`
`
`
`Iowa Neonatology Handbook
`
`Edward F. Bell, M.D.
`Professor of Pediatrics
`
`Jeffrey L. Segar, M.D.
`Professor of Pediatrics
`Director, Division of
`Neonatology
`
`The University of Iowa
`
`Peer Review Status: Internally
`Peer Reviewed
`First Published: November 8,
`1994
`Last Revised: January 2006
`
`
`
`Chapters
`
`Table of Contents (or View Expanded
`Contents)
`
`l Preface
`l Contributing Authors
`
`
`
`l General
`l Temperature
`l Jaundice
`l Pulmonary
`l Neurology
`l Metabolic
`l Fluid Management
`l Feeding
`l Infection
`l Hematology
`l Pharmacology
`l Procedures
`l Abbreviations Commonly Used in the
`Nursery
`
`Email this Page | We Welcome Your Comments
`The University of Iowa | Copyright & Disclaimer Statements
`
`Last modification date: Fri Jan 27 11:21:50 2006
`URL: http://www.uihealthcare.com /depts/med/pediatrics/iowaneonatologyhandbook/index.html
`
`Handbook Home
`
`General
`
`Temperature
`
`Jaundice
`
`Pulmonary
`
`Neurology
`
`Metabolic
`
`Fluid Management
`
`Feeding
`
`Infection
`
`Hematology
`
`Pharmacology
`
`Procedures
`
`Abbreviations Commonly
`Used in the Nursery
`
`
`
`
`
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`Iowa Neonatology Handbook
`
`Feeding
`
`Susan J. Carlson, M.M.Sc., R.D., C.S.P., L.D., C.N.S.D. and Ekhard E. Ziegler, M.D.
`Peer Review Status: Internally Peer Reviewed
`
`l Nutritional Management of the Preterm Infant
`l Parenteral Nutrition
`l Enteral Feedings
`l Guidelines for Use of Human Milk in the Nursery
`l Guidelines for the Use of Human Milk Fortifier in the Neonatal Intensive Care Unit
`l Guidelines to Enhance Successful Breast-feeding
`
`Title Page
`
`
`
`
`
`
`
`
`Handbook Home
`
`General
`
`Jaundice
`
`Pulmonary
`
`Neurology
`
`Metabolic
`
`Fluid Management
`
`Feeding
`
`Infection
`
`Hematology
`
`Pharmacology
`
`Procedures
`
`Abbreviations Commonly
`Used in the Nursery
`
`
`
`Email this Page | We Welcome Your Comments
`The University of Iowa | Copyright & Disclaimer Statements
`
`Last modification date: Thu Jan 26 14:55:21 2006
`URL: http://www.uihealthcare.com /depts/med/pediatrics/iowaneonatologyhandbook/feeding/index.html
`
`
`
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`
`Handbook Home
`
`General
`
`Temperature
`
`Jaundice
`
`Pulmonary
`
`Neurology
`
`Metabolic
`
`Fluid Management
`
`Feeding
`
`Infection
`
`Hematology
`
`Pharmacology
`
`Procedures
`
`Abbreviations Commonly
`Used in the Nursery
`
`
`
`
`
`
`
`Iowa Neonatology Handbook
`
`Abbreviations Commonly Used in the Nursery
`
`Edward F. Bell, M.D.
