Parenteral Nutrition Presenter:Dr Sachin Anand Mod: Dr Sanjeev Aneja

Parenteral Nutrition (Definition)

Components are in elemental or “pre-Components are in elemental or “pre-digested” formdigested” form Protein as amino acidsProtein as amino acids CHO as dextroseCHO as dextrose Fat as lipid emulsionFat as lipid emulsion Electrolytes, vitamins and mineralsElectrolytes, vitamins and minerals

Parenteral Nutrition (PN) Definition Delivery of nutrients intravenously, e.g. via Delivery of nutrients intravenously, e.g. via

the bloodstream.the bloodstream. Central Parenteral Nutrition: often called Central Parenteral Nutrition: often called

Total Parenteral Nutrition (TPN); Total Parenteral Nutrition (TPN); delivered into a central veindelivered into a central vein

Peripheral Parenteral Nutrition (PPN): Peripheral Parenteral Nutrition (PPN): delivered into a smaller or peripheral veindelivered into a smaller or peripheral vein

Indications for PN When Specialized Nutrition Support (SNS) When Specialized Nutrition Support (SNS)

is indicated, EN should generally be used in is indicated, EN should generally be used in preference to PN. (B)preference to PN. (B)

When SNS is indicated, PN should be used When SNS is indicated, PN should be used when the gastrointestinal tract is not when the gastrointestinal tract is not functional or cannot be accessed and in functional or cannot be accessed and in patients who cannot be adequately patients who cannot be adequately nourished by oral diets or EN. (B)nourished by oral diets or EN. (B)

The anticipated duration of PN should be The anticipated duration of PN should be >>7 days7 days

Common Indications for PN Patient has failed EN with appropriate tube Patient has failed EN with appropriate tube

placementplacement Severe acute pancreatitis Severe acute pancreatitis Severe short bowel syndrome Severe short bowel syndrome Mesenteric ischemiaMesenteric ischemia Paralytic ileusParalytic ileus Small bowel obstructionSmall bowel obstruction GI fistula unless enteral access can be placed GI fistula unless enteral access can be placed

distal to the fistula or where volume of output distal to the fistula or where volume of output warrants trial of ENwarrants trial of EN

.

PN Central Access

May be delivered via femoral lines, internal May be delivered via femoral lines, internal jugular lines, and subclavian vein catheters jugular lines, and subclavian vein catheters in the hospital settingin the hospital setting

Peripherally inserted central catheters Peripherally inserted central catheters (PICC) are inserted via the cephalic and (PICC) are inserted via the cephalic and basilic veins basilic veins

Central access required for infusions that Central access required for infusions that are toxic to small veins due to medication are toxic to small veins due to medication pH, osmolarity, and volumepH, osmolarity, and volume

Venous Sites for Access to the Superior Vena Cava

PICC Lines (peripherally inserted central catheter) PICC lines may be used in ambulatory PICC lines may be used in ambulatory

settings or for long term therapysettings or for long term therapy Used for delivery of medication as well as Used for delivery of medication as well as

PNPN Inserted in the cephalic, basilic, median Inserted in the cephalic, basilic, median

basilic, or median cephalic veins and basilic, or median cephalic veins and threaded into the superior vena cavathreaded into the superior vena cava

Can remain in place for up to 1 year with Can remain in place for up to 1 year with proper maintenance and without proper maintenance and without complicationscomplications

PN: Peripheral Access

PN may be administered via peripheral access PN may be administered via peripheral access when when

Therapy is expected to be short term (10-14 Therapy is expected to be short term (10-14 days)days)

Energy and protein needs are moderateEnergy and protein needs are moderate Formulation osmolarity is <600-900 mOsm/LFormulation osmolarity is <600-900 mOsm/L Fluid restriction is not necessaryFluid restriction is not necessary

Parenteral Nutrition

Macronutrients &Macronutrients &

MicronutrientsMicronutrients

Macronutrients: Carbohydrate

Source:Source: Monohydrous dextroseMonohydrous dextrose Properties:Properties: Nitrogen sparing Nitrogen sparing

Energy sourceEnergy source3.4 Kcal/g3.4 Kcal/gHyperosmolarHyperosmolar

Recommended intake:Recommended intake:2 – 5 mg/kg/min2 – 5 mg/kg/min50-65% of total calories50-65% of total calories

Macronutrients: Carbohydrate

Potential Adverse Effects:Potential Adverse Effects: Increased minute ventilationIncreased minute ventilation Increased CO2 productionIncreased CO2 production Increased RQIncreased RQ Increased O2 consumptionIncreased O2 consumption Lipogenesis and liver problemsLipogenesis and liver problems HyperglycemiaHyperglycemia

Macronutrients: Amino Acids Source:Source: Crystalline amino acids— Crystalline amino acids—

standard or specialtystandard or specialty Properties:Properties: 4.0 Kcal/g4.0 Kcal/g

EAA 40–50% NEAA 50-EAA 40–50% NEAA 50-60%60%

Glutamine / CysteineGlutamine / Cysteine Recommended intake:Recommended intake:

0.8-2.0 g/kg/day0.8-2.0 g/kg/day15-20% of total calories15-20% of total calories

Macronutrients: Amino Acids

Potential Adverse Potential Adverse Effects:Effects:

Increased renal solute Increased renal solute loadload

AzotemiaAzotemia

Macronutrients: Lipid Source:Source: Safflower and/or soybean oilSafflower and/or soybean oil Properties:Properties: Long chain triglyceridesLong chain triglycerides

Isotonic or hypotonicIsotonic or hypotonic

Stabilized emulsionsStabilized emulsions 10 Kcals/g10 Kcals/g

Prevents essential fatty acid Prevents essential fatty acid deficiencydeficiency

Recommended intake: Recommended intake:

0.5 – 1.5 g/kg/day 0.5 – 1.5 g/kg/day (not >2 g/kg)(not >2 g/kg) 12 – 24 hour 12 – 24 hour infusion rateinfusion rate

