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 MotorVehicle accident in 26 ID: 912308
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Slide1
Estimation of TPN Requirement
Slide2Case - 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
Slide3Case - 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
Slide4Steps 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
Slide5Steps 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
Slide6Steps in establishing a TPN case
Interpretation of baseline parameters
Nutritional assessment -Continued
Biochemical
Albumin
Transferrine
Pre Albumin
Slide7Steps in establishing a TPN case
Interpretation of baseline parameters
Organ function
Cardiovascular
Renal
Liver
Slide8Estimation 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.
Slide9Estimation 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 %
Slide10Fluid 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.
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)
Slide12Case - 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
Slide13Case - Study
Energy requirement
ER = BMR x Stress level (Laparatomy)
= 1600 x 1.75
=
2800 Cal
Slide14Energy 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.
Slide15Energy Requirements
Stress Level
Raito of Calories Components (%)
Protein
Dextrose
Fats
Mild
20
50
30
Moderate
25
40
35
Sever
30
70
0
Slide16Protein 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
Slide17Protein 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
Slide18Protein 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
Slide19Protein 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
Slide20Amino Acid
10 % give 10 gm/100 ml
14 % give 14 gm/100 ml
Choose
1000 ml of 14%
will give 140 gm amino acid
Slide21Fat 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
Slide22Fat 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
-------------------------------------------------
Slide23Fat 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)
Slide24Fat requirement
Fat = 30% of NPC
= 30% of (2800 – 560)
= 30% x 2240
= 672 cal
500 ml of 10%
will provide 550 cal/day
Slide25Carbohydrate 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
Slide26Carbohydrate requirements
Carbohydrate calorie
= 2800 – 560 – 550 cal
= 1690 cal
= 422.5 gm
D50% = 0.5 gm/ml
422.5 gm =
845 ml of D50%
Slide27Electrolytes
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.
Slide28Electrolytes
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
---------------------------------------------------------------------
Slide29Trace 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
----------------------------------------------------------------------
Slide30Vitamins
---------------------------------------------------------
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
---------------------------------------------------
------
Slide31Vitamins
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.
Slide32Final 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
Thank you