpreted as a marker of excessive protein load.

Urea can also increase due to renal failure (then the level of creatinine will also increase) and be a marker of increased protein catabolism with a lack of energy substrates or the protein itself.

4. FATS An important source of energy;

The biological role of lipids is due to the fact that they are:

Fatty acids are essential for the maturation of the brain and retina;

Phospholipids are a component of cell membranes and surfactant;

Prostaglandins, leukotrienes and other mediators are fatty acid metabolites.

Fat Requirements Starting doses, rate of increase, and target level of fat supplementation by gestational age are shown in Appendix Table 1.

If it is necessary to limit fat intake, the dose should not be reduced below 0.5-1.0 g / kg / day. it is this dose that prevents the deficiency of essential fatty acids.

Modern research indicates the benefits of using in parenteral nutrition fat emulsions containing four types of oils (olive oil, soybean oil, fish oil, medium chain triglycerides), which are not only a source of energy, but also a source of essential fatty acids, including Omega-3 fatty acids.

In particular, the use of such emulsions reduces the risk of developing cholestasis.

One gram of fat contains 10 kilocalories.

The least number of complications causes the use of 20% fat emulsion. fatty

Appointment tactics:

Fat emulsion infusion should be carried out evenly at a constant rate of 20 emulsions approved for use in neonatology are given in Table 3;

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If the fat emulsion is infused through a common venous route, a peripheral vein should be connected;

infusion lines as close as possible to the catheter connector, while it is necessary to use a fat emulsion filter;

Do not add heparin solution to fat emulsion.

must be protected from light;

Monitoring the safety and effectiveness of fat supplementation Safety control of the administered amount of fat is carried out on the basis of monitoring the concentration of triglycerides in the blood plasma one day after changing the rate of administration. If it is impossible to control the level of triglycerides, a serum "transparency" test should be performed. At the same time, 2-4 hours before the analysis, it is necessary to suspend the introduction of fat emulsions.

Normal triglyceride levels should not exceed 2.26 mmol/L (200 mg/dL), although according to the German Parenteral Nutrition Working Group (GerMedSci 2009), plasma triglyceride levels should not exceed 2.8 mmol/L. If the level of triglycerides is higher than acceptable, the subsidy of the fat emulsion should be reduced by 0.5 g/kg/day.

Some drugs (such as amphotericin and steroids) lead to elevated triglyceride levels.

Side effects and complications of intravenous lipid administration, including hyperglycemia, occur more frequently at infusion rates greater than 0.15 g lipid per kg/h.

Table 3

Limitations for the introduction of fat emulsions

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5. CARBOHYDRATES Carbohydrates are the main source of energy and an essential component of parenteral nutrition, regardless of gestational age and birth weight.

One gram of glucose contains 3.4 Calories In adults, endogenous glucose production begins at levels of glucose intake below

3.2 mg / kg / min, in full-term newborns - below 5.5 mg / kg / min (7.

2 g / kg / day), in premature newborns - at any rate of glucose intake less than 7.5-8 mg / kg / min (44 mmol / kg / min or g / kg / day). Basic production of glucose without exogenous administration is approximately equal in full-term and preterm infants and is 3.0 - 5.5 mg / kg / min 3-6 hours after feeding. In full-term infants, the basic production of glucose covers 60 needs, while in preterm infants, only 40-70%. This means that without exogenous administration, premature infants will rapidly deplete glycogen stores, which are small, and break down their own proteins and fat. Therefore, the minimum necessary is the rate of entry, which allows minimizing endogenous production.

Carbohydrate requirement The carbohydrate requirement of a newborn is calculated based on the calorie requirement and the rate of glucose utilization (see Appendix Table 1). If the carbohydrate load is tolerable (blood glucose level is not more than 8 mmol / l), the carbohydrate load should be increased daily by 0.5 - 1 mg / kg / min, but not more than 12 mg / kg / min.

Monitoring the safety and effectiveness of glucose supplementation is carried out by monitoring blood glucose levels. If the blood glucose level is between 8 and 10 mmol/l, the carbohydrate load should not be increased.

IT IS NECESSARY TO REMEMBER THAT HYPERGLYCEMIA IS MOST OFTEN

A SYMPTOM OF ANOTHER DISEASE THAT SHOULD BE EXCLUDED.

If the patient's blood glucose level remains below 3 mmol/L, the carbohydrate load should be increased by 1 mg/kg/min. If the patient's blood glucose level during monitoring is less than 2.2 mmol/l, a bolus of 10% glucose solution should be administered at a rate of 2 ml/kg.

REMEMBER THAT HYPOGLYCEMIA IS LIFE DANGEROUS

A CONDITION THAT MAY LEAD TO DISABILITY

6. REQUIREMENTS FOR ELECTROLYTES AND MICRONUTRIENTS

6.1 Potassium Potassium is the main intracellular cation. Its main biological role is to provide neuromuscular transmission of impulses. The initial indicators of potassium subsidies, the rate of increase, are indicated in Table No. 3 of the Appendix.

The appointment of potassium to children with ENMT is possible after the concentration in the blood serum will not exceed 4.5 mmol / l (since the establishment of adequate diuresis on the 3rd-4th day of life). The average daily requirement for potassium in children with ELMT increases with age and reaches 3-4 mmol/kg by the beginning of the 2nd week of life.

The criterion for hyperkalemia in the early neonatal period is an increase in the concentration of potassium in the blood of more than 6.5 mmol/l, and after 7 days of life - more than 5.5 mmol/l.

Hyperkalemia is a serious problem in newborns with ELBW, occurring even with adequate kidney function and a normal supply of potassium (neoliguric hyperkalemia). A rapid increase in serum potassium during the first day of life is characteristic of extremely immature children. The cause of this condition may be hyperaldesteronism, immaturity of the distal renal tubules, metabolic acidosis.

Hypokalemia is a condition in which the concentration of potassium in the blood is less than 3.5 mmol / l. In newborns, it often occurs due to large fluid losses with vomiting and feces, excessive excretion of potassium in the urine, especially with long-term use of diuretics, and infusion therapy without adding potassium. Therapy with glucocorticoids (prednisolone, hydrocortisone), intoxication with cardiac glycosides are also accompanied by the development of hypokalemia. Clinically, hypokalemia is characterized by cardiac arrhythmias (tachycardia, extrasystole), polyuria. Therapy of hypokalemia is based on replenishing the level of endogenous potassium.

6.2 Sodium Sodium is the main cation of extracellular fluid, the content of which determines the osmolarity of the latter. The initial indicators of sodium subsidies, the rate of increase, are indicated in Table No. 3 of the Appendix. Planned administration of sodium begins from 3-4 days of life or from an earlier age with a decrease in the serum sodium content of less than 140 mmol / l. The need for sodium in newborns is 3-5 mmol / kg per day.

Children with ELMT often develop a syndrome of "late hyponatremia" due to impaired renal function and increased sodium intake against the background of accelerated growth.

Hyponatremia (Na level in plasma less than 130 mmol/l), which occurred in the first 2 days against the background of pathological weight gain and edematous syndrome, is called dilutional hyponatremia. In such a situation, the volume of fluid administered should be reviewed. In other cases, additional administration of sodium preparations is indicated with a decrease in its concentration in the blood serum below 125 mmol / l.

Hypernatremia - an increase in the concentration of sodium in the blood more than 145 mmol / l.

Hypernatremia develops in children with ENMT in the first 3 days of life due to large fluid losses and indicates dehydration. It is necessary to increase the volume of fluid, not excluding sodium preparations. A more rare cause of hypernatremia is excessive intravenous intake of sodium bicarbonate or other sodium-containing drugs.

6.3 Calcium and phosphorus The calcium ion takes part in various biochemical processes in the body. It provides neuromuscular transmission, takes part in muscle contraction, provides blood coagulation, plays an important role in the formation of bone tissue.

A constant level of calcium in the blood serum is maintained by parathyroid hormones and calcitonin. With insufficient subsidies of phosphorus, it is delayed by the kidneys and, as a result, the disappearance of phosphorus in the urine. The lack of phosphorus leads to the development of hypercalcemia and hypercalciuria, and in the future, to bone demineralization and the development of osteopenia of prematurity.

The initial indicators of calcium supplementation, the rate of increase, are indicated in Table No. 3 of the Appendix.

Signs of calcium deficiency in newborns: seizures, decreased bone density, development of rickets, osteoporosis, and tetany.

Signs of phosphorus deficiency in newborns: decreased bone density, rickets, fractures, bone pain, heart failure.

Neonatal hypocalcemia is a pathological condition that develops when the concentration of calcium in the blood is less than 2 mmol / l (ionized calcium less than 0.75-0.87 mmol / l) in full-term and 1.75 mmol / l (ionized calcium less than 0.62-0 .75 mmol/l) in premature newborns. Perinatal risk factors for the development of hypocalcemia include prematurity, asphyxia (Apgar score of 7 points), insulin-dependent diabetes mellitus in the mother, and congenital hypoplasia of the parathyroid glands.

Signs of hypocalcemia in a newborn: often asymptomatic, respiratory failure (tachypnea, apnea), neurological symptoms (syndrome of increased neuroreflex excitability, convulsions).

6.4 Magnesium Serum concentration is 0.7-1.1 mmol/L. However, true magnesium deficiency is not always diagnosed, as only about 0.3% of the total body magnesium is found in the blood serum. The physiological significance of magnesium is great: magnesium controls energy-dependent processes (ATP), participates in the synthesis of proteins, nucleic acids, fats, surfactant phospholipids and cell membranes, participates in calcium homeostasis and vitamin D metabolism, is a regulator of ion channels and, accordingly, cellular functions (CNS, heart , muscle tissue, liver, etc.). Magnesium is essential for maintaining potassium and calcium levels in the blood.

The introduction of magnesium in the composition of the PP begins from the 2nd day of life, in accordance with the physiological need of 0.2-0.3 mmol / kg / day (Table No. 3 of the Appendix). Hypermagnesemia should be ruled out before the start of magnesium administration, especially if the woman was given magnesium preparations during childbirth.

The introduction of magnesium is carefully monitored and possibly canceled in cholestasis, since magnesium is one of the elements that is metabolized by the liver.

At magnesium levels less than 0.5 mmol / l, clinical symptoms of hypomagnesemia may appear, which are similar to those of hypocalcemia (including convulsions). If hypocalcemia is refractory to treatment, the presence of hypomagnesemia should be ruled out.

In case of symptomatic hypomagnesemia: magnesium sulfate based on magnesium 0.1-0.2 24 mmol / kg IV for 2-4 hours (if necessary, can be repeated after 8-12 hours).

A solution of magnesium sulfate 25% is diluted at least 1:5 before administration. During the introduction control heart rate, blood pressure. Maintenance dose: 0.15-0.25 mmol/kg/day IV for 24 hours.

Hypermagnesemia. The magnesium level is above 1.15 mmol/l. Causes: an overdose of magnesium preparations; maternal hypermagnesemia due to treatment of preeclampsia in childbirth. It is manifested by a syndrome of CNS depression, arterial hypotension, respiratory depression, decreased motility of the digestive tract, urinary retention.

6.5 Zinc Zinc is involved in energy, macronutrient and nucleic acid metabolism. The rapid growth rate of severely preterm infants results in a higher zinc requirement than full-term infants. Very preterm infants and children with high zinc losses due to diarrhea, the presence of a stoma, severe skin diseases require the inclusion of zinc sulfate in parenteral nutrition.

6.6 Selenium Selenium is an antioxidant and a component of active glutathione peroxidase, an enzyme that protects tissues from damage by reactive oxygen species. Low selenium levels are often found in premature babies, which contributes to the development of BPD, retinopathy of prematurity in this category of children.

The need for selenium in premature babies: 1-3 mg / kg / day (relevant for very long-term parenteral nutrition for several months).

Currently, phosphorus, zinc, and selenium preparations for parenteral administration are not registered in Russia, which makes it impossible to use them in newborns in the ICU.

7. VITAMINS Fat-soluble vitamins. Vitalipid N for children is used in newborns to provide the daily requirement for fat-soluble vitamins A, D2, E, K1. Need: 4 ml/kg/day. Vitalipid N for children is added to the fat emulsion. The resulting solution is stirred by gentle rocking, then used for parenteral infusion.

It is prescribed depending on gestational age and body weight, simultaneously with the appointment of a fat emulsion.

Water-soluble vitamins - Soluvit N (Soluvit-N) - is used as an integral part of parenteral nutrition to meet the daily requirement for water-soluble vitamins (thiamine mononitrate, sodium riboflavin phosphate dihydrate, nicotinamide, pyridoxine hydrochloride, sodium pantothenate, sodium ascorbate, biotin, folic acid, cyanocobalamin ). Need: 1 ml/kg/day. Soluvita H solution is added to glucose solutions (5%, 10%, 20%), fat emulsion, or solution for parenteral nutrition (central or peripheral access). It is prescribed simultaneously with the start of parenteral nutrition.

8. MONITORING DURING PARENTERAL NUTRITION

Simultaneously with the start of parenteral nutrition, a complete blood count and

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Dynamics of body weight;

During parenteral nutrition, it is necessary to determine daily:

The concentration of glucose in the urine;

The concentration of electrolytes (K, Na, Ca);

The concentration of glucose in the blood (with an increase in the rate of glucose utilization - 2 times per plasma triglyceride content (with an increase in the dose of fat).

For long-term parenteral administration, perform a complete blood count and

– – –

Electrolytes (K, Na, Ca);

Plasma creatinine and urea levels.

9. COMPLICATIONS OF PARENTERAL NUTRITION

Infectious complications Parenteral nutrition is one of the main risk factors for nosocomial infection, along with central venous catheterization and mechanical ventilation. The conducted meta-analysis showed no significant differences in the frequency of infectious complications when using central and peripheral vascular catheters.

Extravasation of the solution and the occurrence of infiltrates, which may be the cause.

formation of cosmetic or functional defects. Most often, this complication develops against the background of standing peripheral venous catheters.

Pleural/pericardial effusion (1.8/1000 deep lines, lethality was 0.7/1000 lines).

Cholestasis occurs in 10-12% of children receiving long-term parenteral nutrition.

Proven effective ways to prevent cholestasis are the earliest possible start of enteral nutrition and the use of fat emulsion preparations with the addition of fish oil (SMOF - lipid).

Hypoglycemia/hyperglycemia Electrolyte disorders Phlebitis Osteopenia Algorithm for calculating the parenteral nutrition program This scheme is approximate and takes into account only situations with successful absorption of enteral nutrition.

10. PROCEDURE FOR CALCULATION OF PARENTERAL NUTRITION IN PREMATURES

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2. Calculation of the volume of parenteral nutrition (taking into account the volume of enteral nutrition).

