Parenteral nutrition

In practice, parenteral nutrition is used by a number of terms: total parenteral nutrition, partial, additional. Some authors believe that parenteral nutrition should be adequate and can be combined with natural or tube nutrition.

[ 1 ], [ 2 ], [ 3 ]

What is parenteral nutrition?

With a lack of food, the body's defenses are depleted, the function of the epithelial barrier of the skin and mucous membranes is disrupted, the function of T-cells is disrupted, the synthesis of immunoglobulins decreases, the bactericidal function of leukocytes worsens, as a result of which the risk of infectious diseases and sepsis increases. Hypoalbuminemia has a negative effect on wound healing and increases the risk of edema (lungs and brain), bedsores.

With a deficiency of essential fatty acids (linoleic, linolenic, arachidonic), a specific syndrome develops, which is manifested by a delay in the child's growth, peeling skin, and decreased resistance to infections. This syndrome can occur even with short-term (5-7 days) parenteral nutrition of children without the inclusion of fat emulsions.

Nutrient solutions for parenteral nutrition should contain the same basic ingredients (and in the same proportions) as in normal food intake: amino acids, carbohydrates, fats, electrolytes, trace elements, vitamins.

The success of treating patients largely depends on the balance of the introduced nutrients, careful calculation of all components. In sepsis, severe diarrhea, toxicosis, a state of hypermetabolism is observed, in which the digestibility of fats increases and carbohydrates decreases. In these cases, the introduction of a large amount of carbohydrates can cause a deepening of stress with an increase in the amount of catecholamines, an increase in the need for oxygen and an excess of carbon dioxide. The accumulation of the latter contributes to the development of hypercapnia and associated dyspnea, respiratory failure (RF).

When prescribing parenteral nutrition, the phase of the stress reaction is taken into account:

1. adrenergic (in the first 1-3 days);
2. corticoid, reverse development (on the 4th-6th day);
3. transition to the anabolic phase of metabolism (on the 6th-10th day);
4. phase of fat and protein accumulation (from 1 week to several months or years after the development of shock, stress reaction).

In phase I, the body creates emergency protection for survival, which is accompanied by an increase in the tone of the sympathetic-adrenal system with the participation of a large number of hormones (pituitary gland, adrenal glands, etc.), the need for energy increases sharply, which is satisfied by the breakdown of its own proteins, fats, glycogen, and the VEO is disrupted (water and sodium retention in the body and the release of increased amounts of potassium, calcium, magnesium and phosphorus in the urine are observed).

In the second phase of the stress reaction, the level of counter-insular hormones, catecholamines, glucocorticoids decreases, diuresis increases, nitrogen losses decrease, catabolism decreases, which is clinically reflected in a decrease in body temperature, the appearance of appetite, and improvement in hemodynamics and microcirculation.

In phase III, protein synthesis begins, and hypokalemia is characteristic. Adequate food intake by the patient, regardless of its options (enteral or parenteral), as well as additional administration of potassium and phosphorus salts are important here.

In phase IV, accumulation of MT is possible only with increased consumption of plastic material with food products. For utilization of 1 g of protein (amino acids) 25-30 kcal of energy is required. Therefore, the more severe the stress, the more energy materials the patient needs, but with mandatory consideration of the period of recovery from the stress reaction and tolerance of parenteral nutrition.

Indications and contraindications for parenteral nutrition

Indications for parenteral nutrition:

• intestinal failure, including persistent diarrhea;
• mechanical intestinal obstruction;
• short bowel syndrome;
• severe pancreatitis (pancreatic necrosis);
• external fistula of the small intestine;
• preoperative preparation as part of infusion-transfusion therapy.

Contraindications to parenteral nutrition:

• intolerance to individual nutrients (including anaphylaxis);
• shock;
• overhydration.

Preparations for parenteral nutrition

The drugs used in parenteral nutrition include glucose and fat emulsions. Crystalline amino acid solutions used in parenteral nutrition also serve as an energy substrate, but their main purpose is plastic, since various proteins of the body are synthesized from amino acids. In order for amino acids to fulfill this purpose, it is necessary to supply the body with adequate energy due to glucose and fat - non-protein energy substrates. With a shortage of so-called non-protein calories, amino acids are included in the process of neoglucogenesis and become only an energy substrate.