Macronutrients: LipidsRequirementsRequirements 4% to 10% kcals given as lipid meets EFA 4% to 10% kcals given as lipid meets EFA

requirements; or 2% to 4% kcals given as linoleic requirements; or 2% to 4% kcals given as linoleic acidacid

Generally 500 mL of 10% fat emulsion given two Generally 500 mL of 10% fat emulsion given two times weekly or 500 mL of 20% lipids given once times weekly or 500 mL of 20% lipids given once weekly will prevent EFADweekly will prevent EFAD

Usual range 25% to 35% of total kcalsUsual range 25% to 35% of total kcals Max. 60% of kcal or 2 g fat/kgMax. 60% of kcal or 2 g fat/kg

Macronutrients: Lipids

Potential Adverse Effects:Potential Adverse Effects: Egg allergyEgg allergy HypertriglyceridemiaHypertriglyceridemia Decreased cell-mediated immunity (limit to <1 Decreased cell-mediated immunity (limit to <1

g/kg/day in critically ill immunosuppressed g/kg/day in critically ill immunosuppressed patients)patients)

Abnormal LFTsAbnormal LFTs

Parenteral Base SolutionsParenteral Base Solutions CarbohydrateCarbohydrate

Available in concentrations from 5% to 70%Available in concentrations from 5% to 70% D30, D50 and D70 used for manual mixingD30, D50 and D70 used for manual mixing

Amino acidsAmino acids Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutionsAvailable in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutions 8.5% and 10% generally used for manual mixing8.5% and 10% generally used for manual mixing

FatFat 10% emulsions = 1.1 kcal/ml10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml20% emulsions = 2 kcal/ml 30% emulsions = 3 kcal/ml (used only in mixing TNA, 30% emulsions = 3 kcal/ml (used only in mixing TNA,

not for direct venous delivery)not for direct venous delivery)

CarbohydrateCarbohydrate Available in concentrations from 5% to 70%Available in concentrations from 5% to 70% D30, D50 and D70 used for manual mixingD30, D50 and D70 used for manual mixing

Amino acidsAmino acids Available in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutionsAvailable in 3, 3.5, 5, 7, 8.5, 10, 15, 20% solutions 8.5% and 10% generally used for manual mixing8.5% and 10% generally used for manual mixing

FatFat 10% emulsions = 1.1 kcal/ml10% emulsions = 1.1 kcal/ml 20% emulsions = 2 kcal/ml20% emulsions = 2 kcal/ml 30% emulsions = 3 kcal/ml (used only in mixing TNA, 30% emulsions = 3 kcal/ml (used only in mixing TNA,

not for direct venous delivery)not for direct venous delivery)

Other RequirementsOther Requirements

Fluid—30 to 50 ml/kg (1.5 to 3 Fluid—30 to 50 ml/kg (1.5 to 3 L/day)L/day)

Sterile water is added to PN admixture Sterile water is added to PN admixture to meet fluid requirementsto meet fluid requirements

ElectrolytesElectrolytes Use acetate or chloride forms to Use acetate or chloride forms to

manage metabolic acidosis or alkalosismanage metabolic acidosis or alkalosis Vitamins: multivitamin formulationsVitamins: multivitamin formulations Trace elementsTrace elements

Fluid—30 to 50 ml/kg (1.5 to 3 Fluid—30 to 50 ml/kg (1.5 to 3 L/day)L/day)

Sterile water is added to PN admixture Sterile water is added to PN admixture to meet fluid requirementsto meet fluid requirements

ElectrolytesElectrolytes Use acetate or chloride forms to Use acetate or chloride forms to

manage metabolic acidosis or alkalosismanage metabolic acidosis or alkalosis Vitamins: multivitamin formulationsVitamins: multivitamin formulations Trace elementsTrace elements

Electrolytes/Vitamins/Trace Elements Because parenterally-administered vitamins Because parenterally-administered vitamins

and trace elements do not go through and trace elements do not go through digestion/absorption, recommendations are digestion/absorption, recommendations are lower than DRIslower than DRIs

Salt forms of electrolytes can affect acid-Salt forms of electrolytes can affect acid-base balancebase balance

Adult Parenteral Multivitamins New FDA requirements published in 2000 New FDA requirements published in 2000

replacing NAG-AMA guidelinesreplacing NAG-AMA guidelines Increased B1, B6, vitamin C, folic acid, Increased B1, B6, vitamin C, folic acid,

added Vitamin K added Vitamin K MVI Adult (Mayne Pharma) and Infuvite MVI Adult (Mayne Pharma) and Infuvite

(MVI-13) from Baxter contain Vitamin K (MVI-13) from Baxter contain Vitamin K and are consistent with the new FDA and are consistent with the new FDA guidelinesguidelines

MVI-12 (Mayne Pharma) does not contain MVI-12 (Mayne Pharma) does not contain Vitamin KVitamin K

Parenteral Nutrition Vitamin Guidelines

Vitamin FDA Guidelines*

A IU 3300 IU

D IU 200 IU

E IU 10 IU

K mcg 150 mcg

C mg 200

Folate mcg 600

Niacin mg 40

Vitamin FDA Guidelines*

B2 mg 3.6

B1 mg 6

B6 mg 6

B12 mg 5.0

Biotin mcg 60

B5 dexpanthenol

mg

15

*

Daily Trace Element Supplementation for Adult PNTRACE ELEMENT INTAKE

Chromium 10-15 mcg

Copper 0.3-0.5 mg

Manganese 60-100 mcg

Zinc 2.5-5.0 mg

Daily Electrolyte Requirements Adult PNElectrolyte PN Equiv

RDAStandard Intake

Calcium 10 mEq 10-15 mEq

Magnesium 10 mEq 8-20 mEq

Phosphate 30 mmol 20-40 mmol

Sodium N/A 1-2 mEq/kg + replacement

Potassium N/A 1-2 mEq/kg

Acetate N/A As needed for acid-base

Chloride N/A As needed for acid-base

PN Contaminants Components of PN formulations have been Components of PN formulations have been

found to be contaminated with trace found to be contaminated with trace elementselements

Most common contaminants are aluminum Most common contaminants are aluminum and manganeseand manganese

