LauraBussey

ProfessorM.Fox
NUTR425
10/21/2015

ParenteralNutritionWorksheet

CalculatethetotalcaloriesanddetermineifthefollowingPNsolutionsarebalanced
(provide%AA,%Dex,and%IL).

1. 34g/LAA,150g/LDex,27.5g/LIL@75ml/hrx24hrs
75mLx24hours=1800mLperday
34g/LAAx1.8L=61.2gAA
150g/LDexx1.8L=270gDex
27.5g/LILx1.8=49.5gIL
61.2gAAx4kcal/g=244.8kcals
270gDexx3.4kcal/g=918kcals
49.5gILx10kcal/g=495kcals
Totalkcals=1657.8
CHO=55.3%Pro=14.7%Fat=29.8%
Isthissolutionbalanced?YES

2. 60g/LAA,165g/LDex,33g/LIL@60ml/hrx24hrs
60mLx24hours=1440mLperday
60g/LAAx1.44L=86.4g
165g/LDexx1.44L=237.6g
33g/LILx1.44L=47.5g
86.4gAAx4kcal/g=345.6
237.6gDexx3.4kcal/g=807.8
47.5gILx10kcal/g=475
Totalkcals=1628.4
CHO=49.6%Pro=21.2%Fat=29.1%
Isthissolutionbalanced?YES

3. 2.5%AA,10%Dex,1.5%IL@100ml/hrx24hrs
100mLx24hours=2400mLperday
25g/LAAx2.4L=60gx4kcal/g=240kcal
100g/LDexx2.4L=240gx3.4kcal/g=816kcal
15g/LILx2.4L=36gx10kcal/g=360kcal
Totalkcals=1416
CHO=57.6%Pro=16.9%Fat=25.4%
Isthissolutionbalanced?YES

4. 55g/LAA,160g/LDex,30g/LIL@125ml/hrx18hrs
125mLx18hours=2250mLperday
55g/LAAx2.25L=123.8g
160g/LDexx2.25L=360g
30g/LILx2.25L=67.5g

123.8gAAx4kcal/g=495.2
360gDexx3.4kcal/g=1224
67.5gILx10kcal/g=675
Totalkcals=2394.2
CHO=51.1%Pro=20.6%Fat=28.2%
Isthissolutionbalanced?YES

5. 4.5%AA,13.5%Dex,4%IL@90ml/hrx16hrs
90mLx16hours=1440mLperday
45g/LAAx1.44L=64.8gx4kcal/g=259.2kcals
135g/LDexx1.44L=194.4gx3.4kcal/g=661
40g/LILx1.44L=57.6gx10kcal/g=576
Totalkcals=1496.2
CHO=44.2%Pro=17.3%Fat=38.5%
Isthissolutionbalanced?NO,dextrosetoolow,ILtoohigh.Dextrose
shouldprovidecarbohydratesof5060%,andILshouldnotexceed35%.

CalculatetheosmolarityofthefollowingPNsolutions.Indicateiftheyaresuitablefora
centralorperipheralline.

6. 34g/LAA,150g/LDex,27.5g/LIL@75ml/hrx24hrs
34g/LAAx10mOsm/g=340mOsm
150g/LDexx5mOsm/g=750mOsm
27.5g/LILx1.5mOsm/g=41.3mOsm
Totalosmolarity=1131.3mOSm
Suitableforcentralorperipheralline?Central

7. 60g/LAA,165g/LDex,33g/LIL@60ml/hrx24hrs
60g/LAAx10mOsm/g=600mOsm
165g/LDexx5mOsm/g=825mOsm
33g/LILx1.5mOsm/g=39.6mOsm
Totalosmolarity=1464.6mOSm
Suitableforcentralorperipheralline?Central

8. 2.5%AA,10%Dex,1.5%IL@100ml/hrx24hrs
25g/LAAx10mOsm/g=250mOsm
100g/LDexx5mOsm/g=200mOsm
15g/LILx1.5mOsm/g=22.5mOsm
Totalosmolarity=472.5mOSm
Suitableforcentralorperipheralline?Peripheral

9. 55g/LAA,160g/LDex,30g/LIL@125ml/hrx18hrs
55g/LAAx10mOsm/g=550mOsm
160g/LDexx5mOsm/g=800mOsm
30g/LILx1.5mOsm/g=45mOsm
Totalosmolarity=1395mOSm
Suitableforcentralorperipheralline?Central

10. 4.5%AA,13.5%Dex,4%IL@90ml/hrx16hrs
45g/LAAx10mOsm/g=450mOsm
135g/LDexx5mOsm/g=675mOsm
40g/LILx1.5mOsm/g=60mOsm
Totalosmolarity=1185mOSm
Suitableforcentralorperipheralline?Central

