TPN PRESCRIPTION 1) Calculate the IBW (ideal body weight in kg) Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet. Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet. New formula: IBW = 22 x H 2 (where H: height in meter) 2) Is the actual body weight is > 130% of the calculated IBW? Then use the adjusted body weight (ABW): adjusted body weight (kg) = IBW + 0.4(actual weight - IBW) 3) Calculate the Total Energy Requirements: 40 Kcal/kg/day (malnutrition with mild stress and normal weight) 4) Calculate the Kcals needed from lipid: 30% of Total Energy Requirements (= 0.3 x TER) 5) Calculate the lipid volume (ml of 20% lipid): Kcals needed from lipids / 2 (or divide by 1.1 for 10% lipid) 6) Calculate the lipid rate of infusion: lipid volume divided by 12 hours (run over 6-12 hours) 7) Calculate the total fluid requirements (including lipid): 1 ml/kcal/day 8) Calculate the TPN volume (excluding lipid): total fluid requirements lipid volume 9) Calculate the rate of TPN (AA/dex) infusion: TPN volume (excluding lipid) / 24 hours (run over 24 hours) 10) Calculate the grams needed of dextrose: 70% of total energy requirements / 3.4 11) Calculate the dextrose concentration (%): grams needed of dextrose / TPN volume (excluding lipid) x 100 12) Calculate the protein requirements: 1.5 g/kg/day for moderately stressed (fracture, surgery...) 13) Calculate the protein (AA) concentration (%): protein requirement (in grams) / TPN volume (excluding lipid) x 100 14) Electrolytes, trace elements, and others: Na (2 /kg/day) Cl (2 /kg/d) K (1 /kg/d) Ca (0.3 /kg/d) Mg (0.4 /kg/d) Trace elements: Tracutil 10 ml ampoule once daily: Balanced mixture of the 9 trace elements Iron, Zinc, Manganese, Copper, Chromium, Molybdenum, Selenium, Fluoride and Iodide; meets the daily requirements of essential trace elements 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. The amount of regular insulin given (added directly to the TPN solution) depends on the blood glucose level; if the level is normal and the final solution contains the usual 25% dextrose concentration, the usual starting dose is 5 to 10 units of regular insulin /L of TPN fluid. 15) Labs (baseline & then biweekly): CBC, creatinine, urea, Na, K, Cl, Ca, Mg, phosphate, total protein & albumin, AST, ALT, alkaline phosphatase, bilirubin (T&D), LDH, cholesterol & triglyceride, PT, PTT, Fe, TIBC, Zn, Cu, RBS (Q 6 hours). 1
1) Charts of Protein Needs (g/kg) Adults APPENDIX Pediatrics Health States Requirement* Age (y) Requirement* Normal Stressed Normal 0.8-1.0 0.0-0.5 2.0 2.2-3.0 Moderately stressed (infarction, fracture, surgery) Severely Stressed (burns, multiple fractures) 1.0-2.0 0.5-1.0 1.6 1.6-3.0 2.0-2.5 1-3 1.2 1.2-3.0 Renal Disease 4-6 1.1 1.1-3.0 Predialysis 0.6-0.8 7-10 1.0 1.0-2.5 Hemodialysis 1.1-1.4 11-14 1.0 1.0-2.5 Peritoneal dialysis 1.2-1.5 15-24 0.85 1.0-2.5 2) Charts of Energy Needs by Kcal/kg Non-Stressed Patients: Stressed Patients: Weight Status Activity Level* Health Status kcal/kg 1 2 3 4 Basal energy needs 25-30 Overweight 20 25 30 35 Ambulatory (st. maintenance) 30-35 Normal weight 25 30 35 40 Malnutrition with mild stress 40 Underweight 30 35 40 45 Severe injuries / sepsis 50-60 Extensive burns 80 *Activity Levels Defined: 1. Sedentary: confined to chair or bedrest 2. Light: Mostly seated or standing, with arm movements 3. Moderate: Frequent movements involving arms and legs, walking briskly 4. Marked: Walking uphill, activities requiring intermittent but frequent spurts of energy. 