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Macronutrient Concentrations in PN
Solutions
Macronutrient concentrations (%) = the
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
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.
Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
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%
dextrose solution
Rate of Amino Acid / Dextrose: 1520
cc / 24hr = 63 cc/hr
TPN recommendation: Suggest two-in-one
PN 17.7% dextrose, 5.8% a.a. @ 63 cc/hr
with 10% lipids piggyback @ 20 cc/hr
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.
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 =
Calculation of Nonprotein
Calories
Some clinicians discriminate between
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.
20 g = 50g
100 ml
x ml
x = 500 ml
X = 250 ml
20 g = 50g
100 ml
x ml
X = 250 ml (50/.20)
Parenteral Nutrition
Monitoring
Frequency
3x/week
Glucose
Initially
Electrolytes
Initially
Parameter
Phos, Mg,
BUN, Cr, Ca
Initially
TG
Weekly
Fluid/Is & Os
Temperature
T. Bili, LFTs
Adapted from K&M, p. 549
Initially
Inpatient Monitoring PN
Parameter
Body Weight
Daily
Frequency
Weekly
Initially
Nitrogen Balance
Initially
HGB, HCT
Catheter Site
Lymphocyte Count
Clinical Status
PRN
Monitorcontd
Urine:
Other:
Monitoring: Nutrition
Serum Hepatic Proteins
Parameter
Albumin
19 days
Transferrin
9 days
Prealbumin
2 3 days
~12 hours
Complications of PN
Refeeding syndrome
Hyperglycemia
Acid-base disorders
Hypertriglyceridemia
Hepatobiliary complications (fatty liver,
cholestasis)
Metabolic bone disease
Vascular access sepsis
Refeeding Syndrome
Patients at risk are malnourished,
Refeeding Syndrome
Prevention/Treatment
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
Delivery coincides with nutrient
infusion
Fluid Excess
Critically ill pts and those with cardiac, renal,
Fluid Deficit
Patients with excessive losses may require
Electrolytes
Electrolytes in PN should be given at a stable dose
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
H+ ion
Ketoacidosis
Renal failure
Lactic acidosis
Excessive Cl- administration
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
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
Defense Against PN
Complications
Select appropriate patients to receive PN
Aseptic technique for insertion and site care of IV
catheters
Do not overfeed
daily