3. Calculation of the daily volume of the protein solution.

4. Calculation of the daily volume of fat emulsion.

5. Calculation of the daily volume of electrolytes.

6. Calculation of the daily volume of vitamins.

7. Calculation of the daily volume of carbohydrates.

8. Calculation of the volume of injected fluid per glucose.

9. Selection of volumes of glucose solutions.

10. Drawing up a list of infusion therapy.

11. Calculation of the rate of introduction of solutions.

10.1. Fluid: multiply the child's weight in kilograms by the estimated amount of fluid per kg.

body weight (see table). If there are indications for increasing or decreasing fluid intake, the dose is adjusted individually.

This volume includes all fluids administered to the child: parenteral nutrition, enteral nutrition, liquid in the composition of parenteral antibiotics.

The minimum trophic nutrition (less than 25 ml / kg / day), which is mandatory on the first day of life, is not taken into account in the total volume of fluid.

m (kg) x fluid dose (ml/kg/day) = daily fluid dose (ml/day)

With the volume of enteral nutrition exceeding the trophic:

Daily fluid dose (ml/day) - volume of enteral nutrition (ml/day) = daily volume of parenteral nutrition.

10.2. Protein: multiply the child's weight in kilograms by the estimated dose of parenteral protein per kg. body weight (see Table) taking into account the entered enteral protein (with the amount of enteral nutrition exceeding the trophic) m (kg) x protein dose (g/kg/day) = daily protein dose (g/day) When using 10% amino acid solution: multiply the daily dose of protein by 10.

daily dose of protein (g / day) x10 = amount of 10% amino acid solution in ml per day When calculating partial parenteral nutrition - the dose of protein in grams is calculated in the daily volume of enteral nutrition, and the result is subtracted from the daily dose of protein.

10.3. Fats: multiply the child's weight (kg.) By the estimated dose of fat per kg. body weight (see

Table) taking into account the administered enteral protein (with the volume of enteral nutrition exceeding the trophic) m (kg) x dose of fat (g / kg / day) = daily dose of fat (g / day) When using a 20% fat emulsion: we multiply the daily dose of fat by 5, when using 10% we multiply by 10, we get the volume in ml / day the daily dose of fat (g / day) x 5 = the amount of 20% fat emulsion in ml per day When calculating partial parenteral nutrition - in the daily volume of enteral nutrition, the dose is calculated fat in grams, and the result is subtracted from the daily fat intake.

10.4. Electrolyte: calculation of the sodium dose when using saline:

M (kg) x dose of sodium (mmol/l) (see table) = volume of NaCl 0.9% (ml) 0.15

m (kg) x sodium dose (mmol/l) (see table) = volume of NaCl 10% (ml) 1.7

Potassium dose calculation:

m (kg) x dose of potassium (mmol/l) (see table) = volume K 4% (ml) 0.56

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m (kg) x dose of calcium (mmol/l) (see table) x 3.3 = volume of calcium gluconate 10% (ml) m (kg) x dose of calcium (mmol/l) (see table) x 1, 1 = volume of calcium chloride 10% (ml)

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10.5. Vitamins:

The preparation of water-soluble vitamins - Soluvit N for children - 1 ml / kg / day. Dissolve by adding to one of the solutions: Vitalipid N for children, Intralipid 20%, SMOFlipid 20%; water for injections; glucose solution (5, 10 or 20%).

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The preparation of fat-soluble vitamins - Vitalipid N for children - is added only to the fat emulsion solution for parenteral nutrition at the rate of 4 ml / kg.

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1. Calculate the number of grams of glucose per day: multiply the weight of the child in kilograms by

10.6. Carbohydrates:

the estimated dose of glucose utilization rate (see Table) is multiplied by a factor of 1.44.

Carbohydrate injection rate (mg/kg/min) x m (kg) x 1.44 = glucose dose (g/day).

2. When calculating partial parenteral nutrition - in the daily volume of enteral nutrition

3. Calculation of the volume of injected liquid per glucose: from the daily dose of liquid, the dose of carbohydrates in grams is calculated and subtracted from the daily dose of carbohydrates.

(ml / day) subtract the amount of enteral nutrition, daily amount of protein, fat, electrolytes, liquid in the composition of parenteral antibiotics.

Daily volume of parenteral nutrition (ml) - Daily volume of protein (ml) - Daily volume of fat emulsion (ml) - Daily volume of electrolytes (ml)

The volume of liquid in the composition of parenterally administered antibiotics, inotropic drugs, etc. - the volume of vitamin solutions (ml) = the volume of glucose solution (ml).

4. Selection of volumes of glucose solutions:

When making a solution outside the pharmacy from standard - 5%, 10% and 40% glucose, there are 2 calculation options:

1. We calculate in what volume of 40% glucose a given amount of dry glucose is contained -

First option:

g/day: glucose dose (g/day)x10 = glucose 40% ml

2. Calculate the amount of water to be added:

Volume of liquid per glucose - volume of 40% glucose = volume of water (ml)

1. Calculate the volume of glucose solution with a higher concentration

Second option:

Dose of carbohydrates (g) x 100 - volume of total glucose solution (ml) x C1 \u003d C2-C1

– – –

where C1 is a lower concentration (for example, 10), C2 is a large one (for example, 40)

2. Calculate the volume of a solution of lower concentration Volume of glucose solutions (ml) - volume of glucose in concentration C2 = volume of glucose in concentration C1

11. CONTROL OF THE OBTAINED GLUCOSE CONCENTRATION IN THE COMBINED

Daily dose of glucose (g) x 100 / total solution volume (ml) \u003d glucose concentration in

SOLUTION

The allowable percentage is compared with the recommendations for administration in solution (%);

central/peripheral vein.

1. Calculation of caloric content of enteral nutrition

12. CALORIE CONTROL

2. Calculation of calorie content of parenteral nutrition:

Dose of lipids g / day x 9 + dose of glucose g / day x 4 \u003d calorie content of parenteral

Amino acids are not counted as a source of calories, although they can be used in nutrition kcal / day;

– – –

Enteral nutrition calories (kcal/day) + PN calories (kcal/day)/body weight (kg).

13. DEVELOPING THE LIST OF INFUSION THERAPY

Add volumes of infusion solutions to the sheet:

Intravenous drip: 40% glucose - ... ml Dist. water - ... ml Or 10% glucose - ... ml 40% glucose - ... ml 10% protein preparation - ... ml 0.9% (or 10%) sodium chloride solution - ... ml 4% potassium chloride solution - ... ml 25% solution magnesium sulfate - ... ml 10% calcium gluconate preparation - ... ml Heparin - ... ml

Soluvit - ... ml Intravenous drip:

20% fat emulsion - ... ml Vitalipid - ... ml Fat emulsion solution is injected in parallel with the main solution in different syringes, through a tee.

14. CALCULATION OF INFUSION RATE

Optimal to start therapy is the intake of parenteral nutrition components at the same rate during the day. When conducting long-term parenteral nutrition, they gradually switch to cyclic infusion.

Calculation of the rate of introduction of the main solution:

Volume of total glucose solution with protein, vitamins and electrolytes / 24 hours = injection rate (ml / h) Calculation of the rate of administration of fat emulsion Volume of fat emulsion with vitamins / 24 hours = rate of administration of fat emulsion (ml / h)

15. VENOUS ACCESSES DURING PARENTERAL

FOOD

Parenteral nutrition can be provided through both peripheral and central venous accesses. Peripheral access is used when long-term parenteral nutrition is not planned and hyperosmolar solutions will not be used. Central venous access is used when long-term parenteral nutrition is planned using hyperosmolar solutions.

Usually, the concentration of glucose in a solution is used as an indirect indicator of osmolarity. It is not recommended to inject solutions with a glucose concentration of more than 12.5% into a peripheral vein. However, for a more accurate calculation of the osmolarity of a solution, you can use the formula:

Osmolarity (mosm/l) = [amino acids (g/l) x 8] + [glucose (g/l) x 7] + [sodium (mmol/l) x 2] + [phosphorus (mg/l) x 0, 2] -50 Solutions whose calculated osmolarity exceeds 850 - 1000 mosm / l are not recommended to be injected into a peripheral vein.

In clinical practice, when calculating osmolarity, the concentration of dry matter 40 should be considered.

16. TECHNOLOGY OF PREPARATION AND APPOINTMENT OF SOLUTIONS FOR

PARENTERAL NUTRITION

Solutions for parenteral nutrition should be prepared in a separate room.

The room must comply with the ventilation standards of the extra clean room.

Preparation of solutions should be carried out in a laminar cabinet. The preparation of solutions for parenteral nutrition should be entrusted to the most experienced nurse. Before preparing the solutions, the nurse must perform a surgical treatment of the hands, put on a sterile cap, mask, mask, sterile gown and sterile gloves. A sterile table should be set in the laminar flow cabinet. The preparation of solutions should be carried out in compliance with all the rules of asepsis and antisepsis. Mixing in one package of solutions of glucose, amino acids and electrolytes is allowed. To prevent catheter thrombosis, heparin should be added to the solution.

The dose of heparin can be determined either at the rate of 0.5 - 1 IU per 1 ml. ready-made solution, or 25 - 30 IU per kilogram of body weight per day. Fat emulsions with fat-soluble vitamins are prepared in a separate vial or syringe without the addition of heparin. In order to prevent catheter-associated infection, the infusion system should be filled under sterile conditions and its tightness should be violated as little as possible. From this point of view, it seems reasonable to use volumetric infusion pumps during parenteral nutrition with sufficient accuracy of dispensing the solution at low injection rates. Syringe dispensers are more appropriate to use when the volume of the injected medium does not exceed the volume of one syringe. To ensure maximum tightness, it is advisable to use three-way stopcocks and needleless connectors for the introduction of single appointments when collecting the infusion circuit. Changing the infusion circuit at the patient's bedside should also be carried out in compliance with all the rules of asepsis and antisepsis.

17. ENTERAL NUTRITION MANAGEMENT. FEATURES OF CALCULATION

PARTIAL PARENTERAL NUTRITION

Starting from the first day of life, in the absence of contraindications, it is necessary to begin trophic nutrition. In the future, in the case of tolerability of trophic nutrition, the volume of enteral nutrition should be systematically expanded. Until the volume of enteral nutrition reaches 50 ml/kg, adjustments should be made to the parenteral fluid, but not to the parenteral nutrients. After the volume of parenteral nutrition exceeds 50 ml/kg, partial parenteral nutrition is carried out according to the residual principle, covering the deficiency of enteral nutrition.

18. WITHDRAWAL OF PARENTERAL NUTRITION

When the volume of enteral nutrition reaches 120-140 ml/kg, parenteral nutrition may be discontinued.

– – –

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GOU VPO St. Petersburg State Pediatric Medical Academy of the Ministry of Health and Social Development of Russia

Mostovoy A.V., Prutkin M.E., Gorelik K.D., Karpova A.L.

PROTOCOL OF INFUSION THERAPY AND PARENTERAL

NUTRITION FOR NEWBORN

Reviewers:

Prof. Aleksandrovich Yu.S. Prof. Gordeev V.I.

St. Petersburg

A.V. Mostovoy1, 4 , M.E. Prutkin2, K.D. Gorelik4 , A.L. Karpova3.

1 St. Petersburg state pediatric medical academy

2 Regional Children's Hospital, Yekaterinburg

3 Regional maternity hospital, Yaroslavl

4 City Children's Hospital № 1, St. Petersburg

Purpose of creating the protocol: to unify approaches to the organization of infusion therapy and parenteral nutrition for newborns with various perinatal pathologies who, for whatever reason, do not receive adequate enteral nutrition in a given age period (the volume of actual enteral nutrition is less than 75% of what should be).

The main task of organizing parenteral nutrition in a newborn child with severe perinatal pathology is to simulate (create a model) the intrauterine intake of nutrients.

The concept of early parenteral nutrition:

the main task is the subsidy of the required amount of amino acids

providing energy by introducing fats as soon as possible

the introduction of glucose, taking into account the characteristics of its intrauterine intake.

Some features of intrauterine intake of nutrients:

In utero, amino acids enter the fetus in the amount of 3.5 - 4.0 g / kg / day (more than he can absorb)

Excess amino acids in the fetus are oxidized and serve as a source of energy

The rate of glucose intake in the fetus is within 6 - 10 mg / kg / min.

Prerequisites for early parenteral nutrition:

amino acids and fat emulsions should be ingested from the first day of life (B)

protein loss is inversely related to gestational age

in newborns with extremely low body weight (ELBW), losses are 2 times higher than those in comparison with full-term newborns

in newborns with ELMT, the loss of protein from the total depot is 1-2% per day if they do not receive amino acids intravenously

delay in protein donation in the first week of life leads to an increase in protein deficiency up to 25% of the total content in the body of a premature baby with ELBW

cases of hyperkalemia can be reduced by subsidizing amino acids in a parenteral nutrition program at a dose of at least 1 g / kg / day, starting from the first day of life in preterm infants weighing less than 1500 grams (II)

administration of amino acids intravenously can maintain protein balance and improve protein absorption

early introduction of amino acids is safe and effective

early introduction of amino acids promotes better growth and development

maximum parenteral intake of amino acids should be between 2 and a maximum of 4 g/kg/day in preterm and term infants (B)

maximum lipid intake should not exceed 3–4 g/kg/day in preterm and term neonates (B)

fluid restriction with sodium chloride restriction may reduce the need for mechanical ventilation

_____________________

*A - High quality meta-analyses or RCTs, and RCTs of sufficient strength performed on a "target population" of patients.

B - meta-analyses or randomized controlled trials (RCTs) or high-quality case-control studies or low-grade RCTs but with high sensitivity relative to the control group.

C - well collected cases or cohort studies with low risk of error.

D - evidence obtained from small studies, case reports, expert opinion.

Principles of organization of parenteral nutrition:

a complete understanding of the metabolic pathways of parenteral nutrition substrates is necessary

the ability to correctly calculate the dose of drugs is necessary

it is necessary to provide adequate venous access (as a rule, a central venous catheter: umbilical, deep line, etc.; less often peripheral). The use of peripheral venous access is possible in 1-2 days of life in newborns with ENMT and VLBW, provided that the percentage of glucose in the basic infusion program (prepared parenteral nutrition solution) is less than 12.5%

know the features of equipment and consumables used for infusion therapy and parenteral nutrition

it is necessary to know about possible complications, to be able to predict and prevent them.

ALGORITHM FOR CALCULATION OF INFUSION THERAPY AND PARENTERAL NUTRITION

I. Calculation of the total amount of fluid per day

II. Calculation of enteral nutrition

III. Calculation of the required volume of electrolytes

IV. Fat emulsion volume calculation

v. Calculation of the dose of amino acids

VI. Calculation of the dose of glucose based on the rate of utilization VII. Determination of the volume attributable to glucose

VIII. Selection of the required volume of glucose of various concentrations IX. Infusion program, calculation of the infusion rate of solutions and

concentration of glucose in the infusion solution

x. Determination and calculation of the final daily number of calories.

I. Calculation of the total amount of liquid

1. All newborns requiring fluid therapy and / or parenteral nutrition should determine the total amount of fluid administered. However, before proceeding with the calculation of the volume of infusion and / or parenteral nutrition, it is necessary to answer the following questions:

a. Does the child have signs of arterial hypotension?

