Parenteral NutritionParenteral NutritionDesigning the SolutionDesigning the Solution

Mark H. DeLegge, MD, FACG, AGAF, Mark H. DeLegge, MD, FACG, AGAF, FASGEFASGE

Digestive Disease CenterDigestive Disease CenterMedical University of South CarolinaMedical University of South Carolina

Avoid That Which is UnknownAvoid That Which is Unknown

Lipids

Carbohydrates

Protein

Parenteral NutritionParenteral Nutrition

Infusion of nutrients through a veinInfusion of nutrients through a vein

Indications: dysfuntional GI systemIndications: dysfuntional GI system– MalabsorptionMalabsorption– ObstructionObstruction– FistulaFistula– Inability to obtain enteral accessInability to obtain enteral access– Bowel rest ?Bowel rest ?

Parenteral NutritionParenteral Nutrition

Central: Infused into a major vein (CPN)Central: Infused into a major vein (CPN)– Generally with catheter tip in the last 1/3 of Generally with catheter tip in the last 1/3 of

Superior Vena CavaSuperior Vena Cava

Peripheral: Infused into a peripheral vein Peripheral: Infused into a peripheral vein (PPN)(PPN)– Limited by mixture osmolality (< 900 mOsmo)Limited by mixture osmolality (< 900 mOsmo)– May limit ability to deliver total caloric needsMay limit ability to deliver total caloric needs

PPN CPN

Superior Vena Cava

Osmolality Gradient and Osmolality Gradient and CarbohydratesCarbohydrates

Glucose Glucose

ConcentrationConcentration % %CaloriesCalories

Kcal/LKcal/L

OsmolalityOsmolality

mOsmo/LmOsmo/L

55 170170 252252

1010 340340 505505

2020 680680 10101010

4040 13601360 20202020

5050 17001700 25252525

6060 20402040 30303030

7070 23802380 35353535

Knowing the SolutionKnowing the Solution

% Solution% Solution 10% AA10% AA = 10 gm AA/100 H= 10 gm AA/100 H200

20% Lipids20% Lipids = 20 gm lipids/100 cc H= 20 gm lipids/100 cc H22OO

30% Jack Daniels30% Jack Daniels = 30 gm Jack = 30 gm Jack Daniels/100 cc HDaniels/100 cc H2200

What You Need to Know To Write What You Need to Know To Write A PN PrescriptionA PN Prescription

Calorie RequirementsCalorie Requirements Protein RequirementsProtein Requirements Electrolyte RequirementsElectrolyte Requirements Mineral RequirementsMineral Requirements Vitamin RequirementsVitamin Requirements Water RequirementsWater Requirements Other AdditivesOther Additives

Calorie NeedsCalorie Needs

Harris Benedict:Harris Benedict: Male 66 + 13.8 (wt in Male 66 + 13.8 (wt in

kg) + 5 (height in cm) – kg) + 5 (height in cm) – 6.8 (age in years)6.8 (age in years)

Female 655 + 9.6 Female 655 + 9.6 (weight in kg) + 1.8 (ht (weight in kg) + 1.8 (ht in cm) – 4.7 (age in in cm) – 4.7 (age in years)years)

Stress Factor

Mild 1-1.2

Moderate 1.3-1.4

Severe 1.5

Simple Calorie CalculationSimple Calorie Calculation

Maintenance/mild Maintenance/mild stress:stress: 20-25 20-25 kcal/kg/daykcal/kg/day

Moderate stress:Moderate stress: 25- 25-28 kcal/kg/day28 kcal/kg/day

Severe StressSevere Stress : : 28-35 28-35 kcal/kg/daykcal/kg/day

Protein NeedsProtein Needs

Maintenance – mild Maintenance – mild stress: 0.8-1.2 stress: 0.8-1.2 g/kg/dayg/kg/day