Carbohydrates for parenteral nutrition

The most common nutrient for parenteral nutrition is glucose. Its energy value is about 4 kcal/g. The proportion of glucose in parenteral nutrition should be 50-55% of the actual energy expenditure.

The rational rate of glucose delivery during parenteral nutrition without the risk of glucosuria is considered to be 5 mg/(kg x min) [0.25-0.3 g/(kg x h)], the maximum rate is 0.5 g/kg x h). The dose of insulin, the addition of which is necessary during glucose infusion, is indicated in Table 14-6.

The daily amount of glucose administered should not exceed 5-6 g/kg x day). For example, with a body weight of 70 kg, it is recommended to administer 350 g of glucose per day, which corresponds to 1750 ml of a 20% solution. In this case, 350 g of glucose provide delivery of 1400 kcal.

[ 4 ], [ 5 ], [ 6 ], [ 7 ], [ 8 ], [ 9 ]

Fat emulsions for parenteral nutrition

Fat emulsions for parenteral nutrition contain the most energy-intensive nutrient - fats (energy density 9.3 kcal/g). Fat emulsions in a 10% solution contain about 1 kcal/ml, in a 20% solution - about 2 kcal/ml. The dose of fat emulsions is up to 2 g/kg x day). The rate of administration is up to 100 ml/h for a 10% solution and 50 ml/h for a 20% solution.

Example: an adult weighing 70 kg is prescribed 140 g, or 1400 ml of a 10% fat emulsion solution per day, which should provide 1260 kcal. This volume is transfused at the recommended rate in 14 hours. If a 20% solution is used, the volume is halved.

Historically, three generations of fat emulsions have been distinguished.

• First generation. Fat emulsions based on long-chain triglycerides (intralipid, lipofundin 5, etc.). The first of these, intralipid, was created by Arvid Wretlind in 1957.
• Second generation. Fat emulsions based on a mixture of long- and medium-chain triglycerides (MCG and LCT). The ratio MCT/LCT=1/1.
• Third generation. Structured lipids.

Among lipids, in recent years, drugs containing co-3-fatty acids - eicosapentaenoic (EPA) and decosapentaenoic (DPA), contained in fish oil (omegaven) have become widespread. The pharmacological action of co-3-fatty acids is determined by the substitution of arachidonic acid for EPA/DPA in the phospholipid structure of the cell membrane, which reduces the formation of proinflammatory metabolites of arachidonic acid - thromboxanes, leukotrienes, prostaglandins. Omega-3-fatty acids stimulate the formation of eicosanoids with anti-inflammatory action, reduce the release of cytokines (IL-1, IL-2, IL-6, TNF) and prostaglandins (PGE2) by mononuclear cells, reduce the frequency of wound infection and the length of hospital stay.

[ 10 ], [ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ], [ 16 ], [ 17 ], [ 18 ]

Amino acids for parenteral nutrition

The main purpose of amino acids for parenteral nutrition is to provide the body with nitrogen for plastic processes, but in case of energy deficiency they also become an energy substrate. Therefore, it is necessary to maintain a rational ratio of non-protein calories to nitrogen - 150/1.

WHO requirements for amino acid solutions for parenteral nutrition:

• absolute transparency of solutions;
• contains all 20 amino acids;
• the ratio of essential to replaceable amino acids is 1:1;
• the ratio of essential amino acids (g) to nitrogen (g) is closer to 3;
• the leucine/isoleucine ratio is about 1.6.

[ 19 ], [ 20 ], [ 21 ], [ 22 ], [ 23 ], [ 24 ]

Branched-chain amino acids for parenteral nutrition

The inclusion of essential branched-chain amino acids (valine, leucine, isoleucine-VLI) in the solution of crystalline amino acids creates distinct therapeutic effects, especially manifested in liver failure. Unlike aromatic ones, branched-chain amino acids prevent the formation of ammonia. The VLI group serves as a source of ketone bodies - an important energy resource for patients in critical conditions (sepsis, multiple organ failure). The increase in the concentration of branched-chain amino acids in modern solutions of crystalline amino acids is justified by their ability to oxidize directly in muscle tissue. They serve as an additional and effective energy substrate in conditions when the absorption of glucose and fatty acids is slow.