The main signs of arterial hypotension to which you need to pay attention: violation of peripheral perfusion of tissues (pale skin, turns pink when rubbed, a symptom of a "white spot" for more than 3 seconds, a decrease in the rate of diuresis), tachycardia, weak pulsation in the peripheral arteries, the presence of partially compensated metabolic acidosis

b. Does the child show signs of shock?

The main signs of shock: signs of respiratory failure (apnea, decreased saturation, swelling of the wings of the nose, tachypnea, retraction of compliant places of the chest, bradypnea, increased work of breathing). Violation of peripheral perfusion of tissues (pale skin, turns pink when rubbed, a symptom of a "white spot" for more than 3 seconds, cold extremities). Disorders of central hemodynamics (tachycardia or bradycardia, low blood pressure), metabolic acidosis, decreased diuresis (during the first 6-12 hours less than 0.5 ml/kg/hour, at the age of more than 24 hours less than 1.0 ml/kg/hour) . Impaired consciousness (apnea, lethargy, decreased muscle tone, drowsiness, etc.).

2. If you answer yes to one of the questions posed, it is necessary to start therapy for arterial hypotension or shock using appropriate protocols, and only after stabilization of the condition, restoration of tissue perfusion and normalization of oxygenation, parenteral administration of nutrients can be started.

3. If you can firmly answer “No” to the questions, start the traditional calculation of parenteral nutrition using this protocol.

4. Table 1 presents a simplified approach to determining the daily fluid requirement for preterm infants placed in an incubator with adequate humidification of the baby's environment and a thermoneutral environment:

Table 1

Fluid requirements for incubated neonates (ml/kg/day)

Age, days			Body weight, g.

5. If the child has reached the third day of life or the so-called "transitional phase", you can focus on the values below (table No. 2). The transition phase ends when urine output stabilizes at 1 ml/kg/h, urine relative gravity becomes > 1012, and sodium excretion decreases:

				table 2
	Transitional phase (first 3 - 5 days of life)


	increase	(ml/kg/day)
	increase	(ml/kg/day)	mEq/kg/day
	body weight		mEq/kg/day
	body weight
1000 <

* - if the baby is in an incubator, the need is reduced by 10-20%

** - for monovalent ions 1 mEq = 1 mmol

6. Table 3 shows the recommended physiological fluid requirements for newborns up to two weeks of age (the so-called stabilization phase). For premature babies, an increase in sodium excretion is important, against the background of the development of polyuria. Also during this period, it is important to expand the volume of enteral nutrition, so this age requires special attention from the doctor when calculating the total volume of fluid and nutrients.

			Table 3
Stabilization phase (5 - 14 days of life)

increase	(ml/kg/day)	mEq/kg/day
body weight		mEq/kg/day
body weight

CLINICAL EXAMPLE:

A child of 3 days of life, weight - 1200 g at birth Due volume of infusion per day = Daily fluid requirement (DAF) × body weight (kg)

Lifespan = 100 ml/kg Due infusion per day = 120 ml × 1.2 = 120 ml

Answer: total fluid volume (infusion therapy + parenteral nutrition

Enteral nutrition) = 120 ml per day

II. Calculation of enteral nutrition

AT Table No. 4 presents data on the energy value, composition and osmolarity of some milk mixtures in comparison with the average composition of female breast milk. These data are necessary for accurate calculation of nutrients for newborns with mixed enteral and parenteral nutrition.

		Table 4
Composition of female breast milk and milk formulas
Milk/mixture	Carbohydrates	Osmolarity

Breast milk is mature
(term delivery)




Nutrilon

Enfamil Premium 1

Breast milk
(premature birth)




Nutrilon Pepti TSC

Pre-Nutrilon

Similac Neo Sure

Similac Special Care

Frisopre

Pregestimil

Enfamil Premature

Energy requirements of newborns:

The energy requirements of newborns depend on various factors: gestational and postnatal age, body weight, energy pathway, growth rate, child activity, and environmentally determined heat loss. Sick children, as well as newborns who are in serious stressful situations (sepsis, BPD, surgical pathology), need to increase the energy supply to the body

Protein is not an ideal source of energy, it is intended for the synthesis of new tissues. When a child receives an adequate amount of non-protein calories, he maintains a positive nitrogen balance. Part of the protein in this case is spent on synthetic purposes. Therefore, it is impossible to take into account all the calories from the injected protein, since part of it will not be available to cover energy needs, and will be used by the body for plastic purposes.

The ideal ratio of incoming energy: 65% from carbohydrates and 35% from fat emulsions. In general, starting from the second week of life, children with a normal growth rate need 100-120 kcal / kg / day, and only in rare cases, the requirements can increase significantly, for example, in patients with BPD up to 160 - 180 kcal / kg / day

Table 5

Energy needs of newborns in the early neonatal period

		Kcal/kg/day

Physical activity (+30% of the requirement for the main exchange)
	Heat loss (thermoregulation)
Specific dynamic action of food

	Loss with stool (10% of incoming)
Growth (energy reserves)
	General costs
	Energy requirements for basal metabolism (at rest) are 49 - 60
	kcal/kg/day from 8 to 63 days of age (Sinclair, 1978)
	For a premature baby on full enteral
feeding, the calculation of incoming energy will be different (table No. 6)
			Table 6
	Total energy requirement against the background of weight gain at 10 - 15 g / day *
	Energy costs per day	Kcal/kg/day
	Energy expenditure at rest (basal metabolic rate)
Minimum physical activity
	Possible cold stress
Losses with stool (10 - 15% of incoming energy)
	Height (4.5 kcal/gram)
General Needs
*According to N Ambalavanan, 2010

The need for energy in children of the early neonatal period is unevenly distributed. Table No. 7 shows the approximate number of calories depending on the age of the child:

								Table 7
	Energy requirements in the early neonatal period

In the first week of life, the optimal energy supply should be in the range - 50-90 kcal / kg / day. Sufficient energy supply by the 7th day of life in full-term newborns should be - 120 kcal / kg / day. When parenteral nutrition is given to preterm infants, the energy requirement is less due to no stool loss, no episodes of heat or cold stress, and less physical activity. Thus, the general energy

needs for parenteral nutrition can be about 80 -

100 kcal/kg/day.

Calorie method for calculating nutrition for preterm infants

CLINICAL EXAMPLE:

Patient's body weight - 1.2 kg Age - 3 days of life Milk formula - Pre-Nutrilon

* where 8 is the number of feedings per day

Minimum trophic nutrition (MTP). The minimum trophic nutrition is defined as the amount of nutrition received by the child enterally in an amount of ≤ 20 ml / kg / day. Advantages of MTP:

accelerates the maturation of motor and other functions gastrointestinal tract (GIT)

improves tolerability of enteral nutrition

accelerates the time to achieve full enteral nutrition

does not increase (according to some reports reduces) the frequency of NEC

reduces the duration of hospitalization.

The child assimilates the mixture "Pre-Nutrilon" 1.5 ml every 3 hours

Enteral Actual Daily Feeding (ml) = Single Feeding Volume (ml) x Number of Feeds

Enteral feeding volume per day = 1.5 ml x 8 feedings = 12 ml/day

Calculation of the amount of nutrients and calories that the child will receive per day enterally:

Carbohydrate enteral = 12 ml x 8.2 / 100 = 0.98 g Protein enteral = 12 ml x 2.2 / 100 = 0.26 g Fat enteral = 12 ml x 4.4 / 100 = 0.53 g

Enteral calories = 12 ml x 80/100 = 9.6 kcal

III. Calculation of the required volume of electrolytes

It is advisable to start the introduction of sodium and potassium no earlier than the third day of life, calcium

- from the first days of life.

1. SODIUM DOSE CALCULATION

Sodium requirement is 2 mmol/kg/day

Hyponatremia<130 ммоль/л, опасно < 125 ммоль/л

Hypernatremia > 150 mmol/l, dangerous > 155 mmol/l

1 mmol (mEq) of sodium is contained in 0.58 ml of 10% NaCl

1 mmol (mEq) of sodium is contained in 6.7 ml of 0.9% NaCl

1 ml of 0.9% (physiological) sodium chloride solution contains 0.15 mmol Na

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, sodium requirement - 1.0 mmol / kg / day

V saline = 1.2 × 1.0 / 0.15 = 8.0 ml

CORRECTION OF HYPONATREMIA (Na< 125 ммоль/л)

Volume of 10% NaCl (ml) = (135 - Patient's Na) × body m × 0.175

2. CALCULATION OF THE DOSE OF POTASSIUM

The need for potassium is 2 - 3 mmol / kg / day

Hypokalemia< 3,5 ммоль/л, опасно < 3,0 ммоль/л

Hyperkalemia > 6.0 mmol/L (in the absence of hemolysis), dangerous > 6.5 mmol/L (or if there are pathological changes on the ECG)

1 mmol (mEq) of potassium is contained in 1 ml of 7.5% KCl

1 mmol (mEq) of potassium is contained in 1.8 ml of 4% KCl

V (ml 4% KCl) = K+ requirement (mmol) × mbody × 2

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, potassium requirement - 1.0 mmol / kg / day

V 4% KCl (ml) = 1.0 x 1.2 x 2.0 = 2.4 ml

* Influence of pH level on K+ : pH changes by 0.1 → change9 K+ by 0.3-0.6 mmol/l (Much acid, more K+ ; Low acid, less K+ )

III. CALCULATION OF THE DOSE OF CALCIUM

The need for Ca++ in newborns is 1-2 mmol / kg / day

hypocalcemia< 0,75 – 0,87 ммоль/л (доношенные – ионизированный Са ++ ), < 0,62 – 0,75 ммоль/л (недоношенные – ионизированный Са++ )

Hypercalcemia > 1.25 mmol/l (ionized Ca++ )

1 ml of 10% calcium chloride contains 0.9 mmol Ca++

1 ml of 10% calcium gluconate contains 0.3 mmol Ca++

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, calcium requirement - 1.0 mmol / kg / day

V 10% CaCl2 (ml) = 1 x 1.2 x 1.1*= 1.3 ml

* - calculation coefficient for 10% calcium chloride is 1.1, for 10% calcium gluconate - 3.3

4. CALCULATION OF THE DOSE OF MAGNESIUM:

The need for magnesium is 0.5 mmol / kg / day

Hypomagnesemia< 0,7 ммоль/л, опасно <0,5 ммоль/л

Hypermagnesemia > 1.15 mmol/l, dangerous > 1.5 mmol/l

1 ml of 25% magnesium sulfate contains 2 mmol of magnesium

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, magnesium requirement - 0.5 mmol / kg / day

V 25% MgSO4 (ml)= 0.5 x 1.2/ 2= 0.3 ml

catad_tema Neonatology - articles Comments Published in the journal: Bulletin of Intensive Care, 2006.

Lecture for practitioners E.N. Baibarina, A.G. Antonov

State Institution Scientific Center for Obstetrics, Gynecology and Perinatology (Director - Academician of the Russian Academy of Medical Sciences, Professor V.I. Kulakov), Russian Academy of Medical Sciences. Moscow

Parenteral nutrition (PN) of newborns has been used in our country for more than twenty years, during which time a lot of data has been accumulated both on theoretical and practical aspects of its use. Although the world is actively developing and producing drugs for PN available in our country, this method of nutrition in newborns is not widely used and is not always adequate.

The development and improvement of intensive care methods, the introduction of surfactant therapy, high-frequency ventilation of the lungs, and intravenous immunoglobulin replacement therapy have significantly improved the survival of children with very low and extremely low body weight. Thus, according to the data of the Scientific Center for Anti-Age and Psychiatry of the Russian Academy of Medical Sciences for 2005, the survival rate of premature babies weighing 500-749 g was 12.5%; 750-999g - 66.7%; 1000-1249g - 84.6%; 1250-1499 - 92.7%. Improving the survival of very preterm infants is impossible without the widespread and competent use of parenteral nutrition, a complete understanding of the pathways of metabolism of PN substrates by doctors, the ability to correctly calculate doses of drugs, predict and prevent possible complications.

I. METABOLISM PATHWAYS OF PP SUBSTRATES

The purpose of PP is to provide protein synthesis processes, which, as can be seen from the scheme in Fig. 1, require amino acids and energy. The supply of energy is carried out by the introduction of carbohydrates and fats, and, as will be said below, the ratio of these substrates can be different. The pathway of amino acid metabolism can be twofold - amino acids can be consumed to carry out protein synthesis processes (which is favorable) or, under conditions of energy deficiency, enter the process of gluconeogenesis with the formation of urea (which is unfavorable). Of course, in the body all of these transformations of amino acids occur simultaneously, but the predominant path may be different. Thus, in an experiment on rats, it was shown that under conditions of excessive protein intake and insufficient energy intake, 57% of the obtained amino acids are oxidized to urea. To maintain sufficient anabolic effectiveness of PP, at least 30 non-protein kilocalories should be administered for each gram of amino acids.

II. EFFICIENCY EVALUATION OF PP

Evaluating the effectiveness of PN in critically ill neonates is not easy. Such classical criteria as weight gain and an increase in the thickness of the skin fold in acute situations mainly reflect the dynamics of water metabolism. In the absence of kidney pathology, it is possible to use the method for assessing the urea increment, which is based on the fact that if an amino acid molecule does not enter into protein synthesis, then it decomposes with the formation of a urea molecule. The difference in the concentration of urea before and after the introduction of amino acids is called the increment. The lower it is (up to negative values), the higher the efficiency of the PP.

The classical method for determining the nitrogen balance is extremely laborious and is hardly applicable in wide clinical practice. We use a rough estimate of the nitrogen balance based on the fact that 65% of the nitrogen excreted by children is urine urea nitrogen. The results of applying this technique correlate well with other clinical and biochemical parameters and allow monitoring the adequacy of the therapy.

III. PRODUCTS FOR PARENTERAL NUTRITION

Sources of amino acids. Modern preparations of this class are solutions of crystalline amino acids (RCA). Protein hydrolysates have many disadvantages (imbalance of the amino acid composition, the presence of ballast substances) and are no longer used in neonatology. The most famous drugs of this class are Vamin 18, Aminosteril KE 10% (Fresenius Kabi), Moriamin-5-2 (Russel Morisita). The composition of the RCA is constantly being improved. Now, in addition to general-purpose drugs, so-called targeted drugs are being created that contribute not only to optimal absorption of amino acids in certain clinical conditions (renal and liver failure, hypercatabolic conditions), but also to eliminate the types of amino acid imbalance inherent in these states.

