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Total Parenteral Nutrition (TPN)

Glucose: Seventy to eighty five percent of total TPN calories Lipids: Fifteen to thirty percent of total TPN calories.

Instructions Note: TPN is usually needed only if the patient cannot receive adequate nutrition via the gut. Consider alternate supplementation if appropriate.

Use appropriate worksheet a guide to ordering. Note: There are two different worksheets depending on weight (30 kg or less and more than 30 kg) For "Calculations," multiply patient weight (wt) or total volume of TPN by multiplication factors. Multi factors are usual ranges. Note suggestions for first day and maximum amounts. Adjust as needed. Right column corresponds to CRIS ordering template Be sure to order an inpatient schedule. Standard for short term TPN is to run over 24 hours. For longer t seek advice on "short-cycle" TPN. Intralipids (20% Fat Emulsion): Placed as a separate order under "Fat Emulsion." See appropriate TPN for suggestions. Seek advice from nutritionist, clinical pharmacy specialist, or pediatric consultant as needed.

References

Clinical Center Nutrition Support Handbook, January 2001. Website: http://intranet.cc.nih.gov/nutrition Cox J and Symons H. Nutrition and Growth. In Gunn VL and Nechyba C. The Harriet Lane Handbook. edition. Mosby, 2002.

TPN Ordering for young children < 30 kg

Components

Suggestions

Calculations (Weight = kg (wt))

Order in CRIS Everything except volum

the TPN Additives? fi ? CRIS order form ____mL Final Volume

Volume

Use daily fluid requirement formulas

TPN desired = ___mL

Amino Acids

- Day 1: 1 g/kg - Day 2 and on: 2 g/kg - Max.: 3g/kg - Day 1: D10% - Advance by 5%/day to goal - Day 2: D10-15% - Max. peripheral D12.5%

wt 1.5-2.5g/kg = ___ grams

____g Amino Acids

Glucose

Volume % desired ____g glucose Examples: For 5% = Volume 0.05 =____grams For 12.5% = Volume 12.5/100 =____grams Day 1, order 5 mL/kg/day. Day 2, order 10 mL/kg/day. Day 3 and on, order 15 mL/kg /day. Wt 2-4 mEq/kg = ____ mEq Total of Na components should equal this amount. Day 1: - wt 3mEq NaCl - 0 mEq Na Acetate - 0 mEq Na Phos

Intralipids

- Ordered separately - Maximum 20mL/kg/day

Order volume desired un Emulsion," part of the TP set.

Sodium

- Start with all sodium as NaCl - Adjust each day based on serum bicarb. - If acidotic, increase acetate and decrease chloride. - If alkalotic, decrease acetate

____mEq NaCl (____MEq Na Acetate) (____mMol Na Phos)

Potassium

Wt 2-3 mEq/kg = ____ mEq - Total phosphorus (K Phos or Na Total of K components Phos) should be 0.5-2 mMol/kg should equal this amount. - 1mMol K Phos = 1.5mEq K Day 1: - If alkalotic, can change Acetate - wt 1 mMol/kg K Phos to KCl - wt 1 mEq K Acetate - 0 mEq KCl Adjust based on labs - Start with 0.5 mEq/day - Advance if needed - Maximum = 40 mEq/ day and 30mEq/liter - Start with 0.3 mEq/kg/day -Advance if low magnesium. - Maximum = 24 mEq/day Max = 40 mcg Max = 10 mL/day wt 0.5-2.5 mEq/kg = ____mEq wt 0.3-1 mEq/kg = ___ mEq

(____mEq KCl) ____MEq K Acetate ____mMol K Phos

Calcium

____mEq Ca gluconate

Magnesium Selenium Pediatric trace minerals

____mEq MgSO4

wt 2 mcg/kg = ____mEq ____mcg Selenium wt 0.2mL/kg ___ mL trace minerals

Vitamins Other additives Consult with nutritionist

Dose Pediatric MVI Ranitidine = 3 mg/kg Heparin (For central lines: Only order as needed. Vol. 0.5U/mL)

Total calories from TPN/ L = (____g glucose 3.4) + (____ g protein 4) + (____ mL lipids 2) Suggested labs: Acute panel daily Metabolic and Hepatic panels daily until stable, then 2x/week. Triglycerides 1x/week. Prealbumin 1x/week

TPN Ordering for Children and Adolescents >30 kg

Components

Suggestions

Calculations (Weight = ____kg (wt))

Order in CRIS Everything except volu in the TPN Additives? f ? CRIS order for ____mL Final Volume ____g Amino Acids

Volume Amino Acids

Use daily fluid requirement formulas - Day 1: 1 g/kg - Day 2 and on: 2 g/kg - Day 1: D10% - Advance by 5%/day to goal - Day 2: D10-15% - Max. peripheral D12.5%

TPN desired = ___mL wt 1-2 g/kg = ___ grams Glucose = Volume %desired Examples: For 5% = Volume 0.05 =____grams For X%= Volume X/100=____grams Day 1, order 5 mL/kg/day. Day 2, order 10 mL/kg/day. Day 3 and on, order 15 mL/kg /day. Wt 2-4 mEq/kg = ____ mEq Total of Na components should equal this amount. Day 1: - wt 3 mEq NaCl - 0 mEq Na Acetate - 0 mEq Na Phos

Glucose

____g glucose

Intralipids

- Ordered separately - Maximum 20mL/kg/day

Order volume desired u Emulsion," part of the set.

Sodium

- Start with all sodium as NaCl. - Adjust each day based on serum bicarb. - If acidotic, increase acetate and decrease chloride. - If alkalotic, decrease acetate. - Total phosphorus (K Phos or

____mEq NaCl (____MEq Na Acetate) (____mMol Na Phos)

Potassium

Wt 2-3 mEq/kg = ____ mEq (____mEq KCl)

Na Phos) should be 0.5-2 mMol/kg. - 1mMol K Phos = 1.5mEq K - If alkalotic, can change K Acetate to KCl - Start with 0.5 mEq/day - Advance if needed - Maximum = 40 mEq/day and 30mEq/liter - Start with 0.2 mEq/kg/day - Maximum = 24 mEq/day Max = 40 mcg Max = 10 mL/day - Use pediatric MVI if desired - Skip Pediatric MVI if using adult MVI - Consult with nutritionist - New screen - Skip Pediatric MVI if using adult MVI

Total of K components should equal this amount. Day 1: - wt 1 mMol/kg K Phos - wt 1 mEq K Acetate - 0 mEq KCl Adjust based on labs

____MEq K Acetate ____mMol K Phos

Calcium

wt 0.5-1 mEq/kg = ____mEq ____mEq Ca gluconate wt 0.2-0.3 mEq/kg = ___ mEq Selenium = 40 mcg wt 0.2mL/kg

Magnesium Selenium Pediatric trace minerals Vitamins

____mEq MgSO4 40 mcg Selenium ___ mL trace minerals Dose Pediatric MVI

Other additives

Vitamins Ranitidine wt 3 mg/kg (Max Dose Adult MVI* 150 mg) Heparin (For central lines: Only order Ranitidine an Vol. 0.5U/mL) needed. Consult with nut Others as needed.

Total calories from TPN/ IL = (____g glucose 3.4) + (____ g protein 4) + (____ mL lipids 2) Suggested labs: Acute panel daily Metabolic and Hepatic panels daily until stable, then 2x/week. Triglycerides and Prealbumin 1x/week.

This information is prepared specifically for caregivers involved in clinical research at the NIH Clinical Center National Institutes of Health. This page last reviewed on 06/23/08

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