nutrition parenteral formula nurpudji astuti department of nutrition school of medicine hasanuddin...
TRANSCRIPT
![Page 1: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/1.jpg)
NUTRITION PARENTERAL formula
Nurpudji Astuti
Department of Nutrition
School of Medicine Hasanuddin University
@2013
![Page 2: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/2.jpg)
‘A slender and restricted diet is always dangerous in chronic and in acute diseases’
Hippocrates 400 B.C.
![Page 3: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/3.jpg)
ICU Nutrition in the 1970s
![Page 4: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/4.jpg)
Safety Parenteral Nutritional
![Page 5: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/5.jpg)
5
GOAL OF NUTRITION THERAPY(medical nutrition therapy) Minimized loss of prot and energy for patient
with in adequate intake Through enteral and parenteral nutrition
NUTRITIONNUTRITION
An
tib
ioti
c
Dru
gs
Rad
ioth
erap
y
Op
erat
ion
SUCCESSTHERAPY
Dikutip dari Presentasi Prof. DR. Dr. Eddy Rahardjo, SpAn KIC.
![Page 6: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/6.jpg)
Parenteral Nutrition
![Page 7: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/7.jpg)
![Page 8: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/8.jpg)
Organisation of Nutrition Support
3. NICE Guidelines for Nutrition Support in Adults 2006
Screen
Recognise
Treat
Oral Enteral Parenteral
Monitor & Review
![Page 9: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/9.jpg)
Treat: Enteral
use the most appropriate route of access and mode of delivery
has a functional and accessible gastrointestinal tract
if patient malnourished/at risk of malnutritiondespite the use of oral interventions and
3. NICE Guidelines for Nutrition Support in Adults 2006
![Page 10: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/10.jpg)
Treat: PN
and has either
introduce progressively and monitor closely
if patient malnourished/at risk of malnutrition
a non-functional, inaccessible or perforated
gastrointestinal tract
inadequate or unsafe oral or enteral nutritional intake
use the most appropriate route of access and mode of delivery
3. NICE Guidelines for Nutrition Support in Adults 2006
![Page 11: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/11.jpg)
Objectives
Define Parenteral Nutrition Therapy (PN) Explain PN components Describe PN follow-up parameters
![Page 12: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/12.jpg)
Definition
Parenteral nutrition is partial or total nutrition
administered intravenously. A peripheral or
central vein is used for access.
![Page 13: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/13.jpg)
Indications: Parenteral Nutrition
Non-functional gastrointestinal tract Impossible to use the gastrointestinal tract Need for intestinal rest
Palliative use in terminal patients is controversial.
JPEN 2002;26(Suppl 1):83SA
![Page 14: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/14.jpg)
Containdications:Parenteral Nutrition
Ability to adequately receive and absorb
necessary foods orally or by gastric or
enteral tube Hemodynamic instability
![Page 15: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/15.jpg)
Central Parenteral Nutrition
Selection depends on caloric requirements, volume to be
administered and patient condition, as well as final
concentration of components:
Amino acids > 5%
Dextrose > 20%
Lipids
Includes vitamins, minerals, and trace elements
Osmolality > 700 mOsm/kg H2O
![Page 16: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/16.jpg)
Formulas : Parenteral Nutrition
Dextrose Provides 3.4 kcal/g Can be the only source of energy Dextrose infusion rate should not exceed 5 mg/kg/min Closely related to solution osmolality
Hill GL, et al. Br J Surg 1964;7:1
![Page 17: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/17.jpg)
Formulas : Parenteral Nutrition
Amino Acids Standard concentrations can vary between 5% and 15% Energy value of amino acids (4 kcal/g) Nitrogen (g) = protein (g) / 6.25
![Page 18: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/18.jpg)
Formulas : Parenteral NutritionLipids Prevent essential fatty acids deficiency Non-protein source of kcal. Recommended dose
1 g/kg/day Available 10%, 20%, and 30% concentrations Included as LCT or a mix of MCT/LCT at 10% and 20% Added to basic parenteral nutrition solutions or
