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Par enter al

Margel Camille Luy-Galagar
 Parenteral nutrition is administered outside the
digestive tract, intravenously. This is in contrast to
enteral nutrition, which encompasses oral and
tube feedings into the digestive tract.
 The general rule of thumb for deciding whether to
use parenteral or enteral feeding, is "if the gut
works, use it". The GI tract should be used if
possible because it tends to atrophy when not
used. Gut bacteria can translocate to the
circulatory system through an atrophied GI tract
and increase the risk of infection.
Peripheral Parenteral
 With peripheral parenteral nutrition (PPN)
nutrients are supplied via a peripheral
vein, usually a vein in the arm. Another
term for PPN is peripheral venous
nutrition (PVN)
Hypertonic Solutions
 Peripheral parenteral nutrition feedings usually
supplement enteral feedings. Large amounts of
nutrients cannot be supplied via a peripheral
vein, because these relatively small veins
cannot tolerate the rush of fluid into the vein
that occurs when a hypertonic solution is
introduced into the circulatory system.
 Body fluids have an osmolarity of about 300
mOsm. The introduction of a hypertonic
solution into a body compartment will cause an
osmotic gradient, resulting in a fluid shift.
 Hypertonic- having a higher osmolality
than the comparison solution.
 osmotic gradient- solutions on either side
of a semipermeable membrane.
 Osmolarity- The osmolarity of a PPN
solution is an important consideration in
PN solutions. Osmolarity is the number of
dissolved molecules and ions per liter of a
It may be easier to think of osmolarity as the
number of particles per liter of water.
Hypertonic Solutions
 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.
 A hypertonic PN solution results in an osmotic
gradient that causes water to enter the blood
vessel, as is illustrated in the picture, where
high concentrations of glucose (green) and
amino acids (yellow) draw water (blue) into a
blood vessel (red).
Osmolarity of
 Protein and carbohydrate both contribute
to hypertonicity. Fat is isotonic, and can
therefore be administered peripherally.
However, if the patient has delayed lipid
clearance, the use of lipids is
Infusion of Peripheral
 In peripheral PN, the catheter is inserted
into the arm vein of the patient. Up to
1800-2500 kcal and 90g protein can be
supplied via peripheral parenteral
nutrition. However, this relatively high
kcalorie/protein amount can be
supported peripherally only for a short
period of time.
Recommended Rates
IBW Infusion rate (cc/hr)
40 60-80
50 75-100
70 100-140
80 120-160
90 130-170
Total Parenteral
 Total parenteral nutrition (TPN) is
sometimes called central parenteral
nutrition (CPN) or "hyperal"
Hypertonic Solutions
 Large amounts of nutrients in a hypertonic
solution can be supplied via TPN. The catheter
is surgically placed into the superior vena cava.
 The reason that larger amounts of nutrients in
a hypertonic solution can be supplied via the
superior vena cava than with peripheral
parenteral nutrition is that the superior vena
cava has a much larger diameter and a higher
blood flow rate, both of which serve to quickly
dilute the TPN solution.
Amino Acid Solutions
 Protein is provided as a crystalline amino acid
solution. 500 ml bottles are standard.
 Solutions vary in amino acid concentration and
amino acid composition. The patient's protein
needs determine the protein concentration to
use, and the underlying disease state
determines the composition of amino acids to
 Amino acid (AA) % solution AA content
solutions are (g/100ml)
generally available in 3.0% 3.0
the following
concentrations: 3.5% 3.5
5.0% 5.0
7.0% 7.0
8.5% 8.5
10.0% 10.0
Uses of Amino Acids

 Although amino acids have 4 kcalories
per gram, they do not normally contribute
to the kcalorie requirement of the patient.
Instead of being used for energy, amino
acids should be used for protein
synthesis. Typically, to determine protein
needs, a nonprotein kcalorie to nitrogen
ratio of 80:1 to 150:1 is used.
 Nonprotein kcal:N ratio
 80:1 the most severely stressed
 100:1 severely stressed patients
 150:1 unstressed patient
Dextrose Solutions
 Dextrose in solution has 3.4 kcalories per
gram rather than 4 kcalories per gram as
in dietary carbohydrates, because a
noncaloric water molecule is attached to
dextrose molecules. Dextrose solutions
come in different concentrations, and the
solution is abbreviated D(%solution)W.
For example, D50W indicates a 50%
dextrose in water solution.
Infusion Rate of
 Dextrose solutions should not be administered at
a rate higher than 0.36g per kg body weight/hour.
This is the maximum oxidation rate of glucose.
Excess glucose is converted to fat, which can
result in fatty liver. In addition, the conversion of
carbohydrate to fat can cause excess CO2
production, which is undesirable for patients with
respiratory problems.
 Example maximum dextrose calculation
60 kg patient:

Dextrose infusion should not be greater than .