Arginine becomes an essential amino acid under stress. It also serves as a substrate for the formation of nitric oxide, has a positive effect on the secretion of polypeptide hormones (insulin, glucagon, somatotropic hormone, prolactin). Additional inclusion of arginine in food reduces thymus hypotrophy, increases the level of T-lymphocytes, improves wound healing. In addition, arginine dilates peripheral vessels, reduces systemic pressure, promotes sodium excretion and increases myocardial perfusion.

Pharmaconutrients (nutraceuticals) are nutrients that have therapeutic effects.

Glutamine is the most important substrate for the cells of the small intestine, pancreas, alveolar epithelium of the lungs and leukocytes. About 1/3 of all nitrogen is transported in the blood as part of glutamine; glutamine is used directly for the synthesis of other amino acids and protein; it also serves as a nitrogen donor for the synthesis of urea (liver) and ammoniagenesis (kidneys), the antioxidant glutathione, purines and pyrimidines involved in the synthesis of DNA and RNA. The small intestine is the main organ consuming glutamine; under stress, the use of glutamine by the intestine increases, which increases its deficiency. Glutamine, being the main source of energy for the cells of the digestive organs (enterocytes, colonocytes), is deposited in skeletal muscles. A decrease in the level of free glutamine in muscles to 20-50% of the norm is considered a sign of damage. After surgical interventions and other critical conditions, the intramuscular concentration of glutamine decreases by 2 times and its deficiency persists for up to 20-30 days.

Glutamine administration protects the mucosa from the development of gastric stress ulcers. Inclusion of glutamine in nutritional support significantly reduces the level of bacterial translocation by preventing mucosal atrophy and stimulating the immune function.

The most widely used is the alanine-glutamine dipeptide (dipeptiven). 20 g of dipeptiven contains 13.5 g of glutamine. The drug is administered intravenously together with commercial solutions of crystalline amino acids for parenteral nutrition. The average daily dose is 1.5-2.0 ml/kg, which corresponds to 100-150 ml of dipeptiven per day for a patient weighing 70 kg. The drug is recommended to be administered for at least 5 days.

According to modern research, alanine-glutamine infusion in patients receiving parenteral nutrition allows:

• improve nitrogen balance and protein metabolism;
• maintain the intracellular glutamine pool;
• correct the catabolic reaction;
• improve immune function;
• protect the liver. Multicenter studies have noted:
• restoration of bowel function;
• reduction in the frequency of infectious complications;
• reduction of mortality;
• reduction in the duration of hospitalization;
• reduction of treatment costs with parenteral administration of glutamine dipeptides.

[ 25 ], [ 26 ], [ 27 ], [ 28 ], [ 29 ], [ 30 ]

Parenteral nutrition technique

Modern parenteral nutrition technology is based on two principles: infusion from different containers ("bottle") and the "all in one" technology, developed in 1974 by K. Solassol. The "all in one" technology is presented in two versions: "two in one" and "three in one".

Technique of infusion from different containers

The method involves the intravenous administration of glucose, crystalline amino acid solutions and fat emulsions separately. In this case, the technique of simultaneous transfusion of crystalline amino acid solutions and fat emulsions in the synchronous infusion mode (drop by drop) from different vials into one vein through a Y-shaped adapter is used.

The "two in one" method

For parenteral nutrition, preparations containing a glucose solution with electrolytes and a solution of crystalline amino acids are used, usually produced in the form of two-chamber bags (Nutriflex). The contents of the bag are mixed before use. This technique allows for maintaining sterility conditions during infusion and makes it possible to simultaneously administer parenteral nutrition components that are pre-balanced in terms of component content.

The "three in one" method

When using this method, all three components (carbohydrates, fats, amino acids) are introduced from one bag (kabiven). The "three in one" bags are designed with an additional port for introducing vitamins and microelements. This method ensures the introduction of a fully balanced composition of nutrients, reducing the risk of bacterial contamination.

Parenteral nutrition in children

In newborns, the metabolic rate per BW is 3 times higher than in adults, with approximately 25% of energy spent on growth. At the same time, children have significantly limited energy reserves compared to adults. For example, a premature baby weighing 1 kg at birth has only 10 g of fat reserves and is therefore quickly utilized in the metabolic process when there is a shortage of food elements. The glycogen reserve in younger children is utilized in 12-16 hours, and in older children - in 24 hours.

