WASHINGTON UNIVERSITY IN ST. LOUIS SCHOOL OF MEDICINE PEDIATRICS GI PARENTERAL NUTRITION Situations
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Gastroenterology & Nutrition | Parenteral Nutrition

Specific Clinical Situations Underlying Special Needs

Provided below are problems (and possible solutions for those problems) associated with each of the following:


High Body Mass Index

Problems

Body Mass Index is a recently employed methodology for evaluating body composition. Body mass index is determined by the formula: weight(kg)/ height(m) x height(m). Graphs of BMI versus age are readily available to determine where an individual patient plots at any particular age. A BMI above expected normals indicates that a patient's body composition is not normal, usually because weight exceeds what is expected for height at a particular age. Excessive weight may be caused by:

  • excess body fat
  • edema
  • comparmentalized fluid such as ascites or effusion

These excesses contribute to body weight, but not to metabolic activity. Calculations with body weight assume that body composition is normal, consisting of 70 to 75% lean body mass and 25 to 30% fat mass. Lean body mass is the energy-consuming compartment of the body. Thus, using excess weight to calculate energy expenditures results in an overestimation of energy needs since the increased weight is assumed to contain 70 to 75% metabolically active tissue.

Solutions

To estimate energy expenditure accurately when BMI is high, calculations of energy expenditure should employ ideal body weight for height or length rather than actual body weight. Ideal body weight(IBW) can be determined by:

  • Employing the BMI formula: Ideal body weight(kg) = BMI (50%tile for age) x height(m) x height (m)
    BMI for Girls [chart]
    BMI for Boys [chart]
  • Using normal growth charts: Ideal body weight(kg) = weight at the 50%tile for the actual height or length at the patient's age
    Girls 0-36 Months Growth Chart [growth chart]
    Girls 2-20 Years Growth Chart [growth chart]
    Boys 0-36 Months Growth Chart [growth chart]
    Boys 2-20 Years Growth Chart [growth chart]
  • Another location to access BMI and Growth Charts: CDC compilation of BMI and Growth Charts [clinical charts]

The use of ideal body weight results in a more accurate determination of actual resting and total daily energy expenditures. Thus, when the BMI exceeds the expected value for age, the IBW should be substituted for the actual body weight when performing calculations of energy expenditure and nutritional needs.

Extra Fluid Requirements

Problems

Solutions

Additional fluid and/or electrolyte administered as a separate IV solution through a Y-connector with TPN. As fluid and salt needs change, these supplemental fluids can be altered in amount and type without interruption of nutritional support.


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Fluid Restrictions

Problems

  • pre- or post-operative congenital heart disease
  • renal failure
  • severe lung disease with cor pulmonale

Solutions

PN is provided via central access. Peripheral PN cannot be designed to provide sufficient energy intake to justify use. Special solutions with high concentrations of dextrose (> 30%) and amino acids (AAM > 30 gm/L) may be needed.


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Higher Energy Needs

The nutrition literature is replete with various recommendations for increasing energy intake in patients with underlying disease. Documentation of increased energy needs has accumulated for only a few specific conditions:

Problems

Infection without fever, post-operative status, or trauma may not necessitate any calorie increase above the usual requirements. Even with extra needs, TDEE does not usually exceed 2.0 x REE.

Solutions

Carefully considered inceases in energy intake are achievable. Generally, glucose infusion rates should not exceed 20 mg/kg/min, and IL infusion rates should not exceed 0.1 gm/kg/hour.


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Lower Energy Needs

(See also Nutrition Literature Resource)

Many patients with severe underlying disease actually consume less energy than would be expected.

Problems

  • mechanically ventilated patients
  • paralyzed patients
  • comatose patients
  • patients with markedly altered body composition, e.g. obese children with profound neurological impairment

Solutions

When estimating energy requirements, begin with measured, calculated, or estimated REE and do not assume extra needs for underlying illness.


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Minor Biochemical Alterations

Mild alterations is serum concentrations of sodium, potassium, calcium, phosphorus, magnesium, and albumin are common in ill patients. Often, these abnormalities will improve with remission of the basic illness and routine TPN support. Special adjustments of PN solutions are not necessary.


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Specific Disease States

Diagnosis Problem Potential Solutions

Cardiac, renal and liver transplant
  Fluid restrictions

Increase nutrient concentrations

  Hyperglycemia

Monitor glucose homeostasis.  Substitute IL for glucose for calories. Initiate insulin.

  Hypomagnesemia

Increase amount in PN

  Hypoalbuminemia

Albumin infusion if ascites or effusions compromise patient

  Cyclosporin infusion

Not compatible with PN solutions. Switch to enteral route.

Congenital cardiac disease
  Diuretics produce hypokalemia, hypomagnesemia, or hypocalcemia

Provide supplemental electrolytes, magnesium, or calcium

  Magnesium depletion prolongs hypokalemia

Provide additional magnesium. Monitor serum magnesium levels.

  Higher energy needs

Increase glucose concentration or add IL

  Fluid restrictions

Central PN required

Liver synthetic dysfunction
  Hypalbuminemia

Albumin infusion only if ascites & edema compromise respiration or comfort

  Hyponatremia

May not require specific therapy. May indicate hepatorenal syndrome

  Coagulopathy

Assure vitamin K delivery. Refractory bleeding requires FFP or factor infusion

  Hyperammonemia

Lactulose or neomycin enterally if encephalopathic

  Hypoglycemia

Avoid interruption of glucose infusion

Chronic lung disease
  Compensatory metabolic alkalosis

No specific therapy

  Diuretics produce hypokalemia

Supplement potassiium

  Hypercarbia

Reduce glucose infusion rate & supply IL

  Hypoalbuminemia

Often dilutional, not nutritional

Neurologic disorder
  Elevated serum transaminases

Often occurs with anti-convulsants

  Paralysis and/or coma

Reduce energy intake

  Constant chorea or seizures

Increase energy intake

Oncologic disease
  Tumor lysis syndrome with elevated phosphorus and uric acid

Special fluid management, allopurinol, and alkalinization

  Hypomagnesemia

Provide additional magnesium

  Limited oral intake

Continue PN

Intestinal surgery [reference]
  High nasogastric tube output

Replace with supplemental electrolyte solution

  High ostomy output

Replace with supplemental electrolyte solution

  Infection

Tailored antibiotics

Renal failure
  Fluid restriction

Central PN required. Provide IL for supplemental energy.

  Azotemia

Review with Pediatric Nephrology

  Hyperkalemia or hyperphosphatemia

Adjust PN constituents

Intrahepatic cholestasis
  Elevated direct or conjugated & delta bilirubin

Consider potential contributing etiologies, e.g. infection, obstuction, etc.

   

Promote bile flow with enteral feeds


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