Parenteral Nutrition Designing the Solution

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Parenteral NutritionDesigning the Solution

• Mark H. DeLegge, MD, FACG, AGAF, FASGE
• Digestive Disease Center
• Medical University of South Carolina

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Avoid That Which is Unknown
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Lipids
Protein
Carbohydrates
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Parenteral Nutrition

• Infusion of nutrients through a vein
• Indications dysfuntional GI system
• Malabsorption
• Obstruction
• Fistula
• Inability to obtain enteral access
• Bowel rest ?

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Parenteral Nutrition

• Central Infused into a major vein (CPN)
• Generally with catheter tip in the last 1/3 of
  Superior Vena Cava
• Peripheral Infused into a peripheral vein (PPN)
• Limited by mixture osmolality (lt 900 mOsmo)
• May limit ability to deliver total caloric needs

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PPN
CPN
Superior Vena Cava
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Osmolality Gradient and Carbohydrates
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Knowing the Solution

• Solution
• 10 AA 10 gm AA/100 H20
• 20 Lipids 20 gm lipids/100 cc H2O
• 30 Jack Daniels 30 gm Jack Daniels/100 cc H20

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What You Need to Know To Write A PN Prescription

• Calorie Requirements
• Protein Requirements
• Electrolyte Requirements
• Mineral Requirements
• Vitamin Requirements
• Water Requirements
• Other Additives

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Calorie Needs
Stress Factor Mild 1-1.2 Moderate 1.3-1.4 Severe
1.5

• Harris Benedict
• Male 66 13.8 (wt in kg) 5 (height in cm)
  6.8 (age in years)
• Female 655 9.6 (weight in kg) 1.8 (ht in cm)
  4.7 (age in years)

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Simple Calorie Calculation

• Maintenance/mild stress 20-25 kcal/kg/day
• Moderate stress 25-28 kcal/kg/day
• Severe Stress 28-35 kcal/kg/day

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Protein Needs

• Maintenance mild stress 0.8-1.2 g/kg/day
• Moderate stress 1.3-1.5 gm/kg/day
• Severe stress 1.5 2.0 gm/kg/day
• Very high stress gt 2 gm/kg/day

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Make Note of Common Lab Values

• Na 135-145 mEq/L
• K Serum 3.5-5.0 mEq/L
• Chloride 98-107 mmol/L
• CO2 22-32 mmol/L
• BUN 8-20 mg/dL
• Creatinine 0.7-1.3 mg/dL
• Calcium 8.4-10.2 mg/dL
• Phosphorus 2.3-4.7 mg/dL
• Magnesium 1.6-2.3 mg/dL

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Example of a Standard PN Electrolyte Matrix

• NACl 75 mEq/L
• Na Acetate 25 m Eq/L (CO2)
• K Phosphate 15 mmol
• (3 mmol of P 4.4 mEq/K)
• Na Phosphate 15 mmol
• (3 mmol of P 4 mEq Na)
• Ca Gluconate 2 gm
• Mg sulfate 1 gram

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Standard Trace Minerals

• Added to Daily PN Prescription
• Chromium 10 mcg
• Copper 1 mg
• Manganese 0.5 mg
• Selenium 60 mcg
• Zinc 5 mg

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Standard MultivitaminsProvided Daily

• Vitamin A 3300 IU
• Vitamin D 200 IU
• Vitamin E 10 IU
• Vitamin B1 6 mg
• Vitamin B2 3.6 mg
• Vitamin B3 40 mg
• Vitamin B5 15 mg
• Vitamin B6 6 mg
• Vitamin C 200 mg
• Biotin 60 mcg
• Folic Acid 600 mcg
• Vitamin K 150 mcg

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Daily Fluid Needs

• 30 cc/kg/day
• Reduce if volume overloaded
• Increase for excessive stool, urine, vomiting,
  sweating.
• You do not have to correct major electrolyte,
  mineral, fluid abnormalities in the PN solution.
  Use a supplemental infusion.

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Additives

• H2 Blocker
• Heparin
• Insulin
• Need at least 10 units/L to see clinical effect
• Add ½ to ¾ of previous days insulin requirements
  to TPN bag

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Additional Potential Additives

• Vitamin C
• 500-1000 mg/day for wound healing.
• Zinc
• 3-5 mg/day for wound healing
• Folic Acid
• 1 mg/day with alcohol abuse or pregnancy
• Thiamine
• 100 mg/day with alcohol abuse

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Important Facts

• Lipids no more than 2.5 gm/kg/day
• Carbohydrates Maximal glucose infusion rate 3-5
  g/kg/day
• Protein as described

• 1 gram lipids 9 kcal
• 1 gram protein 4 kcal
• 1 gram carbohydrates 3.4 kcal

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The Situation

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

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Estimated Needs

• Calories 30 kcal/g x 70 kg 2100 kcal
• Protein 1.2 g/kg x 70 kg 84 kg
• Fluids 30 ml/kg 2100 cc
• His electrolytes are normal except for a K of
  3.3.

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1st Add Protein

• 84 g of protein
• 4 kcal/g (326 kcal)
• 2100 kcal 326 kcal 1774 kcal more required

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2nd Add Lipids

• 1-1.5 g/kg
• 70 kg x 1 g/kg 70 gm
• 70 gm 700 kcal
• 1774 calories 700 kcal 1074 kcal remaining

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3rd Add Carbohydrates

• 1074 kcal remaining
• 1074/3.4 kcal/g carbohydrate 295 g
• Double check for maximal carbohydrate infusion
• 295 g carbohydrate/70 kg 4.21 g/kg/day

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Determine a Volume

• 70 kg x 30 cc/kg 2100 cc
• Add multivitamins
• Add trace minerals
• Add drugs if necessary

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

• 15 amino acids (15 gm/100 cc)
• We need 84 grams 560 cc
• 20 Lipids (20 gm/100 cc)
• We need 70 gm 350 cc
• 70 dextrose (70 gm/100 cc)
• We need 295 gm 421 cc
• 2100 cc volume 1361 cc 739 cc H20
• Add trace minerals, multivitamins and other drugs

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How do you Determine a Rate

• Continuous
• Total volume/24 hr cc/hr
• 2100/24 87 cc/hr
• Intermittent
• Total volume over 12 hours
• 2100/12 175 cc/hr

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Conclusion

• 1. Be able to determine calorie, protein, fluid
  needs
• 2. Be familiar with a standard electrolyte
  formulation
• 3. Make your PN formula sequentially
• 4. Be familiar with solutions and what they mean
• 5. Add this to your knowledge base

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Dont leave Nutrition Support up to Someone Else