Nutrition, PICU, Initiation and Advancement — Parenteral Nutrition — Clinical Pathway: ICU and Inpatient

Nutrition Initiation and Advancement Clinical Pathway — PICU/PCU

Parenteral Nutrition (PN) Guidelines

Indications

Consider initiation of PN:

  • Day 3 if moderate-severe malnutrition present
  • Day 4-5 if healthy, well-nourished and NOT able to advance beyond trophic feeds; unable to meet minimum nutritional needs by oral or enteral route
  • Day 4-5 if patient has NOT attained a minimum of 60% of goal feeds and is NOT anticipated to attain this minimum in the next 24-48 hours via the oral or enteral route

Overview

These are initial starting dose recommendations for central PN. Use patient’s dosing weight.

The use of PN through a PIV or midline catheter is strongly discouraged.

Initiate Central PN

PN composition is chosen using the recommended ranges based on: serum laboratory findings, urine output, medications, current IVF content, age, and weight. (Guidelines also available in formulary or PN order form).

  • PN Composition: (PN + INTRAlipids, unless documented contraindication)
  • Total Volume: Use 80% Maintenance fluid volume to initiate PN and consider TFL
Weight in Kg   0-5 kg 5-20 kg 20-40 kg ≥ 40 kg
Macronutrients Dextrose % 10% 10% 10% 10%
Protein (gm/kg) 2 gm/kg 2 gm/kg 1 gm/kg 1 gm/kg
(Max 150 gm/day)
INTRAlipid Fat Emulsion 20%
(soy-based)		 If the patient has an egg, soy or peanut allergy and has never received INTRAlipids, we recommend a test dose.
(Test does = 0.1g/kg over 1 hour)		 2 gm/kg 2 gm/kg 1 gm/kg 1 gm/kg
OMEGAven Fat Emulsion 10%
(fish oil-based)		 Restricted to approval by Nutrition Support Services
SMOFlipid Fat Emulsion 20%
(mixed oil-based)		 Restricted to approval by Nutrition Support Services

Electrolytes

  0-5 kg 5-20 kg 20-40 kg Above 40 kg
Sodium 2-5 mEq/kg 2-6 mEq/kg 2-3 mEq/kg 80-150 mEq/DAY
Potassium 2-4 mEq/kg 2-3 mEq/kg 1.5-2.5 mEq/kg 40-60 mEq/DAY
Chloride 2-5 mEq/kg 2-5 mEq/kg 2-3 mEq/kg 80-150 mEq/DAY
Acetate Balance Balance Balance Balance
Calcium 1-4 mEq/kg
(Neonates may need 3-4 mEq/kg)		 0.5-1 mEq/kg 10-25 mEq/DAY 10-20 mEq/DAY
Phosphorus 1-2 mmol/kg 0.5-2 mmol/kg 0.5–2 mmol/kg 10-40 mmol/DAY
Magnesium 0.3-0.5 mEq/kg 0.3-0.5 mEq/kg 0.3-0.5 mEq/kg 10-30 mEq/DAY

For questions, please call TPN Pharmacy (4-1904).

Parenteral Nutrition — Lab Value Monitoring

  Lab – Lab Panel Information Frequency
Initiation TPN Panel
(BMP, Mg, Phos, Hepatic Panel, Triglycerides, Pre-albumin) 		Prior to initiation (preferable)
OR
In a.m. following initiation
Maintenance
(once stable on PN)		 TPN Panel Minimum weekly
BMP Mag, Phos Daily until stable

Additional Recommendations

For patients with long-term PN requirements, consider cycling PN — discuss with unit RD.