Aluminum toxicity a problem in pts with Aluminum toxicity a problem in pts with renal compromise on long-term PN and in renal compromise on long-term PN and in infants and neonatesinfants and neonates

Can cause osteopenia in long term adult PN Can cause osteopenia in long term adult PN patientspatients

PN Contaminants

FDA requires disclosure of aluminum FDA requires disclosure of aluminum content of PN componentscontent of PN components

Safe intake of aluminum in PN is set at 5 Safe intake of aluminum in PN is set at 5 mcg/kg/daymcg/kg/day

PN Contaminants Manganese toxicity has been reported in Manganese toxicity has been reported in

long term home PN patients long term home PN patients May lead to neurological symptomsMay lead to neurological symptoms Manganese concentrations of 8 to 22 Manganese concentrations of 8 to 22

mcg/daily volume have been reported in mcg/daily volume have been reported in formulations with no added manganeseformulations with no added manganese

May need to switch to single-unit trace May need to switch to single-unit trace elements that don’t include manganeseelements that don’t include manganese

Calculating Nutrient NeedsCalculating Nutrient Needs Provide adequate calories so protein is Provide adequate calories so protein is

not used as an energy sourcenot used as an energy source Avoid excess kcal (>35 kcal/kg) Avoid excess kcal (>35 kcal/kg) Determine energy and protein needs Determine energy and protein needs

using usual methods (kcals/kg, Ireton-using usual methods (kcals/kg, Ireton-Jones 1992, Harris-Benedict)Jones 1992, Harris-Benedict)

Use specific PN dosing guides for Use specific PN dosing guides for electrolytes, vitamins, and mineralselectrolytes, vitamins, and minerals

Provide adequate calories so protein is Provide adequate calories so protein is not used as an energy sourcenot used as an energy source

Avoid excess kcal (>35 kcal/kg) Avoid excess kcal (>35 kcal/kg) Determine energy and protein needs Determine energy and protein needs

using usual methods (kcals/kg, Ireton-using usual methods (kcals/kg, Ireton-Jones 1992, Harris-Benedict)Jones 1992, Harris-Benedict)

Use specific PN dosing guides for Use specific PN dosing guides for electrolytes, vitamins, and mineralselectrolytes, vitamins, and minerals

Caloric requirements

Based on Total Energy ExpenditureBased on Total Energy Expenditure

Can be estimated using predictive equationsCan be estimated using predictive equations

TEE = REE + Stress Factor + Activity TEE = REE + Stress Factor + Activity FactorFactor

Can be measured using metabolic chartCan be measured using metabolic chart

Caloric requirements

Stress FactorStress Factor

•Malnutrition - 30%

•peritonitis + 15%

•soft tissue trauma + 15%

•fracture + 20%

•fever (per oC rise) + 13%

•Moderate infection + 20%

•Severe infection + 40%

•<20% BSA Burns + 50%

•20-40% BSA Burns + 80%

•>40% BSA Burns + 100%

Increase WHO REE by stress factorsFever Increase 13% per degree

C

Cardiac Failure 15-25%

Traumatic Injury 20-30%

Severe respiratory distress or broncho-pulmonary dysplasia

25-30%

Severe sepsis 45-50

Caloric requirements

Activity FactorActivity Factor

Bed-bound + 20%

Ambulant + 30%

Active + 50%

Caloric requirements

REE Predictive equationsREE Predictive equations

Harris-Benedict EquationHarris-Benedict Equation

Males: REE = 66 + (13.7W) + (5H) - 6.8AMales: REE = 66 + (13.7W) + (5H) - 6.8AFemales: REE= 655 + (9.6W) + 1.8H - 4.7AFemales: REE= 655 + (9.6W) + 1.8H - 4.7A

Schofield EquationSchofield Equation

25 to 30 kcal/kg/day25 to 30 kcal/kg/day

Protein Requirements

1.2 to 1.5 g protein/kg 1.2 to 1.5 g protein/kg IBW IBW mild or moderate stressmild or moderate stress

Up to 2.5 g protein/kg Up to 2.5 g protein/kg IBW IBW burns or severe traumaburns or severe trauma

How much protein to give?

Based on calorie : nitrogen ratioBased on calorie : nitrogen ratio

Based on degree of stress & body weightBased on degree of stress & body weight

Based on Nitrogen BalanceBased on Nitrogen Balance

Calorie : Nitrogen Ratio

Normal ratio is Normal ratio is

150 cal : 1g Nitrogen150 cal : 1g Nitrogen

Critically ill patientsCritically ill patients

85 to 100 cal : 1 g Nitrogen in85 to 100 cal : 1 g Nitrogen in

Based on Stress & BW

Non-stress patientsNon-stress patients 0.8 g / kg / day0.8 g / kg / day

Mild stress Mild stress 1.0 to 1.2 g / kg / day1.0 to 1.2 g / kg / day

Moderate stressModerate stress 1.3 to 1.75 g / kg / day1.3 to 1.75 g / kg / day

Severe stressSevere stress 2 to 2.5 g / kg / day2 to 2.5 g / kg / day

Based on Nitrogen Balance

Aim for positive balance of Aim for positive balance of

1.5 to 2g / kg / day1.5 to 2g / kg / day

Peripheral Parenteral Nutrition Hyperosmolar solutions cause Hyperosmolar solutions cause

thrombophlebitis in peripheral veinsthrombophlebitis in peripheral veins Limited to 800 to 900 mOsm/kg (MHS Limited to 800 to 900 mOsm/kg (MHS

uses 1150 mOsm/kg w/ lipid in the uses 1150 mOsm/kg w/ lipid in the solution)solution)

Dextrose limited to 5-10% final Dextrose limited to 5-10% final concentration and amino acids 3% final concentration and amino acids 3% final concentrationconcentration

Electrolytes may also be limitedElectrolytes may also be limited Use lipid to protect veins and increase Use lipid to protect veins and increase

caloriescalories

Peripheral Parenteral Nutrition

New catheters allow longer support via New catheters allow longer support via this method this method

