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

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

ICU Nutrition in the 1970s

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

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.

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Parenteral Nutrition

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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

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

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.

Parenteral Nutrition Formula Calculations and Monitoring Protocols

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

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

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.

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

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: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html

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: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html

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: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html

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: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html

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: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html

Example Calculation Nutrient Needs: Kcals: 1800. Protein: 88 g. Fluid: 2000 cc   1800 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

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 – (528 + 352) = 920 kcal

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% a.a. @ 63 cc/hr with 10% lipids piggyback @ 20 cc/hr

Re-check calculations TPN recommendation: Suggest two-in-one PN 17.7% dextrose, 5.8% a.a. @ 63 cc/hr with 10% lipids piggyback @ 20 cc/hr 63 cc/hr x 24 = 1512 ml 1512 * (.177) = 268 g D X 3.4 kcals= 911 kcals 1512 * (.058) = 88 g a.a. x 4 kcals = 352 20 cc/hr lipids*24 = 480*1.1 kcals/cc = 528 1791

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.

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

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

Sample Calculation 3-in-1(cont) Dextrose: 908 kcal (1800 – 540 - 352) 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

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

Evaluation of a PN Order PN 15% dextrose, 4.5% a.a., 3% lipid @ 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

Evaluation of a PN Order Amino acids: 4.5 grams/100 ml * 2400 ml = 108 grams protein 108 x 4 = 432 kcals 1224 + 720 + 432 = 2376 total kcals Lipid is 30% of total calories Dextrose is 51.5% of total calories Protein is 18% of total calories

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

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) + 720 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

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: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html

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 Source: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html

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

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.

IV-Related Phlebitis

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 = 500 + 300 + 60 + 160 = 1020 mOsm/L Source: K&M and PN Nutrition in ADA, Nutrition in Clinical Practice. P 626

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: http://www.csun.edu/~cjh78264/parenteral/calculation/calc07.html

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

Is the Solution Compoundable? What is the minimum volume to compound the PN prescription? Example: 75 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

Is the solution compoundable? Dextrose: 70 g = 350 g x = 500 ml 100 ml X ml Lipid: 20 g = 50g X = 250 ml 100 ml x ml Total volume = 750 ml AA + 500 ml D + 250 ml lipid + 100 ml (for electrolytes/trace) = 1600 ml (minimum volume to compound solution) Tip: Substrates should easily fit in 1 kcal/ml solutions

Is this solution compoundable? PN prescription: AA 125 g D 350 g Lipid 50 g Fluid restriction 1800 ml/day

Is this solution compoundable? AA: 10 g = 125 g = 1250 ml 10% AA 100 ml X ml Dextrose: 70 g = 350 g x = 500 ml (350/.70) 100 ml X ml Lipid: 20 g = 50g X = 250 ml (50/.20) 100 ml x ml Total volume = 1250 ml AA + 500 ml D + 250 ml lipid + 100 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%)

Parenteral Nutrition Monitoring

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

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

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

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

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)

Monitoring: Nutrition Serum Hepatic Proteins Parameter t ½ Albumin 19 days Transferrin 9 days Prealbumin 2 – 3 days Retinol Binding Protein ~12 hours

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

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