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Parenteral Nutrition Designing the Solution

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Parenteral Nutrition. Designing the Solution. Mark H. DeLegge, MD, FACG, AGAF, FASGE ... Parenteral Nutrition. Central: Infused into a major vein (CPN) ... – PowerPoint PPT presentation

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Title: Parenteral Nutrition Designing the Solution


1
Parenteral NutritionDesigning the Solution
  • Mark H. DeLegge, MD, FACG, AGAF, FASGE
  • Digestive Disease Center
  • Medical University of South Carolina

2
Avoid That Which is Unknown
3
Lipids
Protein
Carbohydrates
4
Parenteral Nutrition
  • Infusion of nutrients through a vein
  • Indications dysfuntional GI system
  • Malabsorption
  • Obstruction
  • Fistula
  • Inability to obtain enteral access
  • Bowel rest ?

5
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

6
PPN
CPN
Superior Vena Cava
7
Osmolality Gradient and Carbohydrates
8
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

9
What You Need to Know To Write A PN Prescription
  • Calorie Requirements
  • Protein Requirements
  • Electrolyte Requirements
  • Mineral Requirements
  • Vitamin Requirements
  • Water Requirements
  • Other Additives

10
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)

11
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

12
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

13
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

14
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

15
Standard Trace Minerals
  • Added to Daily PN Prescription
  • Chromium 10 mcg
  • Copper 1 mg
  • Manganese 0.5 mg
  • Selenium 60 mcg
  • Zinc 5 mg

16
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

17
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.

18
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

19
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

20
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

21
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.

22
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.

23
1st Add Protein
  • 84 g of protein
  • 4 kcal/g (326 kcal)
  • 2100 kcal 326 kcal 1774 kcal more required

24
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

25
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

26
Determine a Volume
  • 70 kg x 30 cc/kg 2100 cc
  • Add multivitamins
  • Add trace minerals
  • Add drugs if necessary

27
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

28
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

29
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

30
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