During stress, up to 80% of energy is formed from fat. The reserve is the formation of glucose from amino acids - gluconeogenesis, in which carbohydrates come from the proteins of the child's body, primarily from muscle protein. Protein breakdown is provided by stress hormones: GCS, catecholamines, glucagon, somatotropic and thyroid-stimulating hormones, cAMP, as well as hunger. These same hormones have counter-insular properties, therefore, in the acute phase of stress, glucose utilization worsens by 50-70%.

In pathological conditions and hunger, children quickly develop loss of MT, dystrophy; to prevent them, timely use of parenteral nutrition is necessary. It should also be remembered that in the first months of life, the child's brain develops intensively, nerve cells continue to divide. Malnutrition can lead to a decrease not only in growth rates, but also in the level of mental development of the child, which is not compensated for later.

For parenteral nutrition, 3 main groups of ingredients are used, including proteins, fats and carbohydrates.

Protein (amino acid) mixtures: protein hydrolysates - "Aminozol" (Sweden, USA), "Amigen" (USA, Italy), "Izovac" (France), "Aminon" (Germany), hydrolysin-2 (Russia), as well as amino acid solutions - "Polyamine" (Russia), "Levamin-70" (Finland), "Vamin" (USA, Italy), "Moriamine" (Japan), "Friamin" (USA), etc.

Fat emulsions: "Intralipid-20%" (Sweden), "Lipofundin-S 20%" (Finland), "Lipofundin-S" (Germany), "Lipozyne" (USA), etc.

Carbohydrates: glucose is usually used - solutions of various concentrations (from 5 to 50%); fructose in the form of 10 and 20% solutions (less irritating to the intima of veins than glucose); invertose, galactose (maltose is rarely used); alcohols (sorbitol, xylitol) are added to fat emulsions to create osmolarity and as an additional energy substrate.

It is generally believed that parenteral nutrition should be continued until normal gastrointestinal function is restored. Most often, parenteral nutrition is needed for a very short period (from 2-3 weeks to 3 months), but in chronic bowel diseases, chronic diarrhea, malabsorption syndrome, short loop syndrome and other diseases, it may be longer.

Parenteral nutrition in children can cover the basic needs of the body (in the stable phase of intestinal inflammation, in the preoperative period, with long-term parenteral nutrition, in the unconscious state of the patient), moderately increased needs (in sepsis, cachexia, gastrointestinal diseases, pancreatitis, in cancer patients), as well as increased needs (in severe diarrhea after stabilization of VEO, burns of II-III degree - more than 40%, sepsis, severe injuries, especially of the skull and brain).

Parenteral nutrition is usually performed by catheterization of the patient's veins. Catheterization (venipuncture) of peripheral veins is performed only if the expected duration of parenteral nutrition is less than 2 weeks.

Calculation of parenteral nutrition

The energy requirement of children aged 6 months and older is calculated using the formula: 95 - (3 x age, years) and is measured in kcal/kg*day).

For children in the first 6 months of life, the daily requirement is 100 kcal/kg or (according to other formulas): up to 6 months - 100-125 kcal/kg*day), for children over 6 months and up to 16 years old, it is determined based on the calculation: 1000 + (100 n), where n is the number of years.

When calculating energy needs, you can focus on average indicators for minimum (basic) and optimal metabolism.

In case of an increase in body temperature at GS, the specified minimum requirement should be increased by 10-12%, with moderate physical activity - by 15-25%, with severe physical activity or convulsions - by 25-75%.

The need for water is determined based on the amount of energy required: for infants - from a ratio of 1.5 ml/kcal, for older children - 1.0-1.25 ml/kcal.

In relation to BW, the daily water requirement for newborns over 7 days old and infants is 100-150 ml/kg, with BW from 10 to 20 kg - 50 ml/kg + 500 ml, over 20 kg - 20 ml/kg + 1000 ml. For newborns in the first 7 days of life, the volume of fluid can be calculated using the formula: 10-20 ml/kg x l, where n is age, days.

For premature and low birth weight infants born with a BW of less than 1000 g, this figure is 80 ml/kg or more.

It is also possible to calculate the water requirement using the Aber-Dean nomogram, adding the volume of pathological losses. In case of MT deficiency, which develops as a result of acute fluid loss (vomiting, diarrhea, perspiration), it is necessary to first eliminate this deficiency using the standard scheme and only then proceed to parenteral nutrition.

