1. NUTRITION PARENTERAL formula
Nurpudji Astuti
Department of Nutrition
School of Medicine Hasanuddin University
@2013

2. ‘A slender and restricted diet is always dangerous in chronic and in acute diseases’
Hippocrates 400 B.C.

3. ICU Nutrition in the 1970s

4. Safety Parenteral Nutritional
Slide pembukaan presentasi ;
Untuk 2010, tema presentasi adalah Safety Parenteral Nutrition, yaitu Penggunaan Nutrisi parenteral yang aman bagi pasien
Introduction:
Selamat pagi/siang/ sore Bapak Ibu dokter sekalian. Saya (sebutkan nama dan responsibility) sebagai perwakilan dari BBraun mengucapkan terimakasih atas waktu yang diberikan kepada kami untuk menyampaikan sharing mengenai produk - produk unggulan dari BBraun.
Pada saat ini kami akan menyampaikan mengenai Produk Nutrisi parenteral dari BBraun.
Tetapi sebelumnya kami ingin sharing dengan Bapak Ibu sekalian mengenai kasus yang saat ini terjadi di seluruh dunia, yaitu Malnutrisi 4

5. GOAL OF NUTRITION THERAPY (medical nutrition therapy)
Minimized loss of prot and energy for patient with in adequate intake
Through enteral and parenteral nutrition
SUCCESS
THERAPY
Antibiotic
Drugs
Radiotherapy
Operation
NUTRITION
NUTRITION
Dikutip dari Presentasi Prof. DR. Dr. Eddy Rahardjo, SpAn KIC.

6. APA YANG TERJADI PADA PUASA 1-2 HARI

7. APA YANG TERJADI PADA TRAUMA MAYOR

8. APA YANG TERJADI PADA SEPSIS SERIUS

9. Parenteral Nutrition

11. Organisation of Nutrition Support
3. NICE Guidelines for Nutrition Support in Adults 2006

12. Treat: Enteral if patient malnourished/at risk of malnutrition
despite the use of oral interventions and
has a functional and accessible gastrointestinal tract
NOTES FOR PRESENTERS
For the purposes of this guideline, enteral tube feeding refers to the delivery of a nutritionally complete feed (containing protein or amino acids, carbohydrate with or without fibre, fat, water, minerals and vitamins) directly into the gut via a tube. The tube is usually placed into the stomach, duodenum or jejunum via either the nose, mouth or the direct percutaneous route. Enteral tube feeding is not exclusive and can be used in combination with oral and/or parenteral nutrition. Patients receiving enteral tube feeding should be reviewed regularly to enable re-instigation of oral nutrition when appropriate. Most enteral feeding tubes are introduced at the bedside but some are placed surgically, at endoscopy or using radiological techniques, and some are inserted in the community.
Enteral tube feeding should be considered for patients who are malnourished or at risk of malnourishment, who can’t be fed orally and who have a working and accessible gut.
Whenever possible the patient should be aware of why this form of nutrition support is necessary, how it will be given, for how long, and the potential risks involved. There may be considerable ethical difficulties in deciding if it is in a patient’s best interests to start a tube feed.
use the most appropriate route of access and mode of delivery
3. NICE Guidelines for Nutrition Support in Adults 2006

13. Treat: PN if patient malnourished/at risk of malnutrition
a non-functional,
inaccessible or perforated
gastrointestinal tract
and has either
inadequate or unsafe oral
or enteral nutritional intake
introduce progressively and
monitor closely
NOTES FOR PRESENTERS
Parenteral nutrition refers to the administration of nutrients by the intravenous route. It is usually administered via a dedicated central or peripheral placed line. Parenteral feeding should be considered in patients for whom oral or enteral feeding isn’t appropriate or they have an inaccessible or perforated gut.
Parenteral nutrition is an invasive and relatively expensive form of nutrition support (equivalent to most ‘new generation’ IV antibiotics daily) and in inexperienced hands, can be associated with risks from line placement, line infections, thrombosis and metabolic disturbance. Careful consideration is therefore needed when deciding to who, when and how this form of nutrition support should be given. Whenever possible, patients should be aware of why this form of nutrition support is needed and its potential risks and benefits.
The feed should be given progressively, and monitored closely. Parenteral feeding should be stopped when the patient is established on feeding from the oral or enteral route.
Whichever method of feeding is chosen, the patient should be monitored, and any adjustments needed made accordingly.
use the most appropriate route of access and mode of delivery
3. NICE Guidelines for Nutrition Support in Adults 2006

14. Objectives Define Parenteral Nutrition Therapy (PN)
Explain PN components
Describe PN follow-up parameters

15. Definition Parenteral nutrition is partial or total nutrition
administered intravenously. A peripheral or
central vein is used for access.

