TPN CALCULATIONS

2. TPN PRESENTATION
Muhammad Naeem
Anam Shah

3. TPN SOLUTION
Total parenteral nutrition (also known as
hyperalimentation, hyperal or TPN) is the IV
administration of nutrients needed to sustain life:
carbohydrates, protein, fats, water, electrolytes,
vitamins, and trace elements.
Usually initiated in patients who cannot meet their
nutritional needs from other sources for an
extended period of time.
TPN is used for patients who cannot eat (e.g.
head & neck surgery, comatose, or before or after
surgery), who will not eat (e.g patients with
esophageal obstruction or inflammatory bowel
disease or who cannot eat enough (e.g. patients
with cancer,burns or trauma).

4. ADMINISTRATION
 Most TPN solutions are made for administration through a
central line.
 This route is used because it results in immediate dilution
of the solution being administered and therefore a very
concentrated solution can be administered.
 Administering a concentrated solution often allows the
medical team to completely meet an adult patient’s daily
nutritional needs with 2000 to 3000 mL of TPN solution.
 Occasionally, TPNs are administered through a peripheral
IV line – can contain same ingredient, but diluted to a
lower osmolarity. Since the solution is more dilute, they do
not meet al the patient’s nutritional needs. May need
supplements for caloric intake.

5. RISK LEVELS
 Risk Level 1
- Sterile products without preservatives for individual
patients or batch prepared with preservatives for
multiple patients.
- These are sterile products transferred into a sterile
container (e.g. syringe, IV bag or bottle).
- Storage time for these products, including
administration time, should not exceed 28 hours at
room temperature,
7 days under refrigeration, or 30 days if frozen

6. Risk Level 2
 These products are batch-prepared without
preservatives for multiple patients.
These include products that require multiple sterile
ingredients that are combined in a sterile
container through a closed system transfer that
are then subdivided into multiple parts.

7. Risk Level 3
 These products are compounded from nonsterile
ingredients, containers or equipment or prepared
from sterile or nonsterile ingredients in an open
system.
 The pharmacist is likely to be responsible for
ensuring compliance with the guidelines and other
standards of practice.

8. END PRODUCT EVALUATION
 End-product evaluation is the final inspection
made by the pharmacist before the product is
allowed to leave the pharmacy.
 It includes an inspection for leaks, cloudiness,
particulate matter, color, solution volume, and
container integrity.
 The pharmacist also verifies compounding
accuracy with respect to the correct ingredients
and quantities.
 This check of the technician’s work is an
important step in ensuring that only quality
products are sent for patient use.

10. COMPLICATIONS
TPN fully by-passes the GI tract and
normal methods of nutrient absorption.
Possible complications, which may be
significant, are listed below:

11. INFECTION:
TPN requires a chronic IV access for the
solution to run through, and the most
common complication is infection of this
catheter. Infection is a common cause of
death in these patients, with a mortality
rate of approximately 15% per
infection, and death usually results
from septic shock

12. BLOOD CLOTS
Chronic IV access leaves a foreign body in
the vascular system, and blood clots on this
IV line are common. Death can result
from pulmonary embolism wherein a clot
that starts on the IV line but breaks off and
goes into the lungs.
Patients under long-term TPN will typically
receive a periodic heparin flush to dissolve
such clots before they become dangerous

13. FATTY LIVER AND LIVER FAILURE
Fatty liver is usually a more long term
complication of TPN, though over a long
enough course it is fairly common. The
pathogenesis is due to using linoleic
acid (an omega-6 fatty acid component of
soybean oil) as a major source of calories

15. Parenteral Nutrition Order
TPN * PPN
Central Peripheral *
Route Of Administration
Day of TPN
Date
Time

16. Patient Profile
Name XYZ
Age 2 years
weight 12 kg
MR(Medical Report) ………….
Ward Surgery
Diagnosis Gut Surgery
NPO Since 2 days
Oral feed (if any)
Type of Oral feed
Total oral feed per day
Energy of oral feed per day

17. Lab Findings
ALT Normal Na 120
AST Normal K 2.5
Billirubin Normal Ca 7
Lipid Profile RFT’s
S.Triglycerides S/Cr
(serum
creatini
ne)
0.6 (Normal)
Cholesterol Urea 40
BSR 121 Normal
Others