In adults, requires large fluid volumes to deliver In adults, requires large fluid volumes to deliver adequate nutrition support (2.5-3L)adequate nutrition support (2.5-3L)

May be appropriate in mild to moderate May be appropriate in mild to moderate malnutrition (<2000 kcal required or <14 days)malnutrition (<2000 kcal required or <14 days)

More commonly used in infants and childrenMore commonly used in infants and children ControversialControversial

Contraindications to Peripheral Parenteral Nutrition Significant malnutritionSignificant malnutrition Severe metabolic stressSevere metabolic stress Large nutrition or electrolyte needs Large nutrition or electrolyte needs

(potassium is a strong vascular irritant)(potassium is a strong vascular irritant) Fluid restrictionFluid restriction Need for prolonged PN (>2 weeks)Need for prolonged PN (>2 weeks) Renal or liver compromiseRenal or liver compromise

Compounding Methods Total nutrient admixture (TNA) or 3-in-1Total nutrient admixture (TNA) or 3-in-1

Dextrose, amino acids, lipid, additives are Dextrose, amino acids, lipid, additives are mixed together in one containermixed together in one container

Lipid is provided as part of the PN Lipid is provided as part of the PN mixture on a daily basis and becomes an mixture on a daily basis and becomes an important energy substrateimportant energy substrate

2-in-1 solution of dextrose, amino acids, 2-in-1 solution of dextrose, amino acids, additives additives Typically compounded in 1-liter bagsTypically compounded in 1-liter bags Lipid is delivered as piggyback daily or Lipid is delivered as piggyback daily or

intermittently as a source of EFAintermittently as a source of EFA

Advantages of TNA

Decreased nursing timeDecreased nursing time Decreased risk of touch contaminationDecreased risk of touch contamination Decreased pharmacy prep timeDecreased pharmacy prep time Cost savingsCost savings Easier administration in home PNEasier administration in home PN Better fat utilization in slow, continuous Better fat utilization in slow, continuous

infusion of fatinfusion of fat Physiological balance of macronutrientsPhysiological balance of macronutrients

Disadvantages of TNA

Diminished stability and compatibilityDiminished stability and compatibility IVFE (IV fat emulsions) limits the amount IVFE (IV fat emulsions) limits the amount

of nutrients that can be compoundedof nutrients that can be compounded Limited visual inspection of TNA; reduced Limited visual inspection of TNA; reduced

ability to detect precipitatesability to detect precipitates

Initiation of PN

Adults should be hemodynamically stable, Adults should be hemodynamically stable, able to tolerate the fluid volume necessary able to tolerate the fluid volume necessary to deliver significant support, and have to deliver significant support, and have central venous accesscentral venous access

If central access is not available, PPN If central access is not available, PPN should be considered (more commonly used should be considered (more commonly used in neonatal and peds population)in neonatal and peds population)

Start slowlyStart slowly(1 L 1st day; 2 L 2nd day)(1 L 1st day; 2 L 2nd day)

Initiation of PN: formulation

As protein associated with few metabolic As protein associated with few metabolic side effects, maximum amount of protein side effects, maximum amount of protein can be given on the first day, up to 60-70 can be given on the first day, up to 60-70 grams/litergrams/liter

Maximum CHO given first day 150-200 Maximum CHO given first day 150-200 g/day or a 15-20% final dextrose g/day or a 15-20% final dextrose concentrationconcentration

In pts with glucose intolerance, 100-150 g In pts with glucose intolerance, 100-150 g dextrose or 10-15% glucose concentration dextrose or 10-15% glucose concentration may be given initiallymay be given initially

Initiation of PN: Formulation

Generally energy and protein needs can be Generally energy and protein needs can be met in adults by day 2 or 3met in adults by day 2 or 3

In neonates and peds, time to reach full In neonates and peds, time to reach full support relates inversely to age, may be 3-5 support relates inversely to age, may be 3-5 daysdays

Initiation of PN: Formulation

Dextrose content of PN can be increased if Dextrose content of PN can be increased if capillary blood glucose levels are capillary blood glucose levels are consistently consistently <<180 mg/dL180 mg/dL

IVFE in PN can be increased if triglycerides IVFE in PN can be increased if triglycerides are are <<400 mg/dL400 mg/dL

Parenteral Nutrition Formula Calculations and Monitoring Protocols

Example CalculationNutrient Needs:Nutrient Needs:

Kcals: 1800. Protein: 88 g. Fluid: 2000 cc Kcals: 1800. Protein: 88 g. Fluid: 2000 cc

    1800 kcal x 30% = 540 kcal from 1800 kcal x 30% = 540 kcal from lipidlipid

Lipid (10%):Lipid (10%): 540 kcal/1.1 (kcal/cc) = 491 cc/24 hr =540 kcal/1.1 (kcal/cc) = 491 cc/24 hr =

20 cc/hr 10% lipid (round to 480 ml)20 cc/hr 10% lipid (round to 480 ml) Remaining fluid needs: 2000cc - 480cc = Remaining fluid needs: 2000cc - 480cc =

1520cc 1520cc **||Lipid emulsions contain glycerol, so lipid emulsion does Lipid emulsions contain glycerol, so lipid emulsion does

not have 9 kcal per gram as it would if it were pure fat. not have 9 kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for lipid emulsions.Some use 10 kcal/gm for lipid emulsions.