16. Indications: Parenteral Nutrition
Non-functional gastrointestinal tract
Impossible to use the gastrointestinal tract
Need for intestinal rest
Palliative use in terminal patients is controversial.
JPEN 2002;26(Suppl 1):83SA

17. Containdications: Parenteral Nutrition
Ability to adequately receive and absorb
necessary foods orally or by gastric or
enteral tube
Hemodynamic instability

18. Central Parenteral Nutrition
Selection depends on caloric requirements, volume to be
administered and patient condition, as well as final
concentration of components:
Amino acids > 5%
Dextrose > 20%
Lipids
Includes vitamins, minerals, and trace elements
Osmolality > 700 mOsm/kg H2O

19. Formulas : Parenteral Nutrition
Dextrose
Provides 3.4 kcal/g
Can be the only source of energy
Dextrose infusion rate should not exceed 5 mg/kg/min
Closely related to solution osmolality
Hill GL, et al. Br J Surg 1964;7:1

20. Formulas : Parenteral Nutrition
Amino Acids
Standard concentrations can vary between 5% and 15%
Energy value of amino acids (4 kcal/g)
Nitrogen (g) = protein (g) / 6.25

21. Formulas : Parenteral Nutrition
Lipids
Prevent essential fatty acids deficiency
Non-protein source of kcal. Recommended dose
1 g/kg/day
Available 10%, 20%, and 30% concentrations
Included as LCT or a mix of MCT/LCT at 10% and 20%
Added to basic parenteral nutrition solutions or administered individually
Trimbo SL. et al. Nutr Supp Serv 1986;6:18

22. Formulas : Parenteral Nutrition
Lipids
Less hyperglicemia
Lower concentrations of serum insulin
Less risk of hepatic damage
High dose can interfere with immune functions
High infusion rates can affect respiratory functions
Should be used with care in:
- Hyperlipidemia
- Symptomatic athrosclerosis
- Acute pancreatitis with hypertrigliceridemia

23. Formulas : Parenteral Nutrition
Electrolytes
Calcium, magnesium, phosphorus, chloride, potassium, sodium, and acetate
Forms and amounts are titrated based on metabolic status and fluid/electrolyte balance
Must consider calcium-phosphate solubility
Alpers DH. et al., eds. In: Manual of Nutritional Therapeutics. Little, Brown and Company; 1995

24. Formulas : Parenteral Nutrition
Vitamins and Minerals
In general, amounts below daily recommended intake for healthy people, but nonetheless sufficient to cover requirements, are added to oral or enteral formulas
Added daily to parenteral nutrition.
Acute illness, infection, preexisting malnutrition, and excessive fluid loss increase vitamin requirements.

25. Formulas : Parenteral Nutrition
Trace elements
Include daily zinc, copper, chromium, and manganase for patients with kidney or liver failure.
Different requirements dictated by patient and pathology
Patients under extended parenteral nutrition require the addition of iron and selenium.

26. Peripheral Parenteral Nutrition
Selection of peripheral access depends on clinical
situation, requirements, tolerance to volume, and final
formula concentration.
Osmolality < 700 mOsm/kg
Total kcal limited by concentration and ratio to volume
being administered
Include ½ of the recommended electrolytes for PN
Torosian MH, ed. In: Nutrition for the Hospitalized Patient. Marcel Dekker Inc.;1995

27. Monitoring Patient on Parenteral Nutrition
Metabolic
Glucose
Fluid and electrolyte balance
Renal and hepatic function
Triglycerides and cholesterol
Assessment
Body weight
Nitrogen balance
Plasma protein
Creatinine/height index
Campbell SM, Bowers DF. Parenteral Nutrition. In: Handbook of Clinical Dietetics. Yale University Press. 1992

28. Summary
Parenteral nutrition supplies partial or total nutrition by venous access
Total parenteral nutrition components supply all required nutrients
Metabolic monitoring and changes in solution components are needed to maintain adequate metabolic balance.