0.36 x 60 kg x 24 hr
= 518 grams per day
 Practice Calculation:

70 kg=_______g
80 kg=_______g
90 kg=_______g
100 kg=______g
Lipid Emulsions
 Lipids in parenteral nutrition are used as a
source of essential fatty acids (EFA) and
energy. Lipid emulsions are composed of
soybean and/or safflower oil, glycerol, and egg
 Approximately 4% of total kcaloric intake
should be EFAs to prevent EFA deficiency.
 Since IV lipids are isotonic and calorically
dense, they are a good source of
kcalories for hypermetabolic patients, or
patients with volume or carbohydrate
restrictions. Lipids can provide up to 60%
of non-protein calories.
Essential Fatty Acids

 Before lipids could be administered
intravenously, essential fatty acids were
provided by rubbing vegetable oil into the
patient's skin. Today, however, the efficacy of
this procedure is controversial, but it might be
used in the case of patients who cannot
tolerate a lipid emulsion.
Lipid Emulsion
 IV lipids come in bottles of 10% or 20%
emulsions. The 10%
emulsion contains 1.1 kcal/ml the 20%
emulsion contains 2 kcal/ml.
 Bottles come in the following volumes -
100 ml, 200 ml, 250 ml or 500 ml.
 500 ml of 10% lipids given once or twice
a week is generally enough to prevent
essential fatty acid deficiency.
 The lipid emulsion does not have to be
mixed with the amino acid and dextrose
solutions in a single bag.
Lipid Emulsion
 To prevent hyperlipidemia, lipid emulsions are
not provided continuously. This gives the body
a chance to clear lipids from the blood.
Typically, lipids are administered 2-3 times per
week, but can be provided daily. Infusion times
of 4-6 hours for 10% lipids and 8-12 hours for
20% lipids are recommended, although 12-24
hour infusions may be better tolerated by some
 In any event, a total of 2.5g/kg lipids per
day should not be exceeded.
 Example calculation of maximum daily
60 kg patient

2.5g/kg x 60 kg
= 150g lipid per day maximum
 Practice for 70-100 kg
Evaluation of Lipid
 There are three methods that can be
used for evaluation of a patient's lipid
 Test dose
 Serum triglycerides
 Plasma Turbidity
Test Dose Method

 10% lipid infused @ 1ml/min for 15-30
min; if no adverse symptoms, the rate
can be increase to 80 - 100 ml/h
 20% lipid emulsion infused @ .5 ml/min
for 15 - 30 min; if no adverse symptoms,
the rate can be increase to 40 - 50 ml/h
Serum Triglyceride
 Determine a baseline serum triglyceride level
before the emulsion is administered.
 Determine the triglyceride level 8 hours after
the infusion has been terminated.
 If serum triglycerides are normal or if they
exceed 250 mg/day, lipids should be given at
a reduced rate or should be used only to
prevent essential fatty acid deficiency.
Plasma Turbidity
 Plasma is observed for turbidity, and if
turbidity is present, the lipid infusion must
be adjusted. This is not the best method
for testing lipid tolerance, because
hyperlipidemia can occur without
Contraindications for
Lipid Emulsions
 Contraindications for using lipid
emulstion include:
 Abnormal lipid metabolism
 Lipid nephrosis
 Acute pancreatitis (if concomitant with or
caused by hyperlipidemia)
 Severe egg allergies
 Use lipid emulsions with caution if the patient
 A blood coagulation disorder
 Moderate to severe liver disease
 Compromised pulmonary function