3) Kcals derived from lipid, dextrose, and protein: 1 g Lipids = 9 kcal energy: The 10% lipid emulsion contains 1.1 kcal/ml; the 20% emulsion contains 2 kcal/ml. Dextrose in solution has 3.4 kcal/g rather than 4 Kcal/g as in dietary carbohydrates 1 g Protein = 4 kcal Energy 2
4) Mineral supp. based on health: Amount per Kg Body Weight Mineral Potassium Sodium Calcium Normal 0.7-0.9 1.0-4.0 State of Catabolism Mild- Mod 2.0 2.0-3.0 0.22 0.3 m Eq Phosphorous 0.3 0.8 0.3 0.3-0.4 Severe 3.0-4.0 3.0-4.0 0.4 1.2-2.0 0.6-0.8 m Eq Comments Give 5-6 /g of N infused TPN Prescription 0.25 m Eq/kg needed for calcium equilibrium. Dependent on simultaneous administration of PO and Na, not N retention Needs related to nitrogen retention which is related to kcal intake. Give 15-25 PO per 1000 dex kcals. Give 2 per gram of N infused. 5) Mineral supp. based on lab values Mineral Lab Value Daily need Potassium Sodium Calcium Phosphorous Chloride Above 4.8 4.0-4.8 3.5-3.9 Below 3.5 Above 142 136-142 Below 136 Above 10.5 8.0-10.5 7.0-7.9 Above 3.5 2.5-3.5 Below 2.5 Above 104 101-104 98-100 Below 90 8.1 Eq 20-30 40-50 80-90 25-50 50-100 4.5 9.0 m Eq 15 mm 15-30 mm 20-25 40-50 90-100 3
6) Trace Element Supplementation Zinc Copper Iron Chromium Manganese Iodine Selenium Element Dose 2.5-4.0 mg 0.5-1.5 mg 1.0 mg 10-15 mcg 0.15-1.8 mg 1-2 mcg 20-40 mcg 7) Vitamin Supplementation Recommendations Vitamin Adults Children Under 11 years A (IU) 3300 3300 3300 D(IU) 200 200 400 E(IU) 10 10 7 Thiamin (mg) 3 3 1-2 Riboflavin (mg) 3.6 3.6 1.4 Pantothenic Acid (mg) 40 40 17 Folate (mcg) 15 20 - B-12 (mcg) 0.4 0.4 1.4 Biotin (mg) 5 5 1 C (mg) 100 100 80 8) General PN Initiation Procedures Start with 1 liter of TPN solution during the first 24 hours (or use 42 cc/hr as a typical start rate). Alternatively, the solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make up the balance of fluid. 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. 4
9) Guidelines for Monitoring PN Patients Parameter Initial Period Stable Body temperature Every Shift Every Shift Fluid intake/output Daily Daily Glycosuria Every 8 hours Every 6 hours Electrolytes (Na/K) First 3 days Biweekly Calcuim, Phosphate, Baseline Weekly BUN/creatinine Baseline Biweekly Alb/total protein, Chol. Baseline Weekly Triglycerides Baseline As indicated Liver enzymes: SGPT, SGOT Baseline Weekly LDH, alk phos, dir/indir bilirubin Baseline Weekly PT/PTT Baseline Weekly Platelet count* Baseline As indicated Fe/TIBC, Zn/Cu Baseline As indicated N-Balance (24 hr UUN) 24-48 hours after full rate achieved As indicated *Needed initially for catheter insertion purposes BUN = blood urea nitrogen; SGPT = serum glutamic-pyruvic transaminase; SGOT serum glutamic-oxaloacetic transaminase; LDH = lactate dehydrogenase; PT = prothrombin time; PTT = partial thrommboplastin time; TIBC = total iron-binding caacity, UUN=urinary urea nitrogen 10) Terminating the infusion: 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 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 hypoglycemia. 5