29. Parenteral Nutrition Formula Calculations and Monitoring Protocols

30. Macronutrient Concentrations in PN Solutions
Macronutrient concentrations (%) = the grams of solute/100 ml of fluid
D70 has 70 grams of dextrose per 100 ml.
10% amino acid solution has 10 grams amino acids/100 ml of solution
20% lipids has 20 grams of lipid/100 ml of solution

31. Protein Content Calculations
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.
Example Protein Calculation
1000 ml of 8% amino acids:
1000 ml x 8 g/100 ml = 80g
Or 1000 x .08 = 80 g

32. Calculation of Dextrose Calories
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.

33. Sample Dextrose Calculation
1000 ml of D50W (50% dextrose)
1000 ml x 50g / 100 ml = 500g dextrose
OR 1000 ml x .50 = 500g dextrose
500g dextrose x 3.4 kcal/g = 1700 kcal

34. Calculation of Lipid Content
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.
*|Lipid emulsions contain glycerol, so lipid emulsion does not have 9 kcal per gram as it would if it were pure fat. Some use 10 kcal/gm for lipid emulsions.
Source:

35. Example Lipid Calculation for 2-in-1
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 kcal
Or, alternatively, 500 ml of 10% lipid = 50 grams lipid x 10 kcal/g or 500 kcal
Source:

36. Calculation of Dextrose/AA with Piggyback Lipids (2-in-1)
Determine patient's kcalorie, protein, and fluid needs.
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.
Source:

37. Determine protein concentration
Subtract volume of lipid from total 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 %.
Multiply protein requirement in grams x 4 to determine calories from protein
Source:

38. Determine dextrose concentration.
Subtract kcals of lipid + calories from protein 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 (in protein calculations) and multiply by 100 to determine dextrose concentration.
Determine rate of AA/dex solution by dividing "remaining fluid needs” by 24 hr.
Source:

39. Example Calculation Nutrient Needs:
Kcals: Protein: 88 g. Fluid: 2000 cc
  kcal x 30% = 540 kcal from lipid
Lipid (10%):
540 kcal/1.1 (kcal/cc) = 491 cc/24 hr =
20 cc/hr 10% lipid (round to 480 ml)
Remaining fluid needs: 2000cc - 480cc = 1520cc

40. Protein Calculations
Protein: 88 g / 1520 cc x 100 = 5.8% amino acid solution
88 g. x 4 kcal/gm =352 kcals from protein
Remaining kcal needs: 1800 – ( ) = 920 kcal

41. Dextrose Concentration
920 kcal/3.4 kcal/g = 270 g dextrose
270 g / 1520 cc x 100 = 17.7% dextrose solution
Rate of Amino Acid / Dextrose: 1520 cc / 24hr = 63 cc/hr
TPN recommendation: Suggest two-in-one PN 17.7% dextrose, 5.8% 63 cc/hr with 10% lipids 20 cc/hr

42. Re-check calculations
TPN recommendation: Suggest two-in-one PN 17.7% dextrose, 5.8% 63 cc/hr with 10% lipids 20 cc/hr
63 cc/hr x 24 = 1512 ml
1512 * (.177) = 268 g D X 3.4 kcals= kcals
1512 * (.058) = 88 g a.a. x 4 kcals =
20 cc/hr lipids*24 = 480*1.1 kcals/cc = 528
1791

43. 3 in 1 TNA Solutions |
Determine patient's kcalorie, protein, and fluid needs.
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 10. *
Divide lipid grams by total daily volume (= fluid needs or final rate x 24) and multiply by 100 to determine % lipid.

