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Chen-Maynard, PhD, RD

Total Parenteral Nutrition (TPN) must be individualized for the patient. However, often there are standard concentrations of protein, carbohydrate, and fat available in standard volumes, which limits the degree of individualization using these standard solutions. However, mixing different formulas in calculated amounts can be used to develop feeding solutions for most patients. We can also calculate the nutrients to meet the needs of an individual patient using these standard solutions. Dextrose solution and lipid emulsions are common macronutrients used to provide energy in parenteral solution. Nitrogen for protein synthesis is obtained from synthetic crystalline Lamino acid solutions. When designing a TPN solution, you need to consider these questions: 1. What is the patient’s energy need? (Kcal required/day) 2. How much protein/nitrogen does the patient need in a day? 3. How much fluid can the patient tolerate and need? 4. How much fat emulsion can be given/tolerated? 5. How much dextrose is needed? Dextrose concentration? 6. Which electrolytes are needed and how much? 1. Which vitamins and mineral are needed and how much? 2. What is the osmolality of the solution? 3. What is the route of feeding used?

Where do you start to determine the composition of parenteral feeding? Nutrition assessment should tell you the status of the patient so you can tailor the needs accordingly. Also the TPN solution is going to fully supply the need or is it supplemental? 1. START BY DETERMINING ENERGY NEEDS:

83 gm/Kg and add stress and other factors as needed. usually start with 0.100 Kcal/day 2. how many grams of N are you going to need? 1500 Kcal ÷ 150 Kcal/gm N = 10 gm N Example of your patient. Some patients may need up to 2. The ratio of 100150 Kcal: 1 gm N in stressful condition promote anabolism and 250-300 Kcal: 1 gm N is adequate for normal body maintenance. who needs 2.2 gm/Kg). Choline helps protect the liver from hepatic fat deposits that hinder its function. DETERMINE THE PROTEIN NEEDS: Protein needs are determined by the patients. Another way to estimate protein needs is to use the non-protein energy (Kcal) to nitrogen (N) ratio. we found that he needed 84 grams protein. Note: Prolonged TPN solution should contain 2 amino acids: Glutamine (most abundant amino acid in the blood that protects the gut epithelia tissue lining./gm N = 87. How much protein in the solution? Assume that we give this 70 kg person 85 gm of protein using 10% amino acid solution: .100 Kcal: 2100 ÷ 150 = 14 grams Think back: with the first method of calculation of protein needs.5 g/Kg due to loss and other factors.5 gram protein.25 gm prot. NEXT. you need 14 gm N X 6. For example a malnourished 70 Kg man may need 84 gm protein per day (70 Kg X 1. If your 50 Kg patient needs 1500 Kcal and you want an Energy:N ratio of 150:1.You may use Harris-Benedict + activity + infection/fever factor + etc = Energy (Kcal) or you may use Kcal/Kg based on the following 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 Example: for a 70 Kg male with elective surgery X 30 Kcal/Kg = 2. Either method is correct and both are estimation of need. while with the second method. The non-protein energy to N ratio is based on the premise that sufficient energy must be ingested before protein will be used for tissue maintenance and repair.

NEXT CALCULATE THE AMOUNT OF FLUIDS THE PATIENT NEEDS: There are 3 different methods to calculate fluid needs: a. Another method to calculate fluid needs is 100 cc free water/gram N intake + 1 cc/Kcal provided. a. The third method to calculate fluid needs: 100 cc/Kg for first 10 Kg + 50 cc/Kg for the second 10 Kg + 20 cc/Kg for each additional Kg Example: using method a: 70 Kg X 33 cc/Kg = 2100 cc/day 70 Kg X 50 cc/Kg = 3500 cc/day method b: 14 g N X 100 = 1. In general. If the patient is overhydrated.5) gram protein /day . TPN can be used in concentrated form to "pull off" extracellular fluids (ECF).0 – 87.100 Kcal /day (of non-protein energy) 85 (range is 84. our NUTRITION PRESCRIPTION READS: 2. gm units cancel out 3. b. patients need a minimum of 30 cc fluid/Kg body weight to maintain hydration: 30-50 cc/Kg is a good amount to aim. needs may go up at high as 100 cc/Kg in severely catabolic state such as burns.10% solution has 100 gm protein/L so we can set up equation 85 gm / X ml = 100 gm/1000 ml 100X gm ml = 85000 gm ml solve for X: X = 850 ml.500 cc/day So far.400 cc + 2100 cc for each Kcal provided = 3600 cc/day method c: 100 cc/Kg X 10 Kg = 1000 cc 50 cc/Kg X 10 Kg = 500 cc 20 cc/Kg X 50 Kg = 1000 cc total: 1000 + 500 + 1500 = 2. however.