CASESTUDY
A36yearoldfemalewithahistoryofCrohnsDiseaserefractorytomedicalanddietary
managementwasadmittedtoyoursurgicalfloortwodaysagoafterhavingpartofher
smallintestineremoved.Priortoadmission,shewasstrugglingtomaintainherweight
duetopersistentdiarrheaafterPOintake.Shereportslosing40#overthepastfour
monthswithminimalintakeoneweekbeforehersurgery.Herpostopcoursehasbeen
complicatedbyaparalyticileusleavingthepatientNPO.
Sheis67talland105#.Allergiesincludeshellfish.Labvaluesindicatesheissuffering
fromhypophosphatemiaandhypomagnesaemia.1.7018

11. WhyisthispatientanappropriatecandidateforPNatthistime?
ThispatientisacandidateforPNrightnowbecauseshehasjusthadgastric
surgeryandhashadparalysisoftheileum.SheisNPOnowsoshecannottake
inanyfoodbymouth.ENisnotagoodsolutionbecauseherileumcannot
processfoodthatentersfromtheduodenumorjejunum,sosmallbowel
obstructionwouldlikelyoccur.Itisessentialthatshebeprovidedsomenutrition
assheisunderweightandherweightchangeoverthepast4monthshasbeen
severe.ThisleavesPNasthemostsuitablemethodtoprovidehernutrition.

12. Determinehercalorie,protein,andfluidneeds.
Basedonanempiricalformulaof3035kcal/kgofbodyweight,thispatientneeds
14311670kcalsperday.IchosetouseherCBWasthedosingweightbecause
shehashadsuchminimalintakeforsolongandherBMIof16.5indicatessheis
severelyunderweight.DosingbasedonherUBWwouldprobablynotbewell
toleratedandwouldputherathigherriskforrefeedingsyndrome.Instead,Ihave
chosenadosingweightatherCBWandprovided3035kcals/kgforsomeweight
gain.
Herproteinrequirementsareslightlyhigherthannormal,andshouldsupply
1.21.5g/kgbodyweightperday.Thisworksouttoarangeof5772gofprotein
perday.
Herfluidneedsare35mL/kgbodyweightperday,meaningsheneedsabout
1645mLoffluidperday.

13. DetermineanappropriatePNregimen.
4%AA,15%Dex,2.5%IL@70ml/hrx24hrs
70mLx24hours=1650mLperday
40g/LAAx1.65L=66gAAx4kcal/g=264kcals
150g/LDexx1.65L=247.5gDexx3.4kcals/g=841.5kcals
25g/LILx1.65=41gILx10kcals/g=410kcals
Totalkcals=1515.5

CHO=55.5%Pro=17.4%Fat=27.1%

14. Determineyoursolutionsosmolality.Isyoursolutionbalanced?
4%AA,15%Dex,2.5%IL@65ml/hrx24hrs
40g/LAAx10mOsm/g=400mOsm
150g/LDexx5mOsm/g=750mOsm
25g/LILx1.5mOsm/g=37.5mOsm
Totalosmolarity=1187.5mOSm
Suitableforcentralorperipheralline?Central
Yes,thesolutionisbalanced.

15. Isthispatientatriskforrefeedingsyndrome?Explainrefeedingsyndrome.
Describewhatyouwoulddoinpractice(PNadvancementandrepletion)forthis
patientifshewereatriskforrefeeding.
Thispatientisatriskforrefeedingsyndrome.Sheisunderweightatthispoint,
andhashadsevereweightloss.HerintakeiscurrentlyNPOandhasbeenlow
foratleastoneweek,andsuboptimalforprobablyfourmonths.Whenthe
deliveryofcaloriescomesmainlyforcarbohydrateandincreaserapidlyovera
shortperiodoftime,andwhenpriorcaloricintakewasminimal,refeeding
syndromeislikely.Thepancreasisstimulatedandsecretesalotofinsulinaftera
consistentcarbsourceisintroduced.Thereisanabruptdecreaseinbloodserum
levelsofpotassium,magnesiumand/orphosphorus,andtheremightalsobe
sodiumandwaterretention.Theelectrolytesbecomeunbalancedandcancreate
manynegativesymptomssuchasgeneralfatigue,muscleweakness,edema,
cardiacarrhythmia,anditcanevenleadtodeath.
Thispatientlieswithinthatriskcategory.
IwouldprescribethatthePNcaloriesbeinitiatedandincreasedgraduallythe
prescriptionshouldnotbegivenatfulldoseinthebeginning!Ithinkstartingat
50%(so,35mLperhour)wouldbeasafestartingpoint.Thenthepatients
tolerancecanbeevaluatedafter4hoursandfeedingcanbeadvancedgradually
510%eachtimeoverthenext1224hours.