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Parenteral Nutrition
(PN/TPN)
Barbara L. Magnuson, Pharm.D. CNSC
Nutrition Support Service
Parenteral Nutrition (PN)
Goal of Parenteral Nutrition

To maintain or restore nutritional integrity
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Disease
Injury
Inadequate absorption of nutrients
Must provide total and optimal
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calories, protein, fluids, electrolytes, vitamins,
and trace elements by the IV route
Absolute PN Indications
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Inability to absorb adequate nutrients via the GI tract:
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Bone marrow transplant:
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Massive small bowel resection
Short-gut or syndrome due to disease state
graft vs host disease (GVHD) of the gut or severe malabsorption
from radiation
Enterocutaneous fistulas: proximal or high output
Enteral access not possible due to upper GI obstruction
Low birth weight infants benefit from PN until their GI
tract is able to absorb sufficient nutrients
Relative PN Indications
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NPO > 7-10 days (No benefit with <7-10 days of PN)
Malabsorption from radiation or chemotherapy
Suspected bowel ischemia
Bowel obstruction
Ongoing GI hemorrhage (upper or lower)
Prolong use of vasopressors, unable to advance enteral
nutrition toward goal after 7 days (unless PCM)
No PN Indications:
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Functional GI tract
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Colonic ileus (not a dysfunctional gut)
Awaiting flatus or bowel sounds following surgery
(inappropriate practice to evaluate bowel function)
Patient refuses food or feeding tube
Less than 7 days of PN therapy expected
 Terminal illness where life expectancy is <3
months

PN & The Terminially Ill
PN is a form of medical treatment
Its use should be decided after considering the benefits and
burdens as measured scientifically and clinically as well
as assessed in light of the patient's wishes and values.
PN should not be instituted or continued in patients who
have an untreatable terminal illness, when life
expectancy is less than three months (Hospice Patients).
There is no evidence to suggest that it increases survival,
quality of life, or reduces suffering. In fact, attendant
complications associated with PN may outweigh any
derived benefit.
PN Case
CD is a 35yo male, 5'10", 80kg admitted to
UKMC for severe dehydration.
 CD has excessive drainage from a duodenal
fistula resultant from a gun shot wound to
the abdomen he received 3 months ago.
 Dr. Smith requests PN for at least 3 months
to help close the fistula
 Prealbumin 8.4, Albumin 1.9

PN Case - CD
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Is PN the optimal route for nutrition support
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Which indication applies for CD?
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Duodenal fistula
Why can he not just eat just lots more food?
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YES
Food will come out of fistula before absorption
resulting in malabsoprtion
Does it matter that he has a fistula?
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Yes, it will not close with food/gastric contents
pouring out of it.
PN Case: CD - assessment
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What is the next step?
Assess nutritional status:
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Assess/ Estimate calories and protein needs
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Height, Weight, BUN, Cr, Albumin, Prealbumin - Low
Calculate Ideal body weight (IBW) 75kg
? Adjust weight for obesity (106% IBW, BMI =25) NO!
Measure calories needs
Nitrogen balance
Evaluate serum electrolytes
Create a PN formula
Estimate Caloric Requirements

Basal Energy Expenditure (BEE)
Resting energy expenditure
Mifflin St. Jeor Equation – non critically ill patients
Male = (10 *(Kg)) + (6.26* (Cm)) – (5*(Age))+5
Female = (10 *(Kg)) + (6.26* (Cm)) – (5*(Age))-161
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Harris Benedict Equation (HBE):
– BEE Male = 66+ 13.7(Kg) + 5(Cm) - 6.8(Age)
– BEE Female = 655 + 9.6(Kg)+1.7(Cm)-4.7(Age)
Kcal/kg – quickest but LEAST accurate
Penn State Equation: 1998 & 2003 versions
Ireton-Jones Equastion: 1992 & 1997
Swinamer Equation
Estimate Caloric Requirements
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Includes activity or injury factor
Predicted Energy Expenditure (PEE)
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PEE = BEE (HBE) x stress factor
Stress/Injury factor = injury, disease, or malnutrition
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1.0
1.0 - 1.2
1.2 - 1.3
1.4-1.5
1.4 - 1.7
1.5 – 1.8
Non-stressed / bedridden or inactive
Mild stress (chronic disease state, stroke)
Moderate Stress (elective surgery, infection)
Closed head injury or multi-trauma
Major stress or severely underwt.