 For patients who do not tolerate lipid
emulsions, meeting essential fatty acid needs
can be difficult. Rubbing vegetable oil on the
patient's skin may provide some essential fatty
acids, but the efficacy is controversial.
Administration of
 Traditionally, lipids are administered in a
bottle that is Y-connected, or
piggybacked to the IV line containing
amino acid/dextrose mixture.
 Total nutrient admixtures (TNAs) also
called 3 in 1 systems, allow for lipids to
be administered with amino acids and
Minerals and
 Standard mineral and electrolyte
mixtures are available, and are designed
to meet the normal range of daily
mineral/electrolyte requirements.
Individual electrolyte levels can be
altered to meet the needs of patients.
 Mineral supplementation can be
calculated based on health status or
laboratory values.
Trace Elements
 Standard trace element mixtures are available,
but requirements should be monitored and
adjusted based on serum concentrations.
 Iron can be given intramuscularly as needed.
When transferrin levels are low, free iron
increases and can increase susceptibility to
infections. In addition, critically ill or
malnourished patients often have no bone
marrow response to iron.
 Copper supplementation must be
administered with caution to avoid
toxicity. Extra zinc may be needed by
some patients to promote wound healing.
Trace Element

Element Dose
Zinc 2.5 - 4.0mg
Copper 0.5 - 1.5 mg
Iron 1.0 mg
Chromium 10 - 15 mcg
Manganese 0.15 - 1.8 mg
Iodine 1 - 2 mcg
Selenium 20 - 40 mcg
 Commercial vitamin preparations for TPN are
available. The vitamin requirements for TPN
patients are different from non-TPN patients
because absorption is not a factor with TPN.
 When needs are increased for certain disease
states, single vitamin supplements can be
added to the solution. Serum vitamin levels can
be monitored and dosage adjusted
 Vitamin preparations should be added to
the TPN solution just prior to
administration to avoid losses from light
Water/Fat Soluble
 Water soluble vitamins are provided at
levels greater than the RDA since rapid
administration exceeds renal threshold
and therefore increases urinary losses.
 Fat soluble vitamins can become toxic,
and are provided in amounts equal to the
RDA, except for Vitamin K.
 Vitamin K is not provided because it may
interfere with anticoagulant medications.
Vitamin K must be given parenterally or
intramuscularly, at a dose of 2-4 mg/wk,
depending on prothrombin time. A long
prothrombin time indicates an increased
vitamin K need.
Other Components of
PN Solutions
 Other components commonly added to
parenteral solutions include:
 Albumin
 Can be added if serum albumin levels are very low.
 Heparin
 An anticoagulant used to prevent blood clots from
forming on the IV catheter.
 Insulin
 Used if needed to regulate blood glucose levels.
Ordering and Mixing
PN Solutions
 The physician writes the order for the TPN
prescription. Often a form is used.
 The pharmacist mixes the TPN solution using
aseptic technique. Prescriptions are
compounded by mixing the solutions at a 1:1
dextrose-to-amino acid ratio and placing in 1-L
bags. Alternatively, lipids can be mixed with the
dextrose/amino acid solution, referred to as the
3-in-1 total nutrient admixture (TNA).
Calculation of protein
 Protein requirements vary with the
patient's disease state. Protein needs
can be estimated by multiplying
kilograms of body weight by a factor, or
by making a nitrogen balance study.
Gram/kg Method for
Determining Protein Needs
 The simplest, but least precise, method to
estimate protein needs is by multiplying IBW in
kilograms by a factor appropriate for the
patient's condition.
 If this method is used, the patient must be
monitored for protein status to determine if
adjustment in the protein prescription is
 Example Gram/kg Calculation
IBW: 120lb; 54.5 kg (120/2.2)

