Calculation of Central parenteral Nutrition

Mrs. K. is a 48 year old lady who had a road side accident. She sustained liver laceration, gastric
perforation, a few scrapes on her knee and long bone fracture. A feeding jejunostomy tube was placed
during emergency laparotomy and repair of perforation. When enteral feeding was initiated, she
developed abdominal distention. Her primary physician decided to insert central line and parenteral
nutrition was initiated. Her height is 170 cm, and her weight is 74 kg. Formulate PN plan for her.

1. STEP A: Calculation of fluid requirement

30mL/kg/day = 30mL X 74 kg= 2220 mL/day

2. STEP B: Calculation of proteins and calories

• Kcal: 25-30 kcal/kg/day OR Mifflin St Joer* stress factor = 1850-2220 total kcal/day
• Protein: 1-1.5g /Kg/Day = 89g protein/day (14 g Nitrogen) (6.25 g protein= 1 g Nitrogen)

3. STEP C: Determination of Dextrose content

• 74 Kg X 3 mg dextrose/kg/min X 1440min/day ÷ 1000 g/kg =320g dextrose

4. STEP D: Determination of lipid content

(Usually 0.8-1g/kg body weight/day is safe if SGPT and bilirubin are normal. Starting with a lower
range is safe) 74 X 0.8 g = 59.2g fat (Round off to 60 g fat)

5. STEP E: Calculate protein-non protein ratio

Calories from fat + Calories from dextrose ÷ gram of Nitrogen

Where: 1 g Fat= 10 kcalories, 1 g Dextrose= 3.4 kcalories and 1 g protein= 4 kcalories

60g fat x 10kcal= 600 kcalorie
320g dextrose x 3.4kcal= 1088 kcalories
Therefore, 600 + 1088 ÷ 14 g Nitrogen= 120.5kcal:1g protein (moderate stress)
Where >150:1 Normal 100-150 Moderate stress 85:1 Severe stress

6. STEP F: Calculate total calories and proteins from recommended nutrients

= 2044 kcalories and 87 g protein from TPN advised.

7. STEP G: Recommending electrolytes

Daily electrolyte additions to Adult PN Formulation Error! Bookmark not defined.

Calcium 10-15 mEq Sodium 1-2 mEq/kg

Magnesium 8-20 mEq Potassium 1-2 mEq/kg

Phosphorus 20-40 mMol Chloride As needed to maintain

acid/base balance

You can recommend trace elements Zinc Sulphate 3mg (except in kidney disease) and multivitamin 5-10 mL
 8. STEP H:
• Calculating the volume of the nutrient to be given:

I. Calculating volume of fat to be given:

(250 ml bottle of 20% fat is available in pharmacy)
Calculate grams of fat in the 250 mL bottle = 20 ÷ 100 X 250 =50 gm fat

If 250ml bottle = 50 g fat

Then χmL = 60 gm fat CROSSMULTIPLY

50χ = 250 X 60
χ = 250 X 60 ÷ 50 = 300mL
Thus, 300 mL of 20 % fat will provide us with 60 grams fat.

II. Calculating volume of protein to be given:

(500 ml bottle of 10% protein is available in pharmacy)
Calculate grams of protein in the 500 mL bottle = 10 ÷ 100 X 500 =50 gm protein

If 500ml bottle = 50 g protein

Then χ mL = 89 gm protein CROSSMULTIPLY

50χ = 500 X 89
χ =500 X 89 ÷ 50 = 890mL
Thus, 890 mL of 10% protein will provide us with 89 grams of protein.

III. Calculating volume of dextrose to be given:

(1000 ml bottle of 5%, 10% , 25% dextrose is available in pharmacy)
Calculate grams of dextrose in the 500 mL bottle = 25 ÷ 100 X 1000 =250 gm dextrose

If 1000ml bottle = 250 g dextrose

Then χ mL = 320 gm dextrose CROSSMULTIPLY

250χ = 1000 X 320
χ =1000 X 320 ÷ 250 = 1280mL
Thus, 1280 mL of 25% dextrose will provide us with 320 grams of dextrose

What will the nutrition prescription look like?

