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 Example Protein
of protein supplied by Calculation
a TPN solution, 1000 ml of 8% amino
multiply the total acids:
volume of amino acid 1000 ml x 8 g/100 ml
solution (in ml*) = 80g
supplied in a day by
Or 1000 x .08 = 80 g
the amino acid
concentration.
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% a.a., 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
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
1. Multiply the grams of dextrose per liter by 5.
Example: 100 g of dextrose x 5 = 500 mOsm/L
2. Multiply the grams of protein per liter by 10.
Example: 30 g of protein x 10 = 300 mOsm/L
3. Multiply the grams of lipid per liter by 1.5.
Example: 40 g lipid x 1.5 = 60.
4. Multiply the (mEq per L sodium + potassium +
calcium + magnesium) X 2
Example: 80 X 2 = 160
5. 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
Frequency
Parameter Daily 3x/week Weekly
Glucose Initially
Electrolytes Initially
Phos, Mg, Initially
BUN, Cr, Ca
TG
Fluid/Is & Os
Temperature
T. Bili, LFTs Initially

Adapted from K&M, p. 549

Inpatient Monitoring PN
Frequency
Parameter Daily Weekly PRN
Body Weight Initially
Nitrogen Balance Initially
HGB, HCT

Catheter Site
Lymphocyte Count
Clinical Status
 Monitorcontd
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
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
Refeeding Syndrome
Patients at risk are malnourished,
particularly marasmic patients
Can occur with enteral or parenteral
nutrition
Results from intracellular electrolyte shift
Refeeding Syndrome Symptoms
Reduced serum levels of magnesium,
potassium, and phosphorus
Hyperglycemia and hyperinsulinemia
Interstitial fluid retention
Cardiac decompensation and arrest
Refeeding Syndrome
Prevention/Treatment
Monitor and supplement electrolytes,
vitamins and minerals prior to and during
infusion of PN until levels remain stable
Initiate feedings with 15-20 kcal/kg or 1000
kcals/day and 1.2-1.5 g protein/kg/day
Limit fluid to 800 ml + insensible losses
(adjust per patient fluid tolerance and
status)
Fuhrman MP. Defensive strategies for avoiding and managing parenteral nutrition
complications. P. 102. In Sharpening your skills as a nutrition support dietitian. DNS,
2003.
Glycemic Control in Critical
Care
Until recently, BG<200 mg/dl was tolerated
in critically ill patients.
Now greater attention is given to glycemic
control due to evidence that glucose is
associated with morbidity/mortality and
risk of infection
New recommendation is to keep BG<150
mg/dl or as close to normal as possible

Van den Berghe et al. NEJM, 2001

Glycemic Control in PN
In critically ill patients, recommendation is
to keep dextrose infusion <5 mg/kg/minute
or <60% of total kcals.

ASPEN Nutrition Support Practice Manual, 2005, p. 267

Glycemic Control in PN
For Patients Not Previously on Insulin
Monitor blood glucose levels prior to
initiating PN
When therapy is initiated, monitor BG q 4-6
hours and use sliding scale or insulin drip as
needed
Add a portion of the previous days insulin
to TPN to maintain blood glucose levels

Charney P. A Spoonful of Sugar: Glycemic Control in the ICU. In Sharpening

your skills as a nutrition support dietitian. DNS, 2003.
Glycemic Control in PN
For Patients Previously on Insulin
Determine amount of insulin needed prior
to illness
Determine amount of feedings to be given
Provide a portion of daily insulin needs in
first PN along with sliding scale or insulin
drip to maintain glucose levels (generally
insulin needs will increase while on PN)
Charney P. A Spoonful of Sugar: Glycemic Control in the ICU. In Sharpening your
skills as a nutrition support dietitian. DNS, 2003.
Regular Insulin in PN

Availability in TPN : 53 100%

Short half-life
Delivery coincides with nutrient
infusion
Fluid Excess
Critically ill pts and those with cardiac, renal,
hepatic failure may require fluid restriction
May need to restrict total calories to reduce total
volume
Use most concentrated source of PN components
(70% dextrose = 2.38 kcal/ml; 20% lipid = 2
kcal/ml)
PPN may be contraindicated due to fluid volume
of 2-4 liters
Fluid Deficit
Patients with excessive losses may require
sterile water added to the PN
Provide consistently required fluid volume
in PN
Monitor I/O, weight, serum sodium, BUN,
HCT, skin turgor, pulse rate, BP, urine
specific gravity
 Electrolytes
Electrolytes in PN should be given at a stable dose
with intermittent requirements for
supplementation given outside the PN
Sodium levels often reflect fluid distribution
versus sodium status
Hypokalemia may be due to excessive GI losses,
metabolic alkalosis, and refeeding
Hyperkalemia may be due to renal failure,
metabolic acidosis, potassium administration, or
hyperglycemia
Acid-Base Balance
Balance chloride and acetate to
maintain/achieve equilibrium
The standard acetate/chloride ratio is 1:1
Increase proportion of chloride with
metabolic alkalosis; increase proportion of
acetate with metabolic acidosis
Consider chloride and acetate content of
amino acids
Metabolic Acidosis Etiology
Increased renal or GI loss of bicarbonate
Addition of strong acid or underexcretion of
H+ ion
Ketoacidosis
Renal failure
Lactic acidosis
Excessive Cl- administration
Metabolic Acidosis Treatment
Determine and treat underlying cause
Prove acetate forms of electrolytes with
HCO3- losses
Decrease chloride concentration in TNA
Consider chloride concentration in other IV
fluids
Metabolic Alkalosis Etiology
loss of H+ ion from increased gastric losses
Excessive base administration
Contraction alkalosis
Metabolic Alkalosis Treatment
Determine and treat underlying cause
Increase Cl- when alkalosis is due to
diuretics or NG losses
Transitional Feeding
Maintain full PN support until pt is tolerating 1/3
of needs via enteral route
Decrease TPN by 50% and continue to taper as the
enteral feeding is advanced to total
TPN can reduce appetite if >25% of calorie needs
are met via PN
TPN can be tapered when pt is consuming greater
than 500 calories/d and d-cd when meeting 60%
of goal
TPN can be rapidly d-cd if pt is receiving enteral
feeding in amount great enough to maintain blood
glucose levels
Cessation of TPN
Rebound hypoglycemia is a potential
complication
Decrease the volume by 50% for 1-2 hours
before discontinuing the solution to
minimize risk
PPN can be stopped without concern for
hypoglycemia
Defense Against PN
Complications
Select appropriate patients to receive PN
Aseptic technique for insertion and site care of IV
catheters
Do not overfeed
Maintain glycemic control <150-170 mg/dl
Limit lipids to 1 gm/kg and monitor TG levels
Adjust protein based on metabolic demand and organ
function
Monitor fluid/electrolyte/mineral status
Provide standard vitamin and trace element preps
daily