`Peer Review Status: Internally Peer Reviewed
`
`4WINT - 4 West Intermediate Care Nursery
`A/B - apnea/bradycardia spell
`A/B/D - apnea/bradycardia desaturation spell
`AGA - appropriate for gestational age
`ASD - atrial septal defect
`ATB - antibiotics
`BBT - baby's blood type
`BM - bowel movement
`Br Milk - breast milk (.67 kcal/cc)
`BPD - bronchopulmonary dysplasia
`C/S - cesarean section
`CHD - congenital heart defect
`CHF - congestive heart failure
`CMV - cytomegalovirus
`CNS - central nervous system
`COC - circumoral cyanosis
`CPAP - continuous positive airway pressure
`CPD - cephalo-pelvic disproportion
`CPT - chest physiotherapy
`CS - chemstrip
`CSF - cerebrospinal fluid
`CXR - chest x-ray
`DIC - disseminated intravascular coagulation
`DR - delivery room
`ETT - endotracheal tube
`FOC - frontal-occipital circumference
`FSBG - fingerstick blood gas
`FTP - failure to progress
`G-P- - gravida ____para____ (pregnancies; live births)
`GBS - group B streptococcus
`HCS - hemacombistick
`HCT - hematocrit
`HFV - high frequency ventilation
`HFOV - high frequency oscillating ventilation
`HMD - hyaline membrane disease
`HMF - human milk fortifier (makes breast milk .8 kcal/cc)
`HTN - hypertension
`HUS - head ultrasound
`IDM - infant of diabetic mother
`IMV - intermittent mandatory ventilation
`IUGR - intrauterine growth retardation
`IVF - in vitro fertilization
`IVH - intraventricular hemorrhage
`LGA - large for gestational age
`LLSB - lower left sternal border
`LMD - local medical doctor
`LSB - left sternal border
`MAP - mean airway pressure
`MAS - meconium aspiration syndrome
`MBT - mother's blood type
`
`
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`MCL - midclavicular line
`MGM - maternal grandmother
`NAD - no apparent distress
`NC - nasal cannula
`NEC - necrotizing enterocolitis
`NICU - Neonatal Intensive Care Unit
`NNS - neonatal screen
`NPCPAP - nasopharyngeal continuous positive airway pressure
`NPO - nothing by mouth
`NVN - neonatal venous nutrition
`PDA - patent ductus arteriosis
`PEEP - peak and expiratory pressure
`PF - premie formula (.8 kcal/cc)
`PFC - persistent fetal circulation
`PGE1 - prostaglandin E1
`PGF - paternal grandfather
`PIE - pulmonary interstitial hypertension
`PIH - pregnancy induced hypertension
`PIP - peak inspiratory pressure
`PIV - peripheral intravenous line
`PKU - phenylketonuria, a disease detected on the NNS
`PMI - point of maximum intensity
`PNP - pediatric nurse practitioner
`PPHN - persistent pulmonary hypertension of the newborn
`PPS - peripheral pulmonic stenosis
`PRBCs - packed red blood cells (concentrated)
`PROM - premature rupture of membranes
`PTL - preterm labor
`PVL - periventricular leukomalacia
`RA - room air (21% oxygen)
`RCM - right costal margin
`RDS - respiratory distress syndrome
`ROM - rupture of membranes OR range of motion
`ROP - retinopathy of prematurity
`RSV - respiratory syncitial virus
`SAB - spontaneous abortion
`SF - stock formula (.67 kcal/cc)
`SGA - small for gestational age
`TCM - transcutaneous monitor (PO2, PCO2)
`TG - true glucose
`TTN - transient tachypnea of the newborn
`UAC - umbilical arterial catheter
`UVC - umbilical venous catheter
`VLBW - very low birth weight baby
`VSD - ventricular septal defect
`VS - vital signs
`
`Title Page
`Email this Page | We Welcome Your Comments
`The University of Iowa | Copyright & Disclaimer Statements
`
`Last modification date: Tue Jan 24 07:37:40 2006
`URL: http://www.uihealthcare.com /depts/med/pediatrics/iowaneonatologyhandbook/abbreviations.html
`
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`
`Handbook Home
`
`General
`
`Temperature
`
`Jaundice
`
`Pulmonary
`
`Neurology
`
`Metabolic
`
`Fluid Management
`
`Feeding
`
`Infection
`
`Hematology
`
`Pharmacology
`
`Procedures
`
`
`
`
`
`Iowa Neonatology Handbook
`
`Expanded Table of Contents
`
`Edward F. Bell, M.D. and Jeffrey L. Segar, M.D.