Severe stress (burns)
Estimate Caloric Requirements
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Kcal/kg – quicker but often less accurate
Assumes normal weight (BMI 20-25 or 100-125% IBW)
Normal needs: 20-25kcal/kg
Malnourished: 25-35kcal/kg
Trauma or infections: 25 - 30kcal/kg
Large wounds, severe underweight, burns: 30-40kcal/kg
Quadraplegia and bed-ridden (stroke): 18-22kcal/kg
Protein Requirements
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Determined by degree of injury, disease state,
malnutrition, and or wound healing needs
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Estimate for Protein Dosing: gm/kg/d
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0.8-1.0
1.0
1.0-1.3
1.4-1.6
1.5-2.0
2.0 -2.5
Average daily requirements
Non-stressed hospitalized patient
Mild stress (Stroke, chronic disease)
Moderate stress (Trauma, Surgery,
Infections, or Malnutrition)
Severe stress (Large trauma, Head injury)
Severe stress (Burn, Continuous dialysis)
Body Weight & (Adj BW)
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Adj BW = IBW+((Act. BW - IBW) x 0.25)
Obese patients >125% of IBW
Obese patients burn more calories/protein than someone of
similar size
Using IBW: underestimates protein needs
Using actual BW: overestimates protein needs
Use adjusted weight for protein dose & HBE
If BMI > 30-35 - Use adj BW for BEE
If BMI > 35 & critically ill patient – underfeed with 2225kcal/ IBW kg/day as per ASPEN permissive underfeeding
guidelines
Nitrogen Balance
24 hour urine collection
 Urine Urea Nitrogen (UUN) g/day represents the
protein catabolic rate
 Nitrogen Balance = Nitrogen (in) - Nitrogen (out)
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Nitrogen (in) = Grams of protein /6.25gm
 6.25
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gm protein = 1 gm of Nitrogen
Nitrogen (out) = UUN Gm/D + 4Gm (non-urea losses)
Optimal nitrogen balance +1 - +4
Determine Calorie Requirements
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CD is a 35yo male, 5'10", 80kg
IBW = 75Kg, 106% of IBW, BMI = 25
What is CD's BEE
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What is his PEE?
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Mifflin Equation (1741)
Harris Benedict Equation (1820)
Using mild – moderate stress factors 1.2 -1.3
PEE (HBE)= 1820 x 1.2 - 1.3 = 2184- 2366Kcal/day
25-30Kcal/Kg = 2000-2400kcal/day
Determine Protein Requirements
CD is a 35yo male, 5'10", 80kg
 IBW = 75Kg, 106% of IBW, BMI = 25
 Prealbumin 8.4, Albumin 1.9 Very low
 How much protein will CD need?
 Dose: 1.4g/kg/d - 1.6g/kg/d
 80kg x 1.4g/kg/d - 1.6g/kg/d = 112g/d - 128g/d

PN Components
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Six primary components
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Protein – synthetic amino acids (AA)
Carbohydrates (dextrose)
Fats – (triglycerides)
Electrolytes
Vitamins
Trace Elements
What are the monitoring parameters for each
componenet?