Tg’s do not contribute to serum osmolarity. there are 55.0 Kcal/cc Fat emulsions are available most commonly in 250cc and 500 cc bottle. More than 60% of energy from fat may result in hyperlipidemia due to impaired lipid clearance by the body. Purified egg lecithin phosphatides are used as emulsifier. Actually.6 gm of fat and 5. Example: What is the energy content of a 500 cc bottle of 10% fat emulsion? 500cc X 1. . 10% fat emulsion has 1. However.100 – 3. Lipid emulsions have osmolality of 270 to 340 mOsm/L. THE AMOUNT OF FAT NEEDED DEPENDS ON THE TOTAL ENERGY NEED At present. e. Glycerol is not a fat.0 Kcal/cc 30% fat emulsion has 3. 20% and 30% fat emulsion are available. 500 Kcal ÷ 9 Kcal/gram = 61 gram of fat . MAXIMAL tolerance level of lipid is considered to be 2.0 Kcal/cc = 1000 Kcal Fat has 9 Kcal/gram so you can determine the number of fat grams if you need it.5 gm/Kg body weight and 60% of energy from fat is also considered to be upper limit . add any volume of fat you need. It is estimated that 24% of Kcal must be from EFA and a per needs 1 to 2. How many grams of fat in 500 cc of 10% lipid fat? 500 cc X 1.1 Kcal/cc = 550 Kcal Energy content of a 500 cc of 20% fat? 500 cc X 2.g. in three in one admixture.1 Kcal/cc 20% fat emulsion has 2.5 gram of fat/Kg. emulsions are made isotonic by adding glycerol. 10%.2.1 Kcal/cc = 550 Kcal. The essential fatty acid (EFA) also has to be determined. Soybean and safflowers are rich in linolenic acid. we need to calculate what is the contribution of total energy from fat and CHO? 3.500 cc fluid /day Now. the pharmacist can mix the appropriate amount in the bag.4 gram glycerol.

77 = 423.0 to 2. So if we add 1.5 bottle = 91. so if you give 750 cc (1. D 70 are the most . how much fat and EFA would you recommend? 1. In TPN.5 g fat and 825 Kcal. This provides 825 kcal from fat / 2100 Kcal = 39.0 Kcal/gm). he will need: 84 Kcal X 7 days = 588 Kcal from EFA/week. CHO is given as dextrose monohydrate.000 cc or two 500 cc bottles per week for EFA. glucose provides 4.5 Kcal INTRALIPID(soy based emulsion) has 52% EFA fat: 550 Kcal bottle of INTRALIPID gives 286 Kcal of fat: 550 Kcal X 0. Minimal amount of CHO needed per day is 100 grams. So he will need at least 1 L of Intralipid per week or 143 ml/day to prevent EFA deficiency. EFA: you need 2-4% of energy from EFA: 2. 3.4 Kcal/gram (recall. Dextrose is available in 50 to 70% solution (D50W. CARBOHYDRATE IS THE MAIN SOURCE OF FUEL TO MEET ENERGY NEEDS.02 = 42 Kcal 2. Fat: you need 1.100 Kcal X 0. Therefore he will need at least 1.5 bottle of 500 cc bottle) of Intralipid you will be adding: 61g/bottle X 1.5 bottle = 825 Kcal/day from fat To find out fat content of two commonly used fat emulsions: Safflower oil has 77% EFA fat: 550 Kcal (10% 500cc) bottle of LIPOSIN gives 423.06 bottles of 10% fat emulsion.0 = 70 gm fat 70 Kg X 2.5 gm/Kg body weight (175g/day).5 Kcal of EFA fat: 550 Kcal X 0. so how much INTRALIPID is he going to need in a week? 588 Kcal/week ÷ 286 Kcal from fat = 2.5 g of fat /day and 550 kcal/bottle X 1.5 = 175 gm fat from our calculations.100 Kcal X 0.For our reference 70 Kg male. we will have sufficient EFA and provides 91.5 (500cc) bottle per day.52 = 286 Kcal of fat Your 70 Kg patient needs 84 Kcal of EFA energy. which yields 3. over the week.2 % of energy from fat and it is still way below the limit of 2.5 gram fat/Kg: 70 Kg X 1. 500 cc of 10% lipid emulsion provides 61 grams fat and 550 kcal.04 = 84 Kcal 2.