Protein Calculations

Protein: 88 g / 1520 cc x 100 =Protein: 88 g / 1520 cc x 100 =5.8% amino acid solution5.8% amino acid solution

88 g. x 4 kcal/gm =352 kcals from 88 g. x 4 kcal/gm =352 kcals from proteinprotein

Remaining kcal needs: 1800 – (528 Remaining kcal needs: 1800 – (528 + 352)+ 352) = = 920920 kcal kcal

Dextrose Concentration

920920 kcal/3.4 kcal/g = kcal/3.4 kcal/g = 270270 g dextrose g dextrose 270270 g / 1520 cc x 100 = g / 1520 cc x 100 = 17.717.7% %

dextrose solutiondextrose solution Rate of Amino Acid / Dextrose: 1520 Rate of Amino Acid / Dextrose: 1520

cc / 24hr = 63 cc/hrcc / 24hr = 63 cc/hrTPN recommendation: Suggest two-in-one TPN recommendation: Suggest two-in-one

PN 17.7% dextrose, 5.8% a.a. @ 63 cc/hr PN 17.7% dextrose, 5.8% a.a. @ 63 cc/hr with 10% lipids piggyback @ 20 cc/hrwith 10% lipids piggyback @ 20 cc/hr

Sample Calculation 3-in-1 Nutrient Needs:Nutrient Needs:

Kcals: 1800 Protein: 88 g Fluid: 2000 cc Kcals: 1800 Protein: 88 g Fluid: 2000 cc

    Lipid : 1800 kcal x 30% = 540 kcal Lipid : 1800 kcal x 30% = 540 kcal

540 kcal / 10 kcal per gram = 54 g 540 kcal / 10 kcal per gram = 54 g 54 g / 2000 cc x 100 = 2.7% lipid54 g / 2000 cc x 100 = 2.7% lipid

Protein: 88 g / 2000 cc x 100 =Protein: 88 g / 2000 cc x 100 =4.4% amino acids4.4% amino acids

88 g x 4 = 352 kcals from protein88 g x 4 = 352 kcals from protein In critically ill patients, some clinicians restrict In critically ill patients, some clinicians restrict

lipid to 30% of nonprotein kcalslipid to 30% of nonprotein kcals

Sample Calculation 3-in-1(cont)

Dextrose: Dextrose: 908908 kcal (1800 – 540 kcal (1800 – 540 - 352- 352)) 908/3.4 kcal/g = 908/3.4 kcal/g = 267267 g dextrose g dextrose 267267 g / 2000 cc x 100 = g / 2000 cc x 100 =

13.413.4% dextrose solution% dextrose solution Rate of Amino Acid / Dextrose/Lipid: Rate of Amino Acid / Dextrose/Lipid:

2000 cc / 24hr = 83 cc/hr2000 cc / 24hr = 83 cc/hr TPN prescription: Suggest TNA 13.4% TPN prescription: Suggest TNA 13.4%

dextrose, 4.4% amino acids, 2.7% lipids dextrose, 4.4% amino acids, 2.7% lipids at 83 cc/hour provides 88 g. protein, 1800 at 83 cc/hour provides 88 g. protein, 1800 kcals, 2000 ml. fluidkcals, 2000 ml. fluid

Calculating the Osmolarity of a Parenteral Nutrition Solution1.1. Multiply the grams of dextrose per liter by 5. Multiply the grams of dextrose per liter by 5.

Example: 100 g of dextrose x 5 = 500 mOsm/LExample: 100 g of dextrose x 5 = 500 mOsm/L2.2. Multiply the grams of protein per liter by 10. Multiply the grams of protein per liter by 10.

Example: 30 g of protein x 10 = 300 mOsm/LExample: 30 g of protein x 10 = 300 mOsm/L3.3. Multiply the grams of lipid per liter by 1.5.Multiply the grams of lipid per liter by 1.5.

Example: 40 g lipid x 1.5 = 60.Example: 40 g lipid x 1.5 = 60.4.4. Multiply the (mEq per L sodium + potassium + Multiply the (mEq per L sodium + potassium +

calcium + magnesium) X 2calcium + magnesium) X 2 Example: 80 X 2 = 160Example: 80 X 2 = 160

5.5. Total osmolarity = 500 + 300 + 60 + 160 = 1020 Total osmolarity = 500 + 300 + 60 + 160 = 1020 mOsm/LmOsm/L

PN Administration:Transition to Enteral Feedings in Adults ControversialControversial In adults receiving oral or enteral nutrition In adults receiving oral or enteral nutrition

sufficient to maintain blood glucose, no sufficient to maintain blood glucose, no need to taper PNneed to taper PN

Reduce rate by half every 1 to 2 hrsReduce rate by half every 1 to 2 hrsor switch to 10% dextrose IV) may prevent or switch to 10% dextrose IV) may prevent rebound hypoglycemia (not necessary in rebound hypoglycemia (not necessary in PPN)PPN)

Monitor blood glucose levels 30-60 minutes Monitor blood glucose levels 30-60 minutes after cessationafter cessation

PN Administration:Transition to Enteral Feedings in Pediatrics Generally tapered more slowly than in Generally tapered more slowly than in

adults as oral or enteral feedings are adults as oral or enteral feedings are introduced and advancedintroduced and advanced

Generally PN is continued until 75-80% of Generally PN is continued until 75-80% of energy needs are met enterallyenergy needs are met enterally

Medications That May Be Added to Total Nutrient Admixture (TNA) PhytonadionePhytonadione SeleniumSelenium Zinc chlorideZinc chloride LevocarnitineLevocarnitine InsulinInsulin

MetoclopromideMetoclopromide RanitidineRanitidine Sodium iodideSodium iodide HeparinHeparin OctreotideOctreotide

Parenteral Nutrition

Infusion SchedulesInfusion Schedules

Infusion Schedules

Continuous PNContinuous PN

Non-interrupted infusion of a PN solution over 24 Non-interrupted infusion of a PN solution over 24 hours via a central or peripheral venous accesshours via a central or peripheral venous access

Continuous PN

AdvantagesAdvantages Well tolerated by most patientsWell tolerated by most patients Requires less manipulationRequires less manipulation

decreased nursing timedecreased nursing time decreased potential for “touch” decreased potential for “touch”

contaminationcontamination

Continuous PN

DisadvantagesDisadvantages Persistent anabolic statePersistent anabolic state

altered insulin : glucagon ratiosaltered insulin : glucagon ratios increased lipid storage by the liverincreased lipid storage by the liver

Reduces mobility in ambulatory patientsReduces mobility in ambulatory patients

Infusion Schedules Cyclic PNCyclic PN

The intermittent administration of PN via The intermittent administration of PN via a central or peripheral venous access, a central or peripheral venous access, usually over a period of 12 – 18 hoursusually over a period of 12 – 18 hours

