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    TPN Origin and Calculations

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    majd
    TPN was developed in the 1930s-1960s with the introduction of glucose, electrolytes, protein hydrolysates, and fat emulsions. It is indicated for patients unable to meet nutritional needs enterally due to GI issues, obstruction, or inability to access the GI tract. Complications include those related to vascular access devices and metabolic derangements. Proper calculation of energy, protein, fluid, fat, carbohydrate, and electrolyte needs is required to safely administer TPN.

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    TPN Origin and Calculations

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    majd
    286 views42 pages
    TPN was developed in the 1930s-1960s with the introduction of glucose, electrolytes, protein hydrolysates, and fat emulsions. It is indicated for patients unable to meet nutritional needs enterally due to GI issues, obstruction, or inability to access the GI tract. Complications include those related to vascular access devices and metabolic derangements. Proper calculation of energy, protein, fluid, fat, carbohydrate, and electrolyte needs is required to safely administer TPN.

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    TPN was developed in the 1930s-1960s with the introduction of glucose, electrolytes, protein hydrolysates, and fat emulsions. It is indicated for patients unable to meet nutritional needs enterally due to GI issues, obstruction, or inability to access the GI tract. Complications include those related to vascular access devices and metabolic derangements. Proper calculation of energy, protein, fluid, fat, carbohydrate, and electrolyte needs is required to safely administer TPN.

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    © All Rights Reserved
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    Download as pdf or txt
    286 views42 pages

    TPN Origin and Calculations

    Uploaded by

    majd
    TPN was developed in the 1930s-1960s with the introduction of glucose, electrolytes, protein hydrolysates, and fat emulsions. It is indicated for patients unable to meet nutritional needs enterally due to GI issues, obstruction, or inability to access the GI tract. Complications include those related to vascular access devices and metabolic derangements. Proper calculation of energy, protein, fluid, fat, carbohydrate, and electrolyte needs is required to safely administer TPN.

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    TPN

    origin and calculations


    Naureen Iqbal
    01/09/13

    TPN - History
    Glucose and electrolyte
    Protein hydrolysates in 30s
    Fat emulsion- Intralipid in 60s.
    Vitamins, minerals, trace elements
    Central venous catheter
    Peripheral parenteral nutrition

    Indications - TPN
    1.

    Documented inability to absorb adequate nutrients via


    the GI tract:
    Massive small bowel resection/short bowel syndrome
    Radiation enteritis
    Severe diarrhea
    Untreatable steatorrhea/malabsorption
    2. Complete bowel obstruction or intestinal pseudoobstruction
    3. Severe catabolism with/without malnutrition when GI
    tract is not usable within 5-7 days
    4. Inability to obtain enteral access to provide sufficient
    nutrients

    Indications - TPN
    5. Moderate to severe pancreatitis
    6. Persistent GI hemorrhage
    7. Acute abdomen/ileus
    8. Lengthy GI work-up requiring NPO status for several
    days in a malnourished patient
    9. High output enterocutaneous fistula and inability to gain
    enteral access distal to fistula site
    10. Trauma requiring repeat surgical procedures

    Relative Indications

    Enterocutaneous fistula
    IBD not responding to medical therapy
    Hyperemesis gravidarum
    Intractable vomiting
    Partial small bowel obstruction
    Intensive chemotherapy/severe mucositis
    Major surgery/stress when enteral nutrition not expected
    to resume in 7-10 days
    Chylous ascites or chylothorax when medium chain
    triglycerides enteral nutrition does not adequately
    decrease output

    Peripheral IV Nutrition
    Indications
    Nutritional needs <1,800 Kcal/day
    IV nutrition requirement <10-14 days
    Peripheral venous access is available
    Requires only one IV
    Fluid restriction is not an issue

    Contraindications
    Functional GI tract
    Treatment anticipated for <5 days in patients without
    severe malnutrition
    Inability to obtain venous access
    A prognosis that does not warrant aggressive nutrition
    support
    When the risks of parenteral nutrition are judged to
    exceed the potential benefits

