ICU RAPID RESOURCE 2: TPN TIPS (pg 1)

LINE 1 (per 24 hr) * HOW TO WRITE TPN: STEPS … EXAMPLE: Amino Acid Solution 10% (with lytes) mL 1) Identify energy (kcal) needs: 2000 kcal See next page over (Calorie Calculator). Amino Acid Solution 10% (without lytes) mL 2) Distribute energy (kcal) between SUBSTRATE DISTRIBUTION (a) PRO/CHO/FAT: PRO: 20% = 400 kcal Dextrose 50% mL See “Substrate Distribution” (a), (b), or CHO: 50% = 1000 kcal (c) below. FAT: 30% = 600 kcal Dextrose 20% mL 3) Convert energy (kcal) into gms: PRO: 400 kcal ÷ 4.0 kcal/g = 100g Potassium Acid Phosphate See “Energy Value” below. CHO: 1000 kcal ÷ 3.4 kcal/g = 294g (K+ 4.4 mEq/mL, P 3mmol/mL) mmol P FAT: 600 kcal ÷ 10 kcal/g = 60g 4) Convert gms into solution and Sodium Chloride mEq Na volume: PRO: 1000 mL 10% AA (100g) See “Available Solutions” below. Round CHO: 600 mL D50W (300g) Potassium Chloride mEq K off PRO and CHO to closest 10g FAT: 250 mL 20% lipid (50g) multiple; FAT to closest 25g multiple. Magnesium Sulphate mEq Mg 5) Determine essential additives: ELECTROLYTES: ELECTROLYTES: Requirements TPN can cause profound shifts. Intracellular Calcium Gluconate mEq Ca vary with body wt, nutritional status, redistribution is more pronounced in MVI – 12 mL organ function, disease process, losses, malnourished and/or alcoholic pts (refeeding etc. In the absence of renal dysfunction syndrome). Serum K, Mg, P04 may be Vitamin K AA with lytes is usually appropriate. normal in the unfed state but decrease

‡ Protocol ‡ None ‡ Other mg quickly with TPN initiation. Potassium Acid Phosphate: Individualize dose. In malnourished pts Managing refeeding syndrome: Folic Acid mg (normal renal function) an additional 1) Correct low serum levels pre-TPN. 15 – 30 mmol is a reasonable addition. 2) Limit initial energy intake to <20 kcal/kg. Trace Element Solution 3) Once serum levels normal↑to 25 kcal/kg ‡ Protocol (0.5 mL) ‡ Other mL Sodium Chloride: Individualize dose. 4) Once serum levels normal↑to goal kcal. (Note: achieve goal kcal by day 5 TPN) Zinc Sulphate mg Potassium Chloride: Individualize dose. Renal Failure: Ranitidine mg Magnesium Sulphate: Individualize dose. In malnourished pts (normal renal 1) Caution advised when adding K, Mg, and/or PO to the TPN solution. Provide function) an additional 20 – 40 mEq (5g) 4 repletion dose of K, Mg, and/ or PO is a reasonable addition. 4 Infusion Period 24 hours separate from the TPN solution. Calcium Gluconate: 9 mEq (standard) Acid/base disorders:

LINE 2 (per 24 hr) * 1) Use potassium acetate vs potassium chloride as indicated. VITAMINS: MVI – 12: 10 mL (standard) Fat Emulsion ( order in multiples of 125 mL) mL 2) Use sodium acetate vs sodium (10 mL provides Vit A 3300 IU; Vit D 200 chloride as indicated. Infusion Period 24 hours IU; Vit E 10 IU; Vit C 100 mg; folate 400 ug; niacin 40 mg; riboflavin 3.6 mg; B 3 1 VITAMINS: Additional vitamin C and mg; pyridoxine 4 mg; B 5 ug; 12 thiamine (100 mg) and folate (1mg) can be Additional vitamins (vitamin C, thiamine), trace elements panthothenic acid 15 mg; biotin 60 ug). added to the TPN as indicated (e.g. (zinc, selenium, chromium), electrolytes (sodium acetate, Vitamin K: Protocol interpretation: malnourished; alcoholic). potassium acetate, sodium acid phosphate) and insulin, >200 mL lipid/day:pt receives none. can be ordered in this section. <200 mL lipid/day: pt receives 2 mg TRACE MINERALS: every Wednesday. Zinc: Add additional if high stool output. Selenium: Add additional if high stool 10% AA With Lytes Without lytes TRACE MINERALS: Micro+6 0.5 mL output and/or long-term TPN Solution (1 litre) (1 litre) (standard) (0.5 mL provides: zinc 2.5 mg; Copper/manganese: Reduce dose in (Travasol) copper 0.5 mg; manganese 250 mcg; hepatobiliary disease. chromium 5 mcg; selenium 30 mcg; Na mEq 70 0 Chromium/selenium: Reduce dose in renal iodine 37 mcg). dysfunction. K mEq 60 0 6) MEDICATIONS: Mg mEq 10 0 Ranitidine: Individualize dose. Usual PO4 mmol 30 0 dose (normal renal function) 150 mg. INSULIN: Caution!! When in doubt do not add to TPN solution. Cl mEq 70 40 Insulin: Individualize … see caution. Acetate mEq 150 87

