CALCULATING PARENTERAL FEEDINGS

PARENTERAL NUTRITION (PN) REQUIREMENTS [6]

• What is the patient’s energy need? (kcal required/day)

• How much protein/nitrogen does the patient need in a day?

• How much fluid can the patient tolerate and need?

• How much fat emulsion can the patient be given/tolerate?

• How much dextrose is needed? The dextrose concentration?

• Which electrolytes are needed and how much?

____ is the carbohydrate component of total parenteral nutrition (TPN)

Dextrose

TPN consists of ___, ___, and _____ which can contribute to the patient’s daily energy need differently.

protein, fat, fluid, and dextrose

Hence to know the patient’s daily energy using the TPN, the first thing you should always do is _______ in order to adjust the concentrations of the other components

compute for the total energy requirement

Equivalent calories per gram of nutrient

for every gram of carbohydrate, ____ calories

3.4

Equivalent calories per gram of nutrient

for every gram of lipids, ____ calories

9

Equivalent calories per gram of nutrient

for every gram of protein, ____ calories

4

PARENTERAL NUTRITION (PN) REQUIREMENTS

Type of micronutrients that may be needed by the patient in PN (Parenteral Nutrition)

electrolytes

• Must be individualized → No one size fits all TPN solution

• Standard concentrations of protein, carbohydrate, and fat that are available in standard volumes limit the degree of individualization when used

• Mixing different formulas in calculated amounts can be used in developing feeding solutions for most patients

• Dextrose solutions and lipid emulsions are common macronutrients used to provide energy in a parenteral solution

• Nitrogen for protein synthesis is obtained from synthetic crystalline L-amino acid solutions

TOTAL PARENTERAL NUTRITION (TPN)

TOTAL PARENTERAL NUTRITION (TPN)

Nitrogen for protein synthesis is obtained from ________ solutions

synthetic crystalline L-amino acid

EQUATIONS IN DETERMINING ENERGY NEEDS [3]

• HARRIS-BENEDICT EQUATION

• ENERGY NEEDS BASED ON THE FOLLOWING SCALE

• INDIRECT CALORIMETRY AND METABOLIC CART

DETERMINING ENERGY NEEDS

• Most common formula used in the preparation of TPN or any individualized therapeutic regimen

HARRIS-BENEDICT EQUATION

HARRIS-BENEDICT EQUATION

Variables [4]

• BEE: Basic Energy Expenditure or BMR: Basal Metabolic Rate

• kg wt: Weight in kilograms

• ht cm: Height in centimeters

• age yr: Age in years

HARRIS-BENEDICT EQUATION

• Refers to the variable of what your body naturally expends to function per day

BEE: Basic Energy Expenditure or BMR: Basal Metabolic Rate

To compute the total daily energy expenditure (TDEE):

result (BEE or BMR) x factor depending on the current level of activity (on a weekly basis)

HARRIS-BENEDICT EQUATION: Computing TDEE

Factors depending on the current level of activity (on a weekly basis) [5, and indicate their respective factors]

• Sedentary: 1.2

• Lightly active:1.375

• Moderately active: 1.55

• Very active: 1.725

• Extra active: 1.9

(T/F)

The TDEE can also be used when you want to lose, maintain, or gain weight

T

<TDEE

Losing weight

=TDEE

Maintain weight

>TDEE

Gaining weight

Required Metabolic States for Certain Clinical Conditions

Are conditions where a patient’s metabolic rate of the patient is reduced and there is a need to regulate the caloric intake

Hypometabolic states

Are conditions where little effect are experienced by the patient’s metabolic rate and there are only minor adjustments needed to regulate the caloric intake

Normometabolic states

Are conditions where a patient would have a high BMR

Hypermetabolic states

Daily energy needs (in kcal/kg) per state (Hypometabolic, Normometabolic, Hypermetabolic)

Hypometabolic: 20-25 kcal/kg/day

Normometabolic: 25-30 kcal/kg/day

Hypermetabolic: 30-35 kcal/kg/day

During exams or activities, unless specified, when provided a range, ALWAYS UTILIZE WHAT VALUE?

THE AVERAGE OR MIDPOINT VALUE!

ENERGY NEEDS BASED ON THE FOLLOWING SCALE

for obese patients, what guidelines do we base them?