`Peer Review Status: Internally Peer Reviewed
`
`General
`
`l Blood Pressure in the Newborn
`l Indications for Hearing Screening of Neonates
`l High Risk Infant Follow-up Program
`l Immunization of the Infant in the Hospital
`l Intrauterine Growth Retarded (IUGR) Infants
`l New Ballard Score for Gestational Age Assessment
`l Newborn Metabolic Screen
`l Neonatal Transport to University of Iowa Hospitals & Clinics
`l Transfer of Infant to Referring Hospital from University of Iowa Hospitals & Clinics
`(back-transport)
`l Nonviable Infant Admission Protocol
`l Guidelines for Pediatric Attendance in the Delivery Room
`l Comments on Oxygen Toxicity and Retinopathy (ROP) in the Premature Infant
`l ROP Surveillance
`
`Abbreviations Commonly
`Used in the Nursery
`
`
`
`Temperature
`
`l Detection and Management of Abnormal Body Temperature
`l Servocontrol: Incubator and Radiant Warmer
`l When and How to Move Babies from Radiant Warmer to Incubator, and from Incubator
`to Open Bed
`
`Jaundice
`
`l Management of Hyperbilirubinemia in the Newborn Period
`l Use of Phototherapy
`
`Pulmonary
`
`l Management of Neonatal Apnea
`l Nasopharyngeal Continuous Positive Airway Pressure (NPCPAP)
`l Protocol for Initial Respiratory Settings for Mechanical Ventilation of Infants
`l Use of Mechanical Ventilation in the Neonate
`l High Frequency Ventilation (HFV)
`l Management Strategies with High Frequency Ventilation in Neonates Using the Infant
`Star 950 High Frequency Ventilator
`l Neonatal Resuscitation
`l Medications for Use in Neonatal Resuscitation
`l Care of the Infant with the Meconium Aspiration Syndrome
`l Treatment of Pulmonary Hypertension
`l Present Guidelines for Nitric Oxide (NO) Therapy of Persistent Pulmonary Hypertension
`of the Newborn
`l Inhalational Nitric Oxide (iNO)
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`l Treatment of the Respiratory Distress Syndrome
`l Guidelines for Surfactant Administration (surfactant Replacement Therapy)
`l Surveillance of ph and Blood Gas Status of Neonates
`l Sampling Techniques for Arterial Blood Gas Samples
`l Pulse Oximetry
`l Transcutaneous Oxygen (TcPO2) Monitors
`l Transcutaneous Carbon Dioxide (TcPCO2) Monitors
`
`Neurology
`
`l Neurological Disorders: Asphyxia
`l Neonatal Seizures
`l Intracranial Hemorrhage
`
`Metabolic
`
`l Hypocalcemia
`l Guidelines for the Detection and Management of Hypoglycemia, Hyperglycemia, and
`Normoglycemia in Preterm and Term Neonates
`l Metabolic Problems in Infants of Diabetic Mothers (IDM'S)
`l Recommendations for Plasma Glucose Testing of Neonates While in Hospital
`l Mean Blood Glucose in First Hours of Life
`
`Fluid Management
`
`l Fluid And Electrolyte Management in the Newborn
`l Fluid Therapy in the Neonate
`
`
`
`Feeding
`
`l Nutritional Management of the Preterm Infant
`l Parenteral Nutrition
`l Enteral Feedings
`l Guidelines for Use of Human Milk in the Nursery
`l Guidelines to Enhance Successful Breast-feeding
`
`Infection
`
`l Congenital Infections
`l Management of Perinatal Herpes Simplex Infections
`l Hepatitis B
`l Diagnosis of Infections Caused by Herpes Viruses snd Chlamydia
`l Care of the Infant Born to a Mother with Prolonged Rupture of Membranes (PROM)
`l Suggested Management of Term Infants Whose Mothers Have Positive Group B
`Streptococcal Cultures And/or Have Received Intrapartum Chemoprophylaxis Against
`Group B Streptococcus
`l Suspected Sepsis in the Newborn
`l Use of Drug Monitoring Levels in the Special Care Nurseries
`l Reference Range for WBC Indices (after Manroe Et Al)
`l Scalp Abscess
`l Immunoglobulin Therapy
`l Tolerance of IVIG Administration To Neonates
`l Management of Infants with RSV (Respiratory Syncytial Virus) Infection
`l Guidelines for Immunoprophylaxis Against Respiratory Syncytial Virus in High-Risk
`Infants
`
`Hematology
`
`l Transfusion Guidelines for Preterm and Term Infants
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`l UI NICU Guidelines for Administering 15mL/kg Erythrocyte Transfusions to Neonates