a) Substrate b) Substrate c) Substrate Energy Available Solutions Minimum Maximum Substrate Distribution Distribution Distribution Value Dose Dose (High PRO) (Moderate PRO) (Low PRO) (kcal) PRO 20% 15% 10% 4.0 kcal/g 10% AA: 10g PRO/100 mL 0.6 g/kg/day 2.5 g/kg/day

CHO 50% 55% 60% 3.4 kcal/g D20W: 20g CHO/100 mL 100 g/day 7 g/kg/day D50W: 50g CHO/100 mL FAT 30% 30% 30% 10 kcal/g 20%: 20g FAT/100 mL 100 g/week 1.5 g/kg/day

Developed by: Jan Greenwood, RD, Critical Care Program. Update 29/9/2009.

ICU RAPID RESOURCE 2: TPN TIPS (pg 2)

GI COMPLICATIONS: IDENTIFICATION AND MANAGEMENT DETERMINING ENERGY REQUIREMENTS: CALORIE CALCULATOR COMPLICATION POSSIBLE SYMPTOMS TREATMENT PREVENTION TABLE 1 HOW TO USE TABLE ETIOLOGY Fatty liver • Excess kcal • ↑ liver • ↓ kcal • Avoid over

AGE SEX STRESS ENERGY Step # 1: Refer to Table 1; select patient age and gender. (hepatic • Unbalanced enzymes • Provide feeding steatosis) TPN (excess within 1- 3 cyclic TPN • Provide LEVEL (Kcal) Step # 2: Go to Table 2; identify appropriate stress level. CHO) weeks of TPN (deliver over balanced TPN Step # 3: Return to Table 1; read across to the 18 - 25 M Mild 2150 • Chronic initiation < 24 h) • Avoid CHO Mod 2300 corresponding goal energy requirement. infections • Rule out all >7 g/kg/day High 2650 Step # 4: Table 1 based on weight of 60 - 65 kg for ♀ and possible • Early EN 70 – 75 kg for ♂. Refer to Table 3 to modify energy (kcal) for causes F Mild 1700 • Transition Mod 1850 patients who do not fall within this weight range. High 2150 to EN/oral intake ASAP 26 -35 M Mild 2050 Mod 2200 Note. In significantly malnourished pts, the initial Cholestasis • Precise • ↑ serum alk • ↓ kcal • Avoid High 2600 etiology phosphatase • Rule out overfeeding energy goal (kcal) should not exceed 20 kcal/kg. unknown • Progressive other causes • Early EN F Mild 1650 See page over re refeeding syndrome. (? impaired bile ↑ serum • Transition Mod 1800 flow; lack of bilirubin to EN/oral High 2100 intraluminal • Jaundice feedings TABLE 2 TABLE 3 36 -50 M Mild 1950 stimulation of ASAP Mod 2100 hepatic bile STRESS EXAMPLES - BODY WEIGHT ADJUST High 2400 secretion; LEVEL CLINICAL MASS (Kg) ENERGY CONDITION excess F Mild 1600 substrate). Mod 1700 overdose VERY F <40 − 250 kcal High 2000 NONE - SMALL GI atrophy • Lack of • Bacterial • Transition • Early EN stroke M <55 MILD enteric translocation to enteral/oral <10% burn-injury 51 -70 M Mild 1800 SMALL F 40 - 55 − 125 kcal stimulation Æ feedings Mod 1950 mild infection M 55 - 65 villous atrophy ASAP High 2250 minor elective surgery LARGE F 70 - 80 + 125 kcal NOTES: F Mild 1450 MOD 10 - 20% burn-injury Mod 1550 M 80 – 100 High 1850 significant surgery VERY F >80 250 kcal moderate pancreatitis + LARGE M >100 71 -90 M Mild 1650 >20% burn-injury Mod 1800 HIGH severe infection High 2050 Obese pts: use corrected wt. major surgery F Mild 1400 multiple trauma (ABW – IBW) x 0.25 + IBW Mod 1500 severe pancreatitis High 1750 Calorie Calculator developed severe CHI by: J. Greenwood, RD.