Protein: Amino acids
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Nitrogen source of synthetic/crystalline amino acids
Dose: patient specific
Common PN AA concentrations: 3% (30g/L), 4.25%
(42.5g/L), 6% (60g/L), 7% (70g/L)
Caloric value: 4Kcal/gm
Cysteine, Carnitine, and glutamine not included: due to
relatively unstable or poorly soluble
Cysteine added at compounding for pediatric PN to
enhance Calcium and Phosphorus solubility
Monitor: BUN, renal function, albumin, prealbumin,
wound healing, nitrogen balance
Carbohydrate
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Dextrose (glucose) expensive & efficiently utilized
Caloric value: 3.4Kcal/g
Osmolality: 10% Dextrose = 500mosm/L
Doses: 150 – 500 grams/day
Common concentrations: 10% (100g/L), 15% (150g/L), 20%
(200g/L), 25% (250g/L)
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Alternative: glycerol, sugar alcohol (4.3kcal/g)
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ProcalAmine®: 3%glycerol, 3% AA
Monitor: blood glucose, liver function test
Glucose Utilization rate: (4-7mg/kg/min)
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Excessive CHO  fatty liver disease (PNALD)
IV Fat Emulsion (IVFE)
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Essential (long chain) fatty acids
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Fat Emulsion 10% & 20%
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linoleic (omega 6)
linolenic (omega 3)
10%: 1.1 Kcal/ml
20%: 2.0 Kcal/ml
30%: for compounding only
Extra kcal from glycerol emulsifier
Caloric value 9 kcal/g (oral dietary fat)
USA: Medium chain fatty acids for oral only
Filter: 1.2 micron filter - necessary to stop a fat emboli that
could occur if the fat emulsion cracks from the compounding
process. Do not use with 0.22micron filter (clogs)
IV Fat Emulsion (IVFE)
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Ingredients
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Dose:
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50-100grams/day or 1-2g/kg/day – adult
Optimal:30-40% of calorie source
Max: 50-60% calorie source from IV fat emulsion
Propofol mixed in 10% lipid emulsion
Prevent essential fatty acid disease (EFAD) over 2-4wks
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safflower & soybean oil
Purified egg yolk phospholipid (stabilize emulsion) ALLERGY Caution
glycerin
Alkaline drug – decreases solubility of Ca & Phos
minimum @ 1g/kg/week
Monitor: fasting triglycerides
Electrolytes
Na, K, Cl, Ca, Phos, Mg, & Acetate
 Never add bicarbonate to PN
 Requirements change with clinical course
 AA solutions supply some electrolytes
 Monitor:
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Serum electrolytes - daily or weekly accordingly
Renal & liver function
GI output
Acid/base status
Vitamins
Essential for normal metabolism
 Multi-vitamin (MVI)
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Add Vitamin K
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Contains 9 - 12 vitamins
0.15-1.5mg daily or 10mg weekly
150 mcg/day recommended
Monitor for deficiencies
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special losses
disease state
Trace Elements
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Trace Element (TE4) provides
Zinc, Chromium, Copper, Manganese
Long term requirements
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Iodine - absorbed from povidone iodine
Monitor for deficiencies
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Selenium (TE5) & Molybdenum
special losses & disease state
Cholestatic Liver disease – omit Manganese &
Copper
Renal Failure w/o dialysis – omit selenium
The Case of CD
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Dr. Smith orders the initial PN
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10% Dextrose, 4.25% AA @ 80ml/hr
standard electrolytes, MVI, and trace elements (TE4)
20% IVFE 250ml daily
Metabolic Cart & Nitrogen Balance Studies
Does this PN formula provide adequate AA and
calories for CD according to your estimates?
 Needs: 2184- 2366Kcal/day, 112g/d - 128g/d
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PN Calorie calculations
80ml/hr x 24hr/day = 1.92 liters/day
 Dextrose 10% = 10g/100ml = 100g/L
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Calories from dextrose
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100gm/L x 1.92L/day = 192gm/day
192gm/day x 3.4kcal/g = 653kcal/day (CHO)
IVFE - 20% emulsion 250ml
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250ml x 2kcal/ml = 500kcal/day
PN Calculations
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Amino Acids
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Calories from AA:
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4.25% (AA) = 4.25g/100ml = 42.5g/L
42.5g/L x 1.92L/day = 81.6g/day (AA)
81.6g x 4kcal/g = 326kcal (AA)
Total Calories from PN:
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653kcal (CHO) + 500kcal (lipid) + 326kcal (AA)
1479kcal/d
 Does this meet CD’s Needs?
 NO!