Moderate stress: 1.3-Moderate stress: 1.3-1.5 gm/kg/day1.5 gm/kg/day

Severe stress: 1.5 – Severe stress: 1.5 – 2.0 gm/kg/day2.0 gm/kg/day

Very high stressVery high stress:: > 2 > 2 gm/kg/daygm/kg/day

Make Note of Common Lab ValuesMake Note of Common Lab Values

Na+Na+ 135-145 mEq/L135-145 mEq/LK+ SerumK+ Serum 3.5-5.0 mEq/L3.5-5.0 mEq/LChlorideChloride 98-107 mmol/L98-107 mmol/LCO2CO2 22-32 mmol/L22-32 mmol/LBUN BUN 8-20 mg/dL8-20 mg/dLCreatinineCreatinine 0.7-1.3 mg/dL0.7-1.3 mg/dLCalciumCalcium 8.4-10.2 mg/dL8.4-10.2 mg/dLPhosphorusPhosphorus 2.3-4.7 mg/dL2.3-4.7 mg/dLMagnesiumMagnesium 1.6-2.3 mg/dL1.6-2.3 mg/dL

Example of a Standard PN Example of a Standard PN Electrolyte MatrixElectrolyte Matrix

NACl NACl 75 mEq/L75 mEq/L Na Acetate Na Acetate 25 m Eq/L 25 m Eq/L (CO(CO2))

K PhosphateK Phosphate 15 mmol15 mmol (3 mmol of P = 4.4 mEq/K)(3 mmol of P = 4.4 mEq/K)

Na Phosphate Na Phosphate 15 mmol15 mmol (3 mmol of P = 4 mEq Na)(3 mmol of P = 4 mEq Na)

Ca Gluconate Ca Gluconate 2 gm 2 gm Mg sulfate Mg sulfate 1 gram 1 gram

Standard Trace MineralsStandard Trace Minerals

Added to Daily PN PrescriptionAdded to Daily PN Prescription ChromiumChromium 10 mcg10 mcg CopperCopper 1 mg1 mg ManganeseManganese 0.5 mg0.5 mg SeleniumSelenium 60 mcg60 mcg ZincZinc 5 mg5 mg

Standard MultivitaminsStandard MultivitaminsProvided DailyProvided Daily

Vitamin AVitamin A 3300 IU3300 IU Vitamin DVitamin D 200 IU200 IU Vitamin EVitamin E 10 IU 10 IU Vitamin B1Vitamin B1 6 mg 6 mg Vitamin B2Vitamin B2 3.6 mg 3.6 mg Vitamin B3Vitamin B3 40 mg40 mg Vitamin B5Vitamin B5 15 mg15 mg Vitamin B6Vitamin B6 6 mg 6 mg Vitamin CVitamin C 200 mg200 mg Biotin Biotin 60 mcg60 mcg Folic AcidFolic Acid 600 mcg600 mcg Vitamin KVitamin K 150 mcg150 mcg

Daily Fluid NeedsDaily Fluid Needs

30 cc/kg/day30 cc/kg/day Reduce if volume overloadedReduce if volume overloaded Increase for excessive stool, urine, vomiting, Increase for excessive stool, urine, vomiting,

sweating.sweating. You do not have to correct major electrolyte, You do not have to correct major electrolyte,

mineral, fluid abnormalities in the PN mineral, fluid abnormalities in the PN solution. Use a supplemental infusion.solution. Use a supplemental infusion.

AdditivesAdditives

H2 BlockerH2 Blocker HeparinHeparin InsulinInsulin

– Need at least 10 units/L to see clinical effectNeed at least 10 units/L to see clinical effect– Add ½ to ¾ of previous day’s insulin Add ½ to ¾ of previous day’s insulin

requirements to TPN bagrequirements to TPN bag

Additional Potential AdditivesAdditional Potential Additives

Vitamin C: Vitamin C:

500-1000 mg/day for wound healing. 500-1000 mg/day for wound healing.

Zinc: Zinc:

3-5 mg/day for wound healing3-5 mg/day for wound healing

Folic Acid: Folic Acid:

1 mg/day with alcohol abuse or pregnancy1 mg/day with alcohol abuse or pregnancy

Thiamine: Thiamine:

100 mg/day with alcohol abuse100 mg/day with alcohol abuse

Important FactsImportant Facts

Lipids: no more than Lipids: no more than 2.5 gm/kg/day2.5 gm/kg/day

Carbohydrates: Carbohydrates: Maximal glucose Maximal glucose infusion rate 3-5 infusion rate 3-5 g/kg/dayg/kg/day

Protein: as describedProtein: as described

1 gram lipids = 9 kcal1 gram lipids = 9 kcal 1 gram protein = 4 kcal1 gram protein = 4 kcal 1 gram carbohydrates 1 gram carbohydrates

= 3.4 kcal= 3.4 kcal

The SituationThe Situation

A 40 year old male s/p recurrent fistula A 40 year old male s/p recurrent fistula formation in the distal jejunum. He has lost 6 formation in the distal jejunum. He has lost 6 kg in 2 weeks. A central PN catheter is kg in 2 weeks. A central PN catheter is placed and you are asked to write a PN placed and you are asked to write a PN order. The patient weighs 70 kg.order. The patient weighs 70 kg.

