NUTRITION IN HEMODYNAMICALLY UNSTABLE STATE

[Emilio Escobar]

Good morning to all. For many years, when a term or preterm neonate was admitted in a hemodynamically unstable state to the hospital where I did my fellowship, these neonates were generally managed with intravenous fluids that included dextrose, sodium, potassium and calcium exclusively before deciding to start the enteral route with MEF or administer TPN (this due to lack of the unit). My question is, in this case of hemodynamically unstable patients, and because they may present systemic arterial hypotension and variations in central glycemic levels, would the use of total parenteral nutrition be recommended? That is, how to deal with these variations in blood pressure. central glucose or make adjustments in the amount of fluids to be infused in 24 hours if the patient suddenly worsens and the patient already has TPN ?. Thank you for your kind attention and your comments, I send you my infinite gratitude

[Fossari]

Nice to "talk" to You Emilio, I had worked in more than four institutions (NICU) over the past time, and the best result for ours premies was to have TPN at day first, with a total fluid volume calculated for 80 ml/kg/d , with a dextrose infusion for 4,2 - 5,5 mg/kg/min for 24 hours. We adjusted the volume and variations with Saline Solution, if necessary any reduction of total hidric volume.

We also look for history about asphyxia and low APGAR scores at 5 minutes, at these cases We know We will have to start nutrition with more caution.

We use a very closed monitorization of the diurese and If the respiratory or nephrologic systems are not ok We take the TPN off, We are really afraid of hyperKalemia.

Thank You.

[Emilio Escobar]

My infinite gratitude for taking the time to answer me. One more question, do you administer the saline solution and the TPN in Y? Thanks again

[HickOnACrick]

Most I have worked with, including myself, will begin TPN as soon as possible in VLBW and ELBW babies, even with babies that have evidence of metabolic acidosis. In the larger babies, we are more likely to start a "clear" solution of trophamine, dextrose and calcium, or even just a straight dextrose solution - initially. 

 

To control blood glucose levels, mostly we can get by with just adjusting the IV rate until we can order a new bag of TPN (once daily). If adjusting the rate is not working (or we have reached a rate we are not comfortable with), we will "Y-in" an appropriate dextrose solution. Once we get glucoses under control, we will note the GIR at which that occurred, and tailor our TPN accordingly the next day. 

 

Long ago, I worked with some that would add an insulin drip to control high glucoses. I rarely see this being done anymore. My personal experience with insulin drips, especially in ELBW and VLBW babies, is that it is very difficult to predict how a baby will react. Insulin drips make for a long night of glucose checks, frequent adjustments to the GIR, adjustments to the insulin drip, and boluses of glucose. I suspect this unpredictability is exacerbated by insulin's adsorption to IV tubing. On insulin drips, I have seen glucoses vary between <20 and >200 without making a single change in GIR or insulin drip. I have yet to order an insulin drip, but have needed to manage them when ordered by others, thus my comfort level with insulin drips is minimal. In extreme hyperglycemia when we are already using D5W (in TPN) but still need volume, I have added insulin directly to the TPN. This seems to have a more predictable response. 

 

We are cautious with enteral feeds when we suspect an anoxic/hypoxic event, or in any baby with significant, or worsening, metabolic acidosis. In these babies, we generally assure renal and hepatic function are normal or substantially improving prior to initiating enteral feeds. 

 

Ultimately, it seems that the sooner we can begin enteral feeds, even if only small/trophic volume like 15-20 mL/kg/day, the sooner the blood glucoses become stable. Someone smarter than me can probably explain why, but I suspect intracellular signaling induced by enteral feeds, somehow stabilizes insulin production in the baby. 

 

Hope this helps, 

[Emilio Escobar]

@HickOnACrick thanks you so much

[Fossari]

My infinite gratitude for taking the time to answer me. One more question, do you administer the saline solution and the TPN in Y? Thanks again

I am very sorry to take so long to answer You at this time. We avoid use saline solution for dilutional use with TPN, We agree that could be a lot of Na (mEq) dependent of the weight of the patient.

 

My best regards, 

Thank You.