administered individually
Trimbo SL. et al. Nutr Supp Serv 1986;6:18
![Page 19: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/19.jpg)
Formulas : Parenteral NutritionLipids Less hyperglicemia Lower concentrations of serum insulin Less risk of hepatic damage High dose can interfere with immune functions High infusion rates can affect respiratory functions Should be used with care in: - Hyperlipidemia
- Symptomatic athrosclerosis
- Acute pancreatitis with hypertrigliceridemia
![Page 20: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/20.jpg)
Formulas : Parenteral NutritionElectrolytes Calcium, magnesium, phosphorus, chloride, potassium,
sodium, and acetate Forms and amounts are titrated based on metabolic status
and fluid/electrolyte balance Must consider calcium-phosphate solubility
Alpers DH. et al., eds. In: Manual of Nutritional Therapeutics. Little, Brown and Company; 1995
![Page 21: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/21.jpg)
Formulas : Parenteral Nutrition
Vitamins and Minerals
In general, amounts below daily recommended intake
for healthy people, but nonetheless sufficient to cover
requirements, are added to oral or enteral formulas
Added daily to parenteral nutrition.
Acute illness, infection, preexisting malnutrition, and
excessive fluid loss increase vitamin requirements.
![Page 22: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/22.jpg)
Formulas : Parenteral Nutrition
Trace elements
Include daily zinc, copper, chromium, and manganase
for patients with kidney or liver failure.
Different requirements dictated by patient and pathology
Patients under extended parenteral nutrition require the
addition of iron and selenium.
![Page 23: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/23.jpg)
Peripheral Parenteral Nutrition
Selection of peripheral access depends on clinical
situation, requirements, tolerance to volume, and final
formula concentration.
Osmolality < 700 mOsm/kg
Total kcal limited by concentration and ratio to volume
being administered
Include ½ of the recommended electrolytes for PN
Torosian MH, ed. In: Nutrition for the Hospitalized Patient. Marcel Dekker Inc.;1995
![Page 24: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/24.jpg)
Monitoring Patient on Parenteral Nutrition
Metabolic• Glucose• Fluid and electrolyte balance• Renal and hepatic function• Triglycerides and cholesterol
Assessment • Body weight• Nitrogen balance• Plasma protein• Creatinine/height index
Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press. 1992
![Page 25: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/25.jpg)
Summary Parenteral nutrition supplies partial or total nutrition
by venous access
Total parenteral nutrition components supply all
required nutrients Metabolic monitoring and changes in solution
components are needed to maintain adequate metabolic balance.
![Page 26: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/26.jpg)
Parenteral Nutrition Formula Calculations and Monitoring Protocols
![Page 27: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/27.jpg)
Macronutrient Concentrations in PN Solutions Macronutrient concentrations (%) = the
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
![Page 28: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/28.jpg)
Protein Content Calculations
To calculate the grams 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
![Page 29: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/29.jpg)
Calculation of Dextrose Calories
Calculate grams of dextrose:– Multiply the total volume of dextrose soln (in
ml) supplied in a day by the dextrose concentration. This gives you grams of dextrose supplied in a day.
Multiply the grams of dextrose by 3.4 (there are 3.4 kcal/g dextrose) to determine kcalories supplied by dextrose in a day.
![Page 30: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/30.jpg)
Sample Dextrose Calculation
1000 ml of D50W (50% dextrose)– 1000 ml x 50g / 100 ml = 500g dextrose– OR 1000 ml x .50 = 500g dextrose
500g dextrose x 3.4 kcal/g = 1700 kcal
![Page 31: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/31.jpg)
Calculation of Lipid Content
To determine kcalories supplied by lipid*, 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.
Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
![Page 32: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/32.jpg)
Example Lipid Calculation for 2-in-1 500 ml of 10% lipid
– 500 ml x 1.1 kcal/ml = 550 kcal
500 ml 20% lipid – 500 ml x 2.0 kcal/ml = 1000 kcal
Or, alternatively, 500 ml of 10% lipid = 50 grams lipid x 10 kcal/g or 500 kcal
Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
![Page 33: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/33.jpg)
Calculation of Dextrose/AA with Piggyback Lipids (2-in-1) Determine patient's kcalorie, protein, and fluid
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
![Page 34: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/34.jpg)
Determine protein concentration
Subtract volume of lipid from total fluid 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
Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
![Page 35: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/35.jpg)
Determine dextrose concentration.
Subtract kcals of lipid + calories from protein 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.
Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
![Page 36: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/36.jpg)
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)
Remaining fluid needs: 2000cc - 480cc = 1520cc
![Page 37: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/37.jpg)
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
![Page 38: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/38.jpg)
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/hrTPN recommendation: Suggest two-in-one
PN 17.7% dextrose, 5.8% a.a. @ 63 cc/hr with 10% lipids piggyback @ 20 cc/hr
![Page 39: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/39.jpg)
Re-check calculationsTPN 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
![Page 40: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/40.jpg)
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.
![Page 41: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/41.jpg)
3-in-1 TNA Solutions Determine protein concentration by dividing protein needs
(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
![Page 42: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/42.jpg)
Sample Calculation 3-in-1
Nutrient Needs: – Kcals: 1800 Protein: 88 g Fluid: 2000 cc
Lipid : 1800 kcal x 30% = 540 kcal
– 540 kcal / 10 kcal per gram = 54 g
– 54 g / 2000 cc x 100 = 2.7% lipid
Protein: 88 g / 2000 cc x 100 =4.4% amino acids
88 g x 4 = 352 kcals from protein
![Page 43: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/43.jpg)
Sample Calculation 3-in-1(cont)
Dextrose: 908 kcal (1800 – 540 - 352)– 908/3.4 kcal/g = 267 g dextrose – 267 g / 2000 cc x 100 =
13.4% dextrose solution– Rate of Amino Acid / Dextrose/Lipid: 2000 cc /
24hr = 83 cc/hr– TPN prescription: Suggest TNA 13.4%
dextrose, 4.4% amino acids, 2.7% lipids at 83 cc/hour provides 88 g. protein, 1800 kcals, 2000 ml. fluid
![Page 44: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/44.jpg)
Evaluation of a TNA Order
PN 15% Dextrose, 4.5% AA., and 3% lipid @ 100 cc/hour
![Page 45: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/45.jpg)
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
![Page 46: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/46.jpg)
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
![Page 47: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/47.jpg)
Calculation of Nonprotein Calories Some clinicians discriminate between
protein and nonprotein calories although this is falling out of favor
This is more commonly used in critically ill patients
![Page 48: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/48.jpg)
Calculation of Non-Protein Calories
To determine the nonprotein kcalories (NPC) in a 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 (720/1944) In critically ill patients, some clinicians restrict
lipid to 30% of nonprotein kcals
![Page 49: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/49.jpg)
Calculation of NPC:N Ratio |
Calculate grams of nitrogen supplied per 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
Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
![Page 50: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/50.jpg)
Example NPC:N Calculation
80 grams protein2250 nonprotein kcalories per day
80g protein/ 6.25 = 12.82250/12.8 = 176NPC:N = 176:1
Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
![Page 51: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/51.jpg)
Example %NPC Fat Calculation*
2250 nonprotein kcal550 lipid kcal
550/2250 x 100 = 24% fat kcals
*Limit is 60% NPC
![Page 52: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/52.jpg)
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.
![Page 53: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/53.jpg)
IV-Related Phlebitis
![Page 54: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/54.jpg)
Calculating the Osmolarity of a Parenteral Nutrition Solution1. Multiply the grams of dextrose per liter by 5.
Example: 100 g of dextrose x 5 = 500 mOsm/L2. Multiply the grams of protein per liter by 10.
Example: 30 g of protein x 10 = 300 mOsm/L3. Multiply the grams of lipid per liter by 1.5.
