There are many ways suggested for minimizing or preventing PNAC like:
– Avoid NPO if possible: encourage hypocaloric EF
– Prevent infection of the CVC used for PN
– Cyclic PN
– Specialized Amino acid formula (Parenetral Pediatric amino acid solution containing Taurine)
-Oral Antibiotics: metronidazole , gentamicin
– New lipids generation (SMOF)
– Removal or adjusting manganese and copper
– Minimal phytosterol content in IV lipids
-Finally liver + SB transplant
I highly recommend to initiate ursodeoxycholic acid in this case. Also, as you tried lipids emulsions supported with fish oil, you may it effects after 7 to 8 weeks.
Also, you have to pay attention that the dose of lipids has to adjusted (0.5- 1gm/kg/day) even TG level is normal.
Manganese then copper are the most toxic trace elements. Regarding using the trace elements mixture in this case, you may provide full dose of trace elements twice a week. No trace element supplementations, NPO patients in particular, on long PN term, patient may develop anemia on lung run due to the lack of copper supplementation.