One of the directions in the creation of targeted drugs is the development of special drugs for newborns and infants, which are based on the amino acid composition of human milk. The specificity of its composition lies in the high content of essential amino acids (about 50%), cysteine, tyrosine and proline, while phenylalanine and glycine are present in small quantities. Recently, it has been considered necessary to introduce taurine into the composition of RCA for children, the biosynthesis of which from methionine and cysteine in newborns is reduced. Taurine (2-aminoethanesulfonic acid) for newborns is an indispensable AA. Taurine is involved in several important physiological processes, including regulation of calcium influx and neuronal excitability, detoxification, membrane stabilization, and regulation of osmotic pressure. Taurine is involved in the synthesis of bile acids. Taurine prevents or eliminates cholestasis and prevents the development of retinal degeneration (develops with taurine deficiency in children). The following drugs for parenteral nutrition of infants are best known: Aminoven Infant (Fresenius Kabi), Vaminolact (import to the Russian Federation was stopped in 2004). There is an opinion that glutamic acid (not to be confused with glutamine!) should not be added to RCA for children, since the increase in the content of sodium and water in glial cells caused by it is unfavorable in acute cerebral pathology. There are reports of the effectiveness of the introduction of glutamine in parenteral nutrition of newborns.

The concentration of amino acids in preparations usually ranges from 5 to 10%, with total parenteral nutrition, the dose of amino acids (dry matter!) Is 2-2.5 g / kg.

Energy sources. The drugs in this group include glucose and fat emulsions. The energy value of 1 g of glucose is 4 kcal. 1 g of fat is approximately 9-10 kcal. The best known fat emulsions are Intralipid (Fresenius Kabi), Lipofundin (B.Braun), Lipovenoz (Fresenius Kabi). The proportion of energy supplied by carbohydrates and fats can be different. The use of fat emulsions provides the body with polyunsaturated fatty acids, helps protect the vein wall from irritation by hyperosmolar solutions. Thus, the use of balanced PP should be considered preferable, however, in the absence of fat emulsions, it is possible to provide the child with the necessary energy only due to glucose. According to the classical schemes of PP, children receive 60-70% of non-protein energy supply due to glucose, 30-40% due to fat. With the introduction of fats in smaller proportions, protein retention in the body of newborns decreases.

IV. DOSAGES OF DRUGS FOR PP

When carrying out complete PN for newborns older than 7 days, the dose of amino acids should be 2-2.5 g / kg, fat - 2-4 g / kg glucose - 12-15 g / kg per day. At the same time, the energy supply will be up to 80-110 kcal/kg. It is necessary to come to the indicated dosages gradually, increasing the number of administered drugs in accordance with their tolerance, while observing the necessary proportion between plastic and energy substrates (see the algorithm for compiling PP programs).

The approximate daily energy requirement is:

V. ALGORITHM FOR PLANNING THE PROGRAM

1. Calculation of the total amount of fluid needed by the child per day

2. Decision on the issue of the use of drugs for infusion therapy for special purposes (drugs of volemic action, intravenous immunoglobulins, etc.) and their volume.

3. Calculation of the amount of concentrated solutions of electrolytes / vitamins / microelements needed by the child, based on the physiological daily requirement and the magnitude of the identified deficiency. The recommended dose of a complex of water-soluble vitamins for intravenous administration (Soluvit N, Fresenius Kabi) is 1 ml / kg (when diluted in 10 ml), the dose of a complex of fat-soluble vitamins (Vitalipid Children's, Fresenius Kabi) is 4 ml / kg per day.

4. Determining the volume of the amino acid solution, based on the following approximate calculation: - When prescribing a total liquid volume of 40-60 ml / kg - 0.6 g / kg of amino acids. - When prescribing a total liquid volume of 85-100 ml / kg - 1.5 g / kg of amino acids

When prescribing a total volume of liquid 125-150 ml / kg - 2-2.5 g / kg of amino acids.

5. Determination of the volume of fat emulsion. At the beginning of its use, its dose is 0.5 g / kg, then it increases to 2-2.5 g / kg

6. Determination of the volume of glucose solution. To do this, from the volume obtained in paragraph 1, subtract the volumes obtained in PP.2-5. On the first day of PP, a 10% glucose solution is prescribed, on the second day - 15%, from the third day - a 20% solution (under the control of blood glucose).

7. Checking and, if necessary, correcting the ratios between plastic and energy substrates. In case of insufficient energy supply in terms of 1 g of amino acids, the dose of glucose and / or fat should be increased, or the dose of amino acids should be reduced.

8. Distribute received volumes of preparations. The rate of their administration is calculated so that the total infusion time is up to 24 hours per day.

VI. EXAMPLES OF PR PROGRAMMING

Example 1. (Mixed PP)

A child weighing 3000 g, age 13 days, diagnosed with intrauterine infection (pneumonia, enterocolitis), was on a ventilator for 12 days, did not digest the injected milk, is currently fed through a tube with expressed breast milk 20 ml 8 times a day. 1.Total liquid volume 150ml/kg = 450ml. With food gets 20 x 8 = 160ml. With drinking gets 10 x 5 = 50 ml. Should receive 240 ml intravenously. 2. There are no plans to introduce special drugs. 3. 3 ml of 7.5% potassium chloride, 2 ml of 10% calcium gluconate. 4. Dose of amino acids - 2g/kg = 6g. He receives approximately 3 g with milk. The need for additional administration of amino acids is 3 g. When using the drug Aminoven Infant 6%, which contains 6 g of amino acids per 100 ml, its volume will be 50 ml. 5. It was decided to administer fat at 1g/kg (half the dose used in full PN), which would be 15ml with Lipovenoz 20% or Intralipid 20% (20g in 100ml). 6.Volume of liquid for glucose administration is 240-5-50-15= 170ml 7.Energy requirement is 100 kcal/kg = 300 kcal Receives 112 kcal with milk With fat emulsion - 30 kcal from the fact that 1 g of glucose provides 4 kcal). Requires the introduction of 20% glucose.

8.Destination:

Aminoven Infant 6% - 50.0

Glucose 20% - 170

KCl 7.5% - 3.0

Calcium gluconate 10% - 2.0 The preparations are administered in mixtures with each other, they should be evenly distributed throughout the day in portions, each of which does not exceed 50 ml.

Lipovenosis 20% - 15.0 is administered separately through a tee at a rate of about 0.6 ml / hour (for 24 hours)

The prospect of conducting parenteral nutrition in this child is a gradual, as the condition improves, an increase in the volume of enteral nutrition with a decrease in the volume of parenteral nutrition.

Example 2 (PP of an extremely low birth weight child).

A child weighing 800 g, 8 days of life, the main diagnosis: Hyaline membrane disease. Is on a ventilator, native mother's milk assimilates in a volume not exceeding 1 ml every 2 hours. 1.Total liquid volume 150ml/kg = 120ml. With nutrition gets 1 x 12 = 12ml. Should receive intravenously 120-12=108 ml. 2. Introduction of drugs for special purposes - it is planned to introduce pentaglobin at a dose of 5 x 0.8 = 4 ml. 3. Planned introduction of electrolytes: 1 ml of 7.5% potassium chloride, 2 ml of 10% calcium gluconate. The child receives sodium with saline to dilute drugs. It is planned to introduce Soluvit H 1ml x 0.8 = 0.8ml and Vitalipid Children's 4ml x 0.8 = 3ml 4. Dose of amino acids - 2.5g/kg = 2g. When using the drug Aminoven Infant 10%, which contains amino acids 10g per 100ml, its volume will be 20ml. 5. It was decided to administer fat at the rate of 2.5g/kg x 0.8 = 2g, which would be 10ml with Lipovenose/Intralipid 20% (20g in 100ml). 6. The volume of liquid for glucose administration is 108-4-1-2-0.8-3-20-10 = 67.2 × 68 ml 7. It was decided to inject 15% glucose, which will be 10.2 g. Calculation of energy supply: due to glucose 68 ml 15% \u003d 10.2 g x 4 kcal / g? 41kcal. Due to fat 2 g x 10 kcal = 20 kcal. Due to milk 12 ml x 0.7 kcal / ml \u003d 8.4 kcal. Total 41 + 20 + 8.4 = 69.4 kcal: 0.8 kg = 86.8 kcal / kg, which is a sufficient amount for this age. Checking energy supply per 1g of amino acids administered: 61 kcal (due to glucose and fat): 2g (amino acids) = 30.5 kcal / g, which is sufficient.

8.Destination:

Aminoven Infant 10% - 20.0

Glucose 15% - 68ml

KCl 7.5% -1.0

Calcium gluconate 10% -2.0

Soluvit H - 0.8 The preparations are administered in mixtures with each other, they should be evenly distributed for 23 hours. Within one hour, pentaglobin will be administered.

Lipovenosis 20% (or Intralipid) - 10.0

Vitalipid Children's 3ml Lipovenosis and Vitalipid Children's are administered separately from the main dropper through a tee at a rate of 0.5 ml/hour (? in 24 hours).

The most common problem with PN in extremely low birth weight children is hyperglycemia, which requires insulin administration. Therefore, when carrying out PP, one should carefully monitor the level of glucose in the blood and urine (determination of the qualitative method of glucose in each portion of urine reduces the amount of blood taken from a finger, which is very important for small children).

VII. POSSIBLE COMPLICATIONS OF PARENTERAL NUTRITION AND THEIR PREVENTION

Inadequate fluid dose selection followed by dehydration or fluid overload. Control: calculation of diuresis, weighing, determination of BCC. Necessary measures: correction of the dose of liquid, according to indications - the use of diuretics.
Hypo or hyperglycemia. Control: determination of blood and urine glucose. Necessary measures: correction of the concentration and rate of glucose administered, with severe hyperglycemia - insulin.
Increasing urea concentration. Necessary measures: eliminate the violation of the nitrogen-excreting function of the kidneys, increase the dose of energy supply, reduce the dose of amino acids.
Violation of the absorption of fats - plasma chileness, which is detected later than 1-2 hours after the cessation of their infusion. Control: visual determination of plasma transparency when determining hematocrit. Necessary measures: cancellation of the fat emulsion, the appointment of heparin in small doses (in the absence of contraindications).
An increase in the activity of alanine and asparagine transaminases, sometimes accompanied by a cholestasis clinic. Necessary measures: cancellation of fat emulsion, choleretic therapy.
Infectious complications associated with long standing catheter in the central vein. Necessary measures: the strictest observance of the rules of asepsis and antisepsis.

Although the PP method has been studied quite well by now, it can be used for a long time and give good results, it should not be forgotten that it is not physiological. Enteral nutrition should be introduced when the baby can absorb at least minimal amounts of milk. More even introduction of enteral nutrition, mainly native mother's milk, even if 1-3 ml is administered per feeding, without making a significant contribution to energy supply, improves the passage through the gastrointestinal tract, accelerates the process of switching to enteral nutrition by stimulating bile secretion, reduces the incidence of cholestasis.

Following the above methodological developments - allows you to successfully and effectively carry out PN, improving the outcomes of treatment of newborns.

List of Literature on the website of the journal Intensive Care Bulletin.

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Parenteral nutrition protocol in neonatal intensive care unit practice

Comments

Prutkin M. E. Regional Children's Clinical Hospital No. 1, Yekaterinburg

In the neonatological literature of recent years, much attention has been paid to the issues of nutritional support. Providing adequate nutrition to a critically ill newborn protects him from possible future complications and promotes adequate growth and development. The implementation of modern protocols for adequate nutrition in the neonatal intensive care unit contributes to improved nutrient intake, growth, reduction of the patient's stay in the hospital and, consequently, a decrease in the cost of patient care.

In this review, we would like to present the data of modern evidence-based studies and propose a strategy for nutritional support in the practice of the neonatal intensive care unit.

Physiological characteristics of the newborn and adaptation to independent nutrition. In utero, the fetus receives all the necessary nutrients through the placenta. Placental nutrient metabolism can be regarded as a balanced parenteral nutrition containing proteins, fats, carbohydrates, vitamins and trace elements. I would like to recall that during the 3rd trimester of pregnancy there is an unprecedented increase in fetal body weight. If the body weight of the fetus at 26 weeks of gestation is about 1000 g, then at 40 weeks of gestation (that is, after only 3 months), the newborn baby already weighs about 3000 g. Thus, over the last 14 weeks of pregnancy, the fetus triples its weight. It is during these 14 weeks that the main accumulation of nutrients by the fetus takes place, which it will need for subsequent adaptation to extrauterine life.

Table 2. Physiological features of the newborn

The process of absorption of fatty acids with a long chain is difficult due to insufficient activity of bile acids.

Stocks of nutrients. The more premature a newborn baby is born, the less nutritional supply it has. Immediately after birth and the crossing of the umbilical cord, the flow of nutrients to the fetus through the placental system stops, and a high nutrient requirement remains. It should also be remembered that due to the structural and functional immaturity of the digestive organs, the ability of premature newborns to self-enteral nutrition is limited (Table 2). Since the ideal model for the growth and development of a premature baby for us will be intrauterine growth and development of the fetus, our task is to provide our patient with the same balanced, complete and adequate nutrition as the one he received in utero.

Table 3 provides estimates of the energy needs of the growing preterm infant according to the American Academy of Pediatrics and the European Society of Gastroenterology and Nutrition.

Table 3

Features of the metabolism of nutrients in newborns

fluid and electrolytes. During the first week of life, a newborn baby undergoes significant changes in water and electrolyte metabolism, which reflect the process of its adaptation to the conditions of extrauterine life. The total amount of fluid in the body decreases and the fluid is redistributed between the intercellular and intracellular sectors (Fig. 2).

Rice. 2 Influence of age on fluid distribution between sectors

It is these redistributions that lead to the "physiological" loss in body weight, which develops in the first week of life. A great influence on water-electrolyte metabolism, especially in small premature newborns, can be exerted by the so-called. "imperceptible loss" of fluid. Correction of the dose of liquid is carried out on the basis of the rate of diuresis (2-5 ml / kg / h), the relative density of urine (1002 - 1010) and the dynamics of body weight.

Sodium is the main cation in the extracellular fluid. Approximately 80% of the sodium in the body is metabolically available. The sodium requirement is usually 3 mmol/kg/day. In small premature babies, due to the immaturity of the tubular system, there may be a significant loss of sodium. These losses may require compensation up to 7-8 mmol / kg / day.

Potassium is the main intracellular cation (approximately 75% of potassium is found in muscle cells). Plasma potassium concentration is determined by many factors (acid-base disorders, asphyxia, insulin therapy) and is not a reliable indicator of potassium reserves in the body. The usual requirement for potassium is 2 mmol/kg/day.

Chlorides are the main anions in the extracellular fluid. An overdose, as well as a deficiency of chlorides, can lead to a violation of the acid-base state. The need for chlorides is 2 - 6 mEq / kg / day.

Calcium - mainly localized in the bones. Approximately 60% of plasma calcium is associated with protein (albumin), therefore, even the measurement of biochemically active (ionized) calcium does not allow one to reliably judge the calcium reserves in the body. The need for calcium is usually 1-2 mEq/kg/day.