Patients on continuous therapy may be Patients on continuous therapy may be converted to cyclic PN over 24-48 hoursconverted to cyclic PN over 24-48 hours

Cyclic PN AdvantagesAdvantages

Approximates normal physiology of Approximates normal physiology of intermittent feedingintermittent feeding

Maintains:Maintains:Nitrogen balanceNitrogen balanceVisceral proteinsVisceral proteins

Ideal for ambulatory patientsIdeal for ambulatory patientsAllows normal activityAllows normal activityImproves quality of lifeImproves quality of life

Cyclic PN DisadvantagesDisadvantages

Incorporation of NIncorporation of N22 into muscle stores into muscle stores

may be suboptimalmay be suboptimalNutrients administered when patient is Nutrients administered when patient is

less activeless active Not tolerated by critically ill patientsNot tolerated by critically ill patients Requires more nursing manipulationRequires more nursing manipulation

Increased potential for touch Increased potential for touch contaminationcontamination

Increased nursing timeIncreased nursing time

Common Indications for PN in Peds Surgical GI disordersSurgical GI disorders Intractable diarrhea of infancyIntractable diarrhea of infancy Short bowel syndromeShort bowel syndrome Inflammatory bowel diseaseInflammatory bowel disease Intractable chylothoraxIntractable chylothorax Intensive cancer treatmentIntensive cancer treatment

Pediatric Energy Needs in PN No consensus exists as to how to determine No consensus exists as to how to determine

energy needs of hospitalized childrenenergy needs of hospitalized children RDAs are intended for healthy children but RDAs are intended for healthy children but

can use for healthy/acutely ill children and can use for healthy/acutely ill children and monitor responsemonitor response

Can estimate REE using WHO equation and Can estimate REE using WHO equation and add stress factors, monitor clinical courseadd stress factors, monitor clinical course

Indirect calorimetry recommended in Indirect calorimetry recommended in difficult casesdifficult cases

REE(KCAL/min=3.94*DVo2+1.11DVCO2)REE(KCAL/min=3.94*DVo2+1.11DVCO2)

RDAs for Energy and ProteinCategory Age (yr) Energy

(kcal/kg/d)

Protein(g/kg/d)

Infants 0.0-0.5 108 2.2

Children 1-3 102 1.2

4-6 90 1.1

7-10 70 1.0

Females 11-14 47 1.0

15-18 40 0.8

Males 11-14 44 1.0

15-18 45 0.9

WHO Equations to predict REE from body weightSex/Age Range (years) Equation to Derive REE

(kcal/d)

Males 0-3 (60.0 x wt) – 54

Males 3-10 (22.7 x wt) + 495

Males 10-18 (17.5 x wt) + 651

Females 0-3 (6.1 x wt) – 51

Females 3-10 (22.5 x wt) + 499

Females 10-18 (12.2 x wt) + 746

Trauma/Critically Ill Peds

Age in years Kcals/kg G/pro/kg

0-1 90-120 2.0-3.5

1-6 75-90 1.8-3.0

7-12 50-75 1.5-2.5

13-18 30-60 1.0-2.0

Pediatric PN: Fluids

Standard calculation: Standard calculation: 100 kcal/kg for infant 3-10 kg100 kcal/kg for infant 3-10 kg 1000 kcal + 50 kcal/kg for every kg over 1000 kcal + 50 kcal/kg for every kg over

10 kg for a child 10-20 kg10 kg for a child 10-20 kg 1500 kcal + 20 kcal/kg for every kg over 1500 kcal + 20 kcal/kg for every kg over

20 kg for a child over 20 kg20 kg for a child over 20 kg 1 mL fluid/kcal/d + adjustments for fever, 1 mL fluid/kcal/d + adjustments for fever,

diarrhea, stress, etc.diarrhea, stress, etc.

Pediatric PN: Carbohydrate

Carbohydrate should comprise 45-50% of Carbohydrate should comprise 45-50% of caloric intake in infants and children (C)caloric intake in infants and children (C)

For neonates, CHO delivery in PN should For neonates, CHO delivery in PN should begin at 6-8 mg/kg/minute of dextrose and begin at 6-8 mg/kg/minute of dextrose and advanced to 10-14 mg/kg/minute. (B)advanced to 10-14 mg/kg/minute. (B)

Pediatric PN: Lipid

Preterm: start at .5 g/kg/day and increase by Preterm: start at .5 g/kg/day and increase by .5g/kg q day.5g/kg q day

Infants: Start at 1 g/kg and increase by .5 g/kg/day Infants: Start at 1 g/kg and increase by .5 g/kg/day until the maximum or desired dose is reached; until the maximum or desired dose is reached; need 0.5 to 1 g/kg/day for EFA needsneed 0.5 to 1 g/kg/day for EFA needs

Maximum is 3 g/kg for <24 months old and Maximum is 3 g/kg for <24 months old and 2.5g/kg for 24 months and older2.5g/kg for 24 months and older

Daily Electrolyte and Mineral Requirements for Peds PtsElectrolyte Infants/Children Adolescents

Sodium 2-6 mEq/kg Individualized

Chloride 2-5 mEq/kg Individualized

Potassium 2-3 mEq/kg Individualized

Calcium 1-2.5 mEq/kg 10-20 mEq

Phosphorus 0.5-1 mmol/kg 10-40 mmol

Magnesium 0.3-0.5 mEq/kg 10-30 mEq

Document in Chart Type of feeding formula and tubeType of feeding formula and tube Method (bolus, drip, pump)Method (bolus, drip, pump) Rate and water flushRate and water flush Intake energy and proteinIntake energy and protein Tolerance, complications, and Tolerance, complications, and

corrective actions corrective actions Patient educationPatient education

Parenteral Nutrition

MonitoringMonitoring

Monitoring for Complications Malnourished patients at risk for refeeding Malnourished patients at risk for refeeding

syndrome should have serum phosphorus, syndrome should have serum phosphorus, magnesium, potassium, and glucose levels magnesium, potassium, and glucose levels monitored closely at initiation of SNS. (B)monitored closely at initiation of SNS. (B)