Fat emulsions (intralipid, lipofundin) are administered intravenously to most children, except for premature babies, starting with 1-2 g / kg-day) and increasing the dose in the next 2-5 days to 4 g / kg-day) (if tolerated). In premature babies, the 1st dose is 0.5 g / kg-day), in full-term newborns and infants - 1 g / kg-day). When removing children of the first half of the year of life with severe hypotrophy from the state of intestinal toxicosis, the initial dose of lipids is determined at the rate of 0.5 g / kg-day), and in the next 2-3 weeks it does not exceed 2 g / kg-day). The rate of lipid administration is 0.1 g / kg-hour), or 0.5 ml / (kg-hour).

With the help of fats, 40-60% of energy is supplied to the child's body, and when fat is utilized, 9 kcal is released per 1 g of lipids. In emulsions, this value is 10 kcal due to the utilization of xylitol, sorbitol, added to the mixture as an emulsion stabilizer, and substances that provide osmolarity of the mixture. 1 ml of 20% lipofundin contains 200 mg of fat and 2 kcal (1 liter of 20% mixture contains 2000 kcal).

Lipid solutions should not be mixed with anything when administered intravenously; heparin should not be added to them, although its administration (intravenously, by jet stream in parallel with the administration of fat emulsions) in normal therapeutic doses is desirable.

According to Rosenfeld's figurative expression, "fats burn in the flame of carbohydrates", therefore, when conducting parenteral nutrition according to the Scandinavian scheme, it is necessary to combine the introduction of fats with the transfusion of carbohydrate solutions. Carbohydrates (glucose solution, less often - fructose) according to this system should provide the same amount of energy as fats (50:50%). Utilization of 1 g of glucose gives 4.1 kcal of heat. Insulin can be introduced into glucose solutions at the rate of 1 U per 4-5 g of glucose, but this is not required for long-term parenteral nutrition. With a rapid increase in the concentration of glucose in the solutions administered intravenously, hyperglycemia with coma may develop; to avoid this, it should be gradually increased by 2.5-5.0% every 6-12 hours of infusion.

The Dadrick scheme requires continuity in the introduction of glucose solutions: even an hour's break can cause hypoglycemia or hypoglycemic coma. The glucose concentration is also slowly reduced - in parallel with the reduction in the volume of parenteral nutrition, i.e., over 5-7 days.

Thus, the use of high concentration glucose solutions poses a certain danger, which is why it is so important to follow safety rules and monitor the patient's condition using clinical and laboratory analysis.

Glucose solutions can be administered mixed with amino acid solutions, which will reduce the final glucose content in the solution and decrease the risk of phlebitis. With the Scandinavian scheme of parenteral nutrition, these solutions are administered continuously for 16-22 hours daily, with the Dadrick scheme - around the clock without breaks by drip or using syringe pumps. The required amount of electrolytes (calcium and magnesium are not mixed), vitamin mixtures (vitafuzin, multivitamin, intravit) are added to the glucose solutions.

Amino acid solutions (levamine, moriprom, aminone, etc.) are administered intravenously based on protein: 2-2.5 g/kg-day) in young children and 1-1.5 g/kg-day) in older children. With partial parenteral nutrition, the total amount of protein can reach 4 g/kg-day).

It is better to accurately account for the protein needed to stop catabolism based on the volume of its loss in urine, i.e., based on the amino nitrogen of urea:

The amount of residual nitrogen in daily urine, g/l x 6.25.

1 ml of a 7% amino acid mixture (levamine, etc.) contains 70 mg of protein, and 10% mixture (polyamine) contains 100 mg. The rate of administration is maintained at 1-1.5 ml/(kg-h).

The optimal ratio of proteins, fats and carbohydrates for children is 1:1:4.

The daily parenteral nutrition program is calculated using the formula:

Amount of amino acid solution, ml = Required amount of protein (1-4 g/kg) x MT, kg x K, where the coefficient K is 10 at 10% solution concentration and 15 at 7% concentration.

The need for fat emulsion is determined taking into account the energy value: 1 ml of 20% emulsion gives 2 kcal, 1 ml of 10% solution - 1 kcal.

The concentration of the glucose solution is selected taking into account the amount of kilocalories released during its utilization: thus, 1 ml of a 5% glucose solution contains 0.2 kcal, a 10% solution - 0.4 kcal, 15% - 0.6 kcal, 20% - 0.8 kcal, 25% - 11 kcal, 30% - 1.2 kcal, 40% - 1.6 kcal and 50% - 2.0 kcal.

