it’s an initial and ongoing process of identifying characteristics known to be associated with nutrition problems in order to identify patients who are nutritionally at risk for malnutrition or are malnourished.
For past and present recent medical problems that have affected or may affect nutritional status. For example, medications, diagnostic procedures, surgeries, chemotherapy, radiation, etc.
2. Medical record review:
To identify factors that may affect nutritional status.
|Age in years||Recommended Caloric Intake|
|Amino Acids requirements|
|0-6 months||2-3 g/kg/day|
|6m-6 years||2-2.5 g/kg/day|
|7-12 years||1.5-2 g/kg/day|
|> 12 years-adults||0.8-1.5 g/kg/day|
Any fluid imbalance should be corrected; fluid intake urine output and IV drugs will be taken into account when circulating or calculating fluid requirements.
The TPN fluid should:
Fluid restrictions is for the deciding factor in selecting hypertonic concentrated solutions for infusion through central vein rather than a more diluted solution for peripheral administration.
Neonates: 80-150ml/kg/day according to gestational age, post natal age, incubator condition and phototherapy.
The following table shows the fluid volume in ml/kg/day for the given age of the newborn up to one month, and that volume will be corresponding to the infant weight.
|Day 1||Day 2||Day 3 to 1 month|
|wt< 1200 gm||80-100||100-120||120-140|
|1201 – 2500 gm||70||80-100||100-120|
|2501 – 4500 gm||50-60||60-80||100|
Infants to adults:
|Wt. (1-10 kg)||100ml/kg/day|
|10.1 – 20 kg||1000ml + 50ml/kg above 10 kg|
|>20 kg||1500ml + 20ml/kg above 20 kg|
The increase in concentration should be gradual, till maximum recommended strength:
|Age||Start at conc. of||Increased by|
|Neonates||0.5% amino acid solution||0.5% every other day|
|Infants||1% amino acid solution||0.5% every day|
|Children||1% amino acid solution||0.5% every day|
|Adults||4.25% amino acid solution|
Osmolarity of TPN solution: The maximum osmolarity must not exceed the following values when administered peripherally:
|Age group||Peripheral line TPN|
|Neonates and infants||1100 mOsmol/L|
|Pediatric < 11 years||1050 mOsmol/L|
|Adolescent – Adult||900 mOsmol/L|
|IBW||Maximum utilization of glucose||Maximum rate of oxidation|
|< 8 kg||25 gm/kg/day||17 mg/kg/min|
|8 – 15 kg||20 gm/kg/day||17 – 14 mg/kg/min|
|15.1 – 25 kg||16 gm/kg/day||14 – 11 mg/kg/min|
|25.1 – 50 kg||10 gm/kg/day||11 – 7 mg/kg/min|
|> 50 kg and adults||8 gm/kg/day||5 mg/kg/min|
Begin TPN dextrose infusion at the same dextrose load provided by the current IV fluids, advance 1-3 mg/kg/min as tolerated, till maximum oxidation rate.
The rate of dextrose infusion should be limited to its maximum rate of oxidation, to avoid excess glucose that will be diverted to non oxidative pathway (glycogen storage, hepatic lipogenesis, cholestasis, hepatomegaly, etc.).
|Premature and newborn infants||5% initially||Increased by 2.5% every 2 days||Maximum 10% if peripheral line and to 20% if central line|
|Older infants and children||5% initially||Increased by 2.5% every day||Maximum 10% if peripheral line and to 20% if central line|
|Older children and adults||5% initially||Increased by 5% every day||Maximum 12.5% if peripheral line and to 25% if central line|
Urine sugar spills:
For +1 and +2 no insulin is required.
For +3 obtain stat blood glucose; if exceeds 250 mg%.
Commence blood glucose every 4 hours and potassium measurements and proceed as follow:
|Blood glucose||Insulin IV|
|250 to 300 mg %||5 U regular insulin|
|301 to 350 mg %||10 U regular insulin|
|351 to 400 mg %||15 U regular insulin|
Further management will be determined on basis of response to above.
|Age||Initially||Increased by||Maximum daily dose|
|Premature infants||0.5 gm/kg/day||0.5-1 gm/kg/day||3 gm/kg/day|
|Infants||1 gm/kg/day||0.5-1 gm/kg/day||3 gm/kg/day|
|Older children and adults||1 gm/kg/day||0.5-1 gm/kg/day||2 gm/kg/day|
|Electrolytes||Dosage forms||Concentration||Adult requirements||Pediatric|
|Potassium||Potassium chloride 15%|
|70-180 meq/day||2-3 meq/kg/d|
|Magnesium||Magnesium sulfate 50%||4 meq/ml||8-32 meq/day||0.25-0.5 meq/kg/d|
|9-30 mmol/day||0.5-2 mmol/kg/d|
|Sodium||Sodium chloride concentrate|
|60-150 meq/day||2-4 meq/kg/d|
|Calcium||Calcium gluconate 10%||4.5 meq/10ml||5-40 meq/day||0.5-3 meq/kg/d|
|Chloride||Sodium chloride 23.4%|
Or Sodium chloride 14.6%
|60-150 meq/day||2-4 meq/kg/d|
|Vitamin||Each 5 ml cernevit contains:|
|Vitamin A||3500 IU|
|Vitamin B12||6 mcg|
|Folic acid||414 mcg|
|Vitamin C||125 mg|
|Vitamin E||10.2 mg|
|Vitamin D||220 IU|
|Wt. (kg)||Dosage (ml)|
|< 1 kg||1.5 ml|
|1-3 kg||3 ml|
|> 3 kg and up to 11 years of age||5 ml|
|Infants||0.25-0.5 mg||Twice weekly|
|Older children||2 mg if < 2 years|
5 mg if 2-5 years
10 mg if > 5 years
|Adults||10 mg IM||Weekly to all adult patients, unless the patient is on daily vitamin K|
2. Vitamin B12 (cyanocobolamine):
Infants: 50 mcg twice monthly.
