TPN Calculations (1).pptx

TPN CALCULATIONS

1. TPN Presentation Muhammad Naeem Anam Shah

2. TPN Solution Total parenteral nutrition (also known as hyperalimentation , hyperal or TPN) is the IV administration of nutrients needed to sustain life: carbohydrates, protein, fats, water, electrolytes, vitamins, and trace elements. Usually initiated in patients who cannot meet their nutritional needs from other sources for an extended period of time. TPN is used for patients who cannot eat (e.g. head & neck surgery , comatose, or before or after surgery), who will not eat ( e.g patients with esophageal obstruction or inflammatory bowel disease or who cannot eat enough (e.g. patients with cancer,burns or trauma).

3. ADMINISTRATION Most TPN solutions are made for administration through a central line . This route is used because it results in immediate dilution of the solution being administered and therefore a very concentrated solution can be administered. Administering a concentrated solution often allows the medical team to completely meet an adult patient’s daily nutritional needs with 2000 to 3000 mL of TPN solution. Occasionally, TPNs are administered through a peripheral IV line – can contain same ingredient, but diluted to a lower osmolarity . Since the solution is more dilute, they do not meet al the patient’s nutritional needs . May need supplements for caloric intake.

4. RISK LEVELS Risk Level 1 - Sterile products without preservatives for individual patients or batch prepared with preservatives for multiple patients. - These are sterile products transferred into a sterile container (e.g. syringe, IV bag or bottle). - Storage time for these products, including administration time , should not exceed 28 hours at room temperature, 7 days under refrigeration, or 30 days if frozen

5. Risk Level 2 These products are batch-prepared without preservatives for multiple patients. These include products that require multiple sterile ingredients that are combined in a sterile container through a closed system transfer that are then subdivided into multiple parts.

6. Risk Level 3 These products are compounded from nonsterile ingredients, containers or equipment or prepared from sterile or nonsterile ingredients in an open system. The pharmacist is likely to be responsible for ensuring compliance with the guidelines and other standards of practice.

7. END PRODUCT EVALUATION End-product evaluation is the final inspection made by the pharmacist before the product is allowed to leave the pharmacy. It includes an inspection for leaks, cloudiness, particulate matter, color, solution volume, and container integrity. The pharmacist also verifies compounding accuracy with respect to the correct ingredients and quantities. This check of the technician’s work is an important step in ensuring that only quality products are sent for patient use.

8. C omplication s TPN fully by-passes the GI tract and normal methods of nutrient absorption. Possible complications, which may be significant, are listed below:

9. I nfection : TPN requires a chronic IV access for the solution to run through, and the most common complication is infection of this catheter . Infection is a common cause of death in these patients, with a mortality rate of approximately 15% per infection , and death usually results from septic shock

10. B lood clot s Chronic IV access leaves a foreign body in the vascular system, and blood clots on this IV line are common. Death can result from  pulmonary embolism  wherein a clot that starts on the IV line but breaks off and goes into the lungs . Patients under long-term TPN will typically receive a periodic heparin flush to dissolve such clots before they become dangerous

11. Fatty liver and liver failur e Fatty liver is usually a more long term complication of TPN, though over a long enough course it is fairly common. The pathogenesis is due to using linoleic acid (an omega-6 fatty acid component of soybean oil) as a major source of calories

12. Parenteral Nutrition Order TPN * PPN Central Peripheral * Route Of Administration Day of TPN Date Time

13. Patient Profile Name XYZ Age 2 years weight 12 kg MR(Medical Report) …………. Ward Surgery Diagnosis Gut Surgery NPO Since 2 days Oral feed (if any) Type of Oral feed Total oral feed per day Energy of oral feed per day

14. Lab Findings ALT Normal Na 120 AST Normal K 2.5 Billirubin Normal Ca 7 Lipid Profile RFT’s S.Triglycerides S/Cr (serum creatinine) 0.6 (Normal) Cholesterol Urea 40 BSR 121 Normal Others