In patients with diabetes or risk factors for glucose In patients with diabetes or risk factors for glucose intolerance, SNS should be initiated with a low intolerance, SNS should be initiated with a low dextrose infusion rate and blood and urine glucose dextrose infusion rate and blood and urine glucose monitored closely. (C)monitored closely. (C)

Blood glucose should be monitored frequently Blood glucose should be monitored frequently upon initiation of SNS, upon any change in insulin upon initiation of SNS, upon any change in insulin dose, and until measurements are stable. (B)dose, and until measurements are stable. (B)

Monitoring for Complications

Serum electrolytes (sodium, potassium, chloride, Serum electrolytes (sodium, potassium, chloride, and bicarbonate) should be monitored frequently and bicarbonate) should be monitored frequently upon initiation of SNS until measurements are upon initiation of SNS until measurements are stable. (B)stable. (B)

Patients receiving intravenous fat emulsions Patients receiving intravenous fat emulsions should have serum triglyceride levels monitored should have serum triglyceride levels monitored until stable and when changes are made in the until stable and when changes are made in the amount of fat administered. (C)amount of fat administered. (C)

Liver function tests should be monitored Liver function tests should be monitored periodically in patients receiving PN. (A)periodically in patients receiving PN. (A)

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 √

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:Urine:Glucose and ketones (4-6/day)Glucose and ketones (4-6/day)Specific gravity or osmolarity (2-4/day)Specific gravity or osmolarity (2-4/day)Urinary urea nitrogen (weekly)Urinary urea nitrogen (weekly)

Other:Other:Volume infusate (daily)Volume infusate (daily)Oral intake (daily) if applicableOral intake (daily) if applicableUrinary output (daily)Urinary output (daily)Activity, temperature, respiration (daily)Activity, temperature, respiration (daily)WBC and differential (as needed)WBC and differential (as needed)Cultures (as needed)Cultures (as needed)

Monitoring: NutritionSerum Hepatic ProteinsSerum Hepatic ProteinsParameterParameter t ½ t ½ AlbuminAlbumin 19 days19 days

TransferrinTransferrin 9 days9 days

PrealbuminPrealbumin 2 – 3 2 – 3 daysdays

Retinol Binding ProteinRetinol Binding Protein ~12 ~12 hourshours

Complications of PN

Refeeding syndromeRefeeding syndrome HyperglycemiaHyperglycemia Acid-base disordersAcid-base disorders HypertriglyceridemiaHypertriglyceridemia Hepatobiliary complications (fatty liver, Hepatobiliary complications (fatty liver,

cholestasis)cholestasis) Metabolic bone diseaseMetabolic bone disease Vascular access sepsisVascular access sepsis

Refeeding Syndrome

Patients at risk are malnourished, Patients at risk are malnourished, particularly marasmic patientsparticularly marasmic patients

Can occur with enteral or parenteral Can occur with enteral or parenteral nutritionnutrition

Results from intracellular electrolyte shift.Results from intracellular electrolyte shift. M C due to hypophosphatemia and M C due to hypophosphatemia and

Hypoglycemia .Hypoglycemia .

Refeeding Syndrome Symptoms Reduced serum levels of magnesium, Reduced serum levels of magnesium,

potassium, and phosphoruspotassium, and phosphorus Hyperglycemia and hyperinsulinemiaHyperglycemia and hyperinsulinemia Interstitial fluid retentionInterstitial fluid retention Cardiac decompensation and arrestCardiac decompensation and arrest

Refeeding Syndrome Prevention/Treatment Monitor and supplement electrolytes, Monitor and supplement electrolytes,

vitamins and minerals prior to and during vitamins and minerals prior to and during infusion of PN until levels remain stableinfusion of PN until levels remain stable

Initiate feedings with 15-20 kcal/kg or 1000 Initiate feedings with 15-20 kcal/kg or 1000 kcals/day and 1.2-1.5 g protein/kg/daykcals/day and 1.2-1.5 g protein/kg/day

Limit fluid to 800 ml + insensible losses Limit fluid to 800 ml + insensible losses (adjust per patient fluid tolerance and (adjust per patient fluid tolerance and status)status)

Glycemic Control in Critical Care Until recently, BG<200 mg/dl was tolerated Until recently, BG<200 mg/dl was tolerated

in critically ill patients. in critically ill patients. Now greater attention is given to glycemic Now greater attention is given to glycemic

control due to evidence that glucose is control due to evidence that glucose is associated with morbidity/mortality and associated with morbidity/mortality and risk of infectionrisk of infection

New recommendation is to keep BG<150 New recommendation is to keep BG<150 mg/dl or as close to normal as possiblemg/dl or as close to normal as possible

Glycemic Control in PNFor Patients Not Previously on InsulinFor Patients Not Previously on Insulin Monitor blood glucose levels prior to Monitor blood glucose levels prior to

initiating PNinitiating PN When therapy is initiated, monitor BG q 4-6 When therapy is initiated, monitor BG q 4-6

hours and use sliding scale or insulin drip as hours and use sliding scale or insulin drip as needed needed

Add a portion of the previous day’s insulin Add a portion of the previous day’s insulin to TPN to maintain blood glucose levelsto TPN to maintain blood glucose levels

Glycemic Control in PNFor Patients Previously on InsulinFor Patients Previously on Insulin Determine amount of insulin needed prior Determine amount of insulin needed prior

to illnessto illness Determine amount of feedings to be givenDetermine amount of feedings to be given Provide a portion of daily insulin needs in Provide a portion of daily insulin needs in

first PN along with sliding scale or insulin first PN along with sliding scale or insulin drip to maintain glucose levels (generally drip to maintain glucose levels (generally insulin needs will increase while on PN)insulin needs will increase while on PN)

Fluid Excess

Critically ill pts and those with cardiac, renal, Critically ill pts and those with cardiac, renal, hepatic failure may require fluid restrictionhepatic failure may require fluid restriction

May need to restrict total calories to reduce total May need to restrict total calories to reduce total volumevolume

