Bone Density Test

14.00 800x600

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1.     Calculate energy requirements. (~25-30 kcal/kg)

2.     Calculate protein requirements. (~0.6-2.0 g/kg depending on the stress of pt)

3.     Fluid requirements: ~40mL/kg (16-25 years), ~32mL/kg (25-55 years), ~30mL/kg (55-65 years), and ~25mL/kg (65 years and over). The mL of fluid needed is the total amount of mL in the TPN solution.

4.     Divide the fluid needs by 24 to determine how much fluid the pt is getting per hour.

5.     Carbohydrate tolerance (<4g CHO/kg/min)

·        Formula: 4 x kg x 1.44 = maximum CHO tolerance

·        If pt is diabetic, on steroids, or malnutrition start with 2gm/CHO/kg

6.     Amino Acids are calculated by dividing the gm of protein needed per day by the total volume in liters to give the grams/L.

7.     Multiply the total calories by the desired % to determine the calories provided by dextrose. Dextrose usually provides about 55% of total calories.

·        Divide the grams of dextrose by 3.4 to determine the gm dextrose.

·        Divide the grams of dextrose by the total volume in liters to give gm/L.

8.      Lipids are provided in the TPN as gm/day. The % of calories from lipids should not exceed 30%. If the pt is stressed use <29%.

Example

Calculate the desired solution to provide 1680 calories and 72 gm protein in total volume of 1500 mL.

Amino Acids: 72/1.5 L=48 g/L; 72 x 4 = 288 kcals

Dextrose: 1680 x .55 = 942 kcals; 924/3.4 = 272 grams; 272/1.5 L = 181 g/L

Lipids: (remainder of calories) 1680 – (925 +288) = 486; 486/10 = 47 g/day

Recommend: TPN 63 mL/hr, AA 48 g/L that provides 72g protein (17%),

Dextrose 181g/L that provides 272g CHO (55%), and Lipids 52g/day that provides 52g lipids (28%). This provides 1680 kcals


 

Final Concentrations of Solutions

1.      Determine TPN volume, grams of CHO, protein, and fat.

2.      Determine the volume of dextrose solution.

3.       Determine the volume of amino acid solution.

Determine the volume of lipids.

 

Solutions

Standard Amino Acids    10% solution or 10g/mL

Dextrose                         70% solution or 70g/100mL
                                       50% solution or 50g/100mL

Fat                                  20% emulsion or 20g/100mL
                                       10% emulsion or 10g/100mL

Renal Amino Acid          5.4% solution or 5.4g/100mL

Hepatic Amino Acid       8% solution or 8g/100mL

Example: Determine the volume of TPN required compounding the following solution.

     268g Dextrose (70%) 268   x    100   =                              26800/70   =    383cc

            70g Protein (10%) 70   x    100   =                                7000/10   =    700cc

              55g Lipid (20%) 55   x    100   =                                5500/20   =    275cc

Required volume is 1358cc + 100cc for additives = 1458cc needed

 

Determining Osmolality of TPN

Total Volume in Liters mOsm/L=(10 x g protein)/(6 x g CHO)/(.33 x mL Lipids)

 

 

Notes

- Protein (Amino Acids) = 4 kcal/g

- Standard AA solution is 10%.

- Add a zero to the grams to get the desired volume of AA.

- Carbohydrates (dextrose) = 3.4 kcal/g in the solution.

- D50=50% CHO 3.4 x 5 = 1.7 kcal/cc

- D70=70% CHO 3.4 x 7 = 2.38 kcal/cc

- Fat (Lipids) = 9 kcal/gm

- 20% lipids are 2 kcal/cc

- 10% lipids are 1.1 kcal/cc

 

Cycling TPN

1.      Pt must be stable on continuous TPN for 48 hours with good glucose control before considering cycling TPN.

2.      May begin in an 18-hour cycle. Start at half the goal rate for one hour then decrease rate by half for 1-2 hours prior to stopping. This prevents hypoglycemia. Use 2 hours for pts at a high hourly rate.

3.      Check blood glucose levels 4 and 9 hours starting TPN.

4.      Check blood glucose levels one hour after the TPN is discontinued.

5.      If the blood glucose levels are normal, the pt can be considered for a 12-14 hour cycle.

Additives in TPN

- Zinc and vitamin C can be added for wound healing. (~30mg/day Zinc & ~1g/day vitamin C)

- Thiamin and Folate can be added for alcoholism. (~3mg/day Thiamin & ~400ug/day Folate)

- Insulin can be added

 

Determining Osmolality of PPN

(10 x g protein)/(5 x g CHO)=mOsm/L

- Excludes lipid fluids

- For PPN osmolarity should be <900 mosm/L

- 125 cc/hr is the maximum for PPN to avoid overloading the vein.

- Never go over Dextrose 10%. This is 10% per 100cc.

- Fluid should be based on actual body weight.