APN: 320 g Dextrose 25%, 60 g fat, 14 g Nitrogen, 5 mg ZnSo4, 5-10mL multivit or
1280 mL of 25% dextrose, 890 mL of 10% protein, 300 mL of 20% fat, 5 mg ZnSo4 and 5-10 mL
multivitamin
 Calculation of Peripheral Parenteral Nutrition PPN (Case Based)

Miss Elizabeth is a 60 year old widow with a history of HTN and asthma. She presented to the ER with
absolute constipation since one day along with symptoms of abdominal pain since 2 weeks,
undocumented weight loss, generalized weakness and abdominal distention. U/S abdomen revealed large
bowel obstruction along with dilated small bowel loops. The primary team plans to give her 48 hours to
allow the obstruction to resolve spontaneously, while simultaneously hydrating her and giving her
laxative. Plan B is surgical intervention if necessary. Her primary physician has decided to initiate
peripheral nutrition and has asked for a dietitian consult. Her weight is 70 kg and height is 162 cm.

9. STEP A:
Calculation of fluid requirement. (Same as Central line parenteral nutrition calculation)

10. STEP B:
Calculation of proteins and calories. (Same as Central line parenteral nutrition calculation)

11. STEP C:
• Calculation of Osmolality:
We can only give 900 mOsm/day through Peripheral vein with a maximum of 1150 for three in one solution.
This includes osmolality of protein, dextrose, multivitamins and electrolytes. We usually keep 250-300
mOsm aside for electrolytes. That leaves us with only 850-900mOsm/day through which to provide protein
and dextrose. Osmolarity of Fat is NEGLIGIBLE.
NOTE: Atleast 100-150 g dextrose/day are needed to prevent hypoglycemia. Following are the osmolalities
of select electrolytes i:

1 gm dextrose 5 mOsm 1 gm protein 10 mOsm

Sodium 2 mOsm Potassium 2 mOsm

Magnesium 1 mOsm Calcium 1.4 mOsm

Breaking it down:
• 1150 mOsm (total). Remove 300 mOsm for electrolytes and vitamin. 1150-300= 850 mOsm.
• 100 g dextrose is must to prevent hypoglycemia, thus 100g x 5mOsm= 500 mOsm.
• 850-500= 350 mOsm for proteins left.
• If we give 35 g protein = 35g x 10 mOsm= 350 mOsm.
• Thus We can provide 100 g dextrose, 35 g protein, in addition to 300 mOsm reserved for
electrolytes to provide a safe PPN.
 12. Step D:
• Calculation of Total percentage of protein and dextrose in PN bag.
The % total dextrose concentration in the PPN bag should not exceed 10-12.5%. Values higher than 12.5%
cause thrombophlebitis.Error! Bookmark not defined.
The % total protein concentration in the PPN bag should not exceed 2-2.5%. Values higher than 2-2.5%
cause thrombophlebitis.Error! Bookmark not defined.

• Gram of dextrose in PPN bag ÷ total volume of PPN X 100

• Gram of protein in PPN bag ÷ total volume in PPN X 100
• Where: PPN 1= 2500 mL PPN 2: 2000 mL PPN 3= 2000 mL
(Pharmacy TPN bags have prefixed volumes unless otherwise indicated)

13. STEP D:
• Determination of glucose oxidation Rate
100g dextrose x 1000mL ÷1440 mins ÷70 kg = 0.99 mg dextrose/ kg/min (SAFE)

14. STEP E:
• Determination of lipid content: 70 X 0.86 g = 60g fat

15. STEP F:
• Calculate protein-non protein ratio. (Same as Central line parenteral nutrition calculation)

16. STEP G:
• Calculate total amount of calories and protein from recommended nutrients:

17. STEP H:
• Recommending electrolytes IF asked to.

18. STEP I:
• Calculate the volumes of the nutrient to be given. (Same as Central line PN calculation)

IF ASKED TO CALCULATE OSMOLARITY FROM VOLUME METHOD:

NUTRIENT OSMOLARITY NUTRIENT OSMOLARITY
(mOsm/mL) (mOsm/mL)
Dextrose 5% 0.25 Lipids 10% 0.6
Dextrose 10% 0.505 Lipids 20% 0.7
Dextrose 50% 2.52 Electrolytes Varies by additive
Dextrose 70% 3.53 Multi trace elements 0.36
Amina acids 10% 0.998 Multivitamin 4.11
(simply multiply the volume of particular nutrient given with osmolarity)

Nutrition prescription: PPN: 100 g Dextrose 5%, 50 g fat, 8 g Nitrogen.