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Metabolic Cart Study
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Oxygen Consumption Study
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Calculates Respiratory Quotient (RQ)
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measures oxygen inhaled
measures carbon dioxide exhaled
Calculates daily/measured energy expenditure (MEE)
CO2 (out) /O2 (in)
Normal 0.82-0.85
CD’s MEE = 1930kcal/d
Is the original PN adequate?
NO!
Nitrogen Balance
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CD’s 24 hr urine collection
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UUN = 14gm N2/day
Calculate CD's Nitrogen Balance
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1g nitrogen = 6.25g protein
PN provides 81.6g AA/day (13gN2/day)
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N2 Balance = 13 - (14 + 4) = -5.0gN2/day
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How much AA does CD needs to give a +2 Nitrogen
Balance
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Balance = 14g(out) + 4g(non-urinary) + 2 =
20gN2/D  125g/d
Reformulating the PN
MEE = 1930 kcal/day & AA = @125g/day
 New PN: Dextrose 15% , Amino acids 7%, Std
electrolytes, MVI, & TE (4) @ 75ml/hr plus
250ml bottle of 20% lipids daily
 What does this provide?
 How was this formula determined?
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PN Calculations
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PN: 15% Dextrose, 7% AA @ 75ml/hr plus
250ml of 20% lipids
75ml/hr x 24hr/day = 1.8L/day
AA Needs @ 125g/day
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7% AA = 7g/100ml = 70 gm/L
125g / 70 g / L = 1.78L of a 7% solution
74.4 ml / hr  75 ml / hr x 24 hrs = 1.8 L
1.8 L x 70 g / L = 126 g AA/ day
AA Calories – 126 x 4kcal/g = 504kcal
PN Volume of base solution is 1800ml/day
PN Calculations with Ratios
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PN: 15% Dextrose, 7% AA @ 75ml/hr plus 250ml of
20% lipids
75ml/hr x 24hr/day = 1.8L/day
AA Needs @ 125g/day
125g
= 70g
X= 1,785ml of a 7% solution
1785ml/24 = 74.4ml/hr  75 ml/hr*24 hrs = 1.8 L
X ml
1000ml
1.8 L x 70 g / L = 126 g AA/ day
AA Calories – 126 x 4kcal/g = 504kcal

PN Volume of base solution is 1800ml/day
PN Calculations
PN: 15% Dextrose, 7% AA @ 75ml/hr plus
250ml of 20% lipids (1.8L/day)
 Dextrose 15% = 15gm/100ml (150g/L)
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20% Lipids –250ml
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150g/L x 1.8L/day = 270g/day
270g/day x 3.4Kcal/g = 918kcal/day
250ml x 2.0kcal/ml = 500kcal/day
Calories: 500 + 918 +504 = 1922kcal/day
What if?
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What if
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PN were all glucose?
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Calories only came from lipids?
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Do we need the AA?
PN Compounding
The PN technician asks your assistance
 Pharmacy compounding stock solutions:
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50% & 70% dextrose
8.5%, 10%, & 15% amino acid
How much volume of each stock solution is
needed
 PN: 15% Dextrose (270g), 7% AA (126g) @
75ml/hr plus 250ml of 20% lipids

Compounding PN
Dextrose 70% Stock, (700g/L)
 Need 270g/day

270g/day / 700g/L = 0.386L = 386ml
700g
=
1000ml
270g = 386ml
X ml
Compounding PN
Amino Acids 10% Stock, (100g/L)
 Need 126g/day
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126g/day / 100g/L = 1.26L or 1260ml
100g
=
1000ml
126g = 1260ml
X ml
Compounding PN
Total Volume: 386ml (dextrose) +
1260ml (AA) = 1646ml
 Final Volume = 1800ml
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= 1800ml – 1646ml = 154ml
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154ml: Vitamins (10ml/d), Trace
elements (5ml/d), electrolytes (prn), and
sterile water to qs to the total volume
required
Pharmacy Procedures
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The technician making the PN wants to
know the pharmacy procedures and policies
regarding PN
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Sterility
Stability
compatibility
How can the pharmacy facilitate the
physician in ordering a PN?