Older children: 100 mcg initially and then monthly.
Adults: May be given additionally once a month (1000 mcg) or weekly as required.
*Folic acid is present in Cernivit.
|Trace element||Infants and toddlers|
< 3 months old: 150
> 3 months old: 100
(20 mcg/day if intestinal loss)
0.5-1 unit/ml of the TPN solution added, this amount over 24 hours has little or no effect on a PTT.
Maximum in TPN = 60 gm/day or 20 gm/L.
Frequency of routine monitoring should be increased in critically ill patients.
|Routine monitoring parameters||Frequency|
|Urinary glucose, ketones and specific gravity||Every voided specimen until stable, then daily|
|Finger stick glucose||Every 6 hours until stable|
|Temperature, Vital signs||Every 4 hours|
|Weight, intake and output||Daily|
|Serum glucose, Na, K, CL, HCO3, osmolarity, creatinine, and BUN||Daily until stable, then twice weekly|
|Magnesium, Calcium, and Phosphorous||Daily until stable, then once weekly|
|CBC, and prothrombin time, INR||Baseline then weekly|
|Serum protein, albumin, prealbumin||Baseline then weekly|
|LFTs||Baseline then twice weekly|
|Serum cholesterol and triglycerides||Every day for 2 days then weekly|
|Blood ammonia||Baseline then weekly in renal and hepatic pt.|
Suspicion of sepsis:
Awareness of the patient problems and the predisposing factors will facilitate their prevention
2-Deficit of potassium or phosphorous
4-Medications e.g. corticosteroids
|1-Sepsis workup and treatment|
2-Increase potassium or phosphorous provision
4-Reduce rate of glucose infusion
|Hypoglycemia||1-Abrupt withdrawal or interruption of TPN infusion|
|1-Begin dextrose 50% infusion|
-Ensure correct tapering of TPN infusion
-If accidental disconnection; start dextrose 10% infusion at the same rate of TPN infusion
2-Monitor blood glucose and potassium
|Hypokalemia||Large glucose infusion|
Excessive GI losses (drains, fistula, diarrhea, ..)
Excessive urinary losses (diuretics, amphotericin, ..)
|Hypophosphatemia||Phosphate binding antacids|
Phosphate free dialysis
|Discontinue phosphate binder|
Increase phosphate intake
Extensive small bowel resection
|Increase magnesium intake|
Insufficient vitamin D intake
|Hyponatremia||Relative excess of water|
|Increase sodium provision|
|Metabolic acidosis||High output GI fistula|
Excess amino acids
|Decrease chloride or increase acetate provision|
Decrease amino acids in TPN
Impaired renal function
Excess nitrogen infusion
Increase E:N ratio
|Elevated LFTs||Excess dextrose|
Extended enteral feeding
|Provide lipid, decrease Dextrose, or use cycling TPN|
|Hypertriglyceridemia||Impaired clearance||Hold IV lipid if ser.TG> 400 mg% (4.5 mmol/L)|
|Osmotic diuresis||Failure to recognize initial hyperglycemia and increased glucose in urine||Reduce infusion rate|
Insulin to correct hyperglycemia
|EFA difficiency||Insufficient provision of fat||Provide lipid|
|Excess CO2 production (PCO2)||Excess dextrose intake||Decrease dextrose and increase fat intake if possible, increase ventilation|
Complications related to catheter insertion:
Pneumothorax, puncture of subclavian or carotid artery and air embolism.
Septicemia related to the catheter:
(Vancomycin is the drug of choice), fever should be investigated on occurrence and TPN lines should be changed if no other cause is found, catheter tips must be cultured if the patient becomes septic;
Temporary discontinuation of TPN for surgery or investigation:
Accidental disconnection of TPN:
It is a maneuver to further reduce the pathophysiologic consequences of TPN administration. It needs to be achieved gradually and the usual goal is to infuse the necessary volume of TPN and lipid over a 16-18 hours period. One hour at each end of the infusion time will have the solution running at half the normal rate to allow the pancreas to adjust insulin/glucagon secretion to prevent hypo-or hyperglycemia. To calculate these rates divide the total volume of TPN/day by the number of hours for infusing minus one to obtain the rate of infusion during the main period of infusion. One half that rate is the step-up and step-down rate. Running D10% solution or other fluid should be unnecessary if the patient has been gradually tapered to this regimen from a 24-hour infusion protocol. Infuse other IV fluids over the remaining 6-8 hours or TKO with the TPN fluid (10 ml/hour).