15. Daily Fluid Requirement………………………. (ml/kg/day) With Lipid /Without Lipid……………………… Proteins(gm/kg/day)……………………………... (1-3gm/kg/day) Lipid (gm/kg/day)……………………………... ….(0.5-4gm/kg/day) Dextrose(gm/kg/day)……………………………...( gm/kg/day) Na( mEq /kg/day)……………………………………..(2-4 mEq /kg/day) K( mEq /kg/day)………………………………………..( 2-3 mEq /kg/day) Ca(mg/kg/day)………………………………………..(300-5000 mg/kg/day) Rx Order

16. Drugs being given in dilution for I.V Infusion Serial # Drug Regimen Diluent Vol /day Na content/Dextrose (For Pharmacist) 1 Vancomycin (I/V) 200 mg t.i.d 60 mL 9 mEq 2 3 4 5 6 7 8 ( For Pharmacist )

17. Total fluid being given as drug diluents…………… 60 ………………. mL Total Na content being given as drug diluents……… 9 ………….. mEq Total Dextrose being given as drug diluents…………………………gm Remarks………………………………………………………………………………….. …… ……………………………………………………………………………………… Doctor Signature………………………….

18. Calculations Pharmacist Work Up

19. Parenteral Nutrition Calculation Fluid for TPN( mL )………… 1050 ……… mL

20. Amino Acid Solution (10% solution) Protein(gm/kg/day) 0.5   Protein (gm /day) 6   Volume ( mL ) 60   Na…0.041……( mEq / mL ) 2.46   K…..0.025….(mEq/mL) 1.5   A.A .soln.Energy…0.4 (KCal /mL) 24  

21. Lipid Emulsion Lipid(gm/kg/day) 0.5   Lipid (gm/day) 6   Volume (mL) 30   Lipid Energy (Kcal) 60   Rate of administration 1.25 mL/Hr.    

22. Electrosol injection   K ( mEq /kg/day) 3 K (mEq/Day) 36 K Deficit ( mEq ) 34.5 KCl (mL) 1mEq K /mL 19.5

23. Normal Saline Ca- gluconate Na (mEq/kg/day) 4 Ca- gluconate (mg/kg/day) 400 Na (mEq/Day) 48 Ca- gluconate ( mg/day ) 4800 Na Deficit (mEq) 36.5 Vol. Of 10 % Ca- gluconate inj. 48 Normal Saline (mL) (0.15 mEq Na/mL) 243

24. Remaining Fluid ( mL )…… ( 1050-400 ) =650…………………….

25. Calorie Work Up Max. NNE as per protocol(Kcal/kg/day)=…..550….Kcal Max. deficit of NNE ( Max. NNE-( sorbitol energy+lipid energy)=…490….. Kcal/3.4=144 gm. Dextrose Min. NNE as per amino acid (A.A. dose*25)=…..150…Kcal Min. Deficit NNE ( Min.NNE -( sorbitol energy+lipid energy)=……(150-(0+60)=….90….Kcal/3.4=…..26…gm. Dextrose Amount of Dextrose to be added into remaining fluid=...90 gm. Percentage of Dextrose in remaining fluid= 13.8…..(nearly equals)….= 14 %

26. Do you Know How to apply Alligation Method ? D5% D10% D25% Total NNE/day……….366..……Kcal. Dextrose (gm/kg/ day)……7.5……..gm. Rate of Administration……42.5…. mL /Hr. Osmolarity of TPN………………… mOsm / Litre . Route of Administration… .Peripheral ….. Remarks…..............................................................................................................................................................

27. Osmolarity 0f Peripheral Nutrition Medicine volume mOsm / mL mOsm KCl inj. 19 4 76 Ca-gluconate inj. 48 0.31 14.88 D5% ………… 0.03 ……. D10% 477 0.51 243.27 D25% 173 1.26 218 0.9% NaCl 243 0.31 75.33 Aminoplasmil. 60 1.2 72 Total 1020 700 Osmolarity 686.27 mOsm / Litre

28. mOsm / Litre = (700/1020)*1000=686.27 Pharmacist Signature ………………………………