Total Nutritional Therapy

(TNT)

Water
Daily water requirements can be estimated using a variety of methods.
Method 1

30 mL Water x Body Weight (kg)

Method 2

1 mL Water x Total kcal fed

Method 3

- use height and weight information to determine Body Surface Area (BSA) (m2)
using the Nomogram
- 1500 mL water/m2 BSA x actual BSA (m2)

Harris-Benedict Equation
Basal energy needs can be computed using information on Age, Weight, Height, and Sex, and the HarrisBenedict Equation (HBE) for men or women.
HBE for men

66.47 + 13.75 + 5.0H 6.76A

HBE for women

655.10 + 9.56W + 1.85H 4.67A

Weight in kg

Height in cm

Age in years

Created by : dr. Doni Kurniawan

Total Nutritional Therapy (TNT)

Total Energy Requirements

In the case of severely ill or injured patients, an injury factor should be included as follows :
Total Energy Requirements = HBE x Injury Factor
Injury Factor
Surgery
1.1
1.4 1.6

Minor
Mayor

Trauma
1.35
1.6
1.35

Skeletal
Head injury with steroid therapy
Blunt

Infection
1.2
1.5

Mild
Moderate

Burns
1.5
1.95

40 % of BSA
100 % of BSA

a Quick Method for Estimating Energy Requirements

a quick method for estimating initial energy requirements is to provide energy in the amount of 25 30
kcal/kg of actual body weight. Observe the patient to ensure that desired nutritional objectives are being
met (this method should not include an injury factor).

Protein
Normal protein requirements can be satisfied by providing 0.8 to 1.0 g protein/kg/day. Hypermetabolic
stress increases protein requirements as follows :
Degree of Hypermetabolic Stress
Normal No Stress

Grams of Protein Required (g/kg body

weight/day)
0.8 1.0

Mild

1.0 1.2

Moderate

1.2 1.5

Severe

1.5 2.0

Created by : dr. Doni Kurniawan

Total Nutritional Therapy (TNT)

Vitamins and minerals

The effect of severe illness and injury on vitamin and mineral requirements is not precisely known in
most cases. At least 100 % of the recommended intake of vitamins and minerals should be provided.

Electrolytes
The usual ranges for daily electrolyte requirements are :
Electrolyte

Range

Sodium (Na)
Potassium (K)
Chloride (Cl)
Calcium (Ca)
Magnesium (Mg)
Phosporus (P)

60 80
30 60
80 100
4.6 9.2
8.1 3.0
12 20

mEq
mEq
mEq
mEq
mEq
mEq

(FDA : Code of Federal Regulations 21. Washington, DC 1996)

Electrolyte Content of GI Secretions

Electrolyte Concentration (mEq/L)
Secretion

Sodium

Potassium

Chloride

Bicarbonate

Gastric Secretions

40 65

10

100 140

Pancreatic Fistula

135 155

55 75

70 90

Biliary Fistula

135 155

80 110

35 50

Ileostomy Fluid

120 130

10

50 60

50 70

Diarrhea Fluid

25 50

35 60

20 40

30 45

O Shea M. Fluid and electrolyte management. Manual of medical therapeutics. Washington university, St. Louis, 1992

Created by : dr. Doni Kurniawan

Total Nutritional Therapy (TNT)

Formula Sheet
1. A. Body Mass Index (BMI) :
BMI

Normal =

Weight (kg)/Height (m2)

20 25 kg/m2

B. Ideal Body Weight (IBW)

It is considered that of a BMI

20 25 kg/m2

2. Harris-Benedict Equation (HBE) of Basal Energy Expenditure (consistent with TNT manual) :
Males

= 66.47 + (13.75 x BW) + (5.0 x Height) (6.57 x Age)

Females

= 655.1 + (9.56 x BW) + (1.85 x Height) (4.67 x Age)

Note :
BW

= Body Weight in kg

Height

= Measured in centimeters

Age

= Years

Activity Factors :

1.2 confined to bed

1.3 out of bed

Stress Factors :
- Postoperative (no complications)

1.0

- Long Bone Fracture

1.15 1.30

- Cancer/COPD

1.10 1.30

- Peritonitis/Sepsis

1.10 1.30

- Severe Infection/Multiple Trauma

1.20 1.40

- Multiple Organ Failure Syndrome

1.20 2.00

- Burns

1.20 2.00

Created by : dr. Doni Kurniawan

Total Nutritional Therapy (TNT)

3. Rule of Thumb for Energy Determination :

25 30 kcal/kg Actual Body Weight (ABW) (unless Obese or with Edema)

4. Water :
30 mL x ABW

or

1 mL x kcal fed

or

1500 mL x BSA (m2)

5. Protein :
Baseline :

0.8 1.0 g/kg Usual Body Weight (UBW) (if morbidity Obese use 130 % IBW)

Stress

1.2 2.0 g/kg UBW (if morbidity obese use 130 % IBW)

Protein represents

15 20 % of total calories for hospitalized patients

Protein

4 kcal/g

6. Lipids :
Baseline :

20 35 % of total calories

Usually

25 35 % of total calories

Higher with COPD

35 55 % of total calories

Lipid

9 kcal/g MCTs : 8,3 kcal/g

In parenteral nutrition do not exceed 1 g/kg/day

Created by : dr. Doni Kurniawan

Total Nutritional Therapy (TNT)

7. Carbohidrate (CHO) :
Dextrose (parenteral)

3.4 kcal/g

Oral Carbohydrates

4 kcal/g

Maximum amounts

7 g/kg IBW/day

or

5 mg/kg/min

8. Protein is 16 % nitrogen :
Protein/6.25 = 1 g nitrogen
UUN = Urinary urea nitrogen in 24 hours urine collection
Total nitrogen loss = UUN + correction factor for fecal, skin, and other urinary nitrogen losses (4
g/day)
Total nitrogen loss = UUN + 4 g x 6.25 g protein/nitrogen = protein breakdown/day

9. PNT :
to determine volume of parenteral solution needed to provide X grams of substrate :
X g substrate/% solution concentration
e.g., what volume of 20 % dextrose solution is required to provide 65 g carbohydrate ?
answer

65 g carbohydrate/20 % solution

Created by : dr. Doni Kurniawan

65 g/0.20 = 325 mL

Total Nutritional Therapy (TNT)

Total Calorie Requirements

1. Total Calorie Provision :
30 x (Actual Body Weight or

Ideal Body Weight) x Stress Factors kcal

2. Protein :
20 % x Total Calorie

3. Lipid Provision :
30 % x Total Calorie

4. Carbohydrate Provision :
50 % x Total Calorie

5. Electrolyte Provision :
100 %

6. Micronutrient Provision :
100 %

7. Fluid Provision :

~ Total Calorie

Created by : dr. Doni Kurniawan

Total Nutritional Therapy (TNT)