Use most concentrated source of PN components Use most concentrated source of PN components (70% dextrose = 2.38 kcal/ml; 20% lipid = 2 (70% dextrose = 2.38 kcal/ml; 20% lipid = 2 kcal/ml)kcal/ml)

PPN may be contraindicated due to fluid volume PPN may be contraindicated due to fluid volume of 2-4 litersof 2-4 liters

Electrolytes Electrolytes in PN should be given at a stable dose Electrolytes in PN should be given at a stable dose

with intermittent requirements for with intermittent requirements for supplementation given outside the PNsupplementation given outside the PN

Sodium levels often reflect fluid distribution Sodium levels often reflect fluid distribution versus sodium statusversus sodium status

Hypokalemia may be due to excessive GI losses, Hypokalemia may be due to excessive GI losses, metabolic alkalosis, and refeedingmetabolic alkalosis, and refeeding

Hyperkalemia may be due to renal failure, Hyperkalemia may be due to renal failure, metabolic acidosis, potassium administration, or metabolic acidosis, potassium administration, or hyperglycemiahyperglycemia

Acid-Base Balance

Balance chloride and acetate to Balance chloride and acetate to maintain/achieve equilibriummaintain/achieve equilibrium

The standard acetate/chloride ratio is 1:1The standard acetate/chloride ratio is 1:1 Increase proportion of chloride with Increase proportion of chloride with

metabolic alkalosis; increase proportion of metabolic alkalosis; increase proportion of acetate with metabolic acidosisacetate with metabolic acidosis

Consider chloride and acetate content of Consider chloride and acetate content of amino acidsamino acids

Special populationsDiabeticsDiabetics Careful monitoring of therapy to avoid Careful monitoring of therapy to avoid

hyperglycemiahyperglycemia Insulin may be added to the parenteral Insulin may be added to the parenteral

admixture and combined with sliding-scale admixture and combined with sliding-scale insulin administration insulin administration

Reasonable glucose control should ensure a Reasonable glucose control should ensure a blood glucose level greater than 100 mg/dL blood glucose level greater than 100 mg/dL and less than 220 mg/dL and less than 220 mg/dL

Acute renal failure Patients with acute renal failure are hypercatabolic, Patients with acute renal failure are hypercatabolic,

hypermetabolic,hypermetabolic, Frequently afflicted by coexisting multiple-system organ Frequently afflicted by coexisting multiple-system organ

failure. failure. Assessed carefully for signs of fluid overload and Assessed carefully for signs of fluid overload and Electrolyte abnormalities, particularly hyperkalemia, Electrolyte abnormalities, particularly hyperkalemia,

hyperphosphatemia, and hypermagnesemiahyperphosphatemia, and hypermagnesemia Protein is provided at approximately 1- 1.2 g/kg/dayProtein is provided at approximately 1- 1.2 g/kg/day Dialysis is used as indicated to control uremia.Careful Dialysis is used as indicated to control uremia.Careful

assessment of nitrogen losses in urine, dialysate, and other assessment of nitrogen losses in urine, dialysate, and other source.source.

Branched-chain amino acids (BCAAs; e.g., leucine, Branched-chain amino acids (BCAAs; e.g., leucine, isoleucine, valine) may be combined with other amino isoleucine, valine) may be combined with other amino acids to improve protein use. acids to improve protein use.

Pulmonary disease Overfeeding may increase CO2 production, Overfeeding may increase CO2 production,

complicate respiratory function, and impede complicate respiratory function, and impede weaning from ventilator support. weaning from ventilator support.

Provide adequate carbohydrate calories to meet Provide adequate carbohydrate calories to meet energy needs and (with fat) promote protein energy needs and (with fat) promote protein sparing.sparing.

An acceptable strategy is to increase the proportion An acceptable strategy is to increase the proportion of calories supplied by fat,of calories supplied by fat,

Restrict the administration of carbohydrate to 4 Restrict the administration of carbohydrate to 4 mg/kg/min.mg/kg/min.

Protein needs should be estimated at 1.5 g/kg/dayProtein needs should be estimated at 1.5 g/kg/day . .

Hepatic disease

Lipid, carbohydrate, protein, and vitamin metabolism is Lipid, carbohydrate, protein, and vitamin metabolism is sharply altered in patients with hepatic failuresharply altered in patients with hepatic failure

Lipid clearance is defective, with decreased lipolytic Lipid clearance is defective, with decreased lipolytic activity, increased triglyceridemia, and decreased removal activity, increased triglyceridemia, and decreased removal of free fatty acids.of free fatty acids.

Glucose intolerance and insulin resistance.Glucose intolerance and insulin resistance. Intolerance to protein presents the greatest challenge to Intolerance to protein presents the greatest challenge to

nutritional management. nutritional management. May have fluid overload that may require restriction of May have fluid overload that may require restriction of

TPN volume.TPN volume.

Hepatic disease (cont) Protein needs in patients with liver failure and mild Protein needs in patients with liver failure and mild

or no encephalopathy should be calculated at 1.5 or no encephalopathy should be calculated at 1.5 g/kg/dayg/kg/day

Protein needs in patients with significant Protein needs in patients with significant encephalopathy are reduced to 1.0 g/kg/day.encephalopathy are reduced to 1.0 g/kg/day.

Patients with pronounced encephalopathy should Patients with pronounced encephalopathy should be given a modified amino acid formula containing be given a modified amino acid formula containing a high percentage of BCAAs(Do not require a high percentage of BCAAs(Do not require hepatic metabolism)hepatic metabolism)

Cardiac disease Prolonged malnutrition, patients with long-Prolonged malnutrition, patients with long-

standing cardiac disease are vulnerable to a standing cardiac disease are vulnerable to a typical wasting (cardiac cachexia).typical wasting (cardiac cachexia).

The total volume of TPN solution is The total volume of TPN solution is generally restricted to 1000 to 1500 mL/day generally restricted to 1000 to 1500 mL/day in patients with severe congestive heart in patients with severe congestive heart failure secondary to valvular dysfunction, failure secondary to valvular dysfunction, coronary artery disease, or cardiomyopathy.coronary artery disease, or cardiomyopathy.

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