Adult Total Parenteral Nutrition
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(1) Determine patient weight:

  Actual weight (wt)= weight on scale

  Ideal Body Weight (IBW):
    using height in inches, IBW in lbs:
	M: 106 + (Height-60)*6
	F: 100 + (Height-60)*5

  If wt >1.2* IBW, calculate
  adjusted body weight (ABW) =
	IBW + [wt-IBW]*(0.3 to 0.4)

(2) Determine volume of TPN:
	consider:
	 	fluid requirements
		current IVF
	Use IVF+TPN for maintenance

(3) Determine caloric requirements:
	25-30 kcal/kg for previously
	well nourished patients

	10 kcal/kg for severely
	malnourished.
	Advance, over 5 days to
	20 kcal/kg

(4) Protein:
	1.0-1.5 g/kg for stressed pt.
	1.0-2.0 g/kg for large 
	   surface area burns
	0.5-0.8 g/kg for renal failure
	   with mental status changes

	20-25% total calories
	amino acids: 4 kcal/g

	0.8 g/kg RDA

	[Maximum]= 50 g/l

	need 150-200 g (~700 kcal) of
	glucose to maximally utilize
	protein

(5) Fat emulsion:
	10-20% of total calories
	10% provides 1.1 kcal/ml
	20% provides 2.0 kcal/ml

(6) Carbohydrate (dextrose):
	Remaining calories 
	  = [Total-(protein+lipid)]
	
	3.4 kcal/g
	
	[Maximum]= 100 g/l
	Maximum load= 7g/kg/day
	excess dextrose -> 
			increase LFTs

(7) Electrolytes:
	Adjust based on daily labs
	Cu and Mn held with high bili
	Ca++/PO4- > 49  --> precipitate

(8) Other additives:
	insulin, pepcid, MVI

(9) Tables 
        (compiled by R. Scott Hannay):

Moderate stress TPN delivers:
1.5 g/kg protein per day
24 non-protein calories/kg/day 
58% carbohydrates 42% lipid 
weights in kg, all dosing in grams

WT     DEXTROSE   PROTEIN  LIPID
50		205		 75		 50
55		226		 83		 55
60		246		 90		 60
65		267		 98		 65
70		287		105		 70
75		308		113		 75
80		328		120		 80
85		348		128		 85
90		369		135		 90
95		389		143		 95
100		410		150		100
105		430		158		105
110		451		165		110
115		471		173		115
120		492		180		120

Severe stress TPN delivers:
1.75 g/kg protein per day
28 non-protein calories/kg/day
64% carbohydrates  42% lipid

WT    DEXTROSE    PROTEIN   LIPID
50		265		 88		 50
55		292		 96		 55
60		318		105		 60
65		345		114		 65
70		371		123		 70
75		398		131		 75
80		424		140		 80
85		451		149		 85
90		477		158		 90
95		504		166		 95
100		530		175		100
105		557		184		105
110		583		193		110
115		610		201		115
120		636		210		120

START TPN@ 1/2 normal strength on the first day, then advance.
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by Michael T. Milano, MD PhD
MTMilano@yahoo.com
www.geocities.com/MTMilano/palm/