44. 3-in-1 TNA Solutions
Determine protein concentration by dividing protein needs (grams) by total daily volume and multiply by 100.
Multiply protein needs in grams x 4 kcal/gm = kcals from protein
Determine dextrose grams.
Subtract kcals of lipid and kcals from protein 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

45. Sample Calculation 3-in-1
Nutrient Needs:
Kcals: 1800 Protein: 88 g Fluid: 2000 cc
Lipid : 1800 kcal x 30% = 540 kcal
540 kcal / 10 kcal per gram = 54 g
54 g / 2000 cc x 100 = 2.7% lipid
Protein: 88 g / 2000 cc x 100 = 4.4% amino acids
88 g x 4 = 352 kcals from protein

46. Sample Calculation 3-in-1(cont)
Dextrose: 908 kcal (1800 – )
908/3.4 kcal/g = 267 g dextrose
267 g / 2000 cc x 100 = 13.4% dextrose solution
Rate of Amino Acid / Dextrose/Lipid: 2000 cc / 24hr = 83 cc/hr
TPN prescription: Suggest TNA 13.4% dextrose, 4.4% amino acids, 2.7% lipids at 83 cc/hour provides 88 g. protein, 1800 kcals, 2000 ml. fluid

47. Evaluation of a TNA Order
PN 15% Dextrose, 4.5% AA., and 3% 100 cc/hour

48. Evaluation of a PN Order
PN 15% dextrose, 4.5% a.a., 3% 100 cc/hour
Total volume = 2400
Dextrose: 15g/100 ml * 2400 ml = 360 g
360 g x 3.4 kcal/gram = 1224 kcals
Lipids 3 g/100 ml x 2400 ml = 72 g lipids
72 x 10 kcals/gram = 720 kcals

49. Evaluation of a PN Order
Amino acids: 4.5 grams/100 ml * 2400 ml = 108 grams protein
108 x 4 = 432 kcals
= 2376 total kcals
Lipid is 30% of total calories
Dextrose is 51.5% of total calories
Protein is 18% of total calories

50. Calculation of Nonprotein Calories
Some clinicians discriminate between protein and nonprotein calories although this is falling out of favor
This is more commonly used in critically ill patients

51. Calculation of Non-Protein Calories
To determine the nonprotein kcalories (NPC) in a TPN prescription, add the dextrose calories to the lipid calories
In the last example, 1224 kcals (dextrose) kcals (lipid) = 1944 non-protein kcals
Dextrose is 63% of nonprotein kcals (1224/1944)
Lipid is 37% of nonprotein calories (720/1944)
In critically ill patients, some clinicians restrict lipid to 30% of nonprotein kcals

52. Calculation of NPC:N Ratio |
Calculate grams of nitrogen supplied per day (1 g N = 6.25g protein)
Divide total nonprotein calories by grams of nitrogen
Desirable NPC:N Ratios:
80:1 the most severely stressed patients
100:1 severely stressed patients
150:1 unstressed patient
Source:

53. Example NPC:N Calculation
80 grams protein 2250 nonprotein kcalories per day
80g protein/ 6.25 = /12.8 = 176 NPC:N = 176:1
Source:

54. Example %NPC Fat Calculation*
2250 nonprotein kcal 550 lipid kcal
550/2250 x 100 = 24% fat kcals
*Limit is 60% NPC

55. Osmolarity in PPN
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.

56. IV-Related Phlebitis

57. Calculating the Osmolarity of a Parenteral Nutrition Solution
Multiply the grams of dextrose per liter by 5. Example: 100 g of dextrose x 5 = 500 mOsm/L
Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L
Multiply the grams of lipid per liter by 1.5.
Example: 40 g lipid x 1.5 = 60.
Multiply the (mEq per L sodium + potassium + calcium + magnesium) X 2
Example: 80 X 2 = 160
Total osmolarity = = 1020 mOsm/L
Source: K&M and PN Nutrition in ADA, Nutrition in Clinical Practice. P 626

58. Osmolarity Quick Calculation
To calculate solution osmolarity:
multiply grams of dextrose per liter by 5
multiply grams of protein per liter by 10
add a & b
add 300 to 400 to the answer from "c". (Vitamins and minerals contribute about 300 to 400 mOsm/L.)
Source:

