1. Parenteral Nutrition Designing the Solution Mark H. DeLegge, MD, FACG, AGAF, FASGE Digestive Disease Center Medical University of South Carolina

2. Avoid That Which is Unknown

3. Lipids Carbohydrates Protein

4. Parenteral Nutrition  Infusion of nutrients through a vein  Indications: dysfuntional GI system –Malabsorption –Obstruction –Fistula –Inability to obtain enteral access –Bowel rest ?

5. Parenteral Nutrition  Central: Infused into a major vein (CPN) –Generally with catheter tip in the last 1/3 of Superior Vena Cava  Peripheral: Infused into a peripheral vein (PPN) –Limited by mixture osmolality (< 900 mOsmo) –May limit ability to deliver total caloric needs

6. PPN CPN Superior Vena Cava

7. Osmolality Gradient and Carbohydrates Glucose Concentration % CaloriesKcal/LOsmolalitymOsmo/L 5170252 10340505 206801010 4013602020 5017002525 6020403030 7023803535

8. Knowing the Solution  % Solution  10% AA = 10 gm AA/100 H0  10% AA = 10 gm AA/100 H 2 0  20% Lipids = 20 gm lipids/100 cc H 2 O  30% Jack Daniels = 30 gm Jack Daniels/100 cc H 2 0

9. What You Need to Know To Write A PN Prescription  Calorie Requirements  Protein Requirements  Electrolyte Requirements  Mineral Requirements  Vitamin Requirements  Water Requirements  Other Additives

10. Calorie Needs  Harris Benedict:  Male 66 + 13.8 (wt in kg) + 5 (height in cm) – 6.8 (age in years)  Female 655 + 9.6 (weight in kg) + 1.8 (ht in cm) – 4.7 (age in years) Stress Factor Mild 1-1.2 Moderate 1.3-1.4 Severe 1.5

11. Simple Calorie Calculation  Maintenance/mild stress: 20-25 kcal/kg/day  Moderate stress: 25- 28 kcal/kg/day  Severe Stress : 28-35 kcal/kg/day

12. Protein Needs  Maintenance – mild stress: 0.8-1.2 g/kg/day  Moderate stress: 1.3- 1.5 gm/kg/day  Severe stress: 1.5 – 2.0 gm/kg/day  Very high stress: > 2 gm/kg/day

13. Make Note of Common Lab Values Na+135-145 mEq/L K+ Serum3.5-5.0 mEq/L Chloride98-107 mmol/L CO222-32 mmol/L BUN 8-20 mg/dL Creatinine0.7-1.3 mg/dL Calcium8.4-10.2 mg/dL Phosphorus2.3-4.7 mg/dL Magnesium1.6-2.3 mg/dL

14. Example of a Standard PN Electrolyte Matrix  NACl 75 mEq/L  Na Acetate 25 m Eq/L (CO)  Na Acetate 25 m Eq/L (CO 2 )  K Phosphate15 mmol  (3 mmol of P = 4.4 mEq/K)  Na Phosphate 15 mmol  (3 mmol of P = 4 mEq Na)  Ca Gluconate 2 gm  Mg sulfate 1 gram

15. Standard Trace Minerals  Added to Daily PN Prescription  Chromium10 mcg  Copper1 mg  Manganese0.5 mg  Selenium60 mcg  Zinc5 mg

16. Standard Multivitamins Provided Daily  Vitamin A3300 IU  Vitamin D200 IU  Vitamin E 10 IU  Vitamin B1 6 mg  Vitamin B2 3.6 mg  Vitamin B340 mg  Vitamin B515 mg  Vitamin B6 6 mg  Vitamin C200 mg  Biotin 60 mcg  Folic Acid600 mcg  Vitamin K150 mcg

17. Daily Fluid Needs  30 cc/kg/day  Reduce if volume overloaded  Increase for excessive stool, urine, vomiting, sweating.  You do not have to correct major electrolyte, mineral, fluid abnormalities in the PN solution. Use a supplemental infusion.

18. Additives  H2 Blocker  Heparin  Insulin –Need at least 10 units/L to see clinical effect –Add ½ to ¾ of previous day’s insulin requirements to TPN bag

19. Additional Potential Additives Vitamin C: 500-1000 mg/day for wound healing. Zinc: 3-5 mg/day for wound healing Folic Acid: 1 mg/day with alcohol abuse or pregnancy Thiamine: 100 mg/day with alcohol abuse

20. Important Facts  Lipids: no more than 2.5 gm/kg/day  Carbohydrates: Maximal glucose infusion rate 3-5 g/kg/day  Protein: as described  1 gram lipids = 9 kcal  1 gram protein = 4 kcal  1 gram carbohydrates = 3.4 kcal

21. The Situation  A 40 year old male s/p recurrent fistula formation in the distal jejunum. He has lost 6 kg in 2 weeks. A central PN catheter is placed and you are asked to write a PN order. The patient weighs 70 kg.

22. Estimated Needs  Calories30 kcal/g x 70 kg = 2100 kcal  Protein1.2 g/kg x 70 kg = 84 kg  Fluids30 ml/kg = 2100 cc  His electrolytes are normal except for a Kof 3.3.  His electrolytes are normal except for a K + of 3.3.

23. 1 st Add Protein  84 g of protein  4 kcal/g (326 kcal)  2100 kcal – 326 kcal = 1774 kcal more required

24. 2 nd Add Lipids  1-1.5 g/kg  70 kg x 1 g/kg = 70 gm  70 gm = 700 kcal  1774 calories – 700 kcal = 1074 kcal remaining

25. 3 rd Add Carbohydrates  1074 kcal remaining  1074/3.4 kcal/g carbohydrate = 295 g  Double check for maximal carbohydrate infusion  295 g carbohydrate/70 kg = 4.21 g/kg/day

26. Determine a Volume  70 kg x 30 cc/kg = 2100 cc  Add multivitamins  Add trace minerals  Add drugs if necessary

27. What if the TPN Form Asks Me to Add Components as Solutions?  15% amino acids (15 gm/100 cc) –We need 84 grams = 560 cc  20 Lipids (20 gm/100 cc) –We need 70 gm = 350 cc  70% dextrose (70 gm/100 cc) –We need 295 gm = 421 cc –2100 cc volume – 1361 cc = 739 cc H0 –2100 cc volume – 1361 cc = 739 cc H 2 0 –Add trace minerals, multivitamins and other drugs

28. How do you Determine a Rate  Continuous  Total volume/24 hr = cc/hr  2100/24 = 87 cc/hr  Intermittent  Total volume over 12 hours  2100/12 = 175 cc/hr

29. Conclusion  1. Be able to determine calorie, protein, fluid needs  2. Be familiar with a standard electrolyte formulation  3. Make your PN formula sequentially  4. Be familiar with solutions and what they mean  5. Add this to your knowledge base

30. Don’t leave Nutrition Support up to Someone Else