    Access Devices
    - Peripheral Lines
    - Short
    - Midline
    - Central Lines
    - PICC
    - Hickman/Broviac
    - Groshong Catheter
    - Femoral line
    - Multiple lumen acute care catheters
    - Port

    Complications
    Related to access device
    Metabolic complications

    Complications - Access
    Mechanical
    Hemo/Pneumothorax
    Arterial puncture
    air embolism
    nerve damage
    thoracic duct damage
    Hematoma
    Misplaced catheter
    Thrombotic
    Septic complications

    When to change the line


    PIV- 72-96hrs (adults)
    Midline/CVL- do not replace routinely

    Metabolic Complications

    Hyper- or hypo-glycemia
    Hyperosmolar non-ketotic acidosis
    Hypertriglyceridemia
    Fat Overload Syndrome
    Essential fatty acid deficiency
    Prerenal azotemia
    Hyperammonemia
    Hyperchloremic metabolic acidosis
    Metabolic alkalosis
    Hepatic/biliary complications
    Electrolyte abnormalities
    Refeeding Syndrome

    Recommendations
    Preoperative TPN:
    Only to severely malnourished patients
    7-10 days pre-op
    expected reduction of post-op complications of 10%
    Postoperative TPN:
    Routine post op TPN is contraindicated
    Patients who experience complications resulting in
    inability to tolerate oral diet for
    7-10 days in previously well nourished patients
    5-7 days in malnourished patient

    Calculating Parenteral Feeding


    - Patient's energy needs (Kcal/day)
    - Protein/nitrogen need/day
    - Fluid need/tolerated
    - Fat emulsion need/tolerated
    - Dextrose need/concentration
    - Electrolyte/minerals/vitamin need
    - Osmolality
    - Route
    - TPN soln: 2 in 1, 3 in 1

    Calculating Parenteral Feeding


    Formula for calculating TPN:
    http://health.csusb.edu/dchen/368%20stuff/TPN%
    20calculation.htm
    Formula to calculate macronutrient content:
    http://clincalc.com/TPN/Macronutrients.aspx
    Formula for calculating osmolatity:
    http://www.rxkinetics.com/tpnosmolcalc.html

    Energy requirement
    Harris-Benedict + activity +infection/fever factor = Energy
    (Kcal)

    Scale:

    Normal need: 25-30 kcal/kg/day


    Elective surgery: 28-30 kcal/kg/day
    Severe injury: 30-40 kcal/kg/day
    Extensive trauma/burn: 45-55 kcal/kg/day

    Protein requirement
    Protein: 0.83 - 2.5 gm/kg/day (typically: 1.5 gm/kg/day)
    Nitrogen 1 gm = 6.25 gm protein
    Non protein energy (kcal) to nitrogen (N) ratio:
    80 kcal: 1 gm N severely stressed condition
    100-150 kcal: 1 gm N stressful condition anabolism
    250-300 kcal: 1 gm N normal body maintenance
    Prolonged TPN should contain
    Glutamine
    Choline

    Fluid requirement
    30 50 cc fluid/kg
    100 cc free water/gm N intake + 1cc/kcal intake
    100 cc/kg for first 10kg
    + 50 cc/kg for 2nd 10kg
    + 20 cc/kg for each additional kg

    Fat requirement

    Maximal tolerance level of lipids: 2.5 gm/kg body weight


    av. 30% energy should be from fat
    60% of energy from fat is upper limit. Essential fatty acids
    (EFA) 2-4% Kcal
    Fat energy: 9 kcal/gm
    Fat emulsions are made isotonic by adding glycerol
    Fat emulsions:
    10% fat emulsion: 1.1 kcal/cc
    20% fat emulsion: 2.0 kcal/cc
    30% fat emulsion: 3.0 kcal/cc