Magnesium - mainly (60%) is found in the bones. Most of the remaining magnesium is found intracellularly, so measurement of plasma magnesium does not provide an accurate estimate of magnesium stores in the body. However, this does not mean that plasma magnesium concentrations should not be monitored. Typically, the need for magnesium is 0.5 mEq / kg / day. Magnesium should be dated with caution in newborns whose mothers received magnesium sulfate therapy before delivery. For the treatment of persistent hypocalcemia, an increase in the dose of magnesium may be required.

During the entire gestation period, the fetus receives glucose from the mother through the placenta. The blood sugar level of the fetus is approximately 70% of that of the mother. Under conditions of maternal normoglycemia, the fetus practically does not synthesize glucose itself, despite the fact that gluconeogenesis enzymes are determined starting from the 3rd month of gestation. Thus, in the case of starvation of the mother, the fetus is able to synthesize glucose itself early enough from products such as ketone bodies.

Glycogen begins to be synthesized in the fetus from the 9th week of gestation. Interestingly, in the early stages of gestation, glycogen accumulation occurs mainly in the lungs and in the heart muscle, and then, during the third trimester of pregnancy, the main glycogen stores are formed in the liver and skeletal muscles, and disappear in the lungs. It was noted that the survival of a newborn after asphyxia directly depends on the content of glycogen in the myocardium. A decrease in glycogen content in the lungs begins at 34-36 weeks, which may be due to the consumption of this energy source for the synthesis of surfactant.

Factors such as maternal starvation, placental insufficiency, and multiple pregnancies can influence the rate of glycogen accumulation. Acute asphyxia does not affect the glycogen content in fetal tissues, while chronic hypoxia, such as in maternal preeclampsia, can lead to a deficiency in glycogen storage.

Insulin is the main anabolic hormone of the fetus throughout the gestational period. Insulin appears in the pancreatic tissue by 8-10 weeks of gestation and the level of its secretion in a full-term newborn corresponds to that of an adult. The fetal pancreas is less sensitive to hyperglycemia. It is noted that the increased content of amino acids makes the stimulation of insulin production more effective. Animal studies have shown that under conditions of hyperinsulinism, protein synthesis and the rate of glucose utilization are increased, while with insulin deficiency, the number of cells and the content of DNA in the cell decrease. These data explain the macrosomia of children from mothers with diabetes mellitus, who during the entire gestational period are in conditions of hyperglycemia and, consequently, hyperinsulinism. Glucagon is found in the fetus from the 15th week of gestation, but its role remains unexplored.

After childbirth and the cessation of glucose supply through the placenta, under the influence of a number of hormonal factors (glucagon, catecholamines), gluconeogenesis enzymes are activated, which usually lasts 2 weeks after birth, regardless of gestational age. Regardless of the route of administration (enteral or parenteral), 1/3 of glucose is utilized in the intestines and liver, up to 2/3 is distributed throughout the body. Most of the absorbed glucose is used for energy production

Studies have shown that, on average, the rate of production/utilization of glucose in a full-term newborn is 3.3–5.5 mg/kg/min. .

Maintaining blood glucose levels depends on the level of glycogenolysis and gluconeogenesis in the liver and the rate of its utilization in the periphery.

As mentioned above, during the third trimester of pregnancy, there is a significant growth and development of the child. Since the ideal model for the development of a child is the intrauterine development of a fetus of the appropriate gestational age, the need for protein in a premature baby and the rate of its accumulation can be estimated by observing the protein metabolism of the fetus.

If adequate protein supplementation does not occur after the birth of the baby and the cessation of the placental circulation, this can lead to a negative nitrogen balance and loss of protein. At the same time, several studies have shown that protein intake at a dose of 1 g/kg is able to neutralize the negative nitrogen balance, and increasing the dose of protein, even with a modest energy subsidy, can make the nitrogen balance positive (Table 6).

Table 6. Studies of nitrogen balance in newborns during the 1st week of life.

Protein accumulation in preterm infants is influenced by various factors.

Nutritional factors (number of amino acids in the nutrition program, protein/energy ratio, baseline nutritional status)
Physiological factors (compliance with gestational age, individual characteristics, etc.)
Endocrine factors (insulin-like growth factor, etc.)
Pathological factors (sepsis and other painful conditions).

Protein absorption in a healthy premature baby with a gestational age of 26-35 weeks of gestation is approximately 70%. The remaining 30% is oxidized and excreted. It should be noted that the lower the gestational age of the child, the greater the active protein metabolism in terms of a unit of body weight is observed in his body.

Since the synthesis of endogenous protein is an energy-dependent process, a certain ratio of protein and energy is required for the optimal accumulation of protein in the body of a premature baby. In conditions of energy deficiency, endogenous proteins are used as a source of energy and

Therefore, the nitrogen balance remains negative. Under conditions of suboptimal energy supply (50-90 kcal/kg/day), an increase in both protein and energy intake leads to protein accumulation in the body. Under conditions of sufficient energy supply (120 kcal / kg / day), protein accumulation stabilizes and a further increase in protein supplementation does not lead to its further accumulation. The ratio of 10 kcal/1 g of protein is considered optimal for growth and development. Some sources give a ratio of 1 protein calorie to 10 non-protein calories.

Amino acid deficiency, in addition to negative consequences for protein growth and accumulation, can lead to such adverse effects as a decrease in plasma insulin-like growth factor, impaired activity of cellular glucose transporters and, consequently, hyperglycemia, hyperkalemia, and cell energy deficiency. The exchange of amino acids in newborns has a number of features (Table 7).

Table 7. Features of amino acid metabolism in newborns

The above features determine the need to use special amino acid mixtures for parenteral nutrition of newborns, adapted to the metabolic characteristics of the newborn. The use of such preparations makes it possible to meet the needs of the newborn in amino acids and to avoid rather serious complications of parenteral nutrition.

The protein requirement of a premature newborn is 2.5-3 g/kg.

The latest data from Thureen PJ et all. show that even early administration of 3 g/kg/day of amino acids did not lead to toxic complications, but improved nitrogen balance.

An experiment on premature animals showed that a positive nitrogen balance and nitrogen accumulation in newborns with early use of amino acids is associated with increased synthesis of albumin and skeletal muscle protein.

Taking into account the above considerations, protein supplementation begins from the 2nd day of life, if the child's condition is stabilized by this point in time, or immediately after stabilization of the central hemodynamics and gas exchange, if this occurs later than the 2nd day of life. As a source of proteins during parenteral nutrition, solutions of crystalline amino acids (Aminoven-Infant, Trofamine) specially adapted for newborns are used. Unadapted amino acid preparations should not be used in neonates.

Lipids are a necessary substrate for the normal functioning of the body of a newborn child. The table shows that fats are not only a necessary and beneficial source of energy, but also a necessary substrate for the synthesis of cell membranes and essential biologically active substances such as prostaglandins, lecotriens, etc. Fatty acids contribute to the maturation of the retina and brain. In addition, it should be remembered that the main component of the surfactant are phospholipids.

The body of a full-term newborn baby contains from 16% to 18% white fat. In addition, there is a small amount of brown fat, which is necessary for the production of heat. The main accumulation of fat occurs during the last 12-14 weeks of gestation. Premature babies are born with a significant deficiency of fat. In addition, preterm infants cannot synthesize some essential fatty acids from available precursors. The required amounts of these essential fatty acids are found in breast milk and are not found in artificial formulas. There is some evidence that the addition of these fatty acids to preterm infant formula promotes retinal maturation, although no long-term benefit has been found. .

Recent studies indicate that the use of fats (Intralipid was used in the study) during parenteral nutrition contributes to the formation of gluconeogenesis in preterm infants.

Data have been published showing the feasibility of introducing into clinical practice and using fat emulsions based on olive oil in premature newborns. These emulsions contain less polyunsaturated fatty acids and more vitamin E. Moreover, vitamin E in such formulations is more available than in formulations based on soybean oil. This combination may be beneficial in oxidatively stressed neonates whose antioxidant defenses are weak.

Studies by Kao et al on the utilization of parenteral fats have shown that fat absorption is limited not by the daily dose (eg 1 g/kg/day) but by the rate of administration of the fat emulsion. It is not recommended to exceed the infusion rate of more than 0.4-0.8 g / kg / day. Some factors (stress, shock, surgery) can affect the ability to utilize fat. In this case, the rate of fat infusion is recommended to be reduced or stopped altogether. In addition, studies have shown that the use of 20% fat emulsions was associated with fewer metabolic complications than the use of 10% fat emulsions.

The rate of fat utilization will also depend on both the total energy expenditure of the newborn and the amount of glucose the infant is receiving. There is evidence that the use of glucose at a dose of more than 20 g / kg / day inhibits the utilization of fats.

Several studies have investigated the relationship between plasma free fatty acids and unconjugated bilirubin concentrations. None of them showed a positive correlation.

Data on the effect of fat emulsions on gas exchange and pulmonary vascular resistance remain controversial. Fat emulsions (Lipovenoz, Intralipid) we start using from 3-4 days of life, if we believe that by 7-10 days of life the child will not begin to absorb 70-80 kcal/kg enterally.

vitamins

The need for preterm infants in vitamins is presented in table 10.

Table 10. Newborn needs for water- and fat-soluble vitamins

The domestic pharmaceutical industry produces a fairly large range of vitamin preparations for parenteral administration. The use of these drugs during parenteral nutrition in newborns does not seem rational due to the incompatibility of most of these drugs with each other in solution and the difficulties in dosing, based on the needs shown in the table. The use of multivitamin preparations seems to be optimal. In the domestic market, water-soluble multivitamins for parenteral administration are represented by Soluvit, and fat-soluble ones by Vitalipid.

SOLUVIT N (SOLUVIT N) is added to the solution for parenteral nutrition at the rate of 1 ml/kg. It can also be added to fat emulsion. Provides the child with a daily requirement for all water-soluble vitamins.

Vitalipid N infant - A special preparation containing fat-soluble vitamins to meet the daily requirement for fat-soluble vitamins: A, D, E and K1. The drug is soluble only in fat emulsion. Available in ampoules of 10 ml

Indications for parenteral nutrition.

Parenteral nutrition should provide nutrient delivery when enteral nutrition is not possible (esophageal atresia, necrotizing ulcerative enterocolitis) or its volume is insufficient to cover the metabolic needs of the newborn child.

In conclusion, I would like to note that the method of parenteral nutrition described above has been successfully used in the neonatal intensive care unit of the Regional Children's Hospital in Yekaterinburg for about 10 years. A computer program has been developed to speed up and optimize calculations. The use of this algorithm made it possible to optimize the use of expensive drugs for parenteral nutrition, minimize the frequency of possible complications and optimize the use of blood products.

References: on the website vestvit.ru

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PROTOCOL OF INFUSION THERAPY IN NEWBORN

GOU VPO St. Petersburg State Pediatric Medical Academy of the Ministry of Health and Social Development of Russia

Mostovoy A.V., Prutkin M.E., Gorelik K.D., Karpova A.L.

PROTOCOL OF INFUSION THERAPY AND PARENTERAL

NUTRITION FOR NEWBORN

Reviewers:

Prof. Aleksandrovich Yu.S. Prof. Gordeev V.I.

St. Petersburg

A.V. Mostovoy1, 4, M.E. Prutkin2, K.D. Gorelik4, A.L. Karpova3.

1St. Petersburg State Pediatric Medical Academy,

2Regional Children's Hospital, Yekaterinburg

3Regional maternity hospital, Yaroslavl

4Children's City Hospital No. 1, St. Petersburg

The purpose of the protocol is to unify approaches to the organization of infusion therapy and parenteral nutrition for newborns with various perinatal pathologies who, for whatever reason, do not receive enteral nutrition in the proper amount in a given age period (the volume of actual enteral nutrition is less than 75% of the due).

The main task of organizing parenteral nutrition in a newborn child with severe perinatal pathology is to simulate (create a model) the intrauterine intake of nutrients.

The concept of early parenteral nutrition:

the main task is the subsidy of the required amount of amino acids

providing energy by introducing fats as soon as possible

the introduction of glucose, taking into account the characteristics of its intrauterine intake.

Some features of intrauterine intake of nutrients:

In utero, amino acids enter the fetus in the amount of 3.5 - 4.0 g / kg / day (more than he can absorb)

Excess amino acids in the fetus are oxidized and serve as a source of energy

The rate of glucose intake in the fetus is within 6 - 10 mg / kg / min.

Prerequisites for early parenteral nutrition:

amino acids and fat emulsions should be ingested from the first day of life (B)

protein loss is inversely related to gestational age

in newborns with extremely low body weight (ELBW), losses are 2 times higher than those in comparison with full-term newborns

in newborns with ELMT, the loss of protein from the total depot is 1-2% per day if they do not receive amino acids intravenously

delay in protein donation in the first week of life leads to an increase in protein deficiency up to 25% of the total content in the body of a premature baby with ELBW

administration of amino acids intravenously can maintain protein balance and improve protein absorption

early introduction of amino acids is safe and effective

early introduction of amino acids promotes better growth and development

maximum parenteral intake of amino acids should be between 2 and a maximum of 4 g/kg/day in preterm and term infants (B)

maximum lipid intake should not exceed 3–4 g/kg/day in preterm and term neonates (B)

fluid restriction with sodium chloride restriction may reduce the need for mechanical ventilation

_____________________

* A - high-quality meta-analyses or RCTs, as well as RCTs with sufficient strength, performed on a "target population" of patients.

B - meta-analyses or randomized controlled trials (RCTs) or high-quality case-controlstudies or low-grade RCTs, but with high sensitivity relative to the control group.

C - well collected cases or cohort studies with low risk of error.

D - evidence obtained from small studies, case reports, expert opinion.

Principles of organization of parenteral nutrition:

A complete understanding of the metabolic pathways of parenteral nutrition substrates is required.

The ability to correctly calculate the dose of drugs is necessary

It is necessary to provide adequate venous access (as a rule, a central venous catheter: umbilical, deep line, etc.; less often peripheral). The use of peripheral venous access is possible in 1-2 days of life in newborns with ENMT and VLBW, provided that the percentage of glucose in the basic infusion program (prepared parenteral nutrition solution) is less than 12.5%

Know the features of equipment and consumables used for infusion therapy and parenteral nutrition

It is necessary to know about possible complications, to be able to predict and prevent them.

ALGORITHM FOR CALCULATION OF INFUSION THERAPY AND PARENTERAL NUTRITION

I. Calculation of the total amount of fluid per day

III. Calculation of the required volume of electrolytes

IV. Fat emulsion volume calculation

V. Calculation of the dose of amino acids

VI. Calculation of the dose of glucose based on the rate of utilization VII. Determination of the volume attributable to glucose

VIII. Selection of the required volume of glucose of various concentrations IX. Infusion program, calculation of the infusion rate of solutions and

concentration of glucose in the infusion solution

X. Determination and calculation of the final daily number of calories.

I. Calculation of the total amount of liquid

a. Does the child have signs of arterial hypotension?