METABOLIC COMPLICATIONS: IDENTIFICATION AND MANAGEMENT

COMPLICATION POSSIBLE SYMPTOMS TREATMENT PREVENTION COMPLICATION POSSIBLE SYMPTOMS TREATMENT PREVENTION ETIOLOGY ETIOLOGY Hyperglycemia • Rapid infusion CHO • BG > 11 mmol/L • Initiate insulin • Slow initiation and Hyponatremia • Excessive fluid intake • Edema • Restrict fluid intake • Avoid over hydration solution • Metabolic • ↓ CHO in TPN advancement of CHO • Dilutional states • Wt gain • ↑ Na intake if • Provide 40-60 mEq/day • Diabetes acidosis especially pts with DM (CHF, SIADH) • Muscle weakness deficient per 1000 kcal unless contraindicated • Sepsis/infection • Provide balanced TPN • Excessive Na loss • CNS dysfunction (vomiting, diarrhea) • Monitor fluid status • Steroids (irritability, apathy, confusion, seizure) • Pancreatitis Hypermagnesemia • Excessive Mg • Respiratory • ↓ Mg in TPN • Monitor serum levels Hypoglycemia • Abrupt TPN • Weakness • Administer CHO • Taper TPN and/or provide intake paralysis termination • Sweating CHO from alternate source • Renal insufficiency • Hypotension • Insulin overdose • Palpitations (tube feed, oral intake) • Premature • Lethargy • Monitor BG after TPN ventricular contracts • Shallow termination • Lethargy respirations • Cardiac arrest Hyperkalemia • ↓ renal function • Diarrhea • ↓ K intake • Monitor serum levels. Hypomagnesemia • Refeeding • Cardiac • Mg supplementation • Provide 8-20 mEq Mg per malnourished pt arrhythmias kcal/CHO in TPN day • Excessive K intake • Tachycardia • Provide K binder • Correct acid-base disorder • ↓ • Alcoholism • Tetany • Slow initiation and • Hemolysis • Cardiac arrest • If metabolic • Assess for drug nutrient • Diuretics use • Convulsions advancement of TPN (esp. acidosis change interactions (i.e. K sparing • Metabolic acidosis • Paresthesia • ↑ loss (diarrhea) • Muscular CHO) in malnourished and potassium and diuretics) • K sparing drugs • Drugs (cyclosporin) weakness or alcoholic pts sodium chloride to • DKA • Monitor serum levels acetate alternative Hyperphosphatemia • Excessive PO4 • Parethesia • ↓ PO4 in TPN • Monitor serum levels Hypokalemia • Inadequate K • Nausea • ↑ K in TPN • Provide 1-2 mEq/kg K per administration • Flaccid paralysis intake • Vomiting • Correct acid – day (unless contraindicated) • Renal dysfunction • Mental confusion • ↑ loss (diarrhea, • Confusion base disturbance • Slow initiation of TPN • Hypertension NG loss, diuretics) • Arrhythmias • Discontinue NG (especially CHO) in • Cardiac • Refeeding • Cardiac arrest suction if possible malnourished and/or arrhythmias malnourished pt • Respiratory • Resolve diarrhea alcoholic pt • Tissue calcification • Low Mg depression • ↓ kcal/CHO in Hypophosphatemia • Refeeding • Respiratory failure • ↑ PO4 in TPN • Monitor serum levels • Metabolic alkalosis • Paralytic ileus TPN malnourished pt • Cardiac • ↓ kcal/CHO in TPN • Provide 20 – 40 mmol • Steroids • Alcoholism abnormalities PO4 per day. • ↑ loss (diarrhea, • CNS dysfunction • Initiate TPN (especially Hypernatremia • Inadequate free • Thirst • ↑ free water • Provide optimal free water large NG loss) • Difficulty weaning CHO) slowly in water • ↓ skin turgor intake • Avoid excess Na • DKA from ventilator malnourished pts • Excessive Na intake • ↑ serum Na, • ↓ Na intake • Monitor fluid status Hypertriglyceridemia • Excessive lipid • Serum TG > 4.0 • ↓ TPN lipid • Pre TPN: assess for pre- • Excessive water urea, hematocrit • Sepsis mmol/L • ↑ infusion time existing hx of ↑TG loss • Meds (cyclosporine) • Limit lipid to <1 g/kg/day Prerenal azotemia • Dehydration • Elevated serum • ↑ fluid intake • Monitor serum urea • Excess PRO intake urea • ↓ PRO load • ↑ nonprotein kcal

Reviewed by: Dr. Dean Chittock, MD and members of the ICU QA/QI Committee and members of the Nutrition Practice Council (2006).