Moderate stress (factor = 1.5 from chart)
54.5 kg x 1.5 g/kg = 81.75 (82) grams of
 Practice:
1. Adult non-stressed; IBW= 60 kg
2. Adult moderately stressed; IBW= 70 kg
3. Non- stressed; 2 y/o; IBW= 12 kg
Calculation of Energy
 Energy needs of the hospitalized patient can
be determined by several methods.
1. = Basal Energy Expenditure x activity factor x
stress factor.
2. Kcals per kilogram body weight according to
weight and activity classification.
 Keep in mind that individual needs vary.
Each of these methods provides a
ballpark value. Patients must be
monitored for weight status and the kcal
prescription should be adjusted
 There are two main methods to ascertain
basal energy expenditure (BEE) - either
indirect calorimetry or via a prediction
equation, the most common of which is
the Harris Benedict Equation (HBE).
 Once BEE has been determined, that
figure is multiplied by an activity factor
(AF) then an injury factor (IF) to determine
the total energy needs of the patient.
 Activity factor =
 1.2 if patient is confined to bed
 1.3 if patient is ambulatory
The Harris-Benedict
 The Harris Beneditc Equation (HBE) is
one of over 200 equations for estimating
basal energy expenditure (BEE). The
HBE is a regression equation taking into
consideration gender, height, weight and
age. The HBE for men and women is as
 Men
 BEE (kcal/d) = 66.5 + (13.8 x W) + (5.0 x H) - (6.8 x
 Women
 BEE (kcal/d) = 655.1 + (9.1 x W) + (1.8 x H) - (4.7 x
 Where W = weight in kg
 and H = height in cm
 Example BEE Calculation
Male; W=60 kg; H=150 cm; A=30 years

BEE (kcal/d) = 66.5 + (13.8 x 60) + (5.0 x
150) - 6.8 x 30)

66.5 + 828 + 750 - 204 = 1440
 Practice:
1. Male; 70 kg; 170 cm; 60 y/o
2. Female; 50 kg; 160 cm; 40 y/o
3. Male; 80 kg; 180 cm; 35 y/o
Example Energy Needs
 Estimate energy needs (kcals) using

BEE x AF x IF BEE = 1000 kcals
IF = 1.2

Energy needs = 1000 x 1.2 x 1.2 = 1440
1. BEE: 1200; AF: 1.2; IF: 1.5
2. BEE: 1300; AF: 1.3; IF: 1.3
3. BEE: 1500; AF: 1.3; IF: 1.4
4. BEE: 1600; AF: 1.2; IF: 2.0
Initial Considerations
 TPN infusion should start slowly so that the
body has time to adapt to both the glucose
load and the hyperosmolarity of the solution,
and to avoid fluid overload.
 A pump controls the infusion rate of the TPN
 There are specific steps in the inititiation
procedure to follow regarding the initiation of
TPN infusion.
General PN Initiation
 Start with 1 liter of TPN solution during the first
24 hours (or use 42 cc/hr as a typical start rate)
 Increase volume by 1 liter each day until the
desired volume is reached
 Monitor blood glucose and electrolytes closely
 Pump administer TPN at a steady rate
 Don't attempt to catch up if administration
gets behind.
Continuous vs. Cyclic

 With cyclic TPN, the patient is fed at
so he or she can be free from the TPN
pump during the day
 Typically, the TPN solution is infused at a
constant rate controlled by a pump.
However, if the patient is to be nourished
via TPN for an extended period of time,
cyclic TPN is often used.
 With cyclic TPN the patient is fed for 12-
18 hours during the night and fasts
during the day. This gives the long-term
TPN patient freedom from the machinery
to lead a less restricted life during the
 Cyclic TPN helps prevent hepatotoxicity
that can develop with long-term TPN and
the fasting period allows essential fatty
acids to be released from fat stores.
 The initial TPN prescription is based only
on estimates of the patient's kcalorie,
protein, and micronutrient needs. The
patient's weight, protein, and
micronutrient status must be monitored
to ensure the prescription's adequacy.
 Assessment considerations include:
 Maximum weight gain in anabolism is 1/4
to 1/2 pound per day. More than that
indicates fluid retention.
 Adjust calcium lab values in
hypoalbuminemic patients as follows:
ionized CA = (measured serum CA) +
[4.0 - actual albumin (g/dL)] x 0.8
Terminating the
 The procedure for terminating the TPN
infusion is controversial. Some patients
can tolerate an abrupt stop, and others
tolerate a gradual termination, over a two
hour period, better.
Rebound Hypoglycemia
 Gradual termination prevents rebound
hypoglycemia, especially for diabetic, septic,
and stressed patients.
 The endocrine system adjusts to a continuous
infusion of dextrose by secreting a certain level
of insulin. If the dextrose supply is withdrawn
suddenly, the insulin level will not adjust right
away, resulting in a relative insulin excess and