The main signs of arterial hypotension that you need to pay attention to: violation of peripheral perfusion of tissues (pale skin, turns pink when rubbed, a symptom of a "white spot" for more than 3 seconds, a decrease in the rate of diuresis), tachycardia, weak pulsation in the peripheral arteries, the presence of partially compensated metabolic acidosis

b. Does the child show signs of shock?

The main signs of shock: signs of respiratory failure (apnea, decreased saturation, swelling of the wings of the nose, tachypnea, retraction of compliant chest areas, bradypnea, increased work of breathing). Violation of peripheral perfusion of tissues (pale skin, turns pink when rubbed, a symptom of a "white spot" for more than 3 seconds, cold extremities). Disorders of central hemodynamics (tachycardia or bradycardia, low blood pressure), metabolic acidosis, decreased diuresis (during the first 6-12 hours less than 0.5 ml/kg/hour, at the age of more than 24 hours less than 1.0 ml/kg/hour) . Impaired consciousness (apnea, lethargy, decreased muscle tone, drowsiness, etc.).

2. If you answer yes to one of the questions, it is necessary to start therapy for arterial hypotension or shock, using the appropriate protocols, and only after stabilization of the condition, restoration of tissue perfusion and normalization of oxygenation, parenteral administration of nutrients can be started.

3. If you can firmly answer “No” to the questions, start the traditional calculation of parenteral nutrition using this protocol.

Table 1

Fluid requirements for incubated neonates (ml/kg/day)

Age, days			Body weight, g.

*- if the child is in an incubator, the need is reduced by 10-20%

**- for monovalent ions 1 mEq = 1 mmol

6. Table No. 3 presents the recommended values for the physiological need for fluid for newborns under the age of two weeks of life (the so-called stabilization phase). For premature babies, an increase in sodium excretion is important, against the background of the development of polyuria. Also during this period, it is important to expand the volume of enteral nutrition, so this age requires special attention from the doctor when calculating the total volume of fluid and nutrients.

CLINICAL EXAMPLE:

Child 3 days of life, weight - 1200 g at birth Due volume of infusion per day = Daily fluid requirement (ADS) × body weight (kg)

Lifespan = 100 ml/kg Due infusion per day = 120 ml × 1.2 = 120 ml

Answer: total fluid volume (infusion therapy + parenteral nutrition

Enteral nutrition) = 120 ml per day

II.Calculation of enteral nutrition

Table No. 4 presents data on the energy value, composition and osmolarity of some milk mixtures in comparison with the average composition of female breast milk. These data are necessary for accurate calculation of nutrients for newborns with mixed enteral and parenteral nutrition.

		Table 4
Composition of female breast milk and milk formulas
Milk/mixture	Carbohydrates	Osmolarity

Breast milk is mature
(term delivery)




Nutrilon

Enfamil Premium 1

Breast milk
(premature birth)




Nutrilon Pepti TSC

Pre-Nutrilon

Similac Neo Sure

Similac Special Care

Frisopre

Pregestimil

Enfamil Premature

Energy requirements of newborns:

Table 5

Energy needs of newborns in the early neonatal period

		Kcal/kg/day

Physical activity (+30% of the requirement for the main exchange)
	Heat loss (thermoregulation)
Specific dynamic action of food

	Loss with stool (10% of incoming)
Growth (energy reserves)
	General costs
	Energy requirements for basal metabolism (at rest) are 49 - 60
	kcal/kg/day from 8 to 63 days of age (Sinclair, 1978)
	For a premature baby on full enteral
feeding, the calculation of incoming energy will be different (table No. 6)
			Table 6
	Total energy requirement against the background of weight gain at 10 - 15 g / day *
	Energy costs per day	Kcal/kg/day
	Energy expenditure at rest (basal metabolic rate)
Minimum physical activity
	Possible cold stress
Losses with stool (10 - 15% of incoming energy)
	Height (4.5 kcal/gram)
General Needs
*According to N Ambalavanan, 2010

The need for energy in children of the early neonatal period is unevenly distributed. Table No. 7 shows the approximate number of calories depending on the age of the child:

In the first week of life, the optimal energy supply should be in the range of 50-90 kcal / kg / day. Sufficient energy supply by day 7 of life in term newborns should be -120 kcal/kg/day. When parenteral nutrition is given to preterm infants, the energy requirement is less due to no stool losses, no episodes of heat or cold stress, and less physical activity. Thus, the general energy

requirements for parenteral nutrition can be approximately 80 -

100 kcal/kg/day.

Calorie method for calculating nutrition for preterm infants

CLINICAL EXAMPLE:

Patient's body weight - 1.2 kg Age - 3 days of life Milk formula - Pre-Nutrilon

* where 8 is the number of feedings per day

Minimum trophic nutrition (MTP). The minimum trophic nutrition is defined as the amount of nutrition received by the child enterally in an amount of ≤ 20 ml / kg / day. Advantages of MTP:

Accelerates the maturation of motor and other functions of the gastrointestinal tract (GIT)

Improves enteral nutrition tolerance

Accelerates the time to achieve full enteral nutrition

Does not increase (according to some reports reduces) the incidence of NEC

Reduces the duration of hospitalization.

The child assimilates the Pre-Nutrilon mixture, 1.5 ml every 3 hours

Enteral Actual Daily Feeding (ml) = Single Feeding Volume (ml) x Number of Feeds

Enteral feeding volume per day = 1.5 ml x 8 feedings = 12 ml/day

Calculation of the amount of nutrients and calories that the child will receive per day enterally:

Carbohydrate enteral = 12 ml x 8.2 / 100 = 0.98 g Protein enteral = 12 ml x 2.2 / 100 = 0.26 g Fat enteral = 12 ml x 4.4 / 100 = 0.53 g

Enteral calories = 12 ml x 80/100 = 9.6 kcal

III. Calculation of the required volume of electrolytes

It is advisable to start the introduction of sodium and potassium no earlier than the third day of life, calcium

- from the first days of life.

1. CALCULATION OF SODIUM DOSE

Sodium requirement is 2 mmol/kg/day

Hyponatremia 150 mmol/l, dangerous > 155 mmol/l

1 mmol (mEq) of sodium is contained in 0.58 ml of 10% NaCl

1 mmol (mEq) of sodium is contained in 6.7 ml of 0.9% NaCl

1 ml of 0.9% (physiological) sodium chloride solution contains 0.15 mmol Na

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, sodium requirement - 1.0 mmol / kg / day

V saline = 1.2 × 1.0 / 0.15 = 8.0 ml

CORRECTION OF HYPONATREMIA (Na

Volume of 10% NaCl (ml) = (135 - Patient's Na) × body m × 0.175

2. CALCULATION OF THE DOSE OF POTASSIUM

The need for potassium is 2 - 3 mmol / kg / day

Hypokalemia

Hyperkalemia > 6.0 mmol/L (in the absence of hemolysis), dangerous > 6.5 mmol/L (or if there are pathological changes on the ECG)

1 mmol (mEq) of potassium is contained in 1 ml of 7.5% KCl

1 mmol (mEq) of potassium is contained in 1.8 ml of 4% KCl

V (ml 4% KCl) = K+ requirement (mmol) × mbody × 2

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, potassium requirement - 1.0 mmol / kg / day

V 4% KCl (ml) = 1.0 x 1.2 x 2.0 = 2.4 ml

* Effect of pH on K+: 0.1 pH changes → change9 K+ by 0.3-0.6 mmol/L (High acid, more K+; Low acid, less K+)

III. CALCULATION OF THE DOSE OF CALCIUM

The need for Ca ++ in newborns is 1-2 mmol / kg / day

hypocalcemia

Hypercalcemia > 1.25 mmol/l (ionized Ca++)

1 ml of 10% calcium chloride contains 0.9 mmol Ca++

1 ml of 10% calcium gluconate contains 0.3 mmol Ca++

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, calcium requirement - 1.0 mmol / kg / day

V 10% CaCl2 (ml) = 1 x 1.2 x 1.1*=1.3 ml

*- calculation coefficient for 10% calcium chloride is 1.1, for 10% calcium gluconate - 3.3

4. CALCULATION OF THE DOSE OF MAGNESIUM:

The need for magnesium is 0.5 mmol / kg / day

Hypomagnesemia 1.5 mmol/l

1 ml of 25% magnesium sulfate contains 2 mmol of magnesium

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, magnesium requirement - 0.5 mmol / kg / day

V 25% MgSO4 (ml)= 0.5 x 1.2/ 2= 0.3 ml

«2014 PARENTERAL NUTRITION OF NEWBORN METHODOLOGICAL RECOMMENDATIONS Moscow PARENTERAL NUTRITION OF NEWBORN Methodical...»

PARENTERAL NUTRITION

NEWBORN

under the editorship of Academician of the Russian Academy of Sciences N.N. Volodina Prepared by: The Russian Association of Perinatal Medicine Specialists together with the Association of Neonatologists Approved by: The Union of Pediatricians of Russia Prutkin Mark Evgenievich

Chubarova Antonina Igorevna Kryuchko Daria Sergeevna Babak Olga Alekseevna Balashova Ekaterina Nikolaevna Grosheva Elena Vladimirovna Zhirkova Yulia Viktorovna Ionov Oleg Vadimovich Lenyushkina Anna Alekseevna Kitrbaya Anna Revazievna Kucherov Yury Ivanovich Monakhova Oksana Anatolyevna Remizov Mikhail Valerievich Ryumina Irina Ivanovna Terlyakova Olga Yuryevna Mikhail Konstantinovich Shtatnov

Department of Hospital Pediatrics No. 1 of the Russian National Research Medical University. N. I. Pirogov;

State Budgetary Healthcare Institution "City Hospital No. 8" of the Moscow Department of Health;

GGBUZ SO CSTO No. 1 in Yekaterinburg;

OFGBU NTsAGP them. Academician V.I. Kulakov;

Department of Pediatric Surgery, Russian National Research Medical University. N.I. Pirogov;

FFNKTs DGOI them. Dmitry Rogachev;

GGBUZ "Tushino Children's City Hospital" of the Department of Health of Moscow;

Russian Medical Academy of Postgraduate Education.

1. Liquid

2. Energy

5. Carbohydrates

6. Need for electrolytes and trace elements

6.2. Sodium

6.3. calcium and phosphorus

6.4. Magnesium

7. Vitamins

8. Monitoring during the PP

9. Complications of parenteral nutrition

10. Procedure for calculating PP in premature babies

10.1. Liquid

10.2. Protein

10.4. electrolytes

10.5. vitamins

10.6. Carbohydrates

11. Control of the obtained glucose concentration in the combined solution

12. Calorie control

13. Drawing up an infusion therapy sheet

14. Calculation of the infusion rate

15. Venous access during parenteral nutrition

16. Technology for the preparation and administration of solutions for PP

17. Maintaining enteral nutrition. Features of calculating partial PP

18. Termination of parenteral nutrition Appendix with tables Extensive population studies of recent years INTRODUCTION prove that the health of the population in different age periods significantly depends on the nutritional security and growth rate of this generation in the prenatal and early postnatal periods. The risk of developing such common diseases as hypertension, obesity, type 2 diabetes, osteoporosis, increases in the presence of nutritional deficiency in the perinatal period.

Intellectual and mental health are also dependent on the state of nutrition during this period of an individual's development.

Balanced and properly organized nutrition is one of the most important components of nursing premature babies, which determine not only the immediate, but also the long-term prognosis.

To unify approaches to parenteral nutrition, but these recommendations are intended to:

born children in specialized medical institutions;

Provide an understanding of the need for a differentiated approach to parenteral nutrition, depending on gestational age and post-conceptual age;

Minimize the number of complications during parenteral nutrition.

Parenteral (from the Greek para - around and enteron - intestine) nutrition is a type of nutritional support in which nutrients are introduced into the body, bypassing the gastrointestinal tract.

Parenteral nutrition (full or partial) is indicated

Indications for parenteral nutrition:

newborns if enteral nutrition is not possible or insufficient (does not cover 90% of nutrient requirements).

Parenteral nutrition is not carried out against the background of reanimation Contraindications to parenteral nutrition:

interventional measures and begins immediately after stabilization of the condition against the background of the selected therapy. Surgery, mechanical ventilation and the need for inotropic support will not be a contraindication to parenteral nutrition.

– – –

Nomu is an extremely important parameter when prescribing parenteral nutrition. Features of fluid homeostasis are determined by the redistribution between the intercellular space and the vascular bed, which occur in the first few days of life, as well as possible losses through immature skin in children with extremely low body weight.

The need for water with nutritional goals is determined

1. Ensuring urine excretion for elimination is produced by the need:

2. Compensation for imperceptible water losses (with evaporation from the skin and during breathing, losses with sweat in newborns are practically absent),

3. Additional amount to ensure the formation of new tissues: weight gain of 15-20 g/kg/day will require 10 to 12 ml/kg/day of water (0.75 ml/g of new tissue).

In addition to providing nutrition, fluid may also be required to replenish the BCC in the presence of arterial hypotension or shock.

The period of stable weight gain: usually begins after 7-10 days of life. When prescribing nutritional support, the tasks of ensuring physical development come first. A healthy full-term baby gains an average of 7-8 g/kg/day (up to a maximum of 14 g/kg/day). The growth rate of a premature baby should correspond to the growth rate of the fetus in utero - from 21 g / kg in children with ENMT to 14 g / kg in children weighing 1800 g or more. Kidney function is still reduced during this period, so additional amounts of fluid are required to administer sufficient amounts of nutrients for growth (high-osmolar foods cannot be administered as nutrition). Plasma sodium concentration remains constant when sodium is supplied from outside in the amount of 1.1-3.0 mmol/kg/day. The growth rate does not significantly depend on the intake of sodium when providing liquid in the amount of 140-170 ml/kg/day.

The volume of liquid in the composition of parenteral nutrition Fluid balance is calculated taking into account:

Volume of enteral nutrition (enteral nutrition of up to 25 ml/kg is not taken into account when calculating the required fluid and nutrients) Diuresis Changes in body weight Sodium levels Sodium levels should be maintained at 135 An increase in sodium levels indicates dehydration. In this 145 mmol / l.

situation should increase the volume of fluid, not excluding sodium preparations. Decreased sodium levels are most often an indication of overhydration.

Children with ENMT are characterized by the syndrome of "late hyponatremia", associated with impaired renal function and increased sodium intake against the background of accelerated growth.

Table 1.

Estimated fluid requirements for newborns

– – –

750 90-110 110-150 120-150 130-190 750-999 90-100 110-120 120-140 140-190 1000-1499 80-100 100-120 120-130 140-180 1500-2500 70-80 80-110 100-130 110-160 2500 60-70 70-80 90-100 110-160

– – –

As soon as possible (1-3 days of life), ensure the supply of energy equal to the exchange of rest - 45-60 kcal / kg.

Increase parenteral nutrition daily by 10-15 kcal/kg to reach 105 kcal/kg by 7-10 days of age.

With partial parenteral nutrition, increase the total energy intake at the same pace in order to achieve a calorie content of 120 kcal / kg by 7-10 days of life.