ASPEN Guidelines

FOR OBESE PATIENTS (ASPEN Guidelines)

According to the ASPEN guidelines, diet for critically obese patients

Implement high-protein, hypocaloric feeding (Low carbohydrate or calorie, high protein diet) 

→ To preserve lean body mass

→ To minimize/reduce overfeeding

FOR OBESE PATIENTS (ASPEN Guidelines)

BMI for Critically obese patients

• BMI: 30-50

• 1-14 kcal/kg/day of Actual Body Weight (ABW)

FOR OBESE PATIENTS (ASPEN Guidelines)

BMI for Morbidly obese patients

• BMI: > 50

• should receive 22-25 kcal/kg/day of Ideal Body Weight (IBW)

Ideal body weight formula for women (according to CDC)

Ideal body weight formula for men (according to CDC)

FOR OBESE PATIENTS (ASPEN Guidelines)

Variables [3]

• IBW: Ideal Body Weight (in kg)

• ht cm: Height in centimeters

• ht in: Height in inches

• Patients look like they are contained inside a bubble. In it they are measuring the patient’s metabolic rate indirectly

• Measures inspired and expired gas flow, volumes and concentrations of O₂ and CO₂ 

• Determines energy requirements and response to nutrition over time

• For patients with TPN, to be able to discuss the results of TPN, they can be subjected to devices like the one shown in the presentation. However, not all institutions are equipped with the equipment or device as it is expensive

INDIRECT CALORIMETRY AND METABOLIC CART

INDIRECT CALORIMETRY AND METABOLIC CART

Calculates [2]?

Respiratory Quotient (CO₂ production/O₂ consumption) and Resting Energy Expenditure (REE)

INDIRECT CALORIMETRY AND METABOLIC CART

The production of chemical energy is proportional to gas exchange

PI

→ i honestly dont know what PI means, walang nakalagay sa trans

INDIRECT CALORIMETRY AND METABOLIC CART

____ is used to calculate energy expenditure:

Weir equation

EXAMPLE:

• Patient 1: 57 year old female (53 kg, 159 cm) with ischemic bowel and history of physiologic short gut syndrome admitted for malnutrition. Patient has multiple decubitus ulcers/sacral wounds.

• Compute using Harris Benedict Equation, Weight-based (kcal/kg) – Use chart, and Metabolic Cart Study (or Indirect Calorimetry if given with V_O2 inspired and V_CO2 expired)

NOTE:

→ mas gagamitin Option 1: Harris Benedict Equation, but still memorize the other 2 equations.

→ use the complete values (with exact decimals) for computation on activities

PROTEIN NEEDS

Protein is provided through?

amino acids

PROTEIN NEEDS

Protein (CHON) provides ?

4 kcal/g

PROTEIN NEEDS

Criteria/Requirements (status) - give the certain weight

• Maintenance, unstressed: 0.8 – 1 g/kg

• Mild stress: 1-1.2g/kg

• Infections, post-Major surgeries, Cancer, Critically ill: 1.3 – 1.6 g/kg

• Multiple trauma or congested heart infarction (CHI): 1.4 – 1.6 g/kg

• Large wounds, Protein-losing enteropathy: 1.5 – 2 g/kg

• >20% Total Body Surface Area burns: 2 – 3 g/kg

Prolonged TPN solutions should contain (how many?) amino acids. Enumerate the two.

two

• Glutamine

• Choline

PROTEIN NEEDS for prolonged TPN

• Most abundant amino acid in the blood

• Protects the gut epithelial tissue lining

Glutamine

PROTEIN NEEDS for prolonged TPN

Helps protect the liver from hepatic fat deposits (that hinder proper functioning)

Choline

FLUIDS ESTIMATION

In general, patients need a minimum of ____ to maintain hydration

30 cc fluid/kg body weight

for the range: 30-50 cc/kg

→ wherein 1 cubic centimeter (cc) = 1 mL

FLUIDS ESTIMATION

• Most adults will tolerate ____ L/day of PN, comprising of water and other solutions

1.5 – 2.5 L/day of PN

Method for fluid estimation of patients

Holiday-Segar Method

Holiday-Segar Method: Daily Requirements

For pediatrics (3-10 kg)

100 ml/kg

Holiday-Segar Method: Daily Requirements

For patients with 11-20 kg

1000 mL +  50 mL/kg for each kg > 10

Holiday-Segar Method: Daily Requirements

For patients with >20 kg

1500 mL + 20 mL/kg for each kg > 20 kg

[SAMPLE PROBLEM]

Calculate the required fluid intake (RFI) for a patient weighing 17 kg.

[SAMPLE PROBLEM]

Calculate the required fluid intake (RFI) for a patient weighing 64 kg.