Transitioning to Tube
 To ensure that the patient's nutrient needs
continue to be met, the TPN infusion should be
continued when the tube feeding begins..
 If the gut hasn't been used for two or more
weeks, enteral feeding tolerance may be
 TPN infusion can be decreased in proportion
to the increase in tube feeding.
Hints to Increae
Enteral Formula
 To enhance enteral formula tolerance
 Start at slow rate (30 mL/hour) and/or with
half-strength formula
 Avoid hyperosmolar forumlas
 Do not use bolus feedings
 Diluted hydrolyzed protein may stimulate
gut hypertrophy if formula isn't tolerated
Transitioning to Oral
 To ensure that the patient's nutrient
needs are met, TPN infusion should
continue while oral feedings are initiated.
 Because the digestive tract can atrophy
if not used for more than two weeks, food
may not be tolerated well at first. TPN
should be continued until nutrient needs
are met with food.
Hints to Increase
Tolerance of Oral
 To enhance enteral formula tolerance:
 If the patient is consuming an enteral formula
serve it diluted
 Have patient sip small volumes frequently at first
 Gradually increae volumes and time between
 If patient is to be weaned for food, use transitional
diets (easily digested), starting with clear liquid.
Nutritional Recovery
 The nutritional recovery syndrome, (px is
fedd aggressively) sometimes called the
refeeding syndrome, results from overly
aggressively feeding patients who are
severely malnourished or who haven't
eaten in a long period of time.
 Refeeding a starved person results in a
shift of potassium and phosphorus into
the body's cells for ATP production,
which can result in electrolyte imbalance.
Therefore, refeeding a severely
malnourished patient should occur
gradually, and the patient should be
monitored closely.
Calculation of Protein
 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.
 Note:
If the total volume of AA is not stated in the
prescription, you can calculate it. Just multiply the
rate of infusion of AA by 24 hr.
 *Remember that 1 ml = 1 cc.
 Example Protein Calculation

1000 ml of 8% amino acids 1000 ml x 8
g/100 ml = 80g
 Practice:
1. 1.5 L; 5% AA
2. 0.75 L; 7% AA
3. 1.0 L; 3.5% AA
4. 1.25 L; 8.5% AA
Calculation of
Dextrose Content
 To determine kcalories supplied from dextrose
in the TPN solution, you must first 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.
 Note:
If the total dextrose volume is not stated in
the prescription, you can calculate it. Just
multiply the rate of infusion of dextrose by 24
 *Remember that 1 ml = 1 cc.
 Example Dextrose Calculation

1000 ml of D50W 1000 ml x 50g / 100 ml
= 500g dex

500g dex x 3.4 kcal/g = 1700 kcal
 Practice:
1. 1.5 L D50W= g? kcal?
2. 0.75 L D70W
3. 1.0 L D40W
4. 1.25 L D30W
Calculation of Lipid
 Since lipid emulsions contain glycerol,
the lipid emulsion does not have 9 kcal
per gram* as it would if it were pure fat.
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.
 *Note: Some use 10 kcal/gm for lipid
 Example Lipid Calculation

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
 Practice:
1. 1.5 L 10% lipid
2. 0.75 L 10% lipid
3. 0.5 L 20% lipid
4. 1.25 L 20% lipid
Calculation of
Nonprotein Calories
 To determine the nonprotein kcalories
(NPC) supplied per day in a TPN
prescription, add the kcalories supplied
per day from dextrose with the kcalories
supplied per day from lipid emulsion.
 Example NPC Calculation

1000 ml/d D50W = 1700 kcal/d 500 ml/d 10%
lipid = 550 kcal/d

1700 + 550 = 2200 nonprotein kcals per day
 Practice:
1. 1.5 L D50W; 500 mL 10% lipid
2. 0.75 L D70W; 250 mL 10% lipid
3. 1.0 L D40W; 500 mL 20% lipid
4. 1.25 L D30W; 250 mL 20% lipid
Calculation of NPC:N
 The nonprotein kcalorie to nitrogen ratio
(NPC:N) is calculated as follows:
1. Calculate grams of nitrogen supplied per
day (1 g N = 6.25g protein)

2. Divide total nonprotein kcalories by grams
of nitrogen
 Desireable 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 protein