`l Hemolytic Disease of the Newborn Due to Maternal Erythrocyte Alloimmunization
`l Polycythemia-Hyperviscosity Syndrome
`l Bone Marrow Aspiration: Indications
`
`Pharmacology
`
`l Antiarrhythmic Drugs
`l Anticonvulsants
`l Antimicrobials
`l Digoxin
`l Diuretic Agents
`l Effects of Drugs on the Fetus or Newborn
`l The Effect of Drugs Taken by Nursing Mother on Her Infant
`l Emergency Drug Doses
`l NICU Intravenous Drug Compatability Chart
`l Inotropic Agents
`l Monitoring Gentamicin Therapy by Single Serum Sample Determination
`l Pharmacologic Closure of PDA
`l Protocol for Use of Prostaglandin E1
`l Pharmacologic Therapy for Neonatal Systemic Hypertension
`l Neuromuscular Blockers in Neonates
`l Analgesics and Sedatives
`l Apnea
`l Bronchodilators for Reactive Airway Disease
`l Infants of Drug-Abusing Mothers
`l Drug Half-Life Studies
`
`Procedures
`
`l Technique for Insertion of an Endotracheal (ET) Tube
`l Suctioning of Endotracheal Tubes
`l Lumbar Puncture
`l Circumcision
`l Collection of Arterial Blood Gas Samples
`l Obtaining Blood Via Heel Stick
`l Suprapubic Bladder Tap
`l Insertion of Umbilical Vessel Catheters
`l Exchange Transfusion
`l Technique for Insertion of a Chest Tube
`l Technique for Insertion of a Pericardial Tube
`l Intraosseous Infusion
`l Percutaneous Placement of Central Venous Catheters
`l Apt Test for Fetal Hemoglobin
`
`Abbreviations commonly used in the nursery
`
`Title Page
`
`Email this Page | We Welcome Your Comments
`The University of Iowa | Copyright & Disclaimer Statements
`
`Last modification date: Tue Jan 24 14:15:28 2006
`URL: http://www.uihealthcare.com /depts/med/pediatrics/iowaneonatologyhandbook/expandedindex.html
`
`
`
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`

`
`Handbook Home
`
`General
`
`Temperature
`
`Jaundice
`
`Pulmonary
`
`Neurology
`
`Metabolic
`
`Fluid Management
`
`Feeding
`
`Infection
`
`Hematology
`
`Pharmacology
`
`Procedures
`
`Abbreviations Commonly
`Used in the Nursery
`
`
`
`
`
`
`
`Iowa Neonatology Handbook
`
`Preface
`
`Edward F. Bell, M.D. and Jeffrey L Segar, M.D.
`Peer Review Status: Internally Peer Reviewed
`
`The Iowa Neonatology Handbook represents an ongoing effort by the Division of Neonatology
`at the Children's Hospital of Iowa to provide physicians, nurses, and medical students who care
`for newborn infants a collection of protocols outlining rational approaches to the care of
`critically ill neonates. In no way is this document a comprehensive review of the field of
`neonatology, nor is it implied that the therapeutic approaches outlined in this book are
`established policies or standards of care. Rather, they represent a compilation of the experience
`and clinical styles of the members of our division and are intended only as a guide to therapy.
`
`This monograph should be regarded as an educational document. Some of the information
`provided will be outdated by the time you discover it; other information is subject to
`controversy. The Handbook is designed only to supplement and not to replace the education
`gained from the teaching of the faculty and fellows and the experience of taking care of infants
`in the neonatal ICU.
`
`
`
`The Handbook was added to the Virtual Hospital site in 2003 so that it would be more widely
`available and could be updated by section as needed. The material contained in the first on-line
`draft was taken from the 1995 printed edition. The date of the last revision is shown on each
`page. The Handbook is a document that has evolved over many years, since the first edition
`appeared in the early 1980s. The current product, which continues to evolve, has been built upon
`the efforts of many present and former faculty members and fellows, as well as nurses and
`residents who wrote, reviewed or edited sections of this book. The transition from printed to on-
`line format could not have been accomplished without the technical contributions of Nola Riley
`and Mark Hart.
`
`Edward F. Bell, M.D.
`Professor and Director
`Division of Neonatology
`edward-bell@uiowa.edu
`
`Jeffrey L Segar, M.D.
