TOTAL PARENTERAL NUTRITION

CALCULATION

Apt. Rizky Farmasita B, S.Farm., M.Farm

 TPN

• Method of providing nutrition solely via parenteral route to the patient unable
or cannot utilise the oral or enteral feeding.
• notes : those patients with partial GIT function should be given oral / enteral
 PARENTERAL NUTRITION

• A mode of nutrition that involves the administration of nutrients through the iv

route for the maintenance of the patient’s nutritonal requirements in the relation
to his/her clinical status
• Process of transfering of the sterile product into a sterile container / solution to
produce a sterile preparation in a sterile environment using a sterile technique
• Prerequisite : environment, equipment, raw materials and techniques should be
able to prevent contamination.
 OBJECTIVES TPN

• To provide nutrition for the maintenance of the normal physiological function

• To improve recovery / healing process To prevent complication
 PATIENTS ASSESSMENT

• Selection of patients
• Selection of route
• Estimation of energy and nutrient requirement
• Special consideration
SELECTION CRITERIA FOR
TPN

NUTRITION ASSESSMENT
ALGORITMA RUTE PEMBERIAN
NUTRISI
 Gastrointestinal diseases
• Crohn’s disease
• Inflammantory Bowel Disease
• Short-gut syndrome
GASTROINTESTINAL
FUNCTION Surgery
• Resection of GIT

Fistule
Ischemic or infarction
 INDICATION

Pediatric Adult
• Premature/underweight • GI Fistulas

• Respiratory distress syndrome • Decrease GIT motility

• Short-gut syndrome • Short bowel syndrome

• Inflammmantory bosel disease
• Intractable diarrhea
• Pancreatitis
• Surgery
• Renal Failure
• Hepatic Failure
• Trauma/sepsis/burns
• Cancer
• Surgery
 INTRAVENOUS ACCCES

Central Access
• For high energy requirement
• Hyperosmolar solution ( ≥ 800-900 mOsm/L)
• TPN > 7-10 days
Peripheral IV
• Isoosmolar solutions ( ≤ 800-900 mOsm/L)
• TPN < 7-10 days
• Partial/suplement
Complications
• Infectious
• Technical
• Metabolic/substrate
 MALNUTRITION

• Clinical signs and symptomps • Evaluation of Immune status

• Anthopometric Measurement • Immune stores (TLC)  WBC
• Percentage body fat • Immune function  skin testing
• Biochemical asssessment of serum protein • Bioelectrical Impendance Analysis
• Serum Albumin • Assessment Lean Body Mass or Body Cell
Mass
• Serum Transferin
• Serum prealbumin
 ESTIMATION OF NUTRITIONAL
REQUIREMENT

1. Determination of Energy Requirement (ER)

• Harrison-Benedict Equation :

• Male BEE (unit kCal) =

66,47 + 13,75 (Wt,kg) + 5 (Ht,cm) - 6,76 (Age,years)

• Female BEE (unit kCal) =

655,1 + 9,56 (Wt,kg) + 1,85 (Ht,cm) - 4,68 (Age,years)

• 1 kCal = 4,2 kJ
 ESTIMATION OF NUTRITIONAL
REQUIREMENT

2. Determination of Actual Energy Expenditur (AEE)

• AEE= BEE X stress factor X injury factor X thermal factor
• AEE = BEE X stress factor
• EE (WHO)
• Estimated total calorie :
• Most patient  25 – 35 kcal / kg / day
• Patients with trauma  ≥ 35 kcal / kg / day
• Severe burned patient  40 kcal / kg / day
Sterss Factor :
In bed 1.1
In bed but mobile 1.2
Out of bed / mobile 1.3
Ventilator 1.1
Infection : mild 1.0 – 1.2
Moderate 1.2 – 1.4
Severe 1.4 – 1.6
Skeletal trauma 1.2 – 1.35
Multiple trauma 1.5
Multiple trauma + sepsis1.6
Cancer without therapy 1.4 – 1.6
Head injury 1.25
Head injury + corticosteroid 1.6
Burns ≥ 2.0
 
 ESTIMATION OF NUTRITIONAL
REQUIREMENT

3. Calculation of Nutrients b. Non Protein Calorie

a. Protein (Nitrogen Source) • Fat vs Carbohydrate
• 1 g protein = 4 kcal 1 g fat = 9 kcal
• 1gN = 6,25 g protein 1 g CHO = 3,4 - 4 kcal

• 1gN = 25 kcal Fat emulsion : 10 % => 1,1 kcal / ml

• Protein requirement calculated based on NPC : 20 % => 2,0 kcal / ml

N 30 % => 3,0 kcal / ml
• Maintenance 100 – 150 : 1 • Fat supplement recommendation
• Moderate stress 120 – 150 : 1 30% - 50% of NPC
• Severe stress 90 – 120 : 1
• Hypercatabolic patients 200 : 1
• Noncatabolic patients 100 : 1
 ESTIMATION OF NUTRITIONAL
REQUIREMENT

3. Calculation of Nutrients
d. Vitamins
• Based on daily requirements

e. Trace Elements
• may not be required for short term TPN
• GIT loss need to be replaced
 CASE

X is a 45 yo man was admitted to Hosp on March 2021

Cc of epigastric pain on and off, Loss of appetite and significant weight loss
PMH : has no significant medical history, never been admitted to the hospital
Physical examination :
VS : BP 120/70 HR 110 RR 40 T 36,9 Wt 55 kg (on admission) Ht 175 cm
HEENT : hoarsness and difficulty swallowing
CVS : palpitation
ABD : distended and tender, no palpable organo-megaly, vomiting with eating and positive bowel sound
EXT : loss skin turgor
Laboratory results :
Na 139 K 3,7 HCO 26 U 5 Alb 28 Glu 5 Ca 2,0
Endoscopy : partial obstruction of the esophagus prevent the passage of endoscopy
Esophageal biopsy : epidermoid cancer of the esophagus
Provision diagnosis : Esophageal cancer
 
Plan :
NPO
Surgery
PN to built up the patient
 DO’S

1. Do X need nutritional support ?

Subjective..
Objective..

2. Estimation of the nutritional requirements

Kebutuhan Energi  BEE ABW sampai IBW
IBW
ABW

Stress Factor ?

Protein requirement?
Fat requirement? TOTAL …kcal?
CHO requirement?