2250 nonprotein kcalories per day 80g
protein/ 6.25 = 12.8
2250/12.8 = 176
NPC:N = 176:1
 Practice:
1. 2000 kcal; 90 g protein
2. 2250 kcal; 75 g protein
3. 1800 kcal; 105 g protein
4. 3300 kcal; 120 g protein
Calculation of %NPC
from Fat
 As fewer than 60% of a patient's
nonprotein kcals should be from fat in
order to prevent hyperlipidemia, it is
important to calculate the percent of non
protein kcals from fat.
 To determine the percent of nonprotein
kcals from fat, divide the kcals/d from fat
by the total nonprotein kcal/d and
multiply by 100
 Example %NPC Fat Calculation
2250 nonprotein kcal

550 lipid kcal 550/2250 x 100 = 24% fat
 Practice
1. 2000 total kcal; 550 lipid kcal= %
2. 2250 total kcal; 500 lipid kcal
3. 1800 total kcal; 250 lipid kcal
4. 3300 total kcal; 1100 lipid kcal
Calculation of Solution
 The maximum osmolarity tolerated by
PPN is 900-1100 mOsm/L. Therefore, it
is important to calculate the osmolarity of
the PPN solution. Remember that lipids
do not contribute to the osmolarity of the
 To calculate solution osmolarity:
1. multiply grams of dextrose per liter by 5
2. multiply grams of protein per liter by 10
3. add a & b
4. add 300 to 400 to the answer from "c".
(Vitamins and minerals contribute about
300 to 400 mOsm/L.)
 Example Osmolarity Calculation
 1 L D50W (500 g dex/L)
1 L 8% AA (80 g AA/L) 500 g x 5 = 2500
80 g x 10 = 800 mOsm
 2500 + 800 = 3300 mOsm/L3300 + 300 to
400 = 3600 to 3700mOsm/L
 The prescription is not suitable for PPN
 Practice:
1. 1.5 L D50W; 0.5 L 10% AA
2. 0.75 L D70W; 0.75 L 5% AA
3. 1.0 L D40W; 1.0 L 3.5% AA
4. 1.25 L D30W; 1.0 L 3% AA
*Assume vitamin/minerals contribute 350
Determination of
EFA Adequacy
 To determine if essential fatty acid (EFA)
needs are met by the TPN prescription,
you must know the percentage of EFA in
the lipid emulsion. This information is
supplied by the manufacturer. Most lipid
emulsions are at least 50% EFA.
 Multiply the total kcalories of lipid the
patient receives in a day by the percent
of EFA in the emulsion. Compare this to
the patients EFA requirement (2-4% of
 Example EFA Calculation

2250 kcals/d
550 kcal 10% lipid (50% EFA) 550 kcal x 50% = 275
kcal EFA

275/2250 x 100 = 12% EFA

 EFA needs are being met
 Practice:
1. 2000 total kcal; 500 mL 10% lipid
2. 2250 total kcal; 500 mL 20% lipid
Determination of Fluid
 luid needs for an individual can be
calculated as 1 ml/kcal or 35 ml/kg usual
body weight (UBW).
 Patients who have large water losses
through perspiration or oozing wounds
may require more fluids.
Calculation of Fluid
 In general, adults need 35 mL water per kg
body weight, children need 70 -100 mL/kg, and
infants need 150 mL/kg.
 Fluid needs are increased with excessive
sweating, vomiting, diarrhea, or tube drainage.
 Fluids are restricted in certain disease states
such as renal failure and congestive heart
 Example Fluid Needs Calculation
 70 kg man:
35 mL/kg x 70 kg = 2450 mL/d
 30 kg child:
70 to 100 mL/kg x 30 kg = 2100 to 3000
 5 kg infant:
150 mL/kg x 5 kg = 750 mL/d
Obligatory Fluid Output