18. Daily Fluid Requirement………………………. (ml/kg/day)
With Lipid/Without Lipid………………………
Proteins(gm/kg/day)……………………………... (1-3gm/kg/day)
Lipid (gm/kg/day)……………………………... ….(0.5-4gm/kg/day)
Dextrose(gm/kg/day)……………………………...( gm/kg/day)
Na(mEq/kg/day)……………………………………..(2-4 mEq/kg/day)
K(mEq/kg/day)………………………………………..( 2-3 mEq/kg/day)
Ca(mg/kg/day)………………………………………..(300-5000 mg/kg/day)
Rx Order

19. Drugs being given in dilution for I.V Infusion
Serial
#
Drug Regimen Diluent Vol/day Na
content/Dextrose
(For Pharmacist)
1 Vancomycin
(I/V)
200 mg
t.i.d
60 mL 9 mEq
2
3
4
5
6
7
8 ( For Pharmacist )

20. Total fluid being given as drug diluents……………60……………….mL
Total Na content being given as drug diluents………9…………..mEq
Total Dextrose being given as drug diluents…………………………gm
Remarks…………………………………………………………………………………..
……………………………………………………………………………………………
Doctor Signature………………………….

21. CALCULATIONS
Pharmacist Work Up

22. Parenteral Nutrition Calculation
Fluid for TPN(mL)…………1050………mL

23. Amino Acid Solution (10% solution)
Protein(gm/kg/day) 0.5
Protein (gm /day) 6
Volume (mL) 60
Na…0.041……(mEq/mL) 2.46
K…..0.025….(mEq/mL) 1.5
A.A .soln.Energy…0.4 (KCal /mL) 24

24. Lipid Emulsion
Lipid(gm/kg/day) 0.5
Lipid (gm/day) 6
Volume (mL) 30
Lipid Energy (Kcal) 60
Rate of administration 1.25 mL/Hr.

25. Electrosol injection
K (mEq/kg/day) 3
K (mEq/Day) 36
K Deficit (mEq) 34.5
KCl (mL)
1mEq K/mL
19.5

26. Normal Saline Ca-gluconate
Na (mEq/kg/day) 4 Ca-gluconate
(mg/kg/day)
400
Na (mEq/Day) 48 Ca-gluconate
( mg/day )
4800
Na Deficit (mEq) 36.5 Vol. Of 10 % Ca-
gluconate inj.
48
Normal Saline (mL)
(0.15 mEq Na/mL)
243

27. Remaining Fluid (mL)……(1050-400)=650…………………….

28. Calorie Work Up
Max. NNE as per protocol(Kcal/kg/day)=…..550….Kcal
Max. deficit of NNE ( Max. NNE-(sorbitol energy+lipid
energy)=…490…..Kcal/3.4=144 gm. Dextrose
Min. NNE as per amino acid (A.A. dose*25)=…..150…Kcal
Min. Deficit NNE (Min.NNE-(sorbitol energy+lipid energy)=……(150-
(0+60)=….90….Kcal/3.4=…..26…gm. Dextrose
Amount of Dextrose to be added into remaining fluid=...90 gm.
Percentage of Dextrose in remaining fluid= 13.8…..(nearly
equals)….= 14 %

29. Do you Know How to
apply Alligation
Method ?
D5%
D10%
D25%
Total NNE/day……….366..……Kcal.
Dextrose (gm/kg/ day)……7.5……..gm.
Rate of Administration……42.5….mL/Hr.
Osmolarity of TPN…………………mOsm/Litre.
Route of Administration….Peripheral…..
Remarks….........................................................................
.....................................................................................

30. Osmolarity 0f Peripheral Nutrition
Medicine
volume
mOsm/mL mOsm
KCl inj. 19 4 76
Ca-gluconate inj. 48 0.31 14.88
D5% ………… 0.03 …….
D10% 477 0.51 243.27
D25% 173 1.26 218
0.9% NaCl 243 0.31 75.33
Aminoplasmil. 60 1.2 72
Total 1020 700
Osmolarity
686.27
mOsm/Litre

31. mOsm/Litre= (700/1020)*1000=686.27
Pharmacist Signature………………………………