Estimation of TPN Requirement - PowerPoint Presentation

Slide1

Estimation of TPN Requirement

Slide2

Case - Study

MM 32 years old male was admitted to hospital on 27

th

May, 2015 for the closure of colostomy.

His

wt

is 70 kg and

ht

is 175 cm.

Past Medical History:

Motor-Vehicle accident in 26

th

March 2015

Sustained severe intra-abdominal injury

Resection of ileum and sigmoid

Colostomy was done in 26

th

March

TPN indicated

Slide3

Case - Study

30

th

May patient complaining of gastric pain and vomiting.

2nd June – leakage from anastomosis site causing intra-abdominal fluid accumulation.

Laparatomy

done and new anastomosis was done.

Nothing by mouth

TPN started

Slide4

Steps in establishing a TPN case

Identification of patient

Check for the indication – absolute or relative indication

Check for the availability of line – central or peripheral

Check whether partial or total parenteral nutrition

Estimate the expected duration of parenteral nutrition

Slide5

Steps in establishing a TPN case

Interpretation of baseline parameters

Nutritional assessment

Anthropometric parameters

Body Mass Index

Mid arm muscle circumference

Triceps-skinfold

Weight to height comparison

Creatinine

Height Index

Slide6

Steps in establishing a TPN case

Interpretation of baseline parameters

Nutritional assessment -Continued

Biochemical

Albumin

Transferrine

Pre Albumin

Slide7

Steps in establishing a TPN case

Interpretation of baseline parameters

Organ function

Cardiovascular

Renal

Liver

Slide8

Estimation of nutritional requirements

Fluid requirements

infants Fluid requirement

------------------------------------------------------------------------------------------

Premature

initiate with 40 - 60 ml/kg/day during

(birth weight <1500gm)

first week, gradually increased to 100 - 120 ml/kg/day by the end of first week

and 130 - 140 ml/kg/day by the end of second week.

Term (B.W. 1.5 - 3 kg)

125 - 145 ml/kg/day

3 kg - 10 kg

100 ml/kg/day

11 kg - 20 kg

1000 ml + 50 ml/kg for each kg > 10 kg.

> 20 kg

1500 ml + 20 ml/kg for each kg > 20 kg.

Slide9

Estimation of nutritional requirements

Fluid requirements

Changes in the fluid requirement:

Phototherapy

+ 50 %

Radiant warmer

+ 50 %

Environment > 35

0

C

+ 300 to 400 %

Body temperature > 37

0

C

+ 300 to 400 %

Heat Shield

- 25 %

Thermal Blanket

- 70 %

Respirator

- 30 %

Slide10

Fluid requirements

Body weight is 70 kg

Fluid requirements

1500 + (50kg X 20ml/kg)

1500 + 1000 ml

2500 ml.

No other conditions require additional fluid or fluid restriction.

Slide11

Energy Requirements

Traditional – Harrison – Benedict

Male

Basal Metabolic Rate   = 66.5 + [13.8 x

wt

] + [5 x

ht

] - [6.8 x age]

Female

Basal Metabolic Rate = 655 + [9.6 x

wt

] + [1.8 x

ht

] - [4.6 x age]

Note: BMR(

C

al),

Wt

(kg),

Ht

(cm), Age (year)

Slide12

Case - Study

32 years old male, 70 Kg and 175 cm

BMR = 66.5 + [13.8 x wt] + [5 x ht] - [6.8 x age]

= 66.5 + 966 +875 – 312.6

= 1594.9 Cal

=

1600 Cal

Slide13

Case - Study

Energy requirement

ER = BMR x Stress level (Laparatomy)

= 1600 x 1.75

=

2800 Cal

Slide14

Energy Requirements

Energy is derived from

carbohydrates

fat

protein

In catabolic state – proteins will be utilized as part of energy.

During anabolic state – proteins are reserved for the synthesis of body proteins.

Slide15

Energy Requirements

Stress Level

Raito of Calories Components (%)

Protein

Dextrose

Fats

Mild

20

50

30

Moderate

25

40

35

Sever

30

70

0

Slide16

Protein Requirements

1 gm of protein provide 4 cal

Daily protein requirement = 1- 4 gm/kg/d

Proteins metabolism produces urinary nitrogen and urinary nitrogen loss increases with stress.