• The amount depends on the TOTAL ENERGY needed 

FAT NEEDS

FAT NEEDS

Requirement

1.0 – 2.5 g fat/kg (or 30-40% of the total calories needed) 

→ Example: If you compute that the total energy needed is 2000 calories, 30-40% of the calories should come from fat and the remaining will come from carbs and protein

In TPN, CHO is given as ____

dextrose monohydrate

(T/F)

Dextrose and dextrose monohydrate have the same energy density (kcal/g).

True

Dextrose is available in 50 – 70% solutions, where in 50% solutions of _____, and 70% solutions of _____

D50W, D70W

Energy content of one liter (1000 cc) 50% Dextrose solution (D50W):

(T/F)

For diabetic patients, insulin regimens will need to be adjusted.

T

→ to keep the patient’s glucose under control 

(T/F)

For diabetic patients, you must give regular insulin outside of PN.

T

(T/F)

For non-diabetic patients, there should be an increase the dextrose when glucose is >180 mg/dL.

F.

decrease of dextrose if >180 mg/dL

• Determines how quickly a patient is storing/depleting the dextrose that they are being fed through the TPN

Glucose Utilization Rate (GR)

Glucose Utilization Rate (GUR) Formula

Glucose Utilization Rate (GUR) must not exceed __ mg/kg-min

4 mg/kg-min

→ fats provide calories for energy requirements; may result to overfeeding

MICRONUTRIENT NEEDS

Recommended Maximum Electrolytes: Sodium (Na)

130 mEq/L

MICRONUTRIENT NEEDS

Recommended Maximum Electrolytes:Potassium (K)

80 mEq/L

MICRONUTRIENT NEEDS

Recommended Maximum Electrolytes: Magnesium (Mg)

12-16 mEq/L

MICRONUTRIENT NEEDS

Recommended Maximum Electrolytes: Calcium (Ca)

10 mEq/L

MICRONUTRIENT NEEDS

Recommended Maximum Electrolytes: Phosphorus (P)

25 mmol/L

MICRONUTRIENT NEEDS

Trace Elements that are metabolized by the liver and should be omitted more than twice the upper limit of normal [2]

Mn & Cu

Anemia is a deficiency of what trace element?

Copper

Glucose intolerance is a deficiency of what trace element?

Chromium

Cardiomyopathy and other muscle pains is a deficiency of what trace element?

Selenium

Alopecia, dermatitis, poor wound healing and other muscle pains is a deficiency of what trace element?

Zinc

(T/F)

Add less of Zinc to the TPN for wound healing or excessive GI losses.

F. more

BIG NOTE!!

When it comes to adding or mixing ___ and ___ for preparing the TPN, there’s a limit because you want to avoid precipitation.

calcium, phosphate

→ higher likelihood of calcium turning into phosphate that is insoluble in water

OSMOLARITY (mOsm) Formula

• FAT is _____ and does not contribute to Osmolarity

ISOTONIC

Hypertonic solutions may contribute to phlebitis therefore, the osmolarity of the parenteral nutrition solution should be between _________

900-1100 mOsm/L

Hypertonic solutions must be controlled (within 900-1100 mOsm/L) because?

uncontrolled solution can result to phlebitis (inflammation of the vein)

Hypertonic solutions must be administered (amount) _____ if peripheral administration

<900 mOsm/L

[SAMPLE PROBLEM]

Patient 1: 57-year-old female (53 kg, 159 cm) with ischemic bowel and a history of physiologic short gut syndrome admitted for malnutrition. The patient has multiple decubitus ulcers/sacral wounds.

1. Calculate the fluid and macronutrients required for TPN.

2. How much dextrose (in grams) would be needed to prepare the TPN

3. Givenhttps://pmc.ncbi.nlm.nih.gov/articles/PMC6901066/ 6% Amino Acid, how many mL would be required to be placed in the TPN?

4. The hospital at which the patient was admitted only utilized 20% fat emulsion, how many mL of the preparation should you add

5. The only available carbohydrate source for the hospital is a D70 water solution, how much of the solution should you add?

6. Given the liquid preparations used to prepare the TPN, how much additional fluid should the patient need in order to meet her daily needs?

7. What is the total osmolarity of the TPN? Given the computed osmolarity, will you recommend administering the TPN? Assume TPN has electrolytes and contributes to 150 mOsm.

---

there are some parts na hindi alam ni leyan (these are in yellow highlight, pinic ko muna jic pinapalit)