Aseptic Technique
Compounded in a Flow Hood
 Acetate (CAA) > 35meq/L
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prevents bacterial growth (not Candida)
Acidity and hypertonicity not ideal for growth
 Decrease candida growth by cooling to 4o C
 Infuse solution within 36 hours
 Albumin increases fungal & bacterial growth
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PN
Compounding
National Safety Standards
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National Advisor Group on Standards and
Practice Guidelines for Parenteral Nutrition
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Published “Safe Practices for Parenteral
Nutrition” recommendations for labels and
orders, compounding, compatibility, stability,
and administration.
USP – Medium Risk
 ASPEN – 2007, Recommendations on PN
Standardization
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PN Stability
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Base Solution (AA & Dextrose) stable 2 - 4weeks
Vitamins – decreases stability to 36 hrs, affected by:
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pH, storage, light and temperature
Vitamin A adsorbs to plastic bag??
Thiamine degrades in solution with bisulfite
NaHCO3 (basic pH)
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Emits CO2 gas
Precipitates insoluble Ca and Mg carbonates when added to acidic PN
solution
Acetate (Precursor)  lactate  bicarb
Use calcium gluconate salt
PN Compatibility
Calcium and Phosphorus - precipitation risk
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High molar concentration
Basic pH
Drug additives &/or Piggy back medications
Low AA concentrations
High temperatures
Improper mixing sequence
Long storage or standing time
Slow infusion rate
Calcium carbonate is PO only, best to use chloride salt
Medications in PN
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Highly Discouraged
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Lack of stability, compatibility, and efficacy data for PN
administration when multiple medications are added
Advantages
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less fluid administration --> ?? Cost savings
less catheter manipulations
Flexibility with limited IV access
Continuous drug infussion
Common additives - Insulin, H2 antagonists, heparin
Insulin - 50-95% available ?? Adsorption
Avoid – albumin & iron dextran
Facilitate PN Ordering
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Pre-printed (or electronic) Standardized PN Order
Forms
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Standardize base solutions or doses
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Check boxes (recipe style)
Decreases confusion & error & adverse events
_______ g/d dextrose or ______ g/d amino acids
10% or 20% daily lipids _____ml/day
15% or 25% dextrose
3%, 4.25% or 6% AA
Electrolyte options
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standard, low potassium, no potassium
The case of CD
Dr. Smith wants to send CD home on his new
PN
 He asks you if he needs a central line or a
peripheral
 What is the difference?

PN Osmolality
 QUICK
ESTIMATES:
 Dextrose: 50mOsm/1% dextrose
 Amino Acids: 100mOsm/1% AA
 Electrolytes: @200mOsm
 IVFE: 10mOsm/10g (isotonic)

PN: 15% Dextrose, 7%AA & electrolytes
Quick Osmolality Estimates
Dextrose: 50mOsm/1% x 15% = 750mOsm
 AA: 100mOsm/1% x 7% = 700mOsm
 Electrolytes: @ 200mOsm
 PN: 15% Dextrose, 7%AA & electrolytes
250ml IVFE daily
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750 mOsm+700mOsm+200mOsm =1650mOsm
Lipids- 10mOsm/10g (isotonic), can dilute
the PN but not enough to run in peripheral line
Peripheral PN (PPN)
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Maximum – 800-950mOsm
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Advantages
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less infectious complications
Disadvantages
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Higher osmolality results in thrombophlebitis
large volume to meet nutritional needs, 2 - 3L/D
phlebitis > 600mosm
Maximum dextrose @10% (neonates @12%)
AA minimum @ 3% amino acids due to 10% dextrose
Central
Catheter
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Advantages:
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Subclavian vein --> tip advanced to superior vena cava
Enters a high flow vein to quickly dilute concentrated solution
Internal jugular or femoral vein - alternative
Verify cath tip location with X-Ray
higher concentrations, lower flow rates and total daily volume
Disadvantages:
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Insertion complications, infection
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PN: 15% dextrose,7% AA @ 75ml/hr + 250ml of 20% lipids – needs a central line
Tunneled Catheter
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Peripherally Inserted Central Catheter (PICC)
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Inserted into peripheral arm vein, (cephalic, basilic or brachial vein),
advanced through increasingly larger veins, toward the heart until the tip
rests in the distal superior vena cava or cavoatrial junction
Functions as a central line
Provides long term central access for chemotherapy, antibiotics, or PN
Can be placed by an RN
Hickman, Groshong – tunnelled catheters
PortaCath - sub Q central catheter port
The Case of CD
Dr. Smith read about a PN which is “all in one”
 He asks you to provide him advantages and
disadvantages of the TNA?