`Associate Professor
`Division of Neonatology
`jeffrey-segar@uiowa.edu
`
`
`
`
`
`Title Page
`Email this Page | We Welcome Your Comments
`The University of Iowa | Copyright & Disclaimer Statements
`
`Last modification date: Tue Jan 24 07:37:28 2006
`URL: http://www.uihealthcare.com /depts/med/pediatrics/iowaneonatologyhandbook/preface.html
`
`
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`
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`
`
`Iowa Neonatology Handbook
`
`Contributing Authors
`
`l Michael J. Acarregui
`l Valerie Bailey
`l Edward F. Bell
`l Susan J. Carlson
`l John M. Dagle
`l Diane L. Eastman
`l Thomas N. George
`l Janet F. Geyer
`l Charles Grose
`l Herman A. Hein
`l Ronald V. Keech
`l Jonathan M. Klein
`l Maria A. Lofgren
`l Jon E. Mazursky
`l Lou Ann Montgomery
`l Chetan A. Patel
`l Jeffrey L. Segar
`l Mark W. Thompson
`l John A. Widness
`l Ekhard E. Ziegler
`
`Title Page
`
`
`Handbook Home
`
`General
`
`Temperature
`
`Jaundice
`
`Pulmonary
`
`Neurology
`
`Metabolic
`
`Fluid Management
`
`Feeding
`
`Infection
`
`Hematology
`
`Pharmacology
`
`Procedures
`
`Abbreviations Commonly
`Used in the Nursery
`
`
`
`Email this Page | We Welcome Your Comments
`The University of Iowa | Copyright & Disclaimer Statements
`
`Last modification date: Tue Jan 24 07:37:26 2006
`URL: http://www.uihealthcare.com /depts/med/pediatrics/iowaneonatologyhandbook/contributingauthors.html
`
`
`
`Eton Ex. 1088
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`

`

`
`Handbook Home
`
`
`
`
`
`General
`
`Jaundice
`
`Pulmonary
`
`Neurology
`
`Metabolic
`
`Fluid Management
`
`Feeding
`
`Infection
`
`Hematology
`
`Pharmacology
`
`Procedures
`
`Abbreviations Commonly
`Used in the Nursery
`
`Iowa Neonatology Handbook: Feeding
`
`Parenteral Nutrition
`
`Ekhard E. Ziegler, M.D.
`Peer Review Status: Internally Peer Reviewed
`
`General concepts
`
`Most neonatologists now embrace the idea that a nutritional insult (starvation) is unlikely to have
`beneficial effects in an infant already under intense stress. Efforts at minimizing the duration and
`severity of starvation must, of necessity, rely heavily on the parenteral provision of nutrients.
`The prevailing hormonal milieu, which accounts, among other things, for glucose intolerance,
`places limitations on our ability to provide nutritional support. But, within these limitations,
`nutritional intake should be maximized -- and the earlier, the better. Enteral nutrition should be
`pursued all the while, but with a view toward nourishing the gut rather than the whole baby.
`
`Indication and time of intiation
`
`The smaller the infant, the greater the need for parenteral nutrition and the greater the urgency to
`initiate it. Thus, infants with birth weights less than 1500 g should, with few exceptions, receive
`parenteral nutrition as a matter of routine. These infants should be on TPN by 48 hours of age at
`the latest. There is no rationale for withholding TPN in these infants for a period longer than is
`technically required to order and start TPN. Postponing the initiation of TPN simply means that
`greater nutrient deficits will accrue and that it will take more time later on to make up for the
`deficits.
`
`
`
`On the other hand, larger infants require parenteral nutrition only when enteral feedings are not
`possible for periods of more than a few days. Because larger infants have greater nutrient
`reserves, the urgency to start nutrition support is much less than in smaller infants.
`
`Prescribing parenteral nutrition
`
`Three neonatal venous nutrition (NVN) solutions are available. Their main components are
`listed in Table 1.
`
`Table 1: Composition of Neonatal Venous Nutrient Solutions1
`(per liter)
`
`
`
`Standard
`
`High Amino Acid
`
`High Amino Acid
`electrolyte-free
`
`Amino acids2 (g)
`
`1.4
`
`Dextrose (g)
`
`25-250
`
`2.1
`
`25-250
`
`2.1
`
`25-250
`
`Sodium (mEq)
`
`Chloride (mEq)
`
`Potassium (mEq)3
`
`Calcium (mEq)
`
`35
`
`10
`
`0
`
`20
`
`Phosphorus (mmol) 10
`
`Magnesium (mEq)
`
`Acetate (mEq)
`
`4
`
`17
`
`35
`
`10
`
`0
`
`20
`
`10
`
`4
`
`20
`
`1
`
`0
`
`0
`
`20
`
`0
`
`4
`
`10
`
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`1 All solutions also provide (per liter): 2 mg zinc, 0.4 mg copper, 0.2 mg manganese,
`4 µg chromium, 10 µg selenium;
`2 Trophamine or Aminosyn PF; cysteine is added at 14 mg/g amino acids
`3 Higher when potassium is added (e.g., 30 mEq when K is 20 mEq)
`
`
`
`The standard and high-amino acid solutions differ only in their amino acid content. We retain the
`designation "standard" for the solution providing 1.4% amino acids, although high amino acid
`solutions are now used at least as frequently as the standard solution. The concept behind the
`standard solution is that in 100 ml/kg/day it provides 1.4 g amino acids per kg/day, the presumed
`maintenance requirement. If one of the high amino acid solutions is prescribed at 60-70 ml/kg/
`day, that same amino acid intake is achieved, albeit in a smaller volume. In patients with labile
`electrolyte and/or blood glucose levels, the remainder of the daily fluid volume can be provided
`from glucose-electrolyte solutions that can be changed readily in response to changing needs.