Stop parenteral nutrition only when the calorie content of enteral nutrition reaches at least 100 kcal/kg.

After the abolition of parenteral nutrition, continue monitoring anthropometric indicators, make nutritional adjustments.

If it is impossible to achieve optimal physical development with exclusively enteral nutrition, continue parenteral nutrition.

Fats are more energy intensive than carbohydrates.

Proteins in premature babies can also be partly used by the body for energy. Excess non-protein calories, regardless of source, are used for fat synthesis.

Modern studies show that proteins are not only an important source of plastic material for the synthesis of new proteins, but also an energy substrate, especially in children with extremely low and very low body weight. About 30% of incoming amino acids can be used for energy synthesis purposes. The priority task is to ensure the synthesis of new proteins in the child's body. With insufficient provision of non-protein calories (carbohydrates, fats), the proportion of protein used for energy synthesis increases, and a smaller proportion is used for plastic purposes, which is undesirable. Amino acid supplementation at a dose of 3 g/kg/day during the first 24 hours after birth in children with VLBW and ELBW is safe and associated with better weight gain.

REMEMBER THAT METABOLIC ACIDOSIS

IN MOST CASES IT IS NOT AN INDEPENDENT DISEASE, BUT A MANIFESTATION

OTHER DISEASE

The need for protein is determined based on the amount of protein (1) required for protein synthesis and resynthesis in the body (storage protein), (2) used for oxidation as an energy source, (3) the amount of excreted protein.

The optimal amount of protein or amino acids in the diet is determined by the gestational age of the baby, as body composition changes as the fetus grows.

In the least ripe fruits, the rate of protein synthesis is normally higher than in more mature ones; protein occupies a large proportion in newly synthesized tissues. Therefore, the lower the gestational age, the greater the need for protein, a smooth change in the ratio of protein and non-protein calories in the diet from 4 or more g / 100 kcal in the least mature preterm infants to

2.5 g / 100 kcal in more mature ones allows us to model the composition of body weight characteristic of a healthy fetus.

Starting doses, rate of increase and target level of dota Administration tactics:

protein rations depending on gestational age are indicated in Table No. 1 of the Appendix. The introduction of amino acids from the first hours of a child's life is mandatory for newborns with very low and extremely low body weight.

In children with a birth weight of less than 1500 g, parenteral protein dosing should remain unchanged until an enteral feeding volume of 50 ml/kg/day is reached.

1.2 grams of amino acids from parenteral nutrition solutions is equivalent to approximately 1 gram of protein. For routine calculation, it is customary to round this value up to 1 g.

Amino acid supplementation can be carried out both through a peripheral vein and through a central venous catheter. To date, no effective tests have been developed that control the safety and efficacy of allowing to control the sufficiency and safety of parenteral protein administration. It is optimal to use the indicator of nitrogen balance for this purpose, however, in practical medicine, urea is used for an integral assessment of the state of protein metabolism. Control should be carried out from the 2nd week of life with a frequency of 1 time in 7-10 days. At the same time, a low level of urea (less than 1.8 mmol / l) will indicate an insufficient supply of protein. An increase in the level of urea cannot be unambiguously interpreted as a marker of excessive protein load. Urea can also increase due to renal failure (then the level of creatinine will also increase) and be a marker of increased protein catabolism with a lack of energy substrates or the protein itself.

– – –

Fatty acids are essential for the maturation of the brain and retina;

Phospholipids are a component of cell membranes and surfactant;

Prostaglandins, leukotrienes and other mediators are fatty acid metabolites.

Starting doses, rate of increase and target level of dot Fat requirements for fat according to gestational age are indicated If necessary to limit fat intake, Table No. 1 of the Appendix.

the dose should not be reduced below 0.5-1.0 g / kg / day. it is this dose that prevents the deficiency of essential fatty acids.

One gram of fat contains 10 kilocalories.

The smallest number of complications is caused by the use of Tactics of appointment:

20% fat emulsion. Fat emulsions approved for use in neonatology are shown in Table 3;

Fat emulsion infusion should be carried out evenly at a constant rate throughout the day;

The dosing of fat emulsions should preferably be through a peripheral vein;

If the fat emulsion is infused into the general venous access, the infusion lines should be connected as close as possible to the catheter connector, and a fat emulsion filter should be used;

The systems through which the fat emulsion is infused and the syringe with the emulsion must be protected from light;

Do not add heparin solution to fat emulsion.

Monitoring the safety and effectiveness of the grant

Controlling the safety of the administered amount of fats

is based on the control of the concentration of triglycerides in the blood plasma one day after changing the rate of administration. If it is impossible to control the level of triglycerides, a serum "transparency" test should be performed. At the same time, 2-4 hours before the analysis, it is necessary to suspend the introduction of fat emulsions.

If the level of triglycerides is higher than acceptable, the subsidy of the fat emulsion should be reduced by 0.5 g/kg/day.

Some drugs (such as amphotericin and steroids) lead to elevated triglyceride levels.

Side effects and complications of intravenous lipid administration, including hyperglycemia, occur more frequently at infusion rates greater than 0.15 g lipid per kg/h.

Table 3

Limitations for the introduction of fat emulsions

– – –

component of parenteral nutrition, regardless of gestational age and birth weight.

One gram of glucose contains 3.4 Calories In adults, endogenous glucose production begins at levels of glucose intake below 3.2 mg / kg / min, in full-term newborns - below 5.5 mg / kg / min (7.2 g / kg / day), in premature newborns - at any glucose intake rate less than 7.5-8 mg/kg/min (44 mmol/kg/min or

11.5 g/kg/day). Basic production of glucose without exogenous administration is approximately equal in full-term and preterm infants and is 3.0 - 5.5 mg / kg / min 3-6 hours after feeding. In full-term infants, basic glucose production covers 60-100% of needs, while in preterm infants it covers only 40-70%. This means that without exogenous administration, premature infants will rapidly deplete glycogen stores, which are small, and break down their own proteins and fat. Therefore, the minimum necessary is the rate of entry, which allows minimizing endogenous production.

Calculate the carbohydrate requirement of a newborn - Carbohydrate requirement

based on calorie requirement and glucose utilization rate (see Appendix Table 1). If the carbohydrate load is tolerable (blood glucose level is not more than 8 mmol / l), the carbohydrate load should be increased daily by 0.5 - 1 mg / kg / min, but not more than 12 mg / kg / min.

IT IS NECESSARY TO REMEMBER THAT HYPERGLYCEMIA MORE

TOTAL IS A SYMPTOM OF ANOTHER DISEASE THAT SHOULD BE EXCLUDED.

REMEMBER THAT HYPOGLYCEMIA IS DANGEROUS

FOR LIFE CONDITION THAT CAN LEAD TO DISABILITY

6. REQUIREMENTS FOR ELECTROLYTES AND MICRONUTRIENTS

– – –

Its main biological role is to provide neuromuscular transmission of impulses. The initial indicators of potassium subsidies, the rate of increase, are indicated in Table No. 3 of the Appendix.

The appointment of potassium to children with ENMT is possible after the concentration in the blood serum does not exceed 4.5 mmol / l (from the moment an adequate diuresis is established for 3-4

-th day of life). The average daily requirement for potassium in children with ELMT increases with age and reaches 3-4 mmol/kg by the beginning of the 2nd week of life.

The criterion for hyperkalemia in the early neonatal period is an increase in the concentration of potassium in the blood of more than 6.5 mmol/l, and after 7 days of life - more than 5.5 mmol/l. Hyperkalemia is a serious problem in newborns with ELBW, occurring even with adequate kidney function and a normal supply of potassium (neoliguric hyperkalemia).

A rapid increase in serum potassium during the first day of life is characteristic of extremely immature children.

The cause of this condition may be hyperaldesteronism, immaturity of the distal renal tubules, metabolic acidosis.

Sodium is the main cation of the extracellular fluid sodium, the content of which determines the osmolarity of the latter. The initial indicators of sodium subsidies, the rate of increase, are indicated in Table No. 3 of the Appendix. Planned administration of sodium begins from 3-4 days of life or from an earlier age with a decrease in the serum sodium content of less than 140 mmol / l. The need for sodium in newborns is 3-5 mmol / kg per day.

Children with ELMT often develop a syndrome of "late hyponatremia" due to impaired renal function and increased sodium intake against the background of accelerated growth.

Hypernatremia - an increase in the concentration of sodium in the blood more than 145 mmol / l. Hypernatremia develops in children with ENMT in the first 3 days of life due to large fluid losses and indicates dehydration. It is necessary to increase the volume of fluid, not excluding sodium preparations. A more rare cause of hypernatremia is excessive intravenous intake of sodium bicarbonate or other sodium-containing drugs.

The calcium ion takes part in various biochemical calcium and phosphorus processes in the body. It provides neuromuscular transmission, takes part in muscle contraction, provides blood coagulation, plays an important role in the formation of bone tissue. A constant level of calcium in the blood serum is maintained by parathyroid hormones and calcitonin. With insufficient subsidies of phosphorus, it is delayed by the kidneys and, as a result, the disappearance of phosphorus in the urine. The lack of phosphorus leads to the development of hypercalcemia and hypercalciuria, and in the future, to bone demineralization and the development of osteopenia of prematurity.

The initial indicators of calcium supplementation, the rate of increase, are indicated in Table No. 3 of the Appendix.

Signs of calcium deficiency in newborns: convulsions, decreased bone density, development of rickets, osteoporosis, itetania.

Signs of phosphorus deficiency in newborns: decreased bone density, rickets, fractures, bone pain, heart failure.

Signs of hypocalcemia in a newborn: often asymptomatic, respiratory failure (tachypnea, apnea), neurological symptoms (syndrome of increased neuro-reflex excitability, convulsions).

Serum concentration is 0.7-1.1 mmol/l. However, true magnesium deficiency is not always diagnosed, as only about 0.3% of the total magnesium in the body is found in the blood serum. The physiological significance of magnesium is great: magnesium controls energy-dependent processes (ATP), participates in the synthesis of proteins, nucleic acids, fats, surfactant phospholipids and cell membranes, participates in calcium homeostasis and vitamin D metabolism, is a regulator of ion channels and, accordingly, cellular functions (CNS, heart , muscle tissue, liver, etc.). Magnesium is essential for maintaining potassium and calcium levels in the blood.

The introduction of magnesium is carefully monitored and possibly canceled in cholestasis, since magnesium is one of the elements that is metabolized by the liver.

In case of symptomatic hypomagnesemia: magnesium sulfate based on magnesium 0.1-0.2 mmol / kg IV for 2-4 hours (if necessary, can be repeated after 8-12 hours). A solution of magnesium sulfate 25% is diluted at least 1:5 before administration. During the introduction control heart rate, blood pressure.

Maintenance dose: 0.15-0.25 mmol/kg/day IV for 24 hours.

Zinc is involved in the metabolism of energy, macronutrients and nuZinc cleic acids. The rapid growth rate of severely preterm infants results in a higher zinc requirement than full-term infants. Very preterm infants and children with high zinc losses due to diarrhea, the presence of a stoma, severe skin diseases require the inclusion of zinc sulfate in parenteral nutrition.

Selenium is an antioxidant and active ingredient

6.6 Selenium glutathione peroxidase, an enzyme that protects tissues from damage by reactive oxygen species. Low selenium levels are often found in premature babies, which contributes to the development of BPD, retinopathy of prematurity in this category of children.

The need for selenium in premature babies: 1-3 mg / kg / day (relevant for very long-term parenteral nutrition for several months).

Currently, phosphorus, zinc, and selenium preparations for parenteral administration are not registered in Russia, which makes it impossible to use them in newborns in the ICU.

fat soluble vitamins. Vitalipid N for children - isVITAMINS is used in newborns to provide the daily requirement for fat-soluble vitamins A, D2, E, K1. Need: 4 ml/kg/day. Vitalipid N for children is added to the fat emulsion. The resulting solution is stirred by gentle rocking, then used for parenteral infusion. It is prescribed depending on gestational age and body weight, simultaneously with the appointment of a fat emulsion.

8. MONITORING

PARENTERAL NUTRITION

Simultaneously with the start of parenteral nutrition The concentration of glucose in the blood;

do a general blood test and determine:

During parenteral nutrition, it is necessary to change the dynamics of body weight every day;

daily determine:

The concentration of glucose in the urine;

The concentration of electrolytes (K, Na, Ca);

The concentration of glucose in the blood (with an increase in the rate of glucose utilization - 2 times a day);

For long-term parenteral use weekly, the concentration of glucose in the blood;

take a complete blood count and determine electrolytes (K, Na, Ca);

Plasma creatinine and urea levels.

9. COMPLICATIONS OF PARENTERAL NUTRITION

Parenteral nutrition is one of the main infectious complications of risk factors for nosocomial infection, along with central vein catheterization and mechanical ventilation. The conducted meta-analysis showed no significant differences in the frequency of infectious complications when using central and peripheral vascular catheters.

Extravasation of the solution and the occurrence of infiltrates, which may be the cause. formation of cosmetic or functional defects. Most often, this complication develops against the background of standing peripheral venous catheters.

Pleural/pericardial effusion (1.8/1000 deep lines, lethality was 0.7/1000 lines).

Cholestasis occurs in 10-12% of children receiving long-term parenteral nutrition. Proven effective ways to prevent cholestasis are the earliest possible start of enteral nutrition and the use of fat emulsion preparations with the addition of fish oil (SMOF - lipid).

Hypoglycemia/hyperglycemia Electrolyte disorders Phlebitis Osteopenia Algorithm for calculating the parenteral program This scheme is approximate and takes into account nutrition to the situation with successful absorption of enteral nutrition.

10. PROCEDURE FOR CALCULATION OF PARENTERAL NUTRITION

– – –

2. Calculation of the volume of parenteral nutrition (taking into account the volume of enteral nutrition).

3. Calculation of the daily volume of the protein solution.

4. Calculation of the daily volume of fat emulsion.

5. Calculation of the daily volume of electrolytes.

6. Calculation of the daily volume of vitamins.

7. Calculation of the daily volume of carbohydrates.

8. Calculation of the volume of injected fluid per glucose.

9. Selection of volumes of glucose solutions.

10. Drawing up a list of infusion therapy.

11. Calculation of the rate of introduction of solutions.

10.1. Fluid: multiply the child's weight in kilograms by the estimated amount of fluid per kg. body weight (see table). If there are indications for increasing or decreasing fluid intake, the dose is adjusted individually.

This volume includes all fluids administered to the child:

parenteral nutrition, enteral nutrition, liquid as part of parenteral antibiotics. The minimum trophic nutrition (less than 25 ml / kg / day), which is mandatory on the first day of life, is not taken into account in the total volume of fluid.

– – –

With the volume of enteral nutrition exceeding the trophic:

Daily fluid dose (ml/day) - volume of enteral nutrition (ml/day) = daily volume of parenteral nutrition.