 Total Nutrient Admixture
 (TNA), 3:1 (3 in1)
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1. Glucose
2. Amino acids
3. Fats
Electrolytes, MVI, and TE
Total Nutrient Admixture (TNA)
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Advantages
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1 Bag
Cost savings – less inventory, (1 pump and set)
Less administration set up time
Less catheter manipulations
Easier for home PN patients
Well tolerated
Mixed fuel substrate - ?? << hepatic fat
accumulation
TNA
Disadvantages & Controversies:
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Questionable safety and efficacy
Enhanced microbial growth potential with extended fat
hang time
Cannot filter TNA with 0.22micon filter
Filter with 1.2 micron filter stop a fat emboli if the fat
emulsion cracks from the compounding
Cannot visually detect particulate matter
Limited stability information for drug additives
High wastage potential
FDA Alert
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1994 - 2 deaths reported
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Stability
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Calcium and phosphorus precipitated resulted in
pulmonary calcifications
Solubility curves are provided by AA companies
The solubility changes with FINAL AA
concentrations
MUST Follow manufactures guidelines
Multiple drug additives (limited data)
The Case of CD
After writing the PN order and instructing the
technician how to make the PN, CD’s nurse
calls and ask instructions regarding how to
administer the PN.
 She asks if she is to start the PN @ 70/hr?
 She also wants to know what to monitor?
 What do you tell her?

PN Administration
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Dedicated PN line
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Avoid other medications, especially calcium and
phosphorus supplements
Filter (0.22micron) for Dextrose & AA
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Filters particulates, air, and microorganisms
IVFE filtered with a 1.2 micron filter
 IVFE can be administered into a low Y site
of the same PN line
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PN Administration
Begin PN @ 25ml/hr x 8 hours
Advance by 25ml/hr Q8hour until goal rate reached
If blood sugar > 250 do not advance rate
Discontinue PN
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Taper by 25ml/hr Q6-8hours until off OR
Decrease by 1/2 rate for 3-6 hours then off
Concern for hypoglycemia if D/C too fast
Not necessary to taper PN rate if receiving tube
feedings or oral diet
Cycling PN
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Cycled entire solution over 12 - 18 hours instead of 24
Improved quality of life issues
? Beneficial for cholestatic liver disease
Taper up and down over first and last few hours
Cycling is NOT optimal
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Unstable blood glucoses (DM)
High Insulin dose in PN
CHF
Vascular issues
PN Monitoring
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Vital Signs , In’s/Out's, weekly weight
Temperature for infection
Electrolyte levels
Nutritional parameters - visceral proteins, etc.
Liver enzymes
Hematologic indices (PT, PTT, Hct, Hg)
Nutritional intake and goals:
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calories, protein, fat
Energy expenditure and Clinical course
The Case of CD
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Dr. Smith wants you to educate the medical
team regarding potential PN complications.
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Infectious
Mechanical
Metabolic
Nutritional
What will be involved for CD to go home on
PN?
 What counseling will CD’s require for his PN
therapy?