    Carbohydrate requirement

    Main source of fuel


    Min. need/ day : 100gm
    Max. rate: 5 mg/kg/min (7.2 g/kg/day)
    Max. CHO we can use : 500 g/day
    CHO given as dextrose monohydrate
    Energy: 3.4 kcal/gm
    Solutions: 50% and 70%

    Vitamins/minerals

    Include 12 vitamins except Vit K

    Trace elements: iron not routinely added because it changes the


    pH of the solution

    Osmolarity

    Dextrose: 5 mOsm/g
    Protein: 10 mOsm/g
    Lipid: Negligible

    Vitamins/minerals: 300 - 400 mOsm/L

    Peripheral TPN: <900 mOsm/L


    Central TPN: 1500 - 2800 mOsm/L

    A 500ml bottle of 5% amino acid solution


    provides ------ grams of protein

    1- 2.50 g
    2- 5.00 g
    3- 12.5 g
    4- 25.0 g
    5- none of the above

    A 500ml bottle of 5% amino acid solution


    provides ------ grams of protein

    1- 2.50 g
    2- 5.00 g
    3- 12.5 g
    4- 25.0 g
    5- none of the above

    Your patient needs 92g of protein per day.


    remaining fluid needs are 2000cc/day. What
    percent AA solution will meet this patient's
    needs?

    1- 2.3%
    2- 4.6%
    3- 9.2%
    4- 18.4%
    5- None of the above

    Your patient needs 92g of protein per day.


    remaining fluid needs are 2000cc/day. What
    percent AA solution will meet this patient's
    needs?

    1- 2.3%
    2- 4.6%
    3- 9.2%
    4- 18.4%
    5- None of the above

    What is the maximum lipid tolerance (in


    grams) for a patient who weighs 70 kg?

    1- 125 g
    2- 175 g
    3- 250 g
    4- 370 g
    5- None of the above

    What is the maximum lipid tolerance (in


    grams) for a patient who weighs 70 kg?

    1- 125 g
    2- 175 g
    3- 250 g
    4- 370 g
    5- None of the above

    1500 ml of D50W provides ----- grams of


    dextrose and ------ kcals.

    1- 500 g; 1700 kcals


    2- 500 g; 2000 kcals
    3- 750 g; 2550 kcals
    4- 750 g; 3000 kcals
    5- None of the above

    1500 ml of D50W provides ----- grams of


    dextrose and ------ kcals.

    1- 500 g; 1700 kcals


    2- 500 g; 2000 kcals
    3- 750 g; 2550 kcals
    4- 750 g; 3000 kcals
    5- None of the above

    The maximum carbohydrate tolerance for


    a patient who weighs 70 kg is ----- grams per
    day (rounded to nearest whole number)

    1- 504 g
    2- 650 g
    3- 703 g
    4- 811 g
    5- None of the above

    The maximum carbohydrate tolerance for


    a patient who weighs 70 kg is ----- grams per
    day (rounded to nearest whole number)

    1- 504 g
    2- 650 g
    3- 703 g
    4- 811 g
    5- None of the above

    250 mls of a 10% lipid emulsion provides


    ---- kcals

    1- 250 kcals
    2- 275 kcals
    3- 500 kcals
    4- 550 kcals
    5- None of the above

    250 mls of a 10% lipid emulsion provides


    ---- kcals

    1- 250 kcals
    2- 275 kcals
    3- 500 kcals
    4- 550 kcals
    5- None of the above

    What are the fluid needs of a 75 kg man?


    (use ml/kg method)

    1- 1875 ml/d
    2- 2250 ml/d
    3- 2625 ml/d
    4- 3000 ml/d

    What are the fluid needs of a 75 kg man?