Normal daily N loss = 2-4 gm/day

In stress may increase to 10 gm/day

Slide17

Protein Requirements

Estimated base on

non-protein calorie

to nitrogen ratio

(NPC:N)

Clinical Condition

NPC : N

Recovery / Child

> 200

:

1

Maintenance

120 – 150 : 1

Moderate Stress

100 – 120 : 1

Sever Stress

80 – 100 : 1

Slide18

Protein Requirements

The

non-protein calorie

to nitrogen ratio (NPC:N) is calculated as follows:

Calculate grams of nitrogen supplied per day (1 g N = 6.25g protein)

Divide total

non-protein calories

by grams of nitrogen

Slide19

Protein requirement

Protein requirement = NPC : N

= 100 : 1

In

moderate-severe

stress protein is part of energy

1 gm N = 6.25 gm

Prot

= 25

cal

= NPC : PC = 100 : 25

PC = 25 / (100 + 25) x 2800

= 560

cal

Protein = 560/4

= 140 gm

= 2 gm/kg/day

Slide20

Amino Acid

10 % give 10 gm/100 ml

14 % give 14 gm/100 ml

Choose

1000 ml of 14%

will give 140 gm amino acid

Slide21

Fat requirement

Fat gives

9

cal

/gm

Fat requirement = 1-4 gm/kg/d or up to 50% of NPC.

Fat shouldn’t be use in severely stress patient

Slide22

Fat requirement

The dose of fat emulsion in infant and pediatric

Age Dosage

-------------------------------------------------

premature 2 gm/kg/day

Term baby/infant 3.0 gm/kg/day

1 - 8 years 4.0 gm/kg/day

8 - 15 years 2.5 gm/kg/day

-------------------------------------------------

Slide23

Fat requirement

Fat emulsion 10% provide 1.1 cal/ml (0.9 cal from fat and 0.2 cal from glycerol and emulsifying agents)

Fat emulsion 20% provide 2.0 cal/ml (1.8 cal from fat and 0.2 cal from glycerol and emulsifying agents)

Slide24

Fat requirement

Fat = 30% of NPC

= 30% of (2800 – 560)

= 30% x 2240

= 672 cal

500 ml of 10%

will provide 550 cal/day

Slide25

Carbohydrate requirements

1 gm dextrose = 3.4 to 4.0 cal

Carbohydrate can be given up to 100% of NPC

It is used to Qs ER

Slide26

Carbohydrate requirements

Carbohydrate calorie

= 2800 – 560 – 550 cal

= 1690 cal

= 422.5 gm

D50% = 0.5 gm/ml

422.5 gm =

845 ml of D50%

Slide27

Electrolytes

Daily electrolytes requirement is estimated based on the serum level.

Serum sodium and potassium should be checked at least

2 x weekly

Serum calcium and phosphate

weekly or every other week.

Slide28

Electrolytes

Daily electrolytes maintenance is

Electrolytes per 24 hours

---------------------------------------------------------------------

Sodium 60 - 100

Potassium 60 - 100

Magnesium 10 - 20

Calcium 10 - 15

Phosphate 20 - 45

Chloride qs

Acetate qs

---------------------------------------------------------------------

Slide29

Trace elements

Trace elements requirements increase with continuous loss

Multitrace

elements 1 ampoule daily is sufficient

Elements Daily maintenance Additional supplements

----------------------------------------------------------------------

Zinc, mg 2.5 - 4.0 Small bowel loss: 12.2mg/L

Stool : 17.1 mg/L

Illeostomy

: 17.1 mg/L

Manganese, mg 0.15 - 0.8 --

Copper, mg 0.5 - 1.5 --

Chromium, mcg 10 - 15 20

----------------------------------------------------------------------

Slide30

Vitamins

---------------------------------------------------------

Vitamins per day

---------------------------------------------------------

A, IU 3300

D, IU 200

E, IU 10

C, mg 100

Thiamine (B1), mg 3

Riboflavin (B2), mg 3.6

Niacin, mg 40

Pyridoxine (B6), mg 4

Pantothenic acid, mg 15

B12, mcg 5

Folic acid, mcg 400

Biotin, mcg 60

---------------------------------------------------

------

Slide31

Vitamins

One pair of multivitamins preparation is sufficient to provide daily vitamins requirement.

Vitamin K 1-2 mg/day may be needed if the multivitamin does not contain Vit K.

Slide32

Final preparation

Amino Acid 14% 1000 ml

Fat emulsion 10% 500 ml

Dextrose 50% 845 ml

Multitrace elements 10 ml

Multivitamines 10 ml

Electrolytes based on solution used

Volume qs to 3000 ml

Slide33

Thank you