59. Is the solution compoundable?
TPN is compounded using 10% or 15% amino acids, 70% dextrose, and 20% lipids
The TPN prescription must be compoundable using standard base solutions
This becomes an issue if the patient is on a fluid restriction

60. Is the Solution Compoundable?
What is the minimum volume to compound the PN prescription?
Example: g AA
350 g dextrose
50 g lipid
2000 ml fluid restriction
AA: 10 g = 75 g = 750 ml using 10% AA
100 ml X ml
OR divide 75 grams by the % base solution, 75 g/ .10

61. Is the solution compoundable?
Dextrose: 70 g = 350 g x = 500 ml
100 ml X ml
Lipid: g = 50g X = 250 ml
100 ml x ml
Total volume = 750 ml AA ml D ml lipid ml (for electrolytes/trace) = 1600 ml (minimum volume to compound solution)
Tip: Substrates should easily fit in 1 kcal/ml solutions

62. Is this solution compoundable?
PN prescription:
AA 125 g
D g
Lipid 50 g
Fluid restriction 1800 ml/day

63. Is this solution compoundable?
AA: g = g = 1250 ml 10% AA
100 ml X ml
Dextrose: 70 g = 350 g x = 500 ml (350/.70)
100 ml X ml
Lipid: g = 50g X = 250 ml (50/.20)
100 ml x ml
Total volume = 1250 ml AA ml D ml lipid ml (for electrolytes/trace) = 2100 ml (minimum volume to compound solution)
Verdict: not compoundable in 1800 ml.
Action: reduce dextrose content or use 15% AA base solution if available (could deliver protein in 833 ml of 15%)

64. Parenteral Nutrition
Monitoring

65. Monitoring for Complications
Malnourished patients at risk for refeeding syndrome should have serum phosphorus, magnesium, potassium, and glucose levels monitored closely at initiation of SNS. (B)
In patients with diabetes or risk factors for glucose intolerance, SNS should be initiated with a low dextrose infusion rate and blood and urine glucose monitored closely. (C)
Blood glucose should be monitored frequently upon initiation of SNS, upon any change in insulin dose, and until measurements are stable. (B)
ASPEN BOD. Guidelines for the use of enteral and parenteral nutrition in adult and pediatric patients. JPEN 26;41SA, 2002

66. Monitoring for Complications
Serum electrolytes (sodium, potassium, chloride, and bicarbonate) should be monitored frequently upon initiation of SNS until measurements are stable. (B)
Patients receiving intravenous fat emulsions should have serum triglyceride levels monitored until stable and when changes are made in the amount of fat administered. (C)
Liver function tests should be monitored periodically in patients receiving PN. (A)
ASPEN BOD. Guidelines for the use of enteral and parenteral nutrition in adult and pediatric patients. JPEN 26;41SA, 2002

67. Acute Inpatient PN Monitoring
Parameter
Daily
Frequency
3x/week
Weekly
Glucose
Initially √
Electrolytes
Phos, Mg, BUN, Cr, Ca TG
Fluid/Is & Os
Temperature
T. Bili, LFTs
Adapted from K&M, p. 549

68. Inpatient Monitoring PN
Parameter
Daily
Frequency
Weekly
PRN
Body Weight
Initially √
Nitrogen Balance
HGB, HCT
Catheter Site
Lymphocyte Count
Clinical Status

69. Monitor—cont’d
Urine: Glucose and ketones (4-6/day) Specific gravity or osmolarity (2-4/day) Urinary urea nitrogen (weekly)
Other: Volume infusate (daily) Oral intake (daily) if applicable Urinary output (daily) Activity, temperature, respiration (daily) WBC and differential (as needed) Cultures (as needed)

70. Monitoring: Nutrition
Serum Hepatic Proteins
Parameter t ½
Albumin days
Transferrin days
Prealbumin – 3 days
Retinol Binding Protein ~12 hours

71. Complications of PN Refeeding syndrome Hyperglycemia
Acid-base disorders
Hypertriglyceridemia
Hepatobiliary complications (fatty liver, cholestasis)
Metabolic bone disease
Vascular access sepsis

72. Thank you CONCLUSION NUTRITION SUCCESS THERAPY Antibiotic Drugs
Radiotherapy
Operation
NUTRITION
Thank you