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Metabolic Complications
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Fluid & Electrolyte imbalance
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Hyperglycemia #1 complication
Acid/base disturbances
Substrate intolerance – glucose, AA, lipids
Hepatic dysfunction:
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Associated with dextrose infusion (>7mg/kg/min)
Increase Liver Function Tests
Fatty liver infiltrates
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Cholelithiasis
Cholestasis
Infectious Complications
Immunocompromised patient at greatest risk
 Infection due to multiple factors
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multiple catheter manipulations
poor catheter maintenance
poor sterile technique for drug admixture
contaminated solution
lack of filtering
Catheter Related Sepsis (CRS)
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Treat infection or remove catheter
Infectious Complications
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9 Dead After IV Infections at 6 AL Hospitals –
March, 2011. Assoc. Press
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Serratia marcescans bacteremia contaminated PN solutions
from a central compounding pharmacy.
The KES (Klebsiella, Enterobacter, and Serratia) group of
gram-negative bacteremia have essentially been involved in
virtually all outbreaks of IV contaminated solutions - both with
and without protein.
KES does well at the low pH of dextrose containing solutions
and can also fix atmospheric nitrogen as their protein source in
plain dextrose containing solutions.
Preparing and storing PN solutions for transfer to other
hospitals does carry a risk.
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Mechanical Complications
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Equipment
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Pump failure
Catheter leak
Catheter
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Pneumothorax
Catheter misplacement
Arterial puncture
Bleeding
Extravasation
Extravasation of PPN
NEJM.org - March 10, 2011
http://www.extravasation.org.uk/slideshow.htm
Nutritional Complications
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Usually develops after long-term PN
Due to chronic disease state or lack or excess of an
essential vitamins or trace elements
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Manganese toxicity – parkinson like symptoms
Chromium deficiency --> glucose intolerance
Copper deficiency --> hypochromic, normocytic anemia,
& neutropenia
Selenium deficiency --> cardiomyopathy & muscle pain
Zinc deficiency --> alopecia, dermatitis, poor wound
healing
Essential fatty acid deficiency --> dry skin, brittle hair
and nails
Aluminum Contamination
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Common contaminate in PN components
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Patients at risk:
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Large aluminum loads or prolonged therapy (home PN)
Poor renal function
Neonates
Toxicity:
Interferes with bone formation and mineralization  pain & fractures
– CNS – dementia
FDA regulation – July 2004
– Mandates manufacturing labeling of aluminum content at EXPIRATION
– Limits (<25mcg/L)
– Aluminum leaches from the container over time
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Calcium, Phosphorus, Sterile water for injection, Crystalline AA stock,
Dextrose stock, heparin, albumin
Patient Counseling
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Teach caregiver, family or patient
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Infussion pumps
Catheter care
Drugs
 proper
storage
 injecting
the MVI, vitamin K, insulin etc..
Inspecting PN bags prior to infusion
 Refrigeration, electricity, clean water
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Monitoring for PN
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Electrolytes
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Fluids
Duodenal or Gastric fistulas
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Sodium (hydration status), and Potassium
Acid/Base (Chloride & Bicarb)
metabolic alkalosis – loose gastric acid contents
Jejunal fistula
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metabolic acidosis - looses bicarbonate from pancreas
Colostomy output
Metabolic acidosis - bicarb and potassium losses
Sample PN #1
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20% Dextrose, 5% AA, TE, MVI, std
electrolytes @ 65ml/hr over 24hr &20% lipids
250ml Qdaily
CHO _______ g/day = __________Kcal/day
 IVFE _______g/day = __________Kcal/day
 Protein ________g/d = __________Kcal/day
 Total Kcal/d _______
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Sample PN #2
25% Dextrose, 4.5% AA, TE, MVI, std
electrolytes @ 85ml/hr
 20% lipids 500ml QDaily
 CHO _______ g/day = __________Kcal/day
 IVFE _______g/day = __________Kcal/day
 Protein ________g/d = __________Kcal/day
 Total Kcal/d _______
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Sample PN Answers
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Sample #1
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CHO _312_ g/day = 1061_Kcal/day
IVFE __50_g/day = __500_Kcal/day
Protein _78_g/d = __312__Kcal/day
Total Kcal/d _1873___
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Sample #2
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CHO _510_ g/day = 1734_Kcal/day
IVFE __100_g/day = __1000_Kcal/day
Protein _92_g/d = __368__Kcal/day
Total Kcal/d _3102___
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