 One way to assess the appropriateness
of fluid intake is to monitor the patient's
urine output.
 Obligatory fluid output is the minimum
output of urine necessary to remove
wastes and is estimated to be roughly
700 mL per day or 30 mL per hour.
Monitoring Hydration
 Hydration status can be monitored via
daily weights, hematocrit, blood urea
nitrogen (BUN), and electrolyte levels.
 High values for the above parametres
indicate dehydration. Also, a weight
change of 2.2 pounds repesents 1 L of
fluid if the weight change is due entirely
to fluid loss or gain.
 Nutritional assessment indicators of
protein status can be used to determine
adequacy of protein intake, and weight
can be used to determine adequacy of
kcalories, unless the patient is retaining
Calculation of
PN Prescription
 There are different ways to calculate
parenteral nutrition prescriptions to meet
the patient's nutritional needs.
 Standard or "ready-mixed" bags of
dextrose and amino acid solutions exist
and are used for some patients.
 TPN prescriptions can be calculated and
compounded to meet the patient's
specific nutritional needs precisely. Two
methods for calculating TPN solutions
Dex/AA with Piggyback
 Determine patient's kcalorie, protein, and fluid
 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 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 %.
 Determine dextrose concentration.
 Subtract kcals of lipid 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
(see 3a) 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

Lipid (10%): 1800 kcal x 30% = 540 kcal
 540 kcal
 1.1 kcal/cc = 491 cc/24hr =
20 cc/hr 10% lipid

 Remaining fluid needs: 2000cc - 491cc = 1509cc
 Remaining kcal needs: 1800 - 540 = 1260 kcal

Protein: 88 g / 1509 cc x 100 = 5.8% amino acid solution
 Dextrose: 1260 kcal/
3.4 kcal/g = 371 g dex
371 g / 1509 cc x 100 = 24.6%
dextrose solution

 Rate of Amino Acid / Dextrose: 1509 cc /
24hr = 63 cc/hr
 Practice:
1. Nutrient Needs:
 Kcal: 3000
 Protein: 120 g
 Fluid 2800 cc
20% lipid emulsion at 30% of kcals
Lipid kcals provided= ?
Volume of solution=?
Rate of administration= ?
Unmet Needs:
Remaining kcals:
Remaining Fluid:
Protein Concentration:
 Grams of Dextrose:
 Dextrose Concentration:
 Rate of AA/Dex solution administration:
3 in 1 TNA Solutions
 Determine patient's kcalorie, protein, and fluid
 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 9.

 Divide lipid grams by total daily volume (= fluid
needs or final rate x 24) and multiply by 100 to
determine %lipid.
 Determine protein concentration by dividing
protein needs (grams) by total daily volume
and multiply by 100.
 Determine dextrose grams.
 Subtract kcals of lipid 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.
Example Calculation

 Nutrient Needs:
Kcals: 1800 Protein: 88 g Fluid: 2000 cc

Lipid (10%): 1800 kcal x 30% = 540 kcal
 540 kcal / 9 kcal per gram = 60 g
 60 g / 2000 cc x 100 = 3% lipid
 Protein: 88 g / 2000 cc x 100 = 4.4% amino
acid solution

 Dextrose: 1260 kcal
 3.4 kcal/g = 371 g dex
 371 g / 2000 cc x 100 = 18.6% dextrose solution

 Rate of Amino Acid / Dextrose: 2000 cc / 24hr
= 83 cc/hr
Calculation of
Additional Water
 When using standard or "ready-made" TPN
solutions, you need to ensure that fluid needs are
being met. To determine the additional sterile water
prescription for the TPN solution, you need to know
the patient's fluid needs.
 Subtract volume of TPN solution provided in a day
from the fluid requirement. The difference is the
volume of sterile water that should be added to the
TPN solution.
 Example Water Rx Calculation
Fluid needs = 2450 ml/d TPN Rx
provides 2000 ml fluid per day

2450 ml - 2000 ml = 450 ml additional
sterile water needed
Calculation of Fluid
 In general, adults need 35 mL water per kg
body weight, children need 70 -100 mL/kg, and
infants need 150 mL/kg.
 Fluid needs are increased with excessive
sweating, vomiting, diarrhea, or tube drainage.
 Fluids are restricted in certain disease states
such as renal failure and congestive heart
 Example Fluid Needs Calculation
 70 kg man:
 35 mL/kg x 70 kg = 2450 mL/d
 30 kg child:
 70 to 100 mL/kg x 30 kg = 2100 to 3000 mL/d
 5 kg infant:
 150 mL/kg x 5 kg = 750 mL/d