liver abnormalities.275 Kcal needed from CHO.000 cc X 50% = 500 gram dextrose X 3.4 Kcal/gram = 170 Kcal MAXIMUM rate of CHO administration should not exceed 5 mg CHO/Kg/min. to see how many gram of dextrose is this? 1275 Kcal/3.350 cc/day . to obtain 1. 1. The amount of fat used in solution will determine the amount of CHO needed. 750 cc 10% Intralipid.000 cc X 0. with protein needs of 85 gm/day: your formulation for your 70 Kg patient will be: 10% amino acids 850 cc D50W dextrose 750 cc 10% Intralipid 750cc total volume: 2.96 mg CHO/Kg/min. Since the fluid needs are 2. and increased ventilatory drive (increased CO2 production). how much D50W should you add? 1275 Kcal ÷ 1700 Kcal = 750 cc of D50W Either method gives you the same answer of 750 cc of D50W needed in your final solution. one Liter (1 L) of D50W gives 1.05 = 50 gm dextrose X 3.600 cc/day.275 Kcal from CHO.700 Kcal from CHO Energy content of 1000 cc of D5W (5% dextrose solution)? 1. if we solve for X. Energy content of one liter (1000 cc) 50% Dextrose solution (D50W)? 1.700 kcal.100 Kcal – 825 Kcal = 1.100 – 3.100 Kcal/day with 85 gm protein.4 Kcal/gram = 1. we have 375000 / 500 = 750 ml 2.4 Kcal/gm = 375 g dextrose needed: we can calculate it two ways: 1. If we use D50W as starting solution. Excessive administration of CHO can lead to hyperglycemia.common solutions used to prepare TPN solutions). so maximum amount of CHO we can use is 500 gm/day So how much CHO would your patient need? 2. which provides 825 Kcal: 2. we will need to use X ml of this solution: 375 g / X ml = 500g/1000 ml.000 cc of D50W provides 500 gm CHO/L 500 gm CHO ÷ 70 Kg ÷ 24 hours ÷ 60 min/hr = 4.

electrolytes further add to osmolarity e.65% amino acids 15 % dextrose 1000 cc of 10% Intralipid total volume has about 2500 ml so to calculate rate/hr: 2500 ml/24 hr = 105 ml/hr so if we set the pump so that it will administer at 105 cc/hr for 24 hr.g. 50 g dextrose X 5 = 250 mOsm/L by glucose 2. Note: This formulation will be administered by central line only since dextrose concentration is greater than 10%. and additives to give a final volume of say 2500 ml Vitamins/minerals: electrolytes should be monitored and adjusted as needed vitamin solutions include 12 vitamins except vitamin K which can be injected IM trace elements: iron is not routinely added because it changes pH of solution. fat is isotonic and does not contribute to osmolarity 4.g. some minerals are incompatible with TPN solution due to their effects on pH.. multiply the gm of protein per liter by 10 = mOsm/L by protein e. NaCl = 2mOsm per NaCl molecule 250 mOsm/L + 300 mOsm/l = 550 mOsm/L ------------------------------------------------------Milieqivalent vs mg of electrolytes . Osmolarity Calculation for a TPN solution: 1.You need to add 70-150 cc fluid for electrolytes.g 30 g protein X 10 = 300 mOsm/L 3. Final concentration has: 2. vitamins. multiply gm of dextose per liter by 5 = mOsm/L by glucose e. we are ok with the infusion.

23 40 24.5 g X 0. 1000 mg Na = 1000 mg X 2.540 mg NaCl (2.4 39 1 1 1 2 2 2 sodium calcium magnesium sulfur sulfate b.Conversion from mg to mEq a.3 32 96 Conversion of specific wt of sodium to sodium chloride multiply by 2.54 e.0 g sodium ( 1000 mg) .303 = 1.54 = 2.5 gm NaCl = 2. divide mg by atomic wt and then multiply by valance mg/atomic wt X valance = mEq mineral element chemical symbol Atomic wt valance chlorine potassium Cl K Na Ca Mg S SO4 35.g.5 g) to convert specific wt of sodium chloride to sodium multiply by 0. 2.393 e.g.

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