Parenteral Nutrition Calculations
Parenteral Nutrition Calculations
Parenteral Nutrition Calculations
grams of solute/100 ml of fluid D70 has 70 grams of dextrose per 100 ml. 10% amino acid solution has 10 grams amino acids/100 ml of solution 20% lipids has 20 grams of lipid/100 ml of solution
of protein supplied by a TPN solution, multiply the total volume of amino acid solution (in ml*) supplied in a day by the amino acid concentration.
Example Protein Calculation 1000 ml of 8% amino acids: 1000 ml x 8 g/100 ml = 80g Or 1000 x .08 = 80 g
multiply the volume of 10% lipid (in ml) by 1.1; multiply the volume of 20% lipid (in ml) by 2.0. If lipids are not given daily, divide total kcalories supplied by fat in one week by 7 to get an estimate of the average fat kcalories per day.
*|Lipid emulsions contain glycerol, so lipid emulsion does not
have 9 kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for lipid emulsions.
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Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
needs. Determine lipid volume and rate for "piggy back" administration.
Determine kcals to be supplied from lipid. (Usually 30% of total kcals). Divide lipid kcals by 1.1 kcal/cc if you are using 10% lipids; divide lipid kcals by 2 kcal/cc if you are using 20% lipids. This is the total volume. Divide total volume of lipid by 24 hr to determine rate in cc/hr.
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requirement to determine remaining fluid needs. Divide protein requirement (in grams) by remaining fluid requirement and multiply by 100. This gives you the amino acid concentration in %. Multiply protein requirement in grams x 4 to determine calories from protein
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from total kcals to determine remaining kcal needs. Divide "remaining kcals" by 3.4 kcal/g to determine grams of dextrose. Divide dextrose grams by remaining fluid needs (in protein calculations) and multiply by 100 to determine dextrose concentration. Determine rate of AA/dex solution by dividing "remaining fluid needs by 24 hr.
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Example Calculation
Nutrient Needs: Kcals: 1800. Protein: 88 g. Fluid: 2000 cc 1800 kcal x 30% = 540 kcal from lipid Lipid (10%):
540 kcal/1.1 (kcal/cc) = 491 cc/24 hr = 20 cc/hr 10% lipid (round to 480 ml)
1520cc
Protein Calculations
Protein: 88 g / 1520 cc x 100 = 5.8% amino acid solution 88 g. x 4 kcal/gm =352 kcals from protein
Remaining kcal needs: 1800 (528 + 352)
= 920 kcal
Dextrose Concentration
920 kcal/3.4 kcal/g = 270 g dextrose 270 g / 1520 cc x 100 = 17.7%
Re-check calculations
TPN recommendation: Suggest two-in-one PN 17.7% dextrose, 5.8% a.a. @ 63 cc/hr with 10% lipids piggyback @ 20 cc/hr 63 cc/hr x 24 = 1512 ml 1512 * (.177) = 268 g D X 3.4 kcals= 911 kcals 1512 * (.058) = 88 g a.a. x 4 kcals = 352 20 cc/hr lipids*24 = 480*1.1 kcals/cc = 528 1791
3 in 1 TNA Solutions |
Determine patient's kcalorie, protein, and fluid
needs. Divide daily fluid need by 24 to determine rate of administration. Determine lipid concentration.
Determine kcals to be supplied from lipid. (Usually 30% of total kcals). Determine grams of lipid by dividing kcal lipid by 10. * Divide lipid grams by total daily volume (= fluid needs or final rate x 24) and multiply by 100 to determine % lipid.