    (use ml/kg method)

    1- 1875 ml/d
    2- 2250 ml/d
    3- 2625 ml/d
    4- 3000 ml/d

    A patient receives a 1000 ml bag of TPN


    which contains 10% dextrose & 7% protein.
    In addition, this patient receives 250 ml of a
    20% fat emulsion. How many calories does
    this approximately represent?
    1- 1020 kcals
    2- 1420 kcals
    3- 1820 kcals
    4- 2220 kcals

    A patient receives a 1000 ml bag of TPN


    which contains 10% dextrose & 7% protein.
    In addition, this patient receives 250 ml of a
    20% fat emulsion. How many calories does
    this approximately represent?
    1- 1020 kcals
    2- 1420 kcals
    3- 1820 kcals
    4- 2220 kcals

    Calculate the protein, kcals, EFA content of


    the following TPN prescription:
    1.0 L D70W; 1.0 L 7% AA; 214 cc 20%
    lipid/day (50% EFA)

    1- 70g protein; 2601 NP kcals/d; NPC:N 235:1; 14% EFA


    2- 70g protein; 3228 NP kcals/d; NPC:N 286:1; 12% EFA
    3- 70g protein; 2808 NP kcals/d; NPC:N 251:1; 7% EFA
    4- 70g protein; 3228 NP kcals/d; NPC:N 286:1; 8% EFA
    5- None of the above

    Calculate the protein, kcals, EFA content of


    the following TPN prescription:
    1.0 L D70W; 1.0 L 7% AA; 214 cc 20%
    lipid/day (50% EFA)

    1- 70g protein; 2601 NP kcals/d; NPC:N 235:1; 14% EFA


    2- 70g protein; 3228 NP kcals/d; NPC:N 286:1; 12% EFA
    3- 70g protein; 2808 NP kcals/d; NPC:N 251:1; 7%
    EFA
    4- 70g protein; 3228 NP kcals/d; NPC:N 286:1; 8% EFA
    5- None of the above

    and dextrose solutions to be used, along with


    rate of administration. Provide 30% fat kcals
    from a 20% lipid emulsion. (rounded to nearest
    0.1)
    Nutrient needs: 2800 kcals; 100 gm protein;
    2500cc fluid
    1- 3.7% lipid; 23% dextrose; 4% amino acids; 104.2 cc/hr
    2- 3.7% lipid; 20% dextrose; 4% amino acids; 104.2 cc/hr
    3- 3.7% lipid; 23% dextrose; 8% amino acids; 104.2 cc/hr
    4- 8.3% lipid; 23% dextrose; 4% amino acids; 104.2 cc/hr
    5- None of the above

    and dextrose solutions to be used, along with


    rate of administration. Provide 30% fat kcals
    from a 20% lipid emulsion. (rounded to nearest
    0.1)
    Nutrient needs: 2800 kcals; 100 gm protein;
    2500cc fluid
    1- 3.7% lipid; 23% dextrose; 4% amino acids; 104.2 cc/hr
    2- 3.7% lipid; 20% dextrose; 4% amino acids; 104.2
    cc/hr
    3- 3.7% lipid; 23% dextrose; 8% amino acids; 104.2 cc/hr
    4- 8.3% lipid; 23% dextrose; 4% amino acids; 104.2 cc/hr
    5- None of the above

    References
    Recollections of pioneer in nutrition: Landmark in development of
    parenteral nutrition. J Am Coll of Nutrition.1992 Aug;11(4):366-73.
    Perioperative Nutrition support for patients undergoing gastrointestinal
    surgery: critical analysis and recommendations. World J of Surgery, June
    1999, Vol 23, issue 6, p565-569.
    Appropriate protein provision in critical illness: a systematic and narrative
    review. Am J Clin Nutr 2012. 96. 591-600.
    Total parenteral nutrition in the surgical patient: a meta-analysis. Can J
    Surg 2001, 44:102-11.
    http://www.medicine.virginia.
    edu/clinical/departments/medicine/divisions/digestive-health/nutritionsupport-team/nutrition-articles/MadsenArticle.pdf
    http://health.csusb.edu/dchen/368%20stuff/TPN%20calculation.htm
    http://www.csun.edu/~cjh78264/parenteral/calculation/index.html
    http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

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