10.2. Protein: multiply the child's weight in kilograms by the estimated dose of parenteral protein per kg. body weight (see Table) taking into account the administered enteral protein (with the amount of enteral nutrition exceeding the trophic one)

– – –

When calculating partial parenteral nutrition - in the daily volume of enteral nutrition, the dose of protein in grams is calculated, and the result is subtracted from the daily dose of protein.

10.3. Fats: multiply the child's weight (kg.) By the estimated dose of fat per kg. body weight (see Table) taking into account the administered enteral protein (with the amount of enteral nutrition exceeding the trophic one)

– – –

When calculating partial parenteral nutrition - in the daily volume of enteral nutrition, the dose of fat in grams is calculated, and the result is subtracted from the daily dose of fat.

10.4. Electrolyte: calculation of the sodium dose when using saline:

– – –

The preparation of water-soluble vitamins - Soluvit N detVitamins:

sky - 1 ml / kg / day. Dissolve by adding to one of the solutions:

Vitalipid N for children, Intralipid 20%, SMOFlipid 20%;

water for injections; glucose solution (5, 10 or 20%).

– – –

The preparation of fat-soluble vitamins - Vitalipid N for children - is added only to the fat emulsion solution for parenteral nutrition at the rate of 4 ml / kg.

– – –

1. Calculate the number of grams of glucose per day: multiplying Carbohydrates:

We eat the weight of the child in kilograms by the estimated dose of the glucose utilization rate (see Table) and multiply by a factor of 1.44.

Carbohydrate injection rate (mg/kg/min) x m (kg) x 1.44 = glucose dose (g/day).

2. When calculating partial parenteral nutrition - in the daily volume of enteral nutrition, the dose of carbohydrates in grams is calculated and subtracted from the daily dose of carbohydrates.

3. Calculation of the volume of administered liquid attributable to glucose: from the daily dose of liquid (ml / day), subtract the volume of enteral nutrition, the daily volume of protein, fats, electrolytes, liquid in the composition of parenterally administered antibiotics.

Daily volume of parenteral nutrition (ml) - Daily volume of protein (ml) - Daily volume of fat emulsion (ml) - Daily volume of electrolytes (ml)

The volume of liquid in the composition of parenterally administered antibiotics, inotropic drugs, etc. - the volume of vitamin solutions (ml) = the volume of glucose solution (ml).

4. Selection of volumes of glucose solutions:

When making a solution outside the pharmacy from standard - 5%, 10% and 40% glucose, there are 2 calculation options:

1. Calculate how much 40% glucose is contained

First option:

set amount of dry glucose - g / day: dose of glucose (g / day) x10 \u003d glucose 40% ml

2. Calculate the amount of water to be added:

Volume of liquid per glucose - volume of 40% glucose = volume of water (ml)

1. Calculate the volume of glucose solution with a larger con Second option:

– – –

where C1 is a lower concentration (for example, 10), C2 is a large one (for example, 40)

2. Calculate the volume of a solution of lower concentration Volume of glucose solutions (ml) - volume of glucose in concentration C2 = volume of glucose in concentration C1

11. CONTROL OF THE OBTAINED GLUCOSE CONCENTRATION IN

Daily dose of glucose (g) x 100 / total volume of the UNCOMBINED SOLUTION of the solution (ml) = concentration of glucose in the solution (%);

1. Calculation of caloric content of enteral nutrition

12. CALORIE CONTROL

2. Calculation of calorie content of parenteral nutrition:

Dose of lipids g/day x 9 + dose of glucose g/day x 4 = calorie content of parenteral nutrition kcal/day;

Amino acids do not count as a source of calories, although they can be used in energy metabolism.

3. The value of the total calorie intake:

Enteral nutrition calories (kcal/day) + PN calories (kcal/day)/body weight (kg).

13. DEVELOPING THE LIST OF INFUSION THERAPY

Intravenous drip:

Add volumes of infusion solutions to the sheet:

40% glucose - ... ml Dist. water - ... ml Or 10% glucose - ... ml 40% glucose - ... ml 10% protein preparation - ... ml 0.9% (or 10%) sodium chloride solution - ... ml 4% potassium chloride solution - ... ml 25% solution magnesium sulfate - ... ml 10% calcium gluconate preparation - ... ml Heparin - ... ml

In/venous drip:

20% fat emulsion - ... ml Vitalipid - ... ml Fat emulsion solution is injected in parallel with the main solution in different syringes, through a tee.

Optimal for initiation of therapy is the intake

14. CALCULATION OF INFUSION RATE

components of parenteral nutrition at the same rate during the day. When conducting long-term parenteral nutrition, they gradually switch to cyclic infusion.

Calculation of the rate of introduction of the main solution:

15. VENOUS ACCESSES DURING CARRYING OUT

Parenteral nutrition can be administered through

PARENTERAL NUTRITION

peripheral, and through the central venous accesses.

Peripheral access is used when long-term parenteral nutrition is not planned and hyperosmolar solutions will not be used. Central venous access is used when long-term parenteral nutrition is planned using hyperosmolar solutions. Usually, the concentration of glucose in a solution is used as an indirect indicator of osmolarity. It is not recommended to inject solutions with a glucose concentration of more than 12.5% into a peripheral vein.

However, for a more accurate calculation of the osmolarity of a solution, you can use the formula:

In clinical practice, when calculating osmolarity, the concentration of dry matter should be considered.

16. TECHNOLOGY OF PREPARATION AND PURPOSE

Solutions for parenteral nutrition should be prepared from SOLUTIONS FOR PARENTERAL NUTRITION in a separate room. The room must comply with the ventilation standards of the extra clean room. Preparation of solutions should be carried out in a laminar cabinet. The preparation of solutions for parenteral nutrition should be entrusted to the most experienced nurse. Before preparing the solutions, the nurse must perform a surgical treatment of the hands, put on a sterile cap, mask, mask, sterile gown and sterile gloves. A sterile table should be set in the laminar flow cabinet. The preparation of solutions should be carried out in compliance with all the rules of asepsis and antisepsis. Mixing in one package of solutions of glucose, amino acids and electrolytes is allowed. To prevent catheter thrombosis, heparin should be added to the solution. The dose of heparin can be determined either at the rate of 0.5 - 1 IU per 1 ml. ready-made solution, or 25 - 30 IU per kilogram of body weight per day. Fat emulsions with fat-soluble vitamins are prepared in a separate vial or syringe without the addition of heparin. In order to prevent catheter-associated infection, the infusion system should be filled under sterile conditions and its tightness should be violated as little as possible. From this point of view, it seems reasonable to use volumetric infusion pumps during parenteral nutrition with sufficient accuracy of dispensing the solution at low injection rates. Syringe dispensers are more appropriate to use when the volume of the injected medium does not exceed the volume of one syringe. To ensure maximum tightness, it is advisable to use three-way stopcocks and needleless connectors for the introduction of single appointments when collecting the infusion circuit. Changing the infusion circuit at the patient's bedside should also be carried out in compliance with all the rules of asepsis and antisepsis.

17. ENTERAL NUTRITION MANAGEMENT. PECULIARITIES

Starting from the first day of life, in the absence of counter-CALCULATION OF PARTIAL PARENTERAL NUTRITION, it is necessary to begin trophic nutrition. In the future, in the case of tolerability of trophic nutrition, the volume of enteral nutrition should be systematically expanded. Until the volume of enteral nutrition reaches 50 ml/kg, adjustments should be made to the parenteral fluid, but not to the parenteral nutrients. After the volume of parenteral nutrition exceeds 50 ml/kg, partial parenteral nutrition is carried out according to the residual principle, covering the deficiency of enteral nutrition.

Upon reaching the volume of enteral nutrition 120 - 140

18. WITHDRAWAL OF PARENTERAL NUTRITION

ml/kg, parenteral nutrition may be discontinued.

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Although the issues of parenteral nutrition (PN) of newborns began to be widely studied back in the seventies, the world is actively developing and producing drugs for PN available in our country, this method of treatment is unreasonably rarely used in newborns. This is due to the existence of several myths regarding the use of PN in newborns and, in particular, premature babies.
The first of these is that PN may not be used in newborns who are able to absorb at least a small amount of milk and receive intravenous glucose and whole protein preparations (plasma, albumin).
The second is the belief that the use of PN is fraught with serious complications, the risk of which is higher than the risk of adverse effects of partial fasting.
In fact, the effect of partial starvation, although it cannot be easily isolated from a complex set of pathological manifestations characteristic of a seriously ill newborn, it is a background that largely determines the course of the underlying disease, the incidence of complications and, accordingly, the outcome. After all, protein synthesis determines the course of reparative processes, and the synthesis of antibodies, and the normal course of metabolic processes at the cellular level, not to mention the growth and development of the child's body.
Despite the fact that the list of possible complications of PP is large, they occur infrequently and for the most part are easily eliminated.
Based on the foregoing, we believe that parenteral nutrition should be more widely used in those newborns who for some reason do not receive oral nutrition at all or receive it in limited quantities (enterocolitis, paresis or dyskinesia of the gastrointestinal tract, condition after surgical correction bowel disease, extreme immaturity of the digestive system in children with extremely low body weight). According to the neonatal resuscitation department of the Scientific Center for AGP RAMS, among children whose body weight is below 1000 g, 100% needed PP, with a body weight of 1000 to 1499 g - 92%, with a weight of 1500 to 2000 g - 53 %, with a mass of more than 2000 g -38%. However, widespread implementation of PN is possible only if doctors fully understand the pathways of PN substrate metabolism, the ability to correctly calculate doses of drugs, predict and prevent possible complications.

b. Energy sources
The drugs in this group include glucose and fat emulsions. The energy value of 1 g of glucose is 4 kcal, 1 g of fat is approximately 10 kcal. The best known fat emulsions are Intralipid (Phagmacia), Lipofundin MCT (B.Braun), Lipovenoz (Fgesenius).
As can be seen from Fig. 1, the proportion of energy supplied by carbohydrates and fats can be different. This is the basis for the existence of two PP methods - the so-called lipid method (Scandinavian method, balanced PP method) and glucose (Dudrik hyperalimentation method). The difference between these methods lies in the energy substrates used - when using the lipid method, glucose and fat emulsions are used, and when using the hyperalimentation method, only glucose is used. It is clear that in order to provide an equivalent calorie content in the hyperalimentation system, much larger amounts of glucose have to be used than in the Scandinavian method, and since the total volume of fluid administered is limited, glucose is administered in the form of highly concentrated solutions into the central veins. The method of hyperalimentation is less physiological than the method of balanced PP - it does not provide a sufficient supply of energy substrate during the period of gradual adaptation of the body to a carbohydrate load. Tolerance to glucose in seriously ill newborns, especially premature ones, is reduced due to the release of contrinsular hormones. Therefore, in the initial period of PP using the hyperalimentation method, hyperglycemia and glucosuria are frequent, albeit easily eliminated, complications. Long-term intake of large doses of carbohydrates - 20-30 g of dry matter per 1 kg of body weight causes a significant release of endogenous insulin, which causes the frequency of hypoglycemia and makes it difficult to cancel the PP according to this system. In addition, the use of fat emulsions provides the body with polyunsaturated fatty acids, helps protect the vein wall from irritation by hypermolar solutions. Thus, the use of balanced PN should be considered preferable, however, in the absence of fat emulsions, it is quite possible to provide the child with the necessary energy only due to glucose. According to the classical schemes of PP, children receive 60-70% of non-protein energy supply due to glucose, 30-40% due to fat. With the introduction of fats in smaller proportions, protein retention in the body of newborns is reduced (4).

Calculation of the total volume of fluid needed by the child per day.
Solving the issue of the use of drugs for special infusion therapy (blood, plasma, rheopolyglucin, immunoglobulin) and their volume.
Calculation of the amount of concentrated electrolyte solutions needed by the child, based on the physiological daily requirement and the magnitude of the identified deficit. When calculating the need for sodium, it is necessary to take into account its content in blood substitutes and solutions used for intravenous jet injections.
Determination of the volume of the amino acid solution, based on the following approximate calculation:
Determination of the volume of the fat emulsion. At the beginning of its use, its dose is 0.5 g / kg, then it rises to 2.0 g / kg.
Determination of the volume of glucose solution. To do this, from the volume obtained in paragraph 1, subtract the volumes obtained in paragraphs. 2-5. On the first day of PP, a 10% glucose solution is prescribed, on the second day - 15%, from the third day - a 20% solution (under the control of blood glucose).
Checking and, if necessary, correcting the relationship between plastic and energy substrates. In case of insufficient energy supply in terms of 1 g of amino acids, the dose of glucose and / or fat should be increased, or the dose of amino acids should be reduced.
Distribute the received volumes of drugs for infusion based on the fact that the fat emulsion does not mix with other drugs and is administered either continuously throughout the day through a tee, or as part of a general infusion program in two or three doses at a rate not exceeding 5-7 ml /hour. Amino acid solutions are mixed with glucose and electrolyte solutions. The rate of their administration is calculated so that the total infusion time is 24 hours a day.

Additional administration of sodium is not indicated (with plasma and physiological saline, on which the preparations administered by injection are diluted, he receives 2.3 mmol / kg of sodium). The need for potassium is 3 mmol / kg = 9 mmol = 9 ml of a 7.5% potassium chloride solution. The need for magnesium is provided by magnesium sulfate 25% solution 0.1 ml / kg = 0.3 ml. Calcium requirement -1 ml/kg = 3 ml. The volume of liquid for the introduction of electrolytes is 20 ml (taking into account the introduction of other medications).
The dose of amino acids is 2 g / kg = 6 g. When using the drug Aminovenoz (Fgesenius), which contains 6% amino acids (6 g in 100 ml), its volume will be 100 ml.
Dose of fat emulsion 2 g/kg = 6 g. When using the drug Lipovenoz 20% (Fgesenius) (20 g in 100 ml), its volume will be 30 ml.
The volume of glucose will be:
360 ml - 30 ml - 20 ml -100 ml - 30 ml = 180 ml
Since the child received PP with a gradual increase in glucose concentration for 5 days already and no hyperglycemia was noted, 20% glucose is prescribed.
Check: Dose of amino acids 6 g. Energy supply due to fat 6 g = 60 kcal. Energy supply due to glucose 180 ml of a 20% solution = 36 g = 144 kcal. In total, 1 g of amino acids accounts for 34 kcal. Total energy supply 24 kcal (RKA) + 60 kcal (fat) + 144 kcal (glucose) = 228 kcal = 76 kcal / kg.
Appointments:
Lipovenosis 20% 30 ml through a tee at a rate of 1.3 ml/hour
Aminovenosis ped 6% - 40.0
Glucose 20% - 60.0
Potassium chloride 7.5% - 4.5
#
Aminovenosis ped 6% - 30.0 Glucose 20% - 60.0
Calcium gluconate 10% - 3.0
#
Speed 13 ml/hour
Plasma B (111) -30.0
#
Aminovenosis ped 6% - 30.0
Glucose 20% - 60.0
Potassium chloride 7.5% - 4.5
Magnesium sulfate 25% - 0.3