(grams) by total daily volume and multiply by 100. Multiply protein needs in grams x 4 kcal/gm = kcals from protein Determine dextrose grams. Subtract kcals of lipid and kcals from protein from total kcals to determine remaining kcal needs. Divide "remaining kcals" by 3.4 kcal/g to determine grams of dextrose. Determine dextrose concentration by dividing dextrose grams by total daily volume and multiply by 100
100 cc/hour
Evaluation of a PN Order
PN 15% dextrose, 4.5% a.a., 3% lipid @ 100 cc/hour Total volume = 2400 Dextrose: 15g/100 ml * 2400 ml = 360 g 360 g x 3.4 kcal/gram = 1224 kcals Lipids 3 g/100 ml x 2400 ml = 72 g lipids 72 x 10 kcals/gram = 720 kcals
Evaluation of a PN Order
Amino acids: 4.5 grams/100 ml * 2400 ml =
108 grams protein 108 x 4 = 432 kcals 1224 + 720 + 432 = 2376 total kcals Lipid is 30% of total calories Dextrose is 51.5% of total calories Protein is 18% of total calories
protein and nonprotein calories although this is falling out of favor This is more commonly used in critically ill patients
TPN prescription, add the dextrose calories to the lipid calories In the last example, 1224 kcals (dextrose) + 720 kcals (lipid) = 1944 non-protein kcals Dextrose is 63% of nonprotein kcals (1224/1944) Lipid is 37% of nonprotein calories In critically ill patients, some clinicians restrict lipid to 30% of nonprotein kcals
day (1 g N = 6.25g protein) Divide total nonprotein calories by grams of nitrogen Desirable NPC:N Ratios:
80:1 the most severely stressed patients 100:1 severely stressed patients 150:1 unstressed patient
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Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
Osmolarity in PPN
When a hypertonic
solution is introduced into a small vein with a low blood flow, fluid from the surrounding tissue moves into the vein due to osmosis. The area can become inflamed, and thrombosis can occur.
IV-Related Phlebitis
5.
Multiply the grams of dextrose per liter by 5. Example: 100 g of dextrose x 5 = 500 mOsm/L Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L Multiply the grams of lipid per liter by 1.5. Example: 40 g lipid x 1.5 = 60. Multiply the (mEq per L sodium + potassium + calcium + magnesium) X 2 Example: 80 X 2 = 160 Total osmolarity = 500 + 300 + 60 + 160 = 1020 mOsm/L
amino acids, 70% dextrose, and 20% lipids The TPN prescription must be compoundable using standard base solutions This becomes an issue if the patient is on a fluid restriction
X = 250 ml
Total volume = 750 ml AA + 500 ml D + 250 ml lipid + 100 ml (for electrolytes/trace) = 1600 ml (minimum volume to compound solution) Tip: Substrates should easily fit in 1 kcal/ml solutions
Lipid:
20 g = 50g 100 ml x ml
X = 250 ml (50/.20)
Total volume = 1250 ml AA + 500 ml D + 250 ml lipid + 100 ml (for electrolytes/trace) = 2100 ml (minimum volume to compound solution) Verdict: not compoundable in 1800 ml. Action: reduce dextrose content or use 15% AA base solution if available (could deliver protein in 833 ml of 15%)
Parenteral Nutrition
Monitoring
syndrome should have serum phosphorus, magnesium, potassium, and glucose levels monitored closely at initiation of SNS. (B) In patients with diabetes or risk factors for glucose intolerance, SNS should be initiated with a low dextrose infusion rate and blood and urine glucose monitored closely. (C) Blood glucose should be monitored frequently upon initiation of SNS, upon any change in insulin dose, and until measurements are stable. (B)
ASPEN BOD. Guidelines for the use of enteral and parenteral nutrition in adult and pediatric patients. JPEN 26;41SA, 2002
and bicarbonate) should be monitored frequently upon initiation of SNS until measurements are stable. (B) Patients receiving intravenous fat emulsions should have serum triglyceride levels monitored until stable and when changes are made in the amount of fat administered. (C) Liver function tests should be monitored periodically in patients receiving PN. (A)
ASPEN BOD. Guidelines for the use of enteral and parenteral nutrition in adult and pediatric patients. JPEN 26;41SA, 2002
Daily
Initially Initially
Frequency 3x/week
Initially
Weekly
Initially
Inpatient Monitoring PN
Parameter
Body Weight Nitrogen Balance HGB, HCT
Daily
Initially
Frequency Weekly
Initially
PRN
Catheter Site
Lymphocyte Count
Clinical Status
Monitorcontd
Urine:
Glucose and ketones (4-6/day) Specific gravity or osmolarity (2-4/day) Urinary urea nitrogen (weekly)
Other:
Volume infusate (daily) Oral intake (daily) if applicable Urinary output (daily) Activity, temperature, respiration (daily) WBC and differential (as needed) Cultures (as needed)
Monitoring: Nutrition
Serum Hepatic Proteins
Parameter
Albumin
t
19 days
Transferrin
Prealbumin Retinol Binding Protein
9 days
2 3 days ~12 hours
Complications of PN
Refeeding syndrome Hyperglycemia Acid-base disorders Hypertriglyceridemia Hepatobiliary complications (fatty liver,
Refeeding Syndrome
Patients at risk are malnourished,
particularly marasmic patients Can occur with enteral or parenteral nutrition Results from intracellular electrolyte shift
potassium, and phosphorus Hyperglycemia and hyperinsulinemia Interstitial fluid retention Cardiac decompensation and arrest
vitamins and minerals prior to and during infusion of PN until levels remain stable Initiate feedings with 15-20 kcal/kg or 1000 kcals/day and 1.2-1.5 g protein/kg/day Limit fluid to 800 ml + insensible losses (adjust per patient fluid tolerance and status)
Fuhrman MP. Defensive strategies for avoiding and managing parenteral nutrition complications. P. 102. In Sharpening your skills as a nutrition support dietitian. DNS, 2003.