Example: 40 g lipid x 1.5 = 60.4. Multiply the (mEq per L sodium + potassium +
calcium + magnesium) X 2 Example: 80 X 2 = 160
5. Total osmolarity = 500 + 300 + 60 + 160 = 1020 mOsm/L
Source: K&M and PN Nutrition in ADA, Nutrition in Clinical Practice. P 626
![Page 55: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/55.jpg)
Osmolarity Quick Calculation
To calculate solution osmolarity: multiply grams of dextrose per liter by 5 multiply grams of protein per liter by 10 add a & b add 300 to 400 to the answer from "c".
(Vitamins and minerals contribute about 300 to 400 mOsm/L.)
Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html
![Page 56: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/56.jpg)
Is the solution compoundable?
TPN is compounded using 10% or 15% 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
![Page 57: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/57.jpg)
Is the Solution Compoundable?
What is the minimum volume to compound the PN prescription?
Example: 75 g AA350 g dextrose 50 g lipid2000 ml fluid restriction
AA: 10 g = 75 g = 750 ml using 10% AA100 ml X ml
OR divide 75 grams by the % base solution, 75 g/ .10
![Page 58: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/58.jpg)
Is the solution compoundable?
Dextrose: 70 g = 350 g x = 500 ml 100 ml X ml
Lipid: 20 g = 50g X = 250 ml 100 ml x 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
![Page 59: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/59.jpg)
Is this solution compoundable?
PN prescription:
AA 125 g
D 350 g
Lipid 50 g
Fluid restriction 1800 ml/day
![Page 60: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/60.jpg)
Is this solution compoundable?AA: 10 g = 125 g = 1250 ml 10% AA
100 ml X mlDextrose: 70 g = 350 g x = 500 ml (350/.70) 100 ml X ml
Lipid: 20 g = 50g X = 250 ml (50/.20) 100 ml x ml
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%)
![Page 61: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/61.jpg)
Parenteral Nutrition
Monitoring
![Page 62: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/62.jpg)
Monitoring for Complications Malnourished patients at risk for refeeding
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
![Page 63: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/63.jpg)
Monitoring for Complications Serum electrolytes (sodium, potassium, chloride,
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
![Page 64: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/64.jpg)
Acute Inpatient PN Monitoring
Parameter Daily
Frequency
3x/week WeeklyGlucose Initially √
Electrolytes Initially √
Phos, Mg, BUN, Cr, Ca
Initially √
TG √
Fluid/Is & Os √
Temperature √
T. Bili, LFTs Initially √
Adapted from K&M, p. 549
![Page 65: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/65.jpg)
Inpatient Monitoring PN
Parameter Daily
Frequency
Weekly PRNBody Weight Initially √
Nitrogen Balance Initially √
HGB, HCT √
Catheter Site √
Lymphocyte Count √ √
Clinical Status
![Page 66: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/66.jpg)
Monitor—cont’d
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 applicableUrinary output (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)Cultures (as needed)
![Page 67: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/67.jpg)
Monitoring: NutritionSerum Hepatic ProteinsParameter t ½ Albumin 19 days
Transferrin 9 days
Prealbumin 2 – 3 days
Retinol Binding Protein ~12 hours
![Page 68: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/68.jpg)
Complications of PN
Refeeding syndrome Hyperglycemia Acid-base disorders Hypertriglyceridemia Hepatobiliary complications (fatty liver,
cholestasis) Metabolic bone disease Vascular access sepsis
![Page 69: NUTRITION PARENTERAL formula Nurpudji Astuti Department of Nutrition School of Medicine Hasanuddin University @2013](https://reader036.vdocuments.mx/reader036/viewer/2022062309/5697bf771a28abf838c81502/html5/thumbnails/69.jpg)
72
CONCLUSION
NUTRITION
An
tib
ioti
c
Dru
gs
Rad
ioth
erap
y
Op
erat
ion
SUCCESSTHERAPY
Thank you