In this case, the formula for determining the percentage concentration of a glucose solution will take the following form:

Concentration of glucose solution, % = Number of kilocalories / Volume of water, ml x 25

Example of calculation of a total parenteral nutrition program

• Child's BW - 10 kg,
• energy volume (60 kcal x 10 kg) - 600 kcal,
• volume of water (600 kcal x 1.5 ml) - 90 0 ml,
• volume of protein (2g x 10 kg x 15) - 300 ml,
• fat volume (300 kcal: 2 kcal/ml) - 150 ml 20% lipofundin.

The remaining volume of water for diluting glucose (900 - 450) is 550 ml. The percentage of glucose solution (300 kcal: 550 ml x 25) is 13.5%. Sodium (3 mmol/kg) and potassium (2 mmol/kg) are also added, or at a rate of 3 and 2 mmol, respectively, for every 115 ml of liquid. Electrolytes are usually diluted throughout the entire volume of the glucose solution (except calcium and magnesium, which cannot be mixed in one solution).

In partial parenteral nutrition, the volume of solutions administered is determined by subtracting the total amount of calories and ingredients supplied with food.

Example of calculation of a partial parenteral nutrition program

The conditions of the problem are the same. The child's BW is 10 kg, but he receives 300 g of milk formula per day.

• Volume of food - 300 ml,
• remaining energy volume (1/3 of 600 kcal) - 400 kcal,
• the remaining volume of water (2/9 of 900 ml) - 600 ml,
• volume of protein (2/3 of 300 ml) - 200 ml 7% levamine,
• fat volume (1/3 of 150 ml) - 100 ml 20% lipofundin (200 kcal),
• volume of water for diluting glucose (600 ml - 300 ml) - 300 ml.

The percentage of glucose solution (200 kcal: 300 ml x 25) is 15%, i.e. this child needs to be given 300 ml of 15% glucose solution, 100 ml of 20% lipofundin and 200 ml of 7% levamine.

In the absence of fat emulsions, parenteral nutrition can be administered using the hyperalimentation method (according to Dadrick).

An example of calculating a partial parenteral nutrition program using the Dadrick method

• Volume of food - 300 ml, volume of water - 600 ml,
• volume of protein (1/3 of 300 ml) - 200 ml of 7% levamine solution,
• volume of glucose: 400 kcal: 400 ml (600-200 ml) x 25, which corresponds to a 25% glucose solution, which should be used in the amount of 400 ml.

At the same time, it is impossible to allow the development of essential fatty acid deficiency syndrome (linoleic and linolenic) in the child; their required amount with this type of parenteral nutrition can be provided by transfusion of plasma in a dose of 5-10 ml/kg (once every 7-10 days). However, it should be remembered that the introduction of plasma to patients is not used for the purpose of replenishing energy and protein.

[ 31 ], [ 32 ], [ 33 ]

Complications of parenteral nutrition

• infectious (phlebitis, angiogenic sepsis);
• metabolic (hyperglycemia, hyperchloremia, acidosis, hyperosmolar syndrome);
• fat embolism of the pulmonary and cerebral arterial system;
• infection with the development of phlebitis (this is facilitated by the hyperosmolarity of solutions), embolism and sepsis;
• acidosis with the development of hyperventilation;
• osmotic diuresis (hyperglycemia) with dehydration;
• hyper- or hypoglycemic coma;
• imbalance of electrolytes and microelements.

When administering parenteral nutrition, it is necessary to ensure that the concentration of glucose in the blood plasma is within 4-11 mmol/l (the blood sample is taken from the finger, not from the vein into which the glucose solution is injected). Glucose losses with urine should not exceed 5% of the amount injected during the day.

When administering lipids, a visual assessment can be used: the transparency of the patient's plasma 30 minutes after administration (slow jet injection) of 1/12 of the daily dose of fat emulsion.

It is necessary to determine the level of urea, creatinine, albumin, osmolarity, electrolyte content in blood plasma and urine, acid-base balance indicators, bilirubin concentration daily, as well as monitor the dynamics of the child's MT and monitor his diuresis.

Long-term parenteral nutrition (weeks, months) requires providing patients with microelements (Fe, Zn, Cu, Se), essential lipids, and vitamins.

[ 34 ], [ 35 ], [ 36 ], [ 37 ], [ 38 ]