in critically ill patients. Now greater attention is given to glycemic control due to evidence that glucose is associated with morbidity/mortality and risk of infection New recommendation is to keep BG<150 mg/dl or as close to normal as possible
Van den Berghe et al. NEJM, 2001
Glycemic Control in PN
In critically ill patients, recommendation is
Glycemic Control in PN
For Patients Not Previously on Insulin
Monitor blood glucose levels prior to
initiating PN When therapy is initiated, monitor BG q 4-6 hours and use sliding scale or insulin drip as needed Add a portion of the previous days insulin to TPN to maintain blood glucose levels
Charney P. A Spoonful of Sugar: Glycemic Control in the ICU. In Sharpening your skills as a nutrition support dietitian. DNS, 2003.
Glycemic Control in PN
For Patients Previously on Insulin
Determine amount of insulin needed prior
to illness Determine amount of feedings to be given Provide a portion of daily insulin needs in first PN along with sliding scale or insulin drip to maintain glucose levels (generally insulin needs will increase while on PN)
Charney P. A Spoonful of Sugar: Glycemic Control in the ICU. In Sharpening your skills as a nutrition support dietitian. DNS, 2003.
Regular Insulin in PN
Availability in TPN : 53 100%
Short half-life
infusion
Fluid Excess
Critically ill pts and those with cardiac, renal,
hepatic failure may require fluid restriction May need to restrict total calories to reduce total volume Use most concentrated source of PN components (70% dextrose = 2.38 kcal/ml; 20% lipid = 2 kcal/ml) PPN may be contraindicated due to fluid volume of 2-4 liters
Fluid Deficit
Patients with excessive losses may require
sterile water added to the PN Provide consistently required fluid volume in PN Monitor I/O, weight, serum sodium, BUN, HCT, skin turgor, pulse rate, BP, urine specific gravity
Electrolytes
Electrolytes in PN should be given at a stable dose
with intermittent requirements for supplementation given outside the PN Sodium levels often reflect fluid distribution versus sodium status Hypokalemia may be due to excessive GI losses, metabolic alkalosis, and refeeding Hyperkalemia may be due to renal failure, metabolic acidosis, potassium administration, or hyperglycemia
Acid-Base Balance
Balance chloride and acetate to
maintain/achieve equilibrium The standard acetate/chloride ratio is 1:1 Increase proportion of chloride with metabolic alkalosis; increase proportion of acetate with metabolic acidosis Consider chloride and acetate content of amino acids
HCO3- losses Decrease chloride concentration in TNA Consider chloride concentration in other IV fluids
diuretics or NG losses
Transitional Feeding
Maintain full PN support until pt is tolerating 1/3
of needs via enteral route Decrease TPN by 50% and continue to taper as the enteral feeding is advanced to total TPN can reduce appetite if >25% of calorie needs are met via PN TPN can be tapered when pt is consuming greater than 500 calories/d and d-cd when meeting 60% of goal TPN can be rapidly d-cd if pt is receiving enteral feeding in amount great enough to maintain blood glucose levels
Cessation of TPN
Rebound hypoglycemia is a potential
complication Decrease the volume by 50% for 1-2 hours before discontinuing the solution to minimize risk PPN can be stopped without concern for hypoglycemia
Monitor fluid/electrolyte/mineral status Provide standard vitamin and trace element preps
daily