`Potassium, when it is needed after the first few days, has to be prescribed as a separate item. The
`electrolyte-free solution is free of sodium, potassium and chloride. It is intended for the small
`preterm infant during the first few days of life and provides maximum flexibility in working
`around the common fluid-electrolyte problems of small infants. It goes without saying that, once
`the electrolyte disturbance has been resolved that prompted the use of an electrolyte-free
`solution, supplemental electrolytes must be provided or an electrolyte-containing solution used.
`
`Vitamins (MVI Pediatric) must be prescribed separately. The dosage is 2.0 ml/kg/day for babies
`weighing up to 2.5 kg. Babies weighing >2.5 kg receive the maximum dose of 5.0 ml/day.
`
`Dosage of amino acids
`
`There is no rational basis for intakes less than 1.4 g/kg/day (i.e., maintenance, Table 2) at any
`time, even on the first day that TPN is given. Whenever energy intakes exceed 40 kcal/kg/day,
`intakes of amino acids should be increased beyond 1.4 g/kg/day. As a rough guideline, an amino
`acid/energy ratio of approxiamately 3.5 g/100 kcal should be maintained. In this way it is
`ensured that the infant receives sufficient amino acids at all times, especially if and when growth
`occurs. In larger infants, a lower ratio, e.g., 3.0, should be used.
`
`Table 2: Suggested Amino Acid Intakes Of Preterm Infants
`(g/kg/day)
`
`<1000g
`
`1000-1500g
`
`1500-2000g
`
`2000-2700g
`
`
`
`Parenteral
`
`maintenance 1.4
`
`maintenance & growth 3.2
`
`Enteral
`
`4.0
`
`1.4
`
`3.0
`
`3.8
`
`1.4
`
`3.0
`
`3.5
`
`1.4
`
`2.8
`
`3.2
`
`Special needs
`
`When higher than usual intakes of calcium and phosphorus are desired, e.g., in case of marked
`osteopenia, or simply to prevent osteopenia, increased concentrations of these minerals can be
`given. The permissible concentrations depend on the amino acid and glucose concentrations in
`the TPN solution. Consult the dietitian and/or pharmacist regarding prescribing information.
`
`If additional acetate is desired for the management of metabolic acidosis, it can be added as the
`Na or K salt. The choice of salt(s) will depend on serum electrolyte levels.
`
`Parenteral Lipids
`
`The primary reason for providing parenteral lipds remains the provision of essential fatty acids.
`That objective is achieved with a lipid intake of 0.5 g/kg/day. There are good reasons for using
`lipid also as source of fuel, although it appears that a good portion of lipids goes into storage
`rather than being oxidized as fuel. Intakes of up to 2.5 g/kg/day are commonly used in preterm
`infants and appear to be safe, as long as they are given slowly. Lipid emulsions are available as
`10% and 20% emulsions, with some reports suggesting more favorable metabolic effects with
`20% emulsions than 10% emulsions.
`
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`Certain rules must be followed. Lipids should be given as slowly as possible, i.e., spread out
`over 20 hrs each day whenever possible, leaving 4 hrs for administration of intravenous
`medications. Triglyceride levels should be monitored if rates greater than 150 mg/kg/hr are used.
`If visible lipemia is noticed, the lipid infusion should be stopped and a serum triglyceride level
`measured.
`
`Monitoring
`
`Because blood glucose and electrolytes are already being closely monitored in preterm infants,
`no routine monitoring is required specifically for infants receiving parenteral nutrition, with one
`exception. Because electrolyte-free TPN is also phosphate-free, serum phosphorus must be
`monitored if such a solution is used for more than 2 days. Whatever the BUN is, a small rise of it
`is to be expected when TPN is started or when the amino acid intake is increased.
`
`An important rule in monitoring is never to draw the blood sample from a line that contains the
`substance to be monitored. No amount of flushing can guarantee that you are not obtaining a
`falsely high value!
`
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`Eton Ex. 1088
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