nutrition parenteral formula nurpudji astuti department of nutrition school of medicine hasanuddin...

NUTRITION PARENTERAL formula

Nurpudji Astuti

Department of Nutrition

School of Medicine Hasanuddin University

@2013

‘A slender and restricted diet is always dangerous in chronic and in acute diseases’

Hippocrates 400 B.C.

ICU Nutrition in the 1970s

Safety Parenteral Nutritional

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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

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SUCCESSTHERAPY

Dikutip dari Presentasi Prof. DR. Dr. Eddy Rahardjo, SpAn KIC.

Parenteral Nutrition

Organisation of Nutrition Support

3. NICE Guidelines for Nutrition Support in Adults 2006

Screen

Recognise

Treat

Oral Enteral Parenteral

Monitor & Review

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


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


Objectives

Define Parenteral Nutrition Therapy (PN) Explain PN components Describe PN follow-up parameters

Definition

Parenteral nutrition is partial or total nutrition

administered intravenously. A peripheral or

central vein is used for access.

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

Containdications:Parenteral Nutrition

Ability to adequately receive and absorb

necessary foods orally or by gastric or

enteral tube Hemodynamic instability

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

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


Amino Acids Standard concentrations can vary between 5% and 15% Energy value of amino acids (4 kcal/g) Nitrogen (g) = protein (g) / 6.25

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

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

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


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.


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.

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

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

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.

Parenteral Nutrition Formula Calculations and Monitoring Protocols

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

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

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.

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

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

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


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.


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


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.


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

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/hrTPN 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 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

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.

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

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

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

Evaluation of a TNA Order

PN 15% Dextrose, 4.5% AA., and 3% 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 = 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

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

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

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


Example NPC:N Calculation

80 grams protein2250 nonprotein kcalories per day

80g protein/ 6.25 = 12.82250/12.8 = 176NPC:N = 176:1


Example %NPC Fat Calculation*

2250 nonprotein kcal550 lipid kcal

550/2250 x 100 = 24% fat kcals

*Limit is 60% NPC

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

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

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.)


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

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

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

Is this solution compoundable?

PN prescription:

AA 125 g

D 350 g

Lipid 50 g

Fluid restriction 1800 ml/day

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%)

Parenteral Nutrition

Monitoring

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

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

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

Inpatient Monitoring PN

Parameter Daily

Frequency

Weekly PRNBody Weight Initially √

Nitrogen Balance Initially √

HGB, HCT √

Catheter Site √

Lymphocyte Count √ √

Clinical Status

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)

Monitoring: NutritionSerum Hepatic ProteinsParameter t ½ Albumin 19 days

Transferrin 9 days

Prealbumin 2 – 3 days

Retinol Binding Protein ~12 hours

Complications of PN

Refeeding syndrome Hyperglycemia Acid-base disorders Hypertriglyceridemia Hepatobiliary complications (fatty liver,

cholestasis) Metabolic bone disease Vascular access sepsis

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CONCLUSION

NUTRITION

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Thank you

nutrition parenteral formula nurpudji astuti department of nutrition school of medicine hasanuddin...

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