Estimated NeedsEstimated Needs

CaloriesCalories 30 kcal/g x 70 kg = 2100 kcal30 kcal/g x 70 kg = 2100 kcal ProteinProtein 1.2 g/kg x 70 kg = 84 kg1.2 g/kg x 70 kg = 84 kg FluidsFluids 30 ml/kg = 2100 cc30 ml/kg = 2100 cc

His electrolytes are normal except for a KHis electrolytes are normal except for a K+ of 3.3.of 3.3.

11stst Add Protein Add Protein

84 g of protein84 g of protein 4 kcal/g (326 kcal)4 kcal/g (326 kcal) 2100 kcal – 326 kcal = 2100 kcal – 326 kcal = 1774 kcal more 1774 kcal more

requiredrequired

22ndnd Add Lipids Add Lipids

1-1.5 g/kg1-1.5 g/kg 70 kg x 1 g/kg = 70 gm70 kg x 1 g/kg = 70 gm 70 gm = 700 kcal70 gm = 700 kcal 1774 calories – 700 kcal = 1774 calories – 700 kcal = 1074 kcal 1074 kcal

remainingremaining

33rdrd Add Carbohydrates Add Carbohydrates

1074 kcal remaining1074 kcal remaining 1074/3.4 kcal/g carbohydrate = 1074/3.4 kcal/g carbohydrate = 295 g295 g

Double check for maximal carbohydrate Double check for maximal carbohydrate infusioninfusion

295 g carbohydrate/70 kg = 4.21 g/kg/day295 g carbohydrate/70 kg = 4.21 g/kg/day

Determine a VolumeDetermine a Volume

70 kg x 30 cc/kg = 2100 cc70 kg x 30 cc/kg = 2100 cc Add multivitaminsAdd multivitamins Add trace mineralsAdd trace minerals Add drugs if necessaryAdd drugs if necessary

What if the TPN Form Asks Me to What if the TPN Form Asks Me to Add Components as Solutions?Add Components as Solutions?

15% amino acids (15 gm/100 cc)15% amino acids (15 gm/100 cc)– We need 84 grams = 560 ccWe need 84 grams = 560 cc

20 Lipids (20 gm/100 cc)20 Lipids (20 gm/100 cc)– We need 70 gm = 350 ccWe need 70 gm = 350 cc

70% dextrose (70 gm/100 cc)70% dextrose (70 gm/100 cc)– We need 295 gm = 421 ccWe need 295 gm = 421 cc– 2100 cc volume – 1361 cc = 739 cc H2100 cc volume – 1361 cc = 739 cc H200– Add trace minerals, multivitamins and other Add trace minerals, multivitamins and other

drugsdrugs

How do you Determine a RateHow do you Determine a Rate

ContinuousContinuous Total volume/24 hr = cc/hrTotal volume/24 hr = cc/hr 2100/24 = 87 cc/hr2100/24 = 87 cc/hr

IntermittentIntermittent Total volume over 12 hoursTotal volume over 12 hours 2100/12 = 175 cc/hr 2100/12 = 175 cc/hr

ConclusionConclusion

1. Be able to determine calorie, protein, fluid 1. Be able to determine calorie, protein, fluid needsneeds

2. Be familiar with a standard electrolyte 2. Be familiar with a standard electrolyte formulationformulation

3. Make your PN formula sequentially3. Make your PN formula sequentially 4. Be familiar with solutions and what they 4. Be familiar with solutions and what they

meanmean 5. Add this to your knowledge base 5. Add this to your knowledge base

Don’t leave Nutrition Support up Don’t leave Nutrition Support up to Someone Elseto Someone Else