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Discussion

hyperal use in the NICU

Hi, Our NICU is trying to implement starting hyperal (no fats, just AA) on birth day. To me this seems like expensive IV fluid that will, more than likely, not have a significant impact on ...anything!! Is anyone else doing this? What are the supposed benefits? Thanks, Deb

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We usually start the day after. Pharmacy has rules as to what time HAL orders come in, I believe. Our HAL always has the lipids mixed in.

  • Experts

2-3 yrs ago, we started giving trophamine and MVI w/in the first few hours of life. They don't make up the complete HAL, just run those two things in on syringe pumps; that way if the sugars are unstable you don't waste time and $$$ remixing HAL each time you need to change the glucose concentration. The feeling was that it was critical to get that nutritional support going as soon as possible to prevent problems and give the baby support to start healing and growing.

We have pharmacy service 24/7, and there was very little resistance from them because they did NOT have to stop everything else, go into the special place where they mix the hyperal, only to have another stat order 2 hrs later w/ a different glucose. One syringe of trophamine and one of the MVI stuff was manageable. ( Idon;t know but maybe they bribed the night shift w/ something!!) They are run on syringe pumps for a shorter amount of time than the usual 24 hrs.

If your institution doesn't have that kind of pharmacy coverage, it would be a MAJOR hassle to try to do this. But if you can, "evidence-based practice" has apparently shown it to be beneficial.

Our lipids were and still are separate. Lipids are NOT started right away. The rest of the IV fluids were the usual D10 or D5 and maybe Ca and Heparin.

I like the "nutrition" concept, so I guess I think it's a good idea.

We start 'em with D10 ASAP and add Ca or K as needed. You could wait for phamacy to do this but my life is too short.

Our hospital gets hyperal and lipids from an outside company so we usually start that 24 hours later.

I think a neonates chemistry changes so much in those 24 hours it would be a waste to start them so soon on hal.

Do many of you have lipids mixed in the same bag?? Do you run it in the UAC? We have to run the lipids separately in a PIV only.

Our lipids are seperate. We don't run anything in the UA, just the UV. PIVs we use for incombatable meds and blood.

I'm not sure about the hyperal rationale; I'll have to ask about this tonight.

As for our lines, we use the UAC for B/P monitoring and usually only infuse hep solutions TKO. We use our UVC's for PIA and we piggyback our lipids into that at the terminal site. We start heplock's (or saline) for blood and med administration if we can get one; otherwise we use our UVC's for that.

We run HAL in UAC's if we don't have a UVC.

We have two attendings that will start HAL on day one if they can get the order in soon enough. No lipids. They are doing a big study at our hospital about this.

We have double lumen UVC's so we will run Main IVF (including HAL) thru one port and IL thru the other. If we have Dopa or Dobut running, the lipids get IVPB with the HAL and run the vasopressors alone. We rarely start PIV if we have a double lumen in. We have run HAL thru UAC's if we had too, but that is rare.

  • Experts

ALL we run the 1st day are the Amino Acids and the vitamins--not a complete HAL--you don't have the expense, and glucose/electrolyte fluctuations are handled w/the D10/D5 basic IV fluid.

The idea is to avoid muscle breakdown, and the catabolic byproducts that result from not supporting the baby's nutritional needs.

Usually by day 2, "trophic" feedings can be started, i.e., colostrum. Only 1/2 - 1cc q6h.

I've noticed that we are running vits sooner....but with the smaller ones we generally infuse a combo of dextrose....live D5 with D20 to stabalize the gluclose (80-180)...and then the insuline drips get put in there for good measure.

For the most part, I'd say we start TPN on about day 3 to 4 once the gluclose evens out.

I like the idea of the extra nutrition too.

  • Author

Thank you